Novel Practice Pathway Addresses Problem Behaviors Among Patients With Autism

Issues causing children with autism spectrum disorder to be irritable or belligerent can be difficult for parents, teachers and other care providers to uncover.

And, wait times to see a specialist may leave a child frustrated, distressed or in physical pain for months.

Primary care physicians who see the patient and family regularly are in a unique position to help find what’s beneath emotional outbursts and aggressive acts, and work with parents and schools to develop a treatment plan, researchers from across the United States say.

The researchers, assembled by the Autism Intervention Research Network on Physical Health and Autism Speaks Autism Treatment Network, published a practice pathway this year to guide pediatric primary care doctors in the journal Pediatrics.

They warn that irritability and aggressive behaviors interfere with a child’s development and education, may result in isolation as family and classmates avoid them, or make them targets of bullying.

“One of the big points is to consider medical conditions as possible causes for these irritable and problem behaviors,” says Daniel Coury, MD, chief of the Section of Developmental and Behavioral Pediatrics at Nationwide Children’s Hospital and a leader of the research.

“Physicians are pretty good about asking about changes in caregivers or teachers or the environment that may be influencing the behavior,”Dr. Coury says. “But, they are less apt to consider an underlying medical problem.”

In one case, when a child started reaching aggressively for their throats, a mother and father thought the child was trying to choke them. After medicines and behavior management made no improvement, a doctor asked if the parents noticed physical changes in their child when the reaching started. They recalled his breath sometimes smelled sour.

The boy had gastrointestinal reflux. He was trying to tell them his throat hurt, Dr. Coury explains.

“We know primary care pediatrics is a high-volume business – a typical visit is 8 minutes – but we emphasize taking a thorough history,” Dr. Coury says. “It takes time and asking a lot of questions.”

After considering medical problems, physicians are guided to assess and address other possibilities: the patient’s lack of functional communication, psychosocial stressors, maladaptive behavioral patterns and co-occurring psychiatric conditions.

The pathway includes points at which the doctor may want to consider referrals to specialists. But for physicians willing, it provides steps to address the underlying problem with family, teachers and other caregivers.

“There are evidence-based treatments that can help these behaviors,” says Dr. Coury who is also professor of Clinical Pediatrics and Psychiatry at The Ohio State University College of Medicine. “So the physician doesn’t have to take a stab in the dark.”

References:

1. McGuire K, Fung LK, Hagopian L, Vasa RA, Mahajan R, Bernal P, Silberman AE, Wolfe A, Coury DL, Hardan AY, Veenstra-Vander-Weele J, Whitaker AH. Irritability and problem behavior in autism spectrum disorder: A practice pathway for pediatric primary care. Pediatrics. 2016 Feb;137 Suppl 2:S136-S148.
2. Fung LK, Mahajan R, Nozzolillo A, Bernal P, Krasner A, Jo B, Coury D, Whitaker A, Veenstra-Vanderweele J, Hardan AY. Pharmacologic treatment of severe irritability and problem behaviors in autism: A systematic review and meta-analysis. Pediatrics. 2016 Feb;137 Suppl 2:S124-S135.
3. Vasa RA, Mazurek MO, Mahajan R, Bennett AE, Bernal MP, Nozzolillo AA, Arnold LE, Coury DL. Assessment and treatment of anxiety in youth with autism spectrum disorders. Pediatrics. 2016 Feb;137 Suppl 2:S115-S123.
4. McCracken JT, McGough J, Shah B, Cronin P, Hong D, Aman MG, Arnold LE, Lindsay R, Nash P, Hollway J, McDougle CJ, Posey D, Swiezy N, Kohn A, Scahill L, Martin A, Koenig K, Volkmar F, Carroll D, Lancor A, Tierney E, Ghuman J, Gonzalez NM, Grados M, Vitiello B, Ritz L, Davies M, Robinson J, McMahon D; Research Units on Pediatric Psychopharmacology Autism Network. Risperidone in children with autism and serious behavioral problems. New England Journal of Medicine. 2002 Aug 1;347(5):314-321.