The State of the Art for Treating Autism
As we discuss in our page on Therapy for Autism, the main treatment paradigm for autism and, more broadly, autism spectrum disorder, is therapy, not medication. The main thrust of care designed to succeed is one-to-one, in person, supportive, child-centered care. For adults with autism, it’s person-centered care. Designing and executing an autism treatment plan almost always has a skilled, central physician leading the treatment team. That said, the treatment is usually done by a team working the treatment plan. Remarkable progress is the rule if the plan is designed for what’s best for the child. As soon as a problem is suspected it’s important to get solid confirmation of the diagnosis followed by a rapid move to start the therapies. If done appropriately there’s good reason for optimism. (We use “autism” to mean autism and autism spectrum disorders.)
One of our Wisconsin Readers Asked:
I’m 15 and do a lot of babysitting, so I know kids and how to help them have fun. We recently drove to visit an aunt and uncle we rarely see and they have three kids, the youngest is a five-year-old cute little girl. I was playing a board game with her and she suddenly got mad and started hitting and kicking me. She scratched my arms and bit my hand. I stayed away from her the rest of the visit. My aunt and uncle said she has autism, but, I mean, really, what’s wrong with her? They’ve got to do something for her.
We added this question sent to us by one of our readers because it “hits the nail on the head” on why medications need to be in the discussion when treating autism. Some autistic children have behaviors that are worse than just socially unacceptable. They’re dangerous. On the one hand it’s wrong to publicize this behavior as “autistic” because there are plenty of children with autism who show no behavior that could hurt anyone.
On the other hand there are some children with autism who have other medical diagnoses in addition to autism. (See reference here and below.) Examples of conditions that might be associated with problem behaviors are epilepsy, anxiety, attention deficit/hyperactivity disorder (ADHD), depression, obsessive-compulsive disorder (OCD), bipolar disorder, conduct disorder, and oppositional defiant disorder. For example, children with oppositional defiant disorder can have angry, argumentative outbursts and frequent disobedience. Usually this is toward parents and teachers but it can be toward playmates and brothers and sisters. Conduct disorder can be even worse in older children and adolescents with violent behavior, cruelty to others (including animals), and even criminal activity.
As These Examples Show, Medications Can Become Necessary in Autism
Whether from some second diagnosis in addition to autism or just with autism itself, we can, on occasion, see behaviors in autism that are far too over-the-top frightening, or even dangerous. Behaviors like breaking things, hurting oneself, or hurting others, sometimes badly, are too serious to ignore. And when such outbursts or temper tantrums or other problem actions occur, by the time someone says “medication” it’s usually already too late. The child has broken a window with glass flying everywhere, or injured herself, or hurt someone. It best, it’s safest, to think about the possible need for medications before they’re suddenly necessary. We hope you’ll agree, medications do have a place in the overall treatment plan.
Remember We’re Talking About the Brain
A neurologist in one of our training programs had a favorite phrase, a comment that he said all the time. “Bad behavior, bad brain.” Samuel Goldwyn, the movie mogul (you know, Metro-Goldwyn-Mayer, MGM) once said that, “Anyone going to see a psychiatrist should have his head examined.” Back then he meant it as a satirical joke, that you have to be crazy to see a psychiatrist. But these days, seen in another way, it’s medically true. If someone, especially a child, is troubled or has problem behavior it’s good medical care to get a brain scan. (See our page Your Mind and Your Brain.) Everyone has unique wrinkles in their brain and their behavior. Including people with autism. At times a brain can spark and fire off a behavior before other parts of the brain even have time to think about it.
Behavior, That Is, How We Behave. Action in Action!
One autism item that comes up at times is aggression. You know, temper tantrums or outbursts that lead to things like hitting, kicking, scratching, or biting. Throwing things, sometimes heavy things. Such actions are dangerous even if the child is the only one in the room. And the bigger problem is, usually someone else, or several others, are also in the room. Other children, or parents, or teachers. Someone’s going to get hurt. Then there’s being overly-energetic with hyperactivity. A few more examples are repeating the same movements over and over; being remarkably and unexpectantly irritable and cranky; daydreaming and not paying attention at a time when attention is needed; being markedly nervous and anxious; and depression, either depression that socially isolates or angry depression, far more than just a down mood.
Who’s at Risk and Who’s at Fault?
Who’s at risk? Everyone. The child with autism. People, children and adults, who are in the room with him. What if you dodge (or worse, don’t dodge) a book he didn’t want to read so he throws it at you? Often such actions leave the child feeling awful about himself, the exact opposite of what such a child with autism needs in order to feel secure and to do well. Who’s at fault? Last of all the child. The child is not at fault. But what about the “adult in the room”. The adults in the room need to be prepared, to know what might happen, and to have any possibly needed medication ready and available. First of all to protect the child’s self-esteem, and also to stop self-injury, injury to others, property damage, and dangerous situations.
Making the Medication Decisions – Treating Autism with Medication
All the parts of the treatment plan, the various therapies and medication decisions, are made by the physician in the lead. A whole treatment team needs to be in place and working with the child (or adult) with autism. The goal has to be the best possible eventual outcome for the child. (See our page on Therapy for Autism.) Of course, the days of the “dictator doctor” were gone fifty years ago. This lead physician makes the decisions in consultation with the parents and the rest of the treatment team.
Understand That There Are No Medications For Autism
We’ve gone through all this explanation about medications to be used in autism but it’s important to understand that there are no medications to treat the autism itself. No medication has been discovered that can treat the autism. And there likely never will be. Autism is a way the hardwiring of the brain is set during pregnancy, through labor and delivery, and during the early months of life. It would be a wonderful miracle if a medication were actually found to repair that circuitry. If it does happen someday, however, it likely will not be soon.
But There Are Medications That Can Help Avoid Disasters
Any medications that the physician says will help are medications to treat those problem behaviors we described above. They are behaviors that sometimes are just part of autism, the way an autistic brain is wired. It’s great for the child and for everyone around the child to provide safeguards against trouble. What’s more, it’s not always easy to find the best medication for any specific behavior. Any medication needs to be a good fit first of all for the child. A good fit meaning that will be useful in the child’s actual situation, and that actually helps the possible problem behavior. There is no “one-size-fits-all”. A medication that works great for one child’s anxiety might not help at all for anxiety in another child. There’s no one-size-fits-all for the child and no one-size-fits-all for the medications.
You Mean Children with Autism Can Be Irritable?
Hey, listen, everyone can be irritable. No surprise that a kid with autism can be irritable. And good news, the FDA has approved 2 medications for irritability in autism. One is risperidone (Risperdalâ) approved for ages 5 to 16 and the other is aripiprazole (Abilifyâ) for ages 6 to 17. As FDA-approved medications have gone through a lot of clinical studies. The FDA demands a lot of information and testing to approve a medication for such a specific medical reason
Other Medications That Are Good Need Not Be FDA-Approved
A medication can be known to be good and useful for the problems of autism and yet not have a government agency approval. Most medications that are known to work well for one or another problem in autism are used in line with what is called “community standards”. That is, these medications are known to be safe and to work well because physicians with skill and experience give them often to children with autism and usually find that they work well, and with few side effects.
Other Medication Choices Beyond risperidone and aripiprazole
Autism-useful Medications Originally Developed for Adult Depression
One example of this “community standards” way of choosing medications for autism is the use of medications developed to treat adults with depression. These medications were first made for treating major depression in teenagers and adults. Over a long period time physicians treating children with autism came to understand that these medications can lessen autism’s repetitive actions, anxiety, and irritated attitudes. The benefit these medications provide in autism have nothing to do with the child being depressed. They’re are not “depressed” in the same way that we think about depression in adults. At times these medications can lower the energy put into tantrums and lessen the force put into aggressive behavior. In addition, they can at times really help with better eye contact and more socializing and more typical socializing in an autistic child.
Medications for Anxiety and “Nervousness”
This situation is sort of like the situation above with medications for depression. Some medications that were made to treat anxiety or “nervousness” in adults also work in children with autism. Such medications can help lower an autistic child’s anxiety and even treat episodes that look much like panic attacks.
Medications That Work “Backwards” – “Stimulants” that Calm an Autistic Child
Unless you’ve been buried deep in the upset and worry of a child with autism and then seen these medications work, this idea might seem completely backwards. But, it’s real and at times it works. Some children with autism can feel calmer and better if given one of the medications that in adults would be considered “stimulants”. The medications actually seem to work much as they do in children with ADHD (attention deficit hyperactivity disorder). Take a child with ADHD that’s hyperactive and all-over-the-map and give the child a stimulant, and often he’s more calm. As odd as it might seem, it’s a real clinical effect.
A Seizure Medication for a Child with Autism Who Does Not Have Seizures
Medications for seizures were made and are used to prevent seizures and to treat seizure disorders like epilepsy. There are children with autism who also have seizures, and for these kids it makes sense to use a medication to prevent seizures. However, these same medications can also be useful for children with autism who don’t have seizures or any seizure disorder. They can help in some certain situations. One example is a child being upset in an “out-of-control” kind of way. We don’t mean just distressed or agitated. We mean really OUT – OF – CONTROL. These medications for seizures can keep things from getting out of control.
So, There, You Have It – Good News or Bad?
So, that’s the story on treating autism with medication. We wish it didn’t upset anyone but we know some people, good and conscientious people, just don’t “believe” in medication for children with supposed “behavior” problems, including children with autism. But medically, clinically, for the benefit of the child and everyone around the child, there are times when a medication helps, a medication keeps trouble from happening, or a medication stops trouble like nothing else can. We’re talking about the brain here, a bodily organ like a heart or stomach or a lung. It’s a brain, and at times it doesn’t work as well as is needed, and at times a medication can help.
National Institute of Child Health What are the treatments for autism?
PubMed Central Treatment of Autism Spectrum Disorder
PubMed Central Pharmacologic treatments for autism
Centers for Disease Control Treatment for Autism
Autism Speaks Treatments for Autism
Mayo Clinic on Autism Spectrum Disorder