Tag Archives: Daniel B. Kessler

Autism Q & A: What medications are available to treat autism?

By Daniel B Kessler

There are no medications that treat the core challenges of autism, though you can bet the pharmaceutical companies and autism research centers are working on developing some. What we do have available treats only the symptoms or behaviors but that is often so important by itself.

If a child’s behavioral (disruptive behavior or aggression) or emotional (anxiety, obsessive tendencies, sensory overload, meltdowns) challenges limit his or her ability to participate in and therefore benefit from educational, therapy or recreational activities, then these symptoms may be legitimate targets for a medical approach (that means the judicious, careful trial of medications). Medication, used appropriately, doesn’t control behavior. It should allow the child to be in control of his behavior.

The decision to use medication rests with parents. Don’t let anyone tell you different. Find someone to answer your questions and address your fears. Talk to parents who have decided to go ahead and place their child on medication and those that have not. Ask them to let you know their reasons and experiences. But be careful about third-hand accounts (“I know one parent whose sister’s kid had a really bad reaction to ____”).

No parent is excited about having to use medication. Every medication has potential side effects — even “over the counter” medications or “natural” supplements.

But there is also a cost to not getting help for these behaviors. The child may not benefit as much as he or she could. While on medication a child may do better; progress more quickly, with the ability to better regulate their behavior or emotional reactions. Once again, information helps. Ask questions. Look at reliable sources of information. What is this medication supposed to do? How does it work? How long will it take to show a benefit? Has it been studied in children with autism? Has it been shown to be safe and effective? If not FDA-approved and being used off-label* has it been used for children with autism? Has this doctor used it to treat kids with autism?

Next: What are the potential side effects? 

Daniel B. Kessler, M.D., is a developmental and behavioral pediatrician and medical director of the Children’s Developmental Center at Easter Seals Southwest Human Development. His private practice, where he provides evaluation and treatment for children and adolescents, is located at Southwest Human Development.

The views he expresses in this series are based on his training, his reading of the literature and his more than 30 years of experience taking care of hundreds of kids on the autism spectrum. The series begins here.

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*Off-label use is the practice of prescribing a medication for a condition, or an age group, for which it has not been reviewed and “approved” by the Food and Drug Administration.  It is up to the manufacturer of the medication to submit an application for approval. However, the FDA does not have the legal authority to regulate the practice of medicine, and any physician may prescribe a drug off label.

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Autism Q & A: What if I disagree with the services provided for my child?

By Daniel B. Kessler, M.D.

Budgets are the biggest obstacles to getting appropriate services for kids with autism. The reality for school administrators is that resources are limited and available resources drive choices of the services that schools can offer. It’s not that schools want to do “bad” by kids, but with limited budgets in a down economy they are faced with taking money from one group of kids and spending it on another. Never is this an easy choice. On the other hand parents of kids with special needs want what the law and increasingly the courts say is the most appropriate service. Find out what is appropriate for your child and never take no for an answer.

All children are entitled to a “free and appropriate education” (FAPE). This requires a comprehensive evaluation in all areas of suspected disability. In addition, many school district personnel will tell you that autism is a medical diagnosis (that is true), so they cannot test for it (that isn’t exactly true). Autism is also an educational eligibility category (at least by kindergarten age) and the Ninth Circuit Court of Appeals, which covers Arizona, has ruled that to not test for autism denies a student access to FAPE.

If the school district performs an evaluation that the parents disagree with or does not have sufficient resources to do the necessary evaluation, parents have the right to request an Independent Educational Evaluation (IEE) at public expense. If the school district provides you a list of evaluators to choose from, you have the right to pick another evaluator as long as that person has the appropriate credentials.

Parents are their kids’ best advocates and they are in the best position to be so. I can’t give you better advice than that provided by the Coordinated Campaign for Learning Disabilities:

• Know the rules (get help from Raising Special Kids, Arizona Center for Disability Law, Wrightslaw.com)

• Keep records (maintain an organized file of your child’s evaluations)

• Gather information (using reliable sources)

• Communicate effectively (adversarial stances are less effective, except when facing intractable professionals or administrators)

• Know your child’s strengths and interests and share them with educators

• Emphasize solutions (work together to identify ways to improve your child’s experience)

• Focus on the big picture (“don’t sweat the small stuff”) and

• Involve your child in decision making as early as you can and whenever possible (listen to the child).

Next: What medications are available to treat autism?

Daniel B. Kessler, M.D., is a developmental and behavioral pediatrician and medical director of the Children’s Developmental Center at Easter Seals Southwest Human Development. His private practice, where he provides evaluation and treatment for children and adolescents, is located at Southwest Human Development.

The views he expresses in this series are based on his training, his reading of the literature and his more than 30 years of experience taking care of hundreds of kids on the autism spectrum. The series begins here.

Autism Q & A: What about social skills?

By Daniel B. Kessler, M.D.

I believe the core challenge of autism is a social challenge. I believe that social/emotional IQ is more predictive of success in our world than is cognitive IQ. Of course, that depends on your definition of success. What I wish for my families and their children is for them to be both happy and successful in three areas: school or related activity (the work of children), home and friends/leisure time activities. That’s what I wish for all kids, mine included. I want them to find work that is meaningful to them. I want them to love it and be good at it. I believe social skills are at the core of this success.

I tell parents and believe strongly that social skills can be learned but they must be taught. Taught the way we teach reading and the way we teach math. We don’t put kids who cannot read into a room of good readers and expect it to rub off. We can’t teach children with autism social skills by simply putting them in a room of typical kids. They need specific curricula, role playing, practice and homework (sorry kids). It can be done but mostly we aren’t doing it. It’s expensive. But it’s not as expensive as it would be to support them on public funds. Is it not better for everyone that children with autism become productive members of their community? Parents might need to be creative and consider partnering among themselves or with their school districts through the use of combined tuition tax credits to support additional services for their kids. It’s not easy but it’s important.

Next: When parents disagree with the services provided to their child.

Daniel B. Kessler, M.D., is a developmental and behavioral pediatrician and medical director of the Children’s Developmental Center at Easter Seals Southwest Human Development. His private practice, where he provides evaluation and treatment for children and adolescents, is located at Southwest Human Development.

The views he expresses in this series are based on his training, his reading of the literature and his more than 30 years of experience taking care of hundreds of kids on the autism spectrum. The series begins here.

Autism Q & A: What is behavioral therapy?

By Daniel B. Kessler, M.D.

Behavioral therapies are among the most commonly applied intervention methods for autism and the most studied. Many of the intensive behavioral therapies (or Early Intensive Behavioral Interventions — EIBIs) that have been studied are based on the concepts of Applied Behavioral Analysis (ABA).

Applied behavior analysis is a science that involves using modern behavioral learning theory to modify behaviors. Behavior analysts focus on the observable relationship of behavior to the environment. By functionally assessing the relationship between a targeted behavior and the environment, the methods of ABA can be used to change that behavior. Though highly effective for large numbers of children at early ages and later, ABA therapies are not for everyone. Some individuals are put off by the perception of a highly robotic intervention in a disorder characterized by difficult social interactions.

Forms of ABA are not the only tested interventions for children with autism. Other methods, such as Floortime™, are perceived to be more interactive and flexible. Floortime™ (or DIRFloortime™) is designed to both follow the child’s lead and at the same time challenge the child toward greater mastery of social, emotional, and intellectual capacities. DIRFloortime™ emphasizes the importance of the role of parents’ and other family members’ emotional relationships with the child.

Programs and providers increasingly are looking to implement blended models to obtain the benefit of multiple interventions. The Denver Model (which interweaves multiple perspectives) and the child-directed Pivotal Response Training (which blends rewards with play techniques) are examples. The Relationship Development Intervention (RDI) model developed by Dr. Steven Gutstein tends to focus on the social challenges of autistic individuals. Relationship-based models give importance to the relationships that help children reach and master early developmental milestones often missed or not mastered in children with autism spectrum disorder. Examples of these early milestones are engagement and interest in the world, intimacy with a caregiver and intentionality of action.

Often it comes down to what is available and what you can afford in a given community. There is a growing body of evidence that developmental/relationship-based approaches with very young children are showing promise and represent an important and valid treatment approach. Such is the model for the Side-by-Side Program (SxS) at Southwest Human Development, which involves parents and their toddlers. Increasingly parents are looking to train themselves and provide therapy at home.

Next: Will insurance pay for therapies?

Daniel B. Kessler, M.D., is a developmental and behavioral pediatrician and medical director of the Children’s Developmental Center at Easter Seals Southwest Human Development. His private practice, where he provides evaluation and treatment for children and adolescents, is located at Southwest Human Development.

The views he expresses in this series are based on his training, his reading of the literature and his more than 30 years of experience taking care of hundreds of kids on the autism spectrum. The series begins here.

Autism Q & A: What are the benefits of early intervention?

By Daniel B. Kessler, M.D.

What is early intervention and why is it important to my child? Will my child get better?  I have characterized autism as a brain-based developmental disorder. To me, “developmental” means change or open to change over time.

Every child can benefit from early intervention. Make the call. Ask for an evaluation and not a screening. Follow up those phone calls if at first you don’t get a response. Do not wait.

Children with problems of development who are under 3 years will either be eligible for services under the Arizona Early Intervention Program (AzEIP) or the Division of Developmental Disabilities (DDD) based on somewhat different eligibility criteria. Most children who have autistic disorder should be eligible under DDD and many should also be eligible for federal matching funds under Title 19 of the Social Security Act, which is administered by Arizona Long Term Care Services (ALTCS). You should ask about all three. In addition some children may be eligible for Supplemental Security Income (SSI) from the Social Security Administration.

Who benefits from early intervention? All will benefit though all are likely to change at different rates and in response to different forms of help. Not wanting to miss anything that may help is what causes parent to search high and low for the right intervention, the right supplement or the right therapy, even if there is limited scientific support. And because in most regards earlier is better, parents are afraid not to embrace the latest “cure” posted on the Internet. But the old saying still goes, buyer beware. While many are well meaning and many believe what they are telling you about the latest cure or treatment, there are folks who will gladly take your money in exchange for little more than false hope.

We cannot predict who will benefit the most from intervention and we don’t know how much any individual will benefit without waiting and observing and sometimes changing what we do. But early intervention works! While I personally don’t put stock in curing autism I have seen remarkable recovery. It exists. And I see improvement in everyone. But what works for your child may not work for your friend’s child. Education works. Speech therapy and occupational therapy work (especially sensory integration therapy when indicated) and music therapy also can be enormously helpful for many children on the spectrum.

Next: What is behavioral therapy and why would you want it for your child?

Daniel B. Kessler, M.D., is a developmental and behavioral pediatrician and medical director of the Children’s Developmental Center at Easter Seals Southwest Human Development. His private practice, where he provides evaluation and treatment for children and adolescents, is located at Southwest Human Development.

The views he expresses in this series are based on his training, his reading of the literature and his more than 30 years of experience taking care of hundreds of kids on the autism spectrum. The series begins here.

Autism Q & A: What specialists should my child see?

By Daniel B. Kessler

What specialists should a child with autism see? This is another controversial area, so again what follows are my opinions and my recommendations. You should always seek out the advice of your own physician.

Geneticists (genetic or inheritable disorders): Of the 10 percent of children who may have an identifiable genetic condition, half should be identified by a good physical examination by a trained geneticist and now-standard genetic testing. The other half may require more specialized molecular chromosome studies. There are always going to be improvements in our ability to diagnose, but for the majority of children with autism we will not find a cause.

Neurologists(brains and nervous system): Neurologists are sometimes called upon to diagnose autism. However, in state regulation only a licensed psychologist, psychiatrist or (with appropriate review by the Medical Director of DDD) a developmental pediatrician can diagnose autism.  This probably needs to be rethought as it has little to do with what is usual clinical practice. Pediatricians with special training should be allowed to do this as well.

Roughly 30 percent of children with autism will have a seizure disorder. These children should see an epilepsy specialist.

Gastroenterologists (mouth and stomach to anus): There is a difference of opinion as to whether there is a specific “autistic gastroenteropathy” or that kids with autism will get some of the same gastrointestinal disorders as other kids get but have a harder time getting diagnosed. Kids with autism can have significant and impairing stomach disorders and should see a specialist, if possible. When kids cannot communicate their pain it is a challenge to identify that something is wrong. That job often falls onto the parents. Should all kids see a GI doctor? I don’t think so.

Allergists/Immunologists (sensitivity to environmental factors such as allergies and infections): Allergy and immune disorders are two controversial areas in autism. There continue to be challenges on how to properly assess them. Personally I am cynical about the several specialty labs around the country that specialize in exotic assays of immune factors and heavy metals or even neurotransmitters in the blood or urine, having gotten back different results and recommendations from the same sample sent to different labs.

Some kids who have positive laboratory findings to a particular protein (plant or animal) or substance may not show clinical symptoms when exposed to that substance. Some kids will test negative to something but are highly sensitive to it in the environment and consistently and repeatedly show clinical or behavioral symptoms when exposed to it. Sometimes the only way to sort out what is real is to do carefully controlled elimination diets and that isn’t always easy.

Next: The role of early intervention.

Daniel B. Kessler, M.D., is a developmental and behavioral pediatrician and medical director of the Children’s Developmental Center at Easter Seals Southwest Human Development. His private practice, where he provides evaluation and treatment for children and adolescents, is located at Southwest Human Development.

The views he expresses in this series are based on his training, his reading of the literature and his more than 30 years of experience taking care of hundreds of kids on the autism spectrum. The series begins here.

Autism Q & A: What is the role of environment?

By Daniel B. Kessler, M.D.

What about the environmental causes of autism? Other than”What is autism?” there is no more controversial topic.

In particular there is the ongoing controversy surrounding the role of vaccines (particularly the MMR vaccine) and thimerisol, a mercury-based preservative that had been in many vaccines and may continue to be in some flu vaccines. Both have been blamed as causing autism. Though there is absolutely no scientific support for that position, debating the evidence is not appropriate in this brief forum.

If we stopped immunizations today there would be no decrease in the numbers of children diagnosed with autism (there was no decrease when thimerisol was removed from most vaccines, and in studies that compared the rate of autism in children who received immunizations and those who did not there were no differences) but a lot more children and adults would become sick and die from preventable illnesses. This is the critical public health role of immunizations, not to mention the degree of suffering and death that have been eliminated by their widespread use.

There is today little question that the environment plays a role in autism. Potential environmental factors range from the chemicals in food and cosmetics to parental age, maternal infections, stress and reproductive technologies.

A recent study suggests environmental factors play a more important role than previously indicated. In addition to having the right combination of genes, exposure to certain environmental factors might be necessary for autism to develop in certain individuals. The interaction of the two is an important target for future research. By studying genetic factors and determining their underlying mechanisms we may be better able to pinpoint environmental factors that contribute to autism.

What is challenging is identifying the potential environmental factors. Potential environmental factors range from the chemicals in food and cosmetics to parental age, maternal infections, stress and reproductive technologies. Some studies have focused on prenatal environmental factors such as agents that cause birth defects. Thalidomide (a sedative) and valproate (a seizure medicine) are known to increase the occurrence of autism when an exposure comes in the first trimester of pregnancy. All known such agents (teratogens) related to the risk of autism appear to act during the first eight weeks from conception, and though this does not exclude the possibility that autism can be initiated or affected later, it is strong evidence that autism arises very early in development.

The numbers of new chemicals introduced into the environment each year is alarming and growing. Of the 80,000 chemicals registered in the U.S., the EPA has required safety testing on only 200.  Are we testing them on our kids?

Next: Where to get help.

Daniel B. Kessler, M.D., is a developmental and behavioral pediatrician and medical director of the Children’s Developmental Center at Easter Seals Southwest Human Development. His private practice, where he provides evaluation and treatment for children and adolescents, is located at Southwest Human Development.

The views he expresses in this series are based on his training, his reading of the literature and his more than 30 years of experience taking care of hundreds of kids on the autism spectrum. The series begins here.