11/2/2016 INSIDE THE MIND OF A CHILD PSYCHIATRIST: PROBLEM BEHAVIORS IN CHILDREN WITH AUTISM FACULTY DISCLOSURE

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1 FACULTY DISCLOSURE INSIDE THE MIND OF A CHILD PSYCHIATRIST: PROBLEM BEHAVIORS IN CHILDREN WITH AUTISM KristinDawson, MD Assistant Professor University of Kentucky No commercial conflicts of Interest Salary support KY Kids Recovery Grant (Adolescent Substance Use Disorder) Off-label use of medications OBJECTIVES AGENDA Describe behavioral challenges in youth with Autism Spectrum Disorder (ASD) Discuss non-medication interventions Discuss pharmacological interventions Brief overview of criteria changes with DSM V Review treatment approaches to ASD and Aggression/Irritability ADHD Anxiety Case Vignettes SOCIAL COMMUNICATION AND SOCIAL INTERACTION 1. Deficits in social-emotional reciprocity 2. Deficits in nonverbal communicative behaviors used for social interaction 3. Deficits in developing, maintaining, and understanding relationships RESTRICTED, REPETITIVE PATTERNS OF BEHAVIOR, INTERESTS, OR ACTIVITIES Stereotyped or repetitive motor movements, use of objects, or speech Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior Highly restricted, fixated interests that are abnormal in intensity or focus Hyper or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment 1

2 ASD TREATMENT OVERVIEW: BEHAVIORAL Early Intensive Behavioral Intervention (EIBI): ABA program for young kids, intensive and highly individualized with 40 hrs/week of one to one direct teaching ABA techniques: specific problem behaviors, academic tasks, adaptive living skills, communication, social skills, vocational skills ASD TREATMENT OVERVIEW: COMMUNICATION Individualized Education Plan to include Speech Therapy Non-verbal youth: sign language, communication boards, visual supports, picture exchange (PECS) Fluent speech: pragmatic language skills training ASD TREATMENT OVERVIEW: EDUCATIONAL Structured with explicit teaching and family involvement to promote generalization of skills Goals include enhancing verbal/nonverbal communication, academic skills, social, motor and behavioral skills Evidence-based models include Early Start Denver Model (ESDM) and Treatment and Education of Autism and related Communication handicapped Children program (TEACCH) PARENTAL CONCERNS 68% of parents reported high prevalence of aggression amongst children and adolescents with ASD. (Kanne 2011) Parents top three target symptoms 1. Tantrums 2. Aggression 3. Hyperactivity (Arnold 2003) ASSESSING A BEHAVIORAL PROBLEM Communication (Speech Therapist) Family functioning (Mental Health) ABCs of Behavior (BCBA) Physical health (Family Medicine/Pediatrics) Co-existing psychiatric disorder (Psychiatrist) Sensory factors (Occupational Therapist) Daily Living skills (OT) NON-PHARMACOLOGICAL TREATMENTS Applied Behavioral Analysis (ABA) Antecedents Behavior Consequences 2

3 NON-PHARMACOLOGICAL TREATMENTS Communication Supports Non-electronic (PECS) Speech generating Devices DynaVox, AlphaSmart, DynaWriter Software Proloquo2Go, Touchchat NONPHARMACOLOGICAL INTERVENTIONS Cognitive Behavioral Therapy Anxiety in HF-ASD NON-PHARMACOLOGICAL TREATMENTS Social Skills and Social Cognitive Training NONPHARMACOLOGICAL INTERVENTIONS Life Skills NONPHARMACOLOGICAL INTERVENTIONS Sensory Interventions NONPHARMACOLOGICAL INTERVENTIONS Family Interventions 3

4 COMMON MEDICAL PROBLEMS MEDICATION CLASSES STRENGTH OF EVIDENCE Pain Headaches, dental, injury Gastrointestinal Distress Seizures Sleep Deficit Medication adverse effects ANTIPSYCHOTIC MEDICATIONS ADHD MEDICATIONS - STIMULANTS Aripiprazole and Risperidone high Primary target symptoms ABC-I subscale Irritability, agitation, crying Secondary targets hyperactivity/defiance Secondary targets stereotyped behavior Significant side effects Stimulants (methylphenidate) moderate 49% much or very much improved vs 15.5% placebo (RUPP, 2005) 18% discontinued due to adverse effects ADHD MEDICATIONS ALPHA 2 AGONISTS Nonstimulants Clonidine insufficient for ADHD Guanfacine/Intuniv moderate 43.6% decline in ABC-hyperactivity subscale vs 13.2% placebo, 50% with much or very much improved Adverse effects include drowsiness, fatigue, decreased appetite ADHD MEDICATIONS - NRI Atomoxetine moderate Harfterkamp 2012 study NNT was 10 (21% vs 9% very much or much improved) at 1.2 mg/kg Handen 2015 study up to 1.8 mg/kg, effect size , better side effect profile (appetite), 48% much or very much improved vs 19% placebo 4

5 SSRI STRENGTH OF EVIDENCE TARGETS FOR TREATMENT IN ASD Citalopram poor Primary target for King 2009 study was repetitive behaviors in ASD No significant difference in repetitive behaviors Significant side effects including hyperactivity, insomnia, inattention, impulsivity, diarrhea and stereotypy Slight improvement in irritability/agitation Fluoxetine weak Hollander 2005 study target repetitive behavior Decrease in repetitive behaviors without significant side effects reported in 5-17 yo SSRIs may be of benefit in adults with ASD and OCD Medical comorbidity Seizures, GI, Dental, Allergies, Minor injury/pain, Infection (ear), Headaches/migraines Core symptoms (behavioral treatments) Communication (behavioral and speech treatments) Psychosocial (parent training, social interventions, environmental changes) Psychiatric comorbidity Psychopharmacology CBT for high functioning ASD CASE VIGNETTES CASE 1: ACUTE BEHAVIORAL DISRUPTION Emma is a 10 yo with ASD (verbal, high-functioning) and ADHD who participates in main stream classes with IEP. She presents with her parents who report acute worsening of behavioral symptoms in the last few weeks including aggression toward peers and teachers. Had been maintained on methylphenidate ER 18 mg, methylphenidate 5 mg, sertraline 50 mg. Also of concern for parents is decline in academic performance (last year earned mostly 3 s and now earning 1 s and 2 s). CASE 1 You are the treating provider - how do you approach assessment of chief complaint (worsening aggression)? What additional information do you want from the parents? From school? CASE 1 Emma has been running low grade fevers for the last two weeks (documented up to 100.4) As a result school sending Emma home early Worsening irritability/aggression day before or day of fever PCP evaluated x 2 including lab work-up and most recently prescription of Amoxicillin Constipation present off and on Complaining of headache today Red-dye in methylphenidate preparations?pharmacy providing medication that looks different 5

6 CASE 1 What are your treatment recommendations for Emma? CASE 2 Maggie is a 7 yo with ASD, ADHD and aggression presenting for initial evaluation. Significant hyperactivity, impulsivity and inattention occurring at school and at home Difficulty coping with change, insists on routine Pinching mom and pushing peers at school Mom reports that Maggie communicates well verbally but on interview you note mostly stereotyped speech CASE 2 CASE 2 Past Psychiatric History Trial of Concerta dose up to 36 mg resulted in irritability Trial of Citalopram 5 mg resulted in mood lability Intuniv 1 mg demonstrated benefit but 2 mg resulted in syncopal episode Non-pharmacological treatments Limited in-school speech therapy No ABA therapy, parents target behaviors by taking away all privileges for the day What non-pharmacological treatment options might you recommend for Maggie? What pharmacological treatment options would you consider next for Maggie for significant ADHD symptoms? CASE 3 (JVV) CASE 3 Oscar is a 5 yo with ASD, moderate ID, ADHD who presents with his adoptive mother for evaluation and reports significant hyperactivity, poor sleep (3-4 hours per night), aggression of property and pica. Severity of aggression is such that adoptive mother had to stop fostering other children Aggression persists despite 1:1 aide at school so moved to ½ day schedule Current medication regimen: dextroamphetamine, clonidine Past medication trials include: MPH, valproic acid, carbamazepine, topirimate MSE significant for extreme hyperactivity, pinches examiner, bites mother, bites self, rarely provides phrase speech but no complete sentences, damages office furniture 6

7 CASE 3 TREATMENT STRATEGIES FOR COMORBIDITIES Non-pharmacological treatment recommendations? Initiated risperidone at 0.25 mg BID and patient returns in 2 weeks. Mom reports that she is concerned about gynecomastia and wants to discontinue. Next recommendation? ADHD AND ASD Guanfacine/clonidine (lower side effect profile) Methylphenidate Mixed amphetamine salts Atomoxetine Omega 3 fatty acids Amantadine Atypical antipsychotics SEVERE impulsivity with high risk of injury, elopement IRRITABILITY/AGITATION/AGGRESSION AND ASD Guanfacine/clonidine (milder symptoms) Atypical antipsychotics Risperidone, aripiprazole (?lurasidone) Typical antipsychotic Haldol N-acetylcysteine Propranolol? Divalproex/lithium/oxcarbazepine? Clonazepam? ANXIETY AND ASD WRAP-UP QUESTIONS Unclear what role medications should play at this time Social stories Increased structure and routine Improve communication Exposure and response-prevention and CBT in high functioning?shorter half-life SSRIs Beware of behavioral activation One-time family events?benzo, Propranolol 7

8 WHAT CLASS OF MEDICATIONS HAS THE MOST EVIDENCE SUPPORTING ITS USE IN ASD A. Alpha agonists B. Atypical antipsychotics C. Serotonin reuptake inhibitors D. Stimulants WHICH MEDICATION HAS THE LEAST EVIDENCE OF EFFICACY IN KIDS WITH ASD? A. Aripiprazole B. Clonidine C. Guanfacine D. Risperidone WHICH IS A GOOD REASON TO PRESCRIBE RISPERIDONE TO A CHILD WITH ASD? RESOURCE A. Father expresses frustration at his 3 year old s daily screaming tantrums B. Foster mother notes concern about 9 year old s tendency to bite his knuckles when frustrated C. Mother admits that extensive bruising on her arms and legs are from her 10-year-old hitting her D. Teacher complains that a 6 year old child will not stay in his seat during quiet reading time 8