Claudia M. Gold

In autism, medication is only a partial answer

By Claudia M. Gold
December 14, 2009

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AT AGE 3, Evan would run around in circles in preschool, and did not engage in play with other children. He was easily overwhelmed by sensory input and had frequent meltdowns. An expert at a major medical center gave him a diagnosis of autistic spectrum disorder. With intensive support from his family, teachers and therapists, he learned to manage his difficulties.

Once he exploded at a children’s concert where all the other children were quietly sitting on the laps of their mothers. His mother spent that concert sitting with him in the coat closet next to the auditorium, where he was close enough to hear yet not be overwhelmed. She talked to him about how loud noises were hard for him, without conveying a sense that he had been “bad.’’ She was giving him the language to think about what was happening to him. Now 11, Evan plays several instruments, and loves to sing and dance on stage. He has friends and excels in school.

In my behavioral pediatrics practice, I see many families who are struggling under the strain of raising children like Evan. Laura’s parents had to forgo social events because of her unusual behavior. They felt like outcasts. Adam’s mother relied on her visits with me to get support in dealing with his inflexibility. But her husband blamed her for Adam’s behavior. Eventually this marriage fell apart. Parents of these children need ongoing supportive relationships that validate their experience. Such relationships can help them to hold their child in the way that Evan’s mother held him in that coat closet.

A study published in the current issue of Pediatrics gives me hope. An intervention, the Early Start Denver Model, was offered in the homes of families, with parent, child, and therapist playing together. In the two-year study period, toddlers diagnosed with autism showed significant improvement in behavior, language, and IQ. The authors attribute the success of their intervention to the fact that it is “delivered within an affectively rich, relationship-focused context.’’

At the same time, there has been increasing attention given to use of drugs for children with autism. Abilify, a powerful second-generation antipsychotic, was given approval by the Food and Drug Administration to treat the irritability seen in this disorder. A recent study addressed the use of risperidone, another second-generation antipsychotic, in treatment of tantrums associated with autistic spectrum disorder. The latest issue of Child and Adolescent Psychopharmacology News, a newsletter for professionals, was devoted to psychotropic drugs for autism.

I often recommend medication for children. For attention deficit hyperactivity disorder (ADHD), medication can make the difference between success and failure in school. Some children severely affected by autism cannot function without medication. But because medication is the “standard of care’’ for treatment of ADHD, there is often an over-reliance on drugs, on the part of parents, teachers, and physicians, to treat complex problems. I worry that the same could become true for autism.

If we describe Evan as “irritable’’ or “explosive,’’ he might be a candidate for antipsychotics, which have been shown to be effective at eliminating this behavior. But another way to describe the behavior is “dysregulated.’’ These children have a very difficult time with self regulation. They get overwhelmed by sights, sounds, and smells. They may have rigid obsessive behaviors that serve to protect them from the barrage of disorganized sensory input they experience.

Contemporary research integrating developmental psychology and neuroscience demonstrates that children learn to regulate emotions in relationships. Intense experiences that are beyond the capacity of a child to self-regulate can be co-regulated with the help of people close to him.

Recent statistics put the prevalence of autism at around 1 in 100. Aggressive marketing tactics have made second-generation antipsychotics among the highest-selling classes of drugs in the United States. A study published this fall showed that these drugs cause rapid weight gain in children. Add to these facts an epidemic of childhood obesity and a culture that looks for a quick fix over a long-term solution, and we have a potentially dangerous mix.

The Pediatrics study points in the direction of devoting resources to nurturing relationships in treatment of autism.

When considering medication, I hope all who care for these children will exercise extreme caution.

Claudia M. Gold, MD, is a pediatrician in Great Barrington.

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