Psychiatrist With Multiple Relatives With Autism Shares Treatment Journey

Medications for autism spectrum disorder should not replace an effective behavior plan, according to a presentation at Psych Congress 2018.

A psychiatrist with twin brothers with the disorder, as well as a daughter, shared her experiences in a presentation called “My Personal and Professional Journey Through Autism: Update on Autism Treatment Through the Lifespan.”

There are 2 FDA-approved medications for autism, aripiprazole and risperidone, and about 70% of children with autism age 8 and up receive some form of psychoactive medication in a given year, said Ilana Slaff, MD, a psychiatrist from New York.

She noted that people with autism may have other comorbid conditions that require medication. The prevalence of autism in children in the United States is 1 in 59, according to the CDC, and as a spectrum disorder, there is a wide range of impairments, ranging from mild to severe, as well as comorbidities.

However, children are more sensitive to the effects of risperidone (somnolence and sedation) compared with adults, and some of the medications used in autism can exacerbate comorbidities, like the risk of seizures from epilepsy, she said.

In children with autism, she believes, the drugs can be counterproductive, not effective, or even harmful, depressing their ability to learn and improve social functioning.

“It’s not just about depressing the unwanted behaviors, it is also about functioning and quality of life,” she said.

For instance, the self-injury components in the risperidone trials were not looked at in isolation, and in aripiprazole, the self-injury components were no better than placebo, she said. And both also block dopamine transmission in the brain, which is necessary in order to change behavior and for children to learn how to use reward systems in educational settings, Slaff said.

Slaff also said selective serotonin reuptake inhibitors for children with autism have no effect.

Both Slaff and Carol Fiorile, PhD, BCBA, discussed the need for functional behavior assessments (FBA), conducted by a board-certified behavior analyst. An FBA seeks to determine why the problem is happening and under what condition, and show how these behaviors limit the ability of the person to progress in life.

An FBA is essentially a problem-solving process, said Fiorile. It collects specific data on the maladaptive behavior, including frequency. The ultimate purpose of the FBA is to create a behavior modification plan that can be implemented in a highly structured environment, depending on the skill level of the staff.

More collaboration between psychiatrists and behavior analysts are needed, the presenters said. A behavior plan intervention may be paired with medication, and over time, medication may ultimately be cut back, reducing the risk of negative side effects of multiple medications.

In addition, parents need training to implement intervention plans at home, they said.

Slaff compared the results of her 2 brothers: one brother who severely injured himself and has had a behavior analysis implemented, and one who has not.

Matthew has a strict intervention program in place, has a paid job within his school, is able to go on field trips, and has stopped his self-injury behaviors. He is also not on medication. The other twin brother, who is on multiple medications, is not as well-functioning.

Psychiatrists also need more information about the educational rights their patients have, including the right to ask for these therapies and an out-of-district placement, both Fiorile and Slaff said. In addition, they said medication should fit the child and not the educational placement.