Jennifer Zarcone Kennedy Krieger Institute and Johns Hopkins - - PowerPoint PPT Presentation

Jennifer Zarcone

Kennedy Krieger Institute and Johns Hopkins University School of Medicine

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 A description of the biobehavioral approach to the

intervention of severe problem behavior

 Behavioral phenotypes associated with genetic

disorders relate to problem behavior

 Review current state of psychotropic medication use

for individuals with problem behavior

 Review of other biological treatments used for

challenging behavior and/or symptoms of autism

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 Popular catch phrase in science and medicine  Refers to an array of biological, psychobehavioral,

environmental factors that affect disease states (e.g., headaches, irritable bowel syndrome, obesity, cancer- related fatigue)

 If you think about it, everything is “biobehavioral”

 Takes functional assessment one step further -> to look

beyond the environmental factors that occur directly before and after the behavior occurs

 Looks at how biology can interact with the

environment at all points along the continuum from those motivating events to the consequences maintaining the behavior

 Role of biological setting events on

behavior

 Affects the efficacy of reinforcement for

both problem and adaptive behavior

Most common setting events that can affect problem behavior:

• Illness/pain
• Medical condition
• Genetic condition
• Psychiatric condition
• Medication side effects

 Pain due to:

• Otitis Media (earaches)
• Headaches
• Gastroesophageal Reflux Disease or other GI

problems

• Menstrual Pain

 Illness (chronic conditions or acute illness)

Critical part of every FBA is to rule out unidentified or undiagnosed health issues:

• A routine physical examination
• Health screen
• Medication assessment

To help this process have caregivers track:

• medical symptoms
• food diary
• sleep diary
• toileting data
• visible symptoms or complaints of discomfort

Then look for relationships between problem behavior and changes in these conditions

By evaluating and treating these conditions you may be able to decrease the need for more intensive intervention approaches.

• address these conditions and you reduce the

motivation for problem behavior and/or makes the antecedents less aversive

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 Background:

• 8 years old, with ASD

 Concerns:

• Often misses breakfast because he sleeps late and is

difficult to get up

• Math (his worst subject) is scheduled early in the

school day

• Throws worksheets and becomes aggressive during

math when he doesn’t eat breakfast

• Teacher then suspends math until after lunch and

provides preferred art activities during normally scheduled math time

Setting Event

Hunger

“A”

Math

“B”

Aggression Throws materials

“C”

Math delayed Art activity

 Functional Analysis Results:

• Problem behavior to escape demands and to access food

 Treatment ideas?

 Behavioral phenotype are characteristics commonly

associated with a genetic syndrome or condition

• Example: hyperphagia or excessive appetite in Prader-Willi

syndrome

 Can inform diagnosis and intervention (both medical

and behavioral)

Can impact behavior plan on many levels:

• Certain reinforcers are more or less effective
• More predisposed to certain behaviors and

response patterns

• Impacts the types of interventions chosen

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 Deletion:

 About 70% of PWS

individuals

 Paternal in origin  Two subtypes

 Uniparental (maternal)

disomy (UPD)

 About 25-50% of

people with PWS

 Two copies of

chromosome 15 from mother and none from father. Chromosome 15 disorder (not inherited) Two primary forms associated with different behavioral phenotypes:

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Physical phenotype:

• Low muscle tone (floppy

baby)

• Short stature
• Small hands and feet
• Fair complexion*
• Slow metabolism
• High pain tolerance

Behavioral phenotype:

• Hyperphagia
• Temper tantrums
• Obsessive compulsive

behavior

• Skin picking
• Rigidity/stubbornness

 Evaluate the role of food as a motivator for problem

behavior

 Assess role of attention and/or attempts to obtain

something (social positive function)

 Skin picking =>

• Maintained primarily by automatic/sensory reinforcement

(Didden et al., 2007; Hustyi et al., 2013)

• but evidence that there may be other motivators as well (e.g.,

attention; Hustyi et al., 2013)

• No difference between people with deletion and UPD

• The most common inherited cause of intellectual

disability

• Affects males more than females
• Etiology: X chromosome mutation that is caused by

too many repeats of the FMR1 gene and it fails to be expressed normally; when this gene is turned off it causes Fragile X

Physical features:

 Long face,  Large ears,  Flat feet  Hyperextensive joints, especially

fingers

 Seizures (affects about 25% of

people with fragile X)

Behavioral Phenotype:

 Intellectual disability  ADD, anxiety and mood disorders  Symptoms of autism  Speech and language disturbances  Hand biting and hand flapping  Poor eye contact  Unusual responses to various tactile, auditory

• r visual stimuli

 Evaluate motivators associated with:

• increased anxiety
• high levels of hyperactivity
• inattention

 Role of social escape/avoidance behaviors

• Langthorne et al. (2011) – conducted an FA with 8 children

with Fragile X

 5 had escape-maintained problem behavior,  3 had PB maintained by access to tangibles,  none with attention-maintained PB

• Hall, Debernardis, & Reiss (2006) – escape from social

interaction versus demands

Cause: Caused by the deletion of the genetic material from the q11.23 region of chromosome 7. This region contains more than 25 genes that contribute to certain characteristics of the disorder.

Physical Features:

 Heart and blood vessel problems  Musculoskeletal problems  Unusual facial features (wide spaced teeth and

flattened nose)

 Failure to thrive in infancy

Behavioral Phenotype:

 Intellectual disability  Highly verbal  Hyperacusis (sensitive hearing)  Overly friendly, excessively social personality  Hyper focused on eyes of others when engaging

socially with them

 Exceptional music skills  Inattentive  Irritable

 Look at role of attention and social

interactions

 Presence of certain people  Escape from noisy environments/loud noises

O’Reilly, Lacey, & Lancioni, JABA, 2000 - Evaluated the

effects of background noise on problem behavior in child with Williams syndrome.

 Background noise was associated with increases in

problem behavior (aggression) and pain behavior (clasping ears and crying).

 Intervention: child was fitted with earplugs =>

substantial reductions in both problem and pain behavior in noisy environments.

Genetic Syndromes Associated with SIB

Smith-Magenis Syndrome

• 50-70% of individuals engage in

body self-hugging, putting objects in body orifices

• Self-injury primarily

sensory/automatic

• Also engage in aggression which is

more likely to be socially- maintained

Rett Syndrome

Neurodegenerative syndrome in females Early normal growth followed by

• a loss of purposeful use of limbs
• slowed brain and head growth
• gait abnormalities
• seizures
• distinctive hand movements

(hand wringing)

• Not much data on FBA
• Case studies: escape, sensory

• 100% of individuals engage in SIB
• Topography: lip and finger biting
• Functional analysis: 3 young children with LNS: SIB

more likely to occur in low attention conditions (Hall, Oliver & Murphy, 2001)

• Treatment involves constant mechanical and physical

restraints or blocking of SIB

 Definitely has a genetic component  But there is a lot of variability in behavioral

phenotype

 Multiple phenotypes?

• Along the spectrum
• Males vs females

Functional Assessment with Individuals with Autism

Must take into account autism-specific issues

 Sensory issues  Communication issues  Interruption of perseverative activities  Access to perseverative activities/toys

 Repetitive behavior with girls with autism: people and

animals

 Boys with autism: objects and things Kai et al., 2015; Kopp & Gillberg, 2011

Function of Disruptive Behavior in Children with Autism

• Conducted a study with 23 children with

autism (compared to 23 age-matched controls)

• Completed Functional Assessment Interview

with caregivers of the children

• Two categories of “functions” or possible

reinforcers for problem behavior that parents were asked about:

• “standard” FA conditions and
• reinforcers more likely related to autism.

Reese et al., 2003

Comparison of “typical” versus autism- related functions

Standard Conditions:

 Gain attention  Gain access to

toys, activities

 Escape demands

Autism-Related:

 Gain access to

perseverative activities or toys

 Escape demands

when engaged in perseverative activities

 Escape sensory

stimulation

Gender Differences in Autism: Problem Behavior

• Males with autism are:
• more likely to engage in stereotypic play;
• more likely to have problem behavior when

stereotypy interrupted, and

• less likely to find attention from caregivers

reinforcing.

• Females are more likely to find attention

reinforcing

• Extended Reese study to compare males

and females

Males versus Females with Autism

Completed Functional Assessment Interview Form with families in clinic:

 17 males; 6 females  3 to 6 year olds  Males age (m = 40 months)  Females age (m = 48 months)

 Significant overlap in behavioral characteristics

both across and within syndrome groups

 Low incidence of some syndromes makes it

difficult to study systematically

 Not all people with a specific syndrome are the

same (behavioral phenotype varies)

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Psychotropic Medication - Themes

Evidence that children with ASD and other disabilities have:

• a higher rate of co-morbid psychiatric disorders than

nondisabled peers

• are more likely to receive medication for problem behavior

How do you determine when they need medication and when they don’t? What role do we play as clinicians? What do we do when we disagree with medication intervention?

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• Of 2853 children in registry, 27% were taking

psychotropic medication

• 2 or more meds:
• 2% of 3-5 year olds
• 13% of 6-11 year olds
• 20% of 12-17 year olds
• 16% had comorbid psychiatric diagnosis
• ADD, bipolar disorder, OCD, depression, anxiety
• Children with problem behavior more like to be taking

meds

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Coury et al., Pediatrics, 2012

Prescription Guidelines

Nearly all psychotropic medications are prescribed for children, but initially this is done “off label” (i.e., not fully tested or approved by the FDA) Prozac (fluoxetine) is approved for use in children and adolescents for the treatment of major depressive disorder. Prozac (fluoxetine), Zoloft (sertraline), and fluvoxamine maleate are approved for use in children and adolescents for the treatment of obsessive compulsive disorder. Many ADHD meds approved with children

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Prescription Guidelines

Even more rare for individuals with ID Risperdal (risperidone) and Abilify (aripiprazole) approved for irritability in autism Prescription guidelines for nondisabled children generally used, even if symptoms don’t completely match distractibility => stimulant medication behavioral inflexibility or rituals => anxiety or OCD med repetitive behavior => SSRI’s

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 The strictest warning put in the labeling of prescription

drugs or drug products by the FDA when there is reasonable evidence of an association of a serious hazard with the drug.

 Based on data that has come to light after FDA approval  This info sent to all physicians, pharmacists, nurse

practitioners

 Example: warnings about increased risks of suicidal

thinking and behavior (suicidiality) in young adults ages 18 to 24 during initial treatment with antidepressants

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 In the absence of data, doctors must use their best

judgment and a trial and error approach to prescription

 Lower doses should be used with children, the

disabled and the elderly

 Side effects – are children and people with ASD and

ID more susceptible?

 Cultural issues and social acceptability of meds

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 The prevalence of ADD diagnoses has grown among

children, from 7.8% in 2003 to 9.5% in 2007 and 11% in 2011, according to the CDC.

 Use of stimulants to treat children with ADD has also

grown 5-fold since the late 1980s and early 1990s: between 2007 and 2010, 4.2% of children under 18 were treated with a stimulant medication.

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Schwartz et al, 2014

 Most commonly prescribed  Target behaviors: inattention, hyperactivity, impulsivity  Side effects: decreased appetite, insomnia, tics,

increased irritability, paradoxical increase in hyperactivity, restlessness, slowed growth, possible risk for obesity later in life

 Generally works in about 70% of children

• not clear what response rate is with children with ASD or ID

 Works well in combination with behavioral

interventions

 Amphetamines:

• Adderall, Dexidrine, Dextroamphetamine, Vyvanse
• Approved for ages 3+

 Methylphenidates:

• Ritalin, Concerta, Daytrana, Focalin, Quillivant
• Approved for ages 6+

 Non-stimulant: Strattera (atomoxetine)

• doesn’t have same side effects
• recent warnings of suicide risk

 Others: Kapvay (clonidine), Intuniv (guanfacine)

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 Typical versus atypical  Most commonly used medication and most studied

with children with disabilities and problem behavior

 Target behaviors: aggression, irritability, disruption,

self-injury, repetitive behavior

 Risperdal and Abilify approved for children with ASD  Side effects: increased sleep/lethargy, increased

appetite, hyperprolactinemia, tardive dyskinesia (typical antipsychotics only)

 Older antidepressants: tricyclics and MAO

inhibitors not used due to severe side effects and lack of effectiveness

 Currently use selective serotonin reuptake

inhibitors (SSRIs) in treatment of anxiety, repetitive behavior, and OCD

 “black box” warning regarding suicidal ideation

 Mixed results in clinical trials of effectiveness of SSRI’s

in treating repetitive behaviors and “OCD-like” symptoms in individuals with disabilities (Prozac, Zoloft, Paxil)

• Possibly due to differences in underlying mechanisms of

“compulsive” behavior

 Fluvoxamine (Luvox) and sertraline (Zoloft) also may

be effective in treatment of behavior problems and mood

 New research in pharmcogenetics may identify high

and low-metabolizers, particularly for SSRI’s

• May explain heterogeneity in response to meds

 Guanfacine (Tenex or Intuniv) approved for blood

pressure, but used for anxiety and mood stability

 Seizure medications (e.g., Depakote, Neurontin,

Lamictal) used for mood stabilization

 Clonidine, Trazadone, and Melatonin used for sleep

(small clinical trials of melatonin indicate it may be helpful for sleep, especially sleep onset)

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 Seeks to characterize behavior in terms of function

• the events that occasion problem behavior
• the consequences that strengthen it
• and therefore its functionality to the individual

 Understanding of controlling variables guides

treatment development

 A range of assessment procedures and data collection

methods (interviews, observations)

Functional analysis is the most rigorous method for evaluating what is maintaining problem behavior

• Simulate different situations (e.g., school)
• Program antecedent and consequences
• Test how behavior changes as a function of conditions

 E.g. “work” environment - demands are presented and then briefly terminated contingent upon problem behavior

• Direct observation and data collection
• Analysis of patterns of behavior reveals function

 In 60-70% of individuals, the function of the problem

behavior is social (from people/events in the environment)

• To get attention or preferred activities, to escape work

 In 15% of cases, it appears sensory or “Automatic”  In 10-20% of cases, the behavioral function cannot

be ascertained

• Beavers et al. 2013; Hanley et al., 2003;

Functional Analysis - Attention

IOA 60% of sessions = 83%

0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50

SIB Responses per Minute Session

Alone Attention Toy Play Demand

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 Schaal & Hackenberg (1994) first suggested use of FA

during medication treatment

 Growing number of examples of use in clinical settings, but

the area is lacking good research

 Mostly due to difficulty with conducting controlled clinical

trials, thus most are case studies and do not have blind raters or a placebo control

 Double blind, placebo controlled trial of

methylphenidate

 Charlie an 8-year-old attending ADHD summer

program (no ID)

 Evaluating disruptive behaviors and off-task behavior

in typical classroom setting

 Three contexts: teacher reprimand (teacher

attention), timeout (escape from work), peer prompts (peer attention)

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 David, an 18-year-old with ADHD and ID  Engaged in disruptive behavior  Initial FA was inconclusive because he was on

methylphenidate and didn’t engage in any disruptive behavior

 Conducted FA with typical conditions both on and off

the methylphenidate

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Double-blind, placebo controlled study using crossover design

• Placebo (twice)
• a low dose (1 mg/day for children or 2 mg/day for adults)
• a high dose (0.05 mg/kg/day)

17 participants 12 (71%) were responders to the medication

Crosland et al., 2003; Zarcone et al. 2004

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 Sessions conducted at home/school/work  Once per week throughout med trial  Multielement experimental design

Conditions:

• Demand
• Attention
• Tangible
• Ignore
• Play/leisure (control)

Undifferentiated FA with a general suppression of behavior (N=5) Example participant - Jack

• 16-year-old diagnosed with intermittent

explosive disorder and profound ID

• primary target behaviors: aggression, face

slapping, property destruction, stereotypy

Findings, continued

Example participants - Reggie and Sean Primary target behaviors: aggression, disruption, and elopement FA results: escape and tangible (Reggie), escape and attention (Sean)

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Risperidone was effective in reducing problem behavior in 67% of participants Based on results of FA –

• a general suppressive effect on behavior or
• selectively affected escape or avoidance behavior

These data may help us to identify those individuals who may be the best responders to certain types of medication

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 Functional analysis is good for looking at effects of

med on problem behavior; consequences for behavior

 Medications often prescribed for other behaviors:

impulsivity, hyperactivity, mood instability, anxiety

 How do we capture medication effects on these

behaviors?

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 Treating “diseases” or mental illness with therapeutic

dosages

 Focusing on more general aspects of behavior:

• Patterns
• Interference with daily life
• General impression of improvement

 Based on caregiver report or brief observation

• May or may not include data

 May be overwhelmed by behavioral data

 Build a collaborative relationship to make data-based

decisions on medication treatment

• Avoid confrontation language and jargon

 Share data

• Clearly defined, observable target behaviors

 Problem behavior  Sleep, appetite, other aspects too

• Provide graphs but also a summary to assist in

interpretation

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 Conflict between using meds to treat problem

behavior and giving a psychiatric diagnosis

• No corresponding diagnosis for treatment of aggression

(conduct disorder, oppositional defiant disorder?)

• SIB a little easier (stereotypic movement d/x with self-injury)
• Irritability => antipsychotics

 Often have to rely on other diagnoses: mood disorder,

anxiety disorder, OCD (instead of repetitive behavior)

 Most support between diagnosis and target behavior:

stimulants and ADD

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 Response that occurs to stimuli that signal a threat  Heavily linked to environmental events  Situation specific or generalized  Observable indicators of fear, avoidant behavior, and

increased physiological arousal

• Changes in facial expression, sweating, widening of the eyes,

shaking, crying, eloping, physical restlessness, pacing, or rapid motor movement

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 Assessed relationship between self-injury and heart

rate for individual with “anxiety”

 Conducted functional analysis

• Restraints on vs. restraints off

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Restraint On Restraint Off

 Assessed relationship between self-injury and heart

rate for individual with “anxiety”

 Conducted functional analysis

• Restraints on vs. restraints off

 Conducted within-session analysis of heart rate

• Baseline
• Restraint removal
• Restraint off
• Restraint reapplication

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 Frequent or rapid fluctuations in mood that are not proportionate

and are minimally related to environmental changes

 Changes in mood may occur within or across days and include the

full range of affect (depressive to manic)

• May act as an establishing operation/setting event

 Shifts in mood may be accompanied by changes in problem

behavior

 Identify cycles

• Problem behavior
• Affect
• Self-report

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Agitation

 Near constant state of negative affect or distress that

• ccurs irrespective of environmental events

 May co-occur with problem behavior

Hyperactivity/Impulsivity

 Behavior that occurs quickly and indiscriminately in

relation to environmental events

 Does not efficiently access reinforcement  Difficulty waiting

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 10-year-old from NYS with autism and ID  Admitted on unit on Strattera, Zoloft, and Risperdal  Parents reported that Strattera helped, but still had a

high rate of activity on the unit

 Psychiatrist wanted to discontinue Strattera and if

hyperactivity continued, to try other stimulant due to side effects of Strattera

 Out of seat, off task, and problem behavior data were

collected

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90 2 4 6 8 10 12 14 10 20 30 40 50 60 70 80 90 100 8/27/13 8/29/13 8/31/13 9/2/13 9/4/13 9/6/13 9/8/13 9/10/13 9/12/13 9/14/13 9/16/13 9/18/13 9/20/13 9/22/13 9/24/13 9/26/13 9/28/13 9/30/13 10/2/13 10/4/13 10/6/13 10/8/13 10/10/13 10/12/13 10/14/13 10/16/13 10/18/13 10/20/13 10/22/13 10/24/13 10/26/13 10/28/13 10/30/13 11/1/13 11/3/13 11/5/13 11/7/13 Out of Seat Percent of Session Session

Academic Analog Out of Seat

Out of Seat Strattera (mg/10) Zoloft (mg/10) Risperdal (mg) Ritalin (mg)

 10 year boy  Diagnosed with autism and severe ID  On the inpatient unit for the assessment and

treatment of aggression, disruption, SIB, and pica (not

• n graph)

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92 Transition TX added; Removal of non-exclusionary timeout 5 10 15 20 25 30 35 10 20 30 40 50 60 70 80 Milligrams per day Responses per Hour Date

Problem Behavior

(SIB, AGG, DIS)

BASELINE TREATMENT 80% reduction Prozac Risperdal/10

Baseline Extinction 24hr Treatment

80% reduction

 Sasha - 20 year old female  DSM IV diagnoses

• Disruptive Behavior Disorder, Stereotypic Movement Disorder

with Self-Injury, Autism Spectrum Disorder, Unspecified Bipolar and Related Disorder, Moderate Intellectual Disability

 Target behaviors: aggression and disruption  Functions of problem behavior

• Escape from demands
• Appeared sensitive to reprimands

94 20 40 60 80 100 120 140 160 180 200 20 40 60 80 100 120 140 160 Milligrams Responses per Hour Date

Sasha Problem Behavior

(Aggression, Disruption)

Lithium/10 Trazodone Latuda Lamotrigine Clonidine*100 Benztropine*10 Alprazolam*10 Paxil Baseline Extinction Treatment

 Keep data collector blind  If can’t use direct observation data, use time

samples, scatterplots, or rating scales

 Implement interventions systematically and one

and a time

 Develop a collaborative relationship with medical

team to make data-based decisions on medication treatment

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 Academy of Adolescent and Child Psychiatry:

http://www.aacap.org/App_Themes/AACAP/docs/press/guid e_for_community_child_serving_agencies_on_psychotropic_ medications_for_children_and_adolescents_2012.pdf

 MedlinePlus; FDA; drugs.com; WebMD  CDC fact sheets:

http://www.cdc.gov/MedicationSafety/parents_childrenAdve rseDrugEvents.html

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 Use varies from culture to culture  40% of cancer patients use some form of CAM  30-95% of children with autism have been exposed to

some form of CAM

 NIH: National Center for Complementary and

Alternative Medicine

• Conducts and funds clinical trials in this area
• Related to all areas of medicine

 Primary concerns are around the lack of regulation and

safety and efficacy

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 Secretin  Chelation  Hyperbaric chamber  Sensory integration therapies including:

• Sensory diets
• Weighted vests and blankets

 Auditory integration therapy  Swimming with dolphins

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 Winburn et al. (2013) survey found that

• 83% of parents had used a dietary intervention
• 75% of professional have been asked about diets

 Food allergies – how common are they?

• 4% of children have them
• Increased over past decade

 Difference between intolerance (e.g., lactose)

• vs. allergy (immediate reaction after ingestion)

 Avoiding foods required for allergy, but what

about other effects of certain foods to which we aren’t allergic?

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 Some parents/professionals feel that GFCF diet has

positive behavioral effects on symptoms of ASD

• improves communication, social interaction, and sleep patterns,
• reduces symptoms of autism and digestive problems such as

diarrhea (Seroussi, 2000; Pennesi & Klein, 2012).

• Survey by Autism Research Institute found that out of 3593

parents who had used the diet, 69% said it helped, and 3% felt they got worse

 Knivsberg, Reichelt, Hoien, & Nodland (2002) found that, although

the diet did not significantly improve cognitive, language, or motor skills, it may have reduced behaviors associated with autism such as repetitive statements.

 Whiteley et al. (2010) conducted a randomized, controlled,

single blind study of GFCF with 72 children (4-10 years) for 12 months.

• Of the 26 children who completed on the diet, there was significant

improvement in symptoms of ASD on parent checklists.

• Controls were reassigned to treatment group due to significance of

effects.

 Problem with Whiteley study :

• Based on parent rating of improvement
• Parents weren’t blind to the status of the child’s treatment

condition

• No placebo condition
• No direct observation of behavioral outcomes
• Other interventions were not controlled

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 Elder et al. (2006) conducted a double blind placebo

controlled trial with 15 children with ASD over 12 weeks

• No significant changes in autism symptoms

 Hyman et al. (2010) conducted a controlled clinical trial and

also reported no change in their behavior for 14 children who were on the diet for 18 weeks

• Additionally, children had low vitamin D and calcium levels

resulting in the recommendation that nutritional oversight may be important for children on the diet

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 Mulloy et al. (2010) conducted a systematic review of

15 studies of GFCF diet and found that many of the studies lacked experimental rigor and the controlled trials demonstrated no clear evidence in support of GFCF diets

• Again noted possible side effects associated with

stigmatization, bone density

• Recommends allergy testing for sensitivity to gluten or casein

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 General multivitamins  Specific vitamins (vitamins A, B6, B12, C zinc, calcium,

folic acid, magnesium)

 Digestive enzymes  Essential fatty acids (Omega 3 fish oil)  Majority of families surveyed by Autism Research

Institute indicated that supplements had “no effect” with the exception of fatty acids, B12 injections, and digestive enzymes

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 Not synthesized by body but necessary for normal

metabolism; thus, used as a supplement

 Used for treatment of cancer, cardiovascular disease,

inflammation, developmental disorders, psychiatric conditions and cognitive aging.

 No evidence, however, that it is helpful in the

treatment of these conditions, EXCEPT:

• Maybe inflammation
• Some symptoms of ADHD

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 Preliminary studies with children with ASD note

small improvements in stereotypy and hyperactivity

 But Cochrane Review (2011) of two clinical trials with

N=37 found that there was no improvement in social interaction, communication, stereotypy or hyperactivity

 Noted a need for more controlled trials and with

people across the spectrum

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 Acupuncture, acupressure  Oxytocin and social behavior – Autism Speaks study  Probiotics  Hippotherapy and other animal therapies  And ongoing issues with anti-vaccine movement

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 What do you do when you are faced with questions

about medications or other therapies?

• Be sure to “stay in your lane” and not provide advice outside
• f area of training
• Promote evidence-based treatments and data-based decision

making

• Encourage parents to be skeptical of novel (unusual) therapies

and to look for articles/data

• Build a collaborative relationship with family, school and

medical team

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Newhouse-Oisten et al., BAP , 2017 Schall, Focus on Autism, 2002

University of Kansas

• Kimberly Crosland
• Steven Lindauer
• Jessica Hellings
• David McAdam
• Todd McKerchar
• Paige Morse-McKerchar
• Matt Reese
• Stephen Schroeder
• Maria Valdovinos

University of Rochester

• Deborah Napolitano
• Susan Hyman
• Tristram Smith

Kennedy Krieger Institute

• Jonathan Schmidt
• Griffin Rooker
• Louis Hagopian

Supported by NICHD grant 26927, 76653 And NIMH grants 83247, 84870

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