You are on page 1of 135

Anaheim

February, 2010
Go Bolts!
Assistant Clinical Professor,
Dept of Psychiatry, University of
California at San Diego School of
Medicine

Faculty, Interdisciplinary Council on


Developmental and Learning
Disorders
ICDL Faculty – minimal - review of clinical write ups,
travel and room for meetings, token honorarium for co-
writing and running Southern California Institute

NIMH/ Duke University – minimal – administrative time for


pharmacogenetic research

NIH R21 grant/ San Diego BRIDGE Collaborative –


minimal – token honorarium for ongoing consultation
and participation
Feder 411
• 1980 – BU: math and Mass Assn for the Blind
• 1990 – Hawaii: Bernie Lee
• 1992 – ‘Matt’
• 1993 - DC: Greenspan, Wieder, et. al.
• 1996 – San Diego: neurobehavioral -
psychiatric
• 2010 – ICDL, SDPS Ethics, BRIDGE, CAPTN,
SCART
• (etc: dance, engineering)
The Autism File: Becoming More
Matthew January 2009
• Traditional Intervention: ABA – really worked and met
goals: he learned to sit
• Traditional Medicine – indispensible to success
• Family therapy – time to step back and reflect
• SL - long term, wonderful engaging relationships
• SIOT – ‘ah ha!’: let him stand, big activity, etc.
• Nutrition, VT, Tomatis, dogs, dolphins..
• DIR/Floortime – really worked and met goals: he
learned to survive
This is not a DIR/Floortime
talk

And my kid is not your kid


but context is important
DIR
• Broad – whole child, supports family
• Welcoming – all about building love
• Enriching – closeness can bring
progress
DIR in a nutshell
• Developmental levels – from
regulation, to warm trust, and then a
flow of enriching interactions
• Individual Differences – sensory,
motor, communication, visual-spatial,
cognitive, etc.
• Relationship Based – all about
connecting, and making time with
others for support and help
To learn more on
DIR®/Floortime™
• Icdl.com – free podcasts and
downloads
• Circlestretch.com – San Diego
regional website
• Pasadena 2/13/10 – Pasadena
Child Development Associates
• Free community support groups
• Considering medication

• Case examples

• Your experiences
FDA Approved Medications
for the Treatment of Autism

• Risperdal - 10/06 - irritability associated with


autistic disorder, including symptoms of aggression,
deliberate self-injury, temper tantrums, and quickly
changing moods, in children and adolescents aged 5 to
16 years.
• Abilify - 11/09 - irritability associated with
autistic disorder in pediatric patients ages 6 to 17 years,
including symptoms of aggression towards others,
deliberate self-injuriousness, temper tantrums, and
quickly changing moods.
Thanks and Goodnight…
Ok, there’s more to it…
• The main question: Are medications a
good thing for people with autism and
related conditions?
• Involves: medical ethics, the FDA,
Evidence Based Medicine, how little we
know, informed consent, family choice,
working with a doctor, and, yes, what we
do know about medications and how to
sort out medication options
Good Medicine
• Good = it might help (help what?) -
beneficence
• Good = it won’t cause bad side
effects - ‘Do No Harm’ – non-
maleficence
4 Main Principles of Medical
Ethics*
1. Beneficence – doing good (and how do we know it might be good?
Evidence based medicine)
2. Non-maleficence – risk vs. benefit
3. Autonomy – letting the patient (or a family) make decisions. Requires
informed consent, no deception, confidentiality, good communication
4. Justice – what’s the right thing to do? – fairness, equality, e.g., equal
access to services and resources, allocation of resources – competing
morals: treat everyone the same? Or give people with more needs
more care? Wise use of resources, respecting individual and family
choices, respect for morally accepted laws (e.g. child abuse laws,
avoiding aversive practices)

*Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 3rd ed.


New York, Oxford: Oxford University Press, 1989.
History of Trying to do Good
• Food and Drug Act of 1906 – safe
medicines, not diet pills from
tapeworm eggs
• Flexner Report on Medical Education
1910 – medical care has risks and so
medical education requires
standards
The FDA
• Approves medication for marketing
for specific symptoms of specific
conditions
• Allows doctors to use medications for
whatever they think is appropriate
FDA Approval
of a Medicine for Marketing
• Requires studies showing it works for
some symptoms of some condition
• Safety studies – now for kids too!
• Difficult process
• Expensive process
It’s Especially Hard to Do
Studies On Medications in
Kids with ASDs
• Kids are hard to find
• Kids have multiple ‘diagnoses’
• Kids with ‘Autism’ are a very mixed
group
New studies….
• NIH Duke U CAPTN ASK-PARCA
• Efficiency Studies (vs. Efficacy
Studies)
• Pharmacogenetics
• But these are few and results are
pending
The upshot….
• Once a medication is approved, it is unlikely
that a drug company will pursue other
approval for specific uses, unless there is a
big market that will offset the costs of
research and the approval process
• Most psychiatric medication for kids does not
have FDA approval for marketing and is
officially ‘experimental’
In the meantime…
doctors prescribe, with, we
hope:

• adequate education (about grade 26…)


• respect for serious illness, side effects, and
drug interactions
• steady care
• clinical judgment, based on clinical
experience
Clinical Judgment
Doctors have to make rational guesses based
on…
• Experience with the condition
• Experience with the medications
• Experience with other neurobehavioral and
medical conditions (and so less likely to miss
something important)
• Experience with side effects, drug interactions
• Experience with the terrible things
Doctor’s Experience
• Often limited
• ‘In my experience’ = seen one
• ‘In a series’ = seen two
But Doctors Do Have
Experience with Terrible
Things
• Morbidity – severe side effects (e.g.
hepatic failure, etc. etc.)
• Mortality
• House of God: “Did you give him ‘roids?”
• Doctors, if anyone, should know from
experience that we need to avoid
trouble
Avoiding Trouble

• Good care: follow up, AIMS, labs, etc.


• Laws governing medication
• Report medication problems to the
FDA
• Talk to colleagues
• Informed consent: family choice
Family Choice
• For a condition that is likely to present lifelong challenges
• Especially one that has severe symptoms and impact
• We must defend the right of families to know about their options
• And give them a reasonable choice about what they want to do, based on
family culture and values
• Family circumstances and family values are preeminent in this situations.
For some families meds are a last resort, and for others it seems wrong to
withhold them.
• Medications can give hope - essential to survive the journey - yet giving
unfounded hope is cruel
• Family choice is the heart of truly informed consent
• DIAGNOSIS: 
• TARGET SYMPTOMS:
• TREATMENT PROTOCOL:
• ALTERNATIVE TREATMENTS DISCUSSED:
• POSSIBLE RESULTS OF NO TREATMENT:
• SIDE EFFECTS DISCUSSED:
• FDA LABELING DISCUSSED: ‘nearly everything is experimental’
• CONSENT AND ASSENT DISCUSSED:
• COMMENTS/QUESTIONS/CONCERNS: ‘we have to track this fairly
closely’
INFORMED CONSENT IS AN ONGOING PROCESS
With so much to consider,
why use meds at all?
• Medication helps many kids, sometimes
dramatically
• Moreover, doctors may be duty bound to
discuss meds, even if most are not FDA
approved for use for kids, for ASDs, or for
certain symptoms of ASDs
• Information on medication for autism is part
of good medical care
Good information is part of
good medical care
• Failure to consider medication may rob families of
choices that could help, and perhaps allow harm
that could have been avoided.
• So people try to define the standard of care,
developing practice guidelines
• Hence the focus these days on ‘Evidence Based
Medicine”
Evidenced Based Medicine
• Sackett, et. al. British Medical Journal
1996;312:71-72 (13 January)
• “the conscientious, explicit, and
judicious use of current best
evidence in making decisions about
the care of individual patients.”
Meaning… what?
• integrating clinical expertise with
systematic studies
• consideration of clinically relevant
research
• and respect for the individual’s
predicament, rights, and preferences
Some People Misunderstand or
Misuse
the Concept of Evidence Based
• Cost cutters – e.g.Medicine
insurance companies, school
districts, government
• Clinical medicine is driven by patient and family
concerns
• For example, the recent mammography
recommendations which were roundly rejected in
the world of clinical medicine.
We Would Like
Gold Standard Evidence
• Randomized trials and systematic reviews of
randomized trials, are the ‘gold standard’
• Double Blind Placebo (or wait list) Controlled,
prospective, randomized studies, with enough
subjects to have the statistical power and a well
defined population of subjects to find out
something meaningful
Less than perfect is the
norm…
• Some questions about treatment cannot be ethically studied
with randomized trials, e.g., grave conditions that cannot wait
for such trials to be conducted.
• We must look at the evidence we do have to guide clinical
care.
• Often from other populations (e.g. age, gender, level of
challenges), disorders with similar symptoms (OCD,
depression).
• It is easy to have narrow or emotional reasoning, placebo
effects

References: How Doctors Think – Groopman; Science and Fiction


in Autism – Schreibman; Lies, Damn Lies, and Science –
Seethaler
EBM is a tricky combination:
• We need current best evidence,
otherwise medical practice is out of date.
• We need good clinical expertise and
judgment, for even excellent external
evidence may be inapplicable to or
inappropriate for an individual patient.
Evidence Changes Over
Time -
Five Year Half-Life….
• Half of medical knowledge changes
every 5 years
• So 50% of what we ‘know’ is wrong
• And we don’t which half
• Find a doctor you like and can work with
• Keep the doctor in the loop – doctor must have
data
• Don’t overwhelm the doctor with data
• Doctors can be confused with terms like
“biomedical”
• Respectfully offer resources – don’t expect your
doctor to read a book for you, but do expect your
doctor is interested in other opinions from other
doctors
• Look for Basic Competence: APBN Board
Certified Child and Adolescent Psychiatrists
were checked for competence in assessing
autism, and for use of collateral information
from family, school, and other professionals.
• Look for Honesty: AACAP = a promise to be
ethical and do their best
The Role of Medication
• Overview
• Progress?
• A Good Enough Program
• A General Approach to Medication
• Gridding the Problem
• 1989 Magda Campbell: haloperidol helps social learning; others:
methylphenidate causes side effects without benefit.
• 1990’s - 2006: treating target symptoms, based on responses in
other conditions to medications; lots of use of neuroleptics for
aggression, etc.
• 2004 Black Box warning for SSRIs in kids
• 2006 – Risperdal
• Early 2009 – Celexa ‘not working’ for OCD in ASD
• Late 2009 - Abilify
• Most people consider meds because
they feel stuck, maybe desperate
• Emergencies: aggression,
depression, others?
• Lack of progress
• What do we want for our children?
• The usual wish: a meaningful life
(socially, emotionally, maybe cognitively)
• Requires a plan, and medication
alone is not a plan.
• self regulation, sensory, and motor
function
• trusting, supportive relationships
• communication, maybe language
• cognition & learning
• living and life skills: home, school, work
• compliance with important rules
• Are we asking too much of a child?
• Of a family?
• Of a school?
The Central Question

• Are you trying to improve an


appropriate situation or make up for
a bad one?
• Will they change my child’s brain and
fix it?
• Could they injure my child?
• What should I expect?
• To avoid ‘losing time’ while pulling
the program together
• To ‘do as much as possible’
• Awakenings – are we trying for a
miracle?
• We do not know enough to say ‘you really should medicate’
• If there is no emergency, you have more time to think
about it
• When parents differ, it can be an opportunity for more
thoughtful planning
• Side effects e.g., behavioral activation (SSRIs), increased
perseveration (stimulants), sedation (some anticonvulsants,
others).
• Treatment teams often overuse medications, ignoring
engagement, other factors.
• Complete workup a must: consider (24 hour) EEG, labs, etc. along
with complete history, physical, time with the child and family,
and collateral information from school, therapists, etc.
• Diagnosis: a hypothesis meant to focus treatment, as well as
other possible & co-occurring diagnoses. The 5 axis system
helps, and new dimensional axes may work better
• Grid and prioritize target symptoms and possible treatments and
fill in likely +’s & -’s, in a flexible decision matrix
• Availability - doctor MUST stay in touch with family and school
Think carefully before rapid, large changes
in dose or before changing more thing than
one thing at a time.
The Bottom Line:
• medication probably does not treat
core symptoms, but might make
some target symptoms or co-
occurring conditions better, creating
more affective availability so that we
can make progress, if you can avoid
significant side effects.
Gridding Target Symptoms

• Target symptoms
• Prioritizing Symptoms
• Core Symptoms
Name Your Symptoms…
Core Symptoms?
Relating
Communicating
Healthy development: connected, regulated
emotions that breathe life into adaptive
thinking and planning
• Support regulation and co-regulation by
treating, e.g., impulsivity, inattention,
anxiety, rigid thinking, perseveration.
• Widen tolerance of emotions so the
person is less likely to become
overwhelmed.
• Treat co-occurring conditions, e.g.,
depression.
• Might promote abstract reasoning and
thinking.
Specific Psychotropic
Medications
• Try to always know the brand and
generic names of medications
• Rxlist.com is often helpful
• The following list and the information
provided is not comprehensive;
please talk with your own health care
provider for further information
Stimulants
• Methylphenidate: Ritalin, Concerta, Metadate,
Methylin, Focalin
• Dextroamphetamine: Adderall, ‘mixed salts’,
Vyvanse
• Slightly different mechanisms.
• Similar possible side effects: appetite, sleep,
withdrawal, depressed mood, unstable mood, tics,
obsessiveness, etc.
• Drug diversion vs. drug abuse risk
• ‘ADHD’ and ASD
• Often makes a good plan workable.
SSRIs
• One of many classes of ‘antidepressants’
• Can really help depressed mood, maybe anxiety, less likely
obsessiveness (although works well for that for ‘neurotypicals’)
• Prozac (fluoxteine), Zoloft (sertraline), Paxil (paroxetine), Luvox
(fluvoxamine), Celexa & Lexapro (citalopram).
• Similar possible side effects: ‘behavioral activation’, weight
gain (and loss), mood instability, lower seizure threshold, etc.
• Black box warning about suicidal thinking vs. lower rates of
actual suicide in people treated with SSRIs
Neuroleptics
• Zyprexa (olanzapine), Risperdal (risperidone), Abilify (aripiprizole),
Seroquel (quetiapine), Geodan (ziprasidone), Haldol (haloperidol),
Mellaril (thioridizine), Thorazine (chlorpromazine) and others.
• Discovered while looking for cold pills, developed for symptoms of
psychosis.
• Helping aggression, mood stability, and miracles? As well as tics,
and adjunct for depression, perseveration, etc.?
• Side effects can include weight, lipid, and sugar issues, as well as
seizures, fevers (NMS) and new abnormal movements (TD), stroke
(elderly), cardiac
• Should we always consider neuroleptics?
AEDs
• Anti-Epileptic Drugs (aka anti-seizure
medications)
• So many and all so different in character
• For seizures, and for mood stabilization
• Might help other medications work better
(stimulants, antidepressants)
• Combined pharmacology vs. polypharmacy
• Sudden sopping might make seizures more likely
Specific AEDs
• Depakote (valproic acid, valproate) – pretty
reliable, easy to load, watch levels, platelets,
bruising, liver, pancreas, carnitine, menstrual
irregularities, weight, sedation. Problems when
using with Lamictal
• Tegretol (carbemazepine) - ?reliable, watch
levels, blood counts, EKG, lots of drug
interactions, weight gain, sedation, rash
• Trileptal (oxycarbezine) – ‘Tegretol light’?; motor
problems, electrolyte issues, rash?
More AEDs
• Keppra (levetiricetum) – easy to use, but does it work?
• Lamictal (lamotragine) – mood stability, ?better mood. Must go
slow, and watch for rash
• Topamax (topiramate) – adjunct, may cause weight loss, loss of
expressive language, usually need to go slow.
• Neurontin (gabapentin) – Does it work at all? Does it harm at
all? Does help pain syndromes.
• Lyrica (pregabalin) – for pain in fibromyalgia, partial seizures
• Zarontin (ethosuccimide) – for partial/ absence seizures; liver
issues
Steroids
• LKS variant theory – epileptic aphasia – 24 hr
EEGs
• Regression at a young age
• Cell membrane stabilization in inflammation
• So many side effects: cushinoid, moon face,
hump, central obesity, peripheral wasting,
immune compromise, skin striations, mood
instability including depression and hypomania
• Pulsed dosing regimens
Central Alpha Agonists
• Tenex & Intuniv (guanfacine), Catapres
(clonidine)
• Reducing ‘fight – flight’ sympathetic tone,
which can help in many ways
• Vigilance theory
• Side effects can include sedation,
dizziness, early tolerance
• Mild medicine
Other Commonly
Considered Medications…
• Straterra (atamoxetine) – for ADHD; may be as good as
placebo, may act like an antidepressant (+/-)
• Wellbutrin (bupropion, etc.) -
• Rozerem (ramelteon) – melatonin agonist
• SNRIs – Effexor (venlafaxine), Cymbalta (duloxetine),
Remeron (mirtazepine), Serzone (nefazedone)
• Deseryl (trazodone) – antidepressant often used for sleep;
cognitive side effects, priapism
• Buspar (an azaspirone) – mild, serotonergic cross reactions
More Others…
• Lithium – great mood stabilizer; anti-suicidal;
bipolar-ASD connection; levels, thyroid, kidney
function
• Namenda (memantine) – Alzheimer’s med –
‘antagonist of the N-methylD-aspartic acid
(NMDA) glutamate receptor, this drug was
hypothesized to potentially modulate learning,
block excessive glutamate effects that can
include neuroinflammatory activity, and
influence neuroglial activity in autism’
Meds that I often avoid…
• Paxil (paroxetine) - withdrawal
• Effexor (venlafaxine) - withdrawal
• Tegretol (carbemazepine) – hard to make it work
• Combo Depakote and Lamictal
• Tricyclics – Tofranil (imipramine), Norpramin (desipramine), Pamelor
(nortriptyline); and, esp. good for typical OCD, Anafranil (clomipramine).
Cardiac and blood pressure issues.
• Monoamine Oxidase Inhibitors – Nardil (phenelzine) , Parnate
(tranylcypromine), Marplan (isocarboxazide), Emsam (selegiline) – can be
useful although dietary, blood pressure drop and hypertensive crisis must be
considered; lots of drug-drug interactions
Special Caution on
Benzodiazepines!
• Benzodiazepines – Valium (diazapam), Ativan
(lorazepam), Xanax (alprazolam), Klonopin
(clonazepam), and others
• Used so freely by many doctors and families
• Problems nearly always outweigh risks
• Addicting
• Destabilizing mood
• Interfere with learning
• Interfere with motor function
• Interfere with memory
• Ok early history
• words at 12 mo but slow to gain new ones and they didn’t stick
well

• 13 mo: sudden stimming, classic ASD,


but still cuddling
• FH: sister PDDNOS now ‘better’, cousin ASD; others: anxiety,
OCD
• Sp Ed PK and lots of behavioral and language services.
• medical: ?seizures, allergies to eggs, peanuts, amox, eczema

*All names and identifying information have been changed


• ?Meds for anxiety in autism, Jan 2008
• Failure to make gains despite
massive services
• Autism
• SAFETY – fingers in eyes
• extremely perseverative (fans)
• anxiety
• over-activity
• tantrums
• language
• hard to take him out
• ?seizures.
• Mar 08: ‘break the door’ MOV00732.MPG
(0:10)
So what meds might we
consider?
• Autism
• SAFETY – fingers in eyes
• extremely perseverative (fans, light
switches)
• anxiety
• over-activity
• tantrums
• language
• hard to take him out in public
• ?seizures.
Medications:
• Trileptal, EEG improved
• Spring 08 Citalopram at 10 mg helps
anxiety and a bit with perseveration
• Sept 08: Malingo Toya ‘song and dance’
(0:55)
Feder favorite toys
More Medication…
• Fall 08 Metadate CD 15 mg.
Video
• Mar 09: This Little Piggy (4:50)
Not Barely Islands Expands Comes Ok if notOk for
there back stressed age

Co-regulate 3/08 9/08 3/09

Engage 3/08 9/08 3/09

Circles 3/08 9/08 3/09

Flow 3/08 9/08 3/09

Symbolic 3/08 9/08, 3/09

Logical 3/08,3/07,3/08

Multicausal 3/08,3/07,3/08

Grey area 3/08,3/07,3/08

Reflective 3/08,3/07,3/08
Sensor Postural Response to Intent to Visual Praxis -
y Communicatio Communica Exploration
n te
Sensory Best when core isCues into Often Spots fans at Perseverative
seeking, supported important words unintelligible distance; fingers in ideas; can
distractible eyes; rare gleam expand w/
support

Auditory 1 indicate 1.Orient 1.Mirror 1.focus on


desires vocalizations object Ideation
Visual ----3/08---- ----3/08----
----3/08---- ----3/08---- ----3/08----
Tactile
2. key tones 2.. Mirror
2. mirror gestures 2. Alternate Planning
Vestibular
gestures 3. key gestures gaze (including
Proprio- 3. gestures 3. Follow sensory
ceptive 3. imitate 4. key words another’s gaze knowledge to
gesture 4. sounds to determine do this)
Taste ----9/08---- intent. ----9/08----
4. Imitate with 5. Switch auditory 5.words 3. Switch visual
Odor purpose. attention back and ----9/08---- attention Sequencing
----9/08---- forth ----9/08---- ----3/09----
5. Obtain desires 6. Follow 6. two –word 4. visual figure
6. interact: directions ground Execution
- exploration 7. Understand 7. Sentences 5. search for
-purposeful W ?’s ----3/09---- object Adaptation
----3/09---- ----3/09---- 8. logical flow. ----3/09----
8.abstract 6. search two
- self help
conversation. areas of room
-interactions

7. assess
• Learned to quiz him, and quizzing him
• Can engage in some back and forth, coachable
• Discomfort with him in public –so different from
other kids - improving
• Stress: eye issue harrowing, but improving as he
becomes more connected.
• MANY OF OUR FAMILIES HAVE A FORM OF PTSD!
Video
• July 09 – a whiff of symbolic capacity
• What works: playfully getting in his way, modifying
his ideas to make them mutual (e.g. run to fan become a
chase and crash into couch, fan obsession becomes fanning
him), getting him on his back, extending his ideas with fun
engagement (piggy, dollhouse)
• What didn’t work: quizzing him on facts, adding
ideas too quickly
• Medications have been very helpful to this child,
allowing him to respond to developmentally supportive
intervention.
Another Case Example: T

Severe Dysregulation and


Aggression
About T :

• cute but very challenged little girl


• failure to develop language, motor skills.
• multiple medications, with side effects:
sedation, staggering, trouble swallowing,
bruising
• ABA - DTT
• Miller Method
• DIR®
Medications for T:
‘Combined Pharmacotherapy’
vs. Polypharmacy
• Depakote
• Carnitor
• Seroquel
• Trileptal
• Thyroxin
• Keppra
• Lithium
• Lamictal
• (Prior history of many others including
Namenda, other neuroleptics, etc.)
Video clips
• Clip 1: 04/08
• Clip 2: 08/08
• Clip 3: 12/08
Modest Improvement Over
Time
• 4 – could sit a bit, give me a rare glance,
take off my post-it’s on occasion
• 8– moments of gleam and a couple of
circles when I swipe her things…
• 12 – more attached to the book, and I am
able to use it as leverage for more
engagement, many circles, and the bare
beginnings of flow, no real sense of
symbolic (but worth a try)
FEDL - T
1 (not 2 (barely) 3 (islands) 4 (ok w/ 5 (comes 6 (ok 7 (ok)
there) support) back) unless
stress)
Regulate 4 8 12

Engage 4 8 12

Circles 4 8 12

Flow 12
4

8
Symbols 4

8
Individual Differences - T
Sensor Postural Response to Intent to Visual Praxis -
y Communicatio Communica Exploration
n te
Sensory Unstable, made Some Difficulty A relative area Ideas at times,
seeking… worse by meds comprehension of indicating with of difficulty without
sharp redirection gesture, effective
Dysarthric – planning nor
sequencing
Auditory 1 indicate 1. Mirror 1. focus on
Visual desires 1. Orient vocalizations object Ideation
Tactile 2. mirror 2. key tones 2.. Mirror 2. Alternate
Vestibular gaze Planning
gestures gestures
Proprio-
3. imitate 3. key gestures 3. gestures 3. Follow (including
ceptive
gesture 4. key words 4. sounds another’s gaze sensory
Taste
Odor 4. Imitate with 5. Switch auditory 5.words to determine knowledge to
purpose. attention back and 6. two –word intent. do this)
5. Obtain desires forth 7. sentences 3. Switch visual
6. interact: 6. Follow 8. logical flow. attention Sequencing
- exploration directions 4. visual figure
- purposeful 7. Understand ground Execution
- self help W ?’s 5. search for
-interactions 8.abstract object Adaptation
conversation. 6. search two
areas of room

7. assess
space,
shape and
materials.
Reflection:

What worked:
• Miller Method – learned some systems
• ABA - content mastered, some is somewhat functional, e.g., “turn the page”, some is not
functional (points to ‘green’ in trials but doesn’t know what it means with the book)
• I can use her desire to ‘read’ the book to get some lovely connected moments
• She can be a bit more regulated bouncing a bit on the ottoman, steadying herself on my
arm, and that seemed to help her be emotionally connected to me too

• Medication: pros and cons: can’t live with


them, can’t live without them; ethical
concerns about management of medications
when function is impossible without them but
risks are clearly present.
Sample Case 3 - K

Aggression and Rigid Aggressive


Play Themes
About K:
• Why he came to me: aggression toward
peers in private kindergarten. Removed
anyway and placed in public setting.
• Main symptoms: Receptive language,
difficult to understand speech, reactive to
busy environments, low tone, active,
impulsive, sensory seeking, rigid,
controlling, aggressive
Medication:
• Risperdal liquid – carefully titrated;
works well but so hungry on it!
• Abilify – to try to reduce the
Risperdal load
• SSRIs – helped with mood, but did
not help perseveration, and created
overactivity
Course over four years: K
11/05 Rigid, aggressive, hits in ‘play’, not really symbolic

11/06 Allows me to join his aggressive play on his team

11/07 Increased complexity of aggressive themes; able to play


with cousin and brother in water fights, facilitated by
dad
11/08 Creates a dangerous race, still very controlling, but also
torn between me and dad, and nurturing, creative &
symbolic with me; able to play with cousin and brother
in games that are competitive but not overtly aggressive

5/09 Talking with me and parents about problems at school


Video
• 112508
FEDL – Sample Case 3
1 (not 2 (barely) 3 (islands) 4 (ok w/ 5 (comes back) 6 (ok 7 (ok)
there) support) unless
stress)
Regulate 11/05 11/06 11/07 11/08, 5/09

Engage 11/05 11/06 11/07 11/08, 5/09

Circles 11/05, 11/06 11/07 11/08 5/09

Flow 11/05 11/06, 11/07 11/08 5/09

Symbols 11/05 11/06, 11/07 11/08 5/09

Logic 11/05, 11/07, 11/08 5/09


11/06
Individual Differences – Sample case 3
Sensor Postural Response to Intent to Visual Praxis -
y Communicatio Communica Exploration
n te
Sensory A relative Trouble managing Dysarthric – A relative Ideas becoming
seeking… strength; more than one unintelligible strength; more complex
Auditory A bit clumsy - thing at a time Logical Frustrated with support
Visual impedes rapid Can barely tell discourse is looking for Adapting to
Tactile reciprocity in the ‘why’ we fight or difficult (e.g. at things problems that
Vestibular moment what we fight best Some ability to come up (e.g.
Proprio- 1 indicate about hedonistic: work with when my
ceptive desires Can’t track cheating gets shapes and character is
Taste
2. mirror conceptual you objects to solve injured, faints,
Odor
gestures discussion of the disqualified) problems in etc.)
3. imitate reasoning behind 1. Mirror play. Ideation
gesture events and play vocalizations 1. focus on
4. Imitate with 1. Orient 2.. Mirror object Planning
purpose. 2. key tones gestures 2. Alternate Sequencing
5. Obtain desires 3. gestures gaze Execution
6. interact: 3. key gestures 4. sounds 3. Follow Adaptation
- exploration 4. key words 5.words another’s gaze
- purposeful 5. Switch auditory 6. two –word to determine
- self help attention back and 7. sentences intent.
-interactions forth 8. logical flow. 3. Switch visual
6. Follow attention
directions 4. visual figure
7. Understand ground
W ?’s 5. search for
8.abstract object
conversation. 6. search two
areas of room

7. assess
Family:
• Dad works hard. Can facilitate kids when available.
• Mom can set up playdates, engage cousin. Has to work
hard to manage environment at home so that he is not in
continuing conflict with older brother.
• Brother is a good guy, and tries to play with him. But no
one can really keep up with him.
• Mom and Dad can play in office; however life at home is
busy - hard to find time for Floortime.
Reflection:
• What works: office play with him and his parents to help
them see what we can do; play dates with cousin, brother,
facilitated by parents. Now we can talk too!
• What doesn’t work: videogames, busy environments with
many peers.
• Why: He is still developing capacities for solid enough
symbolic play to be able to engage with peers without
becoming aggressive. His language and also his more
subtle postural and visual challenges make it hard for him
to play with peers.
• Medication makes the plan possible. Without it he
is so aggressive there is no working with him.
4. A series of three cases of
children with Aspergers and
Depression

• Partnering with a colleague


• Aspergers and depression with
suicidal thinking – a very scary
combination
• 2 of 3 clearly responding to SSRIs.
5 - Brief Example
Self Injurious Behavior (S.I.B.)
• 30 year old non-verbal old
• Severe clawing at chest
• Not sleeping
• No appetite
• Great live-in aide
• Engagement: support and expectations
What medicine might you think about?
Zyprexa

• sleeping,
• eating
• and engagement
• because he was engaged, he stopped S.I.B.
• cooking,
• riding,
• vacations
• a real life
6 - Brief Example
‘OCD’
• Had come a long way before w/ ‘biomedical’
• Bright but rigid, with ‘real’ OCD too (e.g. germs)
• Aspergers: verbalizes a lot but without connecting
• Years of work to accept use of medication
• But Medication (SSRI) does help OCD for him
• Engagement improving, gradual insight, and improved social
function and reciprocal capacity
• Lessons: SSRI might work for ‘OCD’ and ASD, and therapy over time
can really work for ASD core
7- Brief Example:
Stims 24/7
• A very active non-verbal 8 year old
boy
• Strings
• Not sleeping: severe impact on
family

Medicines you’d think about?


The Medication Angle
• Guanfacine – worked for months
• Rozerem – worked for months
• mirtazepine - working for months…
Intervention: The Engagement
Angle
• Joining the string thing
• Time, time, and more time
• Eventual gleam and non-verbal
communication about it
Video
• String play
8 - Brief Example:
Transitions
• 60ish male, modest verbal ability
• Extremely anxious and reactive
• Apparent PTSD + Autism
• Can’t stand any changes
• Minimally verbal
• Heavy and not exercising

So… medicine you might think of?


The Medication Angle
• Effexor, then reduction over years
• Topamax, then reduction when getting
thin
• Significant improvement in anxiety
• Significant improvement in reactivity
• Significant improvement in weight control
• Significant improvement in engagability
The Engagement Angle
• Engagement has had gradual benefit:
• Enjoys his meals,
• Goes on camping trips
• Engaging, graduated exercise
• Does well in an active day program

Remember routine medical care!


9- Brief example:
Running Off
• Big teen male with mood instability
• On 1200 Trileptal
• Limited verbal ability
• Inclusive high school
• Urgent problem at school

What might you try?


The Medication Angle
• Zyprexa to Stabilize
• Increased the Trileptal over time
• Weight gain, but can’t totally stop
neuroleptics
• Abilify replacing Zyprexa
• NB: RSR’ on EKG – got Cardiology
Consult to think through risk of
Toursades de Pointes
The Engagement Angle
• Loping after him worked really well,
as long as the person was calmly
following, and there was a gate
where he was running.
Video
• Tremor check…
Abnormal Involuntary Movement Scale (AIMS)
10 - Brief Example:
• Young boy with autism, self injurious behavior, low
IQ and inattention; institutionalization
recommended but family declined
• Compliant, and behavioral intervention helps with
sittings and following directions
• Various meds tried early on, settling on
methyphenidate ( ‘MPH’, like Ritalin, etc.) for
attention and central alpha agonists for tics and
withdrawal crankiness
The Engagement Angle
• Lots of intervention, at home and school
with everyone on the team (family, SLP,
OT, ED, etc.) centered on co-regulation,
engagement, and reciprocity
• Inclusion* early on, with social facilitation,
tutoring using his interests to scaffold
academics
*Read Paula Kluth’s books e.g. You’re Going
to Love This Kid
Medication, Outcomes,
and Lessons Learned
• Gradual improvement over many many years in academic
and social function, increase in testable IQ to superior ranges;
ok in church groups, interest groups, ok at 4 year college
(with hovering)
• Academic function and success of placement absolutely
dependent on MPH.
• More social off of MPH, more ‘paranoid’ on it, sleeps less, eats
less. But benefits outweigh risks
Try not to put a ceiling on possible progress.
• Look at the whole picture
• Be careful with meds
• Engage the Child

Your Experiences?

You might also like