Susan N. Van Cleve DNP, CPNP-PC, PMHS, FAANP

Associate Professor, Robert Morris University, Pittsburgh, PA

Pediatric Nurse Practitioner, Behavioral Health,

Pediatrics South, Pittsburgh, PA

Disclosures None to disclose

Objectives

Upon completion of this session the participants will be able to:

1. Review DSM IV and DSM V criteria for Autism Spectrum Disorder (ASD)

2. Identify characteristics of ASD in children and adolescents

3. Describe co-morbid disorders commonly seen in children and adolescents with ASD

4. Identify pharmacologic and non pharmacologic interventions for children with ASD

Prevalence of Autism Spectrum Disorder (ASD) About 1 in 68 children has been identified with ASD

(CDC's Autism and Developmental Disabilities Monitoring [ADDM] Network)

Increase likely due to broader definition & better efforts in diagnosis

Occurs in all racial, ethnic, and socioeconomic groups (CDC, 2015)

Is ~ 5 times more common among boys (1 in 42) than girls (1 in 189) (CDC, 2015)

Studies in Asia, Europe, and North America have identified an average prevalence of about 1% (CDC, 2015)

One in six children identified as having developmental-behavioral conditions (Boyle et al., 2011)

(CDC, 2015)

Risk Factors for ASD Siblings of affected children-recurrence risk (2%–18%)

Identical twins

Closer spacing of pregnancies

Advanced maternal or paternal age

Extremely premature birth (

Neurophysiologic Differences EEG abnormalities & seizure disorders -20 to 25%

Structural MRI-overall brain size increase in autism

Diffusion tensor imaging studies have suggested aberrations in white matter tract development

Elevation of peripheral levels of the neurotransmitter serotonin

Almost half (46%) have average to above average intellectual ability

(AACAP, 2013; CDC, 2015)

Genetics of ASD Genetic link is clear in some cases

Multiple genes involved

Occurs more often in children with Fragile X, tuberous sclerosis, Down syndrome

Co-occurs with other developmental, psychiatric, neurologic, chromosomal, and genetic diagnoses

When taken during pregnancy, valproic acid and thalidomide linked with a higher risk

Some evidence that the critical period for developing ASD occurs before, during, and immediately after birth

(AACAP, 2013; CDC, 2015)

DSM IV-Three different types•Autistic Disorder-Significant language delays, social and communication challenges, unusual behaviors and interests. May have intellectual disability.

•Asperger Syndrome-Milder symptoms. May have social challenges, unusual behaviors and interests. Typically does not have problems with language or intellectual disability.

•Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS)-Meets criteria for autistic disorder or Asperger syndrome, but not all. Has fewer and milder symptoms that may cause social, communication challenges.

Changes in the DSM V Consolidation of autistic disorder into one single diagnosis—

ASD

ASD-when symptoms are present in the core domains of social communication and social interaction (criteria A) and restricted repetitive behaviors, interests, and activities (criteria B)

Must display persistent deficits in both social communication and social interaction across multiple contexts while meeting all 3 areas in criteria A.

Criteria B include the restrictive, repetitive patterns of behavior or interests; individuals must manifest at least 2 of these 4 areas

Criteria C, D, and E must be met

(American Psychiatric Association, 2013)

Autism Spectrum Disorder DSM V Diagnostic Criteria

• A. Persistent deficits in social communication and social interaction across multiple contexts as manifested by the following, currently or by history:

1. Deficits in social-emotional reciprocity, ranging from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.

(American Psychiatric Association, 2013)

Autism Spectrum Disorder DSM V Diagnostic Criteria 2. Deficits in nonverbal communicative behaviors used

for social interaction, ranging from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and the use of gestures; to a total lack of facial expressions and nonverbal communication.

(American Psychiatric Association, 2013)

Autism Spectrum Disorder DSM V Diagnostic Criteria 3. Deficits in developing, maintaining and

understanding relationships, ranging from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or making friends; to absence of interest in peers.

(American Psychiatric Association, 2013)

Autism Spectrum Disorder DSM V Diagnostic Criteria B. Restricted , repetitive patterns of behaviors, interests or

activities as manifested by at least two of the following, currently or by history:

1. Stereotyped or repetitive motor movements, use of objects, or speech

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior

3. Highly restricted, fixated interests that are abnormal in intensity or focus.

4. Hyper or hypo reactivity to sensory input or unusual interest in sensory aspects of the environment

(American Psychiatric Association, 2013)

Autism Spectrum Disorder DSM V Diagnostic Criteria C. Symptoms must be present in the early

developmental period but may not become fully manifest until the social demands exceed limited capabilities, or may be masked by learned strategies later in life.

D. Symptoms cause clinical significant impairment in social, occupational or other important areas of current functioning

(American Psychiatric Association, 2013)

Autism Spectrum Disorder DSM V Diagnostic Criteria E. These disturbances are not better explained by

intellectual disability or global developmental delay.

Specify current severity for A and B

Severity in Level 1, 2 or 3

Level 1- requiring support

Level 2- requiring substantial support

Level 3- Requiring very substantial support

(American Psychiatric Association, 2013)

DSM V Changes Requires clinicians to specify intellectual or language

impairment, known medical or genetic conditions, associated neurodevelopmental or behavior disorders

New diagnosis in DSM-5 called social (pragmatic) communication disorder

For children with significant problems using verbal and nonverbal communication for social purposes

Characterized by persistent difficulty that limits social relationships

Common Presentation

Common Presentation Older Children May have obsessive, intense interests for facts (math,

trains, military machines, etc.)

May have precocious language, reading

May want friends, but not understand how to develop friendships and will prefer to play alone

May not understand personal space boundaries

Relates better to adults than children

May have fine motor delays, poor handwriting

May have multiple sensory issues (limited diet, aversion to loud sounds, smells, sensitive to clothing texture)

*Lacks social reciprocity

Spectrum of ASD John is 7 year old. No speech delay. Advanced

language. Limited in interests in reptiles, salamanders. Will act like reptile and talk at peers about salamanders. Poor social reciprocity. Highly anxious. Very difficult time making friends. In school gets distracted easily.

Danny, 9 years old, is nonverbal, has to swing string or object. Moves nonstop. Can use IPad to do math problems, spell words. Receptive language > than expressive. Eats limited foods. Difficult to take into community due to meltdowns.

Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder (AACAP, 2013)

Recommendation:

The developmental assessment of young children and the psychiatric assessment of all children should routinely include questions about autism spectrum disorder symptomatology

Role of the Screening in Primary Care Provide routine developmental surveillance

Provide developmental screening with standardized instruments (PEDS, ASQ-3)

All children should be screened for developmental delays and disabilities during regular well-child visits at: 9 months

18 months

24 or 30 months

Additional screening might be needed if a child is at high risk for developmental problems due to preterm birth, low birth weight or other reasons

(Council on Children With Disabilities, 2006)

Screening Specific for ASD All children should be screened for autism during

their 18- and/or 24-month well visits (AAP Council on Children With Disabilities, 2006)

M-CHAT-R used to screen between 16 and 30 months within primary care -available in 14 languages https://www.m-chat.org/

A revised M-CHAT-R with follow up (M-CHAT-R/F) was developed & introduced in 2013 by Robins, Fein, and Barton

M-CHAT-R is a free two-step screening tool -more sensitive than the original M-CHAT

https://www.m-chat.org/

MCHAT-R Administer MCHAT-R at 18 month visit and

determine if the child is at a low, medium, or high risk for ASD

If the risk is low, M-CHAT-R is repeated at 24-month-old well visit

If the risk is medium, then administer follow-up questionnaire, the M-CHAT-R/F, and, if the patient remains at medium or high risk, then the child is referred for further evaluation

(Williams et al, 2015)

Examples of M-CHAT-R Questions1. If you point at something across the room, does your child look at it? Yes No(FOR EXAMPLE, if you point at a toy or an animal, does your child look at the toy or animal?)2. Have you ever wondered if your child might be deaf? Yes No3. Does your child play pretend or make-believe? (FOR EXAMPLE, pretend to drink from an empty cup, pretend to talk on a phone, or pretend to feed a doll or stuffed animal?) Yes No5. Does your child make unusual finger movements near his or her eyes? (FOR EXAMPLE, does your child wiggle his or her fingers close to his or her eyes?) Yes No6. Does your child point with one finger to ask for something or to get help? (FOR EXAMPLE, pointing to a snack or toy that is out of reach) Yes No7. Does your child point with one finger to show you something interesting? (FOR EXAMPLE, pointing to an airplane in the sky or a big truck in the road) Yes No(Robins et al, 2009)

Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder (AACAP, 2013) Recommendation: If the screening indicates significant ASD symptomatology,

a thorough diagnostic evaluation should be performed to determine the presence of ASD

Biological diagnostic markers not available Diagnosis based on careful history and physical

examination of the child A complete diagnostic evaluation should be conducted

with careful consideration of DSM-5 diagnostic criteria Consideration of possible comorbid diagnoses Observation of the child should focus on broad areas of

social interaction and restricted, repetitive behaviors

Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder (AACAP, 2013) Recommendation: Clinicians should coordinate an appropriate multi-

disciplinary assessment of children with ASD All children with ASD should have a medical assessment,

including a physical examination, a hearing screen, a Wood’s lamp examination for signs of Tuberous Sclerosis, and genetic testing (G-banded karyotype, Fragile X or chromosomal microarray)

The yield of genetic testing in the presence of clinical suspicion is currently in the range of 1/3 or more of cases

Unusual features in the child (e.g., history of regression, dysmorphology, staring spells, family history) should prompt additional evaluations

Referral for Diagnostic Evaluation If history and or physical exam and M-CHATR are medium

to high risk, refer for comprehensive evaluation Refer to Developmental Pediatricians, Child Neurologists,

Child Psychologists or Psychiatrists, NPs-Pediatric Mental Health Specialists

Should also refer for hearing and vision evaluation While waiting for evaluation, refer to Early Intervention (0-

3 years) If >3 years, refer to local school district for evaluation May also benefit from speech therapy, OT, PT, behavioral

therapy In some states, children with ASD qualify for Medical

Assistance

Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder (AACAP, 2013)

Recommendation:

Clinician should help the family obtain appropriate, evidence-based & structured educational and behavioral interventions for children with ASD

Structured educational & behavioral interventions have been shown to be effective for many children with ASD and are associated with better outcome

Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder (AACAP, 2013)

Recommendation:

The clinician should maintain an active role in long term treatment planning and family support as well as support of the individual

Primary Care Provider Role See every 6 months to one year for well child care and

case management

Monitor growth, diet, elimination and sleep concerns

Refer for treatments- behavioral intervention, speech, OT, other therapies as needed

Review progress in school and advocate for support and specialized educational program (IEP)

Evaluate for co-morbid conditions

Genetic testing

Genetic Testing Recommendations Shen et al (2010) found Chromosomal Microarray

(CMA) identified deletions or duplications in 154 of 848 patients (18.2%) :

CMA (whole-genome coverage) detects more abnormalities than G-banded karyotype and Fragile X DNA testing in patients

CMA should be a first-tier test in addition to Fragile X DNA probe

Feeding, GI Concerns Evidence supports increase risk for GI conditions (constipation,

diarrhea, abdominal pain, gastroesophageal reflux, gastroenteritis, and food allergies)

Have elevated risk of developing a feeding problem compared with peers

Severe food selectivity (narrow food choices) with preference for starches, snack foods, and processed foods most common

Parents may question if they should limit gluten or casein in diet

No strong evidence to support gluten-casein free diet or use of supplements. If parent wants to try this, support 1-2 month trial to see if behavior improves, track behavior and completely eliminate gluten or casein from diet

(McElhanon et al, 2014)

Sleep Concerns Humphreys et al (2013) found from 30 months of age

children with ASD slept less than their peers with night-time sleep duration shortened by later bedtimes and earlier waking times

Frequent waking (3 or more times a night) evident from 30 months of age on

Sleep Tool Kits for children and teens with ASD available for parents: https://www.autismspeaks.org/science/resources-programs/autism-treatment-network/tools-you-can-use/sleep-tool-kit

https://www.autismspeaks.org/science/resources-programs/autism-treatment-network/tools-you-can-use/sleep-tool-kit

Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder (AACAP, 2013)

Recommendation 4:

Clinician should help the family obtain appropriate, evidence-based & structured educational and behavioral interventions for children with ASD

Structured educational & behavioral interventions have been shown to be effective for many children with ASD and are associated with better outcome

Treatment Goals

Once diagnosis is made, refer for treatment with behavioral therapists and others (speech, OT)

Goals:

Enhance communication

Teach social skills

Reduce maladaptive behaviors

Improve overall functioning in home, school, community

Case 24 month old male presents with high risk M-

CHAT-R. Has delay in speech, echolalia, extreme sensory processing issues, extreme hyperactivity

Parents are web designers- mother has dx of Asperger's

Recommended early intervention, (speech, OT, developmental) ordered chromosomal microarray and Fragile X, Pb. Referred for full diagnostic evaluation

Follow every 6 months

Treatment- Focus on Behavior and Communication Applied behavior analysis (ABA)

Is widely accepted Used in schools and treatment clinics Encourages positive behaviors and discourages negative behaviors in

order to improve a variety of skills Child’s progress is tracked and measured

Different types of ABA:

Discrete Trial Training (DTT)-style of teaching that uses a series of trials to teach each step of a desired behavior or response

Lessons broken down into simplest parts Positive reinforcement is used to reward correct answers and behaviors;

incorrect answers ignored(CDC, 2015)

Different Types of ABA Early Intensive Behavioral Intervention (EIBI)

This is a type of ABA for very young children

Pivotal Response Training (PRT) PRT aims to increase a child’s motivation to learn,

monitor his own behavior, and initiate communication with others

Positive changes in these behaviors should have widespread effects on other behaviors

Verbal Behavior Intervention (VBI) Type of ABA that focuses on teaching verbal skills(CDC, 2015)

Other Behavior and Communication Treatments Developmental, Individual Differences, Relationship-

Based Approach (DIR; also called "Floortime")

Treatment and Education of Autistic and related Communication-handicapped CHildren (TEACCH)

Occupational Therapy /Sensory Integration Therapy

Speech Therapy (PECs, focus on pragmatic language)

(CDC, 2015)

Educational Programs for Children with ASD Individualized Education Plan developed

(IEP) and should include:

Speech and language therapy

Social skills instruction

OT/Sensory Integration Therapy

Autism educational support

May include sensory breaks

Educational Programs for Children with ASD

Program should be highly structured and involve intensive behavioral treatment

Based on functional behavior analysis (functional assessment)◦ Identifies problem behavior, antecedents,

consequences, environmental factors

◦ Hypothesizes motivation, function of behavior

◦ Behavior plan developed to address problem behaviors

Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder (AACAP, 2013)

Recommendation:

Pharmacotherapy may be offered to children with ASD where there is a specific target symptom or comorbid condition

Pharmacological interventions may increase ability to benefit from educational and other interventions; remain in less restrictive environments

Targets for pharmacological intervention include associated comorbid conditions (e.g., anxiety, depression) aggression, self-injurious behavior, hyperactivity, inattention, compulsive-like behaviors, repetitive or stereotypic behaviors, and sleep disturbances

Need to assess for co-morbid conditions Behavioral conditions identified include hyperactivity,

inattention, distractibility, impulsivity, obsessive compulsive phenomena, self-injury, aggression, stereotypies, tics, and affective symptoms including depression and anxiety

Making an additional diagnosis of ADHD in those with ASD has been removed in the DSM-5

Combining medication with parent training is moderately more efficacious than medication alone for reducing serious behavioral disturbance, and modestly more efficacious for adaptive functioning

(AACAP, 2013)

Assessment for co-morbid conditions Use traditional screening tools- obtain parent, child

and teacher input (Vanderbilt’s, SCARED)

In teens, use self evaluation screening tools (PHQ-9)

Review DSM V criteria with parents and child

If medication indicated, include behavioral management as part of plan, refer for counseling or parent training

Psychopharmacologic Management Medication may be considered for behavioral

symptoms that cause impairment of functioning and suboptimal response to behavioral interventions

~45-75% of adults with ASD are treated with psychotropic medications (Myers, 2007)

Co-morbid diagnosis may be made and should be treated

SSRIs, atypical antipsychotic agents, stimulants, alpha adrenergic agonists- most common (Myers, 2007)

Target behaviors include repetitive behaviors, irritability, depressive symptoms, tantrums, anxiety, aggression, difficulty with transitions

Medications

There are side effects to medications, but there are also side effects to nontreatment

Children with ADHD & ASD Children with ASD may have hyperactivity and

impulsivity at young ages

Children may present for ADHD but have ASD combined with ADHD

May be highly distractible, inattentive during school age despite having high IQ

If school age, how does child relate to peers? Is child bossy, poor at social reciprocity?

Does child get along better with adults?

Obtain NICHQ Vanderbilt Scales Developed for initial evaluation and follow-up of ADHD in

preschool and school age children Parent Initial and Follow-up Scales Teacher Initial and Follow-up Scales Available at: http://www.nichq.org/childrens-

health/adhd/resources/vanderbilt-assessment-scales

Screens for coexisting conditions (conduct disorder, oppositional-defiant disorder, anxiety/depression)

ADHD diagnoses: Predominately inattentive subtype Predominately hyperactive/impulsive subtype ADHD combined inattention/hyperactivity

http://www.nichq.org/childrens-health/adhd/resources/vanderbilt-assessment-scales

Medication Therapy for ADHD Medical Therapy

Use of medications effective in 70-80% of children Evaluate effectiveness by behavioral changes: motor

activity, attention span, concentration, reduced distractibility (school and home)

Psychostimulants Immediate Release

Psychostimulants Sustained Release

Non- stimulant –Strattera Alpha Adrenergics

ADHD: Psychostimulants Common side effects: anorexia, weight loss or poor

weight gain, delayed sleep onset, headache, stomachache, jitteriness or moodiness

15-30% experience motor tics (may be transient)

Basic principles in use of stimulants: Dosages are not weight dependent

Start with low dose and titrate upward because of marked variability in response

“Start low, go slow” particularly with younger children and children with ASD

Immediate Release Medications

Methylphenidate Methylphenidate (Ritalin)

tablets- scored (5,10 and 20 mg)

Methylphenidate (Methylin) tablets- scored (5,10 and 20 mg)

Dexmethylphenidatehydrochloride (Focalin) tablets- (2.5, 5 and 10 mg)

Duration 3-4 hours

Mixed salts of amphetamine (Dextroamphetamine/

levoamphetamine) Adderall tablets- scored (5,

7.5 10, 12.5, 15, 20, 25, 30 mg tablets)

Duration- 4-6 hours

Sustained Release Medications Methylphenidate

Methylphenidate ER (Concerta) tablets- noncrushable (18, 27, 36 and 54 mg) Duration 9-12 hrs

Methylphenidate ER (Ritalin LA) capsules- can be sprinkled (10, 20, 30 and 40 mg) Duration 8 hrs

Methylphenidate ER (Metadate ER) tablets ( 10 and 20 mg) Duration 4-8 hrs

Methylphenidate ER (Metadate CD) capsules (10, 20, 30, 40, 50, 60 mg) Duration 4-8 hrs. Can be sprinkled.

Dexmethylphenidate hydrochloride (Focalin XR) capsules (5, 10, 15, and 20 mg extended-release) Duration- 6-10 hours

Methylphenidate hydrochloride for extended release oral suspension (Quillivant™ XR)

Extended-release oral suspension (after reconstitution with water): 25 mg per 5 mL (5 mg per mL)

Recommended for patients 6 years and above, recommended starting dose is 20 mg given orally once daily in the morning

Daily dosage above 60 mg is not recommended

Excellent for children who cannot take tablets

Sustained Release Medications Mixed salts of amphetamine

(Dextroamphetamine/

levoamphetamine)

Adderall XR capsules-can be sprinkled (10, 20, 30 mg)

Duration- 8-12 hours

Lisdexamfetamine dimesylate Capsules (Vyvanse) Prodrug Stimulant

Prodrug is a pharmacologic substance that is administered in an inactive or significantly less active form

Metabolized in vivo into the active compound. It is designed to improve oral bioavailability.

Side effects are similar to stimulants

10, 20, 30, 40, 50, 60, 70 mg capsules

Methylphenidate ER (Daytrana) Patch Methylphenidate in a transdermal form

10, 15, 20 and 30 mg patches

Approved for 6-12 year old children

Apply 2 hours before expected effects.

Remove after 9 hours. Effects last another 2 hours

Skin care: vitamin E

Atomoxetine Hcl (Strattera)

Selective norepinephrine reuptake inhibitor Unknown mechanism of action in ADHD but thought

to related to selective inhibition of the pre-synaptic norepinephrine transport

Approved for treatment of ADHD in children, adolescents, and adults

Not a stimulant Side effects upset stomach, decreased appetite,

nausea or vomiting, dizziness, tiredness, and mood swings.

FDA past warning for potential for severe liver injury

Atomoxetine Hcl Must take 24/7 Takes 2-6 weeks to see improvement Doses: 10, 18, 25, 40, 60, 80, 100 mg Need to titrate up in dosage

Alpha Adrenergic Agonists Inhibit adenylyl cyclase activity

Reduce brainstem vasomotor center-mediated CNS activation; used as antihypertensives, sedatives

First line therapy for children with Tourette’s Disorder alone

Tic reducing effect was found secondarily

Alpha Adrenergic Agonists Can be used in conjunction with stimulants

Short Acting: Clonidine HCL (Catapres)

◦ Oral scored tablet (0.1, 0.2, 0.3 mg tablets) given BID, TID

◦ Catapres-TTS-Transdermal patch 0.3 mg patch once every 5 to 7 days

◦ Long Acting: ◦ Clonidine HCL ER (Kapvay)

◦ (0.1mg , 0.2 mg extended release given BID) recently approved by FDA 6-17 years

Clonidine HCL QHS may help with sleep

Alpha Adrenergic Agonists Short acting:

Guanfacine HCL (Tenex) 1, 2 mg tablets given BID or TID

Long Acting: Guanfacine HCL ER (Intuniv)- 6-17 years -approved 6

years and up

Comes in 1, 2, 3, 4 mg once daily

Start 0.25-0.5 mg Guanfacine HCL, or .025-.05 of Clonidine HCL

Slowly progress dose (may increase every 5-7 days) to BID, TID

Alpha Adrenergic Agonists Side effects:

dry mouth, nausea, stomach pain, vomiting, constipation

tiredness, weakness

headache, irritability

More serious side effects:

fainting, blurred vision, rash, slow heart rate

Alpha Adrenergic Agonists Start with low dose usually at bedtime, make weekly

adjustments. If discontinuing, should taper.

Monitor weekly

May take up to 4 weeks to see effect

Side Effects and Warnings-Stimulants Cardiovascular Issues

Recommendation from the American Heart Association followed by the American Academy of Pediatrics for screening include: targeted cardiac history (eg, patient history of previously

detected cardiac disease, palpitations, syncope, or seizures; a family history of sudden death in children or young adults; hypertrophic cardiomyopathy; long QT syndrome)

physical examination, including a careful cardiac examination

Refer for screening ECG or for cardiovascular evaluation if pre-existing conditions or concerns

Monitor pulse and BP

Side Effects During a psychopharmacological intervention for

ADHD, the patient should be monitored for treatment-emergent side effects.

May use low doses of Clonidine or Melatonin (1-3 mg, may go higher to 10 mg) for delay of sleep onset

Alpha agonists such as Clonidine and Guanfacine may be used for tics, as adjunct or for comorbid aggression

Monitor growth

Challenges in Medication Management

Difficulties with medication management:

Wear off- Need to increase dose to maximum (MPH .3-.6 mg/kg/dose BID dextroamphetamine- .1-.3mg/kg/dose BID) and then change medication

Titration- with children

Challenges in Medication Management Extended release may not last long enough- wears off

in 4-6 hours Some are fast metabolizers Side effects- tics Mood changes Children with co-morbidity have unique responses to

meds- start low, go slow Parents require frequent consultation and availability

of provider for concerns when starting medication

Ongoing ADHD-ASD Care Weight, height, vitals and plot at least every 3-6

months

Screen mood, anxiety, opposition, conduct symptoms

Educate / review role of medication, organization for homework and study time (unconditional time), activities

Discuss visits needs, schedule back in 1-3 months

Send for Vanderbilt’s after 6 weeks of school, prn

Stress need for parents to talk with teachers, monitor educational line

ASD and Anxiety or Depression Many children with ASD have co-morbid anxiety,

depression

May emerge as child recognized differences

Must use screening tools to help determine which symptoms are most interfering with function

Selective Serotonin Reuptake Inhibitors (SSRIs) Selective Serotonin Reuptake Inhibitors (SSRIs) are

first line

Fluoxetine has FDA approval for depression and OCD in children 8 years and older, positive studies for Citalopram (Celexa) & Sertraline (Zoloft) published

Act over time

Daily compliance is important

Parents manage medication supply

SSRIs

SSRI Starting

Dose

Increments:

Every 2-4

weeks

Maximum

Daily Dose:

once daily

Available Doses

Fluoxetine (Prozac)

FDA approval to 8 years for

depression, off label OCD,

panic disorder

5 or 10 mg qd 5 mg -40 mg 60 mg in AM 10 mg capsules

10, 20, 40 mg

pulvules

20 mg/5 ml

Sertraline (Zoloft)

FDA approval to 6 years for

OCD, off label anxiety, PTSD

12.5-25 mg qd 12.5-25 mg 200 mg 25, 50, 100 mg

tablets

20 mg/1 ml

Citalopram (Celexa) for

depression

5-10 mg qd 10 mg 40 mg 10, 20, 40 mg tablets,

10 mg/5ml

Escitalopram

(Lexapro) FDA approved for

adolescents >12

5 mg qd 5 mg 20 mg 5, 10, 20 mg tablets

5 mg/5 ml

Teens with ASD John is 14 with ASD.

In regular academic classes. Beginning to realize he is different. Has a hard time talking with peers. Is interested in girls. Has increasing anxiety, depression on screening tools. Avoiding school.

Started on Sertraline (Zoloft) and referred for Cognitive Behavioral Therapy.

SSRIs: Common side effects

Dry Mouth

Constipation/Diarrhea

Sweating

Sleep Disturbance

Headache

Agitation or jitteriness

Appetite changes

Rashes

Sexual dysfunction

Disinhibition: (risk taking, impulsivity that is out of character)

Discontinuation Syndrome may be noted daily in some youth, split dose (not a problem for Fluoxetine)

SSRIs: Common side effects

Agitation or jitteriness

Appetite changes

Nausea

Sweating

Patience, lower dose for a few days or change medication

Patience. Exercise. Healthy choices

Take with food / divide dose

Patience, switch medication

SSRIs: Common side effects and interventions

Dry Mouth

Constipation/Diarrhea

Sleep Disturbance

Headache

Fluids, sugarless candy

Take before meals or divide dose

Change time of dose, change medication, split dose

Split dose

Mild: patience. No

caffeine. Sleep hygiene

SSRI Side Effect Comparison Fluoxetine / Sertraline Least weight gain

Slower onset of action (Fluoxetine)

Least sexual dysfunction (Fluoxetine at 57.7%)

Increased incidence of diarrhea

Higher rates of anxiety and agitation

Higher incidence of headache

Delays sleep onset and changes sleep architecture with less REM and slow wave sleep time for Fluoxetine, minimally improved sleep efficiency and decreased night awakenings with Sertraline

SSRI Side Effect Comparison Citalopram / Escitalopram

Slightly more weight gain

Higher level of sexual dysfunction

Citalopram: increased incidence of dry mouth

Differences in side effects between all SSRI’s are minor!!!

SSRIs: General Information Start Low, Go Slow

Side effects usually occur right away with initiation or increased dose, can go away

Discontinue and see for hypo-manic symptoms

Close follow-up

Knowledge of FDA Black Box Warning

FDA Black Box Warning Based on a 2004 FDA review of reported adverse events

in 23 clinical trials which involved 4,300 children & adolescents, 9 different medications

Studies used two different measures for suicidal thoughts & behavior

FDA clumped both thoughts & behavior as “suicidality”

FDA Black Box Warning Studies that used event reporting noted that 2%

receiving placebo expressed increased suicidality compared to 4% on medication

Studies that used standardized forms that questioned suicidality at each visit demonstrated a slight reduction in suicidality for the medication group

Approved for ASD Risperidone and aripiprazole have been approved by

the FDA for the treatment of irritability, consisting primarily of physical aggression and severe tantrum behavior, associated with autism

Multiple side effects, a last resort

Screening labs: baseline lipid panel, CMP, and every 6 months, or with significant weight gain

Can increase Q-T interval

Monitor for abnormal movements, akathisia, constipation

Serious side effects Tardive Dyskinesia:

random muscle movement, can be irreversible

0.5%, 10 fold decrease from Haldol

Related to dose and duration of treatment

Akathisia

Dystonia: sudden painful muscle spasms

Parkinsonian: tremors, slowed movements

Hyper prolactinemia: breast swelling, tenderness, anovulation

Neuroleptic Malignant Syndrome

Metabolic Syndrome Three of the following:

Central weight

Elevated BP

Triglyceride level above 150 mg/dl

FBS level greater than 100 mg/dl

HDL less than 40 mg/dl

Labs: CMP, lipids, CBC baseline and every 6 months

Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder (AACAP, 2013) Recommendation: Clinicians should inquire about the use of alternative/complementary

treatments, and be prepared to discuss their risk and potential benefits Alternative or complementary treatment approaches have very limited

empirical support for their use in children with ASD they are commonly pursued by families

Important that the clinician be able to discuss these treatments with parents, recognizing the motivation for parents to seek all possible treatments

These treatments have little or no proven benefit, but also have little risk

Some evidence of treatments not effective (e.g., IV infusion of secretin and oral vitamin B6-magnesium)

RCTs do not support its use (e.g. the gluten-free, casein-free (GFCF) diet or omega-3 fatty acids

Vaccines and ASD

Vaccines are not associated with ASD (CDC, 2015)

Wakefield Study has been invalidated

Multiple research done on autism and vaccines and no relationship identified http://www.cdc.gov/ncbddd/autism/topics.html

CDC-Inter- Agency Autism Coordinating Committee (IACC) and National Vaccine Advisory Committee (NVAC) working together on multiple studies and analyzing research

◦ http://www.cdc.gov/ncbddd/autism/research.html

http://www.cdc.gov/ncbddd/autism/topics.htmlhttp://www.cdc.gov/ncbddd/autism/research.html

Resources

PCP support- First Signs http://www.firstsigns.org/

Parent support- Autism Speaks https://www.autismspeaks.org/

Child Mind Institute: http://www.childmind.org/en/health/disorder-guide/autism-spectrum-disorder

Autism and Medication: A Guide for Families of Children with Autism Safe and Careful Use- available as PDF at https://www.autismspeaks.org/news/news-item/autism-speaks-launches-autism-and-medication-tool-kit.

http://www.firstsigns.org/https://www.autismspeaks.org/http://www.childmind.org/en/health/disorder-guide/autism-spectrum-disorderhttps://www.autismspeaks.org/news/news-item/autism-speaks-launches-autism-and-medication-tool-kit

Questions?

References American Academy of Child and Adolescent Psychiatry. (2013) Practice parameter for the

assessment and treatment of children and adolescents with autism spectrum disorder. American Academy of Child and Adolescent Psychiatry .

American Psychiatric Association. (2013) Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association.

Boyle, C A., Boulet, S., Schieve, L.A., Cohen, R.A., Blumberg, MY.A., Visser, S., Kogan, M.D. (2011) Trends in the prevalence of developmental disabilities in US children, 1997-2008. Pediatrics. 127(6), 1034-1043.

Centers for Disease Control and Prevention (2015) Autism Spectrum Disorder. Retrieved from http://www.cdc.gov/ncbddd/autism/index.html

Council on Children With Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, Medical Home Initiatives for Children With Special Needs Project Advisory Committee. (2006) Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental

surveillance and screening. Pediatrics. 118(1), 405-420.

http://www.cdc.gov/ncbddd/autism/index.html

References Humphreys, J.S., Gringras, P., Blair, P.S., Scott, N., Henderson, J., Fleming, P.J., Emondet,

A.M. (2013) Sleep patterns in children with autistic spectrum disorders: a prospective cohort study. Archives of Diseased Child. doi: 10.1136/archdischild-2013-304083.

McElhanon, B.O., McCracken, C., Karpen, S., Sharp, W.G. (2014) Gastrointestinal symptoms in autism spectrum disorder: a meta-analysis. Pediatrics. 133(5), 872-883.

Robins, D., Fein, D., & Barton, M. (2009) Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F)TM. Retrieved from https://www.m-chat.org/

Shen, Y., Dies, K.A., Holm, I.A., Bridgemohan, C. Sobeih, M.M., Caronna, ER.B., Miller, K.J., Frazier, J.A., Silverstein, I., Picker, J., Weissman, L., Raffalli, P., Jeste, S., Demmer, L.A., Peters, H., Brewster, S.J., Kowalczyk, S.J., Rosen-Sheidley, B., McGowan, C., Duda, A.W., Lincoln, S.A., Lowe, K.R., Schonwald, A., Robbins, M., Hisama, F., Wolff, R., Becker, R., Nasir, R., Urion, D.K., Milunsky, J.F., Rappaport, L., Gusella, J.F., Walsh, C.A., Wu, B., Miller, D.T. (2010) Clinical genetic testing for patients with Autism Spectrum Disorders. Pediatrics. 125(4); e727-e735.

https://www.m-chat.org/

References Williams, A.A., Cormack, C.L., Chike-Harris, K., Durham, C.O., Fowler, T.O.,

Jensen, E.A. (2015) Pediatric developmental screenings: A primary care approach. The Nurse Practitioner. 40(4), 34-39.

Wong, C., Odom, S.L., Hume, K., Cox, A. W., Fettig, A., Kucharczyk, S., Brock, M., Plavnick, J., Fleury, V., and Schultz, T. (2013) Evidence-based practices for children, youth, and young adults with Autism Spectrum Disorder. Chapel Hill: The University of North Carolina, Frank Porter Graham Child Development Institute, Autism Evidence-Based Practice Review Group.