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Antibiotics have a role in PANS even with no infection
SAN FRANCISCO – Antibiotics might help in pediatric acute-onset neuropsychiatric syndrome (PANS) even if there’s no apparent infection, according to Kiki Chang, MD, director of PANS research at Stanford (Calif.) University.
The first step at Stanford is to look for an active infection, and knock it out with antibiotics. Dr. Chang has seen remarkable turnarounds in some of those cases, but even if there’s no infection, “we still do use antibiotics.” There are positive data, “although not a lot,” indicating that they can help. Some kids even seem to need to be on long-term antibiotics, and flair if taken off long after infections should have been cleared.
“We don’t know what’s going on. We try to stop antibiotics if we can; if patients relapse, we think the benefit [of ongoing treatment] outweighs the risks. Some kids just have to be on antibiotics for a long time, and that’s an issue.” Perhaps it has something to do with the anti-inflammatory properties of antibiotics like azithromycin and amoxicillin, or there might be a lingering infection, he said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
PANS is a recently coined term for the sudden onset of obsessive compulsive disorder (OCD) within a few days of an infection, metabolic disturbance, or other inflammatory insult. Anxiety, mood problems, and tics are common. There might be severe food restriction – only eating white foods, for instance – that are not related to body image.
PANS broadened the concept of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), which was first described in 1998, although it’s been known for generations that acute streptococcus infections can lead to abrupt psychiatric symptoms.
PANS is the topic of ongoing investigation, and Dr. Chang and many others are working to define the syndrome and its treatment, and trying especially to determine how PANS differs from typical OCD and other problems with more insidious onset. The idea is that inflammation in the patient’s brain, whatever the source, triggers an OCD mechanism in susceptible patients. As a concept, “we believe it’s true,” he said.
For now, it’s best to refer suspected cases to one of several academic PANS programs in the United States, as diagnosis and treatment isn’t ready for general practice, he said.
If more than antibiotics are needed, Stanford considers targeting inflammation. Some children respond to easy options such as ibuprofen. Dr. Chang has seen some helped with prednisone, but treatment is tricky. There might be an occult infection, and PANS can present with psychiatric issues that prednisone can make worse, including depression and mania. Intravenous immunoglobulin is another of the many options, “but we really need about four treatments” to see if it helps.
Cognitive behavioral therapy and family support also helps. As for psychotropic medication, “we often use them, but they rarely take away the acute symptoms,” and PANS children seem especially sensitive to side effects. “I’ve seen many of them become manic on SSRIs. I’ve seen some of them have very strong [extrapyramidal symptoms] with atypical antipsychotics. You have to be very careful; we don’t have any good studies” of psychiatric drugs in this population, he said.
At the moment, PANS seems to be more common in boys than girls, and most patients have a relapsing/remitting course and a family history of autoimmune disease. Suicidal and homicidal ideation can be part of the condition.
Dr. Chang believes PANS could be part of the overall increase in autoimmune disease and psychiatric disorders in children over the past few decades.
“We have more kids who have special needs than ever before,” large, objective increases in bipolar, autism, and other psychiatric problems, as well as increases in psoriasis, nut allergies, and other autoimmune issues. “What causes it is harder to say, but there has been a change for sure in kids and their immune system development that does affect the brain, and has probably led to more neuropsychiatric disturbances,” he said.
“No one talks about it. Everyone thinks that it’s some sort of pharmaceutical industry conspiracy” to sell more drugs by increasing scrutiny of children. “I think it’s caused by something in the environment interacting with genetics,” whether it’s infections, toxins, or something else. “We don’t know. Any kind of inflammation can be a trigger” and “we know inflammation” is key to “many psychiatric symptoms. I do think there’s something going on with kids over the last 30 years,” he said.
Dr. Chang is a consultant for and/or has received research support from Bristol-Myers Squibb, Lilly, Merck, GlaxoSmithKline, and other companies.
SAN FRANCISCO – Antibiotics might help in pediatric acute-onset neuropsychiatric syndrome (PANS) even if there’s no apparent infection, according to Kiki Chang, MD, director of PANS research at Stanford (Calif.) University.
The first step at Stanford is to look for an active infection, and knock it out with antibiotics. Dr. Chang has seen remarkable turnarounds in some of those cases, but even if there’s no infection, “we still do use antibiotics.” There are positive data, “although not a lot,” indicating that they can help. Some kids even seem to need to be on long-term antibiotics, and flair if taken off long after infections should have been cleared.
“We don’t know what’s going on. We try to stop antibiotics if we can; if patients relapse, we think the benefit [of ongoing treatment] outweighs the risks. Some kids just have to be on antibiotics for a long time, and that’s an issue.” Perhaps it has something to do with the anti-inflammatory properties of antibiotics like azithromycin and amoxicillin, or there might be a lingering infection, he said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
PANS is a recently coined term for the sudden onset of obsessive compulsive disorder (OCD) within a few days of an infection, metabolic disturbance, or other inflammatory insult. Anxiety, mood problems, and tics are common. There might be severe food restriction – only eating white foods, for instance – that are not related to body image.
PANS broadened the concept of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), which was first described in 1998, although it’s been known for generations that acute streptococcus infections can lead to abrupt psychiatric symptoms.
PANS is the topic of ongoing investigation, and Dr. Chang and many others are working to define the syndrome and its treatment, and trying especially to determine how PANS differs from typical OCD and other problems with more insidious onset. The idea is that inflammation in the patient’s brain, whatever the source, triggers an OCD mechanism in susceptible patients. As a concept, “we believe it’s true,” he said.
For now, it’s best to refer suspected cases to one of several academic PANS programs in the United States, as diagnosis and treatment isn’t ready for general practice, he said.
If more than antibiotics are needed, Stanford considers targeting inflammation. Some children respond to easy options such as ibuprofen. Dr. Chang has seen some helped with prednisone, but treatment is tricky. There might be an occult infection, and PANS can present with psychiatric issues that prednisone can make worse, including depression and mania. Intravenous immunoglobulin is another of the many options, “but we really need about four treatments” to see if it helps.
Cognitive behavioral therapy and family support also helps. As for psychotropic medication, “we often use them, but they rarely take away the acute symptoms,” and PANS children seem especially sensitive to side effects. “I’ve seen many of them become manic on SSRIs. I’ve seen some of them have very strong [extrapyramidal symptoms] with atypical antipsychotics. You have to be very careful; we don’t have any good studies” of psychiatric drugs in this population, he said.
At the moment, PANS seems to be more common in boys than girls, and most patients have a relapsing/remitting course and a family history of autoimmune disease. Suicidal and homicidal ideation can be part of the condition.
Dr. Chang believes PANS could be part of the overall increase in autoimmune disease and psychiatric disorders in children over the past few decades.
“We have more kids who have special needs than ever before,” large, objective increases in bipolar, autism, and other psychiatric problems, as well as increases in psoriasis, nut allergies, and other autoimmune issues. “What causes it is harder to say, but there has been a change for sure in kids and their immune system development that does affect the brain, and has probably led to more neuropsychiatric disturbances,” he said.
“No one talks about it. Everyone thinks that it’s some sort of pharmaceutical industry conspiracy” to sell more drugs by increasing scrutiny of children. “I think it’s caused by something in the environment interacting with genetics,” whether it’s infections, toxins, or something else. “We don’t know. Any kind of inflammation can be a trigger” and “we know inflammation” is key to “many psychiatric symptoms. I do think there’s something going on with kids over the last 30 years,” he said.
Dr. Chang is a consultant for and/or has received research support from Bristol-Myers Squibb, Lilly, Merck, GlaxoSmithKline, and other companies.
SAN FRANCISCO – Antibiotics might help in pediatric acute-onset neuropsychiatric syndrome (PANS) even if there’s no apparent infection, according to Kiki Chang, MD, director of PANS research at Stanford (Calif.) University.
The first step at Stanford is to look for an active infection, and knock it out with antibiotics. Dr. Chang has seen remarkable turnarounds in some of those cases, but even if there’s no infection, “we still do use antibiotics.” There are positive data, “although not a lot,” indicating that they can help. Some kids even seem to need to be on long-term antibiotics, and flair if taken off long after infections should have been cleared.
“We don’t know what’s going on. We try to stop antibiotics if we can; if patients relapse, we think the benefit [of ongoing treatment] outweighs the risks. Some kids just have to be on antibiotics for a long time, and that’s an issue.” Perhaps it has something to do with the anti-inflammatory properties of antibiotics like azithromycin and amoxicillin, or there might be a lingering infection, he said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
PANS is a recently coined term for the sudden onset of obsessive compulsive disorder (OCD) within a few days of an infection, metabolic disturbance, or other inflammatory insult. Anxiety, mood problems, and tics are common. There might be severe food restriction – only eating white foods, for instance – that are not related to body image.
PANS broadened the concept of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), which was first described in 1998, although it’s been known for generations that acute streptococcus infections can lead to abrupt psychiatric symptoms.
PANS is the topic of ongoing investigation, and Dr. Chang and many others are working to define the syndrome and its treatment, and trying especially to determine how PANS differs from typical OCD and other problems with more insidious onset. The idea is that inflammation in the patient’s brain, whatever the source, triggers an OCD mechanism in susceptible patients. As a concept, “we believe it’s true,” he said.
For now, it’s best to refer suspected cases to one of several academic PANS programs in the United States, as diagnosis and treatment isn’t ready for general practice, he said.
If more than antibiotics are needed, Stanford considers targeting inflammation. Some children respond to easy options such as ibuprofen. Dr. Chang has seen some helped with prednisone, but treatment is tricky. There might be an occult infection, and PANS can present with psychiatric issues that prednisone can make worse, including depression and mania. Intravenous immunoglobulin is another of the many options, “but we really need about four treatments” to see if it helps.
Cognitive behavioral therapy and family support also helps. As for psychotropic medication, “we often use them, but they rarely take away the acute symptoms,” and PANS children seem especially sensitive to side effects. “I’ve seen many of them become manic on SSRIs. I’ve seen some of them have very strong [extrapyramidal symptoms] with atypical antipsychotics. You have to be very careful; we don’t have any good studies” of psychiatric drugs in this population, he said.
At the moment, PANS seems to be more common in boys than girls, and most patients have a relapsing/remitting course and a family history of autoimmune disease. Suicidal and homicidal ideation can be part of the condition.
Dr. Chang believes PANS could be part of the overall increase in autoimmune disease and psychiatric disorders in children over the past few decades.
“We have more kids who have special needs than ever before,” large, objective increases in bipolar, autism, and other psychiatric problems, as well as increases in psoriasis, nut allergies, and other autoimmune issues. “What causes it is harder to say, but there has been a change for sure in kids and their immune system development that does affect the brain, and has probably led to more neuropsychiatric disturbances,” he said.
“No one talks about it. Everyone thinks that it’s some sort of pharmaceutical industry conspiracy” to sell more drugs by increasing scrutiny of children. “I think it’s caused by something in the environment interacting with genetics,” whether it’s infections, toxins, or something else. “We don’t know. Any kind of inflammation can be a trigger” and “we know inflammation” is key to “many psychiatric symptoms. I do think there’s something going on with kids over the last 30 years,” he said.
Dr. Chang is a consultant for and/or has received research support from Bristol-Myers Squibb, Lilly, Merck, GlaxoSmithKline, and other companies.
EXPERT ANALYSIS FROM THE PSYCHOPHARMACOLOGY UPDATE INSTITUTE
Children with psychotic illness aren’t treated soon enough
SAN FRANCISCO – Early detection and treatment of psychotic illness is critical in children, according to Devanand Manoli, MD, PhD, of the University of California, San Francisco.
“After the conversion to psychotic illness, one of the most important prognostic factors is the duration of untreated psychosis.” A longer duration is associated with a greater symptom burden and lower functioning, which have “significant prognostic implications,” but sometimes treatment doesn’t come for a year or more. “There are many patients out there not receiving treatment,” the pediatric psychiatrist said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
The impact of early treatment raises the question of what to do with those who seem to be at risk, but don’t meet criteria for formal diagnosis.
It’s tough to be sure who exactly is at risk. Signs and symptoms can be nonspecific in adolescents, including disorganized communication, suspiciousness, verbal memory deficiencies, and decline in social functioning.
It’s even a tougher call in younger children. Most who exhibit psychotic or psychoticlike symptoms do not have a true psychotic disorder. Loose associations and illogical thinking are fairly common in early childhood, and preschool children can have transient tactile, visual, and other hallucinations that are benign. If there does seem to be a problem, metabolic issues are the most likely culprit before the age of 6 or so.
Again, comprehensive early intervention – including reducing environmental stressors – helps with functioning, symptoms, and other issues even before a formal diagnosis. However, antipsychotics do not decrease the rate of conversion to psychotic illness in truly high-risk children; their use is for symptom management, Dr. Manoli said.
It’s important adolescents avoid cannabis; it’s become clear in recent years that marijuana increases the risk of conversion to schizophrenia and the risk of relapse. “It’s a very important thing to emphasize. Cannabis use is something to counsel against,” he said.
Atypicals seem to be about equally effective, so their selection mostly comes down to side effects and cost. An exception might be clozapine. “It’s a medication we are very resistant to prescribe” because of the need for aggressive neutrophil monitoring and other issues, “but in patients with acute psychotic symptoms, it can be very effective” in both treatment-naïve and treatment-resistant children and help with aggression, he said, noting also that it’s important to remember children are more sensitive than adults to akathisia and other extrapyramidal symptoms with antipsychotics.
In response to audience questions, Dr. Manoli said there isn’t really a need to monitor for prolactin elevations with atypical antipsychotics unless there are symptoms, such as inappropriate breast tissue or lactation. In those cases, augmentation with aripiprazole can normalize levels.
He also noted that he and his colleagues do order baseline and follow-up ECGs when prescribing ziprasidone; prolonged QTc interval is a concern, regardless of family cardiac history.
Dr. Manoli reported research funding from the Brain & Behavior Research Foundation, the One Mind Institute, the National Institutes of Health, and other sources.
SAN FRANCISCO – Early detection and treatment of psychotic illness is critical in children, according to Devanand Manoli, MD, PhD, of the University of California, San Francisco.
“After the conversion to psychotic illness, one of the most important prognostic factors is the duration of untreated psychosis.” A longer duration is associated with a greater symptom burden and lower functioning, which have “significant prognostic implications,” but sometimes treatment doesn’t come for a year or more. “There are many patients out there not receiving treatment,” the pediatric psychiatrist said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
The impact of early treatment raises the question of what to do with those who seem to be at risk, but don’t meet criteria for formal diagnosis.
It’s tough to be sure who exactly is at risk. Signs and symptoms can be nonspecific in adolescents, including disorganized communication, suspiciousness, verbal memory deficiencies, and decline in social functioning.
It’s even a tougher call in younger children. Most who exhibit psychotic or psychoticlike symptoms do not have a true psychotic disorder. Loose associations and illogical thinking are fairly common in early childhood, and preschool children can have transient tactile, visual, and other hallucinations that are benign. If there does seem to be a problem, metabolic issues are the most likely culprit before the age of 6 or so.
Again, comprehensive early intervention – including reducing environmental stressors – helps with functioning, symptoms, and other issues even before a formal diagnosis. However, antipsychotics do not decrease the rate of conversion to psychotic illness in truly high-risk children; their use is for symptom management, Dr. Manoli said.
It’s important adolescents avoid cannabis; it’s become clear in recent years that marijuana increases the risk of conversion to schizophrenia and the risk of relapse. “It’s a very important thing to emphasize. Cannabis use is something to counsel against,” he said.
Atypicals seem to be about equally effective, so their selection mostly comes down to side effects and cost. An exception might be clozapine. “It’s a medication we are very resistant to prescribe” because of the need for aggressive neutrophil monitoring and other issues, “but in patients with acute psychotic symptoms, it can be very effective” in both treatment-naïve and treatment-resistant children and help with aggression, he said, noting also that it’s important to remember children are more sensitive than adults to akathisia and other extrapyramidal symptoms with antipsychotics.
In response to audience questions, Dr. Manoli said there isn’t really a need to monitor for prolactin elevations with atypical antipsychotics unless there are symptoms, such as inappropriate breast tissue or lactation. In those cases, augmentation with aripiprazole can normalize levels.
He also noted that he and his colleagues do order baseline and follow-up ECGs when prescribing ziprasidone; prolonged QTc interval is a concern, regardless of family cardiac history.
Dr. Manoli reported research funding from the Brain & Behavior Research Foundation, the One Mind Institute, the National Institutes of Health, and other sources.
SAN FRANCISCO – Early detection and treatment of psychotic illness is critical in children, according to Devanand Manoli, MD, PhD, of the University of California, San Francisco.
“After the conversion to psychotic illness, one of the most important prognostic factors is the duration of untreated psychosis.” A longer duration is associated with a greater symptom burden and lower functioning, which have “significant prognostic implications,” but sometimes treatment doesn’t come for a year or more. “There are many patients out there not receiving treatment,” the pediatric psychiatrist said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
The impact of early treatment raises the question of what to do with those who seem to be at risk, but don’t meet criteria for formal diagnosis.
It’s tough to be sure who exactly is at risk. Signs and symptoms can be nonspecific in adolescents, including disorganized communication, suspiciousness, verbal memory deficiencies, and decline in social functioning.
It’s even a tougher call in younger children. Most who exhibit psychotic or psychoticlike symptoms do not have a true psychotic disorder. Loose associations and illogical thinking are fairly common in early childhood, and preschool children can have transient tactile, visual, and other hallucinations that are benign. If there does seem to be a problem, metabolic issues are the most likely culprit before the age of 6 or so.
Again, comprehensive early intervention – including reducing environmental stressors – helps with functioning, symptoms, and other issues even before a formal diagnosis. However, antipsychotics do not decrease the rate of conversion to psychotic illness in truly high-risk children; their use is for symptom management, Dr. Manoli said.
It’s important adolescents avoid cannabis; it’s become clear in recent years that marijuana increases the risk of conversion to schizophrenia and the risk of relapse. “It’s a very important thing to emphasize. Cannabis use is something to counsel against,” he said.
Atypicals seem to be about equally effective, so their selection mostly comes down to side effects and cost. An exception might be clozapine. “It’s a medication we are very resistant to prescribe” because of the need for aggressive neutrophil monitoring and other issues, “but in patients with acute psychotic symptoms, it can be very effective” in both treatment-naïve and treatment-resistant children and help with aggression, he said, noting also that it’s important to remember children are more sensitive than adults to akathisia and other extrapyramidal symptoms with antipsychotics.
In response to audience questions, Dr. Manoli said there isn’t really a need to monitor for prolactin elevations with atypical antipsychotics unless there are symptoms, such as inappropriate breast tissue or lactation. In those cases, augmentation with aripiprazole can normalize levels.
He also noted that he and his colleagues do order baseline and follow-up ECGs when prescribing ziprasidone; prolonged QTc interval is a concern, regardless of family cardiac history.
Dr. Manoli reported research funding from the Brain & Behavior Research Foundation, the One Mind Institute, the National Institutes of Health, and other sources.
EXPERT ANALYSIS FROM THE PSYCHOPHARMACOLOGY UPDATE INSTITUTE
Engage parents in treatment as part of family-based therapy for anorexia
SAN FRANCISCO – Parents have to stay level-headed if family-based therapy is going to work for anorexia nervosa, according to an expert on the technique, James Lock, MD, PhD, director of the Child and Adolescent Eating Disorder Program at Stanford (Calif.) University.
The idea of family-based therapy (FBT) is to guide parents to change behaviors – the patients’, but also their own – that undermine weight gain. Early on, the therapist has a meal with the family to observe dynamics that need to be addressed and encourage behaviors that help. It’s a nonauthoritarian approach, where the therapist helps families help themselves.
Heated emotion just opens the door to argument and resistance; patients aren’t rational when it comes to body image and eating, at least at first. Parents also have to learn not to be provoked by the child.
“You just have to ignore it. You don’t argue with the kids,” and “right now, ‘we love you’ just doesn’t go anywhere,” Dr. Lock said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
Instead, caregivers are simply supportive. The only messages that matter initially, when weight gain is critical, are along the lines of, “I know you need to eat this. You need to eat it.” Parents “need to support the behavior change and really be kind of neutral about everything else,” he said.
FBT is one of many therapeutic options for anorexia. It has a strong evidence base going back about 30 years. Dr. Lock and his colleagues have been involved in many of the more recent studies and reported a 12-month remission rate of 49% in one (Arch Gen Psychiatry. 2010 Oct; 67[10]:1025-32). There’s growing support for FBT in bulimia, as well.
The earliest goal is to engage the parents in treatment. They are complimented on what they are doing well and told not to blame themselves or their child for the illness. The seriousness of anorexia is also impressed upon the parents if they are in denial about the illness.
The family meal comes early, too. They’re stressful but necessary to learn what parents are trying to do to help and to coach them about what needs improvement. “You, as a therapist, need” to be at the meal and “join the family in their dilemmas,” Dr. Lock said.
Parents are responsible for weight restoration at first, but when steady weight gain occurs, they are taught to hand control of eating and weight back to the child. In time, therapists help with normal adolescent developmental issues and healthy family relationships.
There are maybe 20 sessions over 6-12 months, more or less depending on how it’s going; each one lasts an hour. Single-parent families seem to need more sessions, likely because there’s no spouse to share in the work. There are no meal plans in FBT, because meal plans “are not a normal way to eat. When you try to empower parents to make reasonable decisions about food, a 24-hour meal plan that the adolescent is aware of is just an opportunity for fighting over what it says,” Dr. Lock said.
Dr. Lock has coauthored a treatment manual on using FBT for anorexia.
SAN FRANCISCO – Parents have to stay level-headed if family-based therapy is going to work for anorexia nervosa, according to an expert on the technique, James Lock, MD, PhD, director of the Child and Adolescent Eating Disorder Program at Stanford (Calif.) University.
The idea of family-based therapy (FBT) is to guide parents to change behaviors – the patients’, but also their own – that undermine weight gain. Early on, the therapist has a meal with the family to observe dynamics that need to be addressed and encourage behaviors that help. It’s a nonauthoritarian approach, where the therapist helps families help themselves.
Heated emotion just opens the door to argument and resistance; patients aren’t rational when it comes to body image and eating, at least at first. Parents also have to learn not to be provoked by the child.
“You just have to ignore it. You don’t argue with the kids,” and “right now, ‘we love you’ just doesn’t go anywhere,” Dr. Lock said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
Instead, caregivers are simply supportive. The only messages that matter initially, when weight gain is critical, are along the lines of, “I know you need to eat this. You need to eat it.” Parents “need to support the behavior change and really be kind of neutral about everything else,” he said.
FBT is one of many therapeutic options for anorexia. It has a strong evidence base going back about 30 years. Dr. Lock and his colleagues have been involved in many of the more recent studies and reported a 12-month remission rate of 49% in one (Arch Gen Psychiatry. 2010 Oct; 67[10]:1025-32). There’s growing support for FBT in bulimia, as well.
The earliest goal is to engage the parents in treatment. They are complimented on what they are doing well and told not to blame themselves or their child for the illness. The seriousness of anorexia is also impressed upon the parents if they are in denial about the illness.
The family meal comes early, too. They’re stressful but necessary to learn what parents are trying to do to help and to coach them about what needs improvement. “You, as a therapist, need” to be at the meal and “join the family in their dilemmas,” Dr. Lock said.
Parents are responsible for weight restoration at first, but when steady weight gain occurs, they are taught to hand control of eating and weight back to the child. In time, therapists help with normal adolescent developmental issues and healthy family relationships.
There are maybe 20 sessions over 6-12 months, more or less depending on how it’s going; each one lasts an hour. Single-parent families seem to need more sessions, likely because there’s no spouse to share in the work. There are no meal plans in FBT, because meal plans “are not a normal way to eat. When you try to empower parents to make reasonable decisions about food, a 24-hour meal plan that the adolescent is aware of is just an opportunity for fighting over what it says,” Dr. Lock said.
Dr. Lock has coauthored a treatment manual on using FBT for anorexia.
SAN FRANCISCO – Parents have to stay level-headed if family-based therapy is going to work for anorexia nervosa, according to an expert on the technique, James Lock, MD, PhD, director of the Child and Adolescent Eating Disorder Program at Stanford (Calif.) University.
The idea of family-based therapy (FBT) is to guide parents to change behaviors – the patients’, but also their own – that undermine weight gain. Early on, the therapist has a meal with the family to observe dynamics that need to be addressed and encourage behaviors that help. It’s a nonauthoritarian approach, where the therapist helps families help themselves.
Heated emotion just opens the door to argument and resistance; patients aren’t rational when it comes to body image and eating, at least at first. Parents also have to learn not to be provoked by the child.
“You just have to ignore it. You don’t argue with the kids,” and “right now, ‘we love you’ just doesn’t go anywhere,” Dr. Lock said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
Instead, caregivers are simply supportive. The only messages that matter initially, when weight gain is critical, are along the lines of, “I know you need to eat this. You need to eat it.” Parents “need to support the behavior change and really be kind of neutral about everything else,” he said.
FBT is one of many therapeutic options for anorexia. It has a strong evidence base going back about 30 years. Dr. Lock and his colleagues have been involved in many of the more recent studies and reported a 12-month remission rate of 49% in one (Arch Gen Psychiatry. 2010 Oct; 67[10]:1025-32). There’s growing support for FBT in bulimia, as well.
The earliest goal is to engage the parents in treatment. They are complimented on what they are doing well and told not to blame themselves or their child for the illness. The seriousness of anorexia is also impressed upon the parents if they are in denial about the illness.
The family meal comes early, too. They’re stressful but necessary to learn what parents are trying to do to help and to coach them about what needs improvement. “You, as a therapist, need” to be at the meal and “join the family in their dilemmas,” Dr. Lock said.
Parents are responsible for weight restoration at first, but when steady weight gain occurs, they are taught to hand control of eating and weight back to the child. In time, therapists help with normal adolescent developmental issues and healthy family relationships.
There are maybe 20 sessions over 6-12 months, more or less depending on how it’s going; each one lasts an hour. Single-parent families seem to need more sessions, likely because there’s no spouse to share in the work. There are no meal plans in FBT, because meal plans “are not a normal way to eat. When you try to empower parents to make reasonable decisions about food, a 24-hour meal plan that the adolescent is aware of is just an opportunity for fighting over what it says,” Dr. Lock said.
Dr. Lock has coauthored a treatment manual on using FBT for anorexia.
EXPERT ANALYSIS FROM THE PSYCHOPHARMACOLOGY UPDATE INSTITUTE
SSRI activation in children, adolescents often misdiagnosed as bipolar
SAN FRANCISCO – It’s not uncommon for children to arrive at the Western Psychiatric Institute and Clinic in Pittsburgh with selective serotonin reuptake inhibitor activation that was misdiagnosed as bipolar disorder, according to Boris Birmaher, MD.
“We get many kids into our clinic with a diagnosis of bipolar because of this, and they are not bipolar. You have to be careful,” he said during a talk about pediatric depression at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
SSRIs activate about 5%-10% of children. There might be sleep problems, fast speech, hyperactivity, agitation, aggression, and even suicidality, he said.
Younger children and those with autism or developmental disabilities are particularly at risk. Occasionally, a child might be a slow metabolizer so that even low SSRI doses cause problems. “Once in a blue moon,” Dr. Birmaher said he will screen for genetic cytochrome P450 deficiency, especially if a child doesn’t seem able to tolerate medications in general, not just psychiatric ones. He’s found a few slow metabolizers over the years.
Psychiatrists also have to be careful when children and adolescents are tagged as “treatment resistant.” It’s important to teach parents what treatment resistance would actually look like for their child, so they don’t jump to conclusions and misdirect therapy, he said.
For example, when a child has been prescribed an SSRI for anxiety, parents might come in and say it’s not helping, when in fact they’re concerned about homework not getting done and restlessness in class. “There’s no treatment resistance. You teach the parent how to measure improvement of anxiety” and tackle the ADHD if it’s truly a problem, said Dr. Birmaher, also professor of psychiatry at the University of Pittsburgh.
If there really is SSRI treatment resistance, he said he first ensures that a maximum dose of the drug has been tried, so long as it’s tolerated. If it doesn’t work after 4-6 weeks, he’ll switch to another SSRI or selective norepinephrine reuptake inhibitor, or combination treatment with, for instance, bupropion (Wellbutrin) or an atypical antipsychotic, which are particularly helpful for irritability, even in small doses. Atypicals seem to take the edge off, he said.
It’s trial and error, since there aren’t much data in children to guide treatment. “The only thing I highly recommend is to make one change at a time. Sometimes we see kids who’ve had two or three changes at the same time.” In those cases, he said, it’s impossible to know what to blame if there are side effects or what to credit if depression improves.
Dr. Birmaher said he had no pharmaceutical industry ties.
SAN FRANCISCO – It’s not uncommon for children to arrive at the Western Psychiatric Institute and Clinic in Pittsburgh with selective serotonin reuptake inhibitor activation that was misdiagnosed as bipolar disorder, according to Boris Birmaher, MD.
“We get many kids into our clinic with a diagnosis of bipolar because of this, and they are not bipolar. You have to be careful,” he said during a talk about pediatric depression at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
SSRIs activate about 5%-10% of children. There might be sleep problems, fast speech, hyperactivity, agitation, aggression, and even suicidality, he said.
Younger children and those with autism or developmental disabilities are particularly at risk. Occasionally, a child might be a slow metabolizer so that even low SSRI doses cause problems. “Once in a blue moon,” Dr. Birmaher said he will screen for genetic cytochrome P450 deficiency, especially if a child doesn’t seem able to tolerate medications in general, not just psychiatric ones. He’s found a few slow metabolizers over the years.
Psychiatrists also have to be careful when children and adolescents are tagged as “treatment resistant.” It’s important to teach parents what treatment resistance would actually look like for their child, so they don’t jump to conclusions and misdirect therapy, he said.
For example, when a child has been prescribed an SSRI for anxiety, parents might come in and say it’s not helping, when in fact they’re concerned about homework not getting done and restlessness in class. “There’s no treatment resistance. You teach the parent how to measure improvement of anxiety” and tackle the ADHD if it’s truly a problem, said Dr. Birmaher, also professor of psychiatry at the University of Pittsburgh.
If there really is SSRI treatment resistance, he said he first ensures that a maximum dose of the drug has been tried, so long as it’s tolerated. If it doesn’t work after 4-6 weeks, he’ll switch to another SSRI or selective norepinephrine reuptake inhibitor, or combination treatment with, for instance, bupropion (Wellbutrin) or an atypical antipsychotic, which are particularly helpful for irritability, even in small doses. Atypicals seem to take the edge off, he said.
It’s trial and error, since there aren’t much data in children to guide treatment. “The only thing I highly recommend is to make one change at a time. Sometimes we see kids who’ve had two or three changes at the same time.” In those cases, he said, it’s impossible to know what to blame if there are side effects or what to credit if depression improves.
Dr. Birmaher said he had no pharmaceutical industry ties.
SAN FRANCISCO – It’s not uncommon for children to arrive at the Western Psychiatric Institute and Clinic in Pittsburgh with selective serotonin reuptake inhibitor activation that was misdiagnosed as bipolar disorder, according to Boris Birmaher, MD.
“We get many kids into our clinic with a diagnosis of bipolar because of this, and they are not bipolar. You have to be careful,” he said during a talk about pediatric depression at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
SSRIs activate about 5%-10% of children. There might be sleep problems, fast speech, hyperactivity, agitation, aggression, and even suicidality, he said.
Younger children and those with autism or developmental disabilities are particularly at risk. Occasionally, a child might be a slow metabolizer so that even low SSRI doses cause problems. “Once in a blue moon,” Dr. Birmaher said he will screen for genetic cytochrome P450 deficiency, especially if a child doesn’t seem able to tolerate medications in general, not just psychiatric ones. He’s found a few slow metabolizers over the years.
Psychiatrists also have to be careful when children and adolescents are tagged as “treatment resistant.” It’s important to teach parents what treatment resistance would actually look like for their child, so they don’t jump to conclusions and misdirect therapy, he said.
For example, when a child has been prescribed an SSRI for anxiety, parents might come in and say it’s not helping, when in fact they’re concerned about homework not getting done and restlessness in class. “There’s no treatment resistance. You teach the parent how to measure improvement of anxiety” and tackle the ADHD if it’s truly a problem, said Dr. Birmaher, also professor of psychiatry at the University of Pittsburgh.
If there really is SSRI treatment resistance, he said he first ensures that a maximum dose of the drug has been tried, so long as it’s tolerated. If it doesn’t work after 4-6 weeks, he’ll switch to another SSRI or selective norepinephrine reuptake inhibitor, or combination treatment with, for instance, bupropion (Wellbutrin) or an atypical antipsychotic, which are particularly helpful for irritability, even in small doses. Atypicals seem to take the edge off, he said.
It’s trial and error, since there aren’t much data in children to guide treatment. “The only thing I highly recommend is to make one change at a time. Sometimes we see kids who’ve had two or three changes at the same time.” In those cases, he said, it’s impossible to know what to blame if there are side effects or what to credit if depression improves.
Dr. Birmaher said he had no pharmaceutical industry ties.
EXPERT ANALYSIS AT THE PSYCHOPHARMACOLOGY UPDATE INSTITUTE
Recreational marijuana use should not rule out ADHD stimulant treatment
SAN FRANCISCO – “If one is going to say ‘you need 6 months of abstinence from cannabis before I am going to treat your ADHD,’ that’s absurd. If [kids] are stoned all the time, no, but if it’s intermittent, it’s really not a factor,” according to James J. McGough, MD, director of the Attention Deficit Disorder Clinic at the University of California, Los Angeles.
There’s no evidence that ongoing stimulant treatment increases the risk of substance abuse, and “we must admit to ourselves that substance use among adolescents and young adults is normative. It happens,” even among well-adapted kids. “Think of your own past histories,” he said to an audience of psychiatrists and other medical professionals at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
“You have” to deal with substance abuse that’s ruining lives, but otherwise, “I’m comfortable giving a prescription under some circumstances even if I know [patients] are using drugs. It’s the extent and type of [drug use] that informs if we should prescribe or not,” said Dr. McGough, also a professor of clinical psychiatry at the university, but be careful to “really document what you’re doing.”
Misuse and diversion is mostly related to performance enhancement, especially at competitive universities, or when grades head south. Children and young adults in those situations, as well as smokers, drinkers, and those with conduct disorders, “are the ones you worry about.” If a Stanford medical school student at age 27 suddenly develops a horrible problem focusing, with no past ADHD history, “I’m a little suspicious,” he said, noting that people who malinger “tend to go off the scale in terms of endorsing symptoms.”
If misuse and abuse are a concern, extended-release stimulants, as well as nonstimulants, are better options than immediate-release formulations.
Audience members also were curious about alternative approaches for ADHD, but the news wasn’t very good.
For now, there’s no brain scan, test, or lab measurement that reliably detects ADHD. Even with neuropsychiatric testing, only half of children and adolescents will have executive-functioning deficits. The problem with computerized tests, meanwhile, is that a lot of children and adolescents with ADHD have no problem focusing on computer games, so they aren’t helpful for diagnosis.
“The gold standard for ADHD assessment remains a good interview,” and documenting DSM-5 criteria, he said.
As for alternative treatments, “what studies have shown is that if you are highly invested in the treatment and not blinded” to it, “you tend to think you do better. In good studies where they look at teachers who don’t know what’s going on, it doesn’t pan out,” he said. Metanalysis of neurofeedback hasn’t shown effect, nor have computer games to train focus; kids will get better at them with practice, but they haven’t been shown to improve ADHD.
The only exception is omega-3, but the effect size is barely measurable. “If you can get the kid so swallow those fish oil things, go for it, or they can eat salmon,” Dr. McGough said.
In short, medications remain the best option for treating the core symptoms of ADHD, first with stimulants then, as needed, nonstimulants.
But “you are not meeting your patients’ needs if you are only prescribing medications,” he said. Psychosocial education, family behavioral therapy, and school interventions – even things as simple as sitting toward the front of the class and having a little more time on tests – are critical for overall improvement.
It’s also important to let patients and families know that “they don’t have to be ashamed of this,” and the patients need to know why they are taking their medication, he said.
Too often, children are started on a low dose of medication and told to come back in a month. “That’s a waste of time, because it’s a whole month when the person is probably inadequately treated,” Dr. McGough said.
Instead, he has patients titrate up at first, with advice to cut back or stop and call if there are problems. The patient returns after 3 weeks, and the most effective, best-tolerated dose is selected for treatment.
Dr. McGough disclosed relationships with Purdue, Shire, Tris, Sunovion, NeuroSigma, and Neurovance.
SAN FRANCISCO – “If one is going to say ‘you need 6 months of abstinence from cannabis before I am going to treat your ADHD,’ that’s absurd. If [kids] are stoned all the time, no, but if it’s intermittent, it’s really not a factor,” according to James J. McGough, MD, director of the Attention Deficit Disorder Clinic at the University of California, Los Angeles.
There’s no evidence that ongoing stimulant treatment increases the risk of substance abuse, and “we must admit to ourselves that substance use among adolescents and young adults is normative. It happens,” even among well-adapted kids. “Think of your own past histories,” he said to an audience of psychiatrists and other medical professionals at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
“You have” to deal with substance abuse that’s ruining lives, but otherwise, “I’m comfortable giving a prescription under some circumstances even if I know [patients] are using drugs. It’s the extent and type of [drug use] that informs if we should prescribe or not,” said Dr. McGough, also a professor of clinical psychiatry at the university, but be careful to “really document what you’re doing.”
Misuse and diversion is mostly related to performance enhancement, especially at competitive universities, or when grades head south. Children and young adults in those situations, as well as smokers, drinkers, and those with conduct disorders, “are the ones you worry about.” If a Stanford medical school student at age 27 suddenly develops a horrible problem focusing, with no past ADHD history, “I’m a little suspicious,” he said, noting that people who malinger “tend to go off the scale in terms of endorsing symptoms.”
If misuse and abuse are a concern, extended-release stimulants, as well as nonstimulants, are better options than immediate-release formulations.
Audience members also were curious about alternative approaches for ADHD, but the news wasn’t very good.
For now, there’s no brain scan, test, or lab measurement that reliably detects ADHD. Even with neuropsychiatric testing, only half of children and adolescents will have executive-functioning deficits. The problem with computerized tests, meanwhile, is that a lot of children and adolescents with ADHD have no problem focusing on computer games, so they aren’t helpful for diagnosis.
“The gold standard for ADHD assessment remains a good interview,” and documenting DSM-5 criteria, he said.
As for alternative treatments, “what studies have shown is that if you are highly invested in the treatment and not blinded” to it, “you tend to think you do better. In good studies where they look at teachers who don’t know what’s going on, it doesn’t pan out,” he said. Metanalysis of neurofeedback hasn’t shown effect, nor have computer games to train focus; kids will get better at them with practice, but they haven’t been shown to improve ADHD.
The only exception is omega-3, but the effect size is barely measurable. “If you can get the kid so swallow those fish oil things, go for it, or they can eat salmon,” Dr. McGough said.
In short, medications remain the best option for treating the core symptoms of ADHD, first with stimulants then, as needed, nonstimulants.
But “you are not meeting your patients’ needs if you are only prescribing medications,” he said. Psychosocial education, family behavioral therapy, and school interventions – even things as simple as sitting toward the front of the class and having a little more time on tests – are critical for overall improvement.
It’s also important to let patients and families know that “they don’t have to be ashamed of this,” and the patients need to know why they are taking their medication, he said.
Too often, children are started on a low dose of medication and told to come back in a month. “That’s a waste of time, because it’s a whole month when the person is probably inadequately treated,” Dr. McGough said.
Instead, he has patients titrate up at first, with advice to cut back or stop and call if there are problems. The patient returns after 3 weeks, and the most effective, best-tolerated dose is selected for treatment.
Dr. McGough disclosed relationships with Purdue, Shire, Tris, Sunovion, NeuroSigma, and Neurovance.
SAN FRANCISCO – “If one is going to say ‘you need 6 months of abstinence from cannabis before I am going to treat your ADHD,’ that’s absurd. If [kids] are stoned all the time, no, but if it’s intermittent, it’s really not a factor,” according to James J. McGough, MD, director of the Attention Deficit Disorder Clinic at the University of California, Los Angeles.
There’s no evidence that ongoing stimulant treatment increases the risk of substance abuse, and “we must admit to ourselves that substance use among adolescents and young adults is normative. It happens,” even among well-adapted kids. “Think of your own past histories,” he said to an audience of psychiatrists and other medical professionals at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
“You have” to deal with substance abuse that’s ruining lives, but otherwise, “I’m comfortable giving a prescription under some circumstances even if I know [patients] are using drugs. It’s the extent and type of [drug use] that informs if we should prescribe or not,” said Dr. McGough, also a professor of clinical psychiatry at the university, but be careful to “really document what you’re doing.”
Misuse and diversion is mostly related to performance enhancement, especially at competitive universities, or when grades head south. Children and young adults in those situations, as well as smokers, drinkers, and those with conduct disorders, “are the ones you worry about.” If a Stanford medical school student at age 27 suddenly develops a horrible problem focusing, with no past ADHD history, “I’m a little suspicious,” he said, noting that people who malinger “tend to go off the scale in terms of endorsing symptoms.”
If misuse and abuse are a concern, extended-release stimulants, as well as nonstimulants, are better options than immediate-release formulations.
Audience members also were curious about alternative approaches for ADHD, but the news wasn’t very good.
For now, there’s no brain scan, test, or lab measurement that reliably detects ADHD. Even with neuropsychiatric testing, only half of children and adolescents will have executive-functioning deficits. The problem with computerized tests, meanwhile, is that a lot of children and adolescents with ADHD have no problem focusing on computer games, so they aren’t helpful for diagnosis.
“The gold standard for ADHD assessment remains a good interview,” and documenting DSM-5 criteria, he said.
As for alternative treatments, “what studies have shown is that if you are highly invested in the treatment and not blinded” to it, “you tend to think you do better. In good studies where they look at teachers who don’t know what’s going on, it doesn’t pan out,” he said. Metanalysis of neurofeedback hasn’t shown effect, nor have computer games to train focus; kids will get better at them with practice, but they haven’t been shown to improve ADHD.
The only exception is omega-3, but the effect size is barely measurable. “If you can get the kid so swallow those fish oil things, go for it, or they can eat salmon,” Dr. McGough said.
In short, medications remain the best option for treating the core symptoms of ADHD, first with stimulants then, as needed, nonstimulants.
But “you are not meeting your patients’ needs if you are only prescribing medications,” he said. Psychosocial education, family behavioral therapy, and school interventions – even things as simple as sitting toward the front of the class and having a little more time on tests – are critical for overall improvement.
It’s also important to let patients and families know that “they don’t have to be ashamed of this,” and the patients need to know why they are taking their medication, he said.
Too often, children are started on a low dose of medication and told to come back in a month. “That’s a waste of time, because it’s a whole month when the person is probably inadequately treated,” Dr. McGough said.
Instead, he has patients titrate up at first, with advice to cut back or stop and call if there are problems. The patient returns after 3 weeks, and the most effective, best-tolerated dose is selected for treatment.
Dr. McGough disclosed relationships with Purdue, Shire, Tris, Sunovion, NeuroSigma, and Neurovance.
Marijuana calms children with autism
SAN FRANCISCO – About once a month, Antonio Y. Hardan, MD, and his colleagues at the Stanford (Calif.) University Autism and Developmental Disorders Clinic see an autistic child who is using or being prescribed marijuana.
“There are two types or responses we see with marijuana,” said Dr. Hardan, director of the clinic. “Most of the time, it calms the kid down for 2 or 3 hours, which is what you’d expect from marijuana. In one out of 10, I am hearing that parents see improvements in the core features of autism. We have several families who would swear by marijuana, but then 4 or 6 months later, they will change their mind and say it’s not helping as much.
Marijuana is just one of many alternatives families and doctors are trying to improve upon the usual medications and therapies for autism; the range of options being tried speaks to the desperation and frustration of families looking for help. There’s no home run so far; the common denominator for alternatives is anecdotal support but little evidence. Stanford has tried to address the evidence gap and continues to do so.
In 2012, for instance, Dr. Hardan and his colleagues reported a 33 patient study that found that N-acetylcysteine (NAC) – another hopeful candidate in recent years – might curb irritability (Biol Psychiatry. 2012 Jun 1;71[11]:956-61).
The tricky part about NAC is that it’s a dietary supplement, so you can’t be sure of what you’re getting in the store. There were questions at the talk about dose and formulations.
“The one we used in the study is made by BioAdvantex,” a Canadian company. “That’s the one that worked for us. One of the advantages is that every dose is wrapped individually.” NAC is an antioxidant, “so if you expose [it] to oxygen or light, it will get oxidized, and over time be less effective,” said Dr. Hardan, also a professor of psychiatry and behavioral sciences at the university.
Most of the time, NAC is very well tolerated, with only a little bit of flatulence and upset stomach.
Dr. Hardan and his colleagues started with 900 mg in one dose once a day for 4 weeks, then one dose twice a day for 4 weeks, followed by one dose three times daily, in children aged 2-12 years old. With experience, they are going faster now, cutting the 4 week interval to 2. “Some people are [even] more aggressive, which is okay,” he said.
Propranolol is another fashionable option, prescribed by a lot of doctors.
It’s not a new option; about 20 years ago, “we used it in very high dosages, 700-800 mg a day for self-injurious behavior. People wonder how you can go that high; above a dose of 200 mg, there is what we call an ‘escape phenomena’ where the heart will stop responding, and the effects on blood pressure and pulse are minimal,” Dr. Hardan said.
Interest in propranolol over the past 5 years has expanded to anxiety, sensory abnormalities, and other non-specific autism symptoms. “Unfortunately, there are no clinical trials to support that,” he said. The only evidence so far is from a functional MRI study in adults that suggested a little bit more efficient processing on a language task; further investigation is underway.
A lot of parents also are asking for oxytocin, and doctors are prescribing it. Someone in the audience wondered whether it had a role in everyday practice.
“Not at this time,” Dr. Hardan said. “I would suggest waiting a little bit until” results are reported from an ongoing trial. They are due soon, and there might be a subgroup of kids who benefit. Oxytocin seemed to help all-comers recognize facial cues.
Arginine vasopressin might do that, too, and be more specific for autism; Stanford is planning a study to look into it.
Attendees also wanted to know what to do about sleep problems, a common issue in autism.
“I’m aggressive in the treatment of insomnia, especially in single-parent households, because if the kid isn’t sleeping, the parent isn’t sleeping” and they may get irritable and moody, which raises the risk of abuse, Dr. Hardan said.
He starts with melatonin, 1 mg in the evening, and increases it by 1 mg every week to hit a target of 6 mg per night. He hasn’t seen much benefit of going higher. It’s important to remember that melatonin might take up to a week to see the full effect.
If melatonin fails, Dr. Hardan goes up the ladder. Diphenhydramine (Benadryl), benzodiazepines, trazodone (Oleptro), and mirtazapine (Remeron) are among the options. Rarely, there’s a need for quetiapine (Seroquel).
To counter benzodiazepine disinhibition, he asks parents to try them on a good day at home, so the effect of environmental stressors like going to the dentist can be divided out from the drug.
Dr. Hardan cautioned that there is “no evidence at this time to support the use of” lamotrigine (Lamictal). “Please don’t use it; somebody will end up developing” Stevens-Johnson syndrome. “It will be difficult to defend against that.”
Dr. Hardan is an adviser for Roche.
SAN FRANCISCO – About once a month, Antonio Y. Hardan, MD, and his colleagues at the Stanford (Calif.) University Autism and Developmental Disorders Clinic see an autistic child who is using or being prescribed marijuana.
“There are two types or responses we see with marijuana,” said Dr. Hardan, director of the clinic. “Most of the time, it calms the kid down for 2 or 3 hours, which is what you’d expect from marijuana. In one out of 10, I am hearing that parents see improvements in the core features of autism. We have several families who would swear by marijuana, but then 4 or 6 months later, they will change their mind and say it’s not helping as much.
Marijuana is just one of many alternatives families and doctors are trying to improve upon the usual medications and therapies for autism; the range of options being tried speaks to the desperation and frustration of families looking for help. There’s no home run so far; the common denominator for alternatives is anecdotal support but little evidence. Stanford has tried to address the evidence gap and continues to do so.
In 2012, for instance, Dr. Hardan and his colleagues reported a 33 patient study that found that N-acetylcysteine (NAC) – another hopeful candidate in recent years – might curb irritability (Biol Psychiatry. 2012 Jun 1;71[11]:956-61).
The tricky part about NAC is that it’s a dietary supplement, so you can’t be sure of what you’re getting in the store. There were questions at the talk about dose and formulations.
“The one we used in the study is made by BioAdvantex,” a Canadian company. “That’s the one that worked for us. One of the advantages is that every dose is wrapped individually.” NAC is an antioxidant, “so if you expose [it] to oxygen or light, it will get oxidized, and over time be less effective,” said Dr. Hardan, also a professor of psychiatry and behavioral sciences at the university.
Most of the time, NAC is very well tolerated, with only a little bit of flatulence and upset stomach.
Dr. Hardan and his colleagues started with 900 mg in one dose once a day for 4 weeks, then one dose twice a day for 4 weeks, followed by one dose three times daily, in children aged 2-12 years old. With experience, they are going faster now, cutting the 4 week interval to 2. “Some people are [even] more aggressive, which is okay,” he said.
Propranolol is another fashionable option, prescribed by a lot of doctors.
It’s not a new option; about 20 years ago, “we used it in very high dosages, 700-800 mg a day for self-injurious behavior. People wonder how you can go that high; above a dose of 200 mg, there is what we call an ‘escape phenomena’ where the heart will stop responding, and the effects on blood pressure and pulse are minimal,” Dr. Hardan said.
Interest in propranolol over the past 5 years has expanded to anxiety, sensory abnormalities, and other non-specific autism symptoms. “Unfortunately, there are no clinical trials to support that,” he said. The only evidence so far is from a functional MRI study in adults that suggested a little bit more efficient processing on a language task; further investigation is underway.
A lot of parents also are asking for oxytocin, and doctors are prescribing it. Someone in the audience wondered whether it had a role in everyday practice.
“Not at this time,” Dr. Hardan said. “I would suggest waiting a little bit until” results are reported from an ongoing trial. They are due soon, and there might be a subgroup of kids who benefit. Oxytocin seemed to help all-comers recognize facial cues.
Arginine vasopressin might do that, too, and be more specific for autism; Stanford is planning a study to look into it.
Attendees also wanted to know what to do about sleep problems, a common issue in autism.
“I’m aggressive in the treatment of insomnia, especially in single-parent households, because if the kid isn’t sleeping, the parent isn’t sleeping” and they may get irritable and moody, which raises the risk of abuse, Dr. Hardan said.
He starts with melatonin, 1 mg in the evening, and increases it by 1 mg every week to hit a target of 6 mg per night. He hasn’t seen much benefit of going higher. It’s important to remember that melatonin might take up to a week to see the full effect.
If melatonin fails, Dr. Hardan goes up the ladder. Diphenhydramine (Benadryl), benzodiazepines, trazodone (Oleptro), and mirtazapine (Remeron) are among the options. Rarely, there’s a need for quetiapine (Seroquel).
To counter benzodiazepine disinhibition, he asks parents to try them on a good day at home, so the effect of environmental stressors like going to the dentist can be divided out from the drug.
Dr. Hardan cautioned that there is “no evidence at this time to support the use of” lamotrigine (Lamictal). “Please don’t use it; somebody will end up developing” Stevens-Johnson syndrome. “It will be difficult to defend against that.”
Dr. Hardan is an adviser for Roche.
SAN FRANCISCO – About once a month, Antonio Y. Hardan, MD, and his colleagues at the Stanford (Calif.) University Autism and Developmental Disorders Clinic see an autistic child who is using or being prescribed marijuana.
“There are two types or responses we see with marijuana,” said Dr. Hardan, director of the clinic. “Most of the time, it calms the kid down for 2 or 3 hours, which is what you’d expect from marijuana. In one out of 10, I am hearing that parents see improvements in the core features of autism. We have several families who would swear by marijuana, but then 4 or 6 months later, they will change their mind and say it’s not helping as much.
Marijuana is just one of many alternatives families and doctors are trying to improve upon the usual medications and therapies for autism; the range of options being tried speaks to the desperation and frustration of families looking for help. There’s no home run so far; the common denominator for alternatives is anecdotal support but little evidence. Stanford has tried to address the evidence gap and continues to do so.
In 2012, for instance, Dr. Hardan and his colleagues reported a 33 patient study that found that N-acetylcysteine (NAC) – another hopeful candidate in recent years – might curb irritability (Biol Psychiatry. 2012 Jun 1;71[11]:956-61).
The tricky part about NAC is that it’s a dietary supplement, so you can’t be sure of what you’re getting in the store. There were questions at the talk about dose and formulations.
“The one we used in the study is made by BioAdvantex,” a Canadian company. “That’s the one that worked for us. One of the advantages is that every dose is wrapped individually.” NAC is an antioxidant, “so if you expose [it] to oxygen or light, it will get oxidized, and over time be less effective,” said Dr. Hardan, also a professor of psychiatry and behavioral sciences at the university.
Most of the time, NAC is very well tolerated, with only a little bit of flatulence and upset stomach.
Dr. Hardan and his colleagues started with 900 mg in one dose once a day for 4 weeks, then one dose twice a day for 4 weeks, followed by one dose three times daily, in children aged 2-12 years old. With experience, they are going faster now, cutting the 4 week interval to 2. “Some people are [even] more aggressive, which is okay,” he said.
Propranolol is another fashionable option, prescribed by a lot of doctors.
It’s not a new option; about 20 years ago, “we used it in very high dosages, 700-800 mg a day for self-injurious behavior. People wonder how you can go that high; above a dose of 200 mg, there is what we call an ‘escape phenomena’ where the heart will stop responding, and the effects on blood pressure and pulse are minimal,” Dr. Hardan said.
Interest in propranolol over the past 5 years has expanded to anxiety, sensory abnormalities, and other non-specific autism symptoms. “Unfortunately, there are no clinical trials to support that,” he said. The only evidence so far is from a functional MRI study in adults that suggested a little bit more efficient processing on a language task; further investigation is underway.
A lot of parents also are asking for oxytocin, and doctors are prescribing it. Someone in the audience wondered whether it had a role in everyday practice.
“Not at this time,” Dr. Hardan said. “I would suggest waiting a little bit until” results are reported from an ongoing trial. They are due soon, and there might be a subgroup of kids who benefit. Oxytocin seemed to help all-comers recognize facial cues.
Arginine vasopressin might do that, too, and be more specific for autism; Stanford is planning a study to look into it.
Attendees also wanted to know what to do about sleep problems, a common issue in autism.
“I’m aggressive in the treatment of insomnia, especially in single-parent households, because if the kid isn’t sleeping, the parent isn’t sleeping” and they may get irritable and moody, which raises the risk of abuse, Dr. Hardan said.
He starts with melatonin, 1 mg in the evening, and increases it by 1 mg every week to hit a target of 6 mg per night. He hasn’t seen much benefit of going higher. It’s important to remember that melatonin might take up to a week to see the full effect.
If melatonin fails, Dr. Hardan goes up the ladder. Diphenhydramine (Benadryl), benzodiazepines, trazodone (Oleptro), and mirtazapine (Remeron) are among the options. Rarely, there’s a need for quetiapine (Seroquel).
To counter benzodiazepine disinhibition, he asks parents to try them on a good day at home, so the effect of environmental stressors like going to the dentist can be divided out from the drug.
Dr. Hardan cautioned that there is “no evidence at this time to support the use of” lamotrigine (Lamictal). “Please don’t use it; somebody will end up developing” Stevens-Johnson syndrome. “It will be difficult to defend against that.”
Dr. Hardan is an adviser for Roche.
EXPERT ANALYSIS AT THE PSYCHOPHARMACOLOGY UPDATE INSTITUTE