Updates in Autism: Behavioral and Medical Treatments1. To learn about updated autism spectrum...
Transcript of Updates in Autism: Behavioral and Medical Treatments1. To learn about updated autism spectrum...
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
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Age-related Trends in Illinois
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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