Transcript Anxiety Disorders

Autism Spectrum Disorders and
Co-occurring Mental Health Concerns
John J. McGonigle, Ph.D.
Assistant Professor of Psychiatry and Rehabilitation Science and Technology
University of Pittsburgh, School of Medicine
Director, Western Region ASERT
Center for Autism and Developmental Disorders
Western Psychiatric Institute and Clinic
Overview
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Past Practices / Current Directions in supporting people with Autism
Defining Dual Diagnoses
Barriers to obtaining an accurate diagnosis
Common Psychiatric Diagnosis in Autism
Role of Functional Behavior Assessments in differentiating diagnoses
Treating the Underlying Syndrome: The Process
Monitoring / Tracking response to medications
Ways to present mental health information to the treating psychiatrist during
the office visits
past practices
changing times
culture of control
protocols
diagnosis not accurate
old generation meds
sedation
chemical restraint
behavior modification
suppression / reduction
limited knowledge of etiology
current trends
culture of care/support
Recovery / Self determination
treatment is individualized
more accurate diagnosis
new generation meds
Diagnosis / symptom specific
treating symptoms
behavior support
teaching alternatives
functional behavior assessment
Persons with Autism and related disorders are a highly
heterogeneous groups, and there is great clinical variability
seen within this population.
• No two individuals are alike
• Treatments and support services need to be individualized
and specific to each person and family
• Treatment is often multi-faceted and requires a cross
systems collaboration and a multidisciplinary team
approach
• Accurate Diagnosis and treatment require, expertise, time,
patience and team work
Pervasive Developmental Disorder
Asperger’s Disorder
Autistic Disorder
Rett’s Disorder
Distinct Neurodevelopmental
Childhood Disintergrative
Disorder
Disability that can reliably diagnosed
Pervasive Developmental
Disorder NOS (Atypical Autism)
Domain and Range of Functioning of
in Autism Spectrum Disorders
Measured IQ
Severe
Aloof
Gifted / Superior
Social Interactions
Passive
Active/Odd
Communication
Nonverbal
Verbal
Motor Skills
Awkward
Uncoordinated
Agile
Coordinated
Sensory Functioning
Hyposensitive
Hypersensitive
Internal Arousal
Low / Non-responsive
or
Extreme
Areas of concern when supporting
person’s with Autism Spectrum Disorder
and Psychiatric Diagnosis
• Importance of Initial and Ongoing Assessments
• Variability of the person’s presentation
• Understanding what the Challenging Behaviors (CB) mean
to the person
• Complex needs disability
•(most cases involved in three or more service areas)
• Critical need for partnerships to ensure success
Introduction
People with an Autism Spectrum Disorder have
primary symptoms in three core domains:
• Impairments in social interaction
• Impairments deficits in communication
• restricted, repetitive and stereotyped patterns of
behavior and activities.
• atypical or unusual responses to sensory
experiences.
Prevalence Studies
• Past and current epidemiological studies have
confirmed an increased prevalence of children
diagnosed with autism creating a need for
more diagnostic, assessment and intervention
supports (Fombonne 2005).
• CDC 2007 1:150
• Autism Speaks 2011 1:88
Autism
A Review of the State of Science for Pediatric Primary Healthcare Clinicians
Barbaresi, Katusic, & Voigt (2006) Archives of Pediatric Adolescent Medicine
Identification of Autism by Pediatric Primary Health Care Clinicians.
Children who fail routine developmental screening, specific screening for
Autism should be performed (M-CHAT and SCQ)
Diagnosing Autism
Comprehensive multidisciplinary assessment is required
Possible Disciplines involved
•Developmental and Behavioral Pediatrician
•Child psychiatrist
•Child Psychologist
•Speech Pathologist
•Medical Geneticist
•Physiatrist (OT/PT) Alternative Treatments
•Medical Social Worker
Identifying Infants and Young Children with Developmental Disorders in
the Medical Home: An Algorithm for Developmental Surveillance and Screening
Pediatrics (2006) 118:1 405-420
Visit
Complete
Child
at Preventative
Care Visit
schedule
early return
visit
Perform
Surveillance
Does Surveillance
Demonstrate Risk?
Is this a 9, 18 or
30 month visit?
Administer
screening tool
Administer
screening tool
Are the screening tools
Positive / Concerning?
Are the screening tools
Positive / Concerning?
Make referrals for
Developmental
Medical Evaluations
And Early Developmental
Early Intervention
Developmental
Medical
Evals
Visit
Complete
Schedule next
Routine Visit
Visit
Complete
American Academy of Pediatrics
Is a
Developmental
Disorder
Identified?
Identify as a
Child with
Special needs
PA diagnostic workgroup Algorithm
Surveillance
Parental, clinician
or care provider concerns
•High Risk status
•Red Flags
Comprehensive
Evaluation
Intake
Confirm concerns of ASD
Obtain demographic information
Early Intervention/Special Education
Involvement: 1) Confirm or refer
2) Ensure coordination
3) Follow up
Stage 1
Collect referral, historical & Initial assessment information
•Trained intake staff
•Records review
•Interviews
•Checklist / Questionnaires
Stage 2
Conduct comprehensive developmental Evaluation
Trained team of clinicians
Stage 1 data
Observations
Developmental Assessments
ASD specific Assessments
Medical Assessments
Consistent
with ASD?
Monitor
as needed
ASD diagnosis
Confirmed?
Stage 3
Conduct specialized Diagnostic Evaluation
Qualified / highly trained clinician(s)
Stages 1&2 data
Natural environment observation
Specialized evaluation tools (i.e.,ADOS,ADI-R, FBA)
•Curriculum based
assessments to
intervention Plan
•Monitor
Individuals with Autism Spectrum Disorder and
Co-occurring Psychiatric Diagnosis
Determinants of Challenging Behaviors
Biological Risk Factors
Developmental Risk Factors
Psychological Risk Factors
Defining Co-morbidity
There is a paucity of research and literature on the co morbidity
of mental health conditions in persons with
Autism Spectrum Disorders
Autism Spectrum Disorder refers to individuals that have
core deficits in three domains:
deficits in social interaction, deficits in communication, deficits
in restricted, repetitive and stereotyped behavior and activities
Mental Illness refers to the severe disturbances of behavior,
mood, thought process and/ or social and
interpersonal relationships
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
More common types of psychiatric diagnoses in ASD
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Depression and Mood Disorders
Anxiety Disorders (OCD)
Attention Deficit Hyperactivity Disorder (ADHD)
Adjustment Disorders
Intermittent Explosive or Impulse Control Disorder
Post Traumatic Stress Disorder
Schizophrenia
Stereotypy / Movement Disorders
Personality Disorders
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Examples of Co-morbid Disorders
in Autism Spectrum Disorders
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Intellectual Disabilities
Seizures
Allergies
Hypoglycemia
Sleep Disorders
Gastrointestinal Disorders
Sensory Integration
Movement and Stereotypic Disorders/Tics
Factors that influencing an accurate Psychiatric Diagnosis in Autism
Spectrum Disorders
Belief that persons with Autism can not have Mental Illness
The psychiatrist can not secure an accurate diagnosis without
relying on the patients self report and input from a variety of
sources
The psychiatrist / psychologist must formulate the diagnosis
alone in one office visit
“Diagnostic Overshadowing” All problems are related to Autism
Or Intellectual Disability
Medication masking
Medical condition that masks the psychiatric illness
Depression
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Major Depressive Disorder
Dysthymic Disorder (chronic depression)
Depressive Disorder, NOS
Adjustment Disorder w/ disturbance in mood
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 ADL’s, changes in
speech patterns (volume, rate)
Subtle Signs of Depression in Autism Spectrum Disorders
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 presentation of the obsession (increase / decrease)
Agitation / Irritability
Spontaneous crying episodes
Increase in self injury /self mutilation and talk about self harm
Mood Disorders in Autism and Asperger’s Syndrome
Depression
- Stewart, Barnard, Pearson, O’Brian (Autism, 2006)
Depression
- behavioral equivalents
• depressed, irritable -
– decreased smiling; increased whining, short
fuse, everything rubs the wrong way
• decreased interests -
– decreased responses to preferred activity and
passions; increased time spent in room or
alone (isolation)
• decreased, increased appetite -
– Fixate on measured weight (125 lbs), meal
portions
• decreased, increased sleep -
– sleep chart
Depression continued - behavioral equivalents
• activity -slowed or agitated (aggression, SIB)
Increase in verbal confrontations, pacing, perseveration,
verbalizing, rituals that may do physical harm to the
person
• worthlessness, negative self esteem -
– verbalizations “I’m no good” “retarded” “marshmallow”
• decreased concentration -
– Failing grades, school, workshop performance, not
completing homework
• death, suicidal thoughts -
– focus on people who have died in the past,
perseveration on videos with dangerous acts
talk about not wanting to live or wish I was never born
Mania - behavioral equivalents
 euphoric, elevated mood or irritable -
 increased smiling, silly, spontaneous laughing, SIB
(tattoos)
 grandiose -
 inappropriate inflated self esteem / know it all,
comparing self to celebrity status (Michael Jackson)
 decreased sleep -
 Up all night on Internet (addiction), increased
preoccupation in passions - sleep chart
 pressured, rapid speech -
 increased swearing, singing, screaming, stuttering
Mania continued - behavioral equivalents
• racing thoughts -
– rapid, disorganized speech and ideas
stammering, stuttering, sentences run together,
end or words are not clear
• distractibility -
– decrease in school performance and work
productivity. Decrease in grades pay checks are
less
• agitation -
– increased negativism, aggression, immediate
refusal refusals on demand and requests
• hypersexual– increased teasing, sexual behaviors
(masturbation), stalking (both male and female),
physical intrusiveness, explicit sexual conversations
Bipolar Disorder
–continuous, rapid-cycling
–mixed symptoms - extreme irritability,
anger, aggressive to overly silly to
sadness
–Hypersexual
–substance use
Anxiety Disorders
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Obsessive Compulsive Disorder (OCD)
Generalized Anxiety Disorder
Separation Anxiety Disorder
Panic Disorder w/ or w/o Agoraphobia
Posttraumatic Stress Disorder (PTSD)
Anxiety Disorder, NOS
Obsessive-Compulsive Disorder
• obsession - intrusive, unwanted thoughts
– perseveration on topics, past and future events
– religion, sex, TV shows, internet, people
– foods, bodily functions
– Needs to hear a specific answer to a question
• Compulsion
unwanted actions, rituals habits
– hoarding, packing / stuffing, rituals, routines
– strict adherence to a schedule, activity, time,
person or objects
– frequently checking, touching, licking, mouthing,
ordering things
Post Traumatic Stress Disorder
• major traumatic event
• acute or chronic
• symptoms of anxiety, distress, fear, panic,
depression, irritability
• flashbacks of trauma - dreams, nightmares,
repeated play or actions
• difficulty returning to location of trauma or
seeing people involved, avoidance
The Merging Science of Trauma Informed Care
NASMHPD, 2004 Best Practice Symposium- Atlanta Georgia
Key Principles
Trauma Informed Care Systems
Integrates philosophies of care that guide all
clinical interventions
Treatments / Interventions / Supports are
based on current literature and are
evidenced based
Recognize that coercive interventions cause trauma
and are to be avoided
Persons with serious mental illness are markedly at
increased risk for trauma exposure
Trauma Informed Care – Key Features
Continued
•Valuing the person in all aspects of care
•Neutral, objective and supportive language
focusing questions on what happened to you
in place of what’s wrong with you
•Individual, flexible treatment plans and approaches
•Awareness/training on re-traumatizing practices
•Agencies that are open to outside experts:
Advocacy and clinical consultants
•Training and supervision in assessment and
treatment of people with trauma histories
Impulse Control Disorder
and Intermittent Explosive Disorder
Sudden Violent Aggression,
Self Injury or Destruction of Property
Psychotic Disorders
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Schizophrenia
Schizoaffective Disorder
Delusional Disorder
Substance-Induced Psychotic Disorder
Psychotic Disorder, NOS
Depressive D. or Bipolar D. with psychosis
Symptoms of Psychosis:
• Confused Thinking
• False Beliefs
• Hallucinations
• Unpredictable Mood changes
• Sudden Behavior Changes
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
The differences between autism and schizophrenia
(Rutter,1972;Ghaziuddin, 2005)
Autism
Schizophrenia
Age of onset
Less than 36 months
Adolescence or early
adulthood
Symptoms
No hallucinations and
delusions
Hallucinations and
delusions are common
Intellectual Disability
Often present
No relationship with
mental retardation
Seizure disorder
Common
30%
No relationship with
seizure disorder
Family history
Increased history of
autism spectrum
disorders
Increased history of
schizophrenia spectrum
disorders
Treatment
Medications palliative
Alleviate symptoms
Not a cure
Antipsychotic
medications specific and
effective
Course
Generally life-long. Few
cases of “recovery”
Generally life-long. But
some cases recover
more fully
Approaches to Challenging Behavior
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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)
4. When challenging behaviors serve multiple functions,
address those derived from biological / medical first
5. Obtain a working diagnosis
6. Tailor treatment to the diagnosis
Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR)
DSM-IV – MULTIAXIAL CLASSIFICATION SYSTEM
•Axis I
•Axis II
•Axis III
•Axis IV
•Axis V
Clinical Disorders (Treatable Syndrome)
Personality Disorders, & Mental Retardation
General Medical Condition
Psychosocial Stressors
Global Assessment Functioning Scale (GAF)
Symptom: A phenomenon, which arises from and accompanies a particular
disorder or disease and serves as an indication of it.
Syndrome: A constellation of symptoms or signs which are found together,
and as a group may lead to a diagnostically significant hypothesis.
Diagnoses
Symptoms/ Behaviors
Axis I __________________
__________________
__________________
__________________
__________________
__________________
Axis II __________________
__________________
__________________
__________________
Axis III __________________
_________________
__________________
__________________
Axis IV _________________
__________________
Axis V GAF = ___
GAF = ____
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
Differentiating Challenging Behavior
from Psychiatric Syndromes in
Autism Spectrum Disorders
Information Processing Deficits
Input
taking in information
Processing
comprehending the information
Output
translating into actions
Executive Functioning Deficits
Emotional Regulation and Impulse Control
•Behavioral Flexibility
•Internal level of Arousal
•Impulse Control
•Self Assessment / Self Monitoring
Impulse Control Difficulties
Input
Setting
Events
Directives
People
Internal
Process
Output
Thoughts
Emotion
Perception
Internal Arousal
Increases
Behavior
Aggression
Self Injury
noncompliance
Decrease Threshold
for aggression
Functional Behavior Assessments (FBA)
Behavior
Person
Environment
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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
• FBA’s 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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Physiological and medical factors
that may influence behavior
Medical Condition
(pain, hypoglycemia, IBS, seizure, cluster headaches, concussion)
Medication Side Effects
(sedation, activation, toxicity)
Physical Deprivation
(sleep, thirst, hunger, fatigue)
Behavioral Health symptoms that are
an expression of Medical Conditions
Medication side effects
Pain
Hypoglycemia / Hyperglycemia
Sleep Disturbance 40 – 80% parent report
Seizures 30%
Motivations / Etiology
for Behavioral Concerns
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Biological (Genetics – Behavioral Phenotypes)
Physiological (Hunger, Thirst, Pain)
Medical (Dental, Seizures, Apnea, IBS,Hypoglycemia)
Psychiatric / Emotional / Behavioral (internal / Psychoses)
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)
Functional Behavior Assessment Recording Sheet
Name: __________________________
date / time
location
those
present
activity
Behavior: ________________
Antecedent
Analyses
events prior
to behavior
Behavior
Analyses
topography
describe
Consequence
Analyses
response
from others
results
Etiology
Irritability
Self injury
Aggression
Eye Rolling
Blank staring
Vomiting
Unusual smells
Seizure Recognition – 30% in ASD
Generalized Tonic Clonic
(also called Grand mal)
Absence
(also called Petit mal)
Simple Partial / Complex Partial
(also call Psychomotor or Temporal Lobe)
Atonic Seizures
(also called drop attacks)
Myoclonic Seizures
Infantile Spasms
Functional Behavior Analysis Recording Sheet
NAME:______________________
Date
Those
Time
present
location
5-10
bedroom
alone
5-12
Living
room
Staff
8-15
mall
Staff
8-18
back
yard
alone
Activity
bedtime
Watching
TV
Antecedent
Analysis
Behavior
Analysis
Consequence Results
Analysis
rocking
Scream
holds head
Nothing
observed
Screaming Interruption
head holding Redirection
shopping
Out of blue
Screaming
Lip biting
playing
Dogs
barking
Screaming
Head holding
Motivation – Medical – Seizure
nothing
Removal
To quiet
area
nothing
Stopped
2 minutes
Stopped
1 minute
Stopped in
3 minutes
Stopped in
1 minute
Etiology
Hyperventalization
Irritability
Breath holding
Temper Tantrums
Rumination
Constipation
Rapid Cycling
Functional Behavioral Assessments Recording Sheet
NAME:______________________
Date
Time
11:30
11:45
4:30
5:15
11:40
Those
present
Activity
Antecedent
Analysis
staff
Sorting
Asked to change yelled ‘no “
activities
Ignore
Increased
peers
Cleaning
Room
Staff Direction
Aggression
Int/Red
Increased
PM
staff
alone
alone
Behavior
Analysis
Consequence Results
Analysis
Leisure Time
None
rapid motor
pace
Orange
Juice
Waiting for
Dinner
None
Hand
Movements
Nothing
Looking at
Book
Reading
motivation
---
Head
Banging
Snack
hypoglycemia - low blood sugar
Stopped
Continue
increased
Stopped
Etiology
Self Injury
yelling
screaming
asked to
participate
in group
Denied request
irritable
isolation
Body Rocking
Fetal Position
FBA’s typically do not assess for pain etiology
Self-Injurious Behavior
Definition: “Any socially unacceptable
behavior involving deliberate and direct
injury to one’s own body surface without
suicidal intent” (Claes & Vandereycken,
2007)
• INTENT is to cause harm
• DELIBERATE action
• ACUTE INJURY involving tissue damage
Differentiating between Suicide and Self-Injurious Behavior
Feature
Suicide
Self-Injurious Behavior
Intent
To cease existence. To
eliminate life
To escape avoid distress.
To feel better
Lethality
High. requires medical
attention
Low. most often does not
require medical attention
Chronicity
Infrequent
repetitive in nature,
chronic
Methods
Often one method chosen
Tendency to use multiple
methods
Cognition
Death, Dying, suicidal
ideation
Thoughts of relief,
no thoughts of dying
Kahn & Pattison, 1984 and Walsh & Rosen (1998)
Reported Etiologies for Self-Injury
To stop bad feelings
To relieve feeling numb or empty
To punish myself
To feel relaxed
To feel something, even if it was pain
To avoid doing something unpleasant or I don’t want to do
To avoid school, work, or other activities
To avoid punishment or paying the consequences
To avoid being with people
To get control of a situation
To get other people to act differently or change
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
Treatment Principles
• Step 1: Conduct Functional Behavior Assessment
• Step 2: Develop Hypothesis about the etiology of the Target
Symptoms / Challenging Behavior
• Step 3: Select a medication or behavioral intervention which
is directed to primary cause of the persons symptoms or
challenging behavior
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
Least Restrictive Treatment Model
Complete Functional Behavior Assessment / Nursing Medical Assessment
Adapt the environment including physical space (prevention), designated areas of the residence
for treatment, increased staffing patterns / observation up to including 1 to 1
Communication Adaptations
Begin Interruption / Redirection (verbal and physical)
Counseling / Contingency Management (CBT-DBT-Incentives)
offer
PRN medication
Relaxation Training
Ask person to go to calming area
Attempt to physically prompt the person to a calming area
Physical redirection / If the person resists – Staff Time Out
Individual Safety Plan
Approaches to
Pharmacotherapy
Approaches to Pharmacotherapy
 Indication
• Each medication needs to have specific rationale
• Greater certainty of “Diagnosis” tends to be associated with
greater likelihood of a successful trial
 Assure Adequacy Start low go slow
• Dose and Time
 Assess Benefit
• Consistent observation/ multiple observers/ genuine response
• Rating Scales
• Clear documentation - presence or absence of response
 Assess Risk
• Know common side effect
• Inform patients, families, other observers & document
Informed Consent
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Reconciliation
Name of medication, dose, schedule
Risks / benefits
Side effects, Monitoring
Pharmacokinetics, duration of action
Limitations
Alternatives
The patients and family / caregiver understands to their ability and
agrees (specify how accommodations are made for special needs
patients)
Principles for Administering Medications
 Principle 1 - Pharmacotherapy should always begin
with a Functional Behavior Assessment
 Principle 2 Physician needs careful history, physical/
neurological exam, lab data to use as baseline prior to
the start of medicine
 Principle 3 Physician should not use medication as first
and only intervention (motivation before medication)
 Principle 4 Medications should only be used following
the assessment on non-medical interventions
 Principle 5 When multiple behavior problems exist,
treatment team should assess medication efficacy &
make treatment recommendations
When initiating antipsychotic, physicians must assess
for and document ant abnormal involuntary movements (AIMS)
Should be completed annually while patient is on antipsychotic
When using stimulants, a physical examination is recommended
and height and weights should be monitored every six months
for patients under 16 yeas of age.
When using alpha-agonists (anti hypertensive )
A physical exam and baseline measurements of heart rate
and blood pressures and monitoring every three months
For Valproate (depakote) Carbamazepine (tergetol)
Liver function tests must be done
prior to treatment and at least once every six months of initiation
Who prescribes the medications?
____Psychiatrist __ PCP __ Pediatrician __ Neurologist ____ Other:______________
Medication Dosing
Drug
Class
Medication
Daily
How
dose (mgs) Monitored
Effective
Reason
for D/C
Antipsychotics
Mood Stabilizers
SSRI’s
Alpha-agonists
Beta-blockers
Stimulants
Anticonvulsants
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Rational approach to treatment and
Psychopharmacology
Increase dosage
and / or blood levels
Monitor for adverse
reactions and side effects
Reductions of
Symptoms / behaviors
Assessing Effects and Side Effects of Medications
Akathisia was identified using the Akathisia Ratings
of Movement Scale (ARMS) (Bodfish et al., 1997),
a modification of the Rating Scale for Drug-Induced
Akathisia (Barnes, 1989)
The Dyskinesia Identification
System Condensed User Scale (DISCUS):
Abnormal Involuntary Movement Scale (AIMS)
Usage of Psychotropic PRN Medications in person’s with
Developmental Disabilities: Chemical Restraint vs. Therapeutic Intervention
PRN protocol procedures (King, Fay, & Croghan, (2000)
1.
2.
3.
4.
5.
6.
Does the consumer engage in severe aggression, self-injury, or
other potentially dangerous behavior that has been operationally
defined and agreed upon?
Are preventative techniques that employ a positive approach
employed?
Does a hierarchy on non intrusive interventions exist that are to be
implemented when the consumer begins to engage in dangerous
behavior?
Are the dangerous behavior symptomatic of an underlying mental
disorder?
Does the consumer take prescribed psychotropic medication that are
intended to treat the identified mental disorder?
Are the behavioral, habilitative, and psychiatric interventions
generally successful in treating the individuals mental disorder?
If the answer is “YES” to all of these questions, then a PRN medication
is reasonable to consider.
Considerations when using PRN Medications
Reason for choosing specific medication
Current Medication of the person
Medical and Psychiatric Condition of the person
Symptom Specific and Individualized
The PRN Medication Needs to be listed on the
treatment plan
Clear documentation of the persons response to
the medication
PRN Medication order
Parameters for administering Pro re Nata (PRN) for episodic behavioral dyscontrol
Patient Name: __________
Date:________
Agency________________
Psychiatric Diagnosis: Schizoaffective Disorder, OCD
Specific symptoms that require medication: Please note that
symptoms should be recorded for a duration of at least 15 minutes, and
when ________ is unresponsive to staff / caregivers attempts to interrupt,
redirect, and provide reinforcement for all alternative behaviors
Specific Symptoms: PRN medication should only be administered
when the following target symptoms are observed
Screaming, hand biting, attempting to biting others, charging at others
Type of PRN: Oral
Specific Medication: Ativan
Parameters / Individual Protocol
1 mg Ativan POq hourly / 3 hours between doses/not to exceed 3 doses in
24 hours.
Possible side effects: Unsteady gait
Dr. Thomas
Date
Using PRN Medications
Considerations
• Reason for choosing specific medication
• Current Medication of the person
• Medical or Psychiatric condition of the person
• Symptom Specific and individualized (no one size fit all)
• Clear documentation of the patients response to the PRN
Preparing for the psychiatric appointment
• Complete any questionnaire sent by the clinic
• Individual’s past history (medical and psychiatric)
• Individual’s past medication and results (Reconciliation)
• Individual’s family history (medical and psychiatric)
• Individual’s present medication (both medical and
psychiatric)
• Some way to indicate a Response to treatment:
Is the person better or worse since last appointment?
not just night before
Everyone’s time is important Use the Doctors time wisely and efficiently
• Initial Evaluation 45 to 60 minutes (Typically)
• Medication Check 15 to 30 minutes (Typically)
• If more time is needed or additional clinician
therapist’s time (Behavior Specialist) – call the
clinic and ask for additional time
• Have data, recordings of target Symptoms /
Behaviors well organized and a visual
representation if possible (Use graphs or charts)
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Psychiatrist Role in the appointment
• Talk to the individual that they are treating
• Listen, REALLY LISTEN, to when the person of team
members express concerns.
• Listen and incorporate input from the individual, family and
support staff into the treatment plan
• Answer questions about medications and or recommended
treatments
• Is anyone looking for unwanted side effects of any treatment
Interventions? Medications or Behavior Interventions
• Review Individual’s lab work and medical consult reports
since last appointment
Expectations in the clinic appointment
• Discuss
– Current Diagnosis
– Rationale for psychiatric diagnosis
– Assessment of current treatments and Recommended
changes
– Alternative treatments (other treatments besides
medicines)
– Risks and benefits of the recommended changes
– Expected outcomes before next appointment
– When to call or notify the clinic of adverse effects
– Current GAF Score
– Fill out needed forms
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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 and family 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 Positive
Behavior Supports
Be Creative / Think out of the box
Team work
References
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References
Kring, S. R., Greensberg, J. S., & Seltzer, M. M. (2008). Adolescents and Adults with Autism without Co-Morbid psychiatric
Disorders: Differences in Maternal Well-Being. Journal of mental Health Research in Intellectual Disabilities, 1 53-74.
Kim, J. A. Szartmari, P., Bryson, S. E., Streiner, D. L., & Wilson, F. J. (2000). The Prevalence of Anxiety and Mood Problems
Among Children with Autism and Asperger Syndrome. Autism, 4 (2) 117-132.
Lainhart, J. E. (1999). Psychiatric problems in individuals with autism, their parents and siblings. International
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Leyfer, O. T., Folstein, S. E., bacalman, S., Davis, N. O., Tager-Flusberg, H., & Lainhart, J. E., (2006)
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Journal Of Autism and Developmental Disorders, 36, 849-861.
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