psychotropic medication for people with asd feb 2010

8/14/2019 Psychotropic Medication for People With ASD Feb 2010

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AnaheimFebruary, 2010


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Go Bolts!


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Assistant Clinical Professor,

Dept of Psychiatry, University ofCalifornia at San Diego School of

Medicine

Faculty, Interdisciplinary Council onDevelopmental and Learning

Disorders


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ICDL Faculty minimal - review of clinical write ups,travel and room for meetings, token honorarium for co-

writing and running Southern California Institute

NIMH/ Duke University minimal administrative time forpharmacogenetic research

NIH R21 grant/ San Diego BRIDGE Collaborative minimal token honorarium for ongoing consultationand participation


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Feder 411

1980 BU: math and Mass Assn for the Blind

1990 Hawaii: Bernie Lee

1992 Matt

1993 - DC: Greenspan, Wieder, et. al.

1996 San Diego: neurobehavioral -psychiatric

2010 ICDL, SDPS Ethics, BRIDGE, CAPTN,SCART

(etc: dance, engineering)


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The Autism File: Becoming MoreMatthew January 2009

Traditional Intervention: ABA really worked and metgoals: he learned to sit

Traditional Medicine indispensible to success

Family therapy time to step back and reflect

SL - long term, wonderful engaging relationships SIOT ah ha!: let him stand, big activity, etc.

Nutrition, VT, Tomatis, dogs, dolphins..

DIR/Floortime really worked and met goals: helearned to survive


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This is not a DIR/Floortimetalk

And my kid is not your kid

but context is important


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DIR

Broad whole child, supports family

Welcoming all about building love

Enriching closeness can bringprogress


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DIR in a nutshell

Developmental levels fromregulation, to warm trust, and then aflow of enriching interactions

Individual Differences sensory,motor, communication, visual-spatial,cognitive, etc.

Relationship Based all aboutconnecting, and making time withothers for support and help


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To learn more onDIR/Floortime

Icdl.com free podcasts anddownloads

Circlestretch.com San Diegoregional website

Pasadena 2/13/10 PasadenaChild Development Associates

Free community support groups


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Considering medication

Case examples

Your experiences


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FDA Approved Medications

for the Treatment of Autism

Risperdal - 10/06 - irritability associated withautistic disorder, including symptoms of aggression,deliberate self-injury, temper tantrums, and quicklychanging moods, in children and adolescents aged 5 to16 years.

Abilify - 11/09 - irritability associated withautistic disorder in pediatric patients ages 6 to 17 years,including symptoms of aggression towards others,deliberate self-injuriousness, temper tantrums, andquickly changing moods.


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Thanks and Goodnight


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Ok, theres more to it

The main question: Are medications agood thing for people with autism andrelated conditions?

Involves: medical ethics, the FDA,Evidence Based Medicine, how little weknow, informed consent, family choice,working with a doctor, and, yes, what wedo know about medications and how tosort out medication options


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Good Medicine

Good = it might help (help what?) -beneficence

Good = it wont cause bad sideeffects - Do No Harm non-maleficence


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4 Main Principles of MedicalEthics*

1. Beneficence doing good (and how do we know it might be good?Evidence based medicine)

2. Non-maleficence risk vs. benefit

3. Autonomy letting the patient (or a family) make decisions. Requiresinformed consent, no deception, confidentiality, good communication

4. Justice whats the right thing to do? fairness, equality, e.g., equal

access to services and resources, allocation of resources competingmorals: treat everyone the same? Or give people with more needsmore care? Wise use of resources, respecting individual and familychoices, respect for morally accepted laws (e.g. child abuse laws,avoiding aversive practices)

*Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 3rd ed.New York, Oxford: Oxford University Press, 1989.


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History of Trying to do Good

Food and Drug Act of 1906 safemedicines, not diet pills fromtapeworm eggs

Flexner Report on Medical Education1910 medical care has risks and somedical education requires

standards


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The FDA

Approves medication for marketingfor specific symptoms of specificconditions

Allows doctors to use medications forwhatever they think is appropriate


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FDA Approvalof a Medicine for Marketing

Requires studies showing it works forsome symptoms of some condition

Safety studies now for kids too!

Difficult process

Expensive process


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Its Especially Hard to Do

Studies On Medications inKids with ASDs

Kids are hard to find Kids have multiple diagnoses

Kids with Autism are a very mixed

group


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New studies.

NIH Duke U CAPTN ASK-PARCA

Efficiency Studies (vs. EfficacyStudies)

Pharmacogenetics

But these are few and results are

pending


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The upshot.

Once a medication is approved, it is unlikelythat a drug company will pursue otherapproval for specific uses, unless there is a

big market that will offset the costs ofresearch and the approval process

Most psychiatric medication for kids does nothave FDA approval for marketing and is

officially experimental


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In the meantimedoctors prescribe, with, we

hope:

adequate education (about grade 26) respect for serious illness, side effects, and

drug interactions

steady care

clinical judgment, based on clinicalexperience


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Doctors Experience

Often limited

In my experience = seen one

In a series = seen two


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But Doctors Do Have Experiencewith Terrible Things

Morbidity severe side effects (e.g.hepatic failure, etc. etc.)

Mortality

House of God: Did you give him roids?

Doctors, if anyone, should know from

experience that we need to avoidtrouble


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Avoiding Trouble

Good care: follow up, AIMS, labs, etc.

Laws governing medication Report medication problems to the

FDA

Talk to colleagues Informed consent: family choice


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Family Choice

For a condition that is likely to present lifelong challenges

Especially one that has severe symptoms and impact

We must defend the right of families to know about their options

And give them a reasonable choice about what they want to do, based onfamily culture and values

Family circumstances and family values are preeminent in this situations.For some families meds are a last resort, and for others it seems wrong towithhold them.

Medications can give hope - essential to survive the journey - yet givingunfounded hope is cruel

Family choice is the heart of truly informed consent


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DIAGNOSIS:

TARGET SYMPTOMS:

TREATMENT PROTOCOL: ALTERNATIVE TREATMENTS DISCUSSED:

POSSIBLE RESULTS OF NO TREATMENT:

SIDE EFFECTS DISCUSSED:

FDA LABELING DISCUSSED: nearly everything is experimental

CONSENT AND ASSENT DISCUSSED: COMMENTS/QUESTIONS/CONCERNS: we have to track this fairly

closely

INFORMED CONSENT IS AN ONGOING PROCESS


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With so much to consider,why use meds at all?

Medication helps many kids, sometimesdramatically

Moreover, doctors may be duty bound todiscuss meds, even if most are notFDAapproved for use for kids, for ASDs, or forcertain symptoms of ASDs

Information on medication for autism is partof good medical care


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Good information is part ofgood medical care

Failure to consider medication may rob families ofchoices that could help, and perhaps allow harmthat could have been avoided.

So people try to define the standard of care,

developing practice guidelines

Hence the focus these days on Evidence BasedMedicine


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Evidenced Based Medicine

Sackett, et. al. British Medical Journal1996;312:71-72 (13 January)

the conscientious, explicit, andjudicious use of current bestevidence in making decisions aboutthe care of individual patients.


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Meaning what?

integrating clinical expertise withsystematic studies

consideration of clinically relevantresearch

and respect for the individualspredicament, rights, and preferences


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Some People Misunderstand or Misusethe Concept of Evidence Based

Medicine

Cost cutters e.g. insurance companies, schooldistricts, government

Clinical medicine is driven by patient and familyconcerns

For example, the recent mammographyrecommendations which were roundly rejected in

the world of clinical medicine.


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We Would LikeGold Standard Evidence

Randomized trials and systematic reviews ofrandomized trials, are the gold standard

Double Blind Placebo (or wait list) Controlled,prospective, randomized studies, with enough

subjects to have the statistical power and a welldefined population of subjects to find outsomething meaningful


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Less than perfect is thenorm

Some questions about treatment cannot be ethically studiedwith randomized trials, e.g., grave conditions that cannot waitfor such trials to be conducted.

We must look at the evidence we do have to guide clinicalcare.

Often from other populations (e.g. age, gender, level ofchallenges), disorders with similar symptoms (OCD,depression).

It is easy to have narrow or emotional reasoning, placeboeffects

References: How Doctors Think Groopman; Science and Fictionin Autism Schreibman; Lies, Damn Lies, and Science Seethaler


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EBM is a tricky combination:

We need current best evidence,otherwise medical practice is out of date.

We need good clinical expertise and

judgment, for even excellent externalevidence may be inapplicable to orinappropriate for an individual patient.

E id Ch O


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Evidence Changes OverTime -

Five Year Half-Life.

Half of medical knowledge changesevery 5 years

So 50% of what we know is wrong

And we dont which half


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Look for Basic Competence: APBN BoardCertified Child and Adolescent Psychiatristswere checked for competence in assessingautism, and for use of collateral information

from family, school, and other professionals.

Look for Honesty: AACAP = a promise to beethical and do their best


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The Role of Medication

Overview

Progress?

A Good Enough Program

A General Approach to Medication Gridding the Problem


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1989 Magda Campbell: haloperidol helps social learning; others:methylphenidate causes side effects without benefit.

1990s - 2006: treating target symptoms, based on responses in

other conditions to medications; lots of use of neuroleptics foraggression, etc.

2004 Black Box warning for SSRIs in kids

2006 Risperdal

Early 2009 Celexa not working for OCD in ASD

Late 2009 - Abilify


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Most people consider meds becausethey feel stuck, maybe desperate

Emergencies: aggression,depression, others?

Lack of progress


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What do we want for our children?

The usual wish: a meaningful life (socially, emotionally, maybe cognitively)

Requires a plan, and medication

alone is not a plan.


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self regulation, sensory, and motorfunction

trusting, supportive relationships communication, maybe language

cognition & learning

living and life skills: home, school, work

compliance with important rules


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Are we asking too much of a child?

Of a family? Of a school?


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The Central Question

Are you trying to improve an

appropriate situation or make up fora bad one?


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Will they change my childs brain and

fix it? Could they injure my child?

What should I expect?


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To avoid losing time while pulling

the program together To do as much as possible

Awakenings are we trying for a

miracle?


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We do not know enough to say you really should medicate

If there is no emergency, you have more time to think

about it When parents differ, it can be an opportunity for more

thoughtful planning

Side effects e.g., behavioral activation (SSRIs), increasedperseveration (stimulants), sedation (some anticonvulsants,others).

Treatment teams often overuse medications, ignoringengagement, other factors.


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The Bottom Line:

medication probably does not treatcore symptoms, but might makesome target symptoms or co-

occurring conditions better, creatingmore affective availability so that wecan make progress, if you can avoid

significant side effects.


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Gridding Target Symptoms

Target symptoms Prioritizing Symptoms

Core Symptoms


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Name Your Symptoms


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Core Symptoms?

Relating

Communicating

Healthy development: connected, regulated

emotions that breathe life into adaptivethinking and planning


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Support regulation and co-regulation bytreating, e.g., impulsivity, inattention,

anxiety, rigid thinking, perseveration. Widen tolerance of emotions so the

person is less likely to becomeoverwhelmed.

Treat co-occurring conditions, e.g.,depression.

Might promote abstract reasoning and

thinking.


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Specific Psychotropic


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Specific PsychotropicMedications

Try to always know the brand andgeneric names of medications

Rxlist.com is often helpful

The following list and the informationprovided is not comprehensive;please talk with your own health care

provider for further information


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Stimulants

Methylphenidate: Ritalin, Concerta, Metadate,Methylin, Focalin

Dextroamphetamine: Adderall, mixed salts,Vyvanse

Slightly different mechanisms.

Similar possible side effects: appetite, sleep,withdrawal, depressed mood, unstable mood, tics,obsessiveness, etc.

Drug diversion vs. drug abuse risk

ADHD and ASD

Often makes a good plan workable.


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SSRIs

One of many classes of antidepressants

Can really help depressed mood, maybe anxiety, less likelyobsessiveness (although works well for that for neurotypicals)

Prozac (fluoxteine), Zoloft (sertraline), Paxil (paroxetine), Luvox(fluvoxamine), Celexa & Lexapro (citalopram).

Similar possible side effects: behavioral activation, weightgain (and loss), mood instability, lower seizure threshold, etc.

Black box warning about suicidal thinking vs. lower rates ofactual suicide in people treated with SSRIs


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Neuroleptics

Zyprexa (olanzapine), Risperdal (risperidone), Abilify (aripiprizole),Seroquel (quetiapine), Geodan (ziprasidone), Haldol (haloperidol),Mellaril (thioridizine), Thorazine (chlorpromazine) and others.

Discovered while looking for cold pills, developed for symptoms ofpsychosis.

Helping aggression, mood stability, and miracles? As well as tics,and adjunct for depression, perseveration, etc.?

Side effects can include weight, lipid, and sugar issues, as well asseizures, fevers (NMS) and new abnormal movements (TD), stroke(elderly), cardiac

Should we always consider neuroleptics?


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AEDs

Anti-Epileptic Drugs (aka anti-seizuremedications)

So many and all so different in character

For seizures, and for mood stabilization

Might help other medications work better(stimulants, antidepressants)

Combined pharmacology vs. polypharmacy

Sudden sopping might make seizures more likely


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Specific AEDs

Depakote (valproic acid, valproate) prettyreliable, easy to load, watch levels, platelets,bruising, liver, pancreas, carnitine, menstrualirregularities, weight, sedation. Problems when

using with Lamictal Tegretol (carbemazepine) - ?reliable, watch

levels, blood counts, EKG, lots of druginteractions, weight gain, sedation, rash

Trileptal (oxycarbezine) Tegretol light?; motorproblems, electrolyte issues, rash?


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More AEDs

Keppra (levetiricetum) easy to use, but does it work?

Lamictal (lamotragine) mood stability, ?better mood. Must goslow, and watch for rash

Topamax (topiramate) adjunct, may cause weight loss, loss ofexpressive language, usually need to go slow.

Neurontin (gabapentin) Does it work at all? Does it harm atall? Does help pain syndromes.

Lyrica (pregabalin) for pain in fibromyalgia, partial seizures

Zarontin (ethosuccimide) for partial/ absence seizures; liverissues


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Steroids

LKS variant theory epileptic aphasia 24 hrEEGs

Regression at a young age

Cell membrane stabilization in inflammation

So many side effects: cushinoid, moon face,hump, central obesity, peripheral wasting,immune compromise, skin striations, moodinstability including depression and hypomania

Pulsed dosing regimens


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Central Alpha Agonists

Tenex & Intuniv (guanfacine), Catapres(clonidine)

Reducing fight flight sympathetic tone,

which can help in many ways Vigilance theory

Side effects can include sedation,

dizziness, early tolerance Mild medicine

Other Commonly


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Other CommonlyConsidered Medications

Straterra (atamoxetine) for ADHD; may be as good asplacebo, may act like an antidepressant (+/-)

Wellbutrin (bupropion, etc.) -

Rozerem (ramelteon) melatonin agonist

SNRIs Effexor (venlafaxine), Cymbalta (duloxetine),Remeron (mirtazepine), Serzone (nefazedone)

Deseryl (trazodone) antidepressant often used for sleep;cognitive side effects, priapism

Buspar (an azaspirone) mild, serotonergic cross reactions


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More Others

Lithium great mood stabilizer; anti-suicidal;bipolar-ASD connection; levels, thyroid, kidneyfunction

Namenda (memantine) Alzheimers med

antagonistof the N-methylD-aspartic acid(NMDA) glutamate receptor, thisdrug washypothesized to potentially modulate learning,blockexcessive glutamate effects that can

include neuroinflammatoryactivity, andinfluence neuroglial activity in autism


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Meds that I often avoid

Paxil (paroxetine) - withdrawal

Effexor (venlafaxine) - withdrawal

Tegretol (carbemazepine) hard to make it work

Combo Depakote and Lamictal

Tricyclics Tofranil (imipramine), Norpramin (desipramine), Pamelor(nortriptyline); and, esp. good for typical OCD, Anafranil (clomipramine).

Cardiac and blood pressure issues.

Monoamine Oxidase Inhibitors Nardil (phenelzine) , Parnate(tranylcypromine), Marplan (isocarboxazide), Emsam (selegiline) can beuseful although dietary, blood pressure drop and hypertensive crisis must beconsidered; lots of drug-drug interactions

Special Caution on


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Special Caution onBenzodiazepines!

Benzodiazepines Valium (diazapam), Ativan(lorazepam), Xanax (alprazolam), Klonopin(clonazepam), and others

Used so freely by many doctors and families

Problems nearly always outweigh risks

Addicting

Destabilizing mood

Interfere with learning Interfere with motor function

Interfere with memory


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Ok early history words at 12 mo but slow to gain new ones and they didnt stick

well

13 mo: sudden stimming, classic ASD,but still cuddling

FH: sister PDDNOS now better, cousin ASD; others: anxiety,OCD

Sp Ed PK and lots of behavioral and language services.

medical: ?seizures, allergies to eggs, peanuts, amox, eczema

*All names and identifying information have been changed


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?Meds for anxiety in autism, Jan 2008

Failure to make gains despitemassive services


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Autism SAFETY fingers in eyes extremely perseverative (fans)

anxiety over-activity tantrums language

hard to take him out ?seizures.


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Mar 08: break the door MOV00732.MPG(0:10)


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So what meds might we


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So what meds might weconsider?

Autism SAFETY fingers in eyes

extremely perseverative (fans, lightswitches)

anxiety over-activity

tantrums

language

hard to take him out in public ?seizures.

M di i


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Medications:

Trileptal, EEG improved

Spring 08 Citalopram at 10 mg helpsanxiety and a bit with perseveration


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Sept 08: Malingo Toya song and dance(0:55)


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F d f it t


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Feder favorite toys

M M di ti


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More Medication

Fall 08 Metadate CD 15 mg.

Vid


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Video

Mar 09: This Little Piggy (4:50)


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Notthere Barely Islands Expands Comesback Ok if notstressedOk forage

Co-regulate 3/08 9/08 3/09

Engage3/08 9/08 3/09

Circles 3/08 9/08 3/09

Flow 3/08 9/08 3/09

Symbolic 3/08 9/08, 3/09

Logical 3/08,3/07,3/08

Multicausal 3/08,3/07,3/08

Grey area 3/08,3/07,3/08

Reflective3/08,3/07,3/08


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Learned to quiz him, and quizzing him

Can engage in some back and forth, coachable

Discomfort with him in public so different fromother kids - improving

Stress: eye issue harrowing, but improving as hebecomes more connected.

MANY OF OUR FAMILIES HAVE A FORM OF PTSD!

Video


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Video

July 09 a whiff of symbolic capacity


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What works: playfully getting in his way, modifyinghis ideas to make them mutual (e.g. run to fan become achase and crash into couch, fan obsession becomes fanninghim), getting him on his back, extending his ideas with funengagement (piggy, dollhouse)

What didnt work: quizzing him on facts, addingideas too quickly

Medications have been very helpful to this child,allowing him to respond to developmentally supportiveintervention.

Another Case Example: T


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Another Case Example: T

Severe Dysregulation andAggression

About T :


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cute but very challenged little girl

failure to develop language, motor skills.

multiple medications, with side effects:

sedation, staggering, trouble swallowing,bruising

ABA - DTT

Miller Method

DIR

Medications for T:Combined Pharmacotherap


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Combined Pharmacotherapyvs. Polypharmacy

Depakote Carnitor

Seroquel

Trileptal

Thyroxin

Keppra

Lithium

Lamictal (Prior history of many others including

Namenda, other neuroleptics, etc.)

Video clips


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Video clips

Clip 1: 04/08

Clip 2: 08/08

Clip 3: 12/08


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Modest Improvement Over


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pTime

4 could sit a bit, give me a rare glance,take off my post-its on occasion

8 moments of gleam and a couple of

circles when I swipe her things 12 more attached to the book, and I am

able to use it as leverage for moreengagement, many circles, and the bare

beginnings of flow, no real sense ofsymbolic (but worth a try)

FEDL T


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FEDL - T1 (not

there)

2 (barely) 3 (islands) 4 (ok w/

support)

5 (comes

back)

6 (ok

unlessstress)

7 (ok)

Regulate 4 8 12

Engage 4 8 12

Circles 4 8 12

Flow 4

8

12

Symbols 4

8

Individual Differences - T


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Sensory Postural Response toCommunication

Intent toCommunicate

VisualExploration

Praxis -

Sensory

seeking

AuditoryVisualTactileVestibularProprio-

ceptiveTasteOdor

Unstable, made worse

by meds

1 indicate desires2. mirror gestures3. imitate gesture4. Imitate withpurpose.

5. Obtain desires6. interact:- exploration- purposeful- self help-interactions

Some comprehension of

sharp redirection

1. Orient2. key tones3. key gestures4. key words

5. Switch auditoryattention back and forth6. Follow directions7. Understand

W ?s8.abstract conversation.

Difficulty indicating

with gesture,Dysarthric

1. Mirrorvocalizations2.. Mirror gestures3. gestures4. sounds5.words

6. two word7. sentences8. logical flow.

A relative area of

difficulty

1. focus on object2. Alternate gaze3. Follow anothersgaze to determineintent.

3. Switch visualattention4. visual figureground5. search for object6. search two areasof room7. assess space,shape and materials.

Ideas at times,

without effectiveplanning norsequencing

IdeationPlanning (includingsensory knowledgeto do this)

Sequencing

Execution

Adaptation

Reflection:


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What worked: Miller Method learned some systems

ABA - content mastered, some is somewhat functional, e.g., turn the page, some is notfunctional (points to green in trials but doesnt know what it means with the book)

I can use her desire to read the book to get some lovely connected moments

She can be a bit more regulated bouncing a bit on the ottoman, steadying herself on myarm, and that seemed to help her be emotionally connected to me too

Medication: pros and cons: cant live withthem, cant live without them; ethicalconcerns about management of medicationswhen function is impossible without them but

risks are clearly present.

Sample Case 3 K


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Sample Case 3 - K

Aggression and Rigid AggressivePlay Themes

About K


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About K:

Why he came to me: aggression towardpeers in private kindergarten. Removedanyway and placed in public setting.

Main symptoms: Receptive language,difficult to understand speech, reactive tobusy environments, low tone, active,impulsive, sensory seeking, rigid,

controlling, aggressive

Medication:


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Medication:

Risperdal liquid carefully titrated;works well but so hungry on it!

Abilify to try to reduce the

Risperdal load

SSRIs helped with mood, but didnot help perseveration, and created

overactivity

Course over four years: K


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Course over four years: K

11/05 Rigid, aggressive, hits in play, not really symbolic

11/06 Allows me to join his aggressive play on his team

11/07 Increased complexity of aggressive themes; able to playwith cousin and brother in water fights, facilitated bydad

11/08 Creates a dangerous race, still very controlling, but alsotorn between me and dad, and nurturing, creative &symbolic with me; able to play with cousin and brother

in games that are competitive but not overtly aggressive

5/09 Talking with me and parents about problems at school

Video


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Video

112508


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FEDL Sample Case 3


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FEDL Sample Case 31 (not

there)

2 (barely) 3 (islands) 4 (ok w/

support)

5 (comes back) 6 (ok

unlessstress)

7 (ok)

Regulate 11/05 11/06 11/07 11/08, 5/09

Engage 11/05 11/06 11/07 11/08, 5/09

Circles 11/05, 11/06 11/07 11/08 5/09

Flow 11/05 11/06, 11/07 11/08 5/09

Symbols 11/05 11/06, 11/07 11/08 5/09

Logic 11/05,11/06

11/07, 11/08 5/09

Individual Differences Sample case 3Sensor Postural Response to Intent to Visual Praxis


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Sensory

Postural Response toCommunication

Intent toCommunicate

VisualExploration

Praxis -

SensoryseekingAuditoryVisualTactileVestibularProprio-ceptiveTasteOdor

A relativestrength;A bit clumsy -impedes rapidreciprocity in themoment1 indicatedesires2. mirror

gestures3. imitategesture4. Imitate withpurpose.5. Obtain desires6. interact:- exploration- purposeful

- self help-interactions

Trouble managingmore than onething at a timeCan barely tellwhy we fight orwhat we fightaboutCant trackconceptual

discussion of thereasoning behindevents and play1. Orient2. key tones3. key gestures4. key words5. Switch auditory

attention back andforth6. Followdirections7. Understand

W ?s8.abstractconversation.

Dysarthric unintelligibleLogicaldiscourse isdifficult(e.g. atbesthedonistic:cheating getsyou

disqualified)1. Mirrorvocalizations2.. Mirrorgestures3. gestures4. sounds5.words6. two word

7. sentences8. logical flow.

A relativestrength;Frustratedlooking forthingsSome ability towork withshapes andobjects to solve

problems inplay.1. focus onobject2. Alternategaze3. Followanothers gazeto determine

intent.3. Switch visualattention4. visual figureground5. search forobject6. search twoareas of room

7. assess

Ideas becomingmore complexwith supportAdapting toproblems thatcome up (e.g.when mycharacter isinjured, faints,

etc.)IdeationPlanningSequencingExecutionAdaptation

Family:


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Family:

Dad works hard. Can facilitate kids when available. Mom can set up playdates, engage cousin. Has to work

hard to manage environment at home so that he is not incontinuing conflict with older brother.

Brother is a good guy, and tries to play with him. But noone can really keep up with him.

Mom and Dad can play in office; however life at home isbusy - hard to find time for Floortime.

Reflection:


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Reflection:

What works: office play with him and his parents to helpthem see what we can do; play dates with cousin, brother,facilitated by parents. Now we can talk too!

What doesnt work: videogames, busy environments withmany peers.

Why: He is still developing capacities for solid enoughsymbolic play to be able to engage with peers withoutbecoming aggressive. His language and also his moresubtle postural and visual challenges make it hard for himto play with peers.

Medication makes the plan possible. Without it he

is so aggressive there is no working with him.

. ser es o t ree cases ochildren with Aspergers and


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children with Aspergers and

Depression Partnering with a colleague

Aspergers and depression withsuicidal thinking a very scarycombination

2 of 3 clearly responding to SSRIs.

5 - Brief Examplelf j i h i ( )


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Self Injurious Behavior (S.I.B.)

30 year old non-verbal old Severe clawing at chest

Not sleeping

No appetite Great live-in aide

Engagement: support and expectations

What medicine might you think about?

Zyprexa


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Zyprexa

sleeping,

eating

and engagement

because he was engaged, he stopped S.I.B. cooking,

riding,

vacations

a real life

6 - Brief ExampleOC


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OCD Had come a long way before w/ biomedical

Bright but rigid, with real OCD too (e.g. germs)

Aspergers: verbalizes a lot but without connecting

Years of work to accept use of medication

But Medication (SSRI) does help OCD for him

Engagement improving, gradual insight, and improved socialfunction and reciprocal capacity

Lessons: SSRI might work for OCD and ASD, and therapy over timecan really work for ASD core

7- Brief Example:Sti 24/7


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Stims 24/7

A very active non-verbal 8 year oldboy

Strings

Not sleeping: severe impact onfamily

Medicines youd think about?


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Intervention: The EngagementA l


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Angle

Joining the string thing Time, time, and more time

Eventual gleam and non-verbal

communication about it

Video


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Video

String play


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8 - Brief Example:T iti


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Transitions

60ish male, modest verbal ability Extremely anxious and reactive

Apparent PTSD + Autism

Cant stand any changes Minimally verbal

Heavy and not exercising

So medicine you might think of?

The Medication Angle


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Effexor, then reduction over years Topamax, then reduction when getting

thin

Significant improvement in anxiety Significant improvement in reactivity

Significant improvement in weight control

Significant improvement in engagability

The Engagement Angle


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Engagement has had gradual benefit: Enjoys his meals,

Goes on camping trips

Engaging, graduated exercise Does well in an active day program

Remember routine medical care!

9- Brief example:Running Off


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Running Off

Big teen male with mood instability On 1200 Trileptal

Limited verbal ability

Inclusive high school

Urgent problem at school

What might you try?



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g

Zyprexa to Stabilize Increased the Trileptal over time

Weight gain, but cant totally stop

neuroleptics

Abilify replacing Zyprexa

NB: RSR on EKG got CardiologyConsult to think through risk of

Toursades de Pointes



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g g g

Loping after him worked really well,as long as the person was calmlyfollowing, and there was a gate

where he was running.

Video


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Tremor check


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Abnormal Involuntary Movement Scale (AIMS)


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g g g

Lots of intervention, at home and schoolwith everyone on the team (family, SLP,OT, ED, etc.) centered on co-regulation,engagement, and reciprocity

Inclusion* early on, with social facilitation,tutoring using his interests to scaffoldacademics

*Read Paula Kluths books e.g. Youre Goingto Love This Kid

Medication, Outcomes,and Lessons Learned


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and Lessons Learned Gradual improvement over many many years in academic

and social function, increase in testable IQ to superior ranges;ok in church groups, interest groups, ok at 4 year college(with hovering)

Academic function and success of placement absolutely

dependent on MPH. More social off of MPH, more paranoid on it, sleeps less, eats

less. But benefits outweigh risks

Try not to put a ceiling on possible progress.


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Look at the whole picture

Be careful with meds Engage the Child

Your Experiences?

psychotropic medication for people with asd feb 2010

Documents