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Anxiety in Autism Spectrum Disorders

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Psychopharmacology Challenges in Children with Autism Spectrum Disorder Author: tlevine Last modified by: awittenberg Created Date: 2/3/2008 12:50:55 PM – PowerPoint PPT presentation

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Title: Anxiety in Autism Spectrum Disorders


1
Anxiety in Autism Spectrum Disorders
  • Todd Levine MD, FAAP
  • Assistant Professor in Psychiatry and Human
    Behavior
  • Brown Center for the Study of Children at Risk
  • Warren Alpert Medical School of Brown University,
    Providence, RI

2
Disclosures
  • No financial relationships or conflicts of
    interest
  • Many of these treatments are off label,
    non-Food and Drug Administration approved

3
Learning Objectives
  • Investigate the relationship between symptoms of
    Autism Spectrum Disorders (ASDs) and those of
    anxiety disorders
  • Understand common anxiety symptoms assessed and
    treated in ASDs
  • Understand how mechanisms of arousal and stress
    may differ in children with ASDs

4
Diagnostic Considerations
  • Core deficits in socialization and communication
    can lead to difficulties with
  • Connecting with ones own feelings and those of
    others
  • Interpretation of motivations behind behaviors
  • Contextualizing behaviors

5
DSM-IV Considerations
  • Some diagnoses exclude/modify for Pervasive
    Developmental Disorders
  • Social Phobia (Social Anxiety Disorder)
  • Separation Anxiety Disorder
  • Selective Mutism
  • Generalized Anxiety Disorder
  • ADHD
  • Pica
  • Rumination Disorder
  • Schizophrenia (Delusions/Hallucinations present)
  • Schizoid Personality Disorder
  • Schizotypal Personality Disorder

6
With this in Mind
  • Children and adults with Autism Spectrum
    Disorders (ASDs) are at higher risk for anxiety1,
    depression2, and ADHD3
  • Psychiatric medications are likely to be
    prescribed to those with ASDs4
  • Psychotherapies have been adapted for children
    with ASDs and anxiety5

1Gillot et al. Autism (2001), 2Ghaziuddin et al.
J Autism Dev Disord. (2002),
3 Ghaziuddin et al. J Intellect Disabil Res
(1998), 4Mandell et al. Pediatrics.
2008, 5Chalfant et al. J Autism Dev Disord (2007)
7
Possible Explanations
  • Some children with ASD may be overstimulated due
    to a hyperactive nervous system1
  • Children with ASD may have difficulty with
    emotional processing2
  • Deficits in socialization and communication may
    cause vulnerability to anxiety and depressive
    symptoms

1Hirstein et al. Proc Biol Sci (2001) 2Losh and
Capps. Dev Psyc (2006)
8
Other Factors in Anxiety in ASDs
  • Intelligence?
  • Social Functioning Difficulties May be worsened
    by higher anxiety
  • Sensory sensitivities
  • Changes in routine
  • Avoidance of non-preferred tasks
  • Lack of expressive language

Eussen et al. Autism (2012), Lane et al. Am J
Occup Ther (2012), Ozsuvadjian et al. Autism
(2012)
9
Psychotropic Prescribing in ASD
Martin et al. JAACAP. 1999
10
Psychotropic Prescribing in ASD
  • In a sample of 60,641 children with ASDs, 56
    used at least 1 psychotropic medication
  • 20 were prescribed 3 medications concurrently
  • Use was common even in children aged 0 to 2 years
    (18) and 3 to 5 years (32)
  • Neuroleptic drugs were the most common
    psychotropic class (31), followed by
    antidepressants (25) and stimulants (22)

Mandell et al. Pediatrics. 2008
11
Taking a Different Perspective
12
Obsessive Compulsive Disorder vs. Repetitive
Interests in ASDs
  • Obsessions are recurrent and persistent
    thoughts, impulses, or images thatcause marked
    anxiety or distress (DSM-IV)
  • Compulsions are acts designed to counteract those
    thoughts, impulses, or images
  • Are either consistent with restricted repetitive
    and stereotyped patterns of behavior, interests,
    and activities in ASDs?
  • Insistence on Sameness different from anxiety
    in study. Gotham et al. Autism Research (2013)

13
(No Transcript)
14
When Does Generalized Anxiety Occur in AS?
  • Persistent worries about scheduling can occur in
    those with ASDs
  • Generalized Anxiety (GAD) includes being keyed
    up, sleep difficulties, and muscle tension
  • As in OCD, dysphoric thoughts and feelings
    delineate problematic anxiety

15
Considering PTSD in AS
  • Is trauma processed differently in those with
    ASD?
  • The symptoms of hyperarousal and social withdrawl
    can be difficult to delineate in people with ASDs
  • Is there a case for chronic trauma affecting
    those with ASDs?
  • Considerations for group therapy

16
Can Someone with AS be Socially Anxious?
  • Excluded from Social Anxiety Disorder diagnosis
  • Socially anxious people are fearful of
    humiliation and opinions of others
  • People with ASDs can be aware of these factors
  • Many with ASDs appear dysphoric or anxious in
    groups of people, but is this anxiety?
  • Cognitive behavior strategies have been applied

17
The Elusive Inner State
  • How reliable/valid are self-reports in adults and
    children with ASDs?
  • Can parents tell us more about their kids with
    ASDs than the kids?
  • Can we look at more concrete, biological markers
    of emotional response to help understand
    psychiatric reporting?
  • There are few psychiatric measures for those with
    ASDs

18
The Study of Social Anxiety in Aspergers Disorder
  • Compares children ages 8-12 years old with
    Aspergers Disorder (AD, n19) to those without
    (n12) during a social stressor
  • Protocol involves parent and child reports of
    anxiety (MASC and SPAI-C), child self-report of
    anxiety during the events, and measurement of
    psychophysiology
  • Salivary cortisol reactivity
  • Electrodermal reactivity (EDR)
  • Heart rate variability, vagal tone (VT)

19
EDR
Vagal Tone
20
Participant Example 1
21
Participant Example 2
22
Who Has Aspergers?
1
2
23
A Look at Cortisol Responses
24
The envelope, please
1
2
25
Gas and Brake Comparison
EDR
Vagal Tone
26
Brief Summary of Study Results
  • Children with Aspergers were twice as likely to
    be cortisol non-responders than controls
    (p0.056)
  • There were no between group differences on EDR
    and VT across time
  • EDR positively correlated with parent reports of
    arousal on the MASC in controls, but not the
    Aspergers group

27
Whats Next?
28
Trends in Medication Treatment Studies in AS/ASD
  • Most studies focus on specific behaviors vs.
    diagnostic criteria
  • Specific behavioral measures have been created or
    modified for AS patients
  • Successful strategies in neurotypical children
    have been applied to children and adults with AS
    and similar behaviors

29
Problem Behaviors Targeted by Psychotropic
Medications
  • Hyperactivity
  • Lack of Attention
  • Agitation
  • Insomnia
  • Aggression
  • Self-injury
  • Stereotypies
  • Tantrums
  • Repetitive Behavior
  • Compulsive Behavior
  • Anxiety
  • Hyperarousal
  • Irritability
  • Impulsivity

30
Side Effects of Psychotropic Medications
  • Hyperactivity
  • Lack of Attention
  • Agitation
  • Insomnia
  • Aggression
  • Activation
  • Agitation
  • Repetitive Behavior
  • Compulsive Behavior
  • Hyperarousal
  • Irritability
  • Tics

31
Antidepressants
  • Serotonin Specific Re-uptake Inhibitors (SSRIs)
    have evidence for use in children and adolescents
    with anxiety and depression
  • U.S. FDA Black Box warning spurned controversy
    over use of SSRIs
  • Applicability to AS behaviors has been explored
    repetitive behaviors and anxiety
  • Recent research has changed previous conceptions
    about SSRI use in ASDs

32
Sertraline for Perseverative Anxiety
  • Based on clinical experience
  • Useful for overly-repetitive concerns or
    anti-Zen states
  • Low doses can work very well
  • Dont have to wait too long for results
  • Low side effect profile
  • Cheap

33
Citalopram for Repetitive Behaviors
King et al. (2009) Arch Gen Psychiatry
34
Risperidone for Irritability
McCracken et al. (2002) NEJM
35
Anxiolytics
  • Family includes benzodiazepines, and
    antihistamines
  • These medications can cause disinhibition and
    irritability
  • Sometimes used in conjunction with
    antidepressants
  • Sometimes used in children

36
MedsThe Ultimate Solution??
37
10 Minute Break
38
Video Examples of Anxiety in ASDs
39
(No Transcript)
40
What is RI-CART? The Rhode Island Consortium for
Autism Research and Treatment
RICART
41
My Home
  • Autism Spectrum Disorders Clinic
  • Child Psychiatry Consultation Service
  • Brown Center for the Study of Children at Risk
  • Women and Infants Hospital
  • (401)274-1122 x 8935
  • tlevine_at_wihri.org
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