Medications for behavior challenges in autism

There are no autism-specific medications. All medications used to treat people with autism are also used by physicians to treat other conditions, such as epilepsy (antiepileptics) anxiety disorder, or explosive rage outbursts (psychotropic medications). Most pediatricians avoid prescribing psychotropic medications to children under 6 or 7 years of age unless their behavior is severely out of control (e.g. severe self injury). In general, most physicians recommend parents and/or staff members working with children and older individuals with autism should obtain assistance implementing social and communication behavior management procedures, in addition to using such medications. Some of the medications that may be prescribed to children with autism include:

Blood pressure medications: Tenormin (atenolol), Propanolol, Tenex (guanfacine), Catapres (clonidine) can have a mildly calming effect and tend to reduce angry outburst or their intensity. Usually among the first medications doctors prescribe. Also used to treat mild ADHD symptoms. Studies suggest they have modest effects, reducing agitation and behavioral outbursts in some individuals. Side effects include mild drowsiness for some children, especially clonidine. These medicines cannot be given to children with low blood pressure or other heart problems without consulting a cardiologist.

Attention/hyperactivity medications: Attention problems are ubiquitous in autism. Stimulants such as Ritalin (methylphenidate), Concerta (a form of methylphenidate) or Adderall (a mixture of dextroamphetamine and amphetamine) or Dexedrine (dextroamphetamine) are prescribed. Straterra (atomoxetine) is a non-stimulant medication used to treat children with ADHD. These medications are mainly used w
ith children with autism that also meet the diagnostic criteria for ADHD. Stimulants tend to be prescribed more by pediatricians than child psychiatrists. Straterra has not been very effective in treating attention and activity problems in autism. Stimulant medications often improve attention and reduce hyperactivity, but are seldom long term solutions alone. Their side effects include loss of appetite and insomnia.

Bipolar Disorder Medications: Eskalith, Lithobid (lithium), Tegretol (carbamazepine), Depakote (valproate), Klonopin (clonazepam), Lamictal (lamotrigine), Neurotonin (gabapentin) and Topamax (topiramate). These medications tend to be prescribed by pediatric neurologists or child psychiatrists to children with unpredictably violent outburst of aggression or self injury. There is limited evidence from controlled studies these medications are helpful for behavior management in autism unless a child also has seizures. One study that combined Lamictal and Depakote showed some improvement in adults with autism. Lithium requires careful monitoring of medication blood level. Tegretol and Depakote have several significant side effects including Dizziness; drowsiness; dry mouth; nausea; unsteadiness; vomiting. Lamictal is associated with a rare disorder of skin, especially in exposure to the sun. Doctors usually run baseline laboratory tests before beginning these medications. Parents should obtain a list of side effects to watch for from their child’s doctor.

Antidepressants with anti-anxiety properties: Buspar (buspirone), Paxil (paroxetine), Prozac (fluoxetine), Luvox (fluvoxamine) and Celexa (citalopram). These are the mainstay of treatment of panic disorder and compulsive rituals in autism, but are approved only for children 8 and older or some, 18 yrs and older. They are often given off-label to younger children. Antidepressants like Prozac (e.g. SSRIs) should be started at 1/4 to 1/3 of the usual dose given to other children, and the d
osage gradually ramped up over 4-8 weeks until the final daily dose is reached. Starting at a typical SSRI dose often causes agitation and insomnia and may lead to violent behavior. Used appropriately beginning with a low dose, they can be very helpful. Anafranil (clomipramine) is effective for treating obsessive-compulsive rituals and stereotypic movements, but the drug has numerous side effects and is only used in adults. Although medications like Clonazepam (Klonopin), Lorazepam (Ativan), Clonazepam (Klonopin, Alprazolam (Xanax), are commonly prescribed to neurotypical people with anxiety problems they often have a disinhibiting effect on individuals with autism and are infrequently prescribed because they may make matters worse.

Antipsychotic medications: Among the more commonly prescribed medications for older children with autism and adults who have more severe behavioral challenges. Risperdal (risperidone), Abilify (aripiprazone), Seroqu
el (quetiapine), and Zyprexa (olanzepine). Most of these drugs are indicated only for children 18 and older, but they are widely prescribed off label to younger children. They all have some risk (less than older antipsychotics) of movement disorder problems, and all atypical antipsychotics but Abilify have significant risk of weight gain and possible diabetes type-2. Risperdal, in particular, is overprescribed by doctors who have insufficient time or experience, to work with the family finding other longer-term behavioral solutions to their child’s behavioral challenges. In most cases a Functional Behavioral Assessment-based behavioral intervention should be combined with such medications.

Vitamins, Minerals and Probiotics: There have been three studies with small numbers of in children diagnosed with autism who were shown to be deficient with Vitamin B6 and magnesium. One showed no differences associated with B6 supplements. Two showed some improvements with high dosages of these substances, one with modest increased IQ the other study with a combined measure of social interaction, communication, compulsivity, impulsivity, or hyperactivity. There is no evidence from other controlled studies that vitamins, minerals or probiotics improve core autism symptoms (i.e. socialization, communication and repetitive behavior and fixed routines). It is possible some children with gastrointestinal problems may feel better if they have fewer episodes of loose stools and flatulence due to treatment with probiotics, but there is no evidence of consistent improvement in core autism symptoms. A recent study reported more gastrointestinal flora differences in children with severe autism symptoms, but the findings were confounded because some children were receiving probiotics and other were not, and there were no dietary records.

Parents of children with extremely violent, destructive behavior, or extreme obsessive-compulsive behavior, often have no choice but to seek assistance from their child’s physician in prescribing an appropriate medication and dose. This can also buy time while psychologists and behavior analysts can determine an effective social/behavioral intervention strategy.