Documente Academic
Documente Profesional
Documente Cultură
February, 2010
Go Bolts!
Assistant Clinical Professor,
Dept of Psychiatry, University of
California at San Diego School of
Medicine
• Case examples
• Your experiences
FDA Approved Medications
for the Treatment of Autism
• 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
Logical 3/08,3/07,3/08
Multicausal 3/08,3/07,3/08
Reflective 3/08,3/07,3/08
Sensory Postural Response to Intent to Visual Praxis -
Communication CommunicateExploration
Sensory Best when core is Cues into important Often unintelligible Spots fans at Perseverative ideas;
seeking, supported words distance; fingers in can expand w/
distractible eyes; rare gleam support
1.Mirror
Auditory 1 indicate desires 1.Orient vocalizations 1.focus on object Ideation
----3/08----
Visual ----3/08---- ----3/08---- ----3/08---- ----3/08----
2.. Mirror gestures
Tactile 2. mirror gestures 2. key tones 2. Alternate gaze Planning (including
3. gestures 3. Follow another’s sensory knowledge
Vestibular 3. imitate gesture 3. key gestures gaze to determine to do this)
4. sounds intent. ----9/08----
Proprio- 4. Imitate with 4. key words 3. Switch visual
ceptive purpose. 5.words attention Sequencing
----9/08---- ----9/08---- ----9/08---- ----9/08---- ----3/09----
Taste 5. Obtain desires 5. Switch auditory 4. visual figure
6. interact: attention back and forth 6. two –word ground Execution
Odor - exploration 6. Follow directions 5. search for object
-purposeful 7. Understand W ?’s 7. Sentences ----3/09---- Adaptation
----3/09---- ----3/09---- ----3/09---- 6. search two areas
8.abstract conversation. 8. logical flow. of room
- self help 7. assess space,
-interactions shape and materials.
• 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
Engage 4 8 12
Circles 4 8 12
Flow 12
4
8
Symbols 4
8
Individual Differences - T
Sensory Postural Response to Intent to Visual Praxis -
Communication CommunicateExploration
Sensory Unstable, made worse Some comprehension of Difficulty indicating A relative area of Ideas at times,
seeking… by meds sharp redirection with gesture, difficulty without effective
Dysarthric – planning nor
sequencing
1. Mirror
Auditory 1 indicate desires 1. Orient vocalizations 1. focus on object Ideation
Visual 2. mirror gestures 2. key tones 2.. Mirror gestures 2. Alternate gaze
Tactile 3. imitate gesture 3. gestures 3. Follow another’s Planning (including
Vestibular 4. Imitate with 3. key gestures 4. sounds gaze to determine sensory knowledge
Proprio- purpose. 4. key words 5.words intent. to do this)
ceptive 5. Obtain desires 5. Switch auditory 6. two –word 3. Switch visual
Taste 6. interact: attention back and forth 7. sentences attention Sequencing
Odor - exploration 6. Follow directions 8. logical flow. 4. visual figure
- purposeful 7. Understand ground Execution
- self help W ?’s 5. search for object
-interactions 8.abstract conversation. 6. search two areas Adaptation
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
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
• 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
Your Experiences?