ASD and Co-Existing Neuropsychiatric Disorders Part II Assessment of Need for Medication Treatments by School Team

Education/ Intervention Outcomes Cognitive Function/ memory Language/Speech Development Motor Function Temperament (moral development) Environment Neuro- development Sensory Function Factors affect Education/Intervention Med-Psych Disorders Genes Epigenetics

“Social Deficits” “Communication Deficits” “Stereotypies/ Restricted Interests” Mental Retardation Neuropsychiatric Disorders Motor Function Deficit ? CAUSES & Treatment

Education Intervention Current Status of Medical Treatment of Students With Autism Spectrum Disorder Where are Doctors?

$$$$ Health Insurance Company $$$$$ You & your child/student Gate keepers Hospital

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 Lamictal Seroquel Celexa Lexapro Tegretol Cymbalta Lithium Topamax Depakote Neurontine Trileptal Effexor Paxil Wellbutrin Geodon Prozac Zoloft Keppra Remeron Zyprex Klonopine Risperdal ????

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

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

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 Poor Attention (ADHD) ADHD Obsessive-compulsive Disorderer Obsessive-compulsive Disorderer Sleep Disorder Learning Disability Lack of Challenge Seizure Disorder Anxiety Disorder Depressive Disorder

Reasonn for Functional Behavior Analysis Aggressive Behavior (Mood Disorder) Frustration Fearful Situation Fearful Situation Aversive Stimulation Aversive Stimulation Medical Disorders Neurological Disorders Neurological Disorders Deprivation States Deprivation States

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. Literature Review

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 Concern(s) Functional Behavior Analysis Team Discussion

Behavior Assessment and Interventions Behavior / Emotion Concern(s) Functional Behavior Analysis Team Discussion Maladaptive Behavior/Emotion Non-medical Interventions Neuropsych. Disord./ Med side effects Medical Assessment 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

SRIs (Prozac, Paxil, Luox, Zoloft, Celexa, Lexapro, etc.) should be used cautiously in suicidal adolescents FDA Warning Be Informed and Know the Truth

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

STUDENT TEACHERS PHYSICIAN PARENTS The Prescribing Physician Needs and Should Get All Feedbacks/Inputs for the Best Result of Treatment