1. Medication Management in Autism and Co-Morbid Diagnoses Sherlene T. Dean APRN University of Utah HOME program Matt’s Place

2. Components of a Psychiatric Evaluation History of Present Illness Determine the diagnoses Previous Psychiatric History Social History Medical History Family History Previous Medication Trials

4. Common Co-Morbid Diagnoses Anxiety: Specific phobia44% Needles and/or shots, crowds, loud noises Typical fears (stores, bridges, tunnels were low) Separation anxiety12% Social Phobia7% GAD- more of a trait of ASD than its own dxs OCD37% -Leyfer, et al. Comorbi psychiatric Disorders in Children with Autism, 2006

5. Common Co-Morbid Diagnoses ADHD31%(Subsyndromal 55%) MDD10%(Subsyndromal 24%) No schizophrenia, psychosis, ODD or panic in kids,( 10% in adults have psychosis) 1%+ had mania Average # of diagnoses per child: 3 72% had at least one diagnosis in addition to ASD Why?

6. Autism and Medications Autistic brains are “Tender” brains- Common to have atypical responses to medication Where do we start: Sleep (and/or Psychosis) Mood Disorders Anxiety Depression ADHD

8. Medication Classifications ADHD Anti-Depressant, Anti-Anxiety Tic Disorders Anxiolytics Mood Stabilizers Anti-Psychotics / Atypical Anti-Psychotics Sleep

10. ADHD Medications Stimulants Methylphenidate (Concerta, Ritalin, Focalin, etc) Dextroamphetamine salts (Adderall, Vyvanse) Dextroamphetamine (Dexedrine) Non-Stimulants Clonidine, Tenex Wellbutrin Strattera Others

11. ADHD Medications Side effects to watch for: Decreased appetite Increased heart rate and Blood pressure Nervous, Irritable- May make anxiety worse Headache, Dry Mouth, Nausea, Dizzy Insomnia Tolerance concerns Tics

12. Anti-Depressants, Anti-Anxiety SSRI Celexa, Prozac, Zoloft, Lexapro, Luvox, Paxil Remeron, Trazodone- more common for sleep SNRI Wellbutrin, Effexor, Cymbalta Buspar TCA (tricyclics) watch EKG Monoamine Oxidase Inhibitors (MAO)

13. Anti-Depressants, Anti-Anxiety Side Effects to watch for: Suicide GI upset Restlessness, agitation, irritability, tremors Weight gain or loss Insomnia, sedation Trigger mania?

14. Tic / Tourettes Disorders -Is Anxiety under control? -wax and wane over time Clonidine and Tenex (Blood Pressure meds) Also for ADHD-I, sleep, PTSD, anxiety Watch for: sedation, dizzy, headache, constipation, dry mouth, confusion, drop in BP and/or heart rate Risperdal (mood, anxiety, agitation,psychosis)

15. Anxiolytics Used for sleep, anxiety, panic, insomnia, mania, aggression, seizures Xanax, Klonopin, Ativan, Valium, Buspar, Restoril Watch For: weight gain or loss, dizzy, paradoxical agitation, somnolence / sedation, blurred vision

16. Mood Stabilizers Traditional Tegretol, Lamictal, Depakote Also called anti-epileptic (seizure) medication Lithium (tremor, wt gain, acne, kidney, thirst, sun) Side effects to watch for: Blood levels, sedation, cognitive dulling Weight gain rashes

17. Adjuvant Mood Stabilizers Supportive Role Neurontin- helps with anxiety & migraine Trileptal –helps with anxiety Topamax- helps with migraine Gabatril- helps with migraine Side Effects to watch for: Sedation, dizzy, ataxia, GI upset, cognitive dulling, Vision changes, tremor, appetite increase or decrease, others.

18. Second Generation Anti-Psychotics / Mood Stabilizers Abilify- schizophrenia, mood stabilization Zyprexa- + agitation Seroquel- + anxiety, PTSD Risperdal- + Tics, Tourettes Geodon- + Tics, Tourettes

19. Second Generation Anti-Psychotics / Mood Stabilizers What to watch for: weight gain (less so with Abilify) Agitation, aggression, insomnia Metabolic syndrome (glucose, lipids) Constipation, dry mouth, rash Changes to WBC EPS Muscle rigidity, stiff muscles

20. SLEEP Sleep Hygiene- behavioral routines OTC: Benadryl, Melatonin, Valerian Prescriptions Trazodone, Remeron (also anxiety/depression) Tenex, Clonidine (also tics, ADHD, anxiety) Anxiolytics Vistaril, Sonata, Ambien, Rozarem, Lunesta

22. Case Example 14 yo male with a history of Autism, ADHD, Anxiety. He is on a stimulant for ADHD, has been doing well. Presents with facial tics, insomnia, and appears more agitated than usual. Considerations: Stimulant too high or too low?, anxious? Emerging mood disorder? Environmental/Social concerns? Pain?

23. PRN “pro re nata” or As Needed Anxiety- acute stress response, panic Agitation or aggression Sleep Short term use or over a longer period of time Risks of addiction

24. MEDICATION MANAGEMENT Not going to fix everything, how much benefit is the medication providing? %? Realistic Expectations Find a balance Are we over medicating, to liberal? Are we under medicating? The Placebo effect

25. Collect Data! Track behaviors Any changes in social, home, school, health Is there a pattern, A-B-C’s Keep a log of meds Start and stop dates, dosages, response Compliance

26. Pain and Constipation A common side effect to medications Presentation: uncomfortable, restless, agitated, irritable, angry Consider Constipation or Pain as a cause for symptoms vs a side effect or med change, especially if non-verbal.

28. COLLABORATION A TEAM APPROACH MEDICAL HEALTH PROVIDERS EDUCATION Teachers, psychologists, counselors Individual with ASD THERAPISTS PSYCHIATRIC PROVIDERS BEHAVIORISTS PARENTS MOST IMPORTANT---THE PATIENT

29. Questions? Thank You