Medication May Facilitate Autism Interventions

SANTA FE, N.M. — Pharmacotherapy does not cure autism, but it can make autistic children accessible to other modes of treatment, Bennett L. Leventhal, M.D., said at a psychiatric symposium sponsored by the University of Arizona.

“There are no pharmacological treatments for the cardinal symptoms of autism. Those things are not responsive to medication,” advised Dr. Leventhal, director of child and adolescent psychiatry at the University of Chicago. “But making kids available to other interventions may help them improve,” he said.

When children are referred for pharmacotherapy, it should begin with a complete work-up, he said. Though additional measures may be used, he said no child should be diagnosed without evaluation by two standard instruments: an Autism Diagnostic Interview (ADI) and the Autism Diagnostic Observation Schedule (ADOS).

Dr. Leventhal recommended doing a physical examination with neurologic studies even if the child has been referred by a family physician.

Moreover, these children may have other impairments that were missed because of challenges in communicating with them.

For example, he said he has seen deaf children who were classified as autistic because no one recognized hearing loss.

Attention-deficit hyperactivity disorders used to be ruled out in autistic children, he said. While these youngsters can concentrate intensely on what interests them, specialists now recognize that many autistic children have difficulty paying attention.

Dr. Leventhal said he treats them with the same stimulants used for attention deficit in children who are not autistic. “There are no studies of stimulants in children with autism, but there is no reason to think these agents would not apply here,” he said.

No one stimulant has proved better than another, he added. The biggest problem, he said, is getting autistic children to swallow pills.

Dr. Leventhal recommended serotonin reuptake inhibitors (SSRIs) for control of stereotypic behaviors, such as repetitive behaviors, self-stimulatory behaviors (“stimming”), habits, and tics. He cited studies showing improvements with fluvoxamine (Arch. Gen. Psychiatry 1996; 53:1001–8) and fluoxetine (Neuropsychopharmacology 2005;30:582–9).

An added benefit is SSRIs can reduce aggression, he added, describing aggression and irritability as another serious problem for people with autism.

Dr. Leventhal reported that he no longer uses traditional neuroleptics because of side effects. Atypicals are coming into use, he said, but there is not much evidence in this population, except for risperidone (Risperdal).

Johnson & Johnson, parent company of risperidone maker Janssen Pharmaceutica Inc., announced in May that the Food and Drug Administration had informed the company that risperidone was “not approvable” for autism. Dr. Leventhal expressed bafflement at the decision, as he quoted data from studies that found risperidone to be effective (J. Am. Acad. Child Adolesc. Psychiatry 2002;41:140–7; Arch. Gen. Psychiatry 1998;55:633–41; N. Engl. J. Med. 2002;347:314–21).

“There's more than ample evidence that at least risperidone as an agent leads to better overall function and reduces irritability. The FDA did not think of much of the application. It looks like ample data to me,” said Dr. Leventhal, who listed a consulting relationship with Janssen in a disclosure of interests with several pharmaceutical companies.

The risperidone doses are “relatively modest”: 1–3 mg per day, he added, reporting better outcomes and fewer side effects with lower doses. Lithium is another option that reduces aggression regardless of diagnosis or cause, according to Dr. Leventhal, who said he has also used propranolol in extreme cases.

Whatever the agent, attention to dosing is critical, Dr. Leventhal said. “In children with autism, side effects are very difficult to treat and very difficult to follow because these kids are not verbal,” he said.

He discouraged use of novel anticonvulsants for mood disorders, anxiolytics for anxiety disorders, and chelation to remove heavy metals when treating autistic patients. Secretin, a drug that failed several randomized trials in autism, “may actually be harmful.”

The cognitive enhancers approved for Alzheimer's disease are a possibility for autism, he said. “Whether it works or not is an open question. Some of our data suggest this might have some utility.”

SANTA FE, N.M. — Pharmacotherapy does not cure autism, but it can make autistic children accessible to other modes of treatment, Bennett L. Leventhal, M.D., said at a psychiatric symposium sponsored by the University of Arizona.

“There are no pharmacological treatments for the cardinal symptoms of autism. Those things are not responsive to medication,” advised Dr. Leventhal, director of child and adolescent psychiatry at the University of Chicago. “But making kids available to other interventions may help them improve,” he said.

When children are referred for pharmacotherapy, it should begin with a complete work-up, he said. Though additional measures may be used, he said no child should be diagnosed without evaluation by two standard instruments: an Autism Diagnostic Interview (ADI) and the Autism Diagnostic Observation Schedule (ADOS).

Dr. Leventhal recommended doing a physical examination with neurologic studies even if the child has been referred by a family physician.

Moreover, these children may have other impairments that were missed because of challenges in communicating with them.

For example, he said he has seen deaf children who were classified as autistic because no one recognized hearing loss.

Attention-deficit hyperactivity disorders used to be ruled out in autistic children, he said. While these youngsters can concentrate intensely on what interests them, specialists now recognize that many autistic children have difficulty paying attention.

Dr. Leventhal said he treats them with the same stimulants used for attention deficit in children who are not autistic. “There are no studies of stimulants in children with autism, but there is no reason to think these agents would not apply here,” he said.

No one stimulant has proved better than another, he added. The biggest problem, he said, is getting autistic children to swallow pills.

Dr. Leventhal recommended serotonin reuptake inhibitors (SSRIs) for control of stereotypic behaviors, such as repetitive behaviors, self-stimulatory behaviors (“stimming”), habits, and tics. He cited studies showing improvements with fluvoxamine (Arch. Gen. Psychiatry 1996; 53:1001–8) and fluoxetine (Neuropsychopharmacology 2005;30:582–9).

An added benefit is SSRIs can reduce aggression, he added, describing aggression and irritability as another serious problem for people with autism.

Dr. Leventhal reported that he no longer uses traditional neuroleptics because of side effects. Atypicals are coming into use, he said, but there is not much evidence in this population, except for risperidone (Risperdal).

Johnson & Johnson, parent company of risperidone maker Janssen Pharmaceutica Inc., announced in May that the Food and Drug Administration had informed the company that risperidone was “not approvable” for autism. Dr. Leventhal expressed bafflement at the decision, as he quoted data from studies that found risperidone to be effective (J. Am. Acad. Child Adolesc. Psychiatry 2002;41:140–7; Arch. Gen. Psychiatry 1998;55:633–41; N. Engl. J. Med. 2002;347:314–21).

“There's more than ample evidence that at least risperidone as an agent leads to better overall function and reduces irritability. The FDA did not think of much of the application. It looks like ample data to me,” said Dr. Leventhal, who listed a consulting relationship with Janssen in a disclosure of interests with several pharmaceutical companies.

The risperidone doses are “relatively modest”: 1–3 mg per day, he added, reporting better outcomes and fewer side effects with lower doses. Lithium is another option that reduces aggression regardless of diagnosis or cause, according to Dr. Leventhal, who said he has also used propranolol in extreme cases.

Whatever the agent, attention to dosing is critical, Dr. Leventhal said. “In children with autism, side effects are very difficult to treat and very difficult to follow because these kids are not verbal,” he said.

He discouraged use of novel anticonvulsants for mood disorders, anxiolytics for anxiety disorders, and chelation to remove heavy metals when treating autistic patients. Secretin, a drug that failed several randomized trials in autism, “may actually be harmful.”

The cognitive enhancers approved for Alzheimer's disease are a possibility for autism, he said. “Whether it works or not is an open question. Some of our data suggest this might have some utility.”

SANTA FE, N.M. — Pharmacotherapy does not cure autism, but it can make autistic children accessible to other modes of treatment, Bennett L. Leventhal, M.D., said at a psychiatric symposium sponsored by the University of Arizona.

“There are no pharmacological treatments for the cardinal symptoms of autism. Those things are not responsive to medication,” advised Dr. Leventhal, director of child and adolescent psychiatry at the University of Chicago. “But making kids available to other interventions may help them improve,” he said.

When children are referred for pharmacotherapy, it should begin with a complete work-up, he said. Though additional measures may be used, he said no child should be diagnosed without evaluation by two standard instruments: an Autism Diagnostic Interview (ADI) and the Autism Diagnostic Observation Schedule (ADOS).

Dr. Leventhal recommended doing a physical examination with neurologic studies even if the child has been referred by a family physician.

Moreover, these children may have other impairments that were missed because of challenges in communicating with them.

For example, he said he has seen deaf children who were classified as autistic because no one recognized hearing loss.

Attention-deficit hyperactivity disorders used to be ruled out in autistic children, he said. While these youngsters can concentrate intensely on what interests them, specialists now recognize that many autistic children have difficulty paying attention.

Dr. Leventhal said he treats them with the same stimulants used for attention deficit in children who are not autistic. “There are no studies of stimulants in children with autism, but there is no reason to think these agents would not apply here,” he said.

No one stimulant has proved better than another, he added. The biggest problem, he said, is getting autistic children to swallow pills.

Dr. Leventhal recommended serotonin reuptake inhibitors (SSRIs) for control of stereotypic behaviors, such as repetitive behaviors, self-stimulatory behaviors (“stimming”), habits, and tics. He cited studies showing improvements with fluvoxamine (Arch. Gen. Psychiatry 1996; 53:1001–8) and fluoxetine (Neuropsychopharmacology 2005;30:582–9).

An added benefit is SSRIs can reduce aggression, he added, describing aggression and irritability as another serious problem for people with autism.

Dr. Leventhal reported that he no longer uses traditional neuroleptics because of side effects. Atypicals are coming into use, he said, but there is not much evidence in this population, except for risperidone (Risperdal).

Johnson & Johnson, parent company of risperidone maker Janssen Pharmaceutica Inc., announced in May that the Food and Drug Administration had informed the company that risperidone was “not approvable” for autism. Dr. Leventhal expressed bafflement at the decision, as he quoted data from studies that found risperidone to be effective (J. Am. Acad. Child Adolesc. Psychiatry 2002;41:140–7; Arch. Gen. Psychiatry 1998;55:633–41; N. Engl. J. Med. 2002;347:314–21).

“There's more than ample evidence that at least risperidone as an agent leads to better overall function and reduces irritability. The FDA did not think of much of the application. It looks like ample data to me,” said Dr. Leventhal, who listed a consulting relationship with Janssen in a disclosure of interests with several pharmaceutical companies.

The risperidone doses are “relatively modest”: 1–3 mg per day, he added, reporting better outcomes and fewer side effects with lower doses. Lithium is another option that reduces aggression regardless of diagnosis or cause, according to Dr. Leventhal, who said he has also used propranolol in extreme cases.

Whatever the agent, attention to dosing is critical, Dr. Leventhal said. “In children with autism, side effects are very difficult to treat and very difficult to follow because these kids are not verbal,” he said.

He discouraged use of novel anticonvulsants for mood disorders, anxiolytics for anxiety disorders, and chelation to remove heavy metals when treating autistic patients. Secretin, a drug that failed several randomized trials in autism, “may actually be harmful.”

The cognitive enhancers approved for Alzheimer's disease are a possibility for autism, he said. “Whether it works or not is an open question. Some of our data suggest this might have some utility.”