Disclosure Financial Disclosure: Shionogi Inc., this speaker has no other conflict of interest to disclosure. Identify key symptoms of autism spectrum disorders (ASD) Outline proposed changes for diagnosis of ASD in DSM 5 Review scope of impact of ASD on child/adolescent and family functioning Examine the evidence of varied psychopharmacologic treatments for children and adolescents with ASD Contrast risk (side effects)versus benefit (efficacy) of varied psychopharmacologic agents used with children and adolescents with ASD Waiting room meet and greet 11 year old mixed ethnicity male Presenting symptoms: Mood instability, crying, whining, withdrawal Regression (toileting), sleep dysruption, suicidal thoughts Developmental backdrop IQ normal to intelligent range, home schooled, only child, cultural and familial concerns Mom Speaking quite adult Sebastian is her friend Source of pride Marital concerns Parenting challenges History of mental health care History of school challenges History of depression Dad Distant, Chinese High emotion Works a lot, travels a lot Very invested in achievement Extended family who travels to states Mother describes as labile Disengaged from treatment What do I do about these developmental concerns? How do I help this mom? How will I help this child? To what extent? What about family work? Carbray 1
Start Lexapro Connected with Autism group Encouraged mother to explore supports Referred mother for therapy Restrained myself Follow up Interfaced with school Follow up: Cycling of mood Family work Social network Strengths based work Language building Addition of Lamictal Education/symptom tracking Neurodevelopmental disorder with core domains: impaired social interaction/ communication, restricted repetitive behaviors and interests 1 IN 88, UP FROM 1 IN 155 IN 2008 Boys 3 4X more than Girls Detection rates are lower than prevalence 44% of PCPs report caring for at least 10 children with ASD; however, only 8% routinely screen Autistic Disorders Asperger s Syndrome Childhood Disintegrative Disorder Rett syndrome Pervasive developmental disorder Trend towards spectrum Exclusion of Retts syndrome Autistic Disorder: merges childhood disintegrative disorder, Asperger syndrome, pervasive developmental disorder NOS Criteria for autistic disorder Social/communication deficits (social interaction, communication) Fixed interests/repetitive behaviors (restricted interests) Deficits in nonverbal and verbal communication Lack of social reciprocity Lack of peer relationships 2 out of three required for fixed interests criteria Stereotypic behaviors or unusual sensory symptoms Adherence to routines Restricted interests Carbray 2
Misdiagnosis is common More so in African Americans Stress on families is significant Burden of care is heavy Educational systems catching up to need high functioning form of autism difficulty interacting socially, repeat behaviors, and often are clumsy Motor milestones may be delayed. The condition appears to be more common in boys than in girls. difficulty socially above average intelligence may excel in fields such as computer programming and science There is no delay in their cognitive development, ability to take care of themselves, or curiosity about their environment. Comorbidity Abnormal eye contact Aloofness Failure to turn when called by name Failure to use gestures to point or show Lack of interactive play Lack of interest in peers 9 10% or up to 70% 41% two or more disorders Social anxiety, ADHD, ODD, most common Dual diagnosis 10% 91% Presentation masked by poor communication skillsreliance on caregivers Symptoms mistaken for aberrant behaviors Profound> greater incident than mild, moderate, severe 20 30% develop epilepsy by adulthood LD, ADHD, Tourettes Disorder, Dual diagnosis 10% 91% Presentation masked by poor communication skillsreliance on caregivers Symptoms mistaken for aberrant behaviors Profound> greater incident than mild, moderate, severe Carbray 3
Fewer Support networks Increased experience of loss, rejection, isolation Low self esteem Lack of Control Over ones Life Poor ability to manage stress Poor problem solving/conflict resolution skills Biological vulnerabilities ADOS ASRS CARS GARS 2 PDD Assessment Clinician observation, parent report of social affect, repetitive behaviors Core symptom control Aggression/irritability ADHD like symptoms Repetitive behaviors Will not help developmental concerns unless if co morbid Thomas Antidepressants Fluoxetine (Prozac) 8 and older Sertraline (Zoloft) 6 and older for OCD only Escitolopram (Lexapro) 12 17 for MDD only Fluvoxamine (Luvox) 8 and older for OCD (Clomipramine)Anafranil 10 and older for OCD Mood stabilizers Valproic Acid (Depakote) 2 and older for seizures Tegretol Any age for seizures Trileptal 4 and older Lithium Carbonate (Eskalith, Lithobid) 12 and older Stimulants Methylphenidate (Ritalin, Concerta, Metadate ER, CD, Methylin, Daytrana, Focalin, Focalin XR, Ritalin SR and LA) 6 and older Dextroamphetamine (Dexedrine, Dextrostat) 3 and older Amphetamines (Adderall) 3 and older (Adderall XR) Lisdexamfetamine dimesylate 6 and older (Vyvanse) Non Stimulants Atomexetine (Strattera) 6 and older Alpha Agonists: Clonidine ( Kapvay), Guanfacine(Intuniv) 6 and older Atypicals Risperidone (Risperal) 6 and older Aripriprazole (Abilify) 10 and older for bipolar mania and mixed episodes; 5 to 16 for irritability associated with autism Ziprasidone (Geodon) 13 and older for schizophrenia; 10 and older for bipolar disorder, manic or mixed episodes; 13 to 17 for schizophrenia and bipolar Quetiepine (Seroquel) 13 and older for schizophrenia; 18 and older for bipolar disorder; 10 17 for treatment of manic and mixed episodes of bipolar disorder Zyprexa (Olanzapine) 18 and older; ages 13 17 as second line treatment for manic or mixed episodes of bipolar disorder and schizophrenia Haldol Ages 3 and older for psychosis Others: Orap Tourettes 12 and older Desmopressin (DDAVP ) Nocturesis/enuresis 6 and older Medications do not always work with ASD kids as they do in neurotypical children Side effects more prominent Positive effects less pronounced Work best in comorbid cases Irritability ADHD Repetitive Behaviors Carbray 4
MOST STUDIED LESS STUDIED ANTIPSYCHOTICS MOOD STABILIZERS Atypicals FDA approved: Risperal (3 RCTS), Abilify Olanzapine, Quitiepine, Ziprasidone, Clozapine Typicals Haldol, Chlorpromazine, Fluphenazine SSRIs Citalopram, Fluoxetine, Fluvoxamine Alpha agonists Guanfacine, Clonidine Mood stabilizers Lithium, Valproic Acid, Lamotrogine Psychostimulants (associated with implsivity and hyperactivity) Risperdal: Most efficacy studies (irritability)high risk of weight gain Abilify: Efficacy with 20% less weight gain Geodon: probably effective, cardiac arrythmias Typicals: TD, movement D/O Lithium: helpful for mania like symptoms Depakote: mixed Lamotrogine:? (hyperactivity or insomnia possible) Response best when symptoms are like Bipolar: irritabile+hyperactive+ mood labile STIMULANTS A2 AGONISTS OVERLAP WITH OTHER DISORDERS (RULE OUT MEDICAL PROBLEMS!) Disappointing trials More sensitive to side effectsmost common agitation, depressed mood, agression Less effect on attention, hyperactivity, impulsivity than non ASD children Typical response: 60 70%, those with ASDs 24% Methylphenidate demonstrated efficacy Clonidine, Guanfacine Clonidine (mixed), Guanfacine (effective) Decreased irritability Side effects: sedation, irritability, sleep disturbance, constipation Kapvay, Intuniv Straterra Effective OCD SSRIs Large study found Celexa to be no better than placebo Poorly tolerated dry mouth, GI upset, anxiety Prozac effective Mood Stabilizers Some promise (Depakote) Risperdal effective ANXIETY RDOC. LESS EFFICACY PROMISING FUTURES? Celexa, Luvox, Prozac, Luvox Depressive or anxious symptoms Can increase impulsivity, insomnia, behavioral activation A note on benzos Antianxiety agents Stimulants SSRIs with repetitive behaviors unless there is co morbid OCD Most studied does not offer best efficacy (case of secretin) Guanfacine (irritability) Depakote (repetitive behaviors) More money into ASD research and pharma Carbray 5
Food Hypersensitivities Diet balance (carbs and proteins) Omega 3 fatty acids Probiotics St. John s Wart Melatonin Management of electronic media Exercise Acupuncture Diagnosis: specific symptom criteria met Clinical significance: symptoms result in distress or disability Functional Impairment across three domains: body, activity, participation Developmental context Correlations between number of symptoms and extent of functional impairment (separation anxiety highest) It effects our whole life. Giving up normal family activities and outings. Lack of spontaneity or flexibility in family life. Lack of personal social activities. Stress surrounding the marital relationship. Difficulties in maintaining employment or pursuing outside activities. Educate the sibling about the consequences of autism Organize activities exclusively for the sibling Involve the sibling whenever possible in activities with the child with autism Higher levels of stress related to parenting incompetence and role restrictions Increased symptoms of depression Low sense of self efficacy Feelings of guilt about not doing enough for the TD child vs. the child with autism Different parenting cognitions about the child with autism and the TD child Deb Keen, Donna Couzens, Sandy Muspratt, and Sylvia Rodger (2010) 2 4 year olds in two different groups Professional Intervention (17 total) DVD Intervention (22 total) Meirsschaut, M, Roeyers, H, Warreyn, P (2010). Parenting in families with a child with autism spectrum disorder and a typically developing child: Mother s experiences and cognitions. Research in Autism Spectrum Disorders. 4, 661-669. Slides 37-39. Carbray 6
1. Professional support was most effective when assisting parents to understand and reframe child s behavior to be viewed as positive vs. changing parent perceptions about the parenting role 2. Majority of DVD group had difficult putting aside time to complete activity sheets and to watch the actual DVD 3. The way the intervention was given benefited parents with handling stress and competence was linked with professional input with individualization of the information given. 4. Fathers and mothers differed in their response to participating early in the intervention Distress higher amongst those with internalizing disorders Functional impairment higher among those with externalizing disroders Family interference>anxiety, ODD, Depression Educational interference>adhd, CD, Substance abuse Peer interference= Studied previous and current range of: Educational interventions Therapy interventions Medical intervention CAM interventions 84 families or preschool aged children with autism spectrum disorders 60 50 Used previously 40 Used currently 30 per week) >4 20 per week) >2 and <4 10 per week) >1 and <2 0 per week) >0.5 and <1 per week) <0.5 per week) NA Carter, M, Roberts, J, Williams, K, Evans, D, Parmenter, T, Silove, N, Clark, T, Warren, A (2011). Interventions used with an Australian sample of preschool children with autism spectrum disorders. Research in Autism Spectrum Disorders. 5, 1033-1041 Carter, M, Roberts, J, Williams, K, Evans, D, Parmenter, T, Silove, N, Clark, T, Warren, A (2011). Interventions used with an Australian sample of preschool children with autism spectrum disorders. Research in Autism Spectrum Disorders. 5, 1033-1041 Carbray 7
Books Barber, K. (2011). The Social and Life Skills Menu: A Skill Building Workshop for Adolescents with Autism Spectrum Disorders Beytien, A. (2011), Autism Every Day: Over 150 Strategies Lived and Learned by a professional Autism Consultant with 3 Sons on the Spectrum Gray C., & Attwood, T. (2010), The New Social Story Book Martin A., Scahill L., & Cratochvil C. (2010), Pediatric Psychopharmacology Matson, J.L. (2010), Applied Behavior Analysis for Children with Autism Spectrum Disorders National Institute of Mental Health and Smith, S. (2012), Autism: Causes, Symptoms, Signs, Diagnosis, and Treatments Everything You Need to Know About Autism Sher, B. (20o9), Early Intervention Games: Fun, Joyful Ways to Develop Social and Motor Skills in Children with Autism Spectrum or Sensory Processing Disorders Smith, T. (2011), Making Inclusion Work for Students with Autism Spectrum Disorders: An Evidence Based Guide Zysk, V. (2010), 1001 Great Ideas for Teaching and Raising Children with Autism or Asperger s Web Reources http://www.autism society.org/ http://www.autismresourcefoundation.org/ Carter, EW, Sisco, LG, Chung, YC, Stanton-chapman, T (2010). Peer interactions of students with intellectual disabilities and/or autism: a map of the intervention literature. Research & Practice for Persons with Severe Disabilities, 35 (3-4), 63-79. Dosreis S, Weiner CL, Johnson L, Newschaffer CJ. Autism spectrum disorder screening and management practices among general pediatric providers. J Dev Behav Pediatr. 2006;27:S88 S94 Johnson, CR, Handen, BL<, Zimmer, M, Sacco, K, Turner, K (2011). Effects of gluten free/casein free diet in young children with autism: a pilot study. Journal of Developmental and Physical Disabilities, 23, 213-225. Johnson, N, Frenn, M., Feetham, S., and Simpson, P (2011). Autism Spectrum Disorder: Parenting Stress, Family Functioning and Health-Related Quality of Life. Families, Systems, & Health, 29 (3), 232 252 McGuinty, E, Armstrong, D, Nelson, J, Sheeler, S (2011) Externalizing metaphors: anxiety and high functioning autism. Journal of child and Adolescent Psychiatric Nursing, 25 (9-16. Carter, M, Roberts, J, Williams, K, Evans, D, Parmenter, T, Silove, N, Clark, T, Warren, A (2011). Interventions used with an Nazeer, A. (2011). Psychopharmacology of autistic spectrum disorders Australian sample of preschool children with autism spectrum in children and adolescents. Pediatric Clinics of North America, 58, disorders. Research in Autism Spectrum Disorders. 5, 1033-1041. 85-97. Meirsschaut, M, Roeyers, H, Warreyn, P (2010). Parenting in Ravindran, N, Meyers, BJ (2011). Cultural influences on perceptions of health, illness, families with a child with autism spectrum disorder and a typically and disability: a review and focus on autism. developing child: Mother s experiences and cognitions. Research Journal of Child Family Studies, 21(311-319. in Autism Spectrum Disorders. 4, 661-669. Robb, A. (2011). Managing irritability and aggression in autism spectrum Keen, D, Couzens, D, Muspratt, S, Rodger, S (2010). The effects disorder in children and adolescents. Developmental Disabilities Research of a parent-focused intervention for children with a recent Reviews, 16, 258-264. diagnosis of autism spectrum disorder on parenting stress and competence. Research in Austim Spectrum Disorders, 4, 229- Williamson, E.D, and Martin, A. (2010). Psychotropic medications in 241. autism: practical considerations for parents. Journal of Autism and Developmental Disorders. 14, 1-10. **Google clipart used throughout this presentation*8 Carbray 8