Medication for children with autism

Transcription

1 Medication for children with autism James Scott Child & Adolescent Psychiatrist Royal Brisbane and Women s Hospital & The University of Queensland Centre for Clinical Research

2 Murray 9 year old boy Autistic spectrum Escalating aggression Siblings upset and frightened Mum feeling exhausted Teachers reporting more difficulties with behaviour at school

3 Medications in ASD Difficult decision Expectations about benefits Anxiety about risks How do we optimise the benefits and reduce the risks of medications?

4 1. What can medication do for children with ASD?

5 Medications for ASD Medication has virtually no role in managing the Core Features Impaired communication Difficulty with socialisation Repetitive behaviours Restricted interests BUT

6 Medications can help with the emotional/ behavioural problems associated with ASD Aggression Inattention Anxiety Depression/ Mood swings Sleep problems

7 Case Example Larry

8 Larry 7 year old boy with ASD Severe tantrums at home and school Running away Aggressive Assessed as being very impulsive and having poor attention Non-medication interventions hadn t worked Atomoxetine resulted in Larry being able to sit still and listen

9 2. Does this child need medication?

10 You need to consider Are the problems severe enough? Have other interventions been tried? Will the medication help the problems?

11 Case study- Joseph

12 Joseph 13 year old boy with Aspergers Disorder Generally happy with his own company Interested in music Attentive in areas of interest Rigid, unsettled with disrupted routine Has few friends but not concerned by this Anger/ swearing at times Cheeky and playful- responds to correction

13 Question 3 Does the medication work?

14 Consider the evidence Highest level of evidence are Meta Analyses Lowest level of evidence is clinical opinion In between are case studies, open label studies and RCTs

15 Clinical Opinion The opinion of clinicians regarding a particular intervention Very low level of evidence

16 Open Label Studies Baseline Measurements are taken Intervention is provided Post Interventions Measurements are taken Has there been an improvement?

17 Open Label and Case Reports Neuroleptics/ antipsychotics Stimulants Anti-depressants Mood Stabilisers Nor-Adrenergic Agents Complementary Medications

18 Randomised Control Trials (RCTs) Patients are randomly assigned to a treatment group and a control group The control group may be an active intervention or a placebo Patients and raters should be binded Adequate patient numbers required Adequate time duration required

19 Research units on Paediatric Psychopharmacology (RUPP) RUPP Risperidone trial 101 patients average age 8.8 years 49 received risperidone 34 of risperidone children vs 6 of placebo improved at 8 weeks Aggression, hyperactivity and Irritably decreased in responders 23 of patients maintained their improvement at 6 months

20 Case Study Michael

21 Risperidone for ASD Michael 9 year old boy with autism spectrum disorder Frequently aggressive at school Reacting to other children in social situations Inattention and hyperactivity treated with Ritalin- no benefit Now suspended from school

22 Risperidone Michael Commenced on Risperidone 0.5 mg daily Provided with support for Educational Adjustment Programme Social difficulties persist Behaviour and academic work markedly improved Doesn t show indiscriminate aggression towards other children

23 Methylphenidate (Ritalin) RUPP study Methylphenidate in ASD with ADHD Stimulants helped some children targeted symptoms of poor attention, hyperactivity and aggression Other children had worsening of behaviour with more hyperactivity and impulsivity Responses were obvious early

24 Case Study- Rebecca

25 Rebecca 12 year old girl with autistic spectrum disorder Unmanageable at school- excluded Violent towards parents Admitted to hospital Very unfocused Annoying, wouldn t listen, aggression continued Ritalin prescribed Able to settle into activities Aggression resolved in hospital

26 A word about ADHD symptoms Impulsive, inattentive, Hyperactive Debilitating Often associated with aggression Methylphenidate (Ritain) and Atomoxetine (Strattera)

27 Antidepressants Fluoxetine- (Prozac, Lovan, Zactin) 1 RCT has shown benefits for anxiety and repetitive behaviours Fluvoxamine (Luvox, Faverin) 1 RCT suggested that there was behavioural activation with worsening of behaviours Citalopram (Cipramil) 1 RCT showing no benefit

28 Victoria

29 Victoria 15 year old girl with Autism Recent onset of Self Injurious behaviours Aggressive to parents Very anxious at school Felt to be depressed Fluoxetine no benefit Zoloft- no benefit Seroquel no benefit

30 Meta-Analysis 4120 papers 18 studies reported Antipsychotics, n = 9 Risperidone 6 studies up to 6 months Aripiprazole 2 studies of 8 weeks SSRIs, n = 5 only 1 RCT Stimulants, n = 4 Only 1 RCT (McPheeters et al 2011 Pediatrics)

31 4. What are the risks of medication No benefit May make things worse Immediate side effects Long term side effects Parental anxiety and guilt Stigma at home or at school

32 Risperidone Side Effects Average weight gain 2.7kg in 6 months Somnolence reported in 70% of children on risperidone (9% of placebo) Dizziness and drooling were more likely Mild increases in heart rate and Blood pressure Long term side effects unclear

33 Kate 11 year old girl with ASD Aggression towards mother and siblings Family feel frustrated, angry Wants friends but can t keep them- because of aggression Commenced on risperidone Excellent response Aggression resolved Happier at school and home BUT

34 Kate Weight gain of 9 kg in 7 months

35 What can parents and carers do to make medication work?

36 Guidelines for medications in children 1. Try other interventions first 2. Keep a record of medication history 3. One medication change at a time 4. Don t pressure for medication changes when times are difficult 5. Ensure the child is monitored regularly by a doctor 6. Lowest dose and lowest number of medications 7. Don t medicate only- try other things

37 1. Try other interventions first Sonya and Rod (6 years old) Rod was stubborn, angry and aggressive Wouldn t listen Work done with Sonya to follow Rod s interests Behaviour at home improved significantly

38 2. Keep a record of medication history Medication Started Stopped Response Ritalin 10 mg morning January 12 January 12 More aggressive, couldn t sleep Prozac 20mg January 12 Aggression better, less rigid Seroquel 25mg January 13 Less aggressive

39 3. One medication change at a time Monica 9 year old girl with autism Aggression Doctor prescribes risperidone Pharmacist recommends Eye-Q (Omega-3) 1 month later aggression has settled Which one has worked?

40 4. Don t pressure for medication changes when times are difficult Mary 10 year old girl Diagnosed with Aspergers Disorder since age 5 Anxiety, aggression and oppositional behaviour created problems at home and school Pharmacotherapy commenced but problems escalated with age Now having home schooling with ongoing aggression

41 4. Don t pressure for medication changes when times are difficult Mary s medication Risperidone 2 mg twice daily Edronax (Reboxetine) 4 mg twice daily Endep (Amitryptilline) 50 mg at night Valproate 200 mg twice daily

42 4. Don t pressure for medication changes when times are difficult Mary Both parents were depressed Father very reactive Both parents were mistrusting of schools Endep and Valproate ceased without worsening Father had depression treated Returned to school with school liaison- 3 months later- Much improved

43 5. Ensure the child is monitored regularly by a doctor Weight gain of 9 kg in 7 months

44 6. Lowest dose and lowest number of medications Reduces side effects Improves adherence Safer in short and longer term

45 7. Don t medicate only- try other things Individual therapy Family support Evidence based Allied health support School Liaison Reinforce strengths Support friendships Dietary changes Pharmacotherapy

46 Thank You