Autism Drug Choice Usually Matter of Trial and Error

Ritualistic, repetitive behaviors, including hand-flapping, rocking, and lining things up, are hallmark symptoms in ASDs and often vary by patient. “Many times patients do it in order to feel better and … reduce anxiety and irritability,” said McDougle.

Although such behaviors may bother the patient's parents, he suggested that clinicians should determine whether they serve as a form of relief for the patient rather than automatically trying to suppress or eliminate the behaviors, unless they interfere with other key aspects of the patient's functioning.

Repetitive behavior in most autism patients is different from obsessive-compulsive disorder symptoms, he emphasized, noting that studies have produced conflicting data on the effectiveness of selective serotonin reuptake inhibitors (SSRIs) in reducing repetitive behavior. Citalopram, for example, was found to be no different from placebo in a large, controlled study of children and adolescent patients. McDougle and colleagues have found fluvoxamine to be helpful in adult but not pediatric patients. Nevertheless, individual patients may respond clinically to an SSRI, he pointed out.

In addition, risperidone and aripiprazole are more effective than placebo in reducing stereotypical behavior in large, controlled clinical studies, according to McDougle. “Beyond that, the field doesn't have great ideas,” he said.

Mood disorders are not uncommon in patients with ASDs or developmental disabilities, but they are often undiagnosed because of communication difficulties between the patient and the clinician, and so far they haven't been studied by researchers, according to McDougle. When SSRIs or antiepileptic drugs are initiated in younger patients, he cautioned, clinicians should be mindful to monitor for suicidal ideation, even if the patient may not be able to articulate it.

In addition, sleep disturbance is common in autism patients, and McDougle recommended melatonin, clonidine, or trazodone as first-line treatment options. Clinicians prescribing trazodone should be alert to the risk for priapism, he advised.

Inappropriate sexual behavior in post-pubertal autism patients can be troubling and very difficult to manage. McDougle pointed out that autism is not a children's disease, even though it is often perceived so. Many adult patients have “mature sexual function with immature sexual judgment,” he said. Hormonal therapies and high-dose SSRIs are tried for some patients but rarely work well. “Generally I haven't had success with pharmacological approaches” to sexual-behavior problems in autism patients, he acknowledged.

He also said that behavioral interventions can be helpful for some patients, but challenges remain in using them effectively.

Unfortunately, the core symptom of ASDs, social impairment, remains pharmacologically untreatable at this time, he noted. Researchers are, however, pursuing a number of promising pharmaceutical and behavioral approaches that may offer hope for patients and families in the near future.