Q&A with Matthew Fisher, MD, Medical Leader, Springbrook Autism Behavioral Health Psychiatric Residential Treatment Program and Outpatient Psychiatry
Individuals with autism spectrum disorder (ASD) commonly experience other medical conditions or comorbidities that can sometimes mask or even exacerbate symptoms of autism. At the top of the list are psychiatric conditions, neurological issues, and even gastrointestinal problems.
In fact, 70 percent of individuals diagnosed with autism also have a comorbid psychiatric diagnosis while 41 percent have two or more diagnoses. The most common comorbidities are attention-deficit/hyperactivity disorder (ADHD), Oppositional Defiant Disorder and Social Anxiety Disorder.
Dr. Fisher is a leading expert in the field of treating autism and comorbidities. His approach to treatment is getting a diagnosis as early as possible, treating the autism first and using a minimal amount of medication to avoid polypharmacy. In his interview below, he explains the importance of this approach.
Q: Which diagnosis comes first—autism or the comorbidity?
It varies from patient to patient and is based on the severity of the autism. More severely impaired autistic kids are identified earlier. Roughly, the average child is around three or four years old when diagnosed. Higher functioning kids, depending on where they are in the country and the availability of treatment services, are usually around six years old when they’re identified, but I’ve seen high functioning individuals who are diagnosed as late as 19 years old.
When it comes to ADHD and other comorbidities, on average, the higher functioning kids tend to be diagnosed with something else first. One of the problems with the ADHD diagnosis is that it tends to get overused in schools when compulsive thoughts or fixations are mistaken for ADHD.
For example, if a child isn’t paying attention in class because he is busy looking out the window at the train tracks and counting the numbers on the boxcars, that behavior mimics ADHD when it could actually be autism. The child is paying attention, but he’s not paying attention to what the teacher wants him to pay attention to. He’s overly focused on the trains.
I’ve seen many patients misdiagnosed with ADHD whose focus was just fine once properly treated. They were so trapped in their own heads that they wouldn’t interact. Teachers weren’t wrong with their observations of the behaviors, but the cause of the behaviors was incorrect.
Q: What factors should be taken into consideration when treating comorbidities?
The proper treatment approach is key when dealing with autism and its comorbidities. I believe in treating the autism first and the comorbidities second. Individuals with autism see and experience the world in a completely different way because of the way their brains are wired. Their brains have never experienced anything other than constant overload, which heightens their anxiety. The anxiety, in turn, can cause agitation, impulsivity, irritability, outbursts and self-injurious behavior. Once medications are introduced to bring that anxiety level down, other—more positive—emotions, interests, and behaviors begin to emerge.
Once an individual’s anxiety is under control, he feels better and, as a result, his behavior tends to improve, and he can communicate better. He can better explain if he is tired, has a headache or is experiencing gastrointestinal pain—all of which could be responsible for symptoms like agitation, irritability or outbursts. Even with nonverbal children, treating the anxiety associated with autism opens the ability of a child to be receptive to learning methods of expressive communication. You’re getting that brain down to a calmer state where your interventions can be effective.
I always use the example of a panic attack. If you’ve ever seen or tried to interact with someone in a full-blown panic attack, you really can’t intervene well. They’re not processing. The person’s brain is overloaded. Anything you say—no matter how nice and calming it is—isn’t being properly processed. Once the person calms down from that panic attack, that’s when you can intervene and hopefully teach the skills to avoid panic attacks in the future.
The opposite approach—treating the panic attack first—may not be as effective or can actually exacerbate the problem because you’re not getting to the underlying cause of the panic attack. In someone with autism, often times that panic attack is brought on by the inability to effectively communicate. By treating the autism first and giving that individual the tools to communicate emotion and pain, the anxiety attacks may never need to surface.
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Q: What medications are effective in treating autism and comorbidities?
Generally, I try to keep medications to a minimum if at all possible. I try to use milder medications at the lowest possible doses, particularly with antipsychotics. I have a tendency to use some of the older medications because, looking at the science and data compared to the newer medications, they are often more effective.
Every individual is different, of course. Therefore, every treatment plan is individualized. If a patient comes to us in crisis, my answer is very different than if I’m treating a calmer ‘get to know you’ outpatient visit. My first line is not the antipsychotics that target the irritability and mood swings. Again, the first line of treatment is to treat the anxiety that leads to the irritability and agitation.
Often, we have to do short trials of medications through process and elimination to see how it works in targeting the comorbidity that is creating the issue. If I am treating a nonverbal child who I think is having headaches and migraines, I may give them Tylenol or something longer-term for maintenance; If headaches are the cause, self-injurious behaviors tend to decrease.
A large number of patients also have sleep issues related to comorbidities like ADHD or seizure activity. Ensuring a good night’s rest will obviously improve mood and lessen the chances of self-injury, for example. I prescribe sleep medicine to a majority of patients.
I have also had success with medications typically used to treat blood pressure. For example, propranolol is used to prevent people with social phobias and public speaking from becoming overwhelmed in social situations. People with autism get overwhelmed in social situations. Propranolol can put their cardiac system at a plateau, preventing panic and overload. My patients have had good success with it.
Q: What is Springbrook Autism Behavioral Health’s approach to treating autism and comorbidities?
Springbrook staff work closely with one another to monitor all aspects of treatment. Our interdisciplinary team meets weekly to review each patient’s progress and treatment path based on the Functional Independence Skills Handbook, or FISH curriculum, which was designed by our behavioral analyst, William Killion, PhD, BCBA, at Springbrook. I get a lot of feedback from the team about which therapies are working and which are not. This holistic review allows me to see marked improvements or setbacks that result from a child’s medication regimen. Our discussion tells us about progress more narratively, but each of our assessments has a measurable score, and from that, we can objectively chart the course of success.
Treating autism and comorbidities isn’t a “one size fits all” approach. There are several factors to consider when putting together a treatment plan, and what works for one person might not work for another person.
We work with your child to discover which treatments and therapies will have the best result. Our goal is to promote growth and independent living for every child, using the means that are most effective for each individual. Let us know if you would like a private consultation or to tour our campus.
Springbrook Behavioral Health is excited to announce that Dr. Temple Grandin, a pioneer in the field of autism, will be the keynote speaker at the 2019 Converge Autism Summit. Converge Autism Summit will be March 7-8, 2019 at the TD Convention Center in Greenville, SC. The Converge Autism Conference is geared towards industry professionals but is also open to parents and caregivers from around the nation as a chance to meet and discuss educational, therapeutic, social, and psychological topics related to Autism Spectrum Disorder. Registration is expected to open soon. More details will be provided as they become available. For more information, please visit convergeautism.com
This article was featured in Issue 79 – Managing Everyday Life