A Qualified Case for the Use of Medication in Treating Children with Autism Spectrum Disorders

Parents and educators know that the main goal of raising and teaching children with Autism Spectrum Disorders (ASD) is to prepare each child to live as normal a life as possible. As the Individuals with Disabilities Education Act (IDEA) of 2004 makes clear, integration of ASD students into the regular classroom to the greatest extent possible is a vital part of this endeavor. Understanding ASD is particularly important to teachers because the number of children diagnosed with ASD is on the rise, and most educators will encounter ASD students at some point. The prevalence of ASD creates the need for teachers, school counselors, and educational administrators to develop a basic understanding of ASD treatments. While preservice teachers learn about classroom interventions, they receive less instruction concerning the medications commonly prescribed for students with ASD, including the symptoms medications are intended to alleviate and their possible side effects. Teachers will benefit, therefore, from seeking out basic information about the types of medication effects they are likely to encounter in their students with ASD. This paper provides basic information on medications prescribed for ASD and the symptoms they are intended to alleviate. It also argues that medication, despite its risks, is frequently a valuable component in normalizing the lives of children with ASD, although with the qualification that much more research is needed in order to make the most effective use of medications.

Children with ASD face considerable challenges in controlling their behaviors, communicating with others, and socializing with their peers. As the name of the disorder implies, these difficulties manifest along a continuum of severity, from mild to debilitating. ASD also includes a variety of symptoms, some of which are caused by comorbid conditions (discussed below). In addition, the medical profession has not reached a consensus on proper treatments. Teachers and parents, as well as health care professionals, struggle to find the best methods of helping children with ASD to achieve a degree of normalcy in their lives and the fullest possible integration into society. To this end, parents and teachers aim to reduce ASD symptoms such as "self-injury, . . . aggression, anxiety, depression, behavioral rigidity, [and] cognitive inflexibility," while promoting the skills of "social interaction, nonverbal/verbal communication, [and] attention to task" (Carlson et al., 2006, p. 22). Children who can control and cope with the symptoms of autism and its comorbid conditions will be best able to determine the path of their futures and advocate for the help they need in managing their ASD when they attend college and/or enter the workforce as adults. For many, if not most, ASD students, medications to alleviate symptoms may be an important component of the overall treatment of the condition.

Despite the lack of consensus on the best treatment(s) for ASD, many pharmacological interventions are prescribed to treat symptoms. Most commonly, these include "antidepressant, antipsychotic, and stimulant medications" (Carlson et al., 2006, p. 21). To this list, Rosenberg, Mandell, Farmer, Law, Marvin, & Law add psychotropic drugs (p. 342). The medication chosen for a particular child may depend, in part, on the practitioner's beliefs about the causes of ASD. Some focus on neurotransmitter dysfunction, while others look to imbalances of serotonin in the brain. Whatever the health care professional's views on the origins of ASD, he or she currently can treat only the symptoms of the disorder; at the present time, there is no cure for ASD, although research continues.

Although the number of studies increases each year, not enough research has been conducted and not enough pertinent questions have been answered to provide a clear indication of the best ways to utilize medicines in treating ASD. The confusion over treatment is compounded by the fact that only one medication, risperidone, has been approved by the FDA for treatment of ASD-related symptoms (NIMH, 2009, Medications Used in Treatment section, para. 2). Risperidone has proved effective in managing "irritability, aggression, [and] tantrums" in children with ASD. Other medications used to treat the symptoms of ASD are prescribed "off-label" (NIMH, 2009, Medications Used in Treatment section, para. 1), meaning that they are not approved specifically for autism, but have been successful in treating its symptoms and the symptoms of comorbid conditions.

Several of the symptoms of ASD can be treated with widely available medications. As described by Carlson et al. (2006), these symptoms include "inattention, hyperactivity, aggression, anxiety, irritability, obsessions/repetitive behavior, disruptive behavior, affective instability, and social withdrawal" (p. 22). Tsai (2007) also mentions Tourette syndrome and sleep disorders in connection with Asperger Syndrome (p. 138). Symptoms of ASD and its comorbid conditions must first be determined by a Functional Behavior Analysis (FBA) before treatments can be considered. Some symptoms may be treated with therapy and educational interventions; others will likely require medical treatment. Using the FBA and a thorough baseline medical assessment, the physician, psychiatrist, or other health care professional can prescribe an appropriate medication to alleviate a particular symptom. Parents should be included in the decision-making process, and close monitoring by the prescriber should follow. Teachers can be of particular importance in the monitoring process, as they see the ASD student frequently and will be familiar with his or her customary behaviors.

Many of the symptoms that inhibit the student's ability to function normally are caused by conditions frequently found alongside ASD, and can be treated with medication. These comorbid conditions include aggression, which is treated with olanzapine, an antipsychotic drug; depression, treated with the antidepressant fluoxetine; and obsessive-compulsive disorder, treated with fluoxetine or sertraline, another type of antidepressant. In addition, other medicines are available to treat anxiety disorders (including panic attacks), bipolar disorder, attention deficit/hyperactivity disorder, Tourette syndrome or other tic-producing conditions, disrupted or unusual sleep patterns, and symptoms of psychosis (Tsai, 2010, pp. 143-146). Since more than one comorbid condition, manifesting in more than one symptom, may be present alongside ASD, proper diagnosis and treatment may prove to be problematic, and optimum results may not be reached without a great deal of trial and error.

Continued monitoring is important in light of the possibility of side effects of prescribed medications, especially in the still-developing bodies and brains of children with ASD. Not only medical professionals, but also parents and teachers should watch for potential side effects. A number of side effects are described by Carlson et al. These include "social withdrawal, dullness, sadness, [and] irritability" caused by psychostimulants; a "decreased seizure threshold" caused by tricyclic antidepressants; or involuntary movements, such as "tremors, shakiness . . . uncontrollable motor restlessness . . . marked arching of the back or eye rolling . . . restlessness, rigidity, and posturing," caused by Selective Serotonin Reuptake Inhibitors (p. 23). In addition, risperidone, "an atypical antipsychotic drug" which, as mentioned above, is used to treat "behavioral disturbance (e.g., irritability, aggression, tantrums) in autism" may be linked with "sleep problems, weight gain, [and] heart rate [and] blood pressure" issues. All teachers of students with ASD should be aware of these potential side effects of medication and immediately report them to parents, should they occur.

The practice of polypharmacy, or "the concurrent use of two or more medications for the treatment of psychiatric or medical conditions" (Carlson et al., 2006, p. 23), is also of concern, particularly since this an area where little research has been conducted. As with all aspects of the medical treatment of ASD, polypharmacy has both risks and benefits, and in addition, the concurrent use of more than one drug may make identifying the efficacy of each individual drug hard to establish. One aspect of the research conducted by Rosenberg et al. was designed to identify the types of medical specialties that are most likely to prescribe medication for the treatment of ASD, and how many prescribers patients had. They used the Interactive Autism Network (IAN), a "voluntary, open enrollment national online ASD registry [that] continually collects data from families with affected children," to conduct a survey of the "prescribing trends by medical specialty for children with ASD" (Rosenberg et al, 2010, p. 343). Analysis of a total of 5,181 online questionnaires returned by the participants revealed that psychotropics were the most commonly prescribed drugs, specifically "stimulants, neuroleptics, and antidepressants" (p. 343), and that children with Asperger syndrome were more likely to be given these medications. Furthermore, psychiatrists and neurologists were more likely to prescribe psychotropics than were developmental or general pediatricians. Of the children who were prescribed at least two types of medication, "73% had only one type of prescriber; 25% had two types of prescribers and 2% reported three types of prescribers" p. 347). Most relevant to this discussion is the researchers' recommendation that further studies on multiple prescribers of multiple medications need to be conducted in regard to ASD patients under the age of eighteen (p. 347).

Despite the lack of consensus on the proper medications and dosages for treating the symptoms of ASD and the risk of side effects, medication has proved effective at alleviating some of the debilitating symptoms of ASD that otherwise would prevent students from integrating as fully as possible into a normal school experience. When the disabling symptoms of ASD and comorbid conditions can be brought under control, the affected child has a much better chance of relating to peers, expressing him- or herself, and attending to the many tasks required in order to receive a quality education. Although teachers must, under the law, comply with the mandates of IDEA, most would gladly do their best for ASD children, even if they were not required to do so. In helping these children function at the highest level of which they are capable, teachers help not only the individual student, but society in general. The ASD child who attends public school today will be attempting to achieve as much independence as possible in the post-education world tomorrow. The more self-control the child is able to achieve, the less support society will need to give him or her in the future. In addition, highly-functioning ASD individuals may be able to advocate for themselves and for others in similar circumstances, achieving further progress in the battle to live productively with ASD. Many more studies need to be done to determine the exact role medications can play in bringing about significant and lasting improvement in the lives of people with ASD, and the push for such studies should be an essential component of recommending medical treatments for the disorder. But while improvements to the level of knowledge are occurring, medications remain an important element of treatment for Autism Spectrum Disorders.

References

Carlson, J. S., Brinkman, T., & Majewicz-Hefley, A. Medication treatment outcomes for school-aged children diagnosed with autism. School Psychologist 11, 21-30.

National Institutes of Mental Health (NIMH). Treatment options. Autism spectrum disorders (pervasive developmental disorders).

Rosenberg, R. E., Mandell, D. S., & Farmer, J. E. Psychotropic medication use among children with autism spectrum disorders enrolled in a national registry, 2007-2008. Journal of Autism and Developmental Disorders, 40(3), 342-351. DOI: 10.1007/s10803-009-0878-1.

Tsai, L. Y. Asperger syndrome and medication treatment. Focus on Autism and Other Developmental Disabilities, 22(3), 138-148.