Gender Differences in Autism: Problem Behavior Males with autism are: • • more likely to engage in stereotypic play; • more likely to have problem behavior when stereotypy interrupted, and • less likely to find attention from caregivers reinforcing. Females are more likely to find attention • reinforcing Extended Reese study to compare males • and females
Males versus Females with Autism Completed Functional Assessment Interview Form with families in clinic: 17 males; 6 females 3 to 6 year olds Males age (m = 40 months) Females age (m = 48 months)
Significant overlap in behavioral characteristics both across and within syndrome groups Low incidence of some syndromes makes it difficult to study systematically Not all people with a specific syndrome are the same (behavioral phenotype varies)
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Psychotropic Medication - Themes Evidence that children with ASD and other disabilities have: - a higher rate of co-morbid psychiatric disorders than nondisabled peers - are more likely to receive medication for problem behavior How do you determine when they need medication and when they don’t? What role do we play as clinicians? What do we do when we disagree with medication intervention? 45
• Of 2853 children in registry, 27% were taking psychotropic medication • 2 or more meds: • 2% of 3-5 year olds • 13% of 6-11 year olds • 20% of 12-17 year olds • 16% had comorbid psychiatric diagnosis • ADD, bipolar disorder, OCD, depression, anxiety • Children with problem behavior more like to be taking meds Coury et al., Pediatrics, 2012 46
Prescription Guidelines Nearly all psychotropic medications are prescribed for children, but initially this is done “off label” (i.e., not fully tested or approved by the FDA) Prozac (fluoxetine) is approved for use in children and adolescents for the treatment of major depressive disorder. Prozac (fluoxetine), Zoloft (sertraline), and fluvoxamine maleate are approved for use in children and adolescents for the treatment of obsessive compulsive disorder. Many ADHD meds approved with children 47
Prescription Guidelines Even more rare for individuals with ID Risperdal (risperidone) and Abilify (aripiprazole) approved for irritability in autism Prescription guidelines for nondisabled children generally used, even if symptoms don’t completely match distractibility => stimulant medication behavioral inflexibility or rituals => anxiety or OCD med r epetitive behavior => SSRI’s 48
The strictest warning put in the labeling of prescription drugs or drug products by the FDA when there is reasonable evidence of an association of a serious hazard with the drug. Based on data that has come to light after FDA approval This info sent to all physicians, pharmacists, nurse practitioners Example: warnings about increased risks of suicidal thinking and behavior (suicidiality) in young adults ages 18 to 24 during initial treatment with antidepressants 49
In the absence of data, doctors must use their best judgment and a trial and error approach to prescription Lower doses should be used with children, the disabled and the elderly Side effects – are children and people with ASD and ID more susceptible? Cultural issues and social acceptability of meds 50
The prevalence of ADD diagnoses has grown among children, from 7.8% in 2003 to 9.5% in 2007 and 11% in 2011, according to the CDC. Use of stimulants to treat children with ADD has also grown 5-fold since the late 1980s and early 1990s: between 2007 and 2010, 4.2% of children under 18 were treated with a stimulant medication. Schwartz et al, 2014 51
Most commonly prescribed Target behaviors: inattention, hyperactivity, impulsivity Side effects: decreased appetite, insomnia, tics, increased irritability, paradoxical increase in hyperactivity, restlessness, slowed growth, possible risk for obesity later in life Generally works in about 70% of children ◦ not clear what response rate is with children with ASD or ID Works well in combination with behavioral interventions
Amphetamines: ◦ Adderall, Dexidrine, Dextroamphetamine, Vyvanse ◦ Approved for ages 3+ Methylphenidates: ◦ Ritalin, Concerta, Daytrana, Focalin, Quillivant ◦ Approved for ages 6+ Non-stimulant: Strattera (atomoxetine) ◦ doesn’t have same side effects ◦ recent warnings of suicide risk Others: Kapvay (clonidine), Intuniv (guanfacine) 53
Typical versus atypical Most commonly used medication and most studied with children with disabilities and problem behavior Target behaviors: aggression, irritability , disruption, self-injury, repetitive behavior Risperdal and Abilify approved for children with ASD Side effects: increased sleep/lethargy, increased appetite, hyperprolactinemia, tardive dyskinesia (typical antipsychotics only)
Older antidepressants: tricyclics and MAO inhibitors not used due to severe side effects and lack of effectiveness Currently use selective serotonin reuptake inhibitors (SSRIs) in treatment of anxiety, repetitive behavior, and OCD “black box” warning regarding suicidal ideation
Mixed results in clinical trials of effectiveness of SSRI’s in treating repetitive behaviors and “OCD - like” symptoms in individuals with disabilities (Prozac, Zoloft, Paxil) ◦ Possibly due to differences in underlying mechanisms of “compulsive” behavior Fluvoxamine (Luvox) and sertraline (Zoloft) also may be effective in treatment of behavior problems and mood New research in pharmcogenetics may identify high and low- metabolizers, particularly for SSRI’s ◦ May explain heterogeneity in response to meds
Guanfacine (Tenex or Intuniv) approved for blood pressure, but used for anxiety and mood stability Seizure medications (e.g., Depakote, Neurontin, Lamictal) used for mood stabilization Clonidine, Trazadone, and Melatonin used for sleep (small clinical trials of melatonin indicate it may be helpful for sleep, especially sleep onset) 57
Seeks to characterize behavior in terms of function ◦ the events that occasion problem behavior ◦ the consequences that strengthen it ◦ and therefore its functionality to the individual Understanding of controlling variables guides treatment development A range of assessment procedures and data collection methods (interviews, observations)
Functional analysis is the most rigorous method for evaluating what is maintaining problem behavior ◦ Simulate different situations (e.g., school) ◦ Program antecedent and consequences ◦ Test how behavior changes as a function of conditions E.g. “work” environment - demands are presented and then briefly terminated contingent upon problem behavior ◦ Direct observation and data collection ◦ Analysis of patterns of behavior reveals function
In 60-70% of individuals, the function of the problem behavior is social (from people/events in the environment) ◦ To get attention or preferred activities, to escape work In 15% of cases, it appears sensory or “Automatic” In 10-20% of cases, the behavioral function cannot be ascertained ◦ Beavers et al. 2013; Hanley et al., 2003;
Functional Analysis - Attention
IOA 60% of sessions = 83%
10.0 9.0 8.0 7.0 SIB Responses per Minute 6.0 5.0 4.0 3.0 2.0 1.0 0.0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Session Alone Attention Toy Play Demand
Schaal & Hackenberg (1994) first suggested use of FA during medication treatment Growing number of examples of use in clinical settings, but the area is lacking good research Mostly due to difficulty with conducting controlled clinical trials, thus most are case studies and do not have blind raters or a placebo control 64
Double blind, placebo controlled trial of methylphenidate Charlie an 8-year-old attending ADHD summer program (no ID) Evaluating disruptive behaviors and off-task behavior in typical classroom setting Three contexts: teacher reprimand (teacher attention), timeout (escape from work), peer prompts (peer attention) 65
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David, an 18-year-old with ADHD and ID Engaged in disruptive behavior Initial FA was inconclusive because he was on methylphenidate and didn’t engage in any disruptive behavior Conducted FA with typical conditions both on and off the methylphenidate 67
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Double-blind, placebo controlled study using crossover design • Placebo (twice) • a low dose (1 mg/day for children or 2 mg/day for adults) • a high dose (0.05 mg/kg/day) 17 participants 12 (71%) were responders to the medication Crosland et al., 2003; Zarcone et al. 2004 69
Sessions conducted at home/school/work Once per week throughout med trial Multielement experimental design Conditions: ◦ Demand - Attention ◦ Tangible - Ignore ◦ Play/leisure (control) 70
Undifferentiated FA with a general suppression of behavior (N=5) Example participant - Jack ◦ 16-year-old diagnosed with intermittent explosive disorder and profound ID ◦ primary target behaviors: aggression, face slapping, property destruction, stereotypy
Findings, continued Example participants - Reggie and Sean Primary target behaviors: aggression, disruption, and elopement FA results: escape and tangible (Reggie), escape and attention (Sean)
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Risperidone was effective in reducing problem behavior in 67% of participants Based on results of FA – • a general suppressive effect on behavior or • selectively affected escape or avoidance behavior These data may help us to identify those individuals who may be the best responders to certain types of medication 75
Functional analysis is good for looking at effects of med on problem behavior; consequences for behavior Medications often prescribed for other behaviors: impulsivity, hyperactivity, mood instability, anxiety How do we capture medication effects on these behaviors? 76
Treating “diseases” or mental illness with therapeutic dosages Focusing on more general aspects of behavior: ◦ Patterns ◦ Interference with daily life ◦ General impression of improvement Based on caregiver report or brief observation ◦ May or may not include data May be overwhelmed by behavioral data
Build a collaborative relationship to make data-based decisions on medication treatment ◦ Avoid confrontation language and jargon Share data ◦ Clearly defined, observable target behaviors Problem behavior Sleep, appetite, other aspects too ◦ Provide graphs but also a summary to assist in interpretation 78
Conflict between using meds to treat problem behavior and giving a psychiatric diagnosis ◦ No corresponding diagnosis for treatment of aggression (conduct disorder, oppositional defiant disorder?) ◦ SIB a little easier (stereotypic movement d/x with self-injury) ◦ Irritability => antipsychotics Often have to rely on other diagnoses: mood disorder, anxiety disorder, OCD (instead of repetitive behavior) Most support between diagnosis and target behavior: stimulants and ADD 79
Response that occurs to stimuli that signal a threat Heavily linked to environmental events Situation specific or generalized Observable indicators of fear, avoidant behavior, and increased physiological arousal ◦ Changes in facial expression, sweating, widening of the eyes, shaking, crying, eloping, physical restlessness, pacing, or rapid motor movement 80
Assessed relationship between self-injury and heart rate for individual with “anxiety” Conducted functional analysis ◦ Restraints on vs. restraints off 81
Restraint Off Restraint On 82
Assessed relationship between self-injury and heart rate for individual with “anxiety” Conducted functional analysis ◦ Restraints on vs. restraints off Conducted within-session analysis of heart rate ◦ Baseline ◦ Restraint removal ◦ Restraint off ◦ Restraint reapplication 83
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Frequent or rapid fluctuations in mood that are not proportionate and are minimally related to environmental changes Changes in mood may occur within or across days and include the full range of affect (depressive to manic) ◦ May act as an establishing operation/setting event Shifts in mood may be accompanied by changes in problem behavior Identify cycles ◦ Problem behavior ◦ Affect ◦ Self-report 85
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Agitation Near constant state of negative affect or distress that occurs irrespective of environmental events May co-occur with problem behavior Hyperactivity/Impulsivity Behavior that occurs quickly and indiscriminately in relation to environmental events Does not efficiently access reinforcement Difficulty waiting 88
10-year-old from NYS with autism and ID Admitted on unit on Strattera, Zoloft, and Risperdal Parents reported that Strattera helped, but still had a high rate of activity on the unit Psychiatrist wanted to discontinue Strattera and if hyperactivity continued, to try other stimulant due to side effects of Strattera Out of seat, off task, and problem behavior data were collected 89
Out of Seat Percent of Session 100 10 20 30 40 50 60 70 80 90 0 8/27/13 8/29/13 8/31/13 9/2/13 Out of Seat 9/4/13 9/6/13 9/8/13 9/10/13 9/12/13 Strattera (mg/10) 9/14/13 9/16/13 9/18/13 9/20/13 Academic Analog 9/22/13 9/24/13 Out of Seat 9/26/13 9/28/13 Zoloft (mg/10) 9/30/13 Session 10/2/13 10/4/13 10/6/13 10/8/13 10/10/13 10/12/13 Risperdal (mg) 10/14/13 10/16/13 10/18/13 10/20/13 10/22/13 10/24/13 Ritalin (mg) 10/26/13 10/28/13 10/30/13 11/1/13 11/3/13 11/5/13 11/7/13 0 2 4 6 8 10 12 14 90
10 year boy Diagnosed with autism and severe ID On the inpatient unit for the assessment and treatment of aggression, disruption, SIB, and pica (not on graph) 91
Problem Behavior (SIB, AGG, DIS) 80 35 Baseline Extinction 24hr Treatment 70 30 60 Transition TX added; Removal of non-exclusionary timeout 25 50 Responses per Hour Milligrams per day 20 40 15 30 10 20 5 10 80% reduction 0 0 Date 92 BASELINE TREATMENT 80% reduction Prozac Risperdal/10
Sasha - 20 year old female DSM IV diagnoses ◦ Disruptive Behavior Disorder, Stereotypic Movement Disorder with Self-Injury, Autism Spectrum Disorder, Unspecified Bipolar and Related Disorder, Moderate Intellectual Disability Target behaviors: aggression and disruption Functions of problem behavior ◦ Escape from demands ◦ Appeared sensitive to reprimands
Sasha Problem Behavior (Aggression, Disruption) Baseline Extinction Treatment 160 200 180 140 160 120 140 100 Responses per Hour 120 Milligrams 80 100 80 60 60 40 40 20 20 0 0 Date Lithium/10 Trazodone Latuda Lamotrigine Clonidine*100 Benztropine*10 Alprazolam*10 Paxil 94
Keep data collector blind If can’t use direct observation data, use time samples, scatterplots, or rating scales Implement interventions systematically and one and a time Develop a collaborative relationship with medical team to make data-based decisions on medication treatment 95
Academy of Adolescent and Child Psychiatry: http://www.aacap.org/App_Themes/AACAP/docs/press/guid e_for_community_child_serving_agencies_on_psychotropic_ medications_for_children_and_adolescents_2012.pdf MedlinePlus; FDA; drugs.com; WebMD CDC fact sheets: http://www.cdc.gov/MedicationSafety/parents_childrenAdve rseDrugEvents.html 96
Use varies from culture to culture 40% of cancer patients use some form of CAM 30-95% of children with autism have been exposed to some form of CAM NIH: National Center for Complementary and Alternative Medicine ◦ Conducts and funds clinical trials in this area ◦ Related to all areas of medicine Primary concerns are around the lack of regulation and safety and efficacy 97
Secretin Chelation Hyperbaric chamber Sensory integration therapies including: ◦ Sensory diets ◦ Weighted vests and blankets Auditory integration therapy Swimming with dolphins 98
Winburn et al. (2013) survey found that ◦ 83% of parents had used a dietary intervention ◦ 75% of professional have been asked about diets Food allergies – how common are they? ◦ 4% of children have them ◦ Increased over past decade Difference between intolerance (e.g., lactose) vs. allergy (immediate reaction after ingestion) Avoiding foods required for allergy, but what about other effects of certain foods to which we aren’t allergic? 99
Some parents/professionals feel that GFCF diet has positive behavioral effects on symptoms of ASD ◦ improves communication, social interaction, and sleep patterns, ◦ reduces symptoms of autism and digestive problems such as diarrhea (Seroussi, 2000; Pennesi & Klein, 2012). ◦ Survey by Autism Research Institute found that out of 3593 parents who had used the diet, 69% said it helped, and 3% felt they got worse
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