Ocular Effects of

Behavior Management Medications
Angela Howell, OD
Paragould, Arkansas

Abstract
Background: Medications are often recommended for patients to control unwanted behaviors. Treatment with
prescription drugs for autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), and
acquired brain injury (ABI) has benefits and side effects. Gains may be made in attention and mental focus while
accommodation and eye tracking may be compromised. Benefits versus side effects must be considered when
managing these conditions with drugs.
Case Summary: A five-year-old girl presented for preschool evaluation. She destroyed the tape in the audio tape
player in the waiting room, broke several legos, tore pages from the children’s books and magazines and spilled a
soda before being called back for her exam. History was positive for Rett’s syndrome. No medications were taken.
All examination parameters were within normal limits.
The following year she returned complaining of difficulty reading and focusing at near. She managed to sit quietly in
the waiting area and play with a puzzle before her eye exam began. The history revealed that she had started taking
Prozac orally during the school year. Her mother reported that she read constantly. Reading material was constantly
held close. She became aggressive when challenged to move it away. Exam findings showed distance visual acuities
at 20/20 and near acuities reduced to 20/50. Accommodative testing showed reduced amplitude. A near prescription
of +1.00 OU was recommended to assist in her reading focus.
Conclusion: Behavior modifying medications were used to help this child and manage behavior in the classroom.
Reduced accommodation is a known side effect of many commonly used drugs in the treatment of disorders such as
ASD, ADHD, and ABI. Awareness of these medications and their side effects is warranted by eye care providers.
Key Words
acquired brain injury, attention deficit hyperactivity disorder, autism spectrum disorder, behavior management
medications, traumatic brain injury

Background Each year, an estimated 1.7 million people sustain a TBI.
Unwanted behaviors secondary to Autism Spectrum Children aged zero to four years, older adolescents aged 15 to
Disorders (ASD), Attention Deficit Hyperactivity Disorder 19 years, and adults aged 65 years and older are most likely
(ADHD), and Acquired/Traumatic Brain Injury (ABI, TBI) to sustain a TBI. Almost half a million (473,947) emergency
are often treated with pharmaceutical agents. These conditions department visits related to TBI are made annually by children
are prevalent in both adult and pediatric populations. aged zero to 14 years. Adults aged 75 years and older have the
ASD occurs in all racial, ethnic, and socioeconomic groups, highest rates of TBI-related hospitalization and death.4
but is four times more likely to occur in males than females.
Medications may be added to the treatment plan for long
The United States Center for Disease Control (CDC) estimates
or short term management of undesired behaviors. A survey
that between 1 in 80 and 1 in 240, with an average of 1 in 110
children, have an ASD.1 of over 3,000 families in North Carolina found that 46% of
respondents reported that their family member with ASD
ADHD is estimated to affect 3% to 7% of school aged was prescribed psychotropic medication for behavioral
children. As of 2007, approximately 9.5% or 5.4 million
symptoms.5,6 Another recent study documented that 13.5%
children four to 17 years of age have been diagnosed with
of children in the welfare system were using psychotropic
ADHD. Boys (13.2%) were more likely than girls (5.6%) to
have been diagnosed with ADHD. Prevalence of ADHD has medications. This is two to three times the rate of other
increased at a greater rate among older teens as compared to children in the community.7 Pharmaceutical agents may allow
younger children. The highest rates of parent-reported ADHD time for patients and their families to learn behavioral and
diagnosis were noted among children covered by Medicaid discipline strategies to keep negative actions and emotional
and multiracial children. Prevalence of parent-reported ADHD outbursts to a minimum. As verbal communication skills
diagnosis varies by state. Nevada has the lowest rate at 5.6% improve, management with prescription medications may be
and North Carolina has the highest rate of 15.6%.2,3 minimized or eliminated.
Journal of Behavioral Optometry Volume 23/2012/Number 3/Page 73

for which FDA approval has been granted. The parents were educated about this condition and were Researchers have begun to investigate whether or not the supportive of the treatment plan. or the (gabapentin). memory.7 million youths aged 4-17 years controls. and Case Summary norepinepherine re-uptake inhibitiors. Reduced accommodation is a known side effect of contact. Depakene (valproate). The importance of regular hormone oxytocin is produced or processed in a dysfunctional follow up visits was stressed. psychotropic medications for those with autism. Disruption of the child attend school and manage behavior in a classroom body’s oxytocin may be at the root of issues with empathy. oxytocin. and ABI/TBI Behavior modification along with medication has shown has benefits and side effects. label” treatments. This case illustrates the beneficial and detrimental classes of medications include anti-psychotics. Optometrists should be A five-year-old girl presented to the clinic for preschool familiar with the desired effects and negative side effects of evaluation. have been reported to be the most prescribed The following year she returned for vision evaluation. The history is synthesized from the dietary amino acid tyrosine. and self-injury.23 (66. anti-convulsants. have been observed to alleviate symptoms of away. Zonegran (zonisamide). Social impairment is a primary symptom of ASD. Accommodative aggression. stimulants.3 Dopamine is a catecholamine that played with a puzzle before her eye exam began. neuroleptics.22 many commonly used drugs to treat disorders such as ADHD. Neurontin approved medication to treat a non-approved condition. Paxil (paroxetine). Felbatol Drug Administration (FDA) approved treatments and “off (felbamate).12 Off label treatments involve the use of an Lamictal (lamotrigine). Keppera (levetiracetam). Recent studies suggest changed or if dosage was increased. Topamax (topiramate). ADHD. Depakote (valproic acid). Ocular health was normal. Dopamine revealed that she had started taking Prozac orally during the function in the brain involves systems that contribute to last school year. and to kill the doctor and staff. A customized treatment plan must be levels of BDNF have been found to be significantly decreased formed with careful observation of behavior by parents and in individuals with ASD when compared to age matched physicians. mood stabilizers.00 OU medication use. Zarontin (ethosuximide). including hyperactivity. The to manage ADHD. emotion. such as close.21 Oxytocin is Discussion associated with lactating mothers and is thought to be involved Behavior modifying medications were used to help this with the mother-child bonding process. and self-injury. dopamine. effects of medication to manage behavioral issues.9. especially if the medication was manner in individuals with ASD.15 exophoria at distance and near. and ability to form and maintain social relationships. BDNF is commercially Behavior management medications are frequently used available as a dietary supplement without a prescription. at near. Commonly used epileptic medications are different categories of medication have been used in Federal Carbechol (carbamazepine). and she became aggressive when challenged to move it antipsychotics. Visual acuities were depletion of the dietary precursor of serotonin (tryptophan) 20/20 in each eye at distance and near. Lyrica (pregabalin).50 increases the symptoms of ASD is stimulating further research in each eye with bright clear reflexes. Brain derived neurotropic factor (BDNF) is a protein Problems with accommodation are noted with tricyclic found in the brain that plays a significant role in long-term antidepressants and low potency antipsychotics. dopamine.16 Dopamine blockers.3% of those with a current diagnosis) were receiving Neuroleptic medications are used in patients with ASD treatment in the form of medications for the disorders. and Celexa set up for one year. She threatened to ASD include serotonin.14 Commonly used system. The mother shared that the child did not sleep at night the development and expression of ASD. anti-depressants. She was diagnosed with the rate of accommodative recovery after discontinuing accommodative insufficiency. but can ASD. oxytocin deregulation may play a role in ASD.13 Behavioral treatment combined with antipsychotic cause unwanted side effects. and Volume 23/2012/Number 3/Page 74 Journal of Behavioral Optometry .18 Dopamine antagonists were testing showed reduced amplitude of accommodation. “All doctors are evil. Cover test showed low on serotonin. broke several legos.00. was recommended to assist her when reading.1 Many and ABI/TBI.15 Serotonin. No Selective serotonin reuptake inhibitors (SSRIs) including prescription for glasses was recommended and follow up was Prozac (fluoxetine). anti- hypertensives.00 and NRA at +2. Increased focus of attention may medication was the most effective approach to reducing be undermined by distress to the accommodative/convergence aggressive behaviors in youths with ASD. She managed to sit quietly in the waiting area and stereotypes. tore pages from the children’s books and magazines in the waiting room. various stereotypical behaviors. acetylcholine. at 20/20 and near acuities reduced to 20/50.11 As of 2007. Gabitril (tiagabine). She destroyed the tape in the audio tape player these pharmaceutical agents Table 1.19 (single vision). saying.20. Dilantin (phenytoin). Reading material was constantly held and higher-order functioning. in the waiting room. eye setting. Retinoscopy was +1. read and read constantly. Examination findings showed distance visual acuities ASD. 2. and brain-derived neurotropic factor. and amino acid neurotransmitters are (a form of autism spectrum disorder). A near prescription of +1. use of the medication for treatment of a child younger than that Trileptal (oxycarbazepine). (citalopram). 10 neuronal development and survival. Managing excessive activity may to have more positive results than medication alone for allow some success in academic and social settings. Pharmaceutical treatment for ASD. Her mother reported that she had learned to movement control. anti-anxiety agents. you should die!” History was positive for Rett’s syndrome acetylcholine. Evidence that acute and was difficult everywhere she went. and spilled Wide arrays of transmitter systems that may contribute a soda before she was called back for her exam. They are She was complaining of difficulty reading and focusing effective in managing behaviors such as compulsions. stimuli reinforcement. with found in one study to decrease accommodative ability and PRA at -1.8 No medications were among the neurochemicals being investigated with regard to taken.17.

Focalin regulation repetitive behaviors Ritalin Monitor arousal system Irritability.nih. Clozaril Reduce aggression. Table 2. Tremors Typical Abilify. 2008. Cylert Affect dopamine Depression Daytrona patch Improve focus and Increase in perseveration & Dexedrine. anxiety. Stimulant Group Trade Name Generic Name Approved Age Adderall (XR) amphetamine 3 and older Concerta methylphenidate (long acting) 6 and older Daytrana methylphenidate patch 6 and older Desoxyn methamphetamine hydrochloride 6 and older Dexedrine dextroamphetamine 3 and older Dextrostat dextroamphetamine 3 and older Focalin (XR) dexmethylphenidate 6 and older Metadate ER methylphenidate (extended release) 6 and older Metadate CD methylphenidate (extended release) 6 and older Methylin methylphenidate (oral solution and chewable tablets) 6 and older Ritalin methylphenidate 6 and older Ritalin SR methylphenidate (extended release) 6 and older Ritalin LA methylphenidate (long acting) 6 and older Strattera atomoxetine 6 and older Vyvanse lisdexamfetamine dimesylate 6 and older Adapted from http://www. Wellbutrin ritualistic behaviors Dizziness Zoloft Hyperactivity & Impulsivity Lowered threshold for seizures Sleep disturbances Anti-anxiety agents Ativan. Celexa Raise serotonin levels Arhythmias Elavil. Lower blood pressure Decrease hyperactivity & impulsivity Sedation Anti-convulsants/ Depakote. Zyprexa Tardive dyskinesia Anti-depressants Anafranil. Psychosis Sedation. Phenobarbitol Lessen mood swings. Envisioning a Bright Future. Santa Clara. hyperactivity & Possibly bipolar disorder re-uptake inhibitor impulsivity Reprinted with permission: Lemer P. Table 1. stereo.nimh. Addiction Neuroleptics Stelazine. Dry mouth Tofranil. Lexapro Reduce anxiety Blurred vision Luvox. Thorazine aggression.shtml Journal of Behavioral Optometry Volume 23/2012/Number 3/Page 75 . self. Prozac Reduce obsessive-compulsive & Constipation. Increased appetite Neuroleptics Geodon. Common Behavior Medications CLASS DRUGS BENEFIT SIDE EFFECTS Anti-psychotics or Haldol. and temper outbursts Dyskinesia. Risperdal injurious behavior Lowers white blood cell count Seroquel. Tenex Calm and improve sleep Irritability. Trileptal eye movements Norepinephrine Strattera Reduces inattention. Dilantin Calm behavior Affects kidney function Mood stabilizers Keppra. Palpitations Decrease impulsivity Sleep disturbance Anti-hypertensives Clonidine. agitation. outbursts Vision impairments such as rapid Tegretol. Interventions that Work for Children and Adults with Autism Spectrum Disor- ders. Valium movements Xanax Crying. Agitation. Mellarill Reduce agitation.gov/health/publications/attention-deficit-hyperactivity-disorder/complete- index. Paxil. Buspar Reduce anxiety Abnormal eye Klonapin. Disinhibition Irritability Stimulants Adderall. CA: Optometric Extension Program Foundation. hyperactivity. Blurred vision typic and self-stimulatory behaviors.

including Clozaril cessed June 24. refractive shifts. Craig SB. Stimulant medications come Pediatrics 2009. Some children may show improvement in monitoring potential side effects. Centers for Disease Control. Autism Society. and self-injury. Volume 23/2012/Number 3/Page 76 Journal of Behavioral Optometry . Astute clinical treatment of ASD symptoms fall into the “off label” category.shtml. et al. fewer pills.26 One of the best-known associations with management were insurance coverage.28 10. Medications prescribed to management showed there were some advantages to treatment brain injury patients: A retrospective analysis. Rennie IG. convergence. State variation in psychotro- to stimulate the central nervous system. gastrointestinal treatments. in different forms. 2. asthenopia. Mandell D. Yinon U. Lebowitz AA. frequent dosing. chelation. Rubin D. maximize desired outcomes and allow concurrent progress as Most of the psychotropic medications prescribed are FDA the management process continues. specialized drugs (AEDs) are chosen based on seizure type.autism-society. Aman MG. risperidone and diplopia. Ocular adverse effects of common psychotropic Vyvanse. lower intensity. Ocular findings in Rett syn- use for ADHD by trade name and the approved age for drome. ADHD facts. Autism Facts. Localio R. Feudtner C. These medicines have positive intended effects and medication. Table 2 illustrates the medication 8. 7. A study to Accessed June 24. behavioral side have addressed safety and effectiveness of most of these effects must be considered. stereotypical behaviors. Concerta. Psychotropic medication use in a national probability sample of children in the child Some medications come in short-acting. few studies blood monitoring. 9. with as high as 32% meeting diagnostic criteria. Koslowe K. Zima B.Valium (diazepam). So far. Andersen RM. Van Bourgondien ME. withdrawal. ADHD is the stimulant group. Risiperdal. The primary care optometrist and mood instability associated with autism.org/about-autism/. less social in combination to control seizures in about 70% of patients.9:196-211. capsule. most importantly. Last Ac- considered atypical antispychotics. J Behav Optom 2009. tablets vs. Paxil ( paroxetine). Prevalence estimates vary from as little as 5% to events. J Child Adolesc Psychopharmacol The most commonly used category of medication to treat 2002. facts.nimh. dosing schedules. 2011.12.and body-based therapies like yoga. Kapoor N. is in part attributed to the chronicity of symptoms of ASD Treatment of children with ASD and epilepsy is guided by and the absence of effective medical treatments. need for mind. extended release varieties. Factors such as available formulations like craniosacral manipulation. Blurred vision. and self injurious behavior. capsules). or skin patch. products in the market by sales for 2009. liquid. and costs of treatments and assist in symptomatology. communication. Joav M. treatment. judgments must be made in dealing with these challenges. such as pill.27 Other drugs prescribed for the the disorder and a side effect of the medication. Practitioners should support families as they assess epilepsy does not usually have a major impact on the ASD the effectiveness. and Geodon (ziprasidone) have been observed to Injury/statistics. deliberate self-injury. and less central nervous system dysfunction is the high risk of epilepsy. 311-22. www. www. Nutritional alternatives to FDA approved medication 11.gov/ncbddd/adhd. or welfare system.nih. National Institute of Mental Health. Advantages of medication as much as 46%. Antidepressant medications References 1. Adderall XR.gov/ncbddd/autism/ and Celexa (citalopram) are effective in managing compulsions. Clinically important ocular reactions to systemic drug therapy. 2011. It is important to note that treating treatments. include SSRIs and have been the most commonly prescribed Last Accessed May 23. and clinicians diets. Raghaven R. light sensitivity. Bergwerk K. markedly fewer adverse with ASD. Risperidone is used in the treatment of irritability negative unintended effects. J Child Adolesc Psychopharmacol 2005:15:97-106. better spontaneity with the examiner. and less weight gain.26 Summary Medications to control unwanted behaviors are clinically Risperdal falls into the category of typical neuroleptic prevalent. Centers for Disease Control.gov/TraumaticBrain- (quetiapine).17 patterns of use of psychoactive medicines in individuals with autism in the Autism Society of North Carolina. Currently. CNS Drugs. The practicalities of certain treatment choices are very treatments include manipulative and body-based treatments important in ASD. Centers for Disease Control. including must be aware of the interactions of these pharmaceutical symptoms of aggression. auditory integration. www. immune therapies. Last with management of undesired behaviors. TBI Statistics. 2011 alleviate symptoms of hyperactivity. Although using antidepressants to treat ADHD and ASD is off Communication with other members of the treatment team will label. Zyprexa (olanzapine). medications in ASD.25. Rutner D.html.html. Higher rates of epilepsy have long been reported in patients less irritability. 2011. Han E. approved for some conditions and some ages. Prevalence and aggression. and. but the ASD diagnosis does not change. 2010. Langworthy-Lam KS. or behavior. long-acting. compare vitamins and minerals versus standard medication 12. less anger. and Focalin XR were among the top two hundred agents: A review.20:151-3. http://www. clinically it is commonly practiced.cdc. 5.5 Dopamine blockers. tantrums in children ages five to 16.124:e305-12. and (liquid vs. et al. Popular the principles of treating childhood epilepsy. strive for maximum seizure control with minimum side and withholding immunizations. and temper agents with accommodation.29 It has been reported to occur in one third of the individuals with Complementary and alternative medical treatments are ASD.cdc. Richa S. The mechanism of action is 6. including lower activity level. Optometry 2008:79:252-8. sterotypes. Anti-epileptic biological based treatments include supplements. Other non-biological effects. www. Yazbek JC.gov/health/publica- need further investigation to document their role in assisting tions/attention-deficit-hyperactivity-disorder/complete-index. 3. Last Accessed April 21.30. The popularity of these treatments populations. 2011.11 Of the medications listed. but may not be approved specifically for ASD. concentrated focus of attention. Seroquel 4. Zoloft (fluoxetine). Last Accessed April 21.31 cognition. thereby allowing pic medication use by foster care children with autism spectrum disorder. (clozapine). and is the only medication that has specific FDA approval to poor depth perception may be reported as both a symptom of treat individuals with ASD.24:501-26.cdc. risks.24 These medications are used alone or with micronutrients. Autism spectrum disorder is also increased in epilepsy often used by families. Drug Saf 1993.

Schultz R. Modahl C. Oblak A. Hollander E. Handen B. Epilepsy drugs to treat Seizures. Date accepted for publication: 26 July 2011. Yeung L. an optometry student Annual Meeting Travel Grant is offered to encourage or resident must: and support optometry student and resident • Be a COVD member (if not already a member. Schultz R. tion/perception in children within the autism spectrum disorder. sus standard medication management in autism: A naturalistic case-control chopharmacol 2010.144:82-91. electrophysiology and visual func. 22. Yaffe R. Rev Optom 2007. Decisions will be made on or before September 4. Top 200 prescription drugs of 2009. NY: Raven Press. your smartphone! 26. et al. Aman MG. Medication and 27. This year. Lin LL. The etiology of autism. 2012. 219 West Main 19. J Child Adolesc Psy.32:56-68. Novotny S. a $7. com/publications/issue/2010/May2010/RxFocusTopDrugs-0510 Last Ac- 14. Speaker’s Journal 2008.oepf. join participation at the meeting. Kennedy C. J Am 28. Morris M. Maino DM. symptoms in children with autism spectrum disorders: A comprehensive 16. et al.8.12:147- 65. study. Texas. in Fort Worth. et al. Fein D. Autism. • Be enrolled in an optometry degree (OD) program at a school or college of optometry. Frazier TW. J Dev Behav Pediatr 2011. 2011. The JBO Online version of this article tor (BDNF) in the cerebellum of patients with autism. Bartholow M. Effectiveness of cessed June 24. Hung PT. Applications are available on the COVD website or by emailing info@covd. Scahill L. J Child Adolesc Psychopharmacol 2010. www. Maino DM. Sinoff A. 25. et al. Angela Howell. The number and amount • Submit an application and current copy of your CV. Web MD. Russell BS. Levy S. Woodruff G. you will be given to eighty-nine $200 grants are available for students the title of an article to summarize. The 2012 COVD Annual Meeting is October 16-20. Jones W. Dopamine (Advances in Biochemical review of pharmacologic and complementary-alternative medicine treat- Psychopharmacology). autistic children. Iversen L. Epilepsy Health Center. Deadline for submission of applications is 11:59 pm on July 26.com/epilepsy/medications-treat-seizures. Acad Child Adolesc Psychiatry 2009. Viola. et al. J Autism Dev Dis 1982.374:1627-38. Hanratty M. Blatt G. 15.17:11-7. Paul S. Yang CH. Pediatr Res 2009. et al. Volkmar F. Last Accessed May 26. Medication treatment in autism spectrum disorder. Optom Vis Dev scanning this QR code with 2009:40:150-6. Clinical neuro- chemistry of autism and related disorders. Youngstrom EA. 2012. SG. Management of Dev 2009. SG. Mandell D. Plasma oxytocin levels in Date submitted for publication: 8 June 2011. of the grants given are based on monies available in Be sure to include any posters or papers you are the fund each year. Haycock T. Sutcliffe TL.10:97-107. OD tometrist. Optom Vis 31. Huffman LC. New York. Handen B. Anderson G. Grant recipients will be selected based on a review of their CV and article summary. Corresponding author: 18. Yip J. Feldman HM.3:157-63. parent training in children with pervasive developmental disorders and se. Access JBO Online at: 24. The role of epilepsy and epileptiform EEGs in autism spectrum disorder.20:95-103.65:599-606. 23. features videos. AR 72450 nists in human eye accommodation. Bio Psychiatry 1998:42:270-7. drangelahowell@yahoo. Oxytocin infusion re- duces repetitive behaviors in adults with autistic and Asperger’s disorders.20:167-77. San Diego 2007. Taub MB. thanks to our donors and presenting at the 2012 Annual Meeting. and residents. 30. www. The grants are provided for free) through the Wold SAFE Fund. McDougle CJ. webmd. Neuropsychopharm 2003:28:193-8. et al. Roberts P.™ LLC. 2012. Journal of Behavioral Optometry Volume 23/2012/Number 3/Page 77 . Donati R. Lancet. 17. Micronutrients ver- aggression in youth with autism spectrum disorder. ments. et al. The article summary and submission of your CV is due 11:59 pm on August 23. Leung B. Young J. 1978. Paragould. Shaywitz B.48:1143-54. Viola.org.org/journals or by 2011. J Ocul Pharmacol Ther 2001. Arch Gen Psychiatry 2002. Effects of dopamine antago. Wold SAFE Fund 2012 COVD Annual Meeting Student & Resident Travel Grants The College of Optometrists in Vision Development To be eligible to receive a grant. Tanner IS. Schneider M.pharmacytimes.com 20. www. Society of Neurosci- ence Annual Conference. Visual fixations patterns during viewing of naturalistic social situations as predictors of social com. Klin A. 2009. Lubesty MJ. You will be given the title of an article to summarize on or before August 2. Green L. COVD members donate to this fund to support student attendance at the meeting.59:809-16. Brain anatomy. up • After your application is received. medication combined with intensive behavioral intervention for reducing 29. Autistic spectrum disorders: A primer for the op. rious behavior problems: Results from a randomized clinical trial. Spence S.000 grant from The Vision Care Institute. Mehl-Madrona L. Kavanagh M. 21. 2012. ADDITIONAL CONTENT AVAILABLE! petence in individuals with autism.13. Decreased levels of brain derived neurotropic fac.