Module 2.2.2 (Management of autism spectrum disorders and ADHD) Flashcards
What are the three aspects to managing ASD?
Structure Educational Therapy
Behavioural therapy
Pharmacotherapy
Why is behavioural management so important in ASD? What does it consist of?
MDT –> multidisciplinary therapy –> psychologist + speech therapist + occupational therapist
- Aim to improve competent behaviours and reducing difficult and antisocial behaviours
- Antecedents and consequences of the target behaviours need to be identified
Behavioural techniques
- Positive re-enforcement
- Verbal and nonverbal prompting
- Behavioural chaining
> ABA – Applied Behavioural Analysis
> TEACCH
> Sensory integration therapy
> Augmentative communication
> Managing sensory-induced stress
> Improving co-ordination by sensory integration and motor interventions , prescribed by an OT or PT
- reducing anxiety
- modelling sequences of behaviour by example
- parent education and skills training autistic behaviours
When is medication therapy used in ASD? Why use them?
To reduce severity of symptoms after behavioural therapy and environmental modification have failed ONLY
Benefits of drug therapy vs harms to patient
Mainly used as adjunct to psychological interventions
Currently no single medication that alleviates symptoms for all 3 domains of ASD.
A very large range of medications have been studied in autism but few are well supported.
1) Restricted repetitive behaviours and interests domain (RRBI) –> why treat for ASD, what to use to treat?
Why treat: stressful to patient and people around them = affects education
SSRIs = fluoxetine 2.5mg daily with a mean dose of 10mg daily
2) Social and communication impairment domain, what to do for ASD?
No medications
Maybe risperidone, glutamatergic drugs and oxytocin
- Glutamtatergic drugs:gabapentin, lamotrigine, memantine, modafinil, and topiramate = block the effects of glutamate
> Dysfunction of the glutamatergic system represents a potential pathophysiologic mechanism responsible for behavioral manifestations in autism spectrum disorder (ASD).
> Glutamate major excitatory neutrotransmitter in CNS
- Oxytocin plays a role in developing social skills and reducing repetitive behaviour.
- Research has shown that some autistic people have reduced levels of oxytocin and also that their brains deal with oxytocin differently from other people’s brains.
Inattention, overactivity and impulsiveness in ASD (symptoms of ADHD), what to use to treat?
Methylphenidate
Atomexetine = only small trials open labelled trials conducted
What to use to treat irritability in ASD? How long to use for?
Published data suggests treatment is of benefit for up to 6-12 months and should be reviewed after this time.
> First Line – ‘second generation’ AP
- Risperidone – side effects vs impact on cognitive performance
> administered once daily or twice daily
> patients experiencing somnolence can benefit from taking whole daily dose at bedtime
> one sufficient clinical response has been achieved and maintained, consideration may be given to gradually lower the dose to achieve optimal balance of efficacy and safety
> insuffficient evidence from controelled trails to indicate how long treatment should continue
Adverse effects: weight gain, somnolence and hyperglycaemia require monitoring, and the long-term safety of risperidone in children and adolescents with ASD remain to be fully determined.
can also use aripiprazole 5-15mg daily
What to use to treat sleep disturbance as part of ASD?
Melatonin 1-10mg at night
What must be done prior to medication implementation for ADHD? When to use medication?
Psychological, psychosocial and behavioural interventions must be embedded prior to medication implementation.
- Only use medication in severe cases –> Hyperkinetic disorder, psychological methods fail after more than 2 months.
4 options for ADHD medication management?
1) Methylphenidate – large evidence base from trials. First line for children and adults.
2) Dexamfetamine - less data on efficacy and safety than for methylphenidate . More abuse.
3) Lisdexamfetamine – pro drug and similar role to slow release methylphenidate .
4) Atomoxetine – useful for patients not responding to above or require once daily dosing
What to monitor for psychostimulants?
Monitor blood pressure, pulse, height (can stunt growth), weight (suppress appetite). Monitor for insomnia, mood and appetite change and the development of tics, although some evidence suggest tics are not associated with psychostimulants.
controlled drug –> potential abuse
When to use IR and SR version of methylphenidate?
Long-acting ADHD stimulant medications may also be less prone to contribute to the development of drug abuse or dependence
Medication adherence is also a well-known problem in a chronic disorder like ADHD, with only about 20 percent of patients remaining on the same medication 15 months after first being prescribed that medication. The need for multiple daily dosing of immediate-release medications only further increases the risk of nonadherence in children, adolescents, and adults
Children and adolescents given long-acting medications for ADHD generally are adequately treated for the entire day with once-daily morning dosing. The benefits of this once-daily dosing are that these children are not forced to go to a very busy school nurse or school office to receive their medications, nor are they singled out from their classmates in order to receive an additional dosage of immediate-release, short-acting ADHD medication.
- There is also less likelihood of diversion of long-acting agents because the giving and taking of medication is supervised at home during the morning dosing.
When stabilised on IR version of methylphendiate, what brand of methylphenidate to swap to and why?
Use concerta XL because it has a DOA of 12 hours (use this if they are taking the drug 3 times a day on the immediate release version)
> ritalin LA has a DOA of 8 hours (if they are on once or twice a day dosing of the immediate release version)
If on a max dose of any stimulant, have to taper it down, but if not on max dose, can stop abruptly.
True or False
true duhhh
