Wednesday, February 4, 2015

Medication Use in Children on the Autism Spectrum

Prescription medications do not address the core symptoms of autism and are not considered to be "first-line" interventions or treatment for children with autism spectrum disorder (ASD). At present, early, intensive, and behaviorally-based interventions are considered the most effective treatments. Nevertheless, research indicates increasing rates of psychotropic use and the simultaneous use of multiple psychotropic medications (polypharmacy) in children with ASD. Reported rates of use have ranged from 27% to 83%, with polypharmacy ranging from 10% to 20%. The most commonly prescribed medications for ASD are selective serotonin reuptake inhibitors or SSRIs such as Prozac, Zoloft, and Paxil; stimulants such as Concerta, Metadate, Methylin, Ritalin, and Adderall, and atypical neuroleptics such as Risperdal and Abilify, both with FDA approved labeling for the symptomatic (aggression and irritability) treatment of children and adolescents with ASD.
Although co-occurring problems such as hyperactivity, inattention, aggression, repetitive or compulsive behaviors, self-injury, anxiety or depression, and sleep problems may respond to a medication regimen, as well as relieve family stress and enhance adaptability, there are general concerns about these medications. For example, there is a lack of evidence documenting the safety or effectiveness of psychotropic treatment during childhood. Likewise, there is a paucity of information about the safety and effectiveness of psychotropic polypharmacy and potential interactions between and among medications that may affect individuals with complex psychiatric disorders, including ASD. As a result, detailing psychotropic use and polypharmacy among children with ASD is crucial for informing families, clinicians, and researchers.
A study published in the journal, Pediatrics, examined the use of psychotropic medications and polypharmacy by using a large and heterogeneous data set of medical and pharmacy claims for commercially insured children with ASD. Psychotropic medications included: (1) anticonvulsants/antiepileptics; (2) antidepressants; (3) antipsychotics; (4) anxiolytics; (5) attention-deficit disorder medications (both stimulants and nonstimulants); (6) lithium; and (7) anticholinergic/antiparkinsonian medications. Among 33,565 children with autism spectrum disorders, 64% used psychotropic medications and 35% had evidence of polypharmacy. Older children and those who had seizures, attention-deficit disorders, anxiety, bipolar disorder, or depression had increased risk of psychotropic use and polypharmacy. In addition, the majority of children who had seen a psychiatrist had evidence of psychotropic use.
The findings of this study indicate that despite minimal evidence of the effectiveness or appropriateness of multidrug treatment of ASD, psychotropic medications are commonly used, singly and in combination (polypharmacy), for ASD and co-occurring conditions. This has important implications for practice. Because some clinicians caring for children with ASD may not be aware of the extent and effects of psychotropic use and polypharmacy, primary care providers should carefully obtain medication histories and monitor symptoms for evidence of effectiveness. Likewise, there is an immediate need to develop standards of care around the prescription of psychotropic medications based on the best available evidence and a coordinated, multidisciplinary approach to improving the health and quality of life of children with ASD and their families. Finally, additional research is needed to understand why medications are being used (for which symptoms, behaviors, or diagnoses, and by which providers)
Spencer, D., Marshall, J., Post, B., Kulakodlu, M., Newschaffer, C., Dennen, T., Azocar, F., & Jain, A. (2013).  Psychotropic medication use and polypharmacy in children with autism spectrum disorders. Pediatrics, 132, 833–840.
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

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