first steps 2014 webinar

First STEPS 2014 WebinarManagement of Behavioral Issues in Children with Autism Spectrum

Disorders

Carol Hubbard MD MPH PhDDivision of Developmental-Behavioral

Pediatrics

Maine Medical Partners Pediatric Specialty Care

Thursday, July 10, 2014

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Maine Child Health Improvement Partnership (ME CHIP)Mission

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All practices providing health care to children will have the

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First STEPS 2014 July Webinar 2

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mailto:[email protected]

CME Disclosure

Dr. Carol Hubbard has no conflicts of interest with commercial products in this presentation.


Management of Behavioral Issues in Children with

Autism Spectrum Disorders

Carol Hubbard MD MPH PhD

Division of Developmental-Behavioral Pediatrics

Maine Medical Partners Pediatric Specialty Care


Outline

• General approach to behavior issues:– Figuring out the purpose of a behavior: behavior analysis – Prevention strategies

• Common behavioral issues – Sleep – Toilet-training – Ritualistic, repetitive, or obsessive/compulsive behaviors– Anxiety/depression– Overactivity, impulsivity, Inattention, distractibility – Self-Injury/Aggression

• Approach to office visits


Characteristics of children with autism that can lead to behavior issues

• Delayed communication skills/ poor auditory processing skills

• Literal interpretation of language• Poor understanding of social expectations and cues• Poor perspective-taking • Short attention span, distractibility• High activity level• Sensory issues- difficulty tuning out environmental stimuli• Low frustration tolerance• Anxiety


It is important to establishthe function of behavior

Behavior = Communication !!!

• To obtain something• To seek attention• Avoidance• Escape: behavior (e.g. tantrum) serves to

remove a demand placed on the child• To overcome boredom• Self-stimulatory-automatic reinforcement

First STEPS 2014 July Webinar8

Functional Behavioral Assessment• The process of gathering information to figure out the

function of a behavior, and the factors that serve to maintain it, in order to develop and implement intervention.

• A-B-C Model: – Antecedent- the context (time of day, setting

events, people involved, etc), and the specific antecedent (eg verbal instruction)

– Behavior- what happens (describe specifically, eg hitting a peer, rather than “aggression”)

– Consequence – how people react, what happens afterward

• Look for patterns of behavior (certain time of day, settings, when hungry, or with certain people)


Case

Jonathan, age 4, has PDD-NOS, and an expressive language delay, and is having difficulty with aggression toward staff and peers at his developmental preschool.

He hits other children at least daily, and recently bit a little girl who was playing near him.


Case: results of FBA

• 6 incidents of aggression in one week

• Antecedents: occurred in the late morning, during choice time (when other children were very close to him, or the room was loud) or during tabletop work

• Behavior: hit staff; pushed, hit and bit peers

• Consequences: He was removed from the activity, to a quiet corner with pillows and his favorite stuffed animal from home


Case: intervention

• Function of behavior: – Escape from over-stimulation– Escape from demands – To obtain access to preferred objects

• Intervention– Prevention: closer staff involvement and coaching

during high-risk time– Teach him to ask for space or for a break– Planned, non-contingent access to preferred items


Intervention 1: Prevention Organize the environment to reduce the likelihood that the

difficult behavior will be triggered

• Stimulation level: – Avoid over-stimulating activities, – Provide calming activities, – “Sensory diet,” – Self-monitoring (How Does Your Engine Run)

• Modify expectations– Break tasks down– Shorten task length– Modify materials– Provide choices

• Communication– Clear, concise language– Visual supports


Visual Strategies/Supports

• 55% of communication is visual• Makes communication non-transient• Can help overcome problems with

receptive language or attention • Can involve visual schedules, calendars,

choice boards, list of rules or tasks, photos, PECS,

international NO symbol,


Augmentative Communication

• PECS (Picture Exchange Communication System)

• Aug. Communication Evaluation– Some speech therapists– Pine Tree Society (Bath)

• Electronic Communication Devices-Dynavox, Vantage

• iPad resources (Autism Speaks website)

• Different from “facilitated communication”


Social Stories

• Social Stories (Carol Gray) are written explanations of an event or new experience. They explain what will happen and how the person is expected to respond. They are also used to address problematic behaviors. For some children, the printed word is much more easily processed than a verbal explanation. It is helpful to illustrate them (or have the child do it) or have photos on each page with brief text

• www.thegraycenter.org


Comic Strip Conversations (Carol Gray)

– Comic Strip Conversations are simple line drawings that show a conversation between 2 or more people, including thoughts as well as spoken words, to help process and understand social situations

– www.thegraycenter.org


Intervention 2: Teaching appropriate ways to obtain the same goal

What are the skills that the child needs to be taught so that they do not need to use the undesired behavior?

• Self-management• Adaptive coping• Communication


Teaching better ways to obtain goals

• Teach and Reinforce a replacement behavior- needs to be efficient, effective, easier (quicker, better) than the maladaptive behavior

• Functional Communication Training: teach a communicative behavior that is functionally equivalent to the maladaptive behavior. – Requesting items– Requesting permission– Requesting a break– Requesting a delay(eg of a transition)– Expressing emotions– Negotiation skills


Think Social: Michelle Garcia Winner

• “Social thinking is required before the development of social skills. Successful social thinkers consider the points of view, emotions, thoughts, beliefs, prior knowledge and intentions of others (perspective taking).”

• Four steps of communication:1. Thinking about others and what they are thinking about

us2. Establishing a physical presence3. Thinking with our eyes4. Using language to relate to others

• www.socialthinking.com


Intervention 3: Reinforcement

• Reinforce desired behavior : social reinforcement, sensory, activities, rewards, token systems

• Is a response (e.g. praise) truly reinforcing for the child?

• Is an undesired behavior being inadvertently reinforced by adult attention (even if it is negative)?


Intervention 4: Consequences

Use with caution. Important to know the function of the behavior to select a consequence.

• Ignore• Redirect• Warning• Time-out from activity• Time out from group• Contingent task• Reinforce other students’ good behavior


Sleep


Daytime Sleepiness in Children

Daytime Sleepiness

Neurobehavioral Deficits Mood Disturbance

Performance Deficits:

Academic FailureImpaired Social

Functioning Behavioral Dyscontrol


• Studies vary but between 53-78% of children with an ASD present with sleep issues

• This compares to 26-32% for typically developing children

• Increased incidence is by parent report but has also been confirmed in studies using actigraphy and polysomnography

• Children with ASDs may have increased sensitivity to noise and short sleep duration

• Not a clear association with having a diagnosis of intellectual disability


Most common sleep issues in ASD• Sleep onset• Sleep maintenance

– Children with ASDs may not wake more frequently, but are awake for longer (up to 2-3 hours) and engage in more disruptive behavior while awake

– Parasomnias such as night terrors, confusional arousals, and sleep walking may be more common

• Sleep duration• Decreased REM sleep compared to typical and

developmentally delayed children• Issues can be caused by less than ideal bedtime

routines or bedtime associations so need to consider standard sleep hygiene recommendations


• Obstructive Sleep Apnea/hypopneas should be considered- less clear data on prevalence with ASD

• Must keep in mind the bidirectional influence of co-morbidities such as ADHD, anxiety, depression, and seizure disorders

• Also need to recognize the toll that a child with poor sleep takes on the entire family


BEARS

• 5 question screening tool

• Yields significantly more information about sleep than standard sleep prompt “Does your child have any sleep problems?”

• Therefore increases likelihood of identifying sleep problems


BEARS

• B = Bedtime problems

• E = Excessive daytime sleepiness

• A = Awakenings during the night

• R = Regularity and duration of sleep

• S = Snoring


Behavioral approaches to sleep

• Regular bedtime and predictable bedtime routine-consider social story or chart

• Limit naps

• Limit electronics before bed, keep lighting low

• For awakening during the night, move bedtime later


Medication for sleep

• Melatonin: neurohormone that organizes circadian physiology- sleep-wake cycle and core body temperature rhythms

• Primarily regulated by light/dark exposure• May also be a true genetic difference in the

secretion of melatonin in patients with ASDs.• May be helpful for children with a true

circadian rhythm disturbance but behavioral intervention and strategies should be attempted first


Medication for sleep (continued)

Melatonin• Dosing 0.5 mg-3 mg

– Lower dosing may be more effective– Give 1 to 2 hours before desired sleep onset

• Two actions of sedating and adjusting clock so may take up to 2 weeks to fully trial a dose

• Theoretical side effects of effect on puberty and decreased sz threshold but well-tolerated in actual use

• Evidence for efficacy in children with ASDs (meta-analysis Rossignal and Frye 2011) for sleep onset, duration and improved daytime behavior

• Possibly better evidence than for other sedative/hypnotics

Clonidine: alpha agonist with side effect of sedation, also helps impulsivity, hyperactivity. Can cause nightmares, constipation, headaches, bradycardia, hypotension


Toilet-training• Cognitive and language delays as well as

decreased imitation and social modeling skills can delay the training process.

• Tips– Monitor readiness signals but do not wait too late to

start the process– Regular daily sitting times (upon awakening, after

meals)– Break the process up into steps if possible– Do sitting with diaper on to start if too stressful– Low threshold to treat for constipation– Use positive incentives (stickers, small treats, take

advantage of hyperfocused interests) –can be challenging to find


Stereotypical, repetitive, or obsessive/compulsive behaviors

(Matson and Dempsey)

• Repetitive “self-stimulatory” behaviors are core diagnostic features of ASDs

• Debate about the relationship of ASDs and OCD• “Sameness” behaviors more common in ASDs

than OCD, and less likely to ameliorate with age• Ordering, hoarding and touching more common

in ASDs, while cleaning, checking and counting more common in OCD


Behavioral intervention for stereotypies and repetitive behavior• Functional assessment• How “interfering” is the behavior? • For physical stereotypies: label the behavior, teach

a replacement behavior that is incompatible with stereotypy, give hand fidget, reinforce alternative behavior or decreased target behavior, allow set times to ‘stim.”

• For sameness behaviors: build variation into daily schedule to build tolerance

• CBT (Cognitive-Behavioral Therapy): exposure and response-prevention, for higher-functioning children


Cognitive Behavioral Therapy (CBT)• May be helpful for older, higher-functioning

children• Based on the idea that our thoughts cause our

feelings and behaviors, not external things, like people and situations, so we can change the way we think to feel / act better even if the situation does not change.

• Time- limited (average # of sessions = 16)• Highly instructive• Homework assignments• Exposure/response-prevention

• www.nacbt.orgFirst STEPS 2014 July Webinar 36

Medication for stereotypies• SSRIs are often used – may be more helpful if the

behavior seems anxiety-driven, and if there are broader anxiety issues

• Evidence: mixed (most studies open-label except 4 RCT) generally showed improvement in global functioning and in symptoms associated with anxiety and repetitive behaviors. Side effects were generally mild, but increased activation and agitation occurred in some subjects (Kolevzon).


Anxiety

• Children with ASDs generally prefer predictability, and can be quite rigid, with high levels of anxiety

• Causes of anxiety– Change in routine– Not getting what they want– Sensory overload– Social situations– Specific phobias: bugs, fire-alarms


Addressing anxiety• Advance warning of upcoming events or schedule

changes – Visual schedules– Social stories http://www.thegraycenter.org/ – Sensory supports

• Allow downtime (? time for self-stim)• Balance need for structure with practicing

flexibility• Cognitive Behavioral Therapy• Omega 3 fatty acids:1000-2000mg fish oil per day• Medication: SSRIs, atypical neuroleptics


Depression and mood disorders

• Common in older and higher-functioning children- diagnosis can be difficult due to flat affect, little expression of emotion

• Consider family history • Look for a change from baseline, or change in

functioning• Consider seasonal affective and PMS/PMDD issues• Counseling if higher-functioning• Omega 3s• Medication: SSRIs, wellbutrin, possibly atypical

neuroleptics


Overactive, impulsive, inattentive, and distractible behavior

• Up to 70% of children with ASDs have ADHD symptoms

• Impairment in functioning (academic, ADLs, social) may be due in part to ADHD symptoms and executive dysfunction, as well as to autism

• If possible, do ADHD assessment with standardized questionnaires (eg Conners or Vanderbilts) esp. if higher functioning


Treatment of ADHD symptoms• Consider classroom placement/supports• Treat as would any child with ADHD• Collect data before and after from teachers• Best evidence for stimulants, Atomoxetine, risperidone,

and alpha-agonists • Psychostimulants

– In studies of psychostimulants, around 50% of subjects with ASD have shown positive clinical responses (not significantly lower than non-autistic children with ADHD)

– Side effects included irritability, emotional outbursts, and initial insomnia, with social withdrawal at higher doses

– Overall, may be a decreased response rate and increased chance of side effects compared to children with ADHD s autism

• Atomoxetine (Strattera): – Studies support efficacy


Self-injurious behavior

• Most common forms: self-hitting or banging of head or face, and self-biting

• Can markedly impact adaptive functioning, interfere with normal activities, lead to a more restrictive environment, and result in injury

• More common in autism than other developmental disabilities

• Inversely correlated with intellectual functioning (4% mild MR, 7% mod, 16% severe, 25% profound)

• More common in individuals in residential settings (estimated 17% vs 1.7% for community)

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Why does self-injurious behavior (SIB) occur?

• Lack of environmental stimulation (boredom)

• Reinforced by social attention, access to preferred items, or avoidance or escape from undesired activities

• May provide automatic reinforcing sensory input (provide endogenous endorphins)


How to approach SIB• Functional assessment: situations in which the

behavior is most and least likely to occur, antecedents, and consequences. Try to figure out the source of the reinforcing component

• Redirect to a safer place (eg soft pillows, carry a matt)• Reinforcement: appropriate behavior is reinforced, SIB

is ignored• Protective equipment: can block sensory input• Functional communication training• Medication: atypical neuroleptics (risperidone), SSRIs,

clonidine, naltrexone


Risperidone in autism(Scott and Dhillon)

• Risperidone is FDA-approved for treatment of irritability associated with ASD in children ages 5 to 16 years

• Several well-designed short-term (8 week) RDBCTs showed significant improvements in irritability, stereotypy, social withdrawal, lethargy, hyperactivity and noncompliance, (and other studies in combo with other meds)

• Benefits were maintained up to 6m, with improvements in adaptive functioning (communication, daily living and social skills)


Risperidone:adverse effects

• Increased appetite – Weight gain: Mean gain = 7.5kg (vs expected 3-3.5kg) in 12

months– Risk of hyperlipidemia and hyperglycemia

• Somnolence (often transitory) and fatigue• Constipation• Increased salivation or dry mouth • Increased prolactin (2-4 fold, 39 vs 10 ng/ml)• Tremor and dystonia both - 12% • Tardive dyskinesia: In pooled studies with n = 1885

(for ASDs and other disorders), there were 2 cases of TD. Risk higher with longer-term use

• Possible decreased bone density with longstanding hyperprolactinemia


Other atypical neuroleptics

• Aripriprazole (Abilify) and ziprasidone (Geodon) have shown promise in small trials of patients with ASD

• Other side effects: – Abilify: Risk of activation or agitation

approx 25% – Geodon: risk of arrythmias


Working with children with ASDs during office visits

• Talk with the parents in advance – Prepare the child before the visit with a ‘social

story’ or photos– Bring the child’s comfort items– Have parents stay with the child

• Schedule a practice visit• Prepare staff

– Defer vitals if uncomfortable– Do not approach the child too closely, or

physically, watch for signs of distress/discomfort– The child may approach staff closely and not

follow social expectationsso should be ready for that First STEPS 2014 July Webinar 49

Office visits, continued

• Minimize waiting, and physical intervention • Recognize that behaviors may be due to

ASDs (rigidity, anxiety) and not to deliberate oppositionality

• Recognize the role of sensory issues (fluorescent lights, crowded waiting room)

• May want to schedule extra time for visits


What parents of ME children with ASDs say about office visits

• “Wait room times – if they are long can cause escalation”• “A lot of pediatric offices have bright colors and toys – most

kids enjoy this but our population can find that over stimulating”

• “The doctors could make sure that the lights are not too bright for those that have sensory issues. Maybe a sheet on the tables for those who do not like the paper (the feel of it on their skin or the sound it makes).”

• “I always say to my doctor when we arrive if we can be put into a exam room as soon as possible that helps cut down on both of the above problems. We don’t need to be seen right away but taken out of the wait room environment.”


Books on behavioral intervention

• Behavioral Intervention for Young Children With Autism, 1996, Maurice, Green and Luce, Pro-Ed, Inc., Austin, Texas

• A Treasure Chest of Behavioral Strategies for Individuals with Autism, 1997, Fouse and Wheeler, Future Horizons, Inc, Arlington, Texas

• Asperger’s Syndrome and Difficult Moments, 1997, Myles and Southwick, Autism Asperger Pub Co, Shawnee Mission, Kansas

• Visual Strategies for Improving Communication, 2000, Hodgdon, QuirkRoberts Publishing, Troy, Michigan

• The Explosive Child. Latest edition 2010. Ross Green


Behavior references• Aman MG, CA Farmer, J Hollway, LE Arnold, Treatment of

Inattention, Overactivity and Impulsiveness in Autism Spectrum Disorders. Child Adolesc Psychiatric Clin N Am 17 (2008) 713–738

• Cortesi F;Giannotti F;Ivanenko A;Johnson KSleep in children with autistic spectrum disorder.Sleep Med 2010 Aug;11(7):659-64.

• King, B et al, Lack of efficacy of citalopram in children with ASDs and high levels of repetitive behavior. Arch Gen Psych 2009 June; 66: 583-590.

• Kodak T and CC Piazza, Assessment and behavioral treatment of sleeping and feeding disorders in children with autism spectrum disorders. Child Adolesc Psychiatric Clin N Am 17 (2008) 887–905

• Kolevzon A, Mathewson KA, Hollander E. Selective serotonin reuptake inhibitors in autism: a review of efficacy and tolerability, J Clin Psychiatry. 2006 Mar;67(3):407-14.

• Malow BA et al, Impact of treating sleep apnea in a child with autism spectrum disorder. Pediatric Neurology 34:4 (2006) 325-328.


Behavior references• Matson,JL and T Dempsey. The nature and treatment of

compulsions, obsessions, and rituals in people with developmental disabilities, Res in Devel Disabil 30 (2009) 603-611.

• Miano S;Ferri R. Epidemiology and management of insomnia in children with autistic spectrum disorders. Paediatr Drugs 2010 Apr 1;12(2):75-84.

• Mindell J and Owens J. Pediatric Sleep: Diagnosis and Management of Sleep Problems, 2nd Edition, 2009, Lippincott, Williams and Wikens.

• Minshawi, NF. Behavioral Assessment and Treatment of Self-Injurious Behavior in Autism, Child Adolesc Psychiatric Clin N Am 17 (2008) 875–886

• Richdale AL and Schreck KA, Sleep problems in autism spectrum disorders: prevalence, nature, and possible biopsychosocial aetiologies. Sleep Medicine Reviews, XXX (2009) 1-9.

• Reed HE et al, Parent-based sleep education workshops in autism. Journal of child neurology, (2009) 1-10.

• Rossignal and Frye, Melatonin in Autism Spectrum Disorders: a systematic review and meta-analysis. Developmental Medicine & Child Neurology 2011

• Scott, L and S. Dhillon, Risperidone: A review of its use in the treatment of irritability associated with autistic disorder in children and adolescents. Pediatr. Drugs 2007; (9):343-354.First STEPS 2014 July Webinar 54

Upcoming First STEPS/Snuggle ME/ ME CHIP

Early Brain and Child Development (EBCD) relates to Improving Developmental Screening and Future Impacts on

Well Child Care

Dr. Andrew Garner, AAP Dr. Bob Holmberg

Friday, August 15, 2014, 12n-1 pm

https://cc.readytalk.com/r/4148heefy2pc&eom

Don’t Forget…

Harvest Meeting!!September 11, 2014

Freeport, MaineGo to: www.mainequalitycounts.org

for a complete agenda and to register!

QI Office Hours!!July 23 12 noon-1PM

1-866-740-1260; 5493654#

www.readytalk.com pass code 5493654


Practice Report Out

• What are you testing in your practice?

• Tell us about any breakthroughs you are experiencing with your work.

• Barriers?• Learnings?• Advice for others?


• Teeing up the conversation:• Martin’s Point

Brunswick Pediatrics

• SMHC Pediatrics

Progress To-Date: General Developmental Screening


Progress To-Date: Autism Screening


Contact Information• Amy Belisle, MD, Director of Child Health Quality Improvement, Maine

Quality Counts, [email protected], 207-847-3582• Sue Butts-Dion, First STEPS Project Manager, 207-283-1560,

[email protected]• Deb Gilbert, QC for Kids Administrative Coordinator, 207-620-8526 x

1017; fax 207-620-8538, [email protected]• Nan Simpson, MSW, DSI Project Manager,

[email protected], 207-441-3722• Sue Mackey Andrews, Consultant to QC for Kids on DSI Project,

[email protected], 207-564-8245• Bob Holmberg, MD, MPH, Consultant to QC First STEPS Project,

[email protected]


Funding Statements

CHIPRA/IHOC Quality Demonstration GrantFebruary 2010 to February 2015: The Improving Health Outcomes for Children (IHOC) work is conducted under a Cooperative Agreement between the Maine Department of Health and Human Services and the Muskie School of Public Service at the University of Southern Maine and is funded by a grant from the Centers for Medicare and Medicaid Services (CMS) through Section 401(d) of the Child Health Insurance Program Reauthorization Act (CHIPRA). This document was developed under grant CFDA 93.767 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. However, these contents do not necessarily represent the policy of the U.S. Department of Health and Human Services, and you should not assume endorsement by the Federal Government.

For more information, please contact the IHOC Project Director, Joanie Klayman at [email protected] or 207-780-4202.

Developmental Systems Integration (DSI)Supported by the Maine DHHS through funding from the US CDC Preventive Health and Health Services Block Grant 3B01DP009026-13 and the US DHHS Health Resources and Services Administration Maternal and Child Health Bureau Grant 2D89MC23149-02-00.


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