Child Psychiatry Consult

The role of medication in autism spectrum disorder

Publish date: March 12, 2020

ADHD

There are positive RCTs of methylphenidate in co-occurring ASD and ADHD,⁵ making it the preferred first line agent for treatment. Amphetamine salt based stimulant preparations do not have any RCTs in co-occurring ASD, but theoretically should be similarly effective. Again, the principle of starting low and going slow is applicable. Second line are the alpha 2 adrenergic agonists guanfacine and clonidine, both of whose long-acting formulations are approved for treatment of ADHD in children and adolescents without ASD, as well as atomoxetine, a selective norepinephrine reuptake inhibitor approved for ADHD. Guanfacine and atomoxetine have the stronger evidence base in the co-occurring condition. None of the second-line medications come in liquid preparation, although the immediate-release forms of guanfacine and clonidine both can be crushed and are used in clinical practice when the extended-release forms are not practicable.

Anxiety disorders and depression

Repetitive behaviors and insistence on sameness are broad headings that can be thought of as similar to obsessive compulsive disorder in children without ASD. However, controlled studies of SSRIs and clomipramine (a tricyclic antidepressant) have not shown a clear benefit in these behaviors in children with autism. There are no RCTs looking specifically at treatment of anxiety disorders in children with ASD, but expert consensus is that pharmacologic treatment is similar to that of children without ASD, with the SSRIs fluoxetine and sertraline the first-line agents due to the robust evidence for these two medications in treatment of anxiety disorders in children.⁶ Especially for kids with higher functioning ASD, cognitive behavioral therapy (CBT) should be considered and has some evidence for the co-occurring condition. Similarly, there are no RCTs for co-occurring depression in ASD, and clinical practice is to treat it as you would depression in the non-ASD population. Be aware that the studies of SSRIs in children with ASD reported higher than typical rates of behavioral activation on these medications, and again the principle of starting low and going slow is emphasized. Fluoxetine and sertraline both come in liquid form.

Insomnia

Insomnia is a common occurrence in children with ASD, and studies suggest melatonin can be effective, with immediate release clonidine a consideration with some limited evidence, if melatonin is not successful.

Dr. Michael A. Hoffnung

Finally I would be remiss in not mentioning that there is preliminary evidence from review⁷ and meta-analysis⁸ articles to suggest that regular exercise for individuals with ASD has a positive effect on multiple symptom domains, suggesting that this is an important additional treatment recommendation for children and families.

In conclusion, identification and treatment of ASD and co-occurring syndromes is often challenging, and while specialty referral often will be necessary, it is hoped that this overview provides a helpful frame of reference for primary care providers who encounter these conditions in clinical practice.

For further reading on this important subject, I recommend the American Academy of Child and Adolescent Psychiatry Practice Parameter for the Assessment and Treatment of Children and Adolescents with ASD and the Parents Medication Guide for Autism Spectrum Disorders.

Dr. Hoffnung is a pediatric psychiatrist at the University of Vermont Children’s Hospital and an assistant professor of psychiatry at the Robert Larner, M.D. College of Medicine at the University of Vermont, both in Burlington. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.