Natalie Roth, Ph.D.
It can often be confusing to sort through the numerous intervention options for Autistic Spectrum Disorders. Possibly one of the more challenging decisions for parents with children that have ASD’s is whether or not medication is an appropriate addition to a treatment plan. In my experience, most parents feel a profound sense of responsibility in making this choice for their child. They often express concern about their child’s comfort and safety, and I regularly hear parents talk protectively about wanting to maintain their child’s unique personality, even if his/her behaviors can sometimes be problematic. At the same time, parents want to maximize their child’s ability to make use of and develop the skills they have so that they are best able to function at school, at home, and in their community. Navigating this decision often requires parents to carefully balance the potential benefits of medication use against the potential drawbacks. This weighing of options is not always easy as neither the benefits nor the drawbacks are not always immediately apparent. As I’ve talked with parents who have been through this process these are a few points that I’ve found to be helpful:
· Keep in mind that there are no medications that treat the core symptoms of Autistic Spectrum Disorders directly (those being delays in speech/communication, qualitative delays in social functioning, and patterns of repetitive/stereotypic behavior). Medication can be very helpful in reducing behavior outbursts, alleviating anxiety, and lessening obsessive thinking or compulsive behavior, for example. This, in turn, can lead to an improved ability to manage some of the challenges of the core symptoms, but it will not alleviate them altogether. It’s important that medication trials be undertaken with realistic expectations.
· Appropriately, most doctors prescribing to children will begin with a low dose of medication to determine whether or not it is well tolerated. However, this low dose may not be within a therapeutic range for your child initially, and I encourage parents to prepare themselves to be patient as they work with their doctor to determine the right dosage.
· Children with ASD sometimes respond differently to medication than is typical. It is important to work with a prescribing doctor who is open to communicating with you about your child’s individual response. As a parent, you should feel supported by your medical providers in your attempt to advocate for the appropriate dose/timing of any medication. You will be the person who is most sensitive to both positive and negative effects of medication and this perspective should be valued.
· A doctor will describe the side effect profile that accompanies medication use. While potential side effects of medication should be considered, I also frequently advise parents to think through the “side effects” of not treating a behavioral/emotional issue that might benefit significantly from medication. Research with children who have ADHD, for example, suggests that those children effectively treated with medication were less likely to become involved in drug/alcohol use because their symptoms were managed.
· Medication for any developmental disorder is most effective when it is part of a more comprehensive treatment plan. Medication can have important benefits, but shouldn’t take the place of therapies designed to teach skills.
· It can be helpful to seek out a doctor or a child psychiatrist who has experience treating children with Autistic Spectrum Disorders. Experience with how certain types of medication affect particular symptoms, how medications work together, and how children with ASD’s respond differently to medications can be invaluable.
· I encourage parents to identify (with the help of their doctor and therapists) 2 or 3 particular behaviors that they are trying to address with medication. Before starting a medication trial, I suggest that they keep some simple data on how often they observe the target behaviors on a daily basis (or during certain times of the day). Once medication has reached a therapeutic dose, continue to keep data on the occurrence of the behaviors during the same time frame to give them some concrete way to monitor its effectiveness.
For those who are interested in the types of medication that are most frequently prescribed for children with Autistic Spectrum Disorders, the following information is adapted from information provided by the National Institutes of Health:
Medication and Autism
Medications are often used to treat behavioral problems such as aggression, self-injurious behavior, and severe tantrums, that keep the person with ASD from functioning more effectively at home or school. The medications used are those that have been developed to treat similar symptoms in other disorders. Many of these medications are prescribed "off-label." This means they have not been officially approved by the FDA for use in children, but the doctor prescribes the medications if he or she feels they are appropriate for your child. Further research needs to be done to ensure not only the efficacy but the safety of psychotropic agents used in the treatment of children and adolescents.
Anxiety and depression. The selective serotonin reuptake inhibitors (SSRI's) are the medications most often prescribed for symptoms of anxiety, depression, and/or obsessive-compulsive disorder (OCD). Only one of the SSRI's, fluoxetine, (Prozac) has been approved by the FDA for both OCD and depression in children age 7 and older. Three that have been approved for OCD are fluvoxamine (Luvox), age 8 and older; sertraline (Zoloft), age 6 and older; and clomipramine (Anafranil), age 10 and older.4 Treatment with these medications can be associated with decreased frequency of repetitive, ritualistic behavior and improvements in eye contact and social contacts. The FDA is studying and analyzing data to better understand how to use the SSRI's safely, effectively, and at the lowest dose possible.
Behavioral problems. Antipsychotic medications have been used to treat severe behavioral problems. These medications work by reducing the activity in the brain of the neurotransmitter dopamine. Among the older, typical antipsychotics, such as haloperidol (Haldol), thioridazine, fluphenazine, and chlorpromazine, haloperidol was found in more than one study to be more effective than a placebo in treating serious behavioral problems. However, haloperidol, while helpful for reducing symptoms of aggression, can also have adverse side effects, such as sedation, muscle stiffness, and abnormal movements.
Placebo-controlled studies of the newer "atypical" antipsychotics are being conducted on children with autism. The first such study, conducted by the NIMH-supported Research Units on Pediatric Psychopharmacology (RUPP) Autism Network, was on risperidone (Risperdal). Results of the 8-week study were reported in 2002 and showed that risperidone was effective and well tolerated for the treatment of severe behavioral problems in children with autism. The most common side effects were increased appetite, weight gain and sedation. Further long-term studies are needed to determine any long-term side effects. Other atypical antipsychotics that have been studied recently with encouraging results are olanzapine (Zyprexa) and ziprasidone (Geodon). Ziprasidone has not been associated with significant weight gain.
Seizures. Seizures are found in one in four persons with ASD. They are treated with one or more of the anticonvulsants. These include such medications as carbamazepine (Tegretol), lamotrigine (Lamictal), topiramate (Topamax), and valproic acid (Depakote). The level of the medication in the blood should be monitored carefully and adjusted so that the least amount possible is used to be effective. Although medication usually reduces the number of seizures, it cannot always eliminate them.
Inattention and hyperactivity. Stimulant medications such as methylphenidate (Ritalin), used safely and effectively in persons with attention deficit hyperactivity disorder, have also been prescribed for children with autism. These medications may decrease impulsivity and hyperactivity in some children, especially higher functioning children.
Several other medications have been used to treat ASD symptoms; among them are other antidepressants, naltrexone, lithium, and some of the benzodiazepines such as diazepam (Valium) and lorazepam (Ativan). The safety and efficacy of these medications in children with autism has not been proven. Since people may respond differently to different medications, your child's unique history and behavior will help your doctor decide which medication might be most beneficial.
I’m continually amazed at the thought and effort that parents dedicate to their children with ASD’s. In many cases, medication can be an option worth considering in the context of a more comprehensive treatment plan. Best wishes to all of you who are continuing on the journey to understand and provide the best for your children.