Meeting the Behavioral Healthcare Needs of Individuals with Autism Spectrum Disorder and Co-occurring Psychiatric Disorder John J. McGonigle, Ph.D. Assistant Professor of Psychiatry and Rehabilitation Science Technology University of Pittsburgh,

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Meeting the Behavioral Healthcare Needs of
Individuals with Autism Spectrum Disorder and
Co-occurring Psychiatric Disorder John J.
McGonigle, Ph.D.Assistant Professor of
Psychiatry and Rehabilitation Science
TechnologyUniversity of Pittsburgh, School of
MedicineCenter for Autism and Developmental
DisordersWestern Psychiatric Institute and
Clinic of UPMC
Martin J. Lubetsky, MDAssociate Professor of
Psychiatry University of Pittsburgh, School of
Medicine Chief, Child Adolescent Psychiatry
and Center for Autism Developmental
DisordersWestern Psychiatric Institute and
Clinic of UPMC
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Overview

• Current directions in supporting people with
  Autism Spectrum Disorder and Co-occurring
  Psychiatric Diagnoses
• Assessing psychopathology in persons with Autism
• Barriers to obtaining an accurate diagnosis
• Common psychiatric diagnosis in ASD
• Processing difficulties, impulse control and
  challenging behavior
• Role of Functional Behavior Assessments in
  differentiating diagnoses
• Treating the underlying syndrome the process
• Components of a Positive Behavioral Support Plan
• Ways to present mental health information to the
  psychiatrist and review of possible medication
  options

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Dual Disabilities (Autism/ Mental Illness)

• Autism and Mental Illness are two different
  disabilities
• ASD is a neurological impairment with core
  features that are expressed in communication and
  social skills deficits and restricted patterns of
  behavior (DSM-IV-TR, 2000)
• Mental Illness refers to the severe disturbances
  of behavior, mood, thought process and/ or social
  and interpersonal relationships (Reiss, 2000)

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Impact of psychiatric co-morbidity can include

• Increased health care utilizations and costs
• increase likelihood of contact with police
• Increase likelihood of multiple placements
• Increase likelihood of admission to a psychiatric
  hospital
• Decrease adherence to treatment regimens
• Increased morbidity and mortality
• Higher potential for drug interactions due to use
  of
• multiple medication
• Increased likelihood of medical complications

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Unmasking Psychiatric Disorder in Autism
Spectrum Disorder
Despite the growing realization that people with
an ASD are prone to increased risk for mental
health problems, clinicians continue to be
challenged in recognizing psychiatric disorders
in the presence of ASD
Understanding the impact of the individuals
Autism diagnosis on the clinical features of a
mental health problem is crucial for both
diagnosis and intervention
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Clarity in Diagnosis

• For persons with mild degrees of Autism and
  individuals with Aspergers Syndrome, standard
  clinical interview techniques can often apply and
  are sufficient for the diagnostic process
• For individuals with moderate and severe degrees
  of Autism the diagnostic process becomes a
  challenge for clinicians
• Limited ability to self report
• Assessing impact of depression on cognitive
  abilities in persons who are non verbal
• Poor insight and comprehension regarding
  presenting concerns
• Clinician has to rely on reports from other who
  may give unreliable information

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Optimal Psychiatric Diagnosis in Autism Spectrum
Disorder requires an extensive data base

• Developmental and family history
• History of behavioral concerns (chronic/ acute)
• Departure form the persons baseline
• Episodic course
• Current mental status

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Clinicians working with people with Autism
are prone to two types of errors

• Fail to identify the presence of a mental health
  problem
• Decomposition addition of other psychiatric
  symptoms
• Isolation - Restrictive Interventions -
  Hospitalization

• 2. Risk of making an inaccurate diagnosis
• Increase in challenging behaviors
• Increase in medication PRNs and (polypharmacy)

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• Persons with Autism Spectrum Disorder are a
  highly heterogeneous group, and great clinical
  variability is seen within this population
• No two individuals are alike
• Treatment needs to be individualized
• Treatment is most often multi-faceted and
  multidisciplinary
• Accurate diagnosis and treatment require time,
  patience and team work

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Clinical IssuesLovell Reiss (1993)
Intellectual distortion patient is unable to
label and report on his/ her own experience
Psychosocial masking as a result of improvised
social skills, mis-assumption of nervous and
illness as psychiatric symptoms
Cognitive disintegration a stress induced
disruption of information processing that
presents as psychotic features (self talk, or
imaginary friend)
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Ten Diagnostic PrinciplesSovner Hurley (1989)

1. Persons with developmental disabilities suffer
   from the full range of psychiatric disorders
2. Psychiatric disorders usually present as
   maladaptive behavior
3. The origin of psychopathology is multi-determined
4. Acute psychiatric disorder may present as an
   exaggeration of a longstanding maladaptive
   behavior
5. Maladaptive behavior rarely occurs alone

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Diagnostic Principles (continued)

• 6. The severity of the problem is not
  diagnostically relevant
• 7. The clinical interview alone is rarely
  diagnostic
• 8. It is virtually impossible to diagnose
  psychotic disorders in patients with moderate or
  greater intellectual involvement
• severely involved / Aspergers (Passions
  from Psychoses)
• 9. Maladaptive behavior can be organized into a
• behavioral hierarchy (first, second and
  third order)
• 10. State and trait psychopathology frequently
  coexist

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• Common categories of acute behavioral
  presentations
• Aggression, self-injurious behavior,
• property destruction
• New onset or escalation of aggression,
  self-injurious behavior,
• or destruction of property or a combination of
  behavior
• Changes in mental status, such as
• Hyperactivity or irritability
• Confusion or disorientation
• Lethargy or withdrawal
• Psychotic symptoms
• Other changes in mood, energy, eating or sleep
  patterns
• Medication side effects, especially
  extrapyramidal symptoms
• Physical complaints or behavioral manifestations
  that might
• signify physical illness

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Approaches to Challenging Behavior

• Identify the problem
• Differential Diagnosis
• Quality of Life or Lifestyle issues
• Medical/ Neurological/ Trauma
• Addictions
• Mental Illness
• Rule out Non-Psychiatric causes
• (specific vs non-specific)
• When challenging behaviors serve multiple
  functions, address those derived from biological
  / medical first
• Obtain a working diagnosis
• Tailor treatment to the diagnosis

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Psychopathology Screening QuestionsSovner

• 1. Is there a significant change in the persons
  behavior or mood that occurs in all settings
  rather than in some setting?
• 2. Is there little or no improvement in the
  persons behavior despite the application of
  consistent, high quality behavior intervention?
• 3. Has the person experienced a decreased ability
  to adapt to the demands of daily living (e.g.,
  decrease in self care and ADLs)?

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Psychopathology Screening Questions continued

• 4. Has the person experienced a decrease in
  involvement with others?
• 5. Has the person lost interest in previously
  preferred activities?
• 6. Has the person had an overall change (increase
  or decrease) in motivation levels?
• 7. Has the person shown/ expressed impairments in
  his/ her perception of reality such as,
  responding to internal stimuli (voices or false
  beliefs)?

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Treating the Underlying Syndrome The Process
Assessment
Symptoms
Differential Diagnosis
Working Diagnosis
Treatment
Psychopharmacology
Is this an adequate medication trial
What else could be tried
Partial response
Response
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More common types of psychiatric disorders in
people with Autism Spectrum Disorder

• Depression and Mood Disorders
• Anxiety Disorders and OCD
• Intermittent Explosive or Impulse Control
  Disorder
• PTSD
• Adjustment Disorder
• Psychotic Disorders / Schizophrenia
• Personality Disorders

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Psychiatric Diagnosis and Behavioral Equivalents
in Individuals with Autism Spectrum
Disorder
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Types of Symptoms
Neurovegetative Sleep difficulties, changes in
appetite, weight loss or gain Affective
Sadness, euphoria, grandiosity, mood swings,
decreased interest in pleasurable activities or
excess interest. Cognitive Difficulty in
concentrating, distractibility, memory and
orientation Perceptual Thought distortion,
delusions, hallucinations, racing
thoughts Behavior Aggression, self injury, loss
of ADLs, changes in speech patterns (volume,
rate)
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Depression risk factors

• family history of depression
• loss of parent or loved one
• break-up of romantic relationship
• loss of job
• trauma
• learning difficulties, school failure, job loss
• recent life changes/ transitions

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Depression in Autism Spectrum Disorder
Evidence suggests that depressive symptoms are
the most common psychiatric concerns among
individuals with ASD Depressive symptoms are
more likely to occur in adolescence and adults
(Ghaziuddin,2002 Rutter 1970 Wing, 1981)
Depressive symptoms have been noted to exacerbate
the core ASD characteristics resulting in reduced
communication, social withdraw and isolation,
psychomotor agitation, self mutilation and self
injury, obsessive compulsive and ritualistic
behavior and sleep disturbance (Lainhart, 1999
Perry, et.al. 2001)
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Subtle Signs of Depression in Autism Spectrum
Disorder
Wanting to be alone / talk about people who have
passed away
Decrease interested in preferred activities and
people
Loss of skills / decrease in performance
(attention / memory)
Increase in need for structure and ritual
/compulsive behaviors
Change in the character of the obsession
(increase / decrease)
Agitation / Irritability
Spontaneous crying episodes
Increase in self injury /self mutilation and talk
about self harm
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Characteristics Associated with
Presence of Depressive Symptoms in Adults
with Autism Sterling, Dawson, Estes
Greeson, (2008)
Depression factors when screening for persons
with ASD
Individuals with less social impairments, higher
cognitive ability and higher rates of other
psychiatric symptoms were more likely to report
depressive symptoms
Children with ASD presenting with depressive
symptoms are more likely to have a family
history of depression and mood disorders
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Autism Depressive Symptoms (continued)
Wing, 1981 suggested that those individuals with
more social awareness are more likely to
experience depressive symptoms
Children and adolescents who have social
awareness and experience school related social
failure are vulnerable to developing depressive
symptoms
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What is Psychosis?
Psychosis describes conditions which affect the
mind where there has been loss of contact with
reality

• Symptoms of Psychosis
• Confused Thinking
• False Beliefs
• Hallucinations
• Unpredictable Mood changes
• Sudden Behavior Changes

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Autism and Schizophrenia Dvir, Y., Frazier, J.,
A. (2011) Psychiatric Times

• Low incidence - shared clinical features
• Although the disorders are distinct, ASD
• and Schizophrenia have shared clinical features
• Social withdraw
• Communication impairment
• Poor eye contact
• During periods of cognitive dysregulation
  (meltdowns),
• higher functions individual with ASD may
  appear to
• have a thought disorder or paranoia

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Adjustment Disorder
  Adjustment Disorders Common Characteristics Rela
tes to a significantly more difficult adjustment
to a life situation than would normally be
expected considering the circumstances.  The
disorders in this category can present themselves
quite differently with varying degrees of
duration and intensity.  The key to diagnosing
is to look at (1) the issue that is causing the
adjustment disorder (2) the primary symptoms
associated with the disorder. 
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Differentiating Behavior Problems from
Psychiatric Disorder in Persons with Autism
Spectrum Disorder
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Information Processing Deficits
Input taking in information
Processing comprehending the
information
Output translating into actions
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Executive Functioning Deficits
Emotional Regulation and Impulse Control

• Behavioral Flexibility
• Internal level of Arousal
• Impulse Control
• Self Assessment / Self Monitoring

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Impulse Control Difficulties
Input Process
Output Setting
Thoughts Events
Emotion
Behavior Directives

People Perception
Aggression Internal
Internal
Arousal Self Injury

Increases


noncompliance

Decrease Threshold

for aggression / self
injury
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Functional Behavior Assessments
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What is an FBA?

• An approach used to help the person with acute or
  chronic behavior problems
• It is a problem solving method requires team
  work and a collaboration among professionals and
  parents
• FBA is based on the assumption that if repeated
  atypical, challenging behaviors are expressed by
  the individual that behavior must be serving some
  purpose for the person
• FBAs are used to help identify , functions,
  purpose, reasons, etiology for identified
  patterns of behaviors, or verify a medical
  condition or disability.

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The Functional Behavior Assessment is part of a
6 step process

• Step 1. Specifically define the behavior of
  concern
• (Form / Topography )
• Step 2. Choose a method to assess (Records
  review, interviews, Rating Scales, Direct
  Observation
• (Function/ Motivation)
• Step 3. Select an accurate data system and
  collect data

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FBA Process Steps (continued)

• Step 4. Analyze the data and develop a hypotheses
  based on the data analysis
• Step 5. Develop a Positive Behavior Support Plan
  that is individualized to the person / family
  needs and based on the presumed etiology /
  function of the behavior of concern
• Step 6. Evaluate the effectiveness of the
  interventions plan

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Motivations / Etiology for Behavioral Concerns

• Biological (Genetics Behavioral Phenotypes)
• Physiological (Hunger, Thirst, Pain)
• Medical (Dental, Seizures, Apnea, Hypoglycemia)
• Psychiatric / Emotional / Behavioral
• Medication (Side Effects)
• Developmental Delay / Trauma
• Environment (including caregiver interactions)
• Cognitive / Executive Functioning Deficits
  (Processing)
• Communication (Expressive / Receptive)
• Social Skills Deficits
• Attention (gaining access to preferred items)
• Escape Avoidance (unpleasant situations /
  experiences)
• Sensory (Self Stimulation)

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Interventions Positive Behavior
Support Plans
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The ultimate goal of a behavior support plan
To create environments and patterns of support
around the individual that make the behaviors of
concern irrelevant, ineffective, or inefficient.
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Best Practice for Interventions
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Categories of Treatment

• Treatments with strong empirical support
• Treatments with limited empirical support
• Treatments with no empirical support

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Treatment Principles

• Step 1 Conduct Functional Behavior Assessment
• Step 2 Develop Hypothesis about the etiology
  of the symptoms / Challenging Behavior
• Step 3 Select a medication or behavioral
  intervention which is directed to primary cause
  of the persons symptoms or challenging behavior

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Treatment Principles (continued)

• Step 4 Specify what will constitute a
  therapeutic trial of selected drug or adequate
  response time for a behavior plan to take effect
• Step 5 Start treatment / intervention only
  after an objective monitoring system is in place
• Step 6 Decide in advance what will constitute
  a positive treatment response

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Best Practice Models

• Use Bio-Psycho-Social Model
• Successful programs have teaching environments
  and generalization strategies
• Application of Applied Behavioral Analytic
  Approach
• Supportive transitions across programs
• Interventions are based in Positive Approaches
• Active person and family involvement
• Motivations before Medications
• Multi-dimensional intervention approach

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Impulse Control Difficulties
Input Process
Output
Setting
Thoughts Events
Emotion
Behavior Directives

People Perception
Isolation Internal
Internal Arousal
Perseveration

Increases Derogatory Comments





Decrease Threshold

for impulsivity



A N X I E T Y
Fear
confusion
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Counseling and Psychotherapy Considerations for
Therapists working with Aspergers patients
Type of Therapist / Counselor and Therapy
Persons with Aspergers receive more benefit
from therapists who provide structure, direction,
verbal and visual information and
suggestions Less benefits from therapists who
rely on talk therapy only which relies on
reflection, emotional encouragement, and support
while patients develop their own solutions
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Therapists consideration (continued)
Poor communication skills make interpretation of
verbal and non-verbal cues difficult i.e., poor
eye contact, poor voice modulation, atypical
affect, or other idiosyncratic communication
tendencies. Perseverating on one topic or
making odd metaphors is not uncommon. The
therapist must be aware that some comments made
by patients should be taken literally (Ramsay et
al., 2005). Sensitive to criticism Feedback on
the content of the conversation can occur
immediately Feedback on non-verbal behavior
should wait until a therapeutic relationship has
been developed Feedback should always be
followed by a rational behind the comment
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Therapists consideration (continued) Individuals
with Aspergers have poor communication skills,
making interpretation of their verbal and
non-verbal cues difficult. They may have poor
eye contact, poor voice modulation,
inappropriate affect, or other idiosyncratic
communication tendencies. Perseverating on
one topic or making odd metaphors is not
uncommon. On the other hand, the therapist must
be aware that some comments made by patient
should be taken entirely literally (Ramsay et
al., 2005).
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CBT for Anxiety and OCD for Aspergers Syndrome
Need to accommodate for the cognitive profile of
the individual (Atwood, 2003) The use of
visuals and direct instruction are most
beneficial Treatment needs to be
experiential Individual with Aspergers learn
more by doing than talking Modeling /
demonstration / role play and practice enhance
treatment outcomes (Ramsay, 2005) The
combination of family / caregiver groups with CBT
are more effective than person in therapy alone
Sofronoff, Atwood Hinton (2005)
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Cognitive Behavior Therapy (CBT) in Autism
Spectrum Disorder
Jeffery Wood UCLA Department of Education
Division of Psychological Studies
Adapting Traditional CBT Approach for Aspergers
Phase 1 Understand Anxiety physiological /
learning body cues recognizing facial expressions
/ cues in the environment behavior chain analysis
/ logs / journaling
Phase 2 Skill set training Relaxation
Training, de-escalating positive self talk,
self reinforcement. (Scripts)
Phase 3 Skills practice De-sensitization -
gradual exposure to challenging fear environments
/ situations to develop confidence and mastery,
self assessment / self monitoring
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Cognitive Behavior Therapy

• CBT includes a focus on developing new skills.
• CBT is brief and time-limited. The therapist will
  typically
• set specific goals and remain focused on these
  goals
• throughout treatment, which generally lasts 12 to
  16 sessions.
• CBT focuses on the present. While a CBT therapist
  is
• likely to agree that the roots of Social Phobia
  may be due,
• in part, to experiences during childhood, the
  emphasis of
• treatment is on uncovering the current cognitive
  and
• behavioral patterns that are causing and
  maintaining
• symptoms and making changes in your present life.

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Cognitive Behavior Therapy (continued)

• CBT is structured. Each session has specific
  objectives
• and agendas.
• CBT emphasizes between-session exercises
• (often referred to as homework) that you complete
  on
• your own. These activities / tasks are planned
  with
• the therapist and are intended to provide you
  with actual,
• "real-life experience working with new ways of
  thinking
• and behaving.
• CBT is Evidenced-based. CBT addresses a variety
  of
• Anxiety symptoms and clinical studies and have
  been shown to be effective for the general
  population.

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Social Anxiety / Social Phobia

• Cognitive Behavioral treatment draws on a number
  of
• therapeutic strategies when addressing Social
  Phobia.
• While the specific approaches used may vary
  based on
• individual symptoms, the therapist, and the
  setting in which the person is being treated, CBT
  for Social Phobia often includes some of the
  following components

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Psychoeducation
Perhaps one of the most difficult aspects of
coping with Social Phobia is simply
understanding what it is, where it comes from,
and how it keeps coming back. Psychoeducation
involves the individual and the therapist
working together to develops ways to identify on
how it is expressed and understand Social Phobia,
and subsequently, how to work with it. Video
Modeling, Toastmasters
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Cognitive Restructuring
Cognitive Restructuring Individuals with Social
Phobia frequently hold negative beliefs about
themselves and others, which often are barriers
in successful social situations. Cognitive
restructuring is an important component of CBT,
and it involves working with the therapist to
identify these thoughts and look for patterns
that may cause them as well as how they are
expressed behaviorally. As the individual
becomes skilled at noticing these negative
thoughts, it is then important to develop
strategies for gaining flexibility in thinking
and considering more positive ways of looking at
the experiences.
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In Vivo Exposure
In Vivo Exposure / desensitization In vivo (real
life) exposure is another core element of CBT for
Social Phobia. The individual and the therapist
identify situations that the person avoids
because of Social Phobia, and then gradually
enter these situations while identifying
beginning signs of anxiety and alternative ways
to reduce anxiety as opposed to escape / avoid
the experience. This step can be quite
intimidating, it is important for the individual
to experience the anxiety by brief exposure that
is systematically planned is gradually increased
over time. Exposure practices can be among the
most useful CBT elements in their treatment.
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Social Skills Training
Social Skills Training In the midst of an
unpleasant social situation, many people with
ASD and Social Phobia fear that they do not have
the necessary social skills to successfully
navigate the exchange. In many instances this
may be due to negative self-talk and
self-consciousness (rather than an actual lack
of skill), In this case the Social skills
training should focus on Effective communication
and active listening. Social skills training
provides a chance to work on these areas in the
therapy session.
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Social Skills Instruction for Adolescent with
High Functioning Autism White, S., W., Koenig,
K., Scahill, L. (2012)

• Components of successful Instruction program
• High Degree of Structure and Predictability
• Explicit teaching
• Use of verbal and visual teaching aides
• Frequent repetition
• Parental / caregiver involvement

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Session Breakdown

• Warm-up brief introduction of the session
• Homework / assignment review
• Skills teaching (Didactic)
• Skills practice (role-play / games)
• Group snack
• Free time for socializing with peers

Wrap-up - Brief Review of the session
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Self Awareness / Monitoring IssuesExecutive
Functioning Deficits

• Challenges with Self Assessment Self
  Monitoring
• Teaching Self-Assessment - Direct Instruction
• (initially make behavior specific)
• (factual info behavior did or did not occur)
• May require some demonstration / modeling on
  desired or expected behaviors. (periodic checks
  with the person on specific behaviors,
  activities)
• Disconnect between affect (how person looks) and
• internal arousal (how person feels)
• Ways to assessing internal levels of
  arousals
• (Likert Scales / Faces/ Pictures, Thermometer,
  Volcano, Dinosaurs)

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Problem Solving / Concept Formation
What was the issue or problem____________________
___________
What happened? Look for sequence of
events________________
What did you do?__________________________________
__
Positive Behaviors
Negative Behaviors
Did your behavior solve your problem?
_____ Yes _____ No
Did it make the problem worse?
_____ Yes _____ No
What should you do the next time?
_________________________
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Using Technology as a component to
CBT Problem
Solving / Anger Management / Relaxation Programs
Scripting/ acceptable and unacceptable small
talk topics Cognitive Rehearsal Review prior to
event to reduce anxiety
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Providing Good Clinical Care includes

• Establishing trust between all partners
• Respect the opinions of all team members
• Be consistent and predictable
• Include the consumer, family/caregivers/ Peer
  Mentors in developing the plan
• Secure expertise when necessary (consultants)
• Communicate / Disseminate latest research and
  treatment information
• Treatment is fully intergraded with other
  disciplines (medicine neurology, sleep, GI)
• Treatment plans are team based and developed in
  the Positive Approaches Philosophy
• Treatment plans are team based and developed in
  Positive Behavior Supports
• Be Creative / Think out of the box / Team work

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Selecting a medication for treatment

• No specific medication to treat core symptoms of
  Autism
• Select medication based upon symptom cluster and
  co-occurring diagnosis
• Informed consent information
• Off-label use for FDA-approved medications

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Informed consent for medication

• Name of medication, dose, schedule
• Effects/ benefits
• Side effects, monitoring
• Pharmacokinetics, duration of action
• Limitations
• Alternatives

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Medication classes

• Stimulants
• Typical and Atypical Neuroleptics
• Antidepressants
• Mood stabilizers (Antimanics)
• Anxiolytics and Sedatives
• Anticonvulsants
• Others

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Inattention, distractibility, impulsivity,
hyperactivity (ADHD) - stimulants

• 2005 MPH study of over 60 children with ASD found
  around 50 response rate with 18 having side
  effects (NIMH RUPP)
• Short-acting (4-6 hrs) Ritalin, Metadate,
  Focalin, Dexedrine, Adderall
• Long-acting (6-12 hrs) Concerta, Metadate CD,
  Ritalin LA, Focalin XR, Adderall XR, Vyvanse

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Inattention, distractibility, impulsivity,
hyperactivity (ADHD) - nonstimulants

• atomoxetine (Strattera)
• clonidine (Catapres)
• Kapvay extended release (2010)
• guanfacine (Tenex)
• Intuniv extended release (2009)

69
NIMH multi-center risperidone study in autism
2002

• Double-blind, placebo-controlled study
• 101 individuals with autism spectrum disorder
• Doses ranged from 0.5 to 3.5 mg/day
• 69 improved on risperidone vs. 11 on placebo

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NIMH multi-center risperidone study in autism
2002

• 57 decrease in symptom severity
• Symptoms returned during placebo discontinuation
  for 62 of individuals
• Research Units on Pediatric Psychopharmacology
  Autism Network Risperidone in children with
  autism and serious behavioral problems. N Engl J
  Med 2002 347314321

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Risperidone in autism

• 10/2006 FDA approval for the treatment of
  irritability associated with autistic disorder,
  including symptoms of aggression, deliberate
  self-injury, temper tantrums in children ages
  5-16
• To treat symptoms but not the disorder
• Possible side effects of weight gain, sedation,
  constipation, salivation, etc.
• Monitor for movements - EPS, TD
• Baseline and follow-up weight, height, BMI,
  (consider fasting glucose and lipid panel)

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aripiprazole Abilify

• 11/2009 FDA approval treatment of irritability
  associated with ASD in children age 6-17
• First study titration with most 5 or 10mg/ day
  improved scores on ABC irritability
• Second study 5, 10 or 15mg fixed dose
• Recommendation to start at 2mg/day, titrate 5mg,
  then 10 mg or 15mg if needed gradually

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Aggressive, impulsive, agitated (psychotic, manic
disorders)

• atypical neuroleptics FDA Advisory
• risperidone (RISPERDAL)
• aripiprazole (ABILIFY)
• olanzapine (ZYPREXA)
• quetiapine (SEROQUEL)
• ziprasidone (GEODON)

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FDA Advisory- atypical neuroleptics

• FDA requested updated labeling to include
  additional information on potential for weight
  gain, and glucose abnormalities (hyperglycemia/
  diabetes) with Risperdal, Zyprexa, Seroquel,
  Geodon, Abilify, Clozaril.
• monitor weight, height, BMI
• may choose to monitor fasting glucose,
  cholesterol, lipid panel

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Anxiety, rituals, compulsions, sadness
(depression anxiety disorders, OCD)

• Antidepressants - SSRIs FDA Warning
• fluoxetine (Prozac)
• sertraline (Zoloft)
• paroxetine (Paxil)
• fluvoxamine (Luvox)
• citalopram (Celexa) no better than placebo for
  repetitive behaviors RUPP 6/2009
• escitalopram (Lexapro)
• venlafaxine (Effexor), bupropion (Wellbutrin)
• -side effects can include irritability,
  activation,
• insomnia, tiredness, weight gain

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FDA Warning- antidepressants

• FDA asked manufacturers of antidepressant
  medications to include in their labeling a
  warning statement that recommends close
  observation of adult and pediatric patients for
  worsening depression, or the emergence of
  suicidality when treated with Prozac, Zoloft,
  Paxil, Luvox, Celexa, Lexapro, Wellbutrin,
  Effexor, Serzone, Remeron
• and Strattera

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Mood lability and aggression(bipolar disorders)

• Lithium
• Anticonvulsants divalproex (Depakote),
  carbamazepine (Tegretol), topiramate (Topamax),
  lamotrigine (Lamictal), oxcarbazepine (Trileptal)
• side effects can include irritability,
  activation, tiredness, weight gain, blood
  abnormalities
• some require regular blood work monitoring
  (difficult in ASD)

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Networking resources

• ASA (Autism Society of America)
  www.autism-society.org
• Autism Speaks www.autismspeaks.org
• Organization for Autism Research (OAR)
  www.researchautism.org
• Interactive Autism Network (IAN)
  www.ianproject.org

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References
Bodfish, J. W., Symons, F. J., Parker, D. E.,
Lewis, M. H.(2000). Varieties of repetitive
behavior in autism Comparisons to mental
retardation. Journal of Autism and Developmental
Disorders, 30, 237243. De Bruin, E. I.,
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