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Parents
Medication Guide
Autism Parents Medication Guide Work Group
CO-CHAIRS:
Matthew Siegel, MD and Craig Erickson, MD, MS
MEMBERS:
Jean A. Frazier, MD
Toni Ferguson, Autism Society of America
Eric Goepfert, MD
Gagan Joshi, MD
Quentin Humberd, MD
Bryan H. King, MD, Representative to the American Psychiatric Association
Amy Lutz, EASI Foundation: Ending Aggression and
Self-Injury in the Developmentally Disabled
Louis Kraus, MD, Representative to the American Psychiatric Association
Alice Mao, MD
Adelaide Robb, MD
Jeremy Veenstra-VanderWeele, MD, PhD
Paul Wang, MD, Autism Speaks
STAFF:
Carmen J. Head, MPH, CHES, Director, Research, Development, & Workforce
CONSULTANT:
Eve Bender, Scientific Editor
2016 American Academy of Child and Adolescent Psychiatry, all rights reserved.
Table of Contents
Introduction...............................................................................................................................................................4
References............................................................................................................................................................ 22
W
hat is ASD? Autism spectrum Why consider medication in ASD? People
disorder (ASD) is a developmental with ASD often experience a host of
disorder characterized by problems difficulties that can be as problematic
with social communication, unusual behaviors as the symptoms of ASD itself. Anxiety,
such as fixed interests, being inflexible, having mood instability, impulsivity, hyperactivity,
repetitive behaviors, or abnormal responses to sleep problems, and even aggression and
sensations. Communication problems include self-injurious behavior can occur in some
difficulty understanding and responding to people. Just as it would be for other medical
social cues and nonverbal communication problems, medication may be helpful in
such as gestures and tone of voice, which treating some of these difficulties. The
can result in challenges in making or keeping use of medication is more often aimed at
friends. Although people with ASD may want treating the symptoms of these associated
to make friends, difficulties in understanding conditions, which we can characterize
social norms or correctly interpreting language as emotional and behavioral challenges,
and facial expressions can get in the way. than for core symptoms of ASD itself, as
no medications have shown clear benefit
In recent years, it has become clear that for social communication impairment or
individuals with ASD, despite sharing some restricted, repetitive behaviors.
behavioral challenges, can be quite different
from one another. Some people with ASD Sitting down with an expert to discuss
may be very intelligent, while others may have whether it is a good idea to try medication
cognitive challenges. Some may have advanced for certain troublesome symptoms in your
vocabularies and others may speak very little child with ASD is reasonable. Although
or not at all. Previous attempts to subdivide the best approach to addressing those
the population on the basis of language and symptoms may not include medication, it
cognitive ability have not been supported by can be helpful to learn about various options
research. Thus, people in the same family and/or begin to gather information on
with autism or who share the same genetic the frequency and intensity of behaviors
risk factor(s) can end up with very different that may ultimately be targets for
symptoms and outcomes. medication treatment.
W
hen a challenge presents itself, it providers can assess the functioning of the
is time for an assessment. The first family and how family relationships could relate
step in helping a child with ASD to to problems, as well as evaluate for co-existing
get assistance with an emotional or behavioral mental health disorders in the child such as
challenge is to have him or her evaluated by anxiety or ADHD. Psychologists and other
an expert or team of experts. Since many experts in behavior can assess factors that may
factors may contribute to these emotional maintain or reinforce the problem behavior(s),
and behavioral problems in a child with ASD, it and can use applied behavioral analysis
is ideal to have the child assessed by a team techniques, as outlined below. The possibility
whose members can consider different causes of a medical issue underlying the emotional
and approaches. In reality, most children will or behavioral symptoms can be assessed by
only have access to a single provider, or the a physician or other medical provider. Finally,
childs emotional or behavioral problems are an occupational therapist can assess the role
severe enough that there is a need to act of over or under sensitivities and challenges in
quickly. Even in these situations, it is important daily living and self-help skills, such as dressing,
for the clinician who evaluates the child to bathing, and eating.
consider multiple sources for the problem, and
refer the child for further assessment if needed.
Children with ASD often have difficulty Speech-language pathologists can recommend
learning. Applied Behavior Analysis (ABA) is an assistive communication system after
an educational and therapeutic approach that a careful evaluation of the unique abilities,
involves breaking down tasks and skills into needs, and communication goals of the
their smallest parts, then teaching them slowly child. Preliminary studies have shown that
while encouraging, shaping, and reinforcing assistive communication devices are generally
functional behaviors and discouraging harmful liked by users and may improve functional
or disruptive behaviors. ABA focuses on communication in children with ASD.3
the relationship between a certain behavior,
the factors that were present before the Cognitive Behavioral Therapy
behavior (antecedents) and the results of Cognitive Behavioral Therapy (CBT) is a type
the behavior (consequences). ABA has been of psychotherapy in which a persons negative
successful in helping children with ASD improve thoughts are challenged in order to reduce
Social skills are verbal communication, academic performance, social associated troubling emotions and behaviors.
behavior, and adaptive living skills as well as CBT is problem-based, meaning that it is used
and non-verbal addressing specific problem behaviors.1 to address the specific concerns of a patient.
behaviors necessary for CBT has been shown to be an effective treatment
positive and effective Communication supports for anxiety in individuals with high functioning
While speech is generally the preferred method ASD (HF-ASD), and it may also be helpful in
social interactions, and of communication in our society, not all children addressing disruptive behaviors, like aggression,
include eye contact, with ASD can use speech effectively. For children and in improving social and communication
who have limited or no verbal ability, alternative skills.4 CBT is typically administered by a
smiling, and asking methods of communicating have been therapist, but parents and teachers may also
and responding developed to improve communication. access books or web-based CBT guides.
to questions. Communication supports are tools to help
children with ASD communicate. A non- Social Skills/
electronic method that has been shown to Social Cognitive Training
increase communication in children with Social skills are verbal and non-verbal behaviors
ASD is the Picture Exchange Communication necessary for positive and effective social
System (PECS), where the child uses pictures interactions, and include eye contact, smiling,
Life Skills
The countless tasks of daily livingincluding
dressing, bathing, mealtimes, homework,
free time, toileting, and waitingpresent
many opportunities for challenging behavior
each day. As children become adolescents
and young adults, new tasks to learn
include keeping their own schedules or
appointments, asking for help, caring for
their own belongings, preparing meals,
navigating transportation, and learning a
trade. An occupational therapist and other
providers can help establish routines and
teach these life skills. By breaking tasks into
parts, making visual charts outlining steps,
presenting rewards for step completion,
and implementing this plan consistently,
especially to the shoulders. The evidence
caregivers can teach life skills to children Occupational therapists
for such interventions is not convincing so
with ASD. Before trying to manage
far, however, due to problems with study can assess the childs
problem behaviors through other means,
consideration should be given to whether methods and research design. Occupational sensory system and direct
the child has adequate support to meet the therapists can assess the childs sensory
system and direct these interventions to these interventions to help
goals being set for them.
help address sensory factors. address sensory factors.
Sensory Interventions
Possible contributing causes of challenging Treatment of
behavior in a child with ASD include Medical Problems to more rare causes. Poor sleep patterns
abnormal sensory responses. Children Prior to starting any therapy for a behavioral should be initially addressed with good
may avoid sensory input, including certain or emotional problem in ASD, consideration sleep hygiene, such as removing television
textures (mushy foods, scratchy labels in should be given to a possible medical and video screens from the bedroom,
clothing), excessive movement (crowded cause. The extent of a medical evaluation having a set bedtime and a bedtime
stores, busy city streets), or noises (fire routine, and learning to fall asleep without
should be decided in collaboration with an
alarms, barking dogs). They may also seek a parent present.
experienced medical provider. A sudden
out sensory experiences, such as tickling or drastic change in behavior may warrant
Medication side effects themselves can
or deep pressure, or more frequent and a more thorough evaluation. The medical contribute to problem behaviors. Possible
intensive movement, such as running, problems mentioned here do not represent medication side effects include changes
climbing, or spinning in circles. Preventing an exhaustive list, but are often causes of in sleep, sedation, cloudiness of thinking,
a childs sensory-seeking or sensory- behavioral problems in children with ASD. constipation, and agitation, among others.
avoiding behaviors can cause distress and/
or tantrums. Interventions for sensory- Sleep problems are present in many When a child experiences pain, yet is
related problems include weighted vests, children with ASD. Inadequate sleep unable to express clearly the nature
swinging, or regular sessions of jumping can certainly contribute to behavioral or source and intensity of the pain,
or bouncing, and applying deep pressure, problems and should be considered prior behavioral changes may result. For
I
n addition to the interventions outlined in and family physicians often see many children
the previous chapter, medication is another with ASD, and many times can appropriately
tool that may play a role in the treatment of recommend a medication for symptoms. Others
the child with ASD. It is important to recognize, with more specialized training include child and
however, that the medications currently used adolescent psychiatrists, child neurologists, and
to treat symptoms and behaviors associated developmental-behavioral pediatricians. Parents
with ASD have not at this point in time been should feel free to ask doctors about their level
shown to improve the core features of autism. of training and experience with patients with
In other words, there is no medication to treat ASD, and if they feel comfortable prescribing
the autism itself. medication, or if they prefer to seek consultation
from more specialized or experienced providers.
Medication may be recommended to reduce
symptoms of an emotional or behavioral disorder
in a child with ASD. These co-occurring disorders
Important Factors to Consider for
are more common than once thought, and Medication Treatment
include ADHD, anxiety, and depression, among Informed consent. A clear and thorough
others. The symptoms and findings that lead discussion between the parent or guardian and
to these diagnoses are the same as those for the prescriber should explain the diagnosis,
children without ASD, but may require a provider symptoms, non-medication treatment options,
with experience in ASD to recognize them. and expected duration of treatment. For
the child or adolescent taking medication,
Armed with this knowledge, it may be easier the provider can obtain his/her permission
to understand some of the reasons for use by offering information about why they are
of medication in children with ASD. Use of taking medication and the symptoms that
medication in ASD is common, but the number the medication is meant to treat. These
of children with ASD that are prescribed discussions should take place not just at
medications has also raised concerns among the beginning of medication treatment, These co-occurring
some doctors and parents. A study in 20139 but be ongoing, so that as issues arise and
symptoms change, treatment can be modified
disorders are more
reported that nearly two out of three children
with ASD had been prescribed a psychoactive to meet the childs needs. common than once
medication during the three-year study period,
Risks and expected benefits. Risks include thought, and include
and one in seven children had been treated with
three or more medications at the same time. the known side effects from the product label ADHD, anxiety and
(if studied in children and adolescents), adult
Appropriate use of medication requires an use side effects (may have different side depression,
ongoing trusting relationship between parents effects than in youth), published research, and among others.
and providers, and clear information about when the experience of the treating clinician with
to use and not use medication for symptoms in the medication. Expected benefits would be to
children with ASD. When parents have questions reduce the target symptoms. If the medication
about medication use in their children, they is effective in reducing target symptoms,
should seek the advice of a professional with other benefits may arise, including improved
training in ASD. Board certified pediatricians functioning in school, with peers, and at home.
M
edications can be used to target a disorders. Haloperidol (Haldol), another anti-
wide range of specific symptoms psychotic, also has evidence of benefit for
in children and adolescents with irritability and aggression, suggesting that this
ASD, some of which are listed below. A table general class of medications may be helpful
summarizing the controlled research evidence in children with ASD. Little evidence supports
for medications in children with autism is other types of medications; although the side
located at the end of this guide. effects associated with antipsychotics can
lead parents and physicians to try medications
Irritability, tantrums, and aggression: that have single controlled studies to support
Irritability, tantrums and aggression are their use, including clonidine or guanfacine
common reasons for families to seek (Tenex or Intuniv).
treatment for their child with ASD. Children
who are irritable are prone to become upset or Self-injurious behavior (SIB) can be a
angry easily, sometimes leading to tantrums, significant and distressing problem for children
property destruction, or aggression. Irritability and their families. Almost 11% of children with
can range from mild, where the only noticeable ASD in a community survey were stated to
problem is that a child cries more easily than have SIB, including hitting, biting, or scratching
peers when frustrated; to severe, where a child directed at themselves.11 SIB can range from
may be so prone to aggression that they need mild to very severe. Some children will engage
to be hospitalized. Addressing symptoms in a mild self-injurious behavior, such as lightly
when a child is young may prevent them hitting their chin, but may do it so often that
from worsening as a child gets older and over time they eventually produce an injury.
Clinicians should physically larger. Clinicians should evaluate Other children may only occasionally engage
evaluate the potential the potential contributing factors to irritability in self-injury, such as banging their head on an
and aggression in a particular child before object, but may do it with such force, that even
contributing factors
prescribing medication, as detailed in the a single episode could cause serious injury. Self-
to irritability and assessment section of this guide. injury that is part of a suicidal episode (such as
cutting ones wrists) is less common in children
aggression in a Medication can be considered to reduce with ASD, though some higher-functioning
particular child before irritability and aggression when contributing individuals may engage in suicidal actions.
factors do not appear to explain the symptoms
prescribing medication, or these contributing factors have been The best evidence for effective treatment of
as detailed in the addressed without resolving the problem. SIB is with applied behavioral analysis (ABA).
Two anti-psychotic medications, risperidone In this method, the provider performs an
assessment section (Risperdal) and aripiprazole (Abilify) have been analysis to try to determine the source of the
of this guide. shown to reduce tantrums and aggression SIB, which is typically escaping from demands,
in multiple large controlled studies in accessing preferred items or activities,
children with ASD, but each of them can also attention-seeking, or changing sensory
lead to significant side effects, including input or pain.12 Functional communication
increased appetite and weight gain, changes strategies have also been shown to reduce
in cholesterol, sedation, and movement problem behaviors in ASD, including self-
* Intellectual Disability=IQ<70;
** Behaviors under irritability include aggression, deliberate self-injury, and temper tantrums; NR=Not reported; AEs=Adverse effects; OCD=obsessive compulsive disorder; EPS=Extra-pyramidal symptoms; SIB=Self injurious
behaviors; URI=Upper respiratory tract infection; LDL=Low-density lipoprotein; HDL= High- density lipoprotein; TG=Triglycerides; MPH=Methylphenidate;
Medication Tracking Form
Use this form to track your childs medication history. Bring this form to appointments with your provider
and update changes in medications, doses, side effects and results.
4. Danial JT, Wood JJ. Cognitive behavioral 11. Lecavalier L. Behavioral and emotional
therapy for children with autism: review and problems in young people with pervasive
considerations for future research. J Dev developmental disorders: relative prevalence,
Behav Pediatr. 2013;34(9):702715. effects of subject characteristics, and
empirical classification. J Autism Dev Disord.
5. Hartup WW. Social relationships and their 2006;36(8):11011114.
developmental significance. American
Psychologist. 1989;44(2):120126. 12. Doehring P, Reichow B, Palka T, Phillips
C, Hagopian L. Behavioral approaches to
6. Rao PA, Beidel DC, Murray MJ. Social skills managing severe problem behaviors in
interventions for children with Aspergers children with autism spectrum and related
syndrome or high-functioning autism: a developmental disorders: a descriptive
review and recommendations. J Autism Dev analysis. Child Adolesc Psychiatr Clin N Am.
Disord. 2008;38(2):353361. 2014;23(1):2540.
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2016 American Academy of Child and Adolescent Psychiatry, all rights reserved.