robin epstein m.d. university of california@ irvine
Post on 19-Dec-2015
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General ConsiderationsNo medical cure for autismEducational and behavioral therapies are the
first line of interventionMedical interventions target intolerable or
severe behaviors that do not respond to therapeutic interventions and thereby impede the child’s progress
Elements of Care PlanMedical diagnosis and evaluationEducational PlanLanguage interventionOccupational/Physical therapySocial SupportFamily support –(Lecavalier) 58% of mom report clinical
stress. 80% divorce rate.Psychological MedicationCAM – Complementary and Alternative Medicines
Take Care of YourselfBreatheGrieveAnger
Educate yourselfSupport systemsJoin with your
spouse80% divorce rate
Mental health support
Heterogeneity–Every Child is Unique!
Intellect – Up to 50% MR, but many gifted (25%).
Use of language –nonverbal, nonfunctional to superior, but nonsocial
Aberrant behaviorsLevels of anxiety PersonalitySuperimposed physical and neurologic
disorders
Assess Strengths and WeaknessesUnderlying
intelligenceMemoryLevel of functioning
(acheivement)Receptive and
Expressive LanguagePragmatic languageMood labilityOverly social
AttentionActivity levelPersonalityAnxiety and OCD
behaviorPerspective-takingAbstract thinkingSensory/motor
issuesProblem-solving
Create Goals
Be reasonableExamples:
Eye contactTry new sports on the playgroundDress by selfSay “hi” to classmate without promptingCreate an imaginary story by himselfTry new foods
Constantly reassess and anticipate
People as ResourcesIn school (public) PrivateTeacherSp/Lang therapistsResource
Specialist(RSP)Occupational Therapist
(OT)School psych/counselorPrincipal
Speech Therapy/Social skills
OTPsychologistMDEducational
specialists/tutorsAdvocacyFriends and family (+/-)
Books as ResourcesAttwoodMichelle Garcia
WinnerCarol GraySkillstreamingHawthorne PressHow Well Does Your
IEP Measure Up
Asperger Syndrome- A Practical Guide for Teachers
Amelia BedeliaAesop’s FablesIdiomsOvercoming
AutismKoegel
Items as ResourcesGames – Pictionary,
Simon, Taboo, Stare, Apples to Apples, Bingo
TrampolineWeighted VestChew stickSensory balls
Tape recorderComputerTeacher SupplyKeyboarding
programsDragon dictateKeep a personal
hanbook
Language Therapy – School and PrivateSpeech therapy by 2 ½ has a 70%
improvement rate. (McGee 1999)AB88 – In California insurance should cover
speech when medically indicated for autism.Pragmatic language (social language) –
Problem solving, Social stories
Occupational Therapy AB88 applies here as well.Fine motor – buttoning, zip, lock, shoes
are all medically necessary! Writing is school responsibility.
Balance and safety.Oromotor – If FTT or anemic, then
medically necessary.Children learn by approach to novel
situationsSensorimotor processing is everywhere!
Social SkillsAt school – lunch bunch, social skills groups,
peer projects, recess, peer buddies.Community social skills group – must be at
patient level, hard to find, but vital!Community camps and challenge teamsPlaydates and siblings – Skills streaming and
Michelle Garcia Winner.
Family and PsychologicalParent groups – SEEPAC, Aspergers groupPsychologists specifically trained to work
with autistic childrenTeaching imaginary play and flexibilityFlexibility and areas of greyDepression and anxietyWorking with family on toileting, sleep,
transitions, sexuality
MedicalPE – Dysmorphology, Neurocutaneous, Reflexes Labs: High resolution karyotype, DNA fragile X,
acyl carnitine, serum AA, urine OA. Consider Pb, TSH, CBC, LFTs, subtelomeric evaluation, FISH for PWS, WS. MRI not usually indicated. Consider EEG-25% abnormal
Not indicated: allergy tests, hair analysis, chelation, gut permeability, stool analysis.
Genetics – Counseling!! Recurrence 7% Even higher for associated issues – ADHD, lang delay, OCD, social issues
Creation of an educational/behavioral programThe majority of interventions should be
provided by - Under age 3 regional center OR Over age 3 the local school district
Conflict of interest (like an insurance co)Educational model
Intervention ModelHow much intervention is enough?Few controlled studies -Unethical, difficultOver 150 uncontrolled studiesSome programs provide a few hours of
speech and others provide 40+ of intensive intervention.
A World of PossibilitiesABA/IBI –AAN – 5 studies,
overall positive, but questionable evidence
PRT-pivotal responseSDC – special day
class1:1 aideFull inclusionReverse
Mainstreaming
TEACCHNPS – nonpublic
schoolsFloortimeSpeech therapySMI – sensorimotor
integrationFacilitated
communicationPECS- picture
exchange
Behavioral interventionsLandmark study of early intervention
Lovaas 1987 UCLA –ave age 2.8yrs, 40hrs/wk, 1:1 . 2yrs led to 50% “recovered”.
Lots of methodological problems Benefits have been shown in similar studies
Educating Children w/Autism 2001 – Nat’l Research Council/ NAS Metanalysis, consensus,
Adopted by AAP,AAN, AACAP
EARLY INTERVENTION WORKS!!! Key features –
-Early (bet 3&5) & intensive = At least 20 hrs/wk
-Focus on social, communication, and behavioral deficits
*Behavioral vs developmental*1:1 vs group and home vs school
Howard – 2006 - UCLAEarly Intensive Beh Tx
Lovaas modified #2130-40 hrs/wkOver 3 yrs starting at
age 3More likely to be
included w/ or w/o aide (6 fully included)
Higher IQ/ higher adaptive levels – significance?
Typ Pub School Spec Ed
Variable #21Intervention over 3 yrs
starting at age 31 fully included
Most research supports 1:1 behavioral program
Cost prohibitive
Classroom Program OptionsSome examples:
Full inclusion – private services onlyFull inclussion – RSP, Sp/lang, OT, SocialFull inclusion – Aide + above (General aide vs DTT
aide)Special Day class mixed with Typical PeersSpecial Day Class – Mild moderate vs Autism
programSpecial Day Class – 1:1 or 1:2County – SELPA programsNonpublic School – Prentice, CDC, Mardan, New
VistaResidential
MedicationsTry behavioral and educational interventions
first.Medications are a last resortNecessary in 2/3rds of cases2 or more meds needed 25% of the timeMedications don’t treat autismMedications treat target symptoms
associated with autismOnly FDA approved medication is Risperdol
Disadvantages To Using Medication Limited research in childrenNegative findings from research, not
publishedLong term effects of many medications are
unknownThe effect of psychotropic medications on
the developing brains are unknownThe neurochemical basis of autism is
unknownMedication use in this population is almost
always chronic
Candidate MedicationsSSRIsStimulantsAtypical
AntipsychoticsAtomoxetineAlpha 2 agonistsBeta blockers
Typical antipsychotics
donazepil/memantine
buspironenaltraxoneMood Stabilizers
Target SymptomsAttention/Hyperactivity
Stimulants AtomoxetineAtypical antipsychotics
Anxiety/Depression/Inflexibility/OCDSSRIsAtypical antipsychotics
Agression/AgitationAtypical antipsychotics
Complementary and AlternativeHyperbaric oxygenChelationSecretinStem cellsNeuron injectionsGFCF dietChiropractics
HerbalsAntifungalsVitaminsAllergiesHeavy metals
CAMSecretin – the most studied drug. N=500. No
benefit!Facilitated Communication – most well controlled
research = negative resultsAuditory Integration – all reviews of research reveal
negative resultsGluten/Casein-free – 29 studies, only one showed
benefit and that was with behaviors only, another 3 showed benefit but children had begun intensive intervention programs simultaneously.
B6 and Mg – research shows no benefit and may cause polyneuropathy
Chelation – no benefit, 2 US deaths*Omega 3 FAs – Positive effect on cognitive abilities*SMI – Improved motor skills
CAM – Omega 3 FAsOxford-Durham Study 2005 – Dev Coord D/O.
117 children. Showed measurable improvements in reading, spelling, behavior over 3mo. Crossover as well.
Pilot study in Vienna (Amminger 2007) 13kids 1.5g/d improved beh in autism
Studies have shown improved attention ADHD
Last month – pregnant woman eating fish high in O3FA – children have higher lang scores
Complementary and Alternative Approaches
Quackwatch.comThere is no quick fixSome support for the use of Omega 3 FAsIf it doesn’t hurt and is not too expensive go
ahead, but don’t forego proven help to pay for the unproven “cure” of the month
Create Your TeamPeople who understand your childProgressive out of the box thinkersNo obstructionistsYou can exclude people from your IEP team
Think Ahead - AnticipateAreas of vulnerability:
ReadingReading Comprehension/Math work problemsTransitions – K-> 1st. 3rd-4th. Middle School. Transition to
adulthood.
Social challenges – 4th Grade, Middle School, Trans. to adulthood.
Written expressionAbstract ThinkingDriving and Independent livingCognitive delaysFine and gross motor issues
Take Care of Yourself/Family/FutureReality CheckEvery family has its own rhythm and limits.
Listen to the rhythm!Financial Security – Find your comfort zone.
Do not overextend. Special needs trust. Consult and attorney.
Other childrenEveryone’s mental health
ConclusionKnow your childCreate a teamBe creativeUtilize interventionsEarly intervention leads to huge improvements in
quality of life for child and family. It can reduce costs by 2/3 lifelong.
Comprehensive care includes behavioral support, sp&lang, social, and occupational therapies.
Medication can be used to improve secondary/severe symptomatology.
Monitor usage.CAM can be enticing, but research first!
National Academy of SciencesCommittee on Educational Interventions
“The available research strongly suggests that a substantial subset of children with ASD are able to make marked progress during the period that they receive early intervention and that nearly all children with ASD show some benefit.”