Download Part 2

ASD and Co-Existing
Neuropsychiatric Disorders
Part II
Assessment of Need for Medication
Treatments by School Team
Factors affect Education/Intervention
Sensory Function
Motor Function
Language/Speech
Development
Education/
Intervention
Neurodevelopment
Cognitive Function/
Genes
memory
Outcomes
Med-Psych
Disorders
Temperament
(moral development)
Environment
Epigenetics
? CAUSES & Treatment
Mental
Retardation
“Social Deficits”
Motor
Function
Deficit
“Stereotypies/
“Communication
Deficits”
Restricted
Neuropsychiatric
Interests”
Disorders
Current Status of Medical Treatment of Students
With Autism Spectrum Disorder
Education Intervention
Where are Doctors?
$$$$ Health Insurance Company $$$$$
Hospital
Gate keepers
You & your
child/student
Very few physicians (gate keepers) have
adequate training & experience in
diagnosing & treating Autism Spectrum Disorder
Today’s doctors are under time
pressure.
 Tantrums or meltdowns tend to be considered by
many physicians as symptoms of Mood Disorder.
Hence, many “mood stabilizers” have been used
to treat “Mood Disorder symptoms”
 Poor school performance tend to be considered
by many physicians as symptoms of ADHD.
Hence, many “Stimulants” have been used to treat
the “ADHD symptoms”
Mood Stabilizers Have Been Marketed
By Pharmaceutical Companies
Abilify
Celexa
Cymbalta
Depakote
Effexor
Geodon
Keppra
Klonopine
Lamictal
Lexapro
Lithium
Neurontine
Paxil
Prozac
Remeron
Risperdal
Seroquel
Tegretol
Topamax
Trileptal
Wellbutrin
Zoloft
Zyprex
????
Contemporary Trend of Practice of
Child and Adolescent Psychiatry
No Time/Need to Get
Information from School
Quick in Making Diagnosis
And begin Medication Therapy
QUICK FIX
Clinical Case Example
Jason is an 11-year-old Caucasian boy living
with his maternal grandparents who are legal
guardians. He has been living with his maternal
grandparents since birth. Grandparents report
that Jason was a difficult child from infancy.
However, his behavioral problems have
become severe since about age 4.
Clinical Case Example (continued)
• He has difficulties with frequent temper tantrums; defiant
and oppositional attitude towards authority figures;
physical aggression toward grandparents and peers; being
mean and aggressive toward family pets and other small
animals; property destruction; having difficulty getting
along with peers because of his intrusiveness, wanting to
dominate others, frequently making socially inappropriate
or embarrassing remarks or comments, being
argumentative, lacking of remorse, and always trying to find
excuses for his "bad" behaviors; and intense obsessions
with violence, sex, and weapons, Heavy Metal music.
Clinical Case Example (continued)
He has difficulty with paying attention and
remaining seated in the class. He has poor
academic grades, even though he has fair normal
intellectual functioning. His recent I.Q. testing
showed a verbal I.Q. of 101, performance I.Q. of 91,
and a full I.Q. of 96. He, however, can play the Play
Station computer games for hours without getting
bored.
Clinical Case Example (continued)
In the past, Jason was evaluated numerous times
and was diagnosed by various clinicians as
having ADHD, or Oppositional Defiant Disorder
(ODD), or Bipolar Mood Disorder. In addition to
outpatient treatments with individual therapy,
family counseling and medications, Jason had
two inpatient hospitalizations and two partial
hospital program treatments.
Clinical Case Example (continued)
•
He has been tried on numerous medications without sustained clinical
benefits. The followings are medications that he had been tried in the
past: Dexedrine, Ritalin, Adderall, Cylert, clonidine, Klonopin, Tegretol,
Zyprexa, Risperdal, Navane, Seroquel, lithium, Neurontin, Lamictal,
Depakote, Wellbutrin, Tofranil, Thorazine, and Benadryl. The
grandparents report that Jason seemed to be better when he was on
Thorazine because he was sleepy all the times.
•
Jason had severe weight gain (about 20-30 pounds) with Zyprexa. His
weight went back to “normal” after Zyprexa was stopped. Jason was
on Risperdal for several years without any noticeable benefit. He
became more irritable while he was on Adderall and Cylert. He
developed side effects of low blood count while he was on Depakote.
There are problems/concerns with Psychotropic
medication therapy in Autism Spectrum Disorder
 Frequent misdiagnosis
 Frequent ineffective treatment
 Frequent development of serious adverse/side effect
 To effectively treat students with Autistic
Disorder or Asperger disorder, it needs
caregivers to work together.
 When you consider medication therapy
for your student, you must do a functional
behavior analysis first.
Why is it so important to do
a Functional Behavioral Analysis
before considering
medication treatment?
Reason for Functional Behavior Analysis
ADHD
Anxiety Disorder
Poor
Attention
(ADHD)
Depressive Disorder
Obsessive-compulsive
Disorderer
Sleep Disorder
Seizure Disorder
Learning Disability
Lack of Challenge
Reasonn for Functional Behavior Analysis
Frustration
Fearful
Situation
Aggressive
Behavior
(Mood Disorder)
Aversive
Stimulation
Deprivation
States
Medical Disorders
Neurological
Disorders
Literature Review
Meta-Analytic study on treatment effectiveness for Challenging
Behaviors with Individuals who have mental retardation
Didden et al, 1997
• Meta-analysis of 482 empirical studies on treatment
effectiveness in MR population
• 34 topographies of challenging behavior and 64 treatment
procedures were analyzed
Literature Review
 Challenging Behaviors (Non-DSM-IV disorders)
Stereotypy
Hyperventilation
Aggression
Tongue protrusion
Destruction
Drooling
Disruption
Pica
Elopement
Rumination
Noncomplianc
Vomiting
Hyperactive behavior
Food refusal
Dawdling
Food theft
Genital stimulation
Over eating obesity
Insomnia
Self-injurious behavior
Inappropriate vocalization
Literature Review
Conclusion:
1. Performing a functional analysis made a
significant contribution to the treatment
effectiveness
2. Pharmacology (medication) treatment shows
least effectiveness.
Many “Behavioral or
Emotional Problems/
Difficulties” in Children/
Adolescents with Autism
Spectrum Disorder are
caused by environmental
factors/reasons.
That is why
You must learn
what and how
to do
Functional
Behavioral
Analysis
Behavior Assessment and Interventions
Behavior/Emotion
Team Discussion
Concern(s)
Functional Behavior
Analysis
Behavior Assessment and Interventions
Behavior / Emotion
Team Discussion
Concern(s)
Functional Behavior Analysis
Team Discussion
Maladaptive
Behavior/Emotion
Neuropsych. Disord./
Med side effects
Medical Assessment
Non-medical
Interventions
Medication plus other
interventions
RECOGNITION OF SIDE EFFECTS
CAUSED BY MEDICATION THERAPY
* Behavioral Effects
* Neuromuscular Effects
* Convulsive Effects
* Cardiovascular Effects
* Gastrointestinal Effects
* Endocrine and Metabolic Effects
* Hematologic Reactions
* Hepatic Effects
* Genitourinary System Effects
* Reproductive and Adverse Sexual Effects
Be Informed and
Know the Truth
FDA Warning
SRIs (Prozac, Paxil, Luox, Zoloft, Celexa,
Lexapro, etc.) should be used cautiously
in suicidal adolescents
WHAT QUESTIONS TO ASK DOCTORS?
• What is the name of the medication? Is it known
by other names?
• How is the medication absorbed and eliminated through
body systems?
• What is known about the medication's effectiveness in
persons with similar symptoms and in individuals with ASD?
• How will the medication help my child?
• How long does it take before we see improvement?
• Is this medication addictive? Can it be abused?
WHAT QUESTIONS TO ASK DOCTORS?
• What side effects commonly occur with use of this medication?
• What serious side effects are possible?
• What is the recommended dosage? How often will the
medication be taken?
• What times of day should the medicine be taken?
• Is there any laboratory test, such as heart function or
blood tests that need to be done before taking the medication?
• Will any test needs to be done while using the medication?
WHAT QUESTIONS TO ASK DOCTORS?
• Will a physician monitor my child's response to the
medication and makes dosage changes if necessary?
• How often will my child's progress be assessed? And by whom?
• How long will the medication be needed? What factors will lead
to a decision to stop this medication?
• Are there any other medications or foods that should be
avoided while taking the medication?
• Are there any activities that should be avoided while taking the
medication?
WHAT QUESTIONS TO ASK DOCTORS?
• What do we do if a problem develops, such as if my child
becomes ill, if doses are missed, or if we see signs of side
effects?
• What is the cost of the medication (generic vs. brand name)?
Is it covered by health insurance?
• Do members of the school staff (supervisors at job place)
need to be informed about this medication?
• Is there any written information about the medication?
MEDICATION TREATMENT SHOULD
BE CARRIED OUT BY A TEAM
Pre-treatment
Baseline
Measures
During Treatment
On going monitoring:
 Positive effects
 Adverse or side effects
MEASURE OF MEDICATION EFFECTS
* Direct behavioral observations
* Behavioral rating scales
* Self-reports
* Standardized tests
* Learning and performance measures
* Mechanic monitors
* Global impression
* Monitoring of Other Medication Effects
The Prescribing Physician Needs and Should Get
All Feedbacks/Inputs for the Best Result of Treatment
STUDENT
TEACHERS
PARENTS
PHYSICIAN