Medication Management in Autism and Co-Morbid DiagnosesSherlene T. Dean APRNUniversity of Utah HOME programMatt’s Place

Components of a Psychiatric Evaluation

• History of Present Illness• Determine the diagnoses

• Previous Psychiatric History• Social History• Medical History• Family History• Previous Medication Trials

Common Co-Morbid Diagnoses• Anxiety:

• Specific phobia 44%• Needles and/or shots, crowds, loud noises• Typical fears (stores, bridges, tunnels were low)

• Separation anxiety 12%• Social Phobia 7%• GAD- more of a trait of ASD than its own dxs• OCD 37%

-Leyfer, et al. Comorbi psychiatric Disorders in Children with Autism, 2006

Common Co-Morbid Diagnoses• ADHD 31% (Subsyndromal 55%)• MDD 10% (Subsyndromal 24%)• No schizophrenia, psychosis, ODD or panic in kids,( 10% in adults

have psychosis) • 1%+ had mania

• Average # of diagnoses per child: 3

• 72% had at least one diagnosis in addition to ASD

• Why?

Autism and Medications

Autistic brains are “Tender” brains- Common to have atypical responses to medication

Where do we start:• Sleep (and/or Psychosis)• Mood Disorders• Anxiety • Depression• ADHD

Medication Classifications• ADHD• Anti-Depressant, Anti-Anxiety• Tic Disorders• Anxiolytics• Mood Stabilizers• Anti-Psychotics / Atypical Anti-Psychotics • Sleep

ADHD Medications• Stimulants• Methylphenidate (Concerta, Ritalin, Focalin, etc)• Dextroamphetamine salts (Adderall, Vyvanse)• Dextroamphetamine (Dexedrine)

• Non-Stimulants• Clonidine, Tenex• Wellbutrin• Strattera• Others

ADHD Medications• Side effects to watch for:• Decreased appetite• Increased heart rate and Blood pressure• Nervous, Irritable- May make anxiety worse• Headache, Dry Mouth, Nausea, Dizzy• Insomnia• Tolerance concerns• Tics

Anti-Depressants, Anti-Anxiety • SSRI• Celexa, Prozac, Zoloft, Lexapro, Luvox, Paxil • Remeron, Trazodone- more common for sleep

• SNRI• Wellbutrin, Effexor, Cymbalta

• Buspar• TCA (tricyclics) watch EKG• Monoamine Oxidase Inhibitors (MAO)

Anti-Depressants, Anti-Anxiety • Side Effects to watch for:• Suicide• GI upset• Restlessness, agitation, irritability, tremors• Weight gain or loss• Insomnia, sedation• Trigger mania?

Tic / Tourettes Disorders

-Is Anxiety under control?-wax and wane over time

Clonidine and Tenex (Blood Pressure meds)• Also for ADHD-I, sleep, PTSD, anxiety• Watch for: sedation, dizzy, headache, constipation, dry mouth,

confusion, drop in BP and/or heart rate• Risperdal (mood, anxiety, agitation,psychosis)

Anxiolytics

Used for sleep, anxiety, panic, insomnia, mania, aggression, seizures

Xanax, Klonopin, Ativan, Valium, Buspar, Restoril

Watch For: weight gain or loss, dizzy, paradoxical agitation, somnolence / sedation, blurred vision

Mood Stabilizers• Traditional• Tegretol, Lamictal, Depakote

• Also called anti-epileptic (seizure) medication• Lithium (tremor, wt gain, acne, kidney, thirst, sun)

• Side effects to watch for:• Blood levels, sedation, cognitive dulling• Weight gain• rashes

Adjuvant Mood Stabilizers• Supportive Role• Neurontin- helps with anxiety & migraine • Trileptal –helps with anxiety• Topamax- helps with migraine • Gabatril- helps with migraine

• Side Effects to watch for:• Sedation, dizzy, ataxia, GI upset, cognitive dulling, Vision changes,

tremor, appetite increase or decrease, others.

Second Generation Anti-Psychotics / Mood Stabilizers

• Abilify- schizophrenia, mood stabilization• Zyprexa- + agitation• Seroquel- + anxiety, PTSD• Risperdal- + Tics, Tourettes• Geodon- + Tics, Tourettes

Second Generation Anti-Psychotics / Mood Stabilizers

• What to watch for:• weight gain (less so with Abilify)• Agitation, aggression, insomnia• Metabolic syndrome (glucose, lipids)• Constipation, dry mouth, rash• Changes to WBC• EPS

• Muscle rigidity, stiff muscles

SLEEP• Sleep Hygiene- behavioral routines• OTC: Benadryl, Melatonin, Valerian• Prescriptions• Trazodone, Remeron (also anxiety/depression)• Tenex, Clonidine (also tics, ADHD, anxiety)• Anxiolytics• Vistaril, Sonata, Ambien, Rozarem, Lunesta

Case Example• 14 yo male with a history of Autism, ADHD, Anxiety. He is on a

stimulant for ADHD, has been doing well. Presents with facial tics, insomnia, and appears more agitated than usual.

• Considerations: • Stimulant too high or too low?, anxious? Emerging mood

disorder? Environmental/Social concerns? Pain?

PRN “pro re nata” or As Needed

Anxiety- acute stress response, panicAgitation or aggressionSleep

Short term use or over a longer period of timeRisks of addiction

MEDICATION MANAGEMENT• Not going to fix everything, how much benefit is the

medication providing? %? • Realistic Expectations• Find a balance• Are we over medicating, to liberal?• Are we under medicating?

• The Placebo effect

Collect Data!• Track behaviors• Any changes in social, home, school, health• Is there a pattern, A-B-C’s

• Keep a log of meds• Start and stop dates, dosages, response

• Compliance

Pain and Constipation• A common side effect to medications

• Presentation: uncomfortable, restless, agitated, irritable, angry

• Consider Constipation or Pain as a cause for symptoms vs a side effect or med change, especially if non-verbal.

COLLABORATIONA TEAM APPROACH

• MEDICAL HEALTH PROVIDERS• EDUCATION• Teachers, psychologists, counselors• Individual with ASD

• THERAPISTS• PSYCHIATRIC PROVIDERS• BEHAVIORISTS• PARENTS• MOST IMPORTANT---THE PATIENT

Questions?

Thank You