Anxiety, ADHD and The Role of Medica6on in ASD

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1 UNIVERSITI KEBANGSAAN MALAYSIA National University of Malaysia Anxiety, ADHD and The Role of Medica6on in ASD Dr Raja Juanita Raja Lope Associate Professor and Consultant Developmental Paediatrician

2 Lecture Outline Anxiety and Obsessive- Compulsive Disorders AFen6on Deficit Hyperac6vity Disorder (ADHD) Case illustra6ons and the role of medica6on Mul6ple Diagnosis in ASD Other medica6on used in ASD

3 Importance of anxiety and afen6on difficul6es? Interferes with everyday func6on Learning Comple6ng tasks Socialising Sleep Ea6ng And other ac6vi6es of daily living

4 Anxiety Normal response to a stressful situa6on

5 Anxiety Disorders Abnormal or excessive response to stressful situa6ons Unable to control anxiety Interferes with day to day lives Separa6on anxiety, selec6ve mu6sm, phobias (agoraphobia, aviophobia- fear of flying, social phobia), panic disorder, generalised anxiety disorder.

6 Obsessive- Compulsive Disorders Obsessive- compulsive disorder (OCD) is diagnos6cally dis6nct but has a lot of anxiety symptoms Individuals have fears and preoccupa6ons, and the need to check things or perform rou6nes repeatedly which interferes with func6on If they do not anxious Eg washing hands, coun6ng things, touching things in a certain order

7 Do children with ASD have anxiety and obsessive- compulsive problems? Absolutely! Go back to defini6on Deficits in social- emo6onal reciprocity and developing rela6onships Stereotyped and repe66ve motor movements, speech, use of objects Insistence on sameness, rou6nes and rituals (OCD symptoms) Restricted interests and preoccupa6ons (?OCD symptoms) Anything interfering = anxiety

8 Anxiety + OCD and ASD Es6mated 25-55% of children and adolescents will have the above problems Occurs more frequently in children with mild ASD (previous diagnosis of Aspergers) -? because verbal Assessment and diagnosis - using parent reported ques6onnaires eg Child Behaviour Checklist

9 How do we iden6fy anxiety and OCD symptoms Depends on age and overall intellectual level Mild ASD Refusal to go to school, socialise Preoccupa6ons (eg nega6ve thoughts) Phobias Moderate to severe Difficulty expressing self when anxious resul6ng in tantrums, repe66ve behaviours, s6mming, self injury Sleep difficul6es

10 Look for Triggers Changes in rou6ne for example, when a weekly piano lesson gets cancelled because the teacher is sick Changes in environment furniture gets moved, new school Unfamiliar social situa6ons par6es, kenduri Sensory eg certain noises or bright lights Fear of a par6cular situa6on, ac6vity or object eg going to the toilet in school, afraid of dolls, certain foods

11 How can we decrease anxiety? Carers and child recognising signs of anxiety

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15 Relaxa6on techniques trampoline, deep breathing, count to 10 Promote coping skills eg rehersals going to the doctor, shopping, cogni6ve behaviour therapy, desensi6za6on/gradual exposure Social stories, visual schedules Sensory Modify environment try to modify/remove precipita6ng event Medica6on?

16 Sensory Problems Gentle vibra6on - calming vibra6on bear, or vibra6ng egg. Slow, repe66ve mo6on items are also calming such as star projec6on lamp mo6on lamps or ooze tubes. Weighted items - weighted blanket or weighted vests Wilbarger brushing protocol

17 Medica6on Usually serotonin specific reuptake inhibitors (SSRIs) fluoxe6ne, sertraline, citalopram. Used ager 6 years of age. Mixed evidence that they work- most evidence with citalopram small studies showing decrease in OCD symptoms and anxiety in ADULTS with ASD. More evidence suppor6ng cogni6ve behavior therapy Anecdotal or no evidence that alterna6ve supplements (eg fish oil, vitamins) work.

18 Background information: Name : WX Age : 5 years 7 months Gender : Male Diagnosis : Autism Spectrum Disorder Problems : Self-injury, temper tantrums

19 Verbal abili6es 5 word sentences, gramma6cal errors Non- verbal cogni6ve performance within average range In mainstream kindergarten

20 History - would bang head on wall, kick the wall, run away, bite own hand when sees a tooth brush, entering the toilet to bathe in the evening or if he doesn t get what he wants Mother stopped brushing teeth

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24 Triggers and Reasons for Behaviour Tangible no access to favourite food, toy, ac6vity. WX spending a lot of 6me watching Mr Bean cartoons and copying behaviours Escape escaping object or ac6vity which he dislikes or is afraid of WX phobia (anxiety) of tooth brushes and tooth brushing Lack of play & leisure skills Lack of emo6onal regula6on

25 Interven6on Adap6ve func6oning skills training Toy play & table 6me ac6vi6es Paren6ng skills training: Token system for good behaviour. Desensi6za6on and social story for brushing teeth (social story, show tooth brush, brush teddy bear s teeth, WX brush w/o tooth paste, with tooth paste) Stopped self- injurious behaviour, reduc6on in temper tantrums, able to get his teeth brushed

26 Background information: Name : MF Age : 8 Gender : Male Diagnosis : Autism Spectrum Disorder Behaviour :Temper Tantrums at home & school

27 Background Background of speech and language delay, diagnosed at the age of 6.5 with ASD Emerging school readiness skills at 6 years could read simple 2 sukukata words, understood concept of addi6on Enrolled in mainstream class Standard 1

28 Problems Increasing temper tantrums in Std 2 would scream, shout and cry loudly in public when his requests were not fulfilled, when anyone speaks loudly to him, his sister cries, or change of rou6ne No friends, teased ++ InaFen6on and walks around in class Would be hit if temper tantrums con6nued for a long 6me Academic results- deteriorated (although passed all subjects)

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33 Date/ Time/ Venue/ Who Antecedent Behavio ur Consequen ces Duration/ Comment pm Living hall Mum Came back fr school and started crying when mum ask him to take shower. Cried Stop by himself after sometimes 5 mins pm Living hall Mum Started to cry when mum told him to get ready for agama class and he was playing computer Cried Stopped when mum said his best friend M is waiting for him. 5 mins

34 Date/ Time/ Venue/ Who Antecedent Behavio ur Consequenc es Duration / Commen t pm Living hall Mum & sis Sister was carrying a book, then he tried to grab it. Started crying when mum stopped him Cried and went to his room Stop by himself after sometimes 10 mins pm Bird park Dad & sis Dad & sis watching birds (X3) Cried because he wanted to buy things Dad calm him down by asking him to choose what he want. 5 mins

35 Date/ Time/ Venue/ Who Antecedent Behavio ur Consequenc es Duration / Commen t pm Living hall Mum, g/ ma & sis He tried to make his sis cry bcoz she was playing wf g/ma & mum Cried when mum asked him to stop Stop when his sis hugged & consoled him 10 mins pm Night market Mum Started crying when mum didn t want to buy him the toy he asked for Cried softly Stopped by himself 2 mins, Came to mum and said he was sorry and he

36 Func%on To get or obtain a0en%on from others To access to tangible items (i.e. favourite food, toy and ac%vity) To avoid or escape from non- preferred s%muli To obtain or avoid from sensory s%muli - when sister cried

37 r Reasons for Anxiety develop and? Behaviour Lack of adap%ve skills Social Learning Family dynamics Paren%ng Expecta%on Time Cogni%ve Cogni%ve difficul%es Sensory Hyper Hypo Others Corporal punishment Bullying Egocentric Environme nt

38 Intervention: Adaptive functioning skills training: Communication/ speech Emotional regulation skills Increase play & leisure skills Time management with visual schedule Social skills Parenting skills training & activities with the family Cognitive: Abstract reasoning skills training Problem solving Generalization School visit Shadow aide

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53 ASD and AFen6on Deficit Hyperac6vity Disorder Hyperac6vity and inafen6on has long been noted to be features of ASD. It is included in some screening tools for ASD eg. Childhood Au6sm Ra6ng Scale Previously we were unable to diagnose both in DSM IV

54 Common: 40-50% of children with ASD have been found to meet criteria of at least one subtype of ADHD Children with ADHD more frequently have social difficul6es Gene6c polymorphisms (small varia6on in very small areas of genes) - common to both condi6ons eg 16p and 22 q Neuroimaging some areas of the brain slightly smaller or bigger - overlap of areas which are affected Combina6on of ASD + ADHD more likely to have other mental health problems such as OCD, anxiety and depression

55 AFen6on Deficit Hyperac6vity Disorder InaFen6on short afen6on span easily distracted making careless mistakes, for example in schoolwork appearing forgepul or losing things unable to s6ck at tasks that are 6me consuming unable to listen to or carry out instruc6ons Hyperac6vity and impulsivity unable to sit s6ll, especially in calm or quiet surroundings constantly fidge6ng unable to sefle to tasks excessive physical movement excessive talking unable to wait for a turn ac6ng without thinking interrup6ng conversa6ons lifle or no sense of danger unable to concentrate constantly changing ac6vity or task having difficulty organising tasks ** Features must be significantly below developmental age

56 Au6sm Spectrum Disoder ADHD Language Disorder

57 How to iden6fy ADHD features in ASD? History Clinical observa6on remember - ** Symptoms must be significantly below developmental age Standard ADHD ques6onnaires and tests Specialised ques6onnaires and checklists have been developed : Mul6 dimensional Scale for PDDs and ADHD (MSPA), Social Communica6on Ques6onnaire

58 Behavioral methods to improve afen6on in Au6sm AFen6on training techniques reward if completes task within certain 6me. Not allowed to leave table un6l alarm clock rings. Give short clear instruc6ons Break tasks up into small chunks Visual schedules

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60 Behavioral methods to improve afen6on Promote language and social interac6on Sensory remove distrac6ng sensory input Modify environment breaks with calming ac6vi6es (eg hold vibra6ng toy- esp for hyperac6vity), sit in front of class) Keep healthy minimise caffeine, balanced diet, enough sleep

61 Does medica6on help? Most commonly used medica6on for ADHD is methyphenidate. Atomoxe6ne is another drug. In ASD+ADHD both medica6ons In some cases YES, Helps Evidence for mild ASD- more effec6ve Effect not as great as for ADHD alone More side- effects

62 Neurofeedback Promotes good/favourable brainwaves evidence seen can improve afen6on in children with only ADHD Uses electroencephelogram (EEG) and videos promo6ng posi6ve brainwaves with rewards Doesn t change au6s6c symptoms, inconclusive evidence regarding improving afen6on in ASD

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64 Case Study KT 6 years old Able to speak in 2-3 word phrases, for reques6ng, names objects. Toilet trained. Parents separated Lives with father on top of coffee shops which father and father s siblings own. No other children Main concerns of EIP centre and father- hyperac6vity +++, poor sleep

65 DRINKS SEVERAL CUPS OF COFFEE A DAY! Hyperac6vity improved when caffeine stopped

66 Case 2 Name: KS Age: 7 years 3 months Gender: Male Diagnosis: ASD Problems: hyperac6ve- unable to sit s6ll in class and at home

67 Behaviour reported by mother language comprehension difficul6es not able to focus, not able to complete his h/w by himself. Not passing up his h/w & not able to inform parents about announcements in school. social difficul6es tease other younger child does not know how to play with his peers

68 17 16 Verbal Comprehension Perceptual Reasoning Processing Speed IN VC WR CO BD MR PCn SS CD 15 X 14 X X X 7 X 6 X 5 X 4 3 X 2 X Wechler Intelligence Scales

69 Had cogni6ve strengths- especially non- verbal and processing speed. +++ Poten6al Decision to start methylphenidate 10mg in the morning Speech and language therapy. Counseling parents and school visit re management of behaviour.

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71 Std 2 Overall befer especially in school. KS and teacher able to cope in mainstream class. Some stereotypic finger and hand mannerisms but not disrup6ve.

72 Should we make mul6ple diagnoses? HUH? Your child has ASD, OCD, ADHD and Anxiety Disorder Oh Nooooo!! This doctor doesn t know what he s talking about

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74 Personal Prac6ce Mul6ple Diagnosis can be confusing- parents and other professionals. Too much emphasis on a par6cular diagnosis, eg; ADHD, many factors can be causing afen6on problems.

75 ADHD- factors Sensory Issues Understanding AFen6on Restricted interests Insistence on Sameness Social Interac6on

76 Personal Prac6ce One overall diagnosis Au6sm Spectrum Disorder List problems eg Intellectual difficul6es AFen6on and hyperac6vity Anxiety Therapy and educa6on individualised and targeted to each problem

77 Mood disorders Depression es6mated 10-15% More frequently in late adolescence adults with ASD Realise that they are different Hard to fit in More academic and social pressures Treatment recognised triggers and teach coping eg social skills training, social ac6vi6es, buddy system, cogni6ve behavioral therapy stop mega6ve thoughts Some6mes medica6on is used an6- depressants (SSRIs)

78 Other medica6ons Second and 3 rd genera6on an6- psycho6cs Risperidone, olanzapine, aripripazole Esp agression and self harm, uncontrollable hyperac6vity

79 Summary Anxiety and afen6on problems in ASD are mul6factorial Medica6ons are some6mes used but may not be effec6ve Need to explore and treat/manage all contribu6ng factors affec6ng afen6on and anxiety

80 Acknowledgements Slides and Cases Ms Ong Eee Lan, Clinical Psychologist and Puan Liana and Puan Rosazlin Psychosocial team at CDC

81 References 1. Williams K, et al. Selec6ve serotonin reuptake inhibitors (SSRIs) for au6sm spectrum disorders (ASD). Cochrane Database Syst Rev White SW et al. Anxiety in Children and Adolescents with Au6sm Spectrum Disorder. Clin. Psych. Rev. 2009;29(3): Taurines R et al. ADHD and Au6sm: Differen6al diagnosis or Overlapping Traits? A7en. Def. Hype. Disord. 2012; 4: