Magazine article Clinical Psychiatry News

Treating Autism-Related Behavioral Problems

Magazine article Clinical Psychiatry News

Treating Autism-Related Behavioral Problems

Article excerpt

Surveys have shown that half of young patients with autism spectrum disorders are prescribed psychotropics, but drug treatment for autism's core social and communication impairments remains "more a goal and a hope than a reality," said Dr. Bryan King, director of child and adolescent psychiatry at the University of Washington, Seattle.

Still, pharmacotherapy research has become active in this area, and the first Food and Drug Administration approval for an autism-related indication was hailed as a milestone ("FDA Approves First Agent for Treating Autism Symptoms," November 2006, p. 1).

As exemplified by the approval of risperidone (Risperdal) for "irritability associated with autism" in children and adolescents, "most of the focus has been on the presence of maladaptive behaviors that occur frequently and arguably cause more difficulty than core symptoms," Dr. King said.

The severe disturbances for which risperidone is indicated, including aggression and self-injurious behavior, are the most urgent motives for pharmacotherapy. Other frequently medicated symptom clusters are hyperactivity and impulsivity, repetitive behavior and associated anxiety, and mood instability, he said.

Medications are probably most common with school-age children and adolescents. 'At around 4 or 5 years, we start seeing the emergence of target symptoms for which they may be helpful," said Dr. Christopher J. McDougle, the Albert E. Sterne Professor and Chairman of Psychiatry at Indiana University, Indianapolis. "In many cases, medications can be reduced or discontinued as patients move into adulthood, as hyperactivity and aggression can lessen over time," he said.

An argument can be made for starting medication earlier rather than later, said Dr. David Posey, chief of the Christian Sarkine Autism Treatment Center at Indiana University. "You want to consider if symptoms are not only disruptive to the caregiver but starting to interfere with the child's ability to be in the classroom and to benefit from available [behavioral] treatments," he said.

In general, greater intellectual impairment is associated with more behavioral disturbances and so with pharmacotherapy, Dr. King said. Mood disorders appear to be more frequent in Asperger's syndrome, however, perhaps because these patients are more aware of their social deficits or have higher expectations, he suggested.

Drug choice is usually driven by the chief complaint, although "things like irritability and aggressiveness tend to trump the others," Dr. Posey said. Here, an atypical antipsychotic is usual, and its approval makes risperidone a logical first choice. Among other atypicals, aripiprazole (Abilify) has gained favor, particularly when weight is an issue. Doses are generally low, he said: 1-2 mg of risperidone for children and 2-3 mg for adults.

Irritability and disruptive behaviors that wax and wane suggest mood dysregulation, for which Dr. King would consider a mood stabilizer: "I'd look at lithium or anticonvulsants like valproate or carbamazepine."

Hyperactivity, impulsivity, and inattention are extremely common. "There are a lot of similarities to attention-deficit/hyperactivity disorder," but the response to psychostimulants is more problematic, Dr. King said. A large multicenter study sponsored by the National Institute of Mental Health found methylphenidate to be more effective for hyperactivity than was placebo, but the response rate was lower than that in ADHD--closer to 50% than 70%--and tolerability was poorer. …

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