Updates in Autism: Behavioral and Medical

Treatments

James Weedon, MD FAAP; Peter Thaxter, MA

Director, Center for Developmental and Behavioral Pediatrics

Autism Treatment Center

Advocate Children's Hospital - Park Ridge

School Nurses’ Conference

April 15, 2014

Objectives

1. To learn about updated autism spectrum classification

and diagnostic criteria.

2. To become familiar with medications commonly

prescribed for comorbid symptoms of autism spectrum.

3. To discuss complementary and alternative treatments

and evaluate the evidence.

4. To gain an understanding of the basic tenets of

behavioral treatment approaches.

5. To learn how behavioral therapy can be used to treat a

variety of developmental disorders and behavior

problems.

Autism Rising Prevalence

Increase in Children with Autism in Illinois

Source: Illinois State Board of Education IDEA Child Count Data December 1, 2011

Graph provided by the Illinois Autism Training and Technical Assistance Project IATTAP

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Number of Children in Ilinois Receiving Special Education under the

Category of Autism Ages 3-21

Age-related Trends in Illinois

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Students with Autism in Illinois by Age Group

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Graph provided by the Illinois Autism Training and Technical Assistance Project IATTAP

History of Autism in the DSM

• DSM I (1952) and DSM II (1968)

– Schizophrenic reaction of childhood

• DSM III (1980)

– Childhood onset PDD, Infantile Autism, Atypical

Autism

• DSM IV (1994)

– Autism, PDD-NOS, Asperger, Childhood

Disintegrative Disorder, Rett Syndrome

• DSM 5 (2013)

– Autism Spectrum Disorder

Pervasive Developmental Disorders

Autism Spectrum Disorder

Diagnostic Criteria

In DSM-IV: In DSM-5:

Impairment in Social Interaction Impairment in Communication Restricted and Repetitive Behaviors

Persistent Deficits in Social Communication and Interactions Restricted and Repetitive Behaviors

Delay or abnormal functioning must be present less than 3 years old

Symptoms must be present in early childhood, but may not manifest fully until social demands increase

Restricted and Repetitive Behaviors

• Addition of sensory modulation problems as a

manifestation of Restricted and Repetitive

Behaviors

– Over or Under Responsive to sensory inputs:

• Movement

• Deep Pressure

• Touch

• Oral

• Sound

• Visual inputs

Children with Autism LEARN and CHANGE

• Autism is not a “snap-shot” diagnosis. It is a

developmental disorder.

• Children with autism change over time.

• The diagnosis does not change depending on

the changing manifestation of the symptoms.

The diagnosis takes into account the history

of the child’s development.

Social (Pragmatic) Communication Disorder

• New disorder in DSM-5

• Children who meet Social Communication

Impairment criteria for Autism Spectrum

Disorder, but not Restricted and Repetitive

Behaviors

• Difficulties with both Verbal and Non-Verbal

Communication (social cues)

• Difficulties with how language is used to

communicate socially (pragmatics)

Medications You May Encounter

• There is no particular medication to treat

autism spectrum alone

• The need for medications depends on

comorbid symptoms, most commonly of

ADHD/hyperactive or inattentive, anxiety,

depression, sleep disorder, and irritability

Stimulants

• Two categories: Methylphenidate and Amphetamines

• Methylphenidates

• Ritalin (methylphenidate)

• Concerta (methylpehnidate)

• Focalin (dexmethylphenidate)

– Amphetamines:

• Adderall (amphentamine salts)

• Vyvanse (lisdexamphetamine)

• Long-Acting vs. Short-Acting

• Dosing considerations: Low and slow

• Side effects

Non-stimulants and Alpha Agonists

• Strattera (atomoxetine)

– Useful with ADHD refractory to stimulants or

ADHD with anxiety

• Alpha-agonists

– Tenex (guanfacine)

– Catapres (clonidine)

– Side effects and benefits

Atypical Antipsychotics

• Risperdal (risperidone)

• Abilify (aripiprazole)

• Side effects: weight gain, diabetes,

cholesterol and lipids

• Only consider if significant agitation/irritability

and safety concerns

• Use as a temporary solution

• Blood testing

Depression and Anxiety

• Consider SSRI use

• Useful for symptoms of significant anxiety

from repetitive behaviors and obsessive-

compulsive disorder

Complementary and Alternative Treatments

• If a CAM therapy is safe and effective then recommend

• If a CAM therapy is safe but effectiveness is unknown

then tolerate

• If a CAM therapy has a concern for safety but is effective

then monitor closely

• If a CAM therapy is unsafe and not effective then advise

against

• Evaluating health information

• www.asatonline.org

Quick Introduction to Behaviorism

• Francis Galton and Eugenics (1883-WWII)

• Ivan Pavlov’s dogs (1901) – Beginning of Classical Conditioning

– Unconditioned Stimulus Unconditioned Response

– Conditioned (Neutral) Stimulus Conditioned Response

– Repeated pairings of an US and CS will eventually elicit CR

• John Watson, Behaviorism, and “Little Albert” (1913-1920) – Classical conditioning can also work on people

• B.F. Skinner and Operant Conditioning (1937) – Voluntary changes in behavior Consequences

– Chaining of behavior

– Question of “free will”

Principles of Behavior Analysis

• Behavior is largely a product of the environment – Behavior is strengthened/weakened based on “the

environment’s” response to the behavior

• Whether a behavior is punished or reinforced can only be seen by observing the behavior in the future – If a behavior increases, it is being reinforced by

something. If it decreases, it is being punished.

• Problem behaviors compete with appropriate behaviors – And usually win (easier, more reinforcement)

Reinforcement and Punishment Type of Consequence

Reinforcement (behavior

is more likely to occur in future)

Punishment (behavior is

less likely to occur in future)

Positive+ (something is added to the environment)

Giving a child a prize for good behavior

Spanking or scolding a child for throwing a toy

Negative - (something is removed from environment)

Child tantrums in a crowded store and is removed from the situation

Putting a child in a time-out for hitting

Determine the Function of Behavior

• All behavior serves a function

– If we know the function, we can alter the behavior

• Functional analysis of behavior

• A B C’s of Behavior

– Antecedent

– Behavior

– Consequence

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Functional Analysis

Behavior: Date:

Where did the behavior happen?

Who was involved?

When did the behavior happen?

What happened before the behavior?

What happened after the behavior/how was it handled?

Why do you think the behavior occurred?

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Possible Functions of Behavior

• Gain attention

• Gain desired item or activity

• Escape from an unpleasant

situation

• Make a comment or

declaration/protest

• Habitual

• Sensory stimulation

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Function of Behavior continued…

• Once we determine the function of behavior,

we can intervene at 2 points:

– Antecedent Control

• Find way of reducing factors in the environment that

may trigger behaviors

• Find ways of reducing the impact/effect size of triggers

– Consequences

• Reinforce positive behavior

• Punish negative behavior

Antecedent Control • Control environment so that

expectations and commands are clear

• Consistent schedule to minimize anxiety and improve predictability

– Use visual schedule if need be

• Structure environment to minimize distractions

– Separate work and play areas

• Help child and parents learn functional communication

Reinforcement: Contingency Management

• Positively reinforce behavior

• Token Economies

– Star/Sticker Charts

– Tokens “cashed in” for rewards

• Level Systems

– Based on behavior, different levels of access to rewards or privileges are available

Punishments • Time-outs

– Chair time-out or room time-out

– Roughly one minute per child’s age in years

– Possibly add “quiet time”

– Remove access to privileges; remove attention

• Remove Preferred Items or Activities

• Planned Ignoring

Behavioral Treatment Approaches

• Applied Behavior Analysis (ABA)

• Behavior Modification

• Treatment and Education of Autistic & Related Communication-Handicapped Children (TEACCH)

• Picture Exchange Communication System (PECS)

• Parent-Child Interaction Therapy (PCIT)

• Social Skills Groups

• Systematic Desensitization

• Cognitive Behavioral Therapy (CBT)

Organization of TEACCH Independence

Task Organization

Independent Work Systems

Daily Structure (Schedules)

Physical Structure (Organizing room/area so expectations are clear)

Disorders/Problems that can be Treated Behaviorally

• Autism Spectrum Disorder

• Intellectual Disabilities

• ADHD

• DBD-NOS, ODD, CD

• Addiction, Substance Abuse

• OCD, Anxiety

• Depression

• Specific Phobias

Autism Resources

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

• http://www.autismspeaks.org/

• http://www.autismillinois.org/

• http://teacch.com/

• http://www.asatonline.org