Post on 05-Apr-2018
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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