For years, the answer to the statement “I am concerned my child has autism” was a referral to the local Regional Center for further assessment and intervention. As medical insurances have become mandated to provide autism assessment and intervention, this automatic referral has shifted as the Regional Center has become the payor of last resort for autism assessment and intervention. It behooves us as providers to direct families first to their medical insurance when this concern comes up. Lets look at this in more detail (https://www.sdrc.org/apply).

When there is concern a child under the age of 3 is at risk for autism, a referral to Early Start which falls under Regional Center, is warranted, as they contract with providers to can complete assessments and provide intervention which can include parent education, infant education, speech therapy and occupational therapy.

This changes dramatically after a child reaches the age of 3. When there is a concern about autism in a child older than the age of 3, the first step is referral to the child’s medical insurance for an autism assessment. Many providers only assess children up to a certain age, so when a child reaches late childhood, it can be tricky to find a provider to complete an autism assessment, especially for a child with Medi-cal. In these cases, sometimes the Regional Center, as the payor of last resort, might be the quickest option, although they will often still have a long waitlist.

Once a child has an autism diagnosis, the next step is to help connect the family to intervention. This can take some time depending on the family’s grieving and acceptance process. Again intervention is primarily mandated through medical insurance so that is the place to start. Sometimes the same provider completes autism assessments and provides intervention but often this involves a referral to another provider. There are different types of autism intervention that vary from a more behavioral approach (ex. ABA) to a more developmental relationship based approach (ex. Relationship Development Intervention, DIR FloorTime), which will be a topic discussed in more detail in a future BHCS newsletter. Additionally the intervention can be home-based or center-based depending on goals and family preferences. There is a varying amount of parent participation that is expected but research has shown that parent participation is hugely beneficial to achieving goals and helping parents feel empowered. (https://www.vistahillccyp.org/the-importance-of-parent-participation-in-autism-intervention-10-23-24).

School-aged children should also be referred to their school IEP team for an assessment to determine if they can qualify for school based interventions through an IEP or 504 plan. These additional supports are available through age 21 and can include vocational training. The Regional Center can provide funding for ancillary supports including respite care services, social/recreational programming, and social skills groups. Importantly, the Regional Center also takes over for day programming needs and other adult supports over the age of 21.

For many families the local autism society is an additional source of support in terms of support groups, meet ups, and resources. There are many other aspects of autism assessment and intervention that could be discussed in this newsletter. We hope we achieved our goal as an introduction for next steps when there is a concern raised by a family with the take home message to start with a screening if you are comfortable and then referral to the family’s medical insurance. Feel free to call us at SmartCare Behavioral Health Consultation Services Provider Line to discuss specific cases or share our Parent Line information with families for help them find referrals.

References:

https://assets-global.website-files.com/600754479f70fb2c4d356be6/64740987101c81b742992e54_SCQ.pdf

https://www.wpspublish.com/srs-2-social-responsiveness-scale-second-edition

AUTHOR:

Charmi Patel Rao MD, DFAACAP

Co-Medical Director, Vista Hill Foundation

Health Science Clinical Professor, UCSD Department of Psychiatry

President, San Diego Academy of Child and Adolescent Psychiatry

Autism spectrum disorder (ASD) and psychosis are distinct but closely related psychiatric conditions. In the twentieth century, Swiss psychiatrist Eugen Bleuler identified autism, which he defined as withdrawal from the world, as a core, pathognomonic symptom of schizophrenia. Since the 1970s and the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), ASD and psychosis have become recognized as separate diagnoses, but they remain highly comorbid. Up to 34.8% of those with ASD exhibit psychosis and 3.6-60% of those with schizophrenia present with autistic traits. Individuals with ASD are 3.5x more likely to develop psychosis than the general population. Both conditions share risk factors including advanced paternal age, pregnancy and birth complications, migration status, specific genetic pathways, abnormalities in brain development, neuroanatomical markers, and social cognition deficits. It is thought that the impairments in information processing seen in ASD may confer a risk for later psychosis.

Identifying psychosis in individuals with ASD can be challenging. First, patients with ASD may have difficulty communicating psychotic experiences, such as delusions and hallucinations due to the social communication impairments inherent to ASD and/or insufficient cognitive ability if they have comorbid intellectual disability. Additionally, overlapping symptoms in both conditions may create complications. For example, hallucinations may be misinterpreted as the anomalous perceptual experiences reported in ASD, or negative symptoms of psychosis, such as flat affect and social withdrawal, may be confused for difficulties with socio-emotional reciprocity seen in ASD.

Considering the overall course of illness can be helpful in distinguishing psychosis from ASD. While the onset of ASD is typically in early childhood, as early as 12-24 months of age, the onset of primary psychotic disorders is typically between late adolescence and the mid-thirties (there are exceptions to this pattern; for example, childhood-onset schizophrenia can be diagnosed before 13 years old). Furthermore, negative symptoms of psychosis typically worsen over time if untreated while autistic traits remain more stable.

There are also key differences between these two disorders that can aid in diagnosis. ASD is generally associated with an impairment in understanding the rules of common social interactions, greater impairment in theory of mind (the ability to understand and predict the mental states of others) and difficulty in distinguishing between one’s subjective perceptions and reality. On the other hand, individuals with psychosis tend to have a greater tendency towards external attributions for negative events and internal attributions for positive events. They are also more likely to demonstrate hostility bias, or the tendency to interpret the ambiguous behaviors of others as hostile.

Distinguishing ASD from psychosis is important, as it can allow for early intervention and treatment. Medications for these diagnoses can overlap; for instance, the second-generation antipsychotics aripiprazole and risperidone are used for both irritability associated with ASD and for psychosis. However, higher doses of such medications may be required in primary psychotic disorders compared to ASD. Additionally, diagnostic clarification can help guide therapy. While Applied Behavior Analysis may be most appropriate for an individual with ASD, Cognitive Behavioral Therapy for Psychosis might be recommended for individuals with psychosis. Understanding the differences and shared features of ASD and psychosis is crucial for accurate diagnosis and effective intervention, ultimately leading to improved outcomes for affected individuals.

Back to the Case: Patient was diagnosed with unspecified psychosis in addition to his existing diagnosis of autism spectrum disorder. He was started on aripiprazole, which was gradually titrated to 20mg daily. He and his mother reported improvement in his aggression, hallucinations, and paranoia on this medication. He was referred to the San Diego Regional Center for interventions related to his autism spectrum disorder and to a psychosis specialty clinic for interventions related to his psychosis.

AUTHOR:

Dr. Kristen Kim, MD

Child, Adolescent and Adult Psychiatrist

Vista Hill Foundation

Your 11 year old male patient with Autism level 2 without intellectual or verbal impairment and Generalized Anxiety Disorder is not tolerating sertraline well (resulting in weight gain and akathisia) with minimal positive effect. Primary concerning symptoms include: agitation, quick to anger, and difficulty with changes in routine. He previously did not tolerate trials of fluoxetine, guanfacine or aripiprazole but another physician. His mother is asking about propranolol which she read about on an autism blog she follows.

Beta-blockers:

There are medications that were developed for physical problems that have subsequently been found to be helpful for mental health problems. Several mood stabilizers, which were originally developed to be helpful for epilepsy, fall into this bucket, as do the alpha-agonists and beta blockers, which were developed for hypertension but have found to be useful for behavioral health concerns as well. This newsletter will focus on the many uses, mostly as an adjunctive treatment, of beta-blockers.

SSRIs are the first line medication treatment for anxiety disorders and are quite effective for the underlying feelings and thoughts linked to anxiety, but often aren’t as helpful for the outward behavioral and physical symptoms of anxiety. Behavioral symptoms of anxiety include: dysregulation, fight or flight response, and agitation. Physical symptoms of anxiety include: elevated heart rate, sweatiness, shaking, tremor, headache and stomachache/nausea. When these don’t respond to the combination of therapy and SSRI, it is helpful to consider alternative treatments, which can include alpha agonists and beta blockers, specifically propranolol.

Propranolol:

Propranolol is a non-selective beta-adrenergic receptor blocker that crosses the blood-brain barrier so can have effects in the central nervous system in addition to its peripheral activity, unlike most other beta-blockers. It has been around since the 1960s as an antihypertensive medication, although there are newer medications for hypertension now. When people feel anxious, their body makes more of the neurotransmitters norepinephrine and epinephrine, which historically served a survival purpose for the “fight or flight” response but can be impairing for someone with excessive anxiety. Propranolol can specifically help with the physical symptoms of anxiety including sweating and shaking but doesn’t directly treat the feeling of anxiety. It can be useful for performance anxiety and panic disorder.

There are some important guidelines to keep in mind when prescribing propranolol. Typically start with 10-20mg daily in children and 20mg in adults with a target dose of 20-40mg (40-60mg for adults) divided into two doses. There is a long acting formulation of propranolol but the minimum dose is 60mg. Someone might feel sleepy when first starting propranolol but this should resolve after a few days and is one of the reasons to start at a lower than therapeutic dose and to give the starting dose in the evening. Common side effects include: dizziness, lightheadedness, cold hands and feet and stomachache. It is important to monitor blood pressure regularly if prescribing propranolol. Use caution when prescribing with other medications that can reduce blood pressure. For example, it is not recommended to use propranolol with an alpha agonist, particularly at high doses. Its use is contraindicated in people with sinus bradycardia, heart failure, and sick sinus syndrome and should be cautioned in people with diabetes, hyperthyroidism, and asthma. It should used with caution in someone with depression because it can worsen depressive symptoms. When stopping propranolol, the medication should be tapered off to avoid discontinuation hypertension.

Studies have not found propranolol to be particularly helpful for PTSD, social anxiety and generalized anxiety. It is a medication to consider when patients have impairing physical and behavioral symptoms with their anxiety presentation. This includes panic disorder and performance anxiety. Propranolol has been studied in children with co-occurring anxiety and autism. It has been found to be helpful for behavioral dysregulation while being relatively well tolerated. It can be a tool in the medication toolbox when first line options do not work well or are not well-tolerated.

Back to the Case Presentation

You plan a trial of propranolol 10mg qday to start and increase to 10mg twice per day after one week. Parents and school report he is tolerating it well (blood pressure remains stable) and mother reports he is “not so quick to react and get upset”. The dose is titrated to 20mg twice per day with a 10mg as needed dose available. He continues with his school-based supports and autism intervention.

References:

https://www.ncbi.nlm.nih.gov/books/NBK557801/

https://pmc.ncbi.nlm.nih.gov/articles/PMC4724794/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5803020/

https://www.news-medical.net/news/20240123/Blood-pressure-drug-could-help-lower-anxiety-for-kids-and-young-adults-with-ASD.aspx

AUTHOR:

Charmi Patel Rao MD, DFAACAP

Co-Medical Director, Vista Hill Foundation

Health Science Clinical Professor, UCSD Department of Psychiatry

President, San Diego Academy of Child and Adolescent Psychiatry

There has been a recent shift in the approach to patients with ID, with greater focus on adaptive functioning across domains, including cognitive, social and practical capacities, rather than based purely on an IQ score. Since ID can be caused by a variety of factors, including genetic, perinatal, environmental and other issues, it is thus important to assess the underlying etiology of the ID, because it can inform the assessment of problems symptoms and guide treatment efforts.

For a patient with Intellectual Disability exhibiting behavioral and emotional symptoms, it is important to conduct a focused medical review of systems as sometimes a patient “acts out” as a way to communicate physical discomfort (for example: from an infection or headache or abdominal issue). Other precipitants may include a behavioral profile to avoid non-preferred activities or as a protest to a change in routine—this particularly with persons who are non-verbal or verbally limited. Individuals with ID are at greater risk of trauma exposure and abuse, so assessment of these potential concerns should also be part of the evaluation protocol.

External considerations aside, co-occurring psychiatric conditions are not uncommon in the population and the most common psychiatric disorders that co-occur are Autism Spectrum Disorders (ASD), Mood Disorders (Anxiety and Depression) and Attention Deficit Hyperactivity Disorder (ADHD). Less frequently, ID patients may also present with co-occurring disorders including psychotic disorders and bipolar conditions which need therapeutic interventions comparable to that given to non-ID individuals.

It is important to ask the patient (if possible) and caregivers about current behavioral and emotional concerns, with attention to how appropriate the symptoms are given the patient’s developmental and functional capacities, and also, how the presenting symptoms are different from their baseline presentation. In this process, it is important to avoid misattributing symptoms to the patient’s ID when they may be a result of a co-morbid psychiatric condition. It can be helpful to use screening tools and use diagnostic criteria adapted for patients with ID conditions.

With respect to patients with co-occurring ID and ADHD, symptoms of hyperactivity tend to occur earlier in the patient’s life and symptoms of inattention tend to last longer into adolescence and young adulthood.   It is of note that stimulant medications, which are the mainstay of treatment for ADHD in youth, are generally less effective in children with co-morbid ID and ADHD. This said, a stimulant trial in patients with co-morbid ADHD symptoms would generally be appropriate along with careful monitoring of side effects and efficacy. Non-stimulants such as the alpha agonists and atypical antipsychotics may be helpful for the young patients with ID and co-morbid disruptive behavioral disorders (including ADHD).

With respect to anxiety and depressive disorders in the ID patient, these individuals may struggle in identifying their feelings, and it can be challenging to assess whether a non-verbal or speech-limited individual’s behaviors is related to underlying anxiety or depression. Input from caregivers across multiple settings can help with this determination. The SSRIs can be useful in patients with ID and clinical depression and/or anxiety, again with close monitoring for side effects.

In summary, when seeing patients with Intellectual Disability, it is important to assess for co-morbid behavioral and emotional concerns and possible psychiatric disorders with full attention to their overall medical and their psychosocial status.

Particularly for those more significantly affected, the issue of agitated and aggressive outbursts is often a major concern, though even in those with less significant symptom profiles, affectively charged outbursts may occur. Helping families and caregivers better understand both the causes of these incidents and the course of such outbursts can aid in reducing and preventing aggressive behaviors and may lead to helpful intervention strategies when they do occur.

Most aggressive and agitated episodes in the ASD population are best conceptualized as “meltdowns” which are a typically a reaction to either an overwhelming intense sensory experience or an unanticipated external frustration.   While sometimes compared to and described as “tantrums”, these meltdown outbursts are typically not goal-directed as most tantrums are in non-affected individuals.

For those with ASD, it is always important to consider what may be causing a meltdown—- parents and caregivers can and should be tasked with being “detectives” in figuring out possible causal factors. This can be a very powerful tool in addressing and reducing meltdowns over the long term.

Things to consider include:

• Is this a medical problem—is the individual in pain or other distress?
• Does the individual not have ability to communicate their wants or needs?
• Are cognitive or social demands too high or too low?
• Sensory dysregulation: Is there too much or too little stimulus?
• Has there been reinforcement of the behavior in the past?
• Is there a co-occurring mental health condition that might explain the problem(s)?
• Are there family/school dynamics such as bullying, moving to a new home/school, caregiver burnout?

Once (and if) a causal factor(s) for the meltdowns has been identified, it will often be feasible for parents and caretakers to intervene, either to address or to minimize their frequency and/or intensity.

An understanding of the concept of the “Rage Cycle” can also be a helpful framework for parents and caretakers in managing meltdown outbursts more effectively. The following graphic of the cycle of rage is very useful for understanding when and how a caretaker can intervene. Although referenced here in the context of individuals with ASD, the concepts can also be applied to other individuals with similar issues of reactivity, impulse control and affect management.

Most importantly, it is important to know that once the cycle of a meltdown has begun, ,,,this is NOT the time to attempt teaching what to do or introducing a new task or skill.

Early recognition of the precursors to a meltdown –when a person begins to “rumble”– can sometimes be helpful and if seen, early intervention may arrest the cycle from becoming a full meltdown. For example, rumbling may present with heightened physical activity such as jumping or pacing about, yelling, fidgeting, rapid movements or making noises. If the individual’s level of agitation is not too advanced, parents and caregivers can utilize simple strategies that may be used during the “rumbling phase” such as:

• Acknowledge the difficulty and coach simply and calmly
• Attempt gentle redirection or refocussing
• Intervene without challenging or raising the temperature
• Keep verbal input simple:   Just “walk”, don’t “talk”
• Move the individual away from the ‘offending’ environment, if feasible.
• Use proximity control– stay with the person, be present and calm
• Refer to a schedule and highlight positive future activities, if available
• Go to a predetermined “home base” or “calming place”

If the meltdown reaches the rage stage, aggressive behaviors are more likely occur and appropriate caution is important. In this phase, the profile may include disinhibition, impulsivity, emotional lability, explosive behavior, property destruction, self-injurious behavior, yelling, biting, hitting or crying. During this time, it is of utmost importance to keep the individual and those around them safe. Interventions during a meltdown may include:

• Protect the individual and others
• Disengage emotionally, this is not about you—getting agitated or loud won’t help.
• Use few words, remain calm and quiet.
• Be flexible—extra tolerance and a bit of slack may help defuse the rage state.
• Have a plan and follow it— e.g., siblings go to their rooms, only certain people will interact with individual, have pre-identified the safe places to go, etc.
• Attempt to move the individual to a “safe place” or “home base”
• Obtain assistance if needed.
• Do not discipline– this is not the “teachable phase” and retribution does no good.

Once the meltdown has begun to pass, the individual with ASD (or any other predisposing condition) will enter a “recovery” phase.   Keep in mind that they have just gone through an intense sensory and emotional overwhelm— often we will see someone needing to sleep, cry, withdraw or appear exhausted. During this time, allowing the person time to sleep, rest or engage in a preferred activity may be needed.

Again, this is not the time to teach a new skill or place demands on the person as they are in cool down mode, not learning mode.

Helping families and caregivers understand meltdowns and the rage cycle is rarely simple, but sustained efforts can provide effective, long term tools for addressing agitation and aggressive outbursts. Consultation with mental health providers and behavioral experts can be an important asset and should be part of the clinical team helping the ASD individual.

Some services provided by the San Diego Regional Center for families struggling with aggression include:

1. Consultation with a behavioral psychologist
2. Safety Alert, Inc. ( https://www.safetyalert.net/ )
3. START program  https://www.exodusrecovery.com/vista-start/.
4.  Fred Finch Specialized Wraparound https://www.fredfinch.org/specialized-wraparound
5. Advance CIRT (Crisis Intervention Response Team) Advance North (760) 294-1188 Advance San Diego (619) 756-4095

   All programs require a referral from the SDRC. Families may request these services through their Regional Center service coordinator.

   Reference:

Myles, B.S., and Southwick, J. (1999) Asperger Syndrome and Difficult Moments: Practical Solutions for Tantrums, Rage, and Meltdowns. Shawnee Mission, KS: Autism Asperger Publishing Company.

https://www.cdc.gov/ncbddd/autism/data.html