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Autism: When to Consider Medications

When should parents consider treating autism spectrum disorder with drugs?

Many parents are terrified of the prospect of using medications to treat their child for symptoms associated with autism spectrum disorder (ASD). They feel these medications should be used as a “last resort.” Admittedly, I too felt this way about treating my own daughter until her symptoms became too severe to ignore. I finally realized that her tantrums and aggressive episodes were going to greatly impact her future learning and socialization, as well as how people perceived her.

Over the last decade of treating ASD, I have found that most parents simply need to be educated on the real—not perceived or exaggerated—side effects and risks of the medications used in treating symptoms associated with ASD. Although not all children with autism spectrum disorder need medications, a discussion and consideration of medications is often necessary. Failing to start medications when needed is later regretted by parents.

Of course, weighing the risks and benefits of medication by the provider and the family is always appropriate. However, parents must appreciate the full impact of deciding against medications. They must understand that refusing medications to avoid possible side effects is also choosing many potential downstream behaviors and outcomes from not treating. Deciding to not use medications may also have adverse consequences. If a parent can coherently weigh treating their child with medications versus without medications and yet still decide not to treat, then this may be very appropriate. It should be noted that some form of treatment, such as applied behavior analysis, is always necessary for ASD regardless of medication use.

The medication types commonly used to treat those with ASD are stimulants, nonstimulants, atypical antipsychotics, and selective serotonin re-uptake inhibitors (SSRIs). Insomnia can be treated with melatonin, clonidine, or trazodone after proper sleep hygiene has been tried.

Stimulants are medications such as methylphenidate or amphetamine products. These stimulants have many different generics and brands with differing lengths of action and delivery methods such as pills to swallow, a patch to place on the skin, liquids, and medication to be sprinkled on food, etc. The most common side effects are insomnia, decreased appetite, and irritability. These medications can help treat the ADHD symptoms of inattention, hyperactivity, and impulsivity that commonly co-occur with ASD. At times the child’s frustration and irritability are also reduced with this medication. Most of the evidence base in treating those with ASD plus ADHD is with the use of methylphenidate products. Stimulants work the same day they are tried and results can be dramatic. Parents should call their provider immediately if their child has significantly worsened tantrums or aggression on a stimulant. Although effects on growth and height are usually negligible, these will be monitored by your provider.

Nonstimulants can be used when a child cannot tolerate stimulants especially due to irritability, aggression, or even markedly reduced appetite. Included within nonstimulants are Strattera (atomoxetine), Intuniv (guanfacine ER), and Kapvay (clonidine ER). These medications generally are weaker in effect compared to stimulants and so are usually used as second-line medications. However, especially guanfacine ER and clonidine may be used to decrease anger as well as ADHD symptoms. These medications do take longer than stimulants to take full effect such as two or more weeks.

The atypical antipsychotics are used to treat tantrums, aggression, irritability, and self-injurious behavior (SIB) associated with ASD. Within this class of medications are risperidone (Risperdal) and aripiprazole (Abilify) which are FDA-approved for the control of these serious and impairing symptoms. These medications can be very effective. For example, the child may go from tantruming several times a day for 30-60 minutes at a time and being unable to participate in educational or social activities, to tantruming two times per week for 5-10 minutes and being able to participate in activities. Often the child’s most impairing and disruptive symptoms are those that can be treated with this class of medication.

However, these medications can have more serious side effects. As such, the decision to use these medications should not be taken lightly. But this class of medication should not be avoided simply out of fear. The most common immediate side effects are often weight gain and increased appetite. Potential long-term side effects include increased cholesterol/lipids, increased blood sugar, rare gynecomastia (abnormal breast development in males), and abnormal muscle movements which could be permanent (very rare).

Selective serotonin re-uptake inhibitors (SSRIs) can be used for anxiety or obsessive-compulsive disorder (OCD) that can co-occur with ASD. The typical SSRIs used in children with ASD are sertraline (Zoloft) or fluoxetine (Prozac), but other SSRIs may be used. These are generally well-tolerated. The most common side effects are nausea and diarrhea. In very rare cases, a child might have suicidal thoughts, especially if being treated for depression. Social anxiety should be treated with therapy or medication plus therapy as this anxiety will further compound the child’s social impairments.

I would advise that every child with ASD be evaluated by a child psychiatrist at regular intervals throughout their life to consider whether or not medication treatment is appropriate.

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