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TABLE 2

Clinical Approach to Psychopharmacologic Management

Identify and assess target behaviors    
    Parent/caregiver interview    
        Intensity    
        Duration    
        Exacerbating factors/triggers (time, setting/location, demand situations, denials, transitions, etc)    
        Ameliorating factors and response to behavioral interventions    
        Time trends (increasing, decreasing, stable)    
        Degree of interference with functioning    
    Consider baseline behavior-rating scales and/or baseline performance measures/direct observational data    
    Include input from school staff and other caregivers    
Assess existing and available supports    
    Behavioral services and supports    
    Educational program, habilitative therapies    
    Respite care, family psychosocial supports    
Search for medical factors that may be causing or exacerbating target behavior(s)    
    Consider sources of pain or discomfort (infectious, gastrointestinal, dental, allergic, etc)    
    Consider other medical causes or contributors (sleep disorders, seizures, menstrual cycle, etc)    
Complete any medical tests that may have a bearing on treatment choice    
Consider psychotropic medication on the basis of the presence of    
    Evidence that the target symptoms are interfering substantially with learning/academic progress, socialization, health/safety (of the patient and/or others around him         or her), or quality of life    
    Suboptimal response to available behavioral interventions and environmental modifications    
    Research evidence that the target behavioral symptoms or coexisting psychiatric diagnoses are amenable to pharmacologic intervention    
Choose a medication on the basis of    
    Likely efficacy for the specific target symptoms    
    Potential adverse effects    
    Practical considerations such as formulations available, dosing schedule, cost, and requirement for laboratory or electrocardiographic monitoring    
    Informed consent (verbal or written) from parent/guardian and, when possible, assent from the patient    
Establish plan for monitoring of effects    
    Identify outcome measures    
    Discuss time course of expected effects    
    Arrange follow-up telephone contact, completion of rating scales, reassessment of behavioral data, and visits accordingly    
    Outline a plan regarding what might be tried next if there is a negative or suboptimal response or to address additional target symptoms    
        Change to a different medication    
        Add another medication to augment a partial or suboptimal therapeutic response to the initial medication (same target symptoms)    
        Add a different medication to address additional target symptoms that remain problematic    
    Obtain baseline laboratory data if necessary for the drug being prescribed and plan appropriate follow-up monitoring    
Explore the reasonable dose range for a single medication for an adequate length of time before changing to or adding a different medication    
Monitor for adverse effects systematically    
Consider careful withdrawal of the medication after 6–12 mo of therapy to determine whether it is still needed    
Identify and assess target behaviors    
    Parent/caregiver interview    
        Intensity    
        Duration    
        Exacerbating factors/triggers (time, setting/location, demand situations, denials, transitions, etc)    
        Ameliorating factors and response to behavioral interventions    
        Time trends (increasing, decreasing, stable)    
        Degree of interference with functioning    
    Consider baseline behavior-rating scales and/or baseline performance measures/direct observational data    
    Include input from school staff and other caregivers    
Assess existing and available supports    
    Behavioral services and supports    
    Educational program, habilitative therapies    
    Respite care, family psychosocial supports    
Search for medical factors that may be causing or exacerbating target behavior(s)    
    Consider sources of pain or discomfort (infectious, gastrointestinal, dental, allergic, etc)    
    Consider other medical causes or contributors (sleep disorders, seizures, menstrual cycle, etc)    
Complete any medical tests that may have a bearing on treatment choice    
Consider psychotropic medication on the basis of the presence of    
    Evidence that the target symptoms are interfering substantially with learning/academic progress, socialization, health/safety (of the patient and/or others around him         or her), or quality of life    
    Suboptimal response to available behavioral interventions and environmental modifications    
    Research evidence that the target behavioral symptoms or coexisting psychiatric diagnoses are amenable to pharmacologic intervention    
Choose a medication on the basis of    
    Likely efficacy for the specific target symptoms    
    Potential adverse effects    
    Practical considerations such as formulations available, dosing schedule, cost, and requirement for laboratory or electrocardiographic monitoring    
    Informed consent (verbal or written) from parent/guardian and, when possible, assent from the patient    
Establish plan for monitoring of effects    
    Identify outcome measures    
    Discuss time course of expected effects    
    Arrange follow-up telephone contact, completion of rating scales, reassessment of behavioral data, and visits accordingly    
    Outline a plan regarding what might be tried next if there is a negative or suboptimal response or to address additional target symptoms    
        Change to a different medication    
        Add another medication to augment a partial or suboptimal therapeutic response to the initial medication (same target symptoms)    
        Add a different medication to address additional target symptoms that remain problematic    
    Obtain baseline laboratory data if necessary for the drug being prescribed and plan appropriate follow-up monitoring    
Explore the reasonable dose range for a single medication for an adequate length of time before changing to or adding a different medication    
Monitor for adverse effects systematically    
Consider careful withdrawal of the medication after 6–12 mo of therapy to determine whether it is still needed    

Adapted from Myers SM. The status of pharmacotherapy for autism spectrum disorders. Expert Opin Pharmacother. 2007;8:1579–1603; and Myers SM, Challman TD. Psychopharmacology: an approach to management in autism and intellectual disabilities. In: Accardo PJ, ed. Capute & Accardo's Neurodevelopmental Disabilities in Infancy and Childhood. 3rd ed. Baltimore, MD: Paul H. Brookes; 2007: In press.

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