Autism Spectrum Disorder Comorbidity and Pharmatherapy 05.21.2012

7/31/2019 Autism Spectrum Disorder Comorbidity and Pharmatherapy 05.21.2012

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AutismSpectrumDisorders;

Psychiatriccomorbiditiesand Pharm


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Patient Case10 y/o autistic female who is part of the UNI HOMEprogram.

HPI upon presentation:

Social Impairment:

-failure to develop peer relationships-lack of social reciprocity

Communication Impairment:

-receptive and expressive language disorder (nottalking at age 3)

-unable to engage in imaginary playStereotyped Behavior:

-flapping, twirling, repetitive jumping and spitting, linesup objects, difficulty releasing objects


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Mood/Behavior Complaints-labile mood

-self injurious behavior

-9/10 energy level, hyperactivity-poor concentration, lack of attention

-difficulty following directions

-impulse control problems

-destruction of property-aggressive behavior

-running away


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SH: Single parent, younger brother, newsister.

FH: mom h/o depression, dad h/odrug/alcohol problems.

CURRENT MEDICATIONS: Risperdal 1.5 mg po q am and q hs

Melatonin 3 mg po q hs


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VS: HT= 52.5 in. WT= 62 lbs. T= 36.2 BP= ref P= ref R= 16Sedated and irritable during the day on Risperdal. Sleeps

well on Melatonin. Continued behavioral problems.MSE: Patient engaged in a variety of negative attention-seeking behavior such as ripping drawings off of the walland tearing them up, climbing up on the window sill,playing with the blind cord, and grabbing tape from mydesk. Mother was actively engaged in containing her,physically restraining and repeatedly trying to redirect her

behavior. She would cry and scream when she was notallowed to be destructive. She kicked the wall. She smiledand looked around when she was doing somethingdestructive. Mood overall appeared irritable anddepressed with a labile affect. She did not appearsedated.Plan:

1. Discontinue am Risperdal and continue 1 mg po q hs2. Continue Melatonin 3 mg po q hs3. Zoloft 12.5 mg po q am to treat depression. Reviewedindications, potential benefits, side effects, and risks.4. In-home behavioral support with Families First.5. Follow-up 1 month.


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The diagnosis of the Autism SpectrumDisorders are based on the early onset of atriad of deficits:

impaired sociability

impaired verbal and nonverbalcommunication skills and

restricted activities and interests


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The incidence of AD has increased steadilyover the past 15 yr.

Current estimates of the prevalence rate of allPDD (63.7/10,000) are approximately 1 in 150-160.

Approximately two thirds of adults with autismshow poor social adjustment (limitedindependence in social relations), and onehalf require institutionalization.

Only 5% to 15% will become competitivelyemployed, lead independent lives, marry,and raise families.

Psychiatric problems are common even in thisgroup.


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Identification of a comorbid illness maymake the patient qualify for insurance or

some services that they might nototherwise

May help guide services provided


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Frequency

Slightly greater than 20% have onecomorbid psychiatric illness

30% have 2

The median and mode of # of diagnoseswas 3


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May be difficult to diagnose

Communication impairment, withdifficulty processing central information,

central coherence and executivefunctioning make it difficult for those withautism to describe their emotional states,mental experiences, and daily life

experiences.


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The DisordersStudies have shown high prevalence of specific and

social phobia, OCD and ADHD in children withAutism


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Anxiety

So common that some investigators havestated that it should be considered one of

the core aspects of Autism, instead of co-morbid

Studies have found incidence of at leastone co-morbid anxiety disorder 17 to 84%


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Specific Phobias

44% of children with autism meet criteriawith a majority having phobias of more

than one object.

Common objects are different than thosecommon in the general population andinclude needles/shots, crowds and loud

noises (10%) 7-10% with Social phobia


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Separation Anxiety Disorder

One of the most common anxietydisorders in general pediatric population

with 3.5-5.5% of children qualifying fordiagnosis. 12% in ASD


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OCD

Found in 37% of those with Autism in onestudy

Most commonly involves a compulsion orritual involving others:

Parents having to perform very specific

daily routines or separation rituals

Need to ask the same question over andover


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GAD

Uncommon

Worries in those with autism usually focuson one or a few things, not multiple orgeneralized, or anxiety was focused onchanges in the environment


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ADHD 31-55% (if sub-syndromal individuals

involved); other studies up to 73%

65% with inattentive sub-type

Difficult to diagnose due to idiosyncraticattention/inattention patterns

Commonly can attend to stimulus almostindefinitely if they find it interesting.


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Oppositional Defiant Disorder

Cognitive and other factors different inchildren with Autism than those without

Often do not understand concepts ofvindictiveness, spitefulness or intention

So is it even the same thing?


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Depression 10-24% Prevalence in Children with ASD

Mean age of first diagnosis 9 years old in

group where NONE preselected forknown comorbid illness


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Treatment for Core Autism

Features There are no medications that can help

with social and language impairments

No treatment has solid empirical supportfor stereotypies in Autism

Best treatment: Applied Behavior analysis


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Applied Behavior Analysis1. Intensive treatment 20-40 hours per week

2. Start treatment ages 2-4 years

3. Individualized treatment based onsymptoms and skills

4. Active parental participation

5. Teaching new skills and multiplerepeated positive stimulus

6.

Starts as one to one intervention


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Irritability/Aggression/Self harm

In study of 1380 68% demonstrated harmto caregiver and 49% to non-caregivers

Risperdone and Abilify approved for

irritability aggression in ASD Abilify 5-15mg/day

4/5 RCT with risperdone show robust

improvement. 3mg max dose in

adolescents

Withdraw showed return of symptoms

Haldol also shown useful, but 2nd line


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Irritability/Aggression/Self harm

Havent been shown to be helpful:

Methylphenidate

SSRIs

Valproate


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ADHD/Hyperactivity

Normal stimulant treatment, but lesseffective than in non-ASD individuals

Increased irritability is common

Also Abilify and Risperdone

Clonidine was equivocal


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Anxiety Early treatment important to avoid

functional impairment

CBT most helpful

SSRIs associated with dis-inhibition,hyperactivity, somatic complaints inchildren, but some positive results seen inadults. Need more research.


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Depression

Research lacking

Strong evidence for SSRIs for

anxiety/depression in non-ASD kids, but notfor ASDs and somatic complaint rate in this

group is high


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Next visit: taking Zoloft 4/7 days per week. Patient is very emotional, less active,and stays in her room all day.

MSE: Patient was well-groomed and neatly dressed. Met in the behavior lab andthe attending physician sat in front of the door to prevent the patient fromescaping. She appeared calmer and more interested in interacting. A physicalexam was performed. Despite containment, the patient appeared happy with abright affect and wasn't irritable or frustrated as she was on previous visit. She wasnot destructive or aggressive, although did try to get past the attending physician.

She played cooperatively with brother and more appropriately with the only toy inthe room which was a wagon of Mega Blocks.

TREATMENT PLAN:

1. Continue Risperdal 1 mg po q hs

2. Continue Melatonin 3 mg po q hs3. Continue Zoloft 12.5 mg po q day but move dose to hs. Mother agreed to givethe medication every day.4. Continue in-home behavioral support with Families First.

5. Release of information obtained from mother to communicate with school.6. Follow-up 6 weeks. Will follow-up with them by phone in 3 weeks.


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Next visit: Her mood is reportedly "better" with less anger, aggression, anddestructive behavior at home. Mother added that the school sent home a note

with the same observation. She goes to bed at 9 pm, but doesn't fall asleep untilmidnight.

MSE: The patient was well-groomed and neatly dressed, carrying a stuffed Tigger.She was more interactive with physicians. She was not as active but still a littledisruptive, trying to leave the room, banging on the metal shelves, and gettingclose to her baby sister. Mother prompted her and she would redirect briefly. Hermood appeared happier with a bright affect. She was intrusive andunpredictable, grabbing the doctors stethoscope and interpreter's glasses fromaround his neck, but she was not overly aggressive or destructive, although limited

access meeting in the behavior lab.

TREATMENT PLAN:

1. Continue Risperdal 1 mg po q hs2. Continue Melatonin 5 mg po q hs

3. Discontinue Zoloft

4. Luvox 12.5 mg po q hs which may be less activating and have less impact onsleep. If sleep does not improve but Luvox

is effective, would consider Trazodone for sleep.5. Continue in-home behavioral support with Families First.6. Follow-up with attending physician in 1 month and see fellow physician in 2months.


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Interim: Luvox increased to 25 mg QHS for sub-therapeutic effect

Next visit: Patient has been doing "much better." She doesn't get upsetthat often except when brother hits her to get her attention when sheisn't interested in playing with him. Her mood is "doing better...not toobad." She is "a little stressed" but mother doesn't know for sure why. Herenergy level is "not too much...sitting more...playing more calmly." Sheis also watching TV for 10 minutes which is a first. School has reportedthat she is "more calm...doing a little more work." She has been playingwith a toy tiger and a plastic fish, which mother has not seen her do

before. She is not as destructive and mother admits that she herself ismore relaxed.

MSE: She was more focused and goal-directed in her play, removingthe toys, not throwing or destroying them, and then sitting in the toybox. She was not intrusive and was not aggressive with siblings, eventhough brother was frequently in her path. She did not make anyattempts to leave the room. Her mood was euthymic with congruentaffect.

Plan: continue current management

Autism Spectrum Disorder Comorbidity and Pharmatherapy 05.21.2012

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