The title of this presentation is What About Health. I m. In this presentation I will discuss a number of health and mental health issues related to children with ASD. 1
Now I am going to switch to discussing challenging behaviors in children with ASD and then finally the use of psychotropic medications. This slide lists a number of different behaviors tahat can be problematic in children with ASD. Some children may meet criteria for other mental health disorders such as ADHD, anxiety disorders and depression or mood disorders. Please note: some of these behaviors may have an adaptive function for the child. For example, repetitive behavior, routines and even self-stimulatory behavior may help a child with ASD and anxiety cope with a given situation. 2
This slide describes an overall approach to understanding challenging behaviors in children with ASD. Any behavior is a form of communication. For example, a child who pushes school material off the desk and throws a tantrum is likely communicating the work is frustrating or too difficult and I need a break. It is always important to rule out any possible medical cause such as pain from an absessed tooth or GERD. Autism specific issues may make challenging behavior more likely. For example, (rest as per slide) 3
The first approach to understanding and treating challenging behaviors is to understand the function of the behavior. An excellent way to understand and interpret a specific behavior is by determining the function of that behavior. The ABC s of behavior is a method parents and professionals can use to analyze the function of a behavior. (rest as per slide) 4
Once the function of a behavior is understood, changing the context in which the behavior occurs may be the only treatment necessary. This is called providing positive behavioral supports. Conside communication needs.. (rest as per slide) 5
Now I weill briefly discuss the use of psychotropic medications in children with ASD. Why are they used? (rest as per slide) 6
In the past there has been limited research on the efficacy of medications in children with ASD. Fortunately this is changing with development of the Autism Network of Research Units on Pediatric Psychopharmacology (RUPP). Another resource is the Autism Treatment Network s Autism Intervention Research Network on Physical Health (AIR-P). 12 universities are participating, OHSU is no longer a participant. When using any psychotropic medication it is important to remember.. (rest as per slide) 7
Before prescribing any medication make sure you have ruled out possible medical causes for the challenging behaviors and then think about the ABC s of behavior and any contextual factors that might be changed. This is particularly important for children with aggression and self-injurious behaviors. Then.. (reat as per the slide) 8
This slide presents the different classes of medications that may be helpful in the treatment of specific behaviors in children with ASD. Following each class of medications is a brief list of possible indications. Please revie the slide 9
This slide lists the possible side effects of the different groups of medications. Please review the slide. *Serotonin syndrome is characterized by agitation, confusion, sweating and shivering, headache, rapid heart rate, muscle twitching, tremor, possible seizures and unconsciousness You will need to follow weight gain and cholesterol/lipid studies regularly in children who take atypical neuroleptics. Increased appetite and weight gain are greater problems with some (e.g., risperidone) than others (e.g., aripiprazole). There is a Black Box warning for anti-depressants (SSRI s and Atomoxetine) regrading the increased risk of suicide in treatment of adolescent depression. 10
Stimulants are the first choice for treatment of hyperactivity and ADHD in children with asd. In general they are somewhat less effective than in typically developing children with ADHD and children with ASD and no intellectual impairment are more likely to respond. (rest as per slide) RCT of extended release guanfacine by RUPP, 2015 Atomoxetine modest benefit, may cause activation in bipolar disorder. Resource: ATN ASD and ADHD guidelines, first stimulant, 2nd stimulant, 3rd alpha agonist or norepinephrine reuptake inhibitor, then atypical (reserve fro severe dysfunction) Stimulant side effects include agitation, irritability, dysphoria, loss of appetite, weihgt loss, and sleep problems Adrenergic agonist side effects include sedation, headache, nausea, hypotension (rare), rebound hypertension if D/Ced quickly. Atomoxetine side effects include sedation, decreased appetite, nausea and vomiting, dizziness, syncope, mood swings, possible liver toxicity also possible increased suicide risk if co-occurring depression Atypical side effects include weight gain, sedation, hyperglycemia, hyperlipidemia, prolactin elevation, occasionally extra-pyramidal, rarely neuroleptic malignant syndrome. Need to monitor blood glucose, lipids and BMI 11
When treating aggression it is particularly important to conduct a functional analysis first, i.e., the ABC s of challenging behaviors! Typical neuroleptics are not used due to the high risk of side effects when compared to the newer atypical neuroleptics medications such as risperidone and aripiprazole. There is limited support for use of anticonvulsants for irritability/mood disorders in children with ASD. (rest as per slide) 12
The combination of medication and behavioral treatments con be effective. For example, this study compared risperidone alone with risperidone combined with parent training,,,,,,,, (rest as per slide) The differences, however, attenuated at the 1 year follow-up. Most children were still on medication and some on additional medications. The parents in combined treatment more likely to seek behavioral supports (additional parent training) 13
Cognitive behavioral therapy CGT) can be effective in adolescents without intellectual disability. Limited data supprts the combination of CBT and medication is more effective than either alone in the treatment of anxiety disorders in typically developing children. Limited data supports the use of SSRI s to teat anxiety in children with ASD. They are more likely to be effective with children who occurring anxiety disorder (rest as per slide) 14
A great deal of current research is focused on medications that address a specific pathogenetic mechanism. For example, children with ADHD who have the DRT 4 gene variant are much more likely to respond to psychostimulants. Minocycline addresses a specific genetic mechanism in Fragile X syndrome, it inhibits MMP9 gene function. Similarly medications that address the dysregulation of the glutaminergic system are being tried in children with ASD or Fragile X. (review the list). And lastly, oxytocin also known as the social hormone is being studied in children with ASD. Studies have reported mixed results, however, with several reporting significant positive change in autistic behaviors. 15
S slide lists behavioral resources for parents and professionals. The Problem Behavior Manual is a guide for parents to conduct their own functional analysis of challenging behaviors using the ABC s method. 16
Here are some resurces on medications, their uses and side effects. The tool kit developed by the AIR-P is an excellent resource for families. It includes questions to ask before starting a new medication, a discussion of monitoring and managing side effects, a table on medications that may be helpful and their indications and side effects, tips on teaching kids to take pills, a medication log and a behavioral log to help parents in following the benefits of a medication. Medline Plus is not written specifically for children but includes a great deal of information on specific medications and supplements. 17
18