A new practice pathway provides primary care providers with evidence-based steps in assessing and addressing irritability and problem behavior in patients at least 3 years old who have been diagnosed with an autism spectrum disorder (ASD).
“As the medical professionals whom children with ASD will probably encounter first and most frequently, pediatric primary care providers need a breadth of knowledge to enable them to identify contributing factors to irritability and problem behavior, decide when and how to initiate treatment, and judge when to refer to specialists,” reported Dr. Kelly McGuire of Columbia University Medical Center and New York State Psychiatric Institute, and her associates ( Pediatrics. 2016 Feb;137 Suppl 2:S136-48 ). “Therefore, this practice pathway can be viewed more as a comprehensive rather than an exhaustive recommendation for [primary care physicians], who must weigh their expertise and resources when addressing the range of issues that a child with ASD and irritability and problem behavior may present.”
The Irritability Workgroup comprised eight child psychiatrists, a developmental pediatrician, and a behavioral psychologist who met regularly to define irritability and problem behavior, and then to review the evidence base on assessing and treating factors that contribute to irritability and problem behavior. They grouped these factors into five domains: “co-occurring medical conditions, lack of functional communication, psychosocial stressors, maladaptive reinforcement patterns, and co-occurring psychiatric conditions.”
Then the group developed a consensus in determining each step in the practice pathway and when it should occur, along with opportunities for a primary care provider to refer the patient to a specialist or to collaborate with school and community providers. The 10 steps in the practice pathway are:
1. Assess the patient for irritability and problem behavior based on the presence of tantrums, meltdowns or rages; property destruction; aggression toward others; and self-injury.
2. Assess the safety of the patient and others in the home, enlisting home-based crisis services or considering hospitalization if safety is threatened.
3. Review the patient’s medical, developmental, communication, environmental, and psychiatric history before and after the problem behavior. Include information on the caretaker’s characteristics, any loss of skills by patient, and any interference occurring with functioning or relationships.
4. Prioritize the behaviors to address based on safety, severity, and impact on daily life.
5. Consider all contributing factors to the problem behavior, including medical problems, difficulties functionally communicating, psychosocial stressors, maladaptive reinforcement patterns (reducing inadvertent triggers), and comorbid psychiatric disorders.
6. Consider possible medication treatments, such as N-acetylcysteine, clonidine, risperidone or aripiprazole, depending on circumstances.
7. Develop an individualized treatment and safety plan.
8. Implement and monitor the treatment plan, setting clear and measurable treatment goals.
9. Follow up at 3 months to assess whether symptoms are continuing and a reassessment is needed.
10. Reevaluate every 3 months.
The article provides a useful and extensive checklist with a variety of specific things to consider when implementing the 10 steps.
“No other provider in the patient’s life combines the medical expertise and first-hand knowledge of the individual patient’s health and development” than the primary care provider, the authors wrote. “The practice pathway is most likely to be efficient and effective in generating a treatment plan if it is systematically followed and the specific combination of individual contributing factors is identified for each patient.”
The research was conducted through the Autism Speaks Autism Treatment Network and funded by the U.S. Department of Health and Human Services with the Autism Intervention Research Network on Physical Health and by Marilyn and James Simons Family Giving. Dr. Jeremy Veenstra-VanderWeele has received research funding from Seaside Therapeutics, Roche, Novartis, Forest, Sunovion, and SynapDx and has consulted with Roche, Novartis and SynapDx.