Challenging ASD Cases November 11, Melanie Penner, MD, MSc, Mohammad Zubairi, MD, MEd,

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1 Challenging ASD Cases November 11, 2017 Melanie Penner, MD, MSc, Mohammad Zubairi, MD, MEd,

2 Learning Objectives By the end of this workshop, participants will: 1) Identify strategies to ask about contributors to challenging behaviors in children with autism, including medical and environmental factors (e.g. pain, communication abilities and systems, sensory difficulties, ABCs) 2) Identify approaches to behavior management 3) Identify how psychotropic medications may influence behavior and the role parents play in medication management (e.g. reactivity to crises, data collection etc)

3 Outline Welcome & Introductions Mini-lecture Case #1 Stretch Break Case #2 Mini-lecture Conclusion & Final Comments

4 Welcome & Introductions Who is in the room?

5 Autism Spectrum Disorder (ASD) aggression/ irritability GI/sleep dysfunction anxiety/ depression immune differences ADHD like Social communication Repetitive behaviours/ restricted interests sensorymotor dysfunction intellectual disability language delay epilepsy Slide credit: Evdokia Anagnostou

6 Behaviour 101 Teachers Behaviour patterns Secondary to reinforcement Behaviours Functional and related to communication External & Internal Supports Child (Consider Communication Ability, Self-Help Needs, Temperament) Family Express real needs and wants (including sensory-seeking behaviours or experiencing pain) Peers Patricia Assouad et al, 2009 (Online Presentation) #autismspearls

7 Managing Behaviour 101 A behaviour is not necessarily problematic unless: Self-injurious or injuring others Causes a safety concern (e.g. inappropriate vocalizations, public masturbation) Limits ability to learn Rule out medical causes Head to toe assessment is essential Behaviours that may look medical, vise versa (*Consider function): Projectile vomiting Severe self injurious behaviour Aggression Compulsive eating Vocalizations #autismspearls

8 Clinical Approach to Behaviour Management Functionally assess the behaviour (Measurable? Characteristic? Too much or too little? Motivation?) Pain Attention-seeking Sensory stimulation Relationship to sleep, bowel movements, feeding Tangibles (to obtain something) Get multi-source input (school, home) & identify supports: Services Family Education Escape/Avoid Myers and Johnson, Pediatrics, 2007; Autism Treatment Network, 2012

9 Specific Behaviours in Children with Autism ***not all require treatment! Part of Diagnostic Criteria Repetitive Behaviour Examples: Rituals & routines Stereotyped Behaviour Example: Hand Movements, Echolalia ADHD-like symptoms Example: hyperactivity Challenging Behaviour Example: Irritability & Aggression e.g. self injury, Tantrums #autismspearls August 21, 2013

10 Reasons for Behaviours in Children with Autism Skills deficits Difficulties with flexibility/ imagination Difficulties with social interaction Difficulties with communication Executive function difficulties Lack of self-awareness/self-regulation (emotion) Short attention span Redirection Transition Change: structure, requirements, routines Poor understanding of expectations Poor perspective taking Delayed language Poor auditory processing Literal interpretation of language Sensory issues Co-morbid Medical or Psychiatric Issues Bothered by sounds or textures Fascination with lights or movements Anxiety or Depression Gastrointestinal (e.g. Reflux) Seizures

11 Examples of Tools Visual schedules First-then boards Use of timers Social stories Token economies & reinforcement Autism Treatment Network, 2012

12 Evidence for Behavioural Interventions Core deficits Applied Behaviour Analysis (ABA)-based = Moderate evidence for effectiveness Intensive Behaviour Intervention (IBI) = Moderate evidence for effectiveness Grounded in both behavioural and developmental (e.g. Early Start Denver Model) = Moderate evidence for effectiveness Developmental (e.g. Floor time) = Low evidence for effectiveness Limited or no language Picture Exchange Communication System (PECS) = Moderate evidence for effectiveness Augmentative Devices = Insufficient evidence Auditory Integration training = Moderate evidence for INEFFECTIVENESS Social Skills Programs Moderate evidence for effectiveness Maglione et al, Pediatrics, 2012; Ylvisaker et al, Behavioral and Social Intervention, 2005 #autismspearls August 21, 2013

13 LET S GO TO YOUR HANDOUT

14 Case #1:

15 Case #1 Continued: ABC Data

16 Case #1 Continued: Plan

17 STRETCH BREAK

18 Case #2:

19 Case #2 Continued: Psychopharmacology History

20 Medication management in children with ASD No medications for core symptoms at present! Medical treatment priorities *The target symptom is one that is targetable with meds Safety of patient, family or others Patient s psychological distress Sources of adversity in life Symptoms that jeopardize sustained educational progress *Chronic, severe and unresponsive to behavioural & educational modifications strategies have failed Identify target symptoms and weigh risk-benefit Efficacy & type of medication: E.g. Stimulants, Antipsychotics, SSRIs Side effects & monitoring Duration of treatment & alternatives Towbin, Child and Adolescent Psychiatric Clinics of North America, 2003 #autismspearls August 21, 2013

21 Medication Decision Aid Autism Treatment Network, 2012 #autismspearls August 21, 2013

22 Evidence for Psychopharmacology Options for Behaviours in Autism: Antipsychotics Aggression / Irritability Repetitive behaviors Inattention / hyperactivity Atypical neuroleptics FDA Approved: Risperidone & Aripiprazole +++ Evidence that WORKS +++ Evidence that WORKS (in highly irritable group) +++ Evidence that WORKS (in highly irritable group) Improvements in irritability, hyperactivity and less so in stereotopy on Aberrant Behaviour Checklist (ABC) Scores Watch for side effects: weight gain, sedation, metabolic complications and extrapyramidal symptoms Chart adapted from Dr. Anagnostou; McPheeters et al, Pediatrics, 2007; Jesner et al, Cochrane Database Systematic Reviews, 2007; Ching & Pringsheim, Cochrane Database Systematic Reviews, 2012 #autismspearls August 21, 2013

23 Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA) Guidelines: Drug specific, metabolic complications, and extrapyramidal symptoms Pringsheim et al, Pediatrics & Child Health, 2011, available at: #autismspearls August 21, 2013

24 Evidence for Psychopharmacology Options for Behaviours in Autism: Other medication options Aggression / Irritability Repetitive behaviors Attention / hyperactivity SSRIs, SNRIs E.g. Fluoxetine (SSRI) Atomoxetine (SNRI) Ø +++ Evidence that NOT WORK ++(+) Evidence that WORKS (SNRI) Stimulants E.g. Methylphenidate Ø Ø +++ Evidence that WORKS α agonists E.g. Clonidine/Guanfacine ++ Evidence that WORKS Ø +++ Evidence that WORKS Chart adapted from Dr. Anagnostou #autismspearls August 21, 2013

25 E.g. Clinical Pathway for ADHD Symptoms & Autism 1 st Consider Stimulants 2 nd Line: SNRIs or Alpha Agonists Mahajan et al, Pediatrics, 2012 #autismspearls August 21, 2013

26 Pathway continued 3 rd Line: Atypical Antipsychotics Mahajan et al, Pediatrics, 2012 #autismspearls August 21, 2013

27 #autismspearls August 21, 2013

28 Practical Pearls In the Office Parents Advance discussion & practice visit Availability to stay Child Preparation e.g. social story Comfort items Minimize boredom Location Minimize waiting, crowding Limit sensory stimuli Extra time Staff Hold off invasive measures (e.g. vitals) Distance, boundaries & space Scarpinato et al, Pediatric Nursing, 2010 #autismspearls August 21, 2013

29 Practical Pearls In the ER Rule out medical causes for behavioural change Treat pain adequately Establish child s baseline developmental level and communication abilities During Hospital Admission Limit number of health care workers in patient s room Assign consistent primary nurse Use visual schedules, maintain routines Consider alternative communication strategies (eg. texting) Minimize noise and sensory stimuli #autismspearls August 21, 2013

30 Conclusion & Final Comments ASD has both core features and co-occurring conditions that can lead to challenging behaviour Remember the A-B-C s of a behavioural history: antecedent, behaviour, consequence Consider PASTE functions for the behaviour: pain, attention, sensory, tangibles (obtaining access), escape Behaviour interventions are the cornerstone of managing challenging behaviour Medications can be used to treat co-occurring conditions in ASD but not the core features Key aspects of prescribing: identify a target, monitor effectiveness, monitor for AE s according to guidelines

31 Questions? Cases? THANK YOU

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