Medications in ABA Therapy: Side Effects, ADHD Treatment, and What Parents Should Know

In this episode of Acorns to Oaks, we explore how medications are used alongside ABA therapy and what parents should know about benefits, risks, and side effects.

From ADHD stimulants like Ritalin to antipsychotic medications often prescribed for autism-related behaviors, we break down how these treatments work, what changes you might see, and why monitoring is essential.

We also discuss common side effects such as appetite suppression, sleep disruption, and behavioral changes, as well as more serious risks that require close attention. This episode highlights the importance of collaboration between parents, behavior analysts, and medical providers to ensure safe and effective care.

If you are navigating ABA therapy, autism support, or ADHD treatment, this conversation will help you ask better questions and make more informed decisions for your child.

Transcript

SPEAKER_00 0:05

Hi.

SPEAKER_01 0:06

Hello. Hello, and welcome to another uh episode of Acorns to Oaks. I am Christine Dixon, behavior analyst.

SPEAKER_00 0:14

And I am Sarah Moreau, also behavior analyst and family nurse practitioner. Today we'll be talking about medications and want to make it clear that should there be any questions, you should reach out to your healthcare provider. This podcast is only for information and educational purposes, and no patient-nurse relationship has been formed.

SPEAKER_01 0:32

Yes, and there is so many important factors in navigating ABA treatment. And we've been practicing for 10 years in Los Angeles as providers, and we've had some really remarkable continuity of care. And what that means is uh we work very collaboratively uh with a lot of developmental pediatricians. Um we have been so blessed to work with some of the finest minds out of UCLA and uh out of uh Stanford. Um, and working collaboratively with a developmental pediatrician, for me, it just provides a beautiful blueprint for um meaningful outcomes and for treatment. Um it also allows for another source to be measuring progress as well. And uh that's always great to validate our data. Uh, one of the things that we see a lot of parents go through is navigating um the use of drugs um during treatment. And we just came back from a PBA in in Knowlands, and we were able to see Dr. Thomas Friedman out of the Florida Institute of Technology, and he did a talk on a tutorial on the ethical practice, what every clinical behavior analyst should know about psychotropic medication. And we attended and it found it to be very valuable.

SPEAKER_00 2:02

Absolutely. So medications can be extremely helpful for some people. Uh, they also come with some side effects that it helps to be aware of at the start of treatment.

SPEAKER_01 2:15

And that's true with even ABA. There's a main effect of ABA, and there's a side effect that can occur. So, for instance, in ABA or when we're using pivotal response treatment to break a lot of language, we can be reinforcing language at such high rates that the child just then starts talking at great length and for a great amount of time. And then we have to work a little bit on the opposite end to um combat that side effect by saying, okay, now we're gonna practice quiet time, right? Because the parents are like, yeah, he's talking, but he won't stop talking. It's like, yeah, we got a huge burst of language very, very quickly. So now we need to kind of bring it back. So with any type of treatment, there's main effect and side effects. Yes. Yes, yes.

SPEAKER_00 3:06

So yeah, we want to make sure that our clients are being reinforced across settings. So if we're talking out of class, we don't want our clients to get into trouble. So that's just an example of how we would kind of learn when we can talk a lot and when maybe we shouldn't talk a lot, which was a struggle for me as a child.

SPEAKER_01 3:21

I also think it was actually a struggle for us at the conference because we sat in the back row because sometimes we like to discuss a little bit. And um, someone was sitting not in a chair, but on the floor behind us, and we didn't know they were there. And they were like, Well, you two shut up. Like, sorry. Yes, sorry. We will. Yeah, we will practice quiet time. Quiet time.

SPEAKER_00 3:44

Yeah. But main effect and side effects. Yes, yeah, yes. So I see this um with our clients that have comorbidities. So ADHD is a big one, um, usually the one that's defined and noticed first. So they may have an autism diagnosis, but then in those early years in school, often get an ADHD diagnosis as well, and then are given an ADHD medication, uh, which are typically stimulants. So, what we'll see with those stimulants often is a reduced appetite. Um, really good focus. I can think of one of our clients right now that it's worked very well for him. Um, and so it's important to keep in mind when you're on a stimulant that can't come off of it right away. It needs to be tapered down because it does affect the heart. Wow. Um, it can also cause, and let me make sure that I'm correct by referencing my phymacological therapy book. Um that we sorry, behind the scenes, we're really quite nerdy.

SPEAKER_01 4:47

We're really don't know that about us. We have lots and lots and lots of books.

SPEAKER_00 4:51

Yes, yes, yes. So I am correct here. So you what you typically will have with ADHD medications are um are side effects, which are anti-cholinergic side effects. And what that means uh in my nursing school is you can't see, you can't spit, you can't pee, and you can't poop. Those are pretty big side effects. Yes. So it's you know, you basically you've been dried out, right? So we have dry mouth, we have dry eye, we have constipation. Um, there were some other uh effects that he spoke about in his uh talk, um, being adults were not able to ejaculate, for example, which when they had an expectation that they would be able to, sometimes in adult homes, would lead to behaviors. You can edit that out, Charlie, if you think that's too weird. Um but side effects are real. Side effects are real because these medications, um all medications, all medications, all treatments, even yes, do have additional effects that are not necessarily uh anticipated all of the time. The drugs that are typically uh prescribed for our clients usually fall into three classes. There's more than that, of course.

SPEAKER_01 6:03

He went over them. Dr.

SPEAKER_00 6:05

Did he went over them? He actually has a great table. He does. So we can put a link to his presentation because I think he's had he put it online. He's pretty brilliant, he's really smart.

SPEAKER_01 6:13

Yeah, but I did learn that one of the most it this tickled me. One of the most interesting things is that if you're on this drug, M-A-O-I, which stands for monoamine oxidase inhibitor.

unknown 6:29

Wow.

SPEAKER_01 6:29

And you eat cheese that you could die. Yes. And that shook me because the side effects can be really real, they can be very severe. And it's so important that both caregivers and parents and behavior analysts are really educated in the commonly used prescribed uh drugs to treat behavior, um, and also to treat ADHD, as you were saying, there's comabidity, and also to treat depression and anxiety and OCD. Yes. And it's really important. He went over a lot of the side effects, and a lot of the side effects I didn't know. Like I knew a lot, but he really filled it in whole pictures. So, what are some of the common drugs that are prescribed to both children and adults? Absolutely.

SPEAKER_00 7:19

So um, antipsychotic medications are often uh prescribed to people on the spectrum. Um, they are off label because an antipsychotic is really intended for people with schizophrenia or bipolar one. Um, but they are prescribed to autistic people for irritability. And is that resprodone and so resprodone or um abilify are like the two big ones that we hear a lot.

SPEAKER_01 7:45

So the side effects are really wild, and we come to see this quite often in these, and I I don't know why we're still allowing this in our society, but these medication commercials like Oh yeah, Sky Rizzy. I don't know what Sky Rizzy does, but I've seen the commercial at least 30 times is for an autoimmune disease. Oh, yeah, and um, you know, and then we hear the side effects, and a lot of times, and I don't know if this is true with Sky Rizzy or all the ones that I've heard over my time of watching TV, but um, a lot of it includes death.

SPEAKER_00 8:23

Yeah, yeah, and I think it's uh that's good to know. Yeah so one of the things that I learned early in nursing school was when you have someone who's very depressed and put them on an antidepressant, one of the big uh side effects to it can be suicidal ideation. And because they now have more energy because they're on the antidepressant, you see suicide rates go up at the start of medication. So it really is crucial to make sure that you're with that person, monitoring, that we're not leaving them alone. Um, because suicidal ideation is something that will pass. So that's why we do things like if someone is expressing that they want to harm themselves, put them on a hold for a day or a few days, because once some time has passed, that feeling will also pass. It's not to say that it won't come back, but to usher people through an episode like that can be life-saving.

SPEAKER_01 9:18

Um, and you've done a lot of that in your work because you also uh worked at a drug withdrawal clinic.

SPEAKER_00 9:28

So I worked in a hospital, two hospitals really, that provide detox services for alcohol opioids. One of them also um provided services for a benzo uh withdrawal as well. Um really wonderful um services available in some places. So uh shout out to Big Bear Valley uh hospital. They provide wraparound services and excellent, excellent mentorship, helping people to get through not only the withdrawal process, but then into life again. So they uh will help them to transition into rehab and then beyond.

SPEAKER_01 10:06

So and Dr. Friedman really drove home the point. And I like, I love this about it. And he said, you know, behavior analysts need to have a neutrality in how we uh look and speak about prescriptions that doctors are recommending. Because um, although they do need our data and they do like to see how the change in condition, right? So when a client uh goes on a new medication, the behavior analyst will do a change in condition line on our graph and we'll start tracking. Um, we put in a change of condition line because um medication is such a uh a confounding variable. It changes treatment uh so often. And then a lot of times, I remember Dr. Susan Schmidt Lochner at UCLA, I would always send her over my data after we did a medication change, and she would take a look at it and say how much she appreciated it. But it's so important that behavior analysts have a neutrality because that's really we talk about scope of competency and scope of practice, yeah, you know, and um, you know, the scope of competency and practice is to not have opinions on medications that doctors are prescribing or nurse practitioners, right? Yes. So my scope of competency and my scope of practice are actually very different than yours because you're a nurse practitioner. So I how do how do nurse practitioners um, you know, what is within their scope of competence?

SPEAKER_00 11:37

So nurse practitioners can work in a large variety of fields. Um, I am primarily interested in primary care. Um, typically, if we have a child that has a developmental disability or some type of neurological condition, um, they will be referred to a specialist, so a psychiatrist, a neuropsychologist, someone like that. Um and then our role is to monitor when they come in for their visits. But I just think that what we have to offer as behavior analysts is so valuable because we are in the home. And none of these, you know, nurse practitioners, physician assistant, physicians, psychologists that prescribe get to have that day-to-day access and to see the change. So I can imagine how happy she was to receive your data. Um, and that's what Dr.

SPEAKER_01 12:30

Freeman was saying is that yeah, you know, they need us, they need behavior analysts, they want to see the data because they're only given a certain limited amount of time to both diagnose and prescribe.

SPEAKER_00 12:42

Yes. And then when they come in for their visit, it's it's kind of a, well, how's it going? Have you noticed a change? Are you having any problems? And then they have to kind of move on. So uh to be able to have that in-depth eye in the home is huge. Um, it improves their treatment. And then also we can coordinate what we're doing with what they are doing, which is really ideal. Um, one of the studies um that Dr. Freeman uh presented uh mentioned how there have been studies that looked at just antipsychotics and antipsychotics with ABA therapy, and you improve when you have both. Um and again, just like ABA, it's not a one size fits all. You have different dosages that work, you have dosages that are kind of dangerous, and we have to really monitor. Um, you have dosages that are maybe too low and for that person not within therapeutic range. I love that.

SPEAKER_01 13:41

Dr. Friedman talked about uh toxicity levels, and he was saying that almost anything can have a toxicity level. And he gave the example of water, and it's like, yeah, you can run. And he gave Well and you can drink too much water and that can kill you too. Yeah. And um yeah, and he was talking about um these drugs have a therapeutic level, but they also have a toxicity level. And he was talking about the dangers of when the toxicity level and therapeutic level were close together. And I believe that's the time in the presentation when I leaned over to you and was like, like fentanyl, right? Yes, because we've had a big um crisis in our country over the last decade about fentanyl overdose.

SPEAKER_00 14:26

And yeah, it's very easy to overdose on fentanyl, but it's also interesting how people build tolerances because I've had people that have been in the detox program that could tolerate incredible amounts of drugs, but eventually, you know, you're gonna push too far. And and with uh opioid, for example, there's um central nervous system suppressant, so they basically just stop breathing. Their brain stops telling them to breathe. And that's how unfortunately, so many people have passed away from opioids. Um, an interesting thing about the therapeutic levels and the toxicity levels is that as we age, our body metabolism changes. So when you have I've noticed that when you have an elderly person, for example, who is often taking a lot of medications for a lot of chronic conditions, uh, it can be really dangerous in terms of how their bodies are able to metabolize and extreme that medication from their bodies.

SPEAKER_01 15:24

Um, what I'm getting from both you and the talk is that ongoing monitoring of effectiveness and also the side effects is really vital. But when you give it to a child, yeah, it's so important that everyone is aware of the side effects.

SPEAKER_00 15:40

And yes, the potential for problems to occur. Um, one of the things that he discussed in his talk, which I have seen clinically, I know you have as well. When you are on an antipsychotic, uh, there's often a side effect of extreme hunger. So these kids can gain a lot of weight. There's also hormonal disruption that can occur, and you will have gynecomastia where males will start to grow breast tissue, which for our teenage males can be really isolating. You're not likely to want to go to that uh pool party if you have to take off your top and look different.

SPEAKER_01 16:13

And that's with Respiridol. Yeah.

SPEAKER_00 16:16

And Respiridone and Respiridol, the same medication.

SPEAKER_01 16:19

What's the difference between them? Because I've heard both used. It's a very common behavioral men. Um, it also has a side effect of hunger, right? That's the big one. Yeah. Yeah. Ravenous hunger, where we've seen clients eating raw pasta and like taking, you know, powdered chocolate milk, like the quick and just being like, ah. Yeah.

SPEAKER_00 16:39

I have been told by people that it makes you feel like you have a hole inside you that just cannot be filled. Um, so the opposite of a zumpic, right? Yes, correct. Correct. Yes. So uh Raspiridone and Raspiridol are essentially the same medication. Resperidol, I believe, is the um uh brand name, where Rasperidone is the generic name. Uh interesting fact about drugs when they're developed. So a pharmacology pharmaceutical company will build um this drug, which is a very expensive process, by the way. Uh, as soon as the drug has been created, the active ingredient is named, and that is the generic name. That generic then is not available for a period of time while the pharmaceutical company recuperates the loss of funding for developing the drug. So the brand name will be available first and is often quite pricey. Then a period of time will go by and that protection is gone. You can still have that brand name drug, it's still on the market, but now other pharmaceutical companies can use that generic to produce new drugs. So the example that he used was Advil became ibuprofen, right? And you can get all these different types of ibuprofen.

SPEAKER_01 17:54

And that was also what I found very interesting about Dr. Friedman. And I was like, I don't, I think my doctor told me it was the same thing, but it's not. It's the same thing, it's different.

SPEAKER_00 18:05

It's the same, but different. It's the same active ingredient. What's different is the binder, right? So um you will get, and and with psychotropic drugs, it's a little bit different too, because the effect that you're looking at is not as physically measurable as like an antibiotic in your body, which we can measure by your blood. So I can tell you, you know, you've had this much vancomycin, you are within the therapeutic range, we have the, you know, trough, and we've got the higher end of that range that is effective and not toxic, right? But with a psychotropic medication, all of these things are sort of a, I think this is how it works. Like I think that it's reducing the dopamine, I think that it's affecting your serotonin levels. It probably is, but I can't take a measurement of your brain and say exactly where you are. So if you have a genetic genetic, excuse me, if you have a generic drug that has a different binder that makes more of that active ingredient available for you to absorb or less, you may have a different dosage that's currently active in your body as opposed to the brand with a different binder. So that's where we have a problem.

SPEAKER_01 19:18

Yeah, that's so interesting because I had a client who was on a seizure medication and she was doing very well on it. Seizures were way down. Um, they made her go to the generic version, and she did have an uptick. There were problems. And I remember her mom was like, I need your data to advocate to go back on the brand name. Yes. Because for some reason, the generic affected her very differently.

SPEAKER_00 19:44

And it was likely this binding capacity difference between the generic and the brand. So is that something parents should also look out for? Absolutely. And also when you switch from the brand to the generic, there may be a pretty big price difference. So your insurance company would prefer you be on the generic medication. I've noticed that. And sometimes that's just fine. And sometimes it's really not like you mentioned with your client. Uh, it wasn't meeting that therapeutic threshold to keep her from having seizures.

SPEAKER_01 20:17

Yeah. Yeah. I think for parents, it's really scary that you're going to be placing your child on when you say antipsychotic, it's like, whoa, like, oh my God. It scares me just saying the words. Um how did that term come about?

SPEAKER_00 20:36

Because obviously autistic people are not psychotic. That's, you know. Yeah. Well, so the drug wasn't developed for autistic people. The drug was developed for schizophrenics and people with bipolar one disorder that have very severe uh symptoms from their disorder. Um, it these drugs can be extremely effective. Um, Cerequel is another one that comes to mind. Um, very commonly prescribed and often tolerated pretty well. Uh, they have um sexual side effects, they also have the appetite side effects, which we discussed. Some of them are pretty tough, pretty tough to live with. So that's why, you know, often you'll hear about people with schizophrenia, for example, they're off their meds. The dog's very upset about that point. Yes, he's off his meds. So when people uh with schizophrenia, for example, decide to go off of their meds because these symptoms are too much to deal with, and then they have the schizophrenia symptoms come back, it can be really devastating. And it's kind of on and off and on and off. I spoke with someone not too long ago that I work with in the nursing world who has a relative with schizophrenia that uh will do this. He'll stop taking the medication and then he's getting arrested, and they put him back in, you know, psychiatric care, and then they get him back on his dreads, and then he's just the nicest guy ever.

SPEAKER_01 22:00

We we hear a lot about those statistics in the unhoused in Los Angeles. Absolutely. Um, which is concerning and is a a problem that's they're addressing. Yeah. They're addressing.

SPEAKER_00 22:11

And you know, I I I really feel for people because if the options were I'm gonna have this awful psychiatric disorder that prevents me from having relationships or having a functional daily life, um, or I'm going to be able to do those things, but I'm going to be overweight and I'm maybe going to have relationship problems because of the sexual side effects, or I'm going to just feel unwell in my body. You know, it's not a great choice. Those aren't really great options. Um, if you have a really great psychiatrist or doctor that's working with you, often they can kind of adjust things. And that's something that he mentioned in his talk that I thought was really important as well, is that sometimes we give a dosage and it works, but maybe it's a pretty high dosage, right? And then you wonder like the example he gave was Haldol. So oh yes, Haldol. Yes. And that's a common medication with some pretty intense side effects. You can get um uh neuroleptic malignant syndrome, uh, which basically is very dangerous and you can't do much about it. You just have to wait for the drug to come out of the system. Um, I've seen one uh patient that had, we think had that um and eventually was transferred to ICU.

SPEAKER_01 23:31

So many times the um developmental pediatricians, the MDs, the neuropsychs, uh they suggest uh drugs very early in life. Um, you know, when there is the core morbidity of the ASD diagnosis and the ADHD diagnosis, we often see stimulants. Yes. Yeah. And what are some common stimulants and what are the side effects?

SPEAKER_00 23:55

So methylphenidate andritalin is probably the most common that we see. Uh, those are the same drugs. Methylphenidate is the generic and Ritalin is the brand. Um, the this is going to be your appetite suppressant. This is also going to have that uh drying effect in the body.

SPEAKER_01 24:11

Um and we see that side effect with some of our clients who are on Ritalin and then just have a very tough time eating throughout the day, eating lunch.

SPEAKER_00 24:23

And we obviously very underweight, uh sleepy. Yeah, sleepy, a little bit um, you know, I have one client that comes to mind from many, many years ago um, who I would see during the week and on the weekend. And during the week, I would see him at the end of the day when he was done with school, and um the medication had pretty well worn off. And then I'd see him during the day on the weekend, and it was a completely different child. You know, he needed the medication to pay attention in school.

SPEAKER_01 24:54

They can have significant effects, both main effects and side effects, that people need to be aware of. Yeah. Um, they can have some wonderful uh main effects as well in terms of increased focus, the ability to learn, the ability to retain information, auditory acuity improves, visual acuity and social skills can improve as well when you're being, you know, you're able to actually focus on the other person and what they're saying, and you're not, you know, distracted by other things in the environment.

SPEAKER_00 25:23

So I think they have there are really positive things that can happen with medications. Um, and like you mentioned, as behavior analysts, it's not really our place to say do it or don't do it. Uh, that's a family decision that's made with their physician or their provider. Um what is really helpful about what we can offer is hey, we're seeing this improvement, or we're seeing a lot of this side effect that we're concerned about, or we're seeing this intense side effect and we need to go to the ER. He was saying, Dr.

SPEAKER_01 25:51

Freeman was saying that targeted dyskinesia, I don't know if targetive dyskinesia, yes, was um uh really happening across multiple populations at a very increased rate. Yes. Can you explain to um our audience and maybe some parents listening, like what that is and and what drugs um may have that side effect? Yes.

SPEAKER_00 26:14

So uh drugs that have what we call extraperymal side effects um are it's affecting how the brain and the nervous system run. Uh these can be permanent effects. And what this means is your mouth will move involuntarily. Um, people can have um like lip smacking, very common um pill rolling where they do this with their hands. Um also just difficulties with movement, like he mentioned the uh cogwheel um symptom. If we try to move their arm and it's like click, click, click instead of a smooth movement. Um, I think the reason that we're seeing more of these effects is that these drugs are being used more. For a long time, I don't think we had very effective drugs for a lot of these psychiatric problems, which is really devastating for people. You know, they really wouldn't be able to hold a job or maybe have relationships or uh, you know, all the great things in life that we all get to enjoy. So a lot of these drugs have really made that possible for a lot of people. Um, but if you're on them for a long period of time, that's when these symptoms will develop. So tardive dyskinesia is one of them. Um ataxia is another one where you just kind of can't really move much at all.

SPEAKER_01 27:33

But he also said that these drugs that are meant to come in, they're meant to do a job. And then he said that it was the physician's job to fade them out as well.

SPEAKER_00 27:44

Well, fade them down to the lowest dosage that will be effective. Okay. Because some of them, you know, if you have schizophrenia, for example, you're going to be on medications for your your lifespan, likely. Um I think when our autistic people are on them for irritability, uh, that's maybe more of a gray area. That's the mood stabilizing drugs, right? Yeah, so those are the antipsychotics, right? Um, that they're on for irritability. Also, I do believe ADHD, I do believe some people do wean off of those drugs eventually, and some people don't, you know. Um, again, personal choice between the family and the physician, and of course, the client. Um, but yes, they're not in the home, so they don't know exactly how this dosage is working. And one of the examples that he gave was working in an adult home, and it was an adult who was on Haldol. He really spoke to HADOL having some real issues. So HALDOL is a very intense drug. Um, it will definitely knock you out. So, for example, when we had have people come in um for uh detox and they would have some psychiatric issues as they're coming off. Um, or if you have someone who does need an antipsychotic or a schizophrenic person that's off their medication and you take them to the ER, often what they will be given is a cocktail of um 10 uh milligrams of Atavan, two milligrams of Haldol, 50 milligrams of Benadryl, and that will knock them out and they will sleep. Not right away. First you give it to them and then they fight you a little bit and then they fall asleep, uh, typically. Not always, sometimes.

SPEAKER_01 29:27

I mean, God bless the earth angels that are working in detox. That just sounds, I don't know if I could handle that on a daily basis. Honestly, interesting. I just do like because I couldn't imagine doing my job with people physically fighting you at times. I just, I mean, that takes a level, a scope of competency and practice that is you know that's above mine. And that's okay, you know, we all have our place, you know.

SPEAKER_00 29:52

It's a little different, you know. Um and it's it's interesting to you how people will respond differently to medications. So Atavan is one that's given a lot during detox. Some people, most people, it really relaxes them. And then there are others that have a paradoxical reaction where they become really aggressive. So um so different meds different work differently, and you don't really know.

SPEAKER_01 30:21

You don't really know, especially when you're dealing with uh medication that's going to affect the brain, how that individual will be responding to highly individualized, highly individualized, which makes value-based health care a real very dang serious thing. Yeah, it does seem very serious. Um, how about I name a medication and you tell me the side effects? I'm back in school. Yes, I'll try. Okay.

SPEAKER_00 30:47

Uh Depacote. So Depicote is an anti-convulsive medication. Um, I think side effects you have to be concerned about there are serotonin syndrome. But now I'm gonna look in my book and make sure that I got it right. Um yeah, there's there's a lot of drugs. I mean, look at this book.

SPEAKER_01 31:04

Yeah. I remember, and that's some of the continuity I care that happens when we speak to these phenomenal developmental pediatricians and neuropsyches, is that they will tell you the side effect to look out for. So for instance, Tenix, which was originally a seizure medication. No, it was a blood pressure medication. It was originally a blood pressure medication, but it has a side effect of really um messing with toileting habits. Uh, that is a common side effect that has occurred. Yeah.

SPEAKER_00 31:37

Um, one of the my favorites is uh trazodone, which is a sleep medication, but that's not what it was developed for. It was an antidepressant that had to be at a really high dosage to work. And then we noticed, oh, it does this other thing, and I totally knocked him out. And so then we started using it as a sleep drug. Um, I was told by the people I gave it to you, it also gives you really bad dreams, like very wicked nightmares, um, which is not a pleasant experience. I I you really feel for people that have to go through this journey of finding medications and getting to the right dosage because it is a journey. It's not just like, well, give him the drug and he's fine. Most of the time, it's we're gonna mess with the dosage, we're gonna try a different drug. We're gonna get this drug and then this drug to deal with these side effects from the first drug, right? So there's so many things that people go through.

SPEAKER_01 32:28

So I really think that Dr. Freeman really opened our eyes in terms of the continuity of care. I think where we can build the conversation is with parents. What are the right questions parents should be asking when they're discussing like medication with their doctor?

SPEAKER_00 32:45

Absolutely. So I think the first thing that the first conversation they should have is what is this medication intending to do? And is that matching up with what you're seeking? Um, because oftentimes you'll get a diagnosis, it's attached to a medication, and this is what I'm recommending. Um, I think having a specific behaviors that we're seeing are going to change, or specific things that we're going to see in his day-to-day experience that should be changing, that's important to know.

SPEAKER_01 33:16

So some of those characteristics would be like impulsivity, right? Extreme impulsivity, extreme aggression.

SPEAKER_00 33:23

Yes. Um yeah, so we should be seeing those changes. Are we more focused? Can we sit at the table and do the homework that we need to do? If I give you an instruction, can you remember it? If you go out of the room, very common ADHD results that we're looking for. Um, so understanding why you're taking the medication in the first place is really important because if you have multiple providers, which a lot of people do, you might end up on too many drugs all trying to do the same thing.

SPEAKER_01 33:51

Isn't that what happened to Michael Jackson?

SPEAKER_00 33:53

Is he on, I think so many people were prescribing drugs, but he was using uh propofol, which is a uh anesthetic for surgery, to sleep around that. Yeah. And yeah, that was a very unfortunate yes. I think that's pretty complex, that guy.

SPEAKER_01 34:08

Other things that other things that parents should know is that not all drugs um have the same time frame of effect. Correct.

SPEAKER_00 34:19

Yes, and it depends on the route in which it's delivered. Some drugs have a multiple amount of ways that you can deliver that drug. You can do it in an IV, you can do it in a shot into your muscle or into your fat, you can do it under your tongue or inside your cheek, you can take a medication that's oral. Uh, when you take a medication that's oral, it's going to go through what we call a first path effect, meaning it's going to go through your liver, some of it's going to be filtered out and will never be available to the body. And then what comes out on the other side of that is what will be available. Um, that takes a little longer than giving a shot or um putting it in your under your tongue or in your cheek. Um, there's a lot of veins in here that move stuff around, right? So uh the root is really important to know.

SPEAKER_01 35:05

And you also, like when you're getting a medication for your child, you also need a letter for the school because a lot of times a dose will be given at the school.

SPEAKER_00 35:15

That should be collaborated with your school nurse. Um, I think it's pretty challenging when there isn't a nurse at school. Um, most public schools, I think, are required to provide that service. But um, yes, you don't you don't want drugs just in the backpack. Um really easy to make mistakes, dangerous. Yeah. And some drugs really look the same, and some drugs really sound the same. So they have very similar names. Um we were discussing earlier today a nurse that made a mistake a few years back with a similar sounding drug that resulted in someone's death. So it can be very serious working with medications. So, yes, understanding why you're taking it, understanding how you're taking it and when is really important. Understanding what happens if you miss a dose is really important for families to know, like, oh, well, you know, I did miss this dose. Do I take give them another one now? Do I wait until later? Do I give them a double? You know, there's a lot of different um things to know in terms of giving that medication.

SPEAKER_01 36:23

Um, and then so the some of the questions for parents would be, oh, what effects am I supposed to see ideally? Yes. What are the common side effects that you need to look out for from and how do I mitigate those?

SPEAKER_00 36:36

Do we need to be drink like having a little candy in our mouth or having water to help with those drymel, for example, symptoms?

SPEAKER_01 36:43

And then can I get a note for the school nurse if medication needs to be distributed at school? And then also um how it reacts to other medications and when the follow-up appointment is. Yes. Is there anything else that parents should know?

SPEAKER_00 37:02

I think they should have uh a plan in place for something adverse happens now. What do I do? Do I take them to the ER? Do they just call the doctor? Do I um induce vomiting, right? Like what is a safety plan. Safety plan is so important when you're dealing with medications at home.

SPEAKER_01 37:20

And behavior analysts should remain very neutral because these medications, although we've talked about side effects, and actually Dr. Friedman talked about like necropathy of the skin or uh. So Stevens Johnson syndrome comes with certain medications and also uh antibiotics where the skin actually dies and falls off, and that can be fatal. Whoa. Yeah, yeah, that is an intense side effect.

SPEAKER_00 37:44

Yeah. So if you're taking a new medication, you develop a rash and they tell you to look out for Stevens Johnson syndrome. If you see any redness at all, yeah. That's an emergency and it can be undone, but you really have to intervene quickly. Yeah.

SPEAKER_01 37:58

And really, it is not the behavior analyst's place to recommend. Absolutely. It is really there to support with observational data if they're interested in that. If the doctor calls for that, if you're doing continuity of care.

SPEAKER_00 38:12

Yeah. And it's helpful too for us to know, I think, when we're looking at behavior change. Um, like I said, there is a paradoxical reaction with some medications. So maybe we're expecting it to do this, but our data shows it does the opposite. And so I think that's really helpful to know when you're starting a new medication. So always changing condition line for every new med change. Documentation and then just keeping an eye out. Like, how are we doing? Is it working? Are we seeing a lot of side effects? How can I support you at home?

SPEAKER_01 38:38

Because sometimes these medications are given to um autistic people who might have communication deficits and they can't even tell you the side effects. You know?

SPEAKER_00 38:48

Yeah.

SPEAKER_01 38:49

Um, so the side effect might look like instead of expressing like I'm itchy, they might like run around and be hyper.

SPEAKER_00 38:57

Like I have a really bad headache. It might turn into SIB, right? You might have self-injury because I'm trying to get this pain to go away. Um, it's so that's a really great point when we're dealing with those who cannot communicate. We really have to have a sharp eye on changes in that we're seeing in their behavior and their personality and their interactions that will show us, you know, what's going on here and what can we do to help them.

SPEAKER_01 39:20

Well, thank you, Dr. Freeman, for your amazing presentation at APBA. We absolutely enjoyed it. And thank you, um, nurse Sarah of course giving insights here on the pharmacology that is really common in behavioral treatment.

SPEAKER_00 39:35

Yeah, and you know, really, really uh collaborate with those primary care providers. I'm a very new nurse practitioner, which is why I still have my pharmacotherapy book uh with us today to make sure I didn't say the wrong things. Um, but yes, always, always communicate and collaborate when we can.

SPEAKER_01 39:50

Well, this wraps it up for Aquines to Oaks. I hope this was beneficial. Um, and if you get a chance to check out Dr. Thomas Freeman's uh presentation, uh please do. It is well worth the time.