11/11/2018. The ABCs of Medication Management for Autism Spectrum Disorder. ABC Logging (FBA) First. ABC Logging HOW TO COMPLEMENT BEHAVIORAL THERAPY

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1 The ABCs of Medication Management for Autism Spectrum Disorder OR HOW TO COMPLEMENT BEHAVIORAL THERAPY ABC Logging (FBA) First We need to know what, when, where and why behaviors happen. Antecedent: What happened right before the behavior? Behavior: i.e. rage, self injury, aggression, elopement, stemming, withdrawal Consequence: What happened right after the behavior? Possible Function: getting attention, accessing item or activity, escape, sensory (What was the outcome for the child?) Key Point: Therapeutic interventions to change behaviors should be explored BEFORE medication management is considered. ABC Logging We need to figuring out why a child acts a certain way and understand what s behind the inappropriate behaviors. Knowing what s behind the behavior can help find ways to change the behavior. A child s behavior serves a purpose and expresses an emotion. We need to figure out what triggers certain behaviors in your child. It s important to remember that the causes for the same behavior is different for every child. Key Point: WHY a child reacts the way they do not only helps with behavioral therapy planning but can guide medication treatment options. 1

2 ABC Logging Define the behavior: Give a good description of child s behavior. It s important to describe the behavior in an objective, specific way. This can help to formulate a behavioral intervention as well as helping to categorize the behaviors and emotions. Does the behavior reflect anxiety, defiance, sadness, distress? Key Point: Physicians don t often observe a child's emotional or behavioral dysregulation in our office. Important Details on Behaiors Collecting, comparing and analyzing information: Where is this behavior happening? Where is it not happening? How often is the behavior occurring? Who is around when it occurs? What tends to happen right before and right after the behavior? What is My Child s Behavior Telling Me? 2

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4 Have Therapy in Place Developing a plan: Once we know the cause for a child s behavior, can changing something in the environment change the behavior? Can the physical environment be modified? Can a change be made in a child s routine or events that happen before the inappropriate behavior to divert it? Can changes be made in the response to the behavior or to the consequences for a behavior? Key point: Medication management can compliment therapy and should not be considered first nor should it be considered without concurrent therapy. Consider Other Treatments First Many children with ASD have challenging behaviors or difficulties with their feelings and emotions. Many treatments help. Medicine is only one of those treatment options, and medicine is not right for every child. It is best to consider medicine only AFTER behavioral and educational methods have been tried first. Key point: FBA is a valuable tool that should be done. The same information gathered from an FBA can help when considering the need for medication management. Treatment Equation Trigger Emotion Behavior The trigger causes an emotion. The emotion causes a behavior. The behavior is the RESULT. Only treating the behavior is like putting a bandaid on an infection. That s sloppy. We need to understand both the trigger (using ABC checklist, FBA) and the emotion before we can fully change the behavior. Key Point: IF medication treatment is considered, we need to identify and treat a child s emotional response (fear, anger, frustration, sadness, distress) and not just aim to medicate away their behavior (outbursts, meltdowns, aggression, self injury.) 4

5 If a Decision is Made to Use Medication It is important families have the right information. A physician should: Explain medicine choices to families. Teach families about watching for effectiveness. Teach families about checking for side effects and good response. Give information about managing common side effects. Be clear with families about goals of treatment, possible risks and benefits. Where to Find Help Medicines commonly prescribed for ASD are usually prescribed by a pediatrician, a psychiatrist or a neurologist. Who knows you and your child? Has experience working with children with ASD and behavior difficulties. Is knowledgeable about the use of medicines in children with ASD. Knows the possible risks and possible benefits of each medicine. Treatment Questions The NEED TO KNOW list: What exactly are we treating? The pros and cons of medication options. Possible side effects and benefits of any medicines for your child. How long will it take to work? If improvement is not seen, then what do we do? If side effects happen, what do we do immediately and then what? Key point: Medication management DOES NOT TREAT ASD. Medications can help ameliorate BEHAVIORS that are disruptive or injurious, or that negatively impact home and the educational progress. 5

6 Identify the Target Symptoms What are Target Symptoms? Target symptoms are those problems or behaviors that are causing trouble for a child. It is important to be clear about what symptoms are the biggest problems. This will help to choose the best medicine. Having clearly targeted symptoms will also help to measure if medicine is helping and assess efficacy of treatment. Key point: There are no medicines that treat the core social and communication symptoms of ASD. Medicines do not help with thinking and learning problems. However, by targeting symptoms with medicine, a child might do better in school or in therapy, which can help them to learn better and improve and expedite therapy outcomes. Common Target Symptoms Hyperactivity Short attention span Impulsive behaviors Irritability Agitation Aggression Self-injury Common Target Symptoms Tantrums Repeating thoughts, interests and behaviors Sleep problems Anxiety Depression Mood problems Tics 6

7 Deciding What RX to Use Every detail can be important when considering what medication to use: What behavioral therapies have been helpful in mitigating symptoms. Also consider: medical history, metabolism, severity of symptoms, family history, support systems in place at home, school, community, academic performance, IEP/504, risks to self or others, self injury, other safety concerns, eating habits, sleep habits. Metabolic workup may be needed prior to starting medications. Gene tests may be useful in guiding medication choices. Key Point: Multiple considerations are important for deciding what medications may be appropriate. RX Dose Once a decision is made on what medication to use, the dose of medicine is not always the same and can differ for each child. Even with the same medicine, some children do well on a low dose and some children need higher doses. The dose depends on things like the severity of emotional or behavioral dysregulation being treated, age, weight, overall health and subsequent to a starting dose, a child s response. A conservative approach should start with a low dose and increase slowly until improvements are seen. This can identify the lowest effective dose. Key Points: A conservative approach to medicine is best. Think: Less is more. And some medications are dosed based on SEVERITY of symptoms and not necessarily on height, weight or age. RX Effect Wait Time How long it takes a medicine to be effective is different for every medicine and every class of medications. Additionally, a medication effect timeline will vary from person to person. Some medicines prescribed for emotional and behavioral dysregulation can work within a few minutes. Others can take up to 6 weeks to see the full effect. The physician should provide an expected time line for effects to be seen. 7

8 RX Side Effects What requires monitoring and why? Side effects are negative or unwanted effects of a medicine. Different medicines have different side effects. For that reason, some medicines have to be monitored much more closely. Some medications require blood work to measure concentration, other medications require monitoring for any side effects, such as blood sugar changes, cholesterol changes, prolactin levels, and impact on the liver and kidneys. A few medications require obtaining an EKG because of impact on the heart. FDA Approved vs. Off-Label Your child s physician should indicate if a medication they are recommending is off-label. Don t be afraid to ask what uses a medication is FDA approved for or if it is being prescribed off-label. Ask about the studies that supports the off-label use. The FDA recognizes that medications are used for other than its original intent, and is considered standard of care even though it has not been officially approved for a particular use. This is common and not illegal not does it indicate bad medical care. Key Points: The drug s website will list the FDA-approved uses and off-label uses and the groups that are approved to take the drug. Trusted websites, such as that of the National Institute of Mental Health (NIMH)are good sources of information about FDA-approved and off-label medication treatment in ASD. Measuring the Success of Treatment When starting a new medicine, it is important to plan a way to measure how helpful it is. How this is done depends on the child, the family, and the target symptoms. In general, measuring the helpfulness of any medication includes keeping track of the target symptoms with a behavioral checklist that should include: 8

9 Behavioral Tracking Frequency: Number of tantrums each day Number of times child wakes during the night each week Severity: How hyperactive is the child? How severe is the tantrum? Duration How long does the target symptom or tantrum last? How long does it take the child to fall asleep? Other Factors that Influence RX Effect Important life events might include: Change in a child s environment can change a medications effects on target symptoms. This can make it harder to know if a medication is helping. A new school New teacher or substitute teacher Moving homes A change in therapist A change in family, such as divorce, marriage or birth of a child Commonly Prescribed Medicines for ASD ADHD/ADD Stimulant Medicines: Methylphenidate Derivatives: Ritalin, Metadate, Concerta, Methylin, Daytrana, Cotempla, Aptensio, Quillivant, Focalin Amphetamine Salt Derivatives: Adderall, Adzenys, Dyanavel, Mydayis, Dexedrine, Vyvanse, Evekeo, Zenzedi, ProCentra Target Behaviors: Hyperactivity, short attention span, poor focus, impulsivity Common Side Effects: Sleep disturbance, less appetite, irritability Less Common Side Effects: Tics, anxiety, depression, repeating behaviors and thoughts, headaches, diarrhea, social withdrawal, rapid heart rate or rhythm Key point: Many RCTs show benefits. 9

10 Commonly Prescribed Medicines for ASD ADHD/ADD Non-Stimulant Medicines: Strattera Alpha Agonists Medicines: guanfacine (Tenex, Intuniv), clonidine (Catapres, Kapvay) Target Behaviors: Hyperactivity, short attention span, impulsive behaviors, sleep problems, tics Common Side Effects: Sleepiness, GI problems (nausea, vomiting, constipation), low appetite, low blood pressure, irritability Less Common Side Effects: Constipation, high blood pressure if stopped quickly, thoughts of harming self Key point: Several RTCs show benefits. Commonly Prescribed Medicines for ASD Anti-Anxiety Medicines: SSRIs: fluoxetine, sertraline, paroxetine, citalopram, escitalopram, fluvoxamine Target Behaviors: Depression, anxiety, repeating thoughts, repeating behaviors (OCD sx), phobias/fears, rigidity, outbursts Common Side Effects: GI problems (nausea, vomiting, constipation, low appetite), headaches, problems falling asleep, sleepiness, agitation, increased activity level, mild weight gain Less Common Side Effects: Seizures, heart rhythm problems, thoughts of harming self, suicide, serotonin syndrome Key point: RTC show benefits in adult ASD, limited efficacy in children/adolescents with ASD. Efficacy strongly supported in anxiety and depression in non-asd. Commonly Prescribed Medicines for ASD Mood Stabilizers, Second Generation Antipsychotic Medicines: risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone Target Behaviors: Irritability, aggression, rage, self-injury, tantrums, outbursts, sleep problems, hyperactivity, repeating behaviors, tics Common Side Effects: Sleepiness, drooling, increased appetite, weight gain Less Common Side Effects: High cholesterol, high blood sugar, diabetes, movement side effects, eye side effects, heart side effects Key point: Multiple RCT for risperidone and aripiprazole show positive results and significant efficacy, other SGAs are considered off-label. 10

11 Commonly Prescribed Medicines for ASD Seizure Medicines: carbamazepine (Tegretol, Carbatrol), valproic acid (Depakote, Depakene), lamotrigine (Lamictal), oxcarbazepine (Trileptal), topiramate (Topamax) Target Behaviors: Seizures, mood problems, aggression, self-injury Common Side Effects: Rashes, sleepiness, nausea, vomiting, memory problems Less Common Side Effects: Hepatitis, liver failure, pancreatitis, bone marrow suppression, tremor, dizziness Key point: Multiple RCTs show efficacy. Thank you for coming. Q&A Peter Stanbro, MD, MPH Medical Director and CEO Stanbro Healthcare Group LLC Edmond, OK & Clinical Assistant Professor, vol. The University of Oklahoma Health Sciences Center Department of Psychiatry & Behavioral Sciences Oklahoma City, OK Additional Information Additional information on specific medicines: Movement disorders are rare but sometimes serious side effects of some medicines. These side effects can happen right after starting a medicine, with dose increases, after a person has taken the medicine for a long time, or when medicines are stopped. There are several different types of movement side effects, but all include changes in how the child moves his body or muscles. Because these side effects can be serious, families should seek medical care right away if these types of changes are seen. Because children with autism often have movements that they do over and over before starting medicine, it is sometimes difficult to know for sure if new movements are medicine side effects. It is important to work with your child s doctor or nurse to monitor. Things families might see that could be a movement side effect: Rigid or stiff muscles, along with high temperature, change in alertness, heart rate or breathing Muscle spasms or cramping Slowed movements of the body Pacing, restlessness, inability to sit still Staring episodes, eye blinking, unusual eye closing, unusual eye movements Unusual mouth or tongue movements Changes in walking, tremors, repetitive movements the child cannot control Some medicines have an alert about side effects from the Food and Drug Administration (FDA) called a boxed or black box warning. For more information on side effects and boxed or black box warnings visit: Resource Books: Dulcan, Mina (2006). Helping Parents, Youth, and Teachers Understand Medications for Behavioral and Emotional Problems: A Resource Book of Medication Information Handouts, American Psychiatric Publishing, 3rd edition. Wilens, Timothy E. (2004). Straight Talk About Psychiatric Medications for Kids, The Guilford Press, Revised edition. Tsai, Luke Y. (2001). Taking the Mystery Out of Medications in Autism/Asperger Syndromes: A guide for parents and non-medical professionals, Future Horizons Publishing. Internet Resources On Medicines: MedlinePlus: provides reliable information on specific medicines, vitamins, and supplements. A service of the U.S. National Library of Medicine, National Institutes of Health. U.S. Food and Drug Administration Drugs@FDA: provides information on FDA approval of medications Internet Resources On General Treatments Of Behavior Challenges, Medicine And NonMedicine Treatments: American Academy of Child and Adolescent Psychiatry (AACAP): national organization of child psychiatrists and physicians interested in mental health. Provides family information on medicine and non-medicine treatments for behavioral and mental health problems. Provides resources for families on autism and mental health problems. Massachusetts General Hospital School Psychiatry program & MADI Resource Center: provides information and resources to families and professionals on diagnosis, medical treatments, non-medical treatments, and educational interventions for children with autism, ADHD, and mental health problems. www2.massgeneral.org/schoolpsychiatry/index.asp National Institute of Mental Health (NIMH): provides family and professional information on diagnosis and treatments of autism and mental health problems. Home page: Autism treatment information: 11