Autism Beyond Diagnosis: Management

Topics for the General Pediatrician

Part 2 Session #: OD0043

Paul Carbone, MD,

FAAP Professor
Department of
Pediatrics University of
Utah
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Learning Objectives (part 1 and
2):
1. Discuss the current knowledge base of causes of
autism spectrum disorder (ASD) and appropriate
medical work up into etiology and recurrence
risk.

2. Report evidence-based treatments in ASD for

children with different clinical profiles, discuss
complementary and alternative medicine
approaches, and outline strategies for
making your practice more autism friendly.

3. Discuss evaluation and management of common

co-occurring medical, emotional, and
behavioral problems in children with ASD.

© U N I V E R S I T Y OF U T A H H E A L T H
• I have the following financial relationships with the manufacturer(s) of any
commercial product(s) and/or provider(s) of commercial services discussed in this
CME activity:”
– Research Support from: The Simons Foundation, Maternal and Child Health
Bureau
– Other: Spouse is a general pediatrician in private practice

• I do intend to discuss an unapproved/investigative use of a commercial product/device

in my presentation

© U N I V E R S I T Y OF U T A H H E A L T H
 CO-OCCURRING
CONDITIONS

Developmental ASD
Conditions Medical Conditions
Intellectual Motor
disability Gastrointestinal
deficits Conditions

Speech/language
disorders Feeding

disorders
Insomnia
Psychiatric/Behavioral Seizures

Anxiety Symptoms/Conditions Wandering

Overweight
Depression
ADHD Irritability
Mood and
disorder aggression
 INSOMNI
A
• Prevalence of 50 – 80%
• Associated with externalizing
and internalizing behavioral
problems
• Higher overall autism severity scores
and social skills deficits and stereotypic
behavior
• Associated with parental
sleep disruption and
caregiver stress

Malow BA, Byars K, Johnson K, et al; Sleep Committee of the Autism Treatment Network. A practice
pathway for the identification, evaluation, and management of insomnia in children and
adolescents with autism spectrum disorders. Pediatrics. 2012;130(suppl 2):S106–S124

© U N I V E R S I T Y OF U T A H H E A L T H
 INSOMNI Screen all children Does your child have problems

A Medical
getting to sleep or staying
asleep?
• GI – GERD, constipation
Assess and treat • Atopic dermatitis
• Epilepsy
medical • Asthma/allergies
contributors • Obstructive sleep apnea
• Restless legs syndrome
• Circadian rhythm disturbances
Consultation/referral Psychiatric
if needed Anxiety, ADHD, mood disorders

Malow BA, Byars K, Johnson K, et al. A practice pathway for the identification, evaluation, and management of insomnia in children and
adolescents with autism spectrum disorders. Pediatrics 2012; 130 Suppl 2: S106-24.
Autism Speaks ATN/AIR-P Strategies to Improve Sleep in Children with Autism:
https://www.autismspeaks.org/tool-kit/atnair-p-strategies-improve-sleep- children-autism
© U N I V E R S I T Y OF U T A H H E A L T H
 INSOMNI Screen all children Does your child have problems

A Medical
getting to sleep or staying
asleep?
• GI – GERD, constipation
Assess and treat • Atopic dermatitis Assess and treat
• Epilepsy
medical behavioral
• Asthma/allergies
contributors • Obstructive sleep apnea insomnias
• Restless legs syndrome
• Circadian rhythm disturbances • Promote good sleep hygiene
• Behavioral treatments can
Consultation/referral Psychiatric be effective
if needed Anxiety, ADHD, mood disorders • Autism Speaks Sleep Toolkit

Malow BA, Byars K, Johnson K, et al. A practice pathway for the identification, evaluation, and management of insomnia in children and
adolescents with autism spectrum disorders. Pediatrics 2012; 130 Suppl 2: S106-24.
Autism Speaks ATN/AIR-P Strategies to Improve Sleep in Children with Autism:
https://www.autismspeaks.org/tool-kit/atnair-p-strategies-improve-sleep- children-autism
© U N I V E R S I T Y OF U T A H H E A L T H
 INSOMNI Screen all children Does your child have problems

A Medical
getting to sleep or staying
asleep?
• GI – GERD, constipation
Assess and treat • Atopic dermatitis Assess and treat
• Epilepsy
medical behavioral
• Asthma/allergies
contributors • Obstructive sleep apnea insomnias
• Restless legs syndrome
• Circadian rhythm disturbances • Promote good sleep hygiene
• Behavioral treatments can
Consultation/referral Psychiatric be effective
if needed Anxiety, ADHD, mood disorders • Autism Speaks Sleep Toolkit

Insomnia
unresolved Medications
Consider medication trial • Melatonin
and/or • Clonidine
Sleep medicine referral • Mirtazapine
Malow BA, Byars K, Johnson K, et al. A practice pathway for the identification, evaluation, and management of insomnia in children and
adolescents with autism spectrum disorders. Pediatrics 2012; 130 Suppl 2: S106-24.
Autism Speaks ATN/AIR-P Strategies to Improve Sleep in Children with Autism:
https://www.autismspeaks.org/tool-kit/atnair-p-strategies-improve-sleep- children-autism
© U N I V E R S I T Y OF U T A H H E A L T H
 GASTROINTESTINAL
• SYMPTOMS
Are children with ASD more likely to have
gastrointestinal (GI) problems?
– constipation (OR 3.86; 95% CI 2.23–6.71)
– diarrhea (OR 3.63; 95% CI 1.82–7.23)
– abdominal pain (OR 2.45; 95% CI 1.19–5.07)
– general GI symptoms (OR 4.42; 95% CI, 1.90-10.28)

• What are the consequences of GI symptoms in

children with ASD?
– Children with ASD and GI symptoms more likely to have daytime
maladaptive behaviors compared with children with ASD without GI
symptoms

• Etiology
– Linked to ASD characteristics
– Ongoing research into differences in immunologic function, motility,
microbiome
McElhanon BO, McCracken C, Karpen S, Sharp WG. Gastrointestinal symptoms in autism spectrum disorder: a meta-analysis. Pediatrics 2014; 133(5): 872-83.
Chaidez V, Hansen RL, Hertz-Picciotto I. Gastrointestinal problems in children with autism, developmental delays or typical development. J Autism Dev Disord.
2014;44(5):1117-1127.
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BEHAVIORS THAT MAY INDICATE ABDOMINAL PAIN OR
DISCOMFORT IN CHILDREN WITH ASD
Vocal Behaviors Motor Behaviors Changes in State
• Frequent • Facial grimacing • Sleep disturbances
throat • Gritting teeth • Increased irritability
clearing • Wincing • Noncompliance
• Screaming • “Grazing” behavior with demands
• Sobbing for • Mouthing behavior that typically
“no reason” (chew on clothes) elicit an
• Sighing, • Tapping behavior appropriate
whining (finger tapping on response
• Moaning, throat)
• Any unusual
groaning posturing (laying
• Delayed over furniture)
echolalia • Agitation (pacing,
• Direct jumping)
verbalizatio • Self-injurious behavior
n • Aggression
Buie T, Fuchs GJ, 3rd, Furuta GT, et al. Recommendations for evaluation and treatment of
common gastrointestinal problems in children with ASDs. Pediatrics 2010; 125 Suppl 1: S19-29.

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 EVALUATION AND MANAGEMENT OF CONSTIPATION IN
CHILDREN WITH ASD
Assessment
• H& P
• Red flags ?

yes

Consider GI
referral, labs (Ca,
Pb, T4/TSH,
celiac screen)

Gorrindo P, Williams KC, Lee EB, Walker LS, McGrew SG, Levitt P. Gastrointestinal dysfunction in autism: parental report, clinical evaluation, and associated
factors.
Autism research : official journal of the International Society for Autism Research 2012; 5(2): 101-8.
Furuta GT, Williams K, Kooros K, et al. Management of constipation in children and adolescents with autism spectrum disorders. Pediatrics. 2012;130 Suppl 2:S98-
S105. Autism Speaks - ATN/AIR-P Guide to Managing Constipation in Children,
https://www.autismspeaks.org/tool-kit/atnair-p-guide-managing-constipation-children © U N I V E R S I T Y OF U T A H H E A L T H
 EVALUATION AND MANAGEMENT OF CONSTIPATION IN
CHILDREN WITH ASD
Assessment Treatment of functional constipation
• H& P • Oral or rectal medications
no
• Red flags ? for disimpaction

• Oral meds, diet, education,

behavioral for
yes
maintenance

Consider GI • Follow up regularly for

referral, labs (Ca, medication adjustments and to
Pb, T4/TSH, assess treatment response
celiac screen)
• Consider labs or GI referral
for treatment resistant
Gorrindo P, Williams KC,patients
Lee EB, Walker LS, McGrew SG, Levitt P. Gastrointestinal dysfunction in autism: parental report, clinical evaluation, and associated
factors.
Autism research : official journal of the International Society for Autism Research 2012; 5(2): 101-8.
Furuta GT, Williams K, Kooros K, et al. Management of constipation in children and adolescents with autism spectrum disorders. Pediatrics. 2012;130 Suppl 2:S98-
S105. Autism Speaks - ATN/AIR-P Guide to Managing Constipation in Children,
https://www.autismspeaks.org/tool-kit/atnair-p-guide-managing-constipation-children © U N I V E R S I T Y OF U T A H H E A L T H
 EVALUATION AND MANAGEMENT OF CONSTIPATION IN
CHILDREN WITH ASD
Assessment Treatment of functional constipation Lessons learned
• H& P • Oral or rectal medications • Majority effectively managed
no by non-GI provider
• Red flags ? for disimpaction
• Follow up is critical because
• Oral meds, diet, education, adjustments in medications
behavioral for are common
yes
maintenance
• Some children are non-
• Follow up regularly for responders, tend to be
Consider GI
children with intellectual
referral, labs (Ca, medication adjustments and to disability
Pb, T4/TSH, assess treatment response
celiac screen)
• Often the only presenting sign
• Consider labs or GI referral was a change in behavior
for treatment resistant
Gorrindo P, Williams KC,patients
Lee EB, Walker LS, McGrew SG, Levitt P. Gastrointestinal dysfunction in autism: parental report, clinical evaluation, and associated
factors.
Autism research : official journal of the International Society for Autism Research 2012; 5(2): 101-8.
Furuta GT, Williams K, Kooros K, et al. Management of constipation in children and adolescents with autism spectrum disorders. Pediatrics. 2012;130 Suppl 2:S98-
S105. Autism Speaks - ATN/AIR-P Guide to Managing Constipation in Children,
https://www.autismspeaks.org/tool-kit/atnair-p-guide-managing-constipation-children © U N I V E R S I T Y OF U T A H H E A L T H
 FEEDING PROBLEMS IN CHILDREN WITH
ASD
Prevalence: Characteristics:
• Up to three-quarters!!! • Relates to core characteristics of
• Selective restrictive and repetitive
eating
• Pica behavior and sensory
• Presents in infancy and
• Rumination differences
often persists into
Treatment:
adolescence
• Nutritional
counseling
Workup: • Sit for meals
• Dietary • Encourage
Avoid grazingstructure /
history
• ASD: insufficient • Referral predictability
(OT, speech, dietician,
fiber, vitamin D, behavioralist, feeding clinic) for
• Consider
calcium other GI those with very selective eating or
conditions (GERD, food feeding problems that affect
allergy, lactose nutrition
intolerance)
Hyman SL, Stewart PA, Schmidt B, et al. Nutrient intake from food in children with autism.
Pediatrics. 2012;130(suppl 2):S145–S153
Emond A, Emmett P, Steer C, Golding J. Feeding symptoms, dietary patterns, and growth in
young with autism spectrum disorders. Pediatrics 2010; 126(2): e337-42.
children
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 OBESITY AND
OVERWEIGHT
Prevalence:
• 19% overweight, 23% obese, significantly higher than youth without ASD (odds ratio
1.48 and 1.49 respectively)
• Begins in early childhood and persists into adulthood

Risk factors:
• Selective eating patterns
• Less physical activity
• Increased screen time
• Medications

Downstream effects:
higher prevalence of diabetes, hypertension, hyperlipidemia

Hill AP, Zuckerman KE, Fombonne E. Obesity and Autism. Pediatrics. 2015;136(6):1051-1061.
Healy S, Aigner CJ, Haegele JA. Prevalence of overweight and obesity among US youth with
autism
spectrum disorder. Autism. 2019;23(4):1046-1050
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WEIGHT MANAGEMENT IN PRIMARY CARE FOR CHILDREN
WITH AUTISM: EXPERT RECOMMENDATIONS
• Screen with BMI at all visits starting at age 2
Screen all • Accommodations: leave shoes on, hold favorite object, parents on scale, vitals at
children the end, visual schedules

Curtin C, Hyman SL, Boas DD, et al. Weight Management in Primary Care for Children With
Autism: Expert Recommendations. Pediatrics. 2020;145(Suppl 1):S126-S139.
© U N I V E R S I T Y OF U T A H H E A L T H
WEIGHT MANAGEMENT IN PRIMARY CARE FOR CHILDREN
WITH AUTISM: EXPERT RECOMMENDATIONS

• Raise the topic of obesity prevention and intervention

Discuss • Take a positive, health oriented approach (nonjudgmental,
concerns nonstigmatizing language, positive role model)

Curtin C, Hyman SL, Boas DD, et al. Weight Management in Primary Care for Children With
Autism: Expert Recommendations. Pediatrics. 2020;145(Suppl 1):S126-S139.
© U N I V E R S I T Y OF U T A H H E A L T H
 WEIGHT MANAGEMENT IN PRIMARY CARE FOR CHILDREN
WITH AUTISM: EXPERT RECOMMENDATIONS

•Same history (dietary, screen time and physical activity), physical exam or lab
Assess workup in children with ASD as other children
• Think selective eating, food reinforcers, opportunities for physical activity
overweight/obesity

Curtin C, Hyman SL, Boas DD, et al. Weight Management in Primary Care for Children With
Autism: Expert Recommendations. Pediatrics. 2020;145(Suppl 1):S126-S139.
© U N I V E R S I T Y OF U T A H H E A L T H
 WEIGHT MANAGEMENT IN PRIMARY CARE FOR CHILDREN
WITH AUTISM: EXPERT RECOMMENDATIONS

• Medical conditions: sleep, GI conditions

Assess for ASD associated
risk factors and health • Psychiatric/behavioral conditions: ADHD, anxiety
conditions • Psychotropic medications: second generation
antipsychotics

Curtin C, Hyman SL, Boas DD, et al. Weight Management in Primary Care for Children With
Autism: Expert Recommendations. Pediatrics. 2020;145(Suppl 1):S126-S139.
© U N I V E R S I T Y OF U T A H H E A L T H
 WEIGHT MANAGEMENT IN PRIMARY CARE FOR CHILDREN
WITH AUTISM: EXPERT RECOMMENDATIONS

• Interdisciplinary team- Occupational/speech/physical/recreation therapist, behavioralist

Staged, • Non-edible reinforcers
interdisciplinary • Eating and/or physical activity goals in IEP; refer to adaptive recreation programs
• Medications to counteract the effects of second generation antipsychotics if
treatment appropriate
Curtin C, Hyman SL, Boas DD, et al. Weight Management in Primary Care for Children With
Autism: Expert Recommendations. Pediatrics. 2020;145(Suppl 1):S126-S139.
 WEIGHT MANAGEMENT IN PRIMARY CARE FOR CHILDREN
WITH AUTISM: EXPERT RECOMMENDATIONS
• Screen with BMI at all visits starting at age 2
Screen all • Accommodations: leave shoes on, hold favorite object, parents on scale, vitals at
children the end, visual schedules
• Raise the topic of obesity prevention and intervention
Discuss • Take a positive, health oriented approach (nonjudgmental,
concerns nonstigmatizing language, positive role model)

•Same history (dietary, screen time and physical activity), physical exam or lab
Assess workup in children with ASD as other children
• Think selective eating, food reinforcers, opportunities for physical activity
overweight/obesity
• Medical conditions: sleep, GI conditions
Assess for ASD associated
risk factors and health • Psychiatric/behavioral conditions: ADHD, anxiety
conditions • Psychotropic medications: second generation
antipsychoticsteam- Occupational/speech/physical/recreation therapist, behavioralist
• Interdisciplinary
Staged, • Non-edible reinforcers
interdisciplinary • Eating and/or physical activity goals in IEP; refer to adaptive recreation programs
• Medications to counteract the effects of second generation antipsychotics if
treatment appropriate
Curtin C, Hyman SL, Boas DD, et al. Weight Management in Primary Care for Children With
Autism: Expert Recommendations. Pediatrics. 2020;145(Suppl 1):S126-S139.
 EPILEPSY IN CHILDREN WITH
ASD
Prevalence: Characteristics:
• Higher risk of seizures/epilepsy, 6-23% • No predominant seizure type
• Increased risk in those with co- • Children with ASD and epilepsy
occurring ID and in females
• Two age peaks for epilepsy in
are more likely to have
children with ASD, early childhood behavioral problems
and adolescence

Workup: Treatment:
• EEG in asymptomatic children • Factors involved in choosing
with ASD not recommended anti- epileptic medications:
• Higher percentage of • The type of seizures
• The presence of associated
electroencephalographic medical and psychiatric
abnormalities without conditions
clinical seizures • The preparation of the medication
• Side effect profile
Jeste SS, Tuchman R. Autism spectrum disorder and epilepsy: two sides of the same coin? J Child Neurol. 2015;30(14): 1963–1971
El Achkar CM, Spence SJ. Clinical characteristics of children and young adults with co-occurring autism spectrum disorder and epilepsy. Epilepsy Behav.
2015;47:183-190
© U N I V E R S I T Y OF U T A H H E A L T H
CO-OCCURRING BEHAVIORAL/PSYCHIATRIC
CONDITIONS

AS
D

© U N I V E R S I T Y OF U T A H H E A L T H
CO-OCCURRING BEHAVIORAL/PSYCHIATRIC
CONDITIONS

ADHD Depression

AS
D Mood
Anxiety disorder

© U N I V E R S I T Y OF U T A H H E A L T H
 ADHD IN CHILDREN WITH
ASD
Prevalence: Characteristics:
• Co-occurs in 41% to 78% of children • May further
with ASD compromise social skills
• Genetic overlap between ASD • May further limit
and ADHD opportunities for
community
participation
Workup: • May exacerbate
• Clinical interview sleep problems
• Questionnaires
• Language/educational
evaluations provide Treatment:
context • Maximize behavioral
and educational
• Evaluate for insomnia or
REFERENCES???? supports
other medical conditions • Same medications
• Evaluate for anxiety, that are used for
mood disorders Mahajan R, Bernal MP, Panzer R, et al. Clinical practice pathways forADHD
evaluation andin medication
children choice for

without ASD
attention- deficit/hyperactivity disorder symptoms iautism pectrum disorders. Pediatrics 2012; 130 Suppl 2: S125-38
Nisonger Child Rating Form - https://nisonger.osu.edu/nisonger-child-behavior-rating-form/

© U N I V E R S I T Y OF U T A H H E A L T H
 ADHD IN CHILDREN WITH ASD -
MEDICATIONS
Stimulants
Support:
•Moderate evidence for short acting methylphenidate
• Methylphenidate Caution: untreated anxiety/mood disorder,
• Mixed amphetamine salts underweight/selective eating, younger age, intellectual
disability,

Posey DJ, Aman MG, Arnold LE, et al; Research Units on Pediatric Psychopharmacology Autism Network. Randomized, controlled, crossover
trial of methylphenidate in pervasive developmental disorders with hyperactivity. Arch Gen Psychiatry. 2005;62(11):1266–1274
Scahill L, McCracken JT, King BH, et al. Extended-Release Guanfacine for Hyperactivity in Children With Autism Spectrum Disorder. Am J Psychiatry 2015;
172(12): 1197-206.
Handen BL, Aman MG, Arnold LE, et al. Atomoxetine, Parent Training, and Their Combination in Children With Autism Spectrum Disorder and
Attention- Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry 2015; 54(11): 905-15.
Mahajan R, Bernal MP, Panzer R, et al. Clinical practice pathways for evaluation and medication choice for attention-deficit/hyperactivity disorder
symptoms in autism spectrum disorders. Pediatrics 2012; 130 Suppl 2: S125-38.

© U N I V E R S I T Y OF U T A H H E A L T H
 ADHD IN CHILDREN WITH ASD -
MEDICATIONS

Support:
Alpha Agonist • 2015 RCT - extended release guanfacine
• Guanfacine effective in reducing hyperactivity/impulsivity and
• Clonidine distractibility
• Caution: Weak evidence for clonidine, may be less
effective for inattentiveness

Posey DJ, Aman MG, Arnold LE, et al; Research Units on Pediatric Psychopharmacology Autism Network. Randomized, controlled, crossover
trial of methylphenidate in pervasive developmental disorders with hyperactivity. Arch Gen Psychiatry. 2005;62(11):1266–1274
Scahill L, McCracken JT, King BH, et al. Extended-Release Guanfacine for Hyperactivity in Children With Autism Spectrum Disorder. Am J Psychiatry 2015;
172(12): 1197-206.
Handen BL, Aman MG, Arnold LE, et al. Atomoxetine, Parent Training, and Their Combination in Children With Autism Spectrum Disorder and
Attention- Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry 2015; 54(11): 905-15.
Mahajan R, Bernal MP, Panzer R, et al. Clinical practice pathways for evaluation and medication choice for attention-deficit/hyperactivity disorder
symptoms in autism spectrum disorders. Pediatrics 2012; 130 Suppl 2: S125-38.

© U N I V E R S I T Y OF U T A H H E A L T H
 ADHD IN CHILDREN WITH ASD -
MEDICATIONS

Norepinephrine Support:
• Modest evidence for hyperactivity, impulsivity, inattentiveness
Reuptake Inhibitor • consider when co-occurring anxiety
• Atomoxetine

Posey DJ, Aman MG, Arnold LE, et al; Research Units on Pediatric Psychopharmacology Autism Network. Randomized, controlled, crossover
trial of methylphenidate in pervasive developmental disorders with hyperactivity. Arch Gen Psychiatry. 2005;62(11):1266–1274
Scahill L, McCracken JT, King BH, et al. Extended-Release Guanfacine for Hyperactivity in Children With Autism Spectrum Disorder. Am J Psychiatry 2015;
172(12): 1197-206.
Handen BL, Aman MG, Arnold LE, et al. Atomoxetine, Parent Training, and Their Combination in Children With Autism Spectrum Disorder and
Attention- Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry 2015; 54(11): 905-15.
Mahajan R, Bernal MP, Panzer R, et al. Clinical practice pathways for evaluation and medication choice for attention-deficit/hyperactivity disorder
symptoms in autism spectrum disorders. Pediatrics 2012; 130 Suppl 2: S125-38.

© U N I V E R S I T Y OF U T A H H E A L T H
 ADHD IN CHILDREN WITH ASD -
MEDICATIONS
Stimulants
Support:
•Moderate evidence for short acting methylphenidate
• Methylphenidate Caution: untreated anxiety/mood disorder,
• Mixed amphetamine salts underweight/selective eating, younger age, intellectual
disability,
Support:
Alpha Agonist • 2015 RCT - extended release guanfacine
• Guanfacine effective in reducing hyperactivity/impulsivity and
• Clonidine distractibility
• Caution: Weak evidence for clonidine, may be less
effective for inattentiveness
Norepinephrine Support:
• Modest evidence for hyperactivity, impulsivity, inattentiveness
Reuptake Inhibitor • consider when co-occurring anxiety
• Atomoxetine

Posey DJ, Aman MG, Arnold LE, et al; Research Units on Pediatric Psychopharmacology Autism Network. Randomized, controlled, crossover
Considerations: trial of methylphenidate in pervasive developmental disorders with hyperactivity. Arch Gen Psychiatry. 2005;62(11):1266–1274

• Lower efficacy Scahill L, McCracken JT, King BH, et al. Extended-Release Guanfacine for Hyperactivity in Children With Autism Spectrum Disorder. Am J Psychiatry 2015;
172(12): 1197-206.

• Side effects more common Handen BL, Aman MG, Arnold LE, et al. Atomoxetine, Parent Training, and Their Combination in Children With Autism Spectrum Disorder and
Attention- Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry 2015; 54(11): 905-15.
Mahajan R, Bernal MP, Panzer R, et al. Clinical practice pathways for evaluation and medication choice for attention-deficit/hyperactivity disorder
symptoms in autism spectrum disorders. Pediatrics 2012; 130 Suppl 2: S125-38.

© U N I V E R S I T Y OF U T A H H E A L T H
 ANXIETY IN CHILDREN WITH
ASD
Prevalence: Workup:
• Information from multiple sources and
• 40% to 66% of school- aged
children and adults with ASD
• ASD and anxiety - common
genetic factors and/or altered
neurophysiologic responses to
stress
Treatment:
• Interdisciplinary, define goals
• Behavioral plans that emphasize
predictable routines and
structure
• CBT in school aged children
with typical-range cognition
• Medications –same as those
without ASD
Vasa RA, Mazurek MO, Mahajan R, et al. Assessment and Treatment of Anxiety in Youth With
Spectrum
Autism
looking at the behavioral manifestations
related to context
• May manifest as behavioral outbursts
or tantrums
• Think about antecedents
• Transitions
• Changes in routine
• Increased fear, phobias, repetitive
behavior, perseverations about upcoming
events
• Consider the language demands of the
environment, academic expectations,
social demands
• Anxiety measures– interpret with caution
• Consider other conditions, medications
Disorders. Pediatrics 2016; 137 Suppl 2: S115-23.
© U N I V E R S I T Y OF U T A H H E A L T H
ANXIETY IN CHILDREN WITH ASD -
MEDICATIONS
SSRIs • Evidence supporting the use of SSRIs in children and
• Sertraline youth with anxiety in the general population, but limited
• Fluoxetine information in ASD
• Citalopram • Side effect: activation
• Escitalopram • Dosing: start low, go slow

Vasa RA, Mazurek MO, Mahajan R, et al. Assessment and Treatment of Anxiety in Youth With Autism Spectrum
Disorders.
Pediatrics 2016; 137 Suppl 2: S115-23.
ANXIETY IN CHILDREN WITH ASD -
MEDICATIONS

Alpha Agonist • Addresses symptoms of behavioral dysregulation

• Guanfacine
• Limited data on use for anxiety in children with ASD
• Clonidine

Vasa RA, Mazurek MO, Mahajan R, et al. Assessment and Treatment of Anxiety in Youth With Autism Spectrum
Disorders.
Pediatrics 2016; 137 Suppl 2: S115-23.
ANXIETY IN CHILDREN WITH ASD -
MEDICATIONS

Situational anxiety
• Lorazepam, 0.25-0.5mg prn
• Propranolol 5-10mg prn
• Not based on data, based on clinical consensus

Vasa RA, Mazurek MO, Mahajan R, et al. Assessment and Treatment of Anxiety in Youth With Autism Spectrum
Disorders.
Pediatrics 2016; 137 Suppl 2: S115-23.
 IRRITABILITY/AGGRESSION/SELF-INJURIOUS
BEHAVIOR IN CHILDREN WITH ASD
Prevalence: Consequences:
• 25-68% • Largest source of stress for caregivers
• Associated with younger age, • Leading cause of residential placement
intellectual disability, insomnia, epilepsy, • Fewer opportunities for community
gastrointestinal, internalizing and involvement and independent
attentional problems functioning
• Higher risk for psychotropic
Workup: medication, hospitalization
• Safety
• Co-occurring medical conditions
Treatment:
• Individualized, interdisciplinary
• Functional communication • Maximize behavioral and
• Caregiver/family stressors educational supports
• Maladaptive reinforcement patterns • Family support
• Co-occurring psychiatric conditions • Consider psychotropic medications

Hill AP, Zuckerman KE, Hagen AD, et al. Aggressive behavior problems in children with autism spectrum disorders: prevalence and correlates in a large
clinical sample. Res Autism Spectr Disord. 2014;8(9):1121–1133
McGuire K, Fung LK, Hagopian L, et al. Irritability and Problem Behavior in Autism Spectrum Disorder: A Practice Pathway for Pediatric Primary Care.
2016; 137 Suppl 2: S136-
Pediatrics
48. © U N I V E R S I T Y OF U T A H H E A L T H
 IRRITABILITY/AGGRESSION IN CHILDREN WITH
ASD – PSYCHOTROPIC MEDICATIONS
FDA approved medications: Risperidone and Aripiprazole
• Strongest evidence in reducing Aberrant Behavior Checklist
Irritability/Aggression Irritability Subscale (ABC-I) scores
• Adverse effects: sedation, weight gain, extrapyramidal symptoms
(tremor, dyskinesia, akathisia), urinary retention, constipation,
insulin resistance, dyslipidemia, hyperprolactinemia, QTc
prolongation
• Need for laboratory monitoring, close follow up

McGuire K, Fung LK, Hagopian L, et al. Irritability and Problem Behavior in Autism Spectrum
Disorder: A Practice Pathway for Pediatric Primary Care. Pediatrics 2016; 137 Suppl 2: S136-
48.
 IRRITABILITY/AGGRESSION IN CHILDREN WITH
ASD – PSYCHOTROPIC MEDICATIONS
FDA approved medications: Risperidone and Aripiprazole
• Strongest evidence in reducing Aberrant Behavior Checklist
Irritability/Aggression Irritability Subscale (ABC-I) scores
• Adverse effects: sedation, weight gain, extrapyramidal symptoms
(tremor, dyskinesia, akathisia), urinary retention, constipation,
insulin resistance, dyslipidemia, hyperprolactinemia, QTc
prolongation
Before • Need for laboratory monitoring, close follow up
: Identified and treated co-occurring medical conditions that exacerbate the
behavior
– e.g. sleep, constipation, pain
Identified antecedents/consequences and have a behavioral plan in place
– e.g. functional behavioral analysis
Identified and treated co-occurring psychiatric conditions
– e.g. anxiety, hyperactivity
Obtained
Reviewed family support,
potential addressed
risks with with caregiver stress
McGuire K, Fung LK, Hagopian L, et al. Irritability and Problem Behavior in Autism Spectrum
family Disorder: A Practice Pathway for Pediatric Primary Care. Pediatrics 2016; 137 Suppl 2: S136-
48.
© U N I V E R S I T Y OF U T A H H E A L T H
 WANDERING/ELOPEMEN
T
Prevalence:
• Nearly half of children with ASD
have wandered away from the
safety of a caregiver
• Half become lost and many
with near misses (drowning and
traffic accidents)
• About 25 % frequently wander
• Increased with autism severity
• Often goal directed
History:
• Include in anticipatory guidance
• Only 1/3 of parents reported
receiving any counseling about
wandering (10% by
pediatrician)
• Non-judgmental
• Preventive measures taken
• Identification
• Swim lessons
Considerations:
• Great source of stress for parents
• Affects community participation
Prevention:
• Door/window locks/alarms
• Fenced backyard
• Wandering resources at:
http://awaare.nationalautismassociation.org/
(Big Red Safety Box)
• Behavioral interventions
• Identification
• Swim lessons
• Electronic tracking devices
Anderson C, Law JK, Daniels A, et al. Occurrence and family impact of elopement in children with
autism spectrum disorders. Pediatrics 2012; 130(5): 870-7.
McLaughlin L, Keim SA, Adesman A. Wandering by Children with Autism Spectrum Disorder: Key Clinical
Factors and the Role of Schools and Pediatricians. J Dev Behav Pediatr 2018; 39(7): 538-46.
Call NA, Alvarez JP, Simmons CA, Lomas Mevers JE, Scheithauer MC. Clinical outcomes of behavioral
treatments for elopement in individuals with autism spectrum disorder and other developmental disabilities.
Autism 2017; 21(3): 375-9.
McLaughlin L, Rapoport E, Keim SA, Adesman A. Wandering by Children with Autism Spectrum Disorders: Impact
of Electronic Tracking Devices on Elopement Behavior and Quality of Life. J Dev Behav Pediatr 2020; 41(7): 513-21.
© U N I V E R S I T Y OF U T A H H E A L T H
 CHANGE YOU MAY WISH TO MAKE IN YOUR
PRACTICE
1. Discuss the causes of autism and offer appropriate
medical work up for children with autism.
2. Learn about evidence based interventions in your
community and how to refer families.
3. Identify a quality improvement project to make your
practice more autism friendly.
4. Screen children with autism for common co-
occurring conditions
5. Ask about integrative, complementary and
alternative therapies.
6. Look up your state’s Family-to-Family Health
Information Center or Family Voices Affiliate.

© U N I V E R S I T Y OF U T A H H E A L T H
REFERENCE
LIST
• Hyman SL, Levy SE, Myers SM, Council On Children With Disabilities SOD, Behavioral P. Identification, Evaluation, and
Management of Children With Autism Spectrum Disorder .
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• 4
Lipkin PH, Okamoto J; Council on Children with Disabilities; Council on School Health. The Individuals With Disabilities Education Act
• (IDEA) for children with special educational needs. Pediatrics. 2015;136(6). Available at: www.pediatrics.org/cgi/content/full/
136/6/e1650
• Adams RC, Levy SE, Council On Children With D. Shared Decision-Making and Children With Disabilities: Pathways to Consensus.
Pediatrics
2017; 139(6).
• Malow BA, Byars K, Johnson K, et al; Sleep Committee of the Autism Treatment Network. A practice pathway for the identification,
evaluation, and management of insomnia in children and adolescents with autism spectrum disorders. Pediatrics. 2012;130(suppl
• 2):S106– S124.
Buie T, Fuchs GJ, 3rd, Furuta GT, et al. Recommendations for evaluation and treatment of common gastrointestinal problems in
• children with ASDs. Pediatrics 2010; 125 Suppl 1: S19-29.
Furuta GT, Williams K, Kooros K, et al. Management of constipation in children and adolescents with autism spectrum disorders.
• Pediatrics.
2012;130 Suppl 2:S98-S105.
• Curtin C, Hyman SL, Boas DD, et al. Weight Management in Primary Care for Children With Autism: Expert Recommendations.
Pediatrics.
2020;145(Suppl 1):S126-S139.
•
Mahajan R, Bernal MP, Panzer R, et al. Clinical practice pathways for evaluation and medication choice for
attention- deficit/hyperactivity disorder symptoms in autism spectrum disorders. Pediatrics 2012; 130 Suppl 2: S125-38.
•
Vasa RA, Mazurek MO, Mahajan R, et al. Assessment and Treatment of Anxiety in Youth With Autism Spectrum Disorders. Pediatrics
2016; 137 Suppl 2: S115-23.
McGuire K, Fung LK, Hagopian L, et al. Irritability and Problem Behavior in Autism Spectrum Disorder: A Practice Pathway for
Pediatric Primary Care. Pediatrics 2016; 137 Suppl 2: S136-48.
Akins RS, Angkustsiri K, Hansen RL. Complementary and alternative medicine in autism: an evidence-based approach to negotiating
safe and efficacious interventions with families. Neurotherapeutics. 2010;7(3):307-319. © U N I V E R S I T Y OF U T A H H E A L T H
RESOURCE
S
• Hyman SL, Levy SE, Myers SM, Council On Children With Disabilities SOD, Behavioral P. Identification, Evaluation,
and Management of Children With Autism Spectrum Disorder. Pediatrics. Jan 2020;145(1)doi:10.1542/peds.2019-
• 3447
• Boston Medical Center, Autism Friendly Inititative: https://www.bmc.org/visiting-us/autism-friendly-initiative
AAP Pedialink online course: Identifying and Caring for Children with Autism Spectrum Disorder: A Course for Pediatric
Clinicians - https://shop.aap.org/identifying-and-caring-for-children-with-autism-spectrum-disorder-a-course-for-pediatric-
 clinicians/
AAP Pediatric Collections: Autism Spectrum Disorder - https://shop.aap.org/pediatric-collections-autism-
 spectrum- disorder-paperback/
Autism Speaks ATN/AIR-P Strategies to Improve Sleep in Children with Autism:
 https://www.autismspeaks.org/tool- kit/atnair-p-strategies-improve-sleep-children-autism
 Autistic Self Advocacy Network - https://autisticadvocacy.org/
Autism Speaks - ATN/AIR-P Guide to Managing Constipation in Children,
 https://www.autismspeaks.org/tool-kit/atnair-p- guide-managing-constipation-children
 National Center for Complementary and Integrative Health -
 https://www.nccih.nih.gov/health/autism Family Voices - https://familyvoices.org/
Autism - Caring for Children With Autism Spectrum Disorders: A Practical Resource Toolkit for Clinicians, 3rd
Edition - https://shop.aap.org/autism-caring-for-children-with-autism-spectrum-disorders-a-practical-resource-
• toolkit-for- clini/?gclid=EAIaIQobChMIu-Ty1rr68QIVqf_ICh1oigREEAAYASAAEgI35_D_BwE
• ECHO Autism: https://echoautism.org/
• National Autism Association – Wandering resources –
• http://awaare.nationalautismassociation.org/ Autism for Science in Autism Treatment -
https://asatonline.org/
Nisonger Child Behavior Rating Form - https://nisonger.osu.edu/nisonger-child-behavior-rating-
form/ © U N I V E R S I T Y OF U T A H H E A L T H
© U N I V E R S I T Y OF U T A H H E A L T H