Polypharmacy in Autism Treatment

Medication Treatment for Autism 

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 benchmark interventions for autism. Pharmacologic interventions are often considered for maladaptive behaviors such as aggression, self-injurious behavior, repetitive behaviors, sleep disturbance, anxiety, mood lability, irritability, hyperactivity, inattention, destructive behavior, or other disruptive behaviors in children with autism. 

The most commonly prescribed medications are selective serotonin reuptake inhibitors (SSRIs) such as Prozac, Zoloft, and Paxil; stimulants such as Concerta, Metadate, Methylin, Ritalin, and Adderall, and atypical neuroleptics such as Risperidone (Risperdal) and Aripiprazole (Abilify), both with FDA approved labeling for the symptomatic (aggression and irritability) treatment of children and adolescents with ASD. Although Methylphenidate (Ritalin) has been reported to be effective for reducing hyperactivity in some autistic children, it has not found to be effective for treating restricted or repetitive behavior or irritability (Huffman et al., 2011). Some marginal evidence of benefit has been reported for various SSRIs in the treatment of restricted, repetitive behaviors, but more study is needed (Huffman et al., 2011; Warren et al., 2011). Although Risperdal and Abilify have been reported by caregivers to reduce problem behaviors such as irritability, hyperactivity, tantrums, abrupt changes in mood, emotional distress, aggression, repetitive behaviors, and self-injury, the risk of adverse (side) effects is considered to be quite high (Warren et al., 2011).

Polypharmacy

Research indicates increasing rates of psychotropic use and the simultaneous use of multiple psychotropic medications (polypharmacy) with autistic children. A research study involving a large sample of children with ASD found 64% used psychotropic medications and 35% had evidence of polypharmacy (Spencer et al., 2013). Older children and those who had seizures, attention-deficit disorders, anxiety, bipolar disorder, or depression had increased risk of psychotropic use and polypharmacy. Although co-occurring problems such as hyperactivity, inattention, aggression, and anxiety or depression, 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 clearly 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 conditions, including autism (Spencer et al., 2013). 

Further research is needed to assess the value of these medications when weighed against their potential for harm. 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 autism and their families. Because clinicians and school-based professionals may not be aware of the extent and effects of psychotropic use and polypharmacy when working with autistic children, they should collaborate with parents, primary care providers, and others to carefully obtain medication histories and monitor treatment effects.

Adapted from Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools (Second Edition). London and Philadelphia: Jessica Kingsley Publishers.

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Key References and Further Reading

Huffman, L. C., Sutcliffe, T. K., Tanner, I. S. D., & Feldman, H. M. (2011). Management of symptoms in children with autism spectrum disorders: A comprehensive review of pharmacologic and complementary-alternative medicine treatments. Journal of Developmental and Behavioral Pediatrics, 32, 56-68. Available from www.jdbp.org

LeClerc, S., & Easley, D. (2015). Pharmacological therapies for autism spectrum disorder: a review. P & T: a peer-reviewed journal for formulary management, 40(6), 389-97.

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.

Warren, Z., Veenstra-VanderWeele, J., Stone, W., Bruzek, J. L., Nahmias, A. S., Foss-Feig, J. H…McPheeters, M. (2011). Therapies for children with autism spectrum disorders. Comparative Effectiveness Review, Number 26. AHRQ Publication No. 11-EHC029-EF. Rockville, MD: Agency for Healthcare Research and Quality. Available from http://www.effectivehealthcare.ahrq.gov/ehc/products/106/656/CER26_Autism_Report_04-14-2011.pdf

Wilkinson, L. A. (2017). Best practice in treatment and intervention. In L. A. Wilkinson, A best practice guide to assessment and intervention for autism spectrum disorder in schools (pp. 136-137). London and Philadelphia: Jessica Kingsley Publishers.

Lee A. Wilkinson, PhD, is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He 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 CBT. He is also editor of a text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest award-winning book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

© 2018 Lee A. Wilkinson, PhD