Last week I called the psychiatrist who did the 2nd opinion on Honeybunches meds, which the new pediatrician requested. I requested that they send the evaluation report to his current psychiatrist. Today at his appointment with her we finally got the results.
Some of the report goes back into his development from infancy and more. It is a pretty comprehensive 4 page evaluation summary. It begins with saying how Honeybunches "Is a very complicated boy and has an existing specialist for his psychiatric medication treatment". Next the doctor stated "As you know, these MCPAP consultations are not comprehensive psychiatric evaluations, therefore, I would like my recommendations to be seen as suggestions and ideas for further progress in his care rather than definitive recommendations". From there he went into his developmental history all the way back to infancy, which I provided him with as well as his psychiatric care history. He talked about his diagnoses (BP, ADHD, PDD-NOS, Receptive-Expressive Language Disorder and Anxiety Disorder). The doctor stated "I am not certain of the validity of all these diagnoses; however, mother describes his history to be very consistent with the autism spectrum disorder as well as having a very compelling overlay of significant mood disorder beyond the mood dysregulation which is ordinarily characteristic of autism spectrum disorders..." From there he went into his hospitalization and medication history. He then went into the family history noting that "His mother has been extremely well motivated to seek all the services that she needs to support ----'s development with his mental health and developmental disability."
Then finally he went onto his examination. He wrote "On examination I found --- to be a very pleasant and cooperative child. He had very apparent signs of autism spectrum disorder. His speech was monotone. He had repetitive verbal mannerisms. He had very poor eye contact. He did show a tendency to be somewhat perseverative. He did not engage in any age appropriate play activities, but was perfectly cooperative with talking. He had a tendency to be concrete in his responses. He had a positive mood throughout the interview. His affect was appropriate. He did not show anxiety. He did not have difficulty separating from his parents. He was not significantly restless or hyperactive. He was attentive to the interview and task at hand. He did not have any suicidal ideation. He did not have any signs or evidence of delusional thinking. He did not appear to respond to any internal stimuli. He was fully oriented. His memory was intact, actually very good for his age and for both immediate and long-term items. He had a reasonable degree of insight and showed normal judgement for his age. He had no tics. He did have some lip smacking movements, which appeared to be consistent with mild tardive dyskinesia. My overall impression of --- is that his history and examination is consistent with the diagnosis of autism spectrum disorder and I do think that there is a high likelihood that his diagnosis is complicated by the co-occuring presence of severe and significant mood disorder on the bipolar spectrum. Therefore, I am provisionally inclined to agree with both of these diagnoses of autism spectrum and bipolar disorder NOS. I do question the presence of a separate diagnosis of expressive-receptive language disorder as well as generalized anxiety disorder as well as ADHD, because I feel that these symptoms pertained to these additional diagnoses are attributed to his autism spectrum and mood disorder diagnoses."
He then goes into:
"I talked with ---'s parents about ideas about medications and I would be happy to discuss this further with his current psychiatric nurse. I shared with mother that the issue of the metabolic side effects of antipsychotic medications are the most important concerns in regard to medication adverse effects and the first priority should be to try to address this. I think it is very unlikely that the current trial of Seroquel is going to offer any advantages to the previous treatment of Abilify in regard to metabolic side effects. Regarding further directions in addressing the mood instability issues in the future, stage I would be to attempt a trial of discontinuation of Seroquel without adding any further mood stabilizing medications. It is possible that now that he is a little bit older, he no longer requires an antipsychotic medication to keep his mood under control. If he is able to tolerate being off the Seroquel and not on other antipsychotic medication, this would be optimal. If this is not possible, then stage II would be to consider trials of a secondary mood stabilizing medication other than an antipsychotic. Notably, he has not had any trials with Depakote, Tegratol or Topomax in the past and I believe that all three of these medications could be considered in addition to his current treatment with Lithium. If these medications do not work, then the third recommendation would be to very carefully and judiciously try conventional antipsychotic medications in very low doses. These would include potentially trials of haloperidol, Prolixin or Trilafon. These medications and doses could be more robust in their effectiveness and may not aggravate his tardive dyskinesia symptoms. They are much less likely to be associated with fatty liver or metabolic effects, then the atypical antipsychotics however of course his movement disorder will need to be closely monitored. After considering the relative advantages and disadvantages I would remark that I believe that the fatty liver is more serious of a concern than the risk of tardive dyskinesia, although admittedly tardive dyskinesia is also an extremely undesirable side effect. If none of these suggestions is helpful, then I would suggest considering further psychiatric consultation to explore other avenues for treatment." (Then he went into discussing some family history stuff regarding my stepson that I don't want to get into on here...) From there he said "Nonetheless, because of the strong family history of serious mood disorders on the mother's side of the family, I do think that it is reasonable to consider that bipolar spectrum disorder is an accurate secondary diagnosis in addition to his primary autism spectrum disorder."
When I emailed the regular psych nurse he sees after my appointment with this 2nd opinion doc telling her about his three step plan she immediately disagreed with it. I trust her judgement more because she knows Honeybunches much better. She did not agree that he would be okay without an antipsychotic. We did trial different ones in Dec-Feb which did not work out well at all, so he went back on Abilify but at a very low dose. She thought with his symptoms of Tardive Dyskinesia and Akathesia, that the old APs would be more likely to cause those symptoms. It did not sound like she approved of using them, which might be an agency decision. I agree that his ADHD, anxiety disorder and language disorder could go along with his Autism. I am glad that they clearly seen those the Autism and Bipolar, because those are what I have considered his main diagnoses for years now. I have always doubted the ADHD. I found it interesting that he seemed to think the autism was his primary diagnosis with mood disorder secondary from the way I understood what he wrote. The reason that was interesting to me, is because when he was three he got the Bipolar diagnosis, but did not get the Autism diagnosis until age six. I was happy to finally read this evaluation. IDK why the 2nd opinion's doc did not want to just give it to me. They were pretty insistent on only sharing it with doctors. That's why I am glad the current psych nurse is so awesome and gives me copies of everything lol.
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