Consider behavioral therapies first for ASD.

BALTIMORE -- Medication is not a surefire solution for the symptoms associated with autism spectrum disorders, according to Dr. Kenneth E. Towbin.

"Many people seek medication for children with autism spectrum disorders, imagining that there is a magic bullet that is going to reduce or eliminate the child's symptoms. There are no magic bullets," said Dr. Towbin, who is chief of clinical child and adolescent psychiatry in the intramural research program at the National Institute of Mental Health.

Still, many children with autism spectrum disorders (ASD) end up on medication, Dr. Towbin said at a conference on autism sponsored by Kennedy Krieger Institute. Several studies estimate that about half of children with ASD have received a prescription medication in the last year.

The primary treatments for autism spectrum disorders are education and behavioral therapies. As a secondary treatment, medication may help reduce some symptoms in ASD, and can be helpful and important, said Dr. Towbin.

Medications should be considered when a child's safety or personal distress is at issue. Drug therapy also can be considered when there is adversity in the child's family life or to sustain educational progress. Lastly, medications can be considered for the treatment of aggression, hyperactivity, perseveration/stereotypy, inattention/distractibility, anxiety, inflexibility, and depression.

Parental collaboration is crucial when choosing drug therapy for ASD symptoms. Parents must understand that medication will not work quickly to improve symptoms, he said.

Be sure to educate parents to assess symptoms, maintain behavioral interventions, and monitor possible side effects. Children with ASD have abnormal sensitivities, which may leave them more vulnerable to medication side effects, Dr. Towbin noted.

Suggested Treatments for ASD

Symptom(s)             Drugs                    Comment

Hyperactivity      methylphenidate          For a child who is
                   haloperidol              hyperactive but not
                   risperidone (Risperdal)  inattentive.
                   atomoxetine (Strattera)
                   clonidine

Aggression and     haloperidol              Evidence not as clear
irritability       risperidone              for clonidine and
                                            divalproex sodium.

Perseveration and  haloperidol              Acceptable choices
stereotypy         risperidone              but SSRIs such as
                                            clomipramine (Anafranil),
                                            fluvoxamine (Luvox), and
                                            fluoxetine have better
                                            safety profiles.

Source: Dr. Towbin

Before starting a child with ASD on medication, take the time to understand the nuances within each child's situation. Dr. Towbin told the story of an adolescent patient who was beginning to act out and be disruptive--but only during school--so much so that he was often sent home. Dr. Towbin was approached to start the boy on medication to minimize this behavior.

After talking with the young man, Dr. Towbin learned that teachers had been openly discussing a possible teachers' strike in front of the special education students. As it turned out, the boy was upset about the possibility of a strike and how this would disrupt school--which he liked very much. Optimizing the child's environment and educating others often might prove more helpful than medication. "Medication does not reverse a bad situation," he said.

Dr. Towbin offered the following guidelines for using pharmacotherapy to treat children with ASD:

* Target specific symptoms.

* Start at the smallest possible dose.

* Increase doses using the smallest possible increments.

* Increase doses only after sufficient time has elapsed to gauge the effects of the current dose.

* Monitor the effects on the specific target symptoms.

* Look for side effects routinely.

* Minimize the use of more than one drug at a time.

* Start a second drug only after reaching the maximum feasible dose of the first drug.

* Start a new drug only after sufficient time at the maximum dose has been achieved.

* If changing a combination of medications, change only one medication at a time over intervals that are long enough to assess the impact of the change.

The symptom of depression may be a feature that occurs more commonly in higher-functioning autism spectrum individuals, especially in the late-childhood/early-adolescence period, he noted. SSRIs (fluvoxamine [Luvox], fluoxetine, and sertraline [Zoloft]) and the tricyclic agent clomipramine (Anafranil) have been suggested for treating depression in children with ASD. However, Dr. Towbin described the data for using these drugs in this patient population as so-so.

Dr. Towbin offered a few cautionary notes. Children on SSRIs can have interactions with medications they might be taking already. "When you get into polypharmacy, you have to be very careful about how the drugs interact with one another."

Dr. Towbin reported that he has no financial conflicts of interest.

RELATED ARTICLE: Questions to Ask Before Treating

1. What are the frequency, intensity, and duration of symptoms?

2. What times and locations are associated with symptom onset?

3. What are the ameliorating and aggravating factors?

4. How are these symptoms trending over time?

Source: Dr. Towbin

BY KERRI WACHTER

Senior Writer