challenge of co morbidity and treatment in autism 131027

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Autism in Spectrum Disorder: Autism in Spectrum Disorder:

Challenge of Comorbidity andChallenge of Comorbidity andTreatmentTreatment

Autism Society of the Philippines Autism Society of the Philippines

Cornelio G. Banaag, Jr., M.D.Cornelio G. Banaag, Jr., M.D.


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Autism Autism Autism first described by Kanner (1943) Autism first described by Kanner (1943)

Term autistic intended to convey profound social isolationTerm autistic intended to convey profound social isolationas hallmark as hallmark

Autism is a brain Autism is a brain --based disorder, onset prenatalbased disorder, onset prenatal Involves abnormalities in:Involves abnormalities in:

Qualitative aspects of social developmentQualitative aspects of social development Qualitative aspects of communication developmentQualitative aspects of communication development Repetitive, stereotyped patterns of behavior &Repetitive, stereotyped patterns of behavior &

interestsinterests Affects 4 males to 1 female Affects 4 males to 1 female


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Children and Adolescents with Autism:Children and Adolescents with Autism:

DefinitionsDefinitionsPervasive Developmental Disorders(PDD)

Autism Spectrum Disorders*

(ASD)

Childhood

DisintegrativeDisorder (CDD)

Rhett Disorder

AutisticDisorder

Pervasive DevelopmentalDisorder not otherwisespecified (PDD-NOS)

AspergersDisorder

*ASD is not a DSM-IV TR definition but reflects the categorization in the general public.Tidmarsh L, et al. Can J Psychiatry. 2003;48:517-525.; DSM-IV TR. Washington, DC:American Psychiatric Association; 2000.


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PrevalencePrevalence Changing prevalence rates of autismChanging prevalence rates of autism Before 1985: 2 per 10,000Before 1985: 2 per 10,000 1998 Study: 40 per 10,0001998 Study: 40 per 10,000 2003 Study: 34 per 10,0002003 Study: 34 per 10,000 Was true prevalence being underestimated?Was true prevalence being underestimated? Diagnostic criteria have expanded to include a spectrum ofDiagnostic criteria have expanded to include a spectrum of

disordersdisorders Increased public awarenessIncreased public awareness

More medical and educational resourcesMore medical and educational resources More training and information for healthcare professionalsMore training and information for healthcare professionals Possible rise in true prevalence?Possible rise in true prevalence? Environmental factors that trigger expression of Autism,Environmental factors that trigger expression of Autism,

remain unclearremain unclearYeargin-Allsopp, et al. JAMA. 2003;289:49-55.


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Importance of an Early DiagnosisImportance of an Early Diagnosis Facilitates earlier educational planningFacilitates earlier educational planning

Participation in intensive, early intervention programsParticipation in intensive, early intervention programsduring toddler and preschool years improves longduring toddler and preschool years improves long --term outcome for many childrenterm outcome for many children

May ease family problemsMay ease family problems Identifies the need for family support and educationIdentifies the need for family support and education Initiates development of strategies to manage stressInitiates development of strategies to manage stress

Ensures early delivery of appropriate medical care:Ensures early delivery of appropriate medical care: For the child with autismFor the child with autism Parents require genetic counseling about increasedParents require genetic counseling about increased

risk of ASD in subsequent childrenrisk of ASD in subsequent childrenCommittee on Children With Disabilities. Pediatrics. 2001;107:E85.Filipek PA, et al. Neurology. 2000;55:468-79.


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The Treatment TeamThe Treatment Team

Effective patientEffective patient

care may include acare may include adynamic treatmentdynamic treatment

teamteam

The Autism Society. http://www.autism-society.org/site/PageServer?pagename=autismprofessionals. Accessed 04.28.04

PsychiatristPsychiatrist

General orGeneral orDevelopmentalDevelopmental

PediatricianPediatrician PediatricPediatric

NeurologistNeurologist

Psychologist SpeechPathologist

TeachersTeachers

Social WorkerSocial Worker

ParentsParents


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Comorbidity in ASDComorbidity in ASD

Very common Very commonIncreases with ageIncreases with age

Worsens the course of ASDWorsens the course of ASDMakes intervention/treatment moreMakes intervention/treatment moredifficultdifficult


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In children with AutismIn children with Autism As many as : As many as :

60% have poor attention/concentration60% have poor attention/concentration 40% hyperactive40% hyperactive 88% with unusual preoccupations/rituals88% with unusual preoccupations/rituals 37% with obsessive thinking37% with obsessive thinking 89% with stereotyped language89% with stereotyped language

74% with significant fears/anxiety74% with significant fears/anxiety 44% with depressed mood, irritability & agitation44% with depressed mood, irritability & agitation 11% with sleep problems11% with sleep problems

43% with self 43% with self --injuryinjury 10% with tics10% with tics Seizures in ~14% of autistics with peaks in Infancy &Seizures in ~14% of autistics with peaks in Infancy &

Adolescence Adolescence A significant # have feeding & nutritional issues A significant # have feeding & nutritional issuesData from Gillberg, 2004


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The Problems of CoThe Problems of Co --morbid Diagnosismorbid Diagnosis

DSMDSM--IV somewhat arbitrarily imposesIV somewhat arbitrarily imposesrestrictions, e.g.restrictions, e.g. CanCan t diagnose ADHD & autismt diagnose ADHD & autism

CanCan t diagnose OCD & autismt diagnose OCD & autism Can diagnose TouretteCan diagnose Tourette s & autisms & autism

Definitely a problem since clinicians CLEARLYDefinitely a problem since clinicians CLEARLYsee e.g. ADHD & autism, etc.see e.g. ADHD & autism, etc.


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CoCo--morbiditiesmorbidities Cognitive delay (ID/MR)(60% AD; 30% ASD)Cognitive delay (ID/MR)(60% AD; 30% ASD)

(Fombonne, 2006)(Fombonne, 2006) Seizure disorder (5% to 44%) (Tuchman & Rapin, 2002:Seizure disorder (5% to 44%) (Tuchman & Rapin, 2002:

Lancet Neurol)Lancet Neurol)

Depression (Depression ( with age) esp with higher functioningwith age) esp with higher functioningindividualsindividuals

Anxiety disorders (all types) Anxiety disorders (all types)

Sleep (up to 80% of children with ASDSleep (up to 80% of children with ASD s have sleeps have sleepissues)issues)

Eating/nutritional issuesEating/nutritional issues ADHD ADHD


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Autism and Comorbid Autism and ComorbidPsychiatric DisordersPsychiatric Disorders

70% had at least 1 comorbid disorder70% had at least 1 comorbid disorder41% had 2 or more comorbid disorders41% had 2 or more comorbid disorders

Anxiety disorders Anxiety disordersDepressionDepression

ADHD ADHDOppositional Defiant DisorderOppositional Defiant Disorder


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Nutrition/Feeding Issues in ASDNutrition/Feeding Issues in ASD

Numerous case studies have reported dietaryNumerous case studies have reported dietaryselectivity among children with autismselectivity among children with autism

Repetitive behaviors and restricted interests, a coreRepetitive behaviors and restricted interests, a corefeature of autism, may play a role in dietaryfeature of autism, may play a role in dietaryselectivityselectivity

Children with ASDs often resist novel experiences,Children with ASDs often resist novel experiences,which may include tasting new foods.which may include tasting new foods.

Many children with ASDs have sensoryMany children with ASDs have sensory

hypersensitivities and may reject foods due to anhypersensitivities and may reject foods due to anaversion to texture, temperature or otheraversion to texture, temperature or othercharacteristics of the foods (e.g appearance).characteristics of the foods (e.g appearance).

Herndon AC et al, 2008


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Sleep Disturbance in AutismSleep Disturbance in Autism

Sleep problems in children with autismSleep problems in children with autism prevalence estimates of 44prevalence estimates of 44 83% for sleep83% for sleep

disorders in this populationdisorders in this population

Poor appetite and poor growth werePoor appetite and poor growth wereassociated with decreased willingness to fallassociated with decreased willingness to fallasleepasleep

Williams PG, et al: J. Sleep Res., 13, 265268; 2004


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Sleep Disturbance in AutismSleep Disturbance in Autism

Sleep problems are associated with other healthSleep problems are associated with other healthconditions and quality of lifeconditions and quality of life Sleep deprivation appears to intensify the behavioralSleep deprivation appears to intensify the behavioral

problems of autistic children, improved sleep mayproblems of autistic children, improved sleep mayimprove childrenimprove children s behavior, alleviating maternals behavior, alleviating maternalstress as a resultstress as a result

Decrease in quality sleep could be a source of stressDecrease in quality sleep could be a source of stressthat affects not only the child, but also other familythat affects not only the child, but also other familymembers (Richdale, et al., 2000)members (Richdale, et al., 2000)


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Anxiety Disorders Anxiety Disorders

A variety of anxiety disorders tend to co A variety of anxiety disorders tend to co --occur with ASDoccur with ASDSpecific phobia: most common coSpecific phobia: most common co --morbidmorbidanxiety disorder, with lifetime prevalenceanxiety disorder, with lifetime prevalenceof 38of 38 --63%63%

Fear of certain places, situations, objects, orFear of certain places, situations, objects, oranimalsanimalsFear of people in uniformFear of people in uniformFear of loud noisesFear of loud noises


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ObsessiveObsessive --compulsive disorder (OCD) occurs in 11compulsive disorder (OCD) occurs in 11 --

35% of individuals with ASD (up to 81% not full35% of individuals with ASD (up to 81% not fullsyndrome)syndrome)

Individuals with ASD exhibit rigid thinking andIndividuals with ASD exhibit rigid thinking andcompulsions (flapping, spinning, repeatingcompulsions (flapping, spinning, repeatingphrases)phrases)Distinct from OCD symptoms (checking, cleaning,Distinct from OCD symptoms (checking, cleaning,counting)counting)

Social phobia/anxiety disorderSocial phobia/anxiety disorder -- 7.4% lifetime7.4% lifetimeprevalenceprevalence

More common in higher functioning ASDMore common in higher functioning ASDDesire social interaction but aware of socialDesire social interaction but aware of social

deficitsdeficits


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Mood DisordersMood DisordersDepression: very common disorder seen individuals withDepression: very common disorder seen individuals with

ASD ASD

Rates has wide range of 4Rates has wide range of 4 --58%58%

Occurs more in highOccurs more in high --functioning individuals duringfunctioning individuals duringadolescence and young adultadolescence and young adultDuring adolescence: greater insight into differencesDuring adolescence: greater insight into differencesfrom othersfrom others

Lower functioning children and adolescent ASDLower functioning children and adolescent ASDManifestation of depression: more behavioralManifestation of depression: more behavioral

(irritability, temper tantrum, regressive behavior)(irritability, temper tantrum, regressive behavior)


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Depression in ASDDepression in ASDComplicated by difficulties in recognizing/expressingComplicated by difficulties in recognizing/expressing

emotionsemotionsSuggestive signs and symptomsSuggestive signs and symptoms

Low/depressed moodLow/depressed moodDiminished interest in activities previously enjoyedDiminished interest in activities previously enjoyedChanges in appetiteChanges in appetiteChanges in sleep: insomnia, hypersomniaChanges in sleep: insomnia, hypersomniaFatigue, loss of energyFatigue, loss of energyFeelings of worthlessness or guiltFeelings of worthlessness or guilt

Diminished ability to think or concentrateDiminished ability to think or concentrateThoughts of deathThoughts of death


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Autism and ADHD Autism and ADHD

Is it ADHD or Autism or both?Is it ADHD or Autism or both?Overlap of symptoms between ADHD and AutismOverlap of symptoms between ADHD and Autism

Close to 50% of Autism/ASD have ADHDClose to 50% of Autism/ASD have ADHD

symptoms (Hyperactivity inattention)symptoms (Hyperactivity inattention) About 20% of children with autism have About 20% of children with autism havecomorbid ADHDcomorbid ADHD

18% of children with ADHD have autistic traits18% of children with ADHD have autistic traitsStudies suggest both disorders share a commonStudies suggest both disorders share a commongenetic risk factorgenetic risk factor


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Autism and ADHD Autism and ADHDOverlap of symptoms seen in youngerOverlap of symptoms seen in younger

childrenchildren As children become older the similarities As children become older the similarities

between the 2 conditions will separate outbetween the 2 conditions will separate outChildren with ASD become more withdrawn,Children with ASD become more withdrawn,hyperactivity wanes out, social skillshyperactivity wanes out, social skills

difficulties emergedifficulties emergeChildren with ADHD unlikely to becomeChildren with ADHD unlikely to becomecalmer with age, will develop social andcalmer with age, will develop social andcommunication skillscommunication skills


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Autism and ADHD Autism and ADHD

ADHD symptoms affect/worsen the daily ADHD symptoms affect/worsen the dailyfunction and quality of life of child withfunction and quality of life of child with ASD ASDOnly 10% receive appropriate treatmentOnly 10% receive appropriate treatmentto relieve ADHD symptomsto relieve ADHD symptoms


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ADHD: Attention Deficit ADHD: Attention DeficitHyperactivity DisorderHyperactivity Disorder

A disorder of self A disorder of self --regulation and executiveregulation and executivefunctions (planning, organizing,functions (planning, organizing,appropriate inhibitions, working memory)appropriate inhibitions, working memory)BrainBrain --based neurodevelopmental disorderbased neurodevelopmental disorderinvariably needing medication as part ofinvariably needing medication as part of

managementmanagementMarked by significant symptoms in 3Marked by significant symptoms in 3areas: Inattention, Hyperactivity,areas: Inattention, Hyperactivity,ImpulsivityImpulsivity


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Common ADHD BehaviorCommon ADHD Behavior(Inappropriate for age)(Inappropriate for age)

Often canOften can t pay attention to details;t pay attention to details;careless mistakecareless mistakeDifficulty sustaining attentionDifficulty sustaining attentionDoes not seen to listen, follow throughDoes not seen to listen, follow throughDifficulty organizingDifficulty organizingLoses thingLoses thingForgetfulForgetful


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Common ADHD BehaviorsCommon ADHD Behaviors

Fidgety, canFidgety, can t stay seatedt stay seatedOften runs around, climb excessivelyOften runs around, climb excessively

As if As if driven by motor; always on the godriven by motor; always on the goTalks excessivelyTalks excessivelyBlurts out answersBlurts out answersHas difficulty awaiting turnHas difficulty awaiting turnOften interrupts or intrudesOften interrupts or intrudes


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Epilepsy and AutismEpilepsy and AutismSeizures, periods of altered consciousnessSeizures, periods of altered consciousness

Due to upset in brain chemistryDue to upset in brain chemistryMessages that travel between nerve cells/neuronsMessages that travel between nerve cells/neuronsbecome scrambledbecome scrambled

Neuron activity disturbed manifesting as seizuresNeuron activity disturbed manifesting as seizures55--40% comorbid with autism40% comorbid with autism

Infancy and early childhoodInfancy and early childhood Adolescence Adolescence

75% of EEG of ASD show abnormal patterns75% of EEG of ASD show abnormal patterns

Up to 40% have seizuresUp to 40% have seizures


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Epilepsy and AutismEpilepsy and Autism

Common types of Seizures in ASDCommon types of Seizures in ASDInfantile spasmInfantile spasm Absence seizure Absence seizureComplex partial seizureComplex partial seizureGran malGran mal

Appropriate diagnosis: neurologist Appropriate diagnosis: neurologist


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Behavior Which May IndicateBehavior Which May Indicate

Comorbid IllnessComorbid IllnessSudden change in behaviorSudden change in behavior

Loss of previously acquired skillsLoss of previously acquired skillsIrritability, low moodIrritability, low mood

Tantrums, oppositional behaviorTantrums, oppositional behavior

Sleep disturbanceSleep disturbanceChange in appetiteChange in appetite

Increase in aggressive behaviorIncrease in aggressive behavior

Self Self --injurious behavior (biting, hits/slaps face, headinjurious behavior (biting, hits/slaps face, headbanging)banging)

Facial grimacing, wincingFacial grimacing, wincing Agitation: pacing, jumping up and down Agitation: pacing, jumping up and down


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Treatment Options:Non-Pharmacologic and

Pharmacologic Interventions

Treatment Options:Treatment Options:NonNon --Pharmacologic andPharmacologic and

Pharmacologic InterventionsPharmacologic Interventions


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Treatment OptionsTreatment Options Initial interventions are largely nonInitial interventions are largely non --

pharmacologicpharmacologic No medicine has significant effect on coreNo medicine has significant effect on coresymptoms of autismsymptoms of autism

Associated challenging behavior (temper Associated challenging behavior (tempertantrum, self tantrum, self --injury, agitation, hyperactivityinjury, agitation, hyperactivitypsychiatric comorbidities): target symptoms forpsychiatric comorbidities): target symptoms forpharmacotherapypharmacotherapy

Medication makes the child receptive to nonMedication makes the child receptive to non --pharmacologic approaches but should notpharmacologic approaches but should notreplace themreplace them


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NonNon --Pharmacologic InterventionsPharmacologic Interventions Structured classroom training + behavioralStructured classroom training + behavioral

methods most effective treatmentmethods most effective treatment Studies indicate gains in language and cognition,Studies indicate gains in language and cognition,

decrease in maladaptive behavior achieved bydecrease in maladaptive behavior achieved by

consistent behavioral programconsistent behavioral program Even with the best psychosocial programsEven with the best psychosocial programs

available, many children/adolescents with Autismavailable, many children/adolescents with Autismremain significantly impairedremain significantly impaired

Pharmacotherapy becomes valuable adjunctivePharmacotherapy becomes valuable adjunctive

treatment to ameliorate associated behavioraltreatment to ameliorate associated behavioralsymptomssymptoms


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Controversies on the use ofControversies on the use ofmedicationsmedications

Exact cause of Autism remains unknownExact cause of Autism remains unknown Fear of tampering with young brainFear of tampering with young brain

actively developingactively developing Before 1997, no FDA approvedBefore 1997, no FDA approved

medications for behavioral andmedications for behavioral and

psychiatric disorders in childrenpsychiatric disorders in children How do you measure efficacy ofHow do you measure efficacy of

medications in children with Autismmedications in children with Autism


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Psychopharmacology in ASDPsychopharmacology in ASD

Dysregulation of DA receptorsDysregulation of 5 hydroxytryptamine(5HT) receptorsImplicated mechanisms for ASD sypmtoms


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Treatment of InsomniaTreatment of Insomnia The primary approach is soThe primary approach is so --calledcalled sleepsleep

hygienehygiene oror behavioralbehavioral approachesapproaches(establishing routines, allowing to fall asleep(establishing routines, allowing to fall asleepalone, etc)alone, etc)

It is only when these fail thatIt is only when these fail that medicalmedical approaches are entertained. These includeapproaches are entertained. These include Traditional Medicines, e.g. diphenhydramine,Traditional Medicines, e.g. diphenhydramine,

clonidine, mirtazapine, risperidone.clonidine, mirtazapine, risperidone.

NonNon --traditional approaches, e.g. Melatonin,traditional approaches, e.g. Melatonin,


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Melatonin in AutisticsMelatonin in Autistics Melatonin (MLT) & sleep:Melatonin (MLT) & sleep:

Jan JE, O'Donnell MEJan JE, O'Donnell ME (1996)(1996) reviewed 100 childrenreviewed 100 childrenwith a variety of developmental disabilities includingwith a variety of developmental disabilities including

Autism, Autism,

Melatonin, which benefited slightly over 80% ofMelatonin, which benefited slightly over 80% oftheir patients, appeared to be a safe,their patients, appeared to be a safe,inexpensive, and a very effective treatment ofinexpensive, and a very effective treatment of

sleepsleep --wake cycle disorderswake cycle disorders


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The AntidepressantsThe Antidepressants

Tricyclic nonTricyclic non --selective serotonin reuptake inhibitor e.g.selective serotonin reuptake inhibitor e.g.ClomipramineClomipramine

In an excellent study by Gordon et al (1993)this drugIn an excellent study by Gordon et al (1993)this drugwas more effective than placebo in treating somewas more effective than placebo in treating some

symptoms e.g. anger/uncooperativeness, hyperactivity,symptoms e.g. anger/uncooperativeness, hyperactivity,& OCD symptoms& OCD symptoms But, side effects of irregular heart rhythm, lowering ofBut, side effects of irregular heart rhythm, lowering of

seizure threshold , make it less desirable than the SSRIseizure threshold , make it less desirable than the SSRI ss


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SSRIs in AutismSSRIs in Autism

Selective Serotonin ReSelective Serotonin Re --uptake Inhibitorsuptake InhibitorsEffective in anxiety and depressionEffective in anxiety and depressionFDA approved for children and adolescentsFDA approved for children and adolescents

FluoxetineFluoxetineSertralineSertraline

FluvoxamineFluvoxamineEscitalopramEscitalopram

E l i i i h l iE l i t ti ith l ti


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Early intervention with selectiveEarly intervention with selective

serotonin reuptake inhibitorsserotonin reuptake inhibitors SSRIs have been presented as a model pharmacologicSSRIs have been presented as a model pharmacologic

treatment, because serotonin is known to enhancetreatment, because serotonin is known to enhancesynapse refinement in the brains of autistic childrensynapse refinement in the brains of autistic children

In the developing cortex, serotonin is concerned withIn the developing cortex, serotonin is concerned withmaturation of thalamic afferents, cortical dendrites, andmaturation of thalamic afferents, cortical dendrites, andaxons, with alterations in the levels of serotoninaxons, with alterations in the levels of serotoninpotentially resulting in negative effects.potentially resulting in negative effects. High levels of serotonin may reduce pruning of the dendriticHigh levels of serotonin may reduce pruning of the dendritic

branchesbranches Too little serotonin causing a smaller number of dendritic spineToo little serotonin causing a smaller number of dendritic spine ss

than usual, miniscule dendritic arbors and somatosensorythan usual, miniscule dendritic arbors and somatosensorybarrels, and a decrease in synaptic densitybarrels, and a decrease in synaptic density


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SSRISSRI s in Autisms in Autism Fluvoxamine has shown excellent results in adultFluvoxamine has shown excellent results in adult

autistics with few side effectsautistics with few side effects decreased repetitivedecreased repetitivethoughts & behavior, & maladaptive behavior &thoughts & behavior, & maladaptive behavior &aggression and improved communicationaggression and improved communication

In children, in contrast, the results were not asIn children, in contrast, the results were not asconsistent, esp. in younger childrenconsistent, esp. in younger children

Adverse effects included insomnia, motor hyperactivity, Adverse effects included insomnia, motor hyperactivity,agitation, aggression & anxiety (esp. preagitation, aggression & anxiety (esp. pre --pubertal)+pubertal)+

+McDougle et al, 2002

SertralineSertraline s effectiveness was assessed ins effectiveness was assessed in


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SertralineSertraline s effectiveness was assessed ins effectiveness was assessed in

children in an openchildren in an open --label triallabel trial

Nine children with autism between the ages of 6 and 12Nine children with autism between the ages of 6 and 12were administered sertraline for the treatment ofwere administered sertraline for the treatment oftransitiontransition --associated anxiety and agitation.associated anxiety and agitation.

It was found that 89% of the subjects had a positiveIt was found that 89% of the subjects had a positiveresponse.response.

Results suggest the importance of future controlledResults suggest the importance of future controlledinvestigation of sertraline in pediatric and adult ASDinvestigation of sertraline in pediatric and adult ASD

populations.populations.

Steingard RJ et al: J Child Adolesc Psychopharmacol. 1997;7(1):915.


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The PsychoThe Psycho --stimulants: Their Rolestimulants: Their Role Significant hyperactivity can exist with autism &Significant hyperactivity can exist with autism &

Asperger syndrome (10 Asperger syndrome (10 --20%) (Ghaziuddin,1998;20%) (Ghaziuddin,1998;

Martin et al, 1999)Martin et al, 1999) These medications act by increasing theThese medications act by increasing the

neurotransmitters norepinephrine & dopamineneurotransmitters norepinephrine & dopamine

indirectly in the brain (CNS)indirectly in the brain (CNS) For years they were not used in children withFor years they were not used in children with

Autism as it was claimed that they increased Autism as it was claimed that they increased

negativism (including self negativism (including self --injurious behaviors), ticsinjurious behaviors), tics& stereotypies& stereotypies


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The PsychoThe Psycho --stimulants: Their Rolestimulants: Their Role In 1995, however, Quintana et al described in anIn 1995, however, Quintana et al described in an

excellent study, that there wasexcellent study, that there was a statisticallya statisticallysignificant reduction insignificant reduction in hyperactivityhyperactivity withoutwithout ananincrease in stereotypic behaviourincrease in stereotypic behaviour , using, using

methylphenidatemethylphenidate In some children, adverse effects are seen,In some children, adverse effects are seen,

includingincluding irritability, paradoxicalirritability, paradoxical in hyperactivity,in hyperactivity,

stereotypic behaviors, or agitationstereotypic behaviors, or agitation

Aman et al, 2000


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The PsychoThe Psycho --stimulants: Their Rolestimulants: Their Role In higher functioning children with ASDIn higher functioning children with ASD s responses response

is better, more predictable & often low doses areis better, more predictable & often low doses areeffectiveeffective

In children with cognitive impairment (IQ


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22-- Adrenergic Adrenergic --agonistsagonists

ClonidineClonidine && GuanfacineGuanfacine are best studiedare best studied

Regulates noradrenergic neurotransmissionRegulates noradrenergic neurotransmission Good study with clonidineGood study with clonidine Improvement inImprovement in

hyperactivity, irritability, stereotypes, inappropriatehyperactivity, irritability, stereotypes, inappropriatespeech & oppositional behavior (only 8 children used!)speech & oppositional behavior (only 8 children used!)

Was a doubleWas a double --blind, placeboblind, placebo --controlled, crossovercontrolled, crossoverstudystudy

Adverse effects were: sedation,irritability & Adverse effects were: sedation,irritability &hypotensionhypotension

Jaselskis et al, 1992 Guanfacine effective in ~22%: Posey


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ConclusionsConclusions


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ConclusionsConclusions ASD is a complex neurodevelopmental disorder ASD is a complex neurodevelopmental disorderPart of its complexity is the frequent coPart of its complexity is the frequent co --

occurrence of medical and psychiatric conditionsoccurrence of medical and psychiatric conditionsComorbid conditions affect the daily functioningComorbid conditions affect the daily functioningand quality of life of individuals with ASD, asand quality of life of individuals with ASD, as

well the familywell the family ssPart of effective management includes the earlyPart of effective management includes the earlyrecognition and treatment of comorbidrecognition and treatment of comorbidconditionsconditionsMedications can be an effective part of aMedications can be an effective part of a

comprehensive management of ASDcomprehensive management of ASD


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ConclusionPharmacotherapy should be used as adjunct tobehavioral and educational therapeutic approachesNo drug as yet can treat the core symptoms of autismTarget maladaptive behaviors which cause significantimpairment generally responsive to medical treatmentConsider potential benefits against risk Monitor carefully for response and side effects

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Thank YouThank You

for your attention!for your attention!

challenge of co morbidity and treatment in autism 131027

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