Keep Open Mind About Alternative Autism Treatments

LOS ANGELES – When conventional approaches fail to help autistic children, parents who suggest alternative treatments should not be ignored, according to Dr. Robert L. Hendren.

Instead, it’s better to talk to them about their ideas and keep an open mind, said Dr. Hendren, director of child and adolescent psychiatry at the University of California, San Francisco. "I try to weigh the evidence [with families], but if they’re doing something I think is dangerous, or they’re avoiding other kinds of treatments, I tend to tell them," he said.

When there’s no harm to an alternative treatment, after a few months, Dr. Hendren said he will help parents assess whether it is working and ask them to reconsider his treatment ideas.

The reasoned approach means parents feel comfortable telling him the alternatives they’re trying and letting alternative practitioners know that Dr. Hendren is involved in the case, he said. Also, with evidence emerging that mitochondrial dysfunction, chronic inflammation, maternal toxin exposure, oxidative stress, and other problems might play a role in autism, some treatments now considered alternative eventually might prove useful, he said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

Dr. Hendren analyzed the evidence – or lack thereof – for many of the currently hot complementary and alternative approaches.

Casein and gluten-free diets are among them. There’s no harm, so long as families work with nutritionists to ensure that children get enough calcium and protein, he said. There’s no harm in trying glutathione, vitamin D, and omega-3 fatty acids, either; Dr. Hendren, in fact, prescribes the latter two for his own patients. Evidence is lacking, however, for amino acids, thyroid supplements, and antifungals. "I don’t think the jury is in on methyl B12 [injections] yet," he said.

Chelation is hot for autism, too, but "I don’t think there’s any reason to try it," he said. "I don’t tell parents that they ought to do it, but I say at least find somebody who knows what they’re doing," he said.

Therapy and Medications

What’s known to help autistic children, among other things, are speech and occupational therapy, cognitive-behavioral treatments, social skills training, and reducing stress by, for instance, removing children from upsetting situations.

Medications can help, too.

For children with comorbid attention-deficit/hyperactivity disorder, stimulants "can make a big difference in their inattention," Dr. Hendren said.

He said he favors immediate-release formulations, titrated up slowly from low doses, and warns parents that stimulants might temporarily unhinge their child.

If that happens, atomoxetine is an option, though stimulants seem to work better for inattention, Dr. Hendren said.

Short-acting tranquilizers like lorazepam help anxiety, especially in tense situations like a visit to the doctor’s office.

As with stimulants, Dr. Hendren said he starts low – 0.5 mg, for example – and slowly titrates up to effect, perhaps going as high as 1 or 2 mg.

"A number of kids do quite well on alpha-adrenergic agonists" as well, he said.

The drugs "seem to help dampen them down, and can be especially useful in some of the younger kids [who] are just very hyperactive and having a lot of difficulty with their impulsivity," he said.

Clonidine is a bit more sedating than guanfacine (Tenex), which can be a benefit.

And some kids do well on Intuniv, the long-acting guanfacine formulation, but "parents don’t like paying that extra price" for the newer medication, Dr. Hendren said.

Topiramate also helps calm anxious children, but Dr. Hendren said he avoids exceeding 75 mg, because the drug can make children squirrelly.

Melatonin helps with sleep problems, "but at times we need to titrate up to as high as 6 or even 8 or 9 mg," he said.

Selective serotonin reuptake inhibitors (SSRIs) might help curb impulsive and compulsive behavior, though a recent study raises doubts about their use in autism (Arch. Gen. Psychiatry 2009;66:583-90). SSRI activation remains a concern, as well.

Among Dr. Hendren’s colleagues, the preference is for escitalopram or sertraline, because these drugs seem less activating. Again, titration is slow from a low dose. He said he prefers "escitalopram because I find I can usually get within range with 20 mg; occasionally I’ll go to 30 mg." Sertraline requires higher dosages. Also, "I like the side effect profile better," he said.

Atypicals and Other Options

Risperidone and aripiprazole, the only drugs approved for autism symptoms, both help irritability, behavior problems, and children who become easily unglued, Dr. Hendren said.

But atypical antipsychotics are associated with significant side effects, including weight gain, sedation, and salivation.

"I’ve had three kids in my practice [who] developed clear symptoms of tardive dyskinesia on risperidone that went away when the medication was taken away," he said. "Some parents are willing to take the risk, but it’s a risk I have them write about."

He’s also had younger girls or boys develop breast buds on risperidone and lactate. In those cases, he usually switches to aripiprazole, though sometimes, children don’t do as well.

Lowering the risperidone dose is another option. "I have some children [whom] I’ve kept just below lactating on risperidone," he said.

When all else fails, there’s some evidence to support propranolol and low-dose naltrexone cream for aggression; divalproex might help affect instability.

Amantadine, d-cycloserine, memantine, cholinesterase inhibitors, and nicotinic agonists all have studies suggesting a small effect size, he said.

Dr. Hendren disclosed that he is an adviser to BioMarin Pharmaceutical Inc., and receives research funding from that company plus Curemark LLC, Forest Laboratories Inc., and Autism Speaks.

LOS ANGELES – When conventional approaches fail to help autistic children, parents who suggest alternative treatments should not be ignored, according to Dr. Robert L. Hendren.

Instead, it’s better to talk to them about their ideas and keep an open mind, said Dr. Hendren, director of child and adolescent psychiatry at the University of California, San Francisco. "I try to weigh the evidence [with families], but if they’re doing something I think is dangerous, or they’re avoiding other kinds of treatments, I tend to tell them," he said.

When there’s no harm to an alternative treatment, after a few months, Dr. Hendren said he will help parents assess whether it is working and ask them to reconsider his treatment ideas.

The reasoned approach means parents feel comfortable telling him the alternatives they’re trying and letting alternative practitioners know that Dr. Hendren is involved in the case, he said. Also, with evidence emerging that mitochondrial dysfunction, chronic inflammation, maternal toxin exposure, oxidative stress, and other problems might play a role in autism, some treatments now considered alternative eventually might prove useful, he said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

Dr. Hendren analyzed the evidence – or lack thereof – for many of the currently hot complementary and alternative approaches.

Casein and gluten-free diets are among them. There’s no harm, so long as families work with nutritionists to ensure that children get enough calcium and protein, he said. There’s no harm in trying glutathione, vitamin D, and omega-3 fatty acids, either; Dr. Hendren, in fact, prescribes the latter two for his own patients. Evidence is lacking, however, for amino acids, thyroid supplements, and antifungals. "I don’t think the jury is in on methyl B12 [injections] yet," he said.

Chelation is hot for autism, too, but "I don’t think there’s any reason to try it," he said. "I don’t tell parents that they ought to do it, but I say at least find somebody who knows what they’re doing," he said.

Therapy and Medications

What’s known to help autistic children, among other things, are speech and occupational therapy, cognitive-behavioral treatments, social skills training, and reducing stress by, for instance, removing children from upsetting situations.

Medications can help, too.

For children with comorbid attention-deficit/hyperactivity disorder, stimulants "can make a big difference in their inattention," Dr. Hendren said.

He said he favors immediate-release formulations, titrated up slowly from low doses, and warns parents that stimulants might temporarily unhinge their child.

If that happens, atomoxetine is an option, though stimulants seem to work better for inattention, Dr. Hendren said.

Short-acting tranquilizers like lorazepam help anxiety, especially in tense situations like a visit to the doctor’s office.

As with stimulants, Dr. Hendren said he starts low – 0.5 mg, for example – and slowly titrates up to effect, perhaps going as high as 1 or 2 mg.

"A number of kids do quite well on alpha-adrenergic agonists" as well, he said.

The drugs "seem to help dampen them down, and can be especially useful in some of the younger kids [who] are just very hyperactive and having a lot of difficulty with their impulsivity," he said.

Clonidine is a bit more sedating than guanfacine (Tenex), which can be a benefit.

And some kids do well on Intuniv, the long-acting guanfacine formulation, but "parents don’t like paying that extra price" for the newer medication, Dr. Hendren said.

Topiramate also helps calm anxious children, but Dr. Hendren said he avoids exceeding 75 mg, because the drug can make children squirrelly.

Melatonin helps with sleep problems, "but at times we need to titrate up to as high as 6 or even 8 or 9 mg," he said.

Selective serotonin reuptake inhibitors (SSRIs) might help curb impulsive and compulsive behavior, though a recent study raises doubts about their use in autism (Arch. Gen. Psychiatry 2009;66:583-90). SSRI activation remains a concern, as well.

Among Dr. Hendren’s colleagues, the preference is for escitalopram or sertraline, because these drugs seem less activating. Again, titration is slow from a low dose. He said he prefers "escitalopram because I find I can usually get within range with 20 mg; occasionally I’ll go to 30 mg." Sertraline requires higher dosages. Also, "I like the side effect profile better," he said.

Atypicals and Other Options

Risperidone and aripiprazole, the only drugs approved for autism symptoms, both help irritability, behavior problems, and children who become easily unglued, Dr. Hendren said.

But atypical antipsychotics are associated with significant side effects, including weight gain, sedation, and salivation.

"I’ve had three kids in my practice [who] developed clear symptoms of tardive dyskinesia on risperidone that went away when the medication was taken away," he said. "Some parents are willing to take the risk, but it’s a risk I have them write about."

He’s also had younger girls or boys develop breast buds on risperidone and lactate. In those cases, he usually switches to aripiprazole, though sometimes, children don’t do as well.

Lowering the risperidone dose is another option. "I have some children [whom] I’ve kept just below lactating on risperidone," he said.

When all else fails, there’s some evidence to support propranolol and low-dose naltrexone cream for aggression; divalproex might help affect instability.

Amantadine, d-cycloserine, memantine, cholinesterase inhibitors, and nicotinic agonists all have studies suggesting a small effect size, he said.

Dr. Hendren disclosed that he is an adviser to BioMarin Pharmaceutical Inc., and receives research funding from that company plus Curemark LLC, Forest Laboratories Inc., and Autism Speaks.

LOS ANGELES – When conventional approaches fail to help autistic children, parents who suggest alternative treatments should not be ignored, according to Dr. Robert L. Hendren.

Instead, it’s better to talk to them about their ideas and keep an open mind, said Dr. Hendren, director of child and adolescent psychiatry at the University of California, San Francisco. "I try to weigh the evidence [with families], but if they’re doing something I think is dangerous, or they’re avoiding other kinds of treatments, I tend to tell them," he said.

When there’s no harm to an alternative treatment, after a few months, Dr. Hendren said he will help parents assess whether it is working and ask them to reconsider his treatment ideas.

The reasoned approach means parents feel comfortable telling him the alternatives they’re trying and letting alternative practitioners know that Dr. Hendren is involved in the case, he said. Also, with evidence emerging that mitochondrial dysfunction, chronic inflammation, maternal toxin exposure, oxidative stress, and other problems might play a role in autism, some treatments now considered alternative eventually might prove useful, he said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

Dr. Hendren analyzed the evidence – or lack thereof – for many of the currently hot complementary and alternative approaches.

Casein and gluten-free diets are among them. There’s no harm, so long as families work with nutritionists to ensure that children get enough calcium and protein, he said. There’s no harm in trying glutathione, vitamin D, and omega-3 fatty acids, either; Dr. Hendren, in fact, prescribes the latter two for his own patients. Evidence is lacking, however, for amino acids, thyroid supplements, and antifungals. "I don’t think the jury is in on methyl B12 [injections] yet," he said.

Chelation is hot for autism, too, but "I don’t think there’s any reason to try it," he said. "I don’t tell parents that they ought to do it, but I say at least find somebody who knows what they’re doing," he said.

Therapy and Medications

What’s known to help autistic children, among other things, are speech and occupational therapy, cognitive-behavioral treatments, social skills training, and reducing stress by, for instance, removing children from upsetting situations.

Medications can help, too.

For children with comorbid attention-deficit/hyperactivity disorder, stimulants "can make a big difference in their inattention," Dr. Hendren said.

He said he favors immediate-release formulations, titrated up slowly from low doses, and warns parents that stimulants might temporarily unhinge their child.

If that happens, atomoxetine is an option, though stimulants seem to work better for inattention, Dr. Hendren said.

Short-acting tranquilizers like lorazepam help anxiety, especially in tense situations like a visit to the doctor’s office.

As with stimulants, Dr. Hendren said he starts low – 0.5 mg, for example – and slowly titrates up to effect, perhaps going as high as 1 or 2 mg.

"A number of kids do quite well on alpha-adrenergic agonists" as well, he said.

The drugs "seem to help dampen them down, and can be especially useful in some of the younger kids [who] are just very hyperactive and having a lot of difficulty with their impulsivity," he said.

Clonidine is a bit more sedating than guanfacine (Tenex), which can be a benefit.

And some kids do well on Intuniv, the long-acting guanfacine formulation, but "parents don’t like paying that extra price" for the newer medication, Dr. Hendren said.

Topiramate also helps calm anxious children, but Dr. Hendren said he avoids exceeding 75 mg, because the drug can make children squirrelly.

Melatonin helps with sleep problems, "but at times we need to titrate up to as high as 6 or even 8 or 9 mg," he said.

Selective serotonin reuptake inhibitors (SSRIs) might help curb impulsive and compulsive behavior, though a recent study raises doubts about their use in autism (Arch. Gen. Psychiatry 2009;66:583-90). SSRI activation remains a concern, as well.

Among Dr. Hendren’s colleagues, the preference is for escitalopram or sertraline, because these drugs seem less activating. Again, titration is slow from a low dose. He said he prefers "escitalopram because I find I can usually get within range with 20 mg; occasionally I’ll go to 30 mg." Sertraline requires higher dosages. Also, "I like the side effect profile better," he said.

Atypicals and Other Options

Risperidone and aripiprazole, the only drugs approved for autism symptoms, both help irritability, behavior problems, and children who become easily unglued, Dr. Hendren said.

But atypical antipsychotics are associated with significant side effects, including weight gain, sedation, and salivation.

"I’ve had three kids in my practice [who] developed clear symptoms of tardive dyskinesia on risperidone that went away when the medication was taken away," he said. "Some parents are willing to take the risk, but it’s a risk I have them write about."

He’s also had younger girls or boys develop breast buds on risperidone and lactate. In those cases, he usually switches to aripiprazole, though sometimes, children don’t do as well.

Lowering the risperidone dose is another option. "I have some children [whom] I’ve kept just below lactating on risperidone," he said.

When all else fails, there’s some evidence to support propranolol and low-dose naltrexone cream for aggression; divalproex might help affect instability.

Amantadine, d-cycloserine, memantine, cholinesterase inhibitors, and nicotinic agonists all have studies suggesting a small effect size, he said.

Dr. Hendren disclosed that he is an adviser to BioMarin Pharmaceutical Inc., and receives research funding from that company plus Curemark LLC, Forest Laboratories Inc., and Autism Speaks.