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Assessment and Treatment of Individuals with ASD and Co-occurring Mental Health Diagnoses John J. McGonigle, Ph.D. Assistant Professor of Psychiatry University of Pittsburgh, School of Medicine Director, Western ASERT Collaborative Center for Autism and Developmental Disorders Western Psychiatric Institute and Clinic of UPMC

Overview

• Past Practices / Current Directions in supporting people with ASD and Co-occurring Behavioral Health conditions • Clinical challenges in obtaining an accurate psychiatric diagnosis • Common Psychiatric Diagnosis in Individuals with Autism • Role of Functional Behavior Assessments (FBA) in assessing

target symptoms and challenging behavior • Discussion on practical ways to monitor / track response to

interventions • Case Presentations

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Dual Diagnosis- ASD/MI • ASD and Mental Illness and are two separate disabilities

• Autism Spectrum Disorder (ASD) is a term that describes a group

of complex disorders of brain development. ASD is characterized, in varying degrees, by difficulties in social interaction, verbal and nonverbal communication and repetitive behaviors or areas on interest. (Autism Speaks) Core features of ASD will be expressed differently in each person, even though people will have the same diagnosis.

• Mental Illness is a condition that impacts a person's thinking, feeling or mood and affects and his or her ability to relate to others and function on a daily basis. (National Alliance on Mental Illness -NAMI) Mental Illness will be expressed differently in each person , even though people will have the same diagnosis.

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changing times

past practices current best practice

culture of control recovery, culture of care and support protocols–one size fits all treatment is individualized diagnosis not accurate more accurate diagnosis old generation meds treating- diagnosis/symptoms Behavior Modification Positive Behavior Supports reduction / punishment teaching alternatives limited knowledge functional behavior assessments of etiology of behavior descriptive behavior analysis

Determinants of Challenging Behavior in DD/ASD

Biological Risk Factors Behavioral Phenotypes Tuberous Sclerosis Fragile X Syndrome Angelman’s Syndrome Landau Kleffner William’s Syndrome Lennox Gastaut Syndrome

Psychological Risk Factors Labeling Rejection Segregation Restricted Opportunities Victimization (bullying)/Abuse/Trauma

Almost half of teens with autism bullied: Archives of Pediatrics & Adolescent Medicine By Andrew M. Seaman, Reuters September 3, 2012

Developmental Risk Factors Delays in Developmental Milestones Delays or Unusual Communication Feeding / Eating Limited and Poor Social Skills Motor / Sensory delays

Complexity

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Health/ Medical

Trauma Neurological

Mental Health

ODP / Positive Practices

Autism Spectrum Disorder

• Persons with ASD are a highly heterogeneous groups, and great clinical variability

• No two individuals are alike

• Treatments and support services need to be individualized and specific to each person and family

• Treatment is often multi-faceted and requires cross- systems collaboration and a Interdisdisciplinary team approach

• Accurate diagnoses and treatment require, expertise, time, patience, and team work.

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• Continued difficulty in securing effective and appropriate diagnostic, clinical, and psychiatric services for people with ASD and co-occurring Behavioral Health conditions.

• Lack of expertise and qualified mental health providers resulted in excessive use of medication and the provision of inadequate care and treatment.

• Continued split between systems and services MH/I/DD/Medical/BHMCO’s.

Clinical Service Findings in ASD/MI

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Increased health care utilizations and costs increase likelihood of contact with police Increase likelihood of multiple placements Increase likelihood of admission to a psychiatric hospital Decrease adherence to treatment regimens Higher potential for drug interactions due to use of multiple medication Increased likelihood of medical complications

Impact of psychiatric co morbidity

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Factors influencing accurate psychiatric diagnosis

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Belief that all persons with Autism have Mental Illness or Autism causes Mental Illness

The psychiatrist can not secure an accurate diagnosis without relying on the patients self report

The psychiatrist must formulate the diagnosis alone in a 1 hour office visit

“Diagnostic Overshadowing”

Medication masking

Medical condition that masks the psychiatric illness

Psychiatric Diagnosis and Behavioral Equivalents in individuals with Developmental Disabilities

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Why is diagnosis important? • Provides a common understanding of a condition(s) and how it is typically treated • Diagnosis helps tailor the treatment plan and medical management • Assists the person and family with education and recovery • Matches data collection / analysis to the presenting concerns • Necessary for reimbursement

• Depression and Mood Disorders • Anxiety Disorders and OCD • Intermittent Explosive / Impulse Control Disorder • Post Traumatic Stress Disorder • Adjustment Disorder • Psychotic Disorders (NOS)

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More common types of psychiatric disorders in Autism Spectrum Disorder

Drug, Alcohol and Substance Abuse Personality Disorders

Less Common, but increasing

The Diagnostic Process

Intellectual distortion – person is unable to label and report on his/ her own experience (feelings to words)

Psychosocial masking – fleeting / limited eye contact and atypical social reciprocity, may lead a clinician to the miss-assumption of an anxiety D/O or psychiatric symptoms (suspiciousness / anxiety / paranoia)

Cognitive disintegration – (meltdowns)a stress induced disruption of information processing may presents as psychotic features (talking or mumbling to self, self talk, imaginary friend, thinking out loud)

Diagnostic challenges for clinicians

Functional Behavior Assessments (FBA)

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The purpose of the Functional Behavior Assessment (FBA )is an attempt to understand, from multiple perspectives, the variables that surround the reason function, etiology, purpose for the occurrence of behavior.

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Purpose of Functional Behavior Assessments

Most common Challenging Behaviors studied using FBA Matson (2011)

Self Injurious Behavior Aggression Stereotypies Tantrums Destruction of property Inappropriate speech / vocal tics Inappropriate meal time /food refusal /pica Noncompliance

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Gathering information / Data for the FBA

• Interview: - Indirect Functional Behavioral Interviews (FBI) Parent /Caregiver/ Teacher

Person Interview Rating Scales Review of performance and behavioral data Direct Observation: Direct

Antecedent - Behavior - Consequence

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General Motivations for Behavior Observable • Gaining access to tangible items • Get attention, acknowledged by others • Escape / Avoidance terminate / prevent unpleasant situations and experiences • Sensory (Positive / Negative) Beyond the Observable • Internal Medical (Seizures, Hypo/Hyperglycemia ,IBS)

• Internal Psychiatric – Depression, Anxiety, Psychoses

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Functional Assessment Recording Sheet

NAME: __________________________ DATE: ________________

DATE / TIME LOCATION

THOSE PRESENT

ACTIVITY ANTECEDENT ANALYSES

BEHAVIOR ANALYSES

CONSEQUENCE ANALYSES

RESULTS

Etiology

Etiology

Self Injury

yelling screaming

irritable isolation

Fetal Position Body Rocking

Denied request

asked to participate in group

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Etiology

Covering ears

Irritability

Blank staring

Aggression Grabbing Biting

Eye Rolling Vomiting

Unusual smells

Tics Stereotypies • Brief and Intermittent Rhythmic and slower • Face, neck, shoulders, arms and Whole body, trunk, hands whole body when complex and fingers • Not purposeful May be purposeful • Waxing and waning More stable over time • Urge and premonitory sensations No premonitory sensation

Tics versus Self Stimulation and Repetitive Behavior patterns

Etiology

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Rapid Cycling

Irritability

Temper Tantrums

Rumination

Hyperventalization Breath holding

Constipation

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Motivations / Etiology for Behavioral Concerns

• Biological (Genetics – Behavioral Phenotypes) • Physiological (Hunger, Thirst, Pain) • Medical (Dental, Seizures, Apnea, Hypoglycemia) • Psychiatric / Emotional / Behavioral • Medication (Side Effects) • Developmental Delay / Trauma • Environment (including caregiver interactions) • Cognitive / Executive Functioning Deficits (Processing) • Communication (Expressive / Receptive) • Social Skills Deficits • Attention (gaining access to preferred items) • Escape Avoidance (unpleasant situations / experiences) • Sensory (Self Stimulation)

Interventions

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Biological Genetics / Medical / Medicine

Psychological

Social

Recovery

Best Practice for Interventions

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Best Practice Models

• Use Bio-Psycho-Social Model • Successful programs have teaching environments and

generalization strategies across settings • Application of Applied Behavioral Analytic Approach • Interventions are based in Positive Approaches • Active person and family involvement • Motivations before Medications • Multi-dimensional intervention approach • Data Collection – ways to measure response to

interventions

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Case Presentation Laura Age: 25 Above average Intellectual ability

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Case Presentation Chris Age: 31 Significant Cognitive Impairment

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Case Presentation Amanda Age: 18 Average Intellectual ability

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Case Presentation Thomas Age: 36 Superior Range of Intelligence

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Treatment Principles • Step 1: Conduct Functional Behavior

Assessment

• Step 2: Develop Hypothesis about the etiology of the symptoms / Challenging Behavior

• Step 3: Select a medication or behavioral intervention which is directed to primary cause of the persons symptoms or challenging behavior 35

• Step 4: Specify what will constitute a therapeutic trial of selected drug or adequate response time for a behavior plan to take effect

• Step5: Start treatment / intervention only after an objective monitoring system is in place

• Step 6: Decide in advance what will constitute a positive treatment response

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Treatment Principles, con’t

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• Is the plan individualized and based on knowledge of the person?

•Is the plan supported by a Functional Behavior Assessment?

•Is the plan based in a Positive Approaches Philosophy?

•Does the plan include ways to increase alternative behaviors?

•Does the person / family according to their ability have the opportunity to participate in the development of the plan?

• Does the plan operate from a Least Restrictive Model?

•Does the plan include a Data Base?

•Does the plan include an Individual Safety or Crisis Plan?

Assessing Your Behavior Support Plan

Least Restrictive Treatment Model Complete Functional Behavior Assessment

Adapt the environment including physical space (prevention), designated areas of the residence school for treatment, increased staffing patterns / observation up to including 1 to 1

Communication Adaptations

Begin Interruption / Redirection (verbal and physical)

Counseling / Behavior Programs

Relaxation Training

Ask person to go to calming area

Removal of the person to calming area

Blocking Pads

Physical redirection / If the person resists – Staff Time Out

Implement Individualized Safety Plan – Crisis Intervention 38

Behavior Interventions are unsuccessful / Imminent risk and danger

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Providing Good Clinical Care includes:

• Establishing trust between all partners

• Respect the opinions of all team members

• Be consistent and predictable

• Include the consumer and family in developing the plan

• Secure expertise when necessary (consultants)

• Communicate / Disseminate latest research and treatment information

Treatment is fully intergraded with other disciplines (medicine neurology, sleep, GI) Treatment plans are team based and developed in the Positive Approaches Philosophy Be Creative / Think out of the box Team work

Providing Good Clinical Care includes:

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Questions & Answer

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References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) DSM-5. Bodfish, J. W., Symons, F. J., Parker, D. E., & Lewis, M. H.(2000). Varieties of repetitive behavior in autism: Comparisons to mental retardation. Journal of Autism and Developmental Disorders, 30, 237–243. Carr, E., & Herbert, M. (2008). Integrating Behavioral and Biomedical Approaches. Autism Advocate, 1, 46-52. Carr, E., Owens-DeSchryver, J., S. (2007). Physical Illness, Pain, and Problem Behavior in Minimally Verbal people with Developmental Disabilities. Journal of Autism and Developmental Disorders, 37, 413-424. De Bruin, E. I., Ferdinand, R.F., Meester, S. de Nijs, P. F. A., Verheij, F. (2007). High rates of Psychiatric Co-Morbidity in PDD-NOS. Journal of Autism and Developmental Disorders, 37, 877-886. Dvir, Y., & . Frazier, J., A. (2001). Autism and Schizophrenia. Psychiatric Times. 28, 1-4. Ferron, F.R., Kern, C.A., Hanson, R.H., & Wieseler, N.A., (1999). Psychiatric diagnosis in mental retardation. In N.A. Wieseler & R.H. Hanson (Eds.), Challenging behavior of persons with mental health disorders and severe developmental disabilities (pp. 3-12). Washington, DC: American Association on Mental Retardation. Fletcher, R., Loschen, E., Stavrakaki, C., & First, M. (2007). Pervasive Developmental Disorders. Diagnostic Manual – Intellectual Disability: The Text Book of Diagnosis of Mental Disorders in Persons with Intellectual Disability, New York, NADD Publishing. Ghaziuddin, M. (2002). Asperger’s Syndrome: Associated Psychiatric and Medical Conditions. Focus on Autism and Other Developmental Disorders, 17(3),138-144. Holden, B., & Gitlessen, J., P. (2008). The relationship between psychiatric symptomology and motivation of challenging behavior: A preliminary study. Research in Developmental Disabilities, 29, 408-413. Iwata, B. A., Dorsey, M. F., Stifler, K. J., Bauman, K. E., & Richman, G. S. (1982). Toward a Functional Analysis of Self-Injury. Journal of Applied Behavior Analysis, 27, 197-209.

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Iwata, B., A., et.al. (1994). The Functions of Self-Injurious Behavior: An Experimental- Epidemiological Analysis, Journal of Applied Behavior Analysis, 27, 215-240. Matson, J. L., Goldin, R., L. (2013). Comorbidity and autism: Trends, topics and future directions. Research in Autism Spectrum Disorders, 7, 1228-1233. Matson, J. L., Gonzalez, C. Terlonge, C., Thorson, R.T., & Laud, R., B. (2006). What symptoms predict the diagnosis of mania in persons with severe / profound intellectual disability in clinical practice? Journal of Intellectual Disability Research, 51, 25-31. Matson, J. L., & Nebel-Schwalm, M., Assessing Challenging Behaviors in Children with Autism Spectrum Disorder: A Review. Research in Developmental Disabilities (2006), doi.10.1016/j.ridd2006.08.001 Matson, J. L., Sipes, M., Horovitz, M., Worley, J. Shoemaker, M. E., & Kozlowski, A. M. (2011). Behaviors and Corresponding functions addressed via functional assessment, Research in Developmental Disabilities, 32, 625- 629. Melville, C., A., Cooper, S., A., Morrison, J., Smiley, E., Allan, L., Jackson, A., Finlayson, J. Mantry, D. (2008). The Prevalence and Incidence of Mental Ill-Health in Adults with Autism and Intellectual Disabilities, Journal of Autism and Developmental Disorders, 38, 1676-1688. Rojahn, J., Matson, J., L., Lott, D., Ebsensen, A., J., & Smalls, Y. (2001). The Behavior problems Inventory: An Instrument for the assessment of Self-Injury, stereotyped behavior and aggression/destruction in individual with developmental disabilities. Journal of Autism and Developmental Disorders, 31, 577-588. Rush, A., J., &Frances, A. (2000). Treatment of Psychiatric and Behavioral Problems in Mental Retardation: Expert Consensus Guideline Series. American Journal on Mental Retardation, 105, (3), 165-188.

References

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