When to Call in the Meds
Non-medical interventions are the best choice for treating autism. But sometimes, medication can be used to help stray symptoms get under control.
Lily is the harried mother of Connor, a 12-year-old with autism. After years of special education services, he’s gotten much better socially, but he still struggles with reading and writing assignments. His teachers say that he tries hard, but he needs support to get his work done. Homework is a nightmare, even with a reward system and a fine-tuned routine. Connor hates it, and can’t focus without his mom sitting next to him. Lily is worried because she knows he can do the work, but he isn’t keeping up with his classmates.
Autism, a developmental disorder primarily defined by delays in social and communication skills, relies on non-medical interventions for children to progress. Behavioral and speech/language therapies are central to autism treatment. Occupational therapy refines fine motor skills and improves self-help abilities, as well as addressing sensory issues (such as being hypersensitive to touch or noise). Many families report benefits from alternative care.
Despite such intensive non-medical approaches, various symptoms sometimes remain in children who have an autism spectrum disorder (a term that has replaced both Asperger’s Syndrome and pervasive developmental disorder (PDD-NOS). When that happens, families face a tough question: Are there any medications worth trying?
In fact, several medications may benefit children with autism when other options are inadequate. These medications do not treat autism itself, but they offer relief from symptoms that commonly occur along with it. The first step for providers and parents is to collaborate in deciding on what most affects a child’s life and to balance the pros and cons in making a choice for or against medication.
There are three groups of medications considered appropriate for autism: those used to treat co-occurring ADHD symptoms, antidepressants/anti-anxiety medications, and atypical anti-psychotic medications. While none directly addresses the developmental disorder of autism, they can profoundly benefit children. Here’s what to consider when discussing medications for someone with autism:
ADHD MEDICATIONS. At one time an autism diagnosis automatically precluded a diagnosis of ADHD. Not so anymore. We now know the two conditions frequently occur together. In fact, nearly half of all kids with autism demonstrate ADHD symptoms — an added burden that undermines academic, behavioral, and social progress.
With or without autism, ADHD requires comprehensive, multi-disciplinary care that usually includes, at minimum, both behavioral and educational interventions. As part of this broad approach, ADHD medication can be life-changing for some children.
There are two groups of medication currently used to treat ADHD: stimulants (such as Ritalin or Adderall) and non-stimulants (such as Strattera or Intuniv). When prescribing ADHD medications, the goal is to avoid persistent, significant side effects. Yet finding a good fit is harder when autism and ADHD occur together, for reasons not yet known.
Research shows the success rate for stimulant use is near 80 percent. These medications can bring substantial improvement to “core” ADHD symptoms that undermine social, behavioral, or academic progress in a child with autism, such as poor focus, inability to complete a task, and impulsivity. Medications are not as useful for other ADHD-related issues, such as difficulty with time management and planning. For anyone struggling with both autism and ADHD, removing the added burden of ADHD can have direct benefit at home, in the classroom, socially, and even during the therapy sessions meant to address autism itself. Reading, writing, and other academics often improve as well.
Generally, stimulants are not active after the medication wears off on any given day, allowing for fairly rapid adjustments if a medication is not working well. Side effects are easily managed and, after a period of sustained trial and error to find a best fit, often entirely avoidable. Since side effects are reversible when medications are stopped, a trial of use — as long as it is carefully observed and monitored — should not bring long-term problems.
ADHD non-stimulants cause side effects less often than stimulants, but succeed less frequently. They are called “non-stimulants” in contrast to the stimulant group, but have similar effects as the stimulants; they work by increasing activity in underactive parts of the brain responsible for ADHD. Advantages of non-stimulants are that they may provide 24-hour coverage, as well as helping with sleep or being overly reactive (quick to anger, frustrate, or upset). Side effects vary, but include excessive sleepiness (Intuniv and Kapvay), irritability, stomach upset, or headache (Strattera).
ANTIDEPRESSANT AND ANXIETY MEDICATIONS. Common challenges for children with autism include persistent anxiety or obsessive behaviors. These behaviors, such as avoiding or running away from new or unknown situations, separation anxiety, or compulsive checking or washing behaviors, cause big problems in day-to-day life. Anxiety is often associated with strict black-and-white thinking, a combination that can be a trigger for explosive behaviors. Children with autism are also at risk for developing depression, another family of symptoms that sometimes become severe enough to require medication.
For these symptoms, the most commonly prescribed medications for children are selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft) or fluoxetine (Prozac). Some of these medications have been studied and approved for use with children, although not specifically for autism. This group of medications may help with mood, anxiety, or obsessive thoughts and compulsive behaviors. As with most mental health medications, side effects should be closely monitored.
ATYPICAL ANTI-PSYCHOTICS. These medications, such as Risperdal or Abilify, are the only group of medications specifically approved for children with autism. This is because studies show them to benefit autism-related irritability. However, atypical anti-psychotics may also improve anxiety, impulsivity, or mood.
Along with the wide range of potential benefits comes a larger risk of side effects. These include weight gain and a risk of developing diabetes, among others. Weight, blood sugar, and other measures are monitored when children remain on these medications for any length of time.
Non-medical options are the best first choice for behavioral challenges, but they do not always succeed. Sleep problems are common in autism, though first-line treatments, such as behavioral therapy, should provide tools for managing it. However, sleep aids, non-stimulant ADHD medications, and other pharmaceutical interventions can be considered when needed. Anti-seizure and other psychiatric medications may be useful in children with autism and mood disorders, or self-injurious behavior associated with autism.
Most parents and providers agree that avoiding medication is best when it comes to managing autism. And yet, for many individuals, non-medical care falls short in resolving their intense symptoms. These difficulties, such as rampant inattention, may undermine work with teachers and therapists, slowing overall progress.
Medications for autism are no better or worse than those for most other medical disorders. There are potential benefits and side effects. Used judiciously, and integrated with ongoing therapies for autism, medication may allow children to take significant steps forward in their lives.
Three months later, Connor comes in smiling and holding a book. His third ADHD medication seems to be a good fit. He isn’t as hungry at lunchtime, but he’s making up for it at dinner. His teachers and therapists say he is able to get his work done better. And at home, he’s having longer conversations and reading for fun for the first time. It was a tough choice, and there’s a lot more to work on, but Lily says Connor has taken a big step forward.