OD7 ‘Mind the Gap’: A logic model for approaching disruptive sleep & wake behaviors with neurodevelopmental & mental health disorders: Bridging to the COVID-19 new normal and reducing vulnerability for waitlisted patients

Summary

The shutdown of “non-essential” health care services during the COVID-19 pandemic and the subsequent “new normal” is causing a dramatic increase in waiting times for specialist services. Pediatric patients with neurodevelopmental and mental health disorders suffering from sleep disturbances are particularly affected, which leaves community-based, primary care physicians responsible for crisis management. These children have been diagnosed with multiple diagnoses, such as autism spectrum disorders, prenatal substance exposure / fetal alcohol spectrum disorders, ADHD, Tourette syndrome, anxiety, depression, obsessive compulsive, or oppositional defiant disorders. In order to close the gap between day and nighttime related diagnoses, we need to develop best practice interventions that can address the increasing burden for patients, their caregivers, and community-based health care providers during the wait time for assessment.

Irrespective of their categorical diagnosis, the vast majority of these patients show restlessness with hyperarousability and hypermotor restlessness during the day and night (H-behaviors) as a core clinical symptom. Desperate clinical circumstances often lead to deviations from common prescription recommendations (e.g. off-label prescription of melatonin, antihistamines, stimulants, or antipsychotics leading to overmedication and/or polypharmacy). Unrecognized drug interactions and adverse drug reactions, such as akathisia, worsen H-behaviors and may lead to the exacerbation of existing, and development of new behavioral challenges.

The take-home message from a COVID-19 shutdown quality assurance initiative in our own clinic has been that triaging disruptive sleep/wake-behaviors for further assessment in specialized clinics can affect life trajectories.  However, symptoms need to be interpreted within the contextual framework of a logic model in order to make them recognizable already at the referral stage.

To approach challenging sleep and wake-behaviors in the community, we present a logic model based on the recognition of H-behaviors and the subsequent characterization of functional diagnoses (e.g. sensory dysfunctions) and probable differential diagnostic root causes (e.g. iron deficiency). The model sets categorical day and nighttime related diagnoses (e.g. ADHD and insomnia, respectively) in equal relation to functional diagnoses and probable root causes, while also incorporating effects of medication (e.g., antipsychotics) and non-medication based interventions (e.g. cognitive behavioral therapy). Evaluation is enabled with the use of Sleep Disturbances Scale for Children (Bruni et al. 1996), which allows harmonization and quantification of the sleep assessment and follow-ups, and, as suggested by WHO, the International Classification of Functioning (https://www.who.int/classifications/icf/en/) allowing the creation of a mathematical model.

Learning Objectives

Upon completion of this CME activity, participants should be able to:

• Recognize challenging behaviors from functional behavior perspectives
• Assess frequent errors in diagnoses of disruptive behaviors
• Explain the value of blood chemistry results as possible causes of exacerbating behaviors
• Recognize the role of overmedication and polypharmacy as a possible cause of exacerbating behaviors
• Assess neurodevelopmental and mental health disorders in context with sleep disturbances before starting medication cascades

Target Audience

Practitioners with various backgrounds. Independent of background, training, and discipline, the goal is to convey a simplified triage and assessment concept guided by a logic model, which helps to develop a roadmap and avoid inappropriate medications as a first line measure

Chair

Osman Ipsiroglu (Canada)

Motivation Guiding Behaviors: Child & parent's perspective of what is a problem

Luci Wiggs (United Kingdom)

Evolving understanding of sleep in ADHD over three decades: The perspectives of professionals (results of a scoping review)

Scout McWilliams (Ireland)

Structured behavioral observations: Vigilance & movement patterns

Gerhard Kloesch (Austria)

Biochemical Imbalances: Errors in assessment result in off-label antipsychotic prescriptions

Osman Ipsiroglu (Canada)

The need for harmonization of clinical best practice outcome measures

Rosalia Silvestri (Italy)