Managing behavioral issues in ASD

[Psychresy]

Curious for feedback from others on this. Have a teenage patient with ASD, fairly low functioning, minimally verbal. A lot of behavior issues at home directed at mom and dad in particular. She has been trialed on numerous antipsychotics in the past in conjunction with clonidine, vistaril. Curious where others may go from here as the SGAs all resulted in intolerable side effects. Difficult to assess for given her clinical picture, but doesn't appear to be a heavy ADHD burden. Thanks in advance for the insights.

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[wolfvgang22]

Behavioral modification is the main approach.
Mood stabilizers may be a good option, if not trialed yet. Often oxcarbazepine is used in such situations due to the side effect profile of others.
Guanfacine may be an option, but not sure how much that would help since you've already trialed clonidine. I've had success with low dose propranolol.
Consider treating for ADHD empirically with frequent monitoring if no cardiac issues.

 

[erg923]

Curious for feedback from others on this. Have a teenage patient with ASD, fairly low functioning, minimally verbal. A lot of behavior issues at home directed at mom and dad in particular. She has been trialed on numerous antipsychotics in the past in conjunction with clonidine, vistaril. Curious where others may go from here as the SGAs all resulted in intolerable side effects. Difficult to assess for given her clinical picture, but doesn't appear to be a heavy ADHD burden. Thanks in advance for the insights.

ABA

 

[Chimed]

Curious for feedback from others on this. Have a teenage patient with ASD, fairly low functioning, minimally verbal. A lot of behavior issues at home directed at mom and dad in particular. She has been trialed on numerous antipsychotics in the past in conjunction with clonidine, vistaril. Curious where others may go from here as the SGAs all resulted in intolerable side effects. Difficult to assess for given her clinical picture, but doesn't appear to be a heavy ADHD burden. Thanks in advance for the insights.

Would try to get in home services with ABA if not already in place. But really need to clarify what is behind the behavioral issues. Is there anxiety or depression? Are the behaviors related to lack of structure due to school being out? Is lack of sleep an issue? Attention issues from poor sleep can turn into poor coping which can lead to aggression. Are there medical issues? Headaches?

But in terms of other medications you could start looking into Depakote or Lithium. But really need to make sure you know what you're targeting. If they have anxiety or depression you'd have a different approach.

Good luck!

 

[liquidshadow22]

of an unrelated note, I have been saying many young adults asking for evaluation for autism spectrum diagnosis despite limited childhood development issues and overall high functioning status. Any thoughts on making a diagnosis of autism or social communication disorder in this type of patient with some odd sensory type sx and quirky social behavior. Seems to be very much a grey area without definitive guidelines to me....

 

[Psychresy]

Would try to get in home services with ABA if not already in place. But really need to clarify what is behind the behavioral issues. Is there anxiety or depression? Are the behaviors related to lack of structure due to school being out? Is lack of sleep an issue? Attention issues from poor sleep can turn into poor coping which can lead to aggression. Are there medical issues? Headaches?

But in terms of other medications you could start looking into Depakote or Lithium. But really need to make sure you know what you're targeting. If they have anxiety or depression you'd have a different approach.

Good luck!

Very difficult to determine if this patient has mood or anxiety symptoms. They are essentially non verbal. Parents don't have concerns regarding mood or anxiety and unfortunately patient is not able to participate in interview. Behavioral outbursts and aggression occur without warning and don't particularly follow a certain rhyme or reason. Behavior maybe slightly worse since COVID, but there were significant ongoing issues prior to the pandemic.

Sleep is poor, although sounds as if that is the chronic baseline. No significant medical issues whatsoever. The thought was to add on a mood stabilizer which as I understand it is off label for ASD aggression. Some options discussed were trileptal vs. lamictal. Will discuss lithium with attending next time we staff this case. Appreciate your insights.

 

[wolfvgang22]

of an unrelated note, I have been saying many young adults asking for evaluation for autism spectrum diagnosis despite limited childhood development issues and overall high functioning status. Any thoughts on making a diagnosis of autism or social communication disorder in this type of patient with some odd sensory type sx and quirky social behavior. Seems to be very much a grey area without definitive guidelines to me....

I think most of us are seeing a lot of this.
I just do a comprehensive evaluation like I do for everyone and consider referring the patient for psychological testing before recommending treatment.

Interestingly, I have a young adult patient with Schizoid Personality Disorder and Social Anxiety that thought he was on the autistic spectum. He was very invested in having a diagnosis of autism or aspergers, socially isolated, estranged from family and now his mother who was his sole comfort, works in IT, spends most of his free time online talking politics and video games on Reddit and other social media. Not much in person interaction with people, and avoidance behavior of that related to past bad experiences. (A military enlistment did not go well.) Psychological testing was very helpful. Formal psychotherapy has been very beneficial for him.

Consider what is the patient's motivation for such evaluation? Make a good diagnosis! It is in vogue currently to claim some autistic spectrum disorder by younger patients (generally under 40) who lack social skills or desired success in life, especially online. Many seek to medicalize general dysphoria and discomfort. People want to feel special and receive a special treatment tailored to them that works right away with minimal effort. Many people feel if you have an ASD diagnosis it absolves them of some personal responsibility and agency as a way to deal with cognitive dissonance.

 

[erg923]

of an unrelated note, I have been saying many young adults asking for evaluation for autism spectrum diagnosis despite limited childhood development issues and overall high functioning status. Any thoughts on making a diagnosis of autism or social communication disorder in this type of patient with some odd sensory type sx and quirky social behavior. Seems to be very much a grey area without definitive guidelines to me....

A very Not-PC response (mostly coming from my mother, a former high school teacher) is that we used to just label said adolescents as "little weirdos" and be done with it.

Not helpful of course, but did stress the point that most will be just fine without labeling them with ASD, or perhaps any other actual "disorder."

 

[Chimed]

Very difficult to determine if this patient has mood or anxiety symptoms. They are essentially non verbal. Parents don't have concerns regarding mood or anxiety and unfortunately patient is not able to participate in interview. Behavioral outbursts and aggression occur without warning and don't particularly follow a certain rhyme or reason. Behavior maybe slightly worse since COVID, but there were significant ongoing issues prior to the pandemic.

Sleep is poor, although sounds as if that is the chronic baseline. No significant medical issues whatsoever. The thought was to add on a mood stabilizer which as I understand it is off label for ASD aggression. Some options discussed were trileptal vs. lamictal. Will discuss lithium with attending next time we staff this case. Appreciate your insights.

Being nonverbal certainly makes it tricky to determine depression and/or anxiety. Have to look at baseline behavior prior to regression and compare things like activity enjoyment, appetite, etc....This is a bit further outside, but don't forget to look for agitated catatonia. People with ASD are at higher risk. What was the issue with the SGAs? Did he worsen? If so, might want to look at his CK, look at vitals, and do a Bush Francis scale. Just a thought....

 

[Candidate2017]

Very difficult to determine if this patient has mood or anxiety symptoms. They are essentially non verbal. Parents don't have concerns regarding mood or anxiety and unfortunately patient is not able to participate in interview. Behavioral outbursts and aggression occur without warning and don't particularly follow a certain rhyme or reason. Behavior maybe slightly worse since COVID, but there were significant ongoing issues prior to the pandemic.

Sleep is poor, although sounds as if that is the chronic baseline. No significant medical issues whatsoever. The thought was to add on a mood stabilizer which as I understand it is off label for ASD aggression. Some options discussed were trileptal vs. lamictal. Will discuss lithium with attending next time we staff this case. Appreciate your insights.

In addition to everything mentioned above, I would first say sleep/sleep hygiene needs to be fixed and not just accepted as "chronic baseline." Everyone gets irritable from sleep issues, especially teens with developing brains. Even more so, autistic nonverbal teens.

I'd put the onus back on the parents and insist on family therapy (without the child). It can help with many different aspects: Parents need to be held accountable for their child's sleep schedule as above. They need to learn coping strategies for dealing with an autistic teen. Med are not a substitute for parenting, and an autistic child requires extensive, skilled parenting. Parents also need to grieve and process the fact that their child will never be "normal" and set whatever hopes and dreams aside to move forward and deal with their child as they are in the here and now. Basically, acceptance of their child who has a neurodevelopmental disorder (and that some degree of random outbursts/aggression is their child's normal).

The child's low function and being nonverbal -- have you considered intellectual disability as the actual diagnosis? Or comorbid with autism? Parents tend to get overly attached to an autism diagnosis when they can't accept their child is ID.

 

[singasongofjoy]

Lack of meaningful structure and predictability in a method that is understandable by the individual is often a root cause of challenging behavior in nonverbal folks with ASD- because not understanding w hat's going on around you, what's coming next, when you'll get to do / have xyz again is a major cause of anxiety (for practically all of us, but most of us don't have to walk through life like this because we're able to learn implicitly and use the info around us to figure things out). This individual needs some behavioral intervention but generally in cases like this I often start with the assumption of underlying anxiety and once predictability and structure (and meaningful ways to communicate and incorporate choice and flexibility) are added, behavior problems often improve. If you were able to work with them in a therapy capacity I'd recommend maybe seeing if you can find/access some TEACCH training on managing difficult behaviors using preventative strategies and skill teaching and if communication methods are in a way that is able to be readily understood by them (e.g., in classrooms I often see teachers using picture schedules with kids who are so very concrete they do not understand pictures so it is really just a meaningless routine, whereas if they use objects to indicate first/then or make choices then they pick up on it more quickly) but at the very least maybe you can find a behaviorally -oriented therapist to refer them to that also does some parent coaching, esp. if they can't get into ABA (difficult around here at that age and at any rate any therapy should heavily involve parents too). IDK what the autism society is like where you are but around here they have resource specialist and parent liasons that help hook families like this up with appropriate therapy. Meds aren't going to fix the big picture here and the wheels are really going to fall off the bus when this kid is finished with school if parents don't learn some strategies now.

 

[Psychresy]

Being nonverbal certainly makes it tricky to determine depression and/or anxiety. Have to look at baseline behavior prior to regression and compare things like activity enjoyment, appetite, etc....This is a bit further outside, but don't forget to look for agitated catatonia. People with ASD are at higher risk. What was the issue with the SGAs? Did he worsen? If so, might want to look at his CK, look at vitals, and do a Bush Francis scale. Just a thought....

Didn't worsen but had extraordinary weight gain...even on trials of geodon and latuda. You can imagine how things went on zyprexa, risperdal, seroquel.

 

[Psychresy]

In addition to everything mentioned above, I would first say sleep/sleep hygiene needs to be fixed and not just accepted as "chronic baseline." Everyone gets irritable from sleep issues, especially teens with developing brains. Even more so, autistic nonverbal teens.

I'd put the onus back on the parents and insist on family therapy (without the child). It can help with many different aspects: Parents need to be held accountable for their child's sleep schedule as above. They need to learn coping strategies for dealing with an autistic teen. Med are not a substitute for parenting, and an autistic child requires extensive, skilled parenting. Parents also need to grieve and process the fact that their child will never be "normal" and set whatever hopes and dreams aside to move forward and deal with their child as they are in the here and now. Basically, acceptance of their child who has a neurodevelopmental disorder (and that some degree of random outbursts/aggression is their child's normal).

The child's low function and being nonverbal -- have you considered intellectual disability as the actual diagnosis? Or comorbid with autism? Parents tend to get overly attached to an autism diagnosis when they can't accept their child is ID.

Yeah, sleep could be improved. He's getting 5 hours a night, going to bed after midnight and waking around 6am. The child is in their later teens - the parents have accepted this is how things are and will always be to a certain degree. They come across as supportive as best they can, but that's not to absolve them of the laxity with sleep hygiene.

There is a component of mild IDD as well. There is a strong current of ASD in the extended family as well which sounds legitimate.

 

[birchswing]

of an unrelated note, I have been saying many young adults asking for evaluation for autism spectrum diagnosis despite limited childhood development issues and overall high functioning status. Any thoughts on making a diagnosis of autism or social communication disorder in this type of patient with some odd sensory type sx and quirky social behavior. Seems to be very much a grey area without definitive guidelines to me....

Starting about maybe 10-12 years ago, I had a few people ask me if I had autism. Like one was a disability coordinator at a college. He said I seemed like I did and was surprised I wasn't diagnosed with it. It had never occurred to me, but then you look back at things and can find ways that they fit. Sort of like a horoscope. I mean I do have weird things, like needing to wear ear plugs and sunglasses especially when I get anxious or in places like Costco. As a child I remember a girl asking me why I never smiled, and so I would start smiling randomly when I remembered to. Never was interested in having friends.

Anyhow, it never really mattered to me whether I had it or not, but then last year I tried getting services from a community clinic I had gone to before. They used to have someone come out to the house who would go on walks with me, would go out to stores with me (I have severe agoraphobia so that was a huge thing), and it actually really improved my life a lot. I started going back to college. Things backslid, so I tried to get services again, and they told me I should have never been eligible for the services to begin with. They had a strict set of guidelines now which included either having been involuntarily hospitalized or having a developmental disorder like autism. My aunt works with someone who has autism who is more functional than I am (I've spoken to him and he seems pretty much like me but more functional in day to day life), and she said she's heard it's the only way to get services--that it opens a lot of doors for people who couldn't otherwise get services. I wonder if that's why more people seek or get the diagnosis.

 

[hallowmann]

Beyond the many great recommendations for ABA and other behavioral interventions, I agree with a trial of a mood stabilizer. I've seen agitation improve with relatively low doses of mood stabilizer, and for whatever reason, have seen it the most with valproate. The drowsiness aspect is also something that is helpful maintaining a regular schedule. If the patient is prone to metabolic side effects and weight gain, obviously another mood stabilizer may be better. That said, really behavioral intervention would likely result in the most long-term benefit.

 

[calvnandhobbs68]

Do you have a county board of DD? If there is one and the patient isn’t hooked into it, the parents need to start the intake process yesterday. I hammer this home with all my ID/ASD patients. That’s where they’ll usually get the best recommendations for behavioral interventions/therapists. If no DD board, then usually the local autism organization or even a national organization like Autism Speaks has databases for therapy resources since it doesn’t sound like this guy has much of that. At a minimum they could help put behavior plans in place even if he’s pretty old by now for ABA to be much help.

However you also want to make sure everyone is safe and that a therapist will actually interact with him without being worried he’s going to haul off and hit her in the face since he’s a teenage guy now. As above, I’ve had success with propranolol in these situations and can keep increasing until you start seeing significant blood pressure changes. Have you tried 1st gen antipsychotics? If he really can’t tolerate 2nd gen, Haldol or even Thorazine can be alternatives...just have to really be on the ball for any EPS. Depakote also an option as posters mentioned above. If concerned at all about a component of hyperactivity/impulsivity trying out a stimulant as mentioned above can be dramatically helpful sometimes. Stimulants are helpful for aggression even in patients without ID who have some component of ADHD.

 

[Chimed]

how does one explore this when the patient is essentially non verbal?

Basically, you have to obtain a very good history. You have to know the individual's baseline and compare that to when they started to change and/or decomponsated. You also have to know ASD well to be able to tease out the difference between typical ASD behaviors vs. other etiologies. When you know the patient's baseline and their typical autistic behaviors you can start comparing that to what you know about other primary psychiatric syndromes such as depression, anxiety, etc.

 

[WisNeuro]

Basically, you have to obtain a very good history. You have to know the individual's baseline and compare that to when they started to change and/or decomponsated. You also have to know ASD well to be able to tease out the difference between typical ASD behaviors vs. other etiologies. When you know the patient's baseline and their typical autistic behaviors you can start comparing that to what you know about other primary psychiatric syndromes such as depression, anxiety, etc.

Pretty extensive history is needed, including medical of pt and family. There are dozens of differential diagnoses, with many genetic disorders, that can also look like ASD consistent behaviors. To do correctly, these usually go well above and beyond the usual psychiatric evaluation scope.

 

[Chimed]

Pretty extensive history is needed, including medical of pt and family. There are dozens of differential diagnoses, with many genetic disorders, that can also look like ASD consistent behaviors. To do correctly, these usually go well above and beyond the usual psychiatric evaluation scope.

Yep. That's what I was trying to say.

 

[clozareal]

Interestingly, I have a young adult patient with Schizoid Personality Disorder and Social Anxiety that thought he was on the autistic spectum. He was very invested in having a diagnosis of autism or aspergers, socially isolated, estranged from family and now his mother who was his sole comfort, works in IT, spends most of his free time online talking politics and video games on Reddit and other social media. Not much in person interaction with people, and avoidance behavior of that related to past bad experiences. (A military enlistment did not go well.) Psychological testing was very helpful. Formal psychotherapy has been very beneficial for him.

I had the exact same situation happen to me where a patient was convinced he had ASD but did not have any childhood evidence which is required for the diagnosis (school records weren't top notch but looked fine for an average C student). She had NO repetitive or restricted pattern of behavior which is required for the diagnosis. I ended up diagnosing this patient with schizoid personality disorder, social anxiety disorder, and persistent depressive disorder. She was totally fine being isolated although felt that society wanted her to be something she wasn't which caused her some distress from the disagreement rather than the desire to be different.

People tend to hear the criteria of "social communication deficits" and they think they have autism but its more likely that they are just a painfully awkward person. Many of these people can have schizoid or obsessive-compulsive personality traits, but don't meet a criteria for a disorder.