Psychopharmacology

Introduction

Psychotropic medications can be an important part of the treatment of children and adolescents with autism-spectrum disorders. This lecture reviews target symptoms that can be successfully treated with medications, including:

  1. Aggressive, irritable and self-injurious behaviors, for which the atypical antipsychotic risperidone has the best evidence-based track record (including FDA labeling specific for this indication);
  2. Inattention and hyperactivity, for which stimulant medications can be moderately useful, although not as effective, and with more side effects that are seen in typically-developing youths; and
  3. Repetitive behaviors, for which serotonergic antidepressants have not proved to be helpful, despite considerable early interest and promising results.

In addition, the lecture will cover medication intervention that have been tried but not proven effective, including the gastrointestinal hormone secretin, which remains the most extensively studied compound to date. Other topics covered include the prevalence of medication use in autism, the costs of these interventions, and promising leads for future drug development in autism.

Featured Reading

The featured reading for the Psychopharmacology class lecture comes from:

Research Units on Pediatric Psychopharmacology Autism Network 2005a, ‘Risperidone treatment of autistic disorder: longer-term benefits and blinded discontinuation after six months’, Am J Psychiatry, vol. 162, pp. 1361-1369.

This study showed the lasting effects of risperidone six months after the results from the acute double-blind trial. Of note, relapse rates were so high in the group assigned to placebo discontinuation, that the stud had to be prematurely terminated and subjects allowed to go back on active medication.

Read the full article at The New England Journal of Medicine's website.

Reading List

Below are selected readings from the Psychopharmacology class meeting as well as a short annotation from Prof. Martin on the reading material and links to find the reading online or to buy the book online.

Research Units on Pediatric Psychopharmacology Autism Network 2002, ‘Risperidone in children with autism and serious behavioral problems’, N Engl J Med, vol. 347, no. 5, pp. 314-321.

Pivotal double-blind, placebo-controlled trial that first established the efficacy of risperidone in targeting irritable, aggressive and self-injurious behaviors in autism.

Read the full article at The New England Journal of Medicine's website.

Research Units on Pediatric Psychopharmacology Autism Network 2005a, ‘Risperidone treatment of autistic disorder: longer-term benefits and blinded discontinuation after six months’, Am J Psychiatry, vol. 162, pp. 1361-1369.

This study showed the lasting effects of risperidone six months after the results from the acute double-blind trial. Of note, relapse rates were so high in the group assigned to placebo discontinuation, that the stud had to be prematurely terminated and subjects allowed to go back on active medication.

Read the full article at The American Journal of Psychiatry's website.

Aman, MG, McDougle, CJ, Scahill, L, et al, for the Research Units on Pediatric Psychopharmacology Autism Network 2009, ‘Medication and parent training in children with pervasive developmental disorders and serious behavior problems: Results from a randomized clinical trial’, J Am Acad Child Adolesc Psychiatry, vol. 48, no. 12, pp. 1143-1154.

This study was the first to empirically test the combination of parent management training to risperidone, and to document the synergy of medication and psychosocial interventions to target maladaptive behaviors in children and adolescents with autism.

View the Abstract at the PubMed website.

Research Units on Pediatric Psychopharmacology Autism Network 2005b, ‘Randomized, controlled, crossover trial of methylphenidate in pervasive developmental disorders with hyperactivity’, Arch Gen Psychiatry, vol. 62, pp. 1266-1274.

This study assessed the tolerability and efficacy of stimulant medications in autism. Doses used were lower than in typically developing youths; side effects and discontinuation rates were higher, and efficacy results more modest.

Read the full article at the Archives of General Psychiatry website.

King, BH, Hollander, E, Sikich, L, et al, for the STAART Psychopharmacology Network 2009, ‘Lack of efficacy of citalopram in children with autism spectrum disorders and high levels of repetitive behavior: citalopram ineffective in children with autism’, Arch Gen Psychiatry, vol. 66, no. 6, pp. 583-590.

In the largest and best-controlled clinical trial of an SSRI antidepressant to target repetitive behaviors in autism, citalopram fared no better than placebo. Despite early excitement about the use of SSRIs in autism, this study failed to show an active response, and suggests that these medications should be used sparingly, if at all, in this condition.

View the Abstract at the PubMed website.

Chapter 15 (Considering Medications for Behavior Problems), Chapter 10 (Managing Medical Issues and Problems), and Chapter 12 (Dealing with Seizures) from "A Practical Guide to Autism".

Volkmar, Fred; Wiesner, Lisa. "A Practical Guide to Autism". John Wiley & Sons, Inc. New Jersey, 2009.

Find this book online at the Publisher's website.

Media and Other Resources

External Resources

Hormone-infused nasal spray found to help people with autism- The Washington Post
The National Center for Scientific Research in France found that when thirteen adults with autism inhaled oxytocin, a hormone known to make women more maternal and men less shy, they scored significantly better on a test involving facial recognition. This discovery may lead the way toward the adoption of oxytocin replacement therapy.

Psychopharmacology in Autism- Luke Y. Tsai, MD
This article reviews studies of neurochemical systems in autism and related disorders. It identifies clinical indications for pharmacotherapy and suggests various medications. Finally, it discusses new areas of investigation that may lead to the development of more effective treatments.

Drugs Hint At Potential Reversal Of Autism- NPR
Mark Bear, the director of the Picower Institute for Learning and Memory at MIT, has discovered that the mutation responsible for Fragile X Syndrome appears to disrupt the brain's regulation of synapses. Bear and other scientists have identified several drugs that seem to correct the problem.

Psychopharmacology of Autism Spectrum Disorders- Mark H. Lewis, Ph.D., and Martin Lazoritz, M.D.
This article addresses the scope of autism spectrum disorders and examines drug therapies' efficacy in treating relevant disorders and target symptoms. Drug therapies are sorted by drug class, with an emphasis on treatments that have been tested in double-blind, placebo-controlled trials.

Psychopharmacology of Autism- Christopher J. McDougle, M.D., and David Posey, M.D. 

This article discusses the use of various drug therapies in the treatment of target symptoms commonly associated with autism, including hyperactivity, inattention, interfering repetitive thoughts and behavior, and aggression. It suggests that no one drug will treat the wide range of maladaptive behaviors seen in autism.

Faculty and Guest Bios

Bio Profile

Andres S. Martin, MD, MPH

Riva Ariella Ritvo Professor in the Child Study Center and Professor of Psychiatry

Deputy Chair and Director of Medical Studies, Yale Child Study Center

Medical Director, Children's Psychiatric Inpatient Service at Yale-New Haven Children's Hospital

Education

MPH, Yale School of Public Health, 2002

MD, Anahuac University, 1990

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