Review of Research Evidence for Pharmacological Behavioural Interventions for Autism Spectrum Disorder

In the past 15 years there has been a significant increase in the number and range of pharmacological based treatments being used for individuals with ASD. It is commonly acknowledged in the literature that there is no medication that can cure autism, however, there are a number of medications that are recognised to effectively treat symptoms of ASD and conditions that exist co-morbidly with ASD. An American study by Oswald and Sonenklar (2007) reported over 70% of children with ASD aged 8 or above, received at least one course of medication a year. Another American study in 2008 by Mandell et al. reported 32% of 3-5 year olds and 18% of 0-2 year olds with ASD, being treated with medication at least once during a year. Murray (2013) noted that the use of psycho-stimulants and antipsychotics were much higher amongst individuals with ASD than in the general population Research also indicates that pharmacological interventions are used more commonly in America than in the Uk, but is generally increasing world-wide. It is an accepted option in New Zealand as reflected in this comment from a parent of 2 children with ASD that I work with: When the children go to see their paediatricians it's really just checking in to see how [they are] going & a heavy emphasis from both [paediatricians] on getting both my kids medicated!! It's a big push! (personal email , August 3rd, 2013). As pharmacological treatments play an ever increasing role in the treatment of ASD the need to access to quality research examining the effectiveness and validity of these interventions is essential. This artefact looks at pharmacological interventions rated by the NZ ASD Guideline and compares these findings to those given by Research Autism and Raising Children Network Australia.

Pharmacological Intervention

Type of Medication

Claims For individual with ASD

Decreases anxiety or depression

Cautions

Evidence-Based Rating NZASD Research Raising Guideline Autism Children Network

B: Fair, most evidence valid, some concerns U: Ungraded: currently reviewing Yet to be determined, insufficient

Fluoxetine

Antidepressant Increases the level of

Careful monitoring recommended

neurotransmitters in the brain.

Risperidone

Atypical Antipsychotic Alters neurotransmitters especially serotonin and dopamine

Decreases aggression, irritability, self-harm and possibly restrictive, repetitive behaviours

High risk of adverse effects. Uncertainty of long term effects Regular monitoring for side effects e.g. weight gain, drowsiness, is recommended

but not likely to be over turned by other evidence B: Fair, most evidence valid, some concerns but not likely to be over turned by other evidence This rating was maintained after a NZ Living Guideline update (2011) B: Fair, most evidence valid, some concerns but not likely to be over turned by other evidence

evidence.

evidence available. Promising, some positive results but more research needed.

Very strongly positive

Haloperidol

Typical or Conventional Antipsychotics Psychoactive drug

Thioridazine Methylphenidate Stimulant, also

known as Ritalin

Decreases stereotyped behaviours and tantrums. Increases social relationships

Melatonin

Hormone and neurotransmitter

Can improve inattention, hyperactivity and impulsivity. Increases sleep No proven side in individuals effects but may with sleep be associated

May cause weight gain. Dyskinesia (abnormal motor movements) Possible cause of sudden death High risk of C: Supported by adverse side expert opinion effects

U: ungraded, currently reviewing evidence

Unrateable: not yet reviewed

Not yet rated Ungraded: currently reviewing evidence. Mildly hazardous Strong positive evidence

Unrateable: not yet reviewed Not listed on this site

B: Fair, most evidence valid, some concerns

Not listed on this site

Regulates the bodies internal clock

impairment

with blood clotting, seizure and disorientation if taken in large amounts

but not likely to be over turned by other evidence

Clonidine

Anti-hypertensive

Decreases hyper-arousal

I:Insufficient evidence to make a recommendation I:Insufficient evidence to make a recommendation I:Insufficient evidence: unlikely to be useful I:Insufficient evidence: unlikely to be useful

Ungraded: currently reviewing evidence. Not listed on this site

Not listed on this site

Sedatives

Anxiolytics e.g. benzodiazepine, antihistamines

Can decrease sleeplessness

Not listed on this site

Amantadine Intravenous Immunoglobulin

n-methyl-d-aspartate Decreases receptor antagonist hyperactivity Immune disorder treatment May improve symptoms based on theory that ASD may be caused by immune system defect Decreases self-harm, hyperactivity and ritualistic behaviours. Mildly hazardous

Not listed on this site Use for ASD not recommended due to risks and lack of proven effectiveness

Not listed on this site Not listed on this site

Naltrexone

Opioid Antagonist Blocks endorphins in the central nervous system

Mildly hazardous

I:Insufficient evidence: unlikely to be useful

Ungraded: currently reviewing evidence.

Unrateable: not yet reviewed

Fenfluramine

5-HT receptor antagonist

Lowers blood pressure

Mildly hazardous Withdrawn due to safety issues

Secretin

Gastrointestinal hormone

Improves digestion of food. Increases sociability, speech and sleep Can improve symptoms based on theory that ASD may be caused by toxins in the body

Increased temperature, constipation, nausea, hyperactivity and aggression Mildly hazardous Trial in USA stopped due to range of safety concerns

Chelation

Chemical method to remove heavy metals such as mercury from the body.

Not Recommended A: Good evidence from valid, applicable, clinically relevant studies. Not Recommended A: Good evidence from valid, applicable, clinically relevant studies. Not Recommended C: Supported by expert opinion

Ungraded: currently reviewing evidence.

Not listed on this site

Very strong negative evidence

Not listed on this site

Insufficient mixed Unrateable: not evidence yet reviewed

Conclusion
Research surrounding many pharmacological interventions for ASD raises concerns around validity, consistency across studies, low numbers of studies for a specific intervention, application and clinical relevance. There are few studies where a comparison placebo group has been used. However, despite this there are some potentially promising pharmacological interventions currently in use. Much research warns against hazardous side effects and some medications have been withdrawn due to fear of safety risks. The long term effects of many of these medications are, as yet, unestablished and correct dosage for an individual is often difficult to achieve. These factors combined, with the continual release of new medications, highlights the need for large scale studies of both new and current pharmacological approaches to treating individuals with ASD, and the necessity for professionals in the field of ASD to ensure they are aware of changes and additions to this body of evidence. The potential risks involved with use of medications and the lack of well-controlled studies, requires that alternative behavioural, developmental, or psychological interventions be considered before using a pharmacological approach.

References
Bravaccio, C., Marino, M., & Pia Riccio, M. (2013). Relevant issues in the pharmacological treatment of autism spectrum disorders: A critical review. OA Autism, 21(1), 17. Retrieved from http://www.oapublishinglondon.com/article/670 Broadstock, M., & Doughty, C. (2003). The effectiveness of pharmacological therapies for young people and adults with Autism Spectrum Disorder (ASD). NZHTA Report. Retrieved from http://www.otago.ac.nz/christchurch/otago014035.pdf Mandell, D., Morales, K., Marcus, S., Stahmer, A., Doshi, J., & Polsky, D. (2008). Psychotropic medication use among Medicaid-enrolled children with autism spectrum disorders. Pediatrics, 121(3). doi:doi: 10.1542/peds.2007-0984. Ministries of Health and Education. (2008). New Zealand Autism Spectrum Disorder Guideline. Wellington: Ministry of Health. Retrieved from Ministry of Health: http://www.health.govt.nz/ New Zealand Guidelines Group. (2011). New Zealand Autism Spectrum Disorder Guideline Supplementary Evidence on Three Pharmacological Interventions.

Oswald, D., & Sonenklar, N. (2007, June). Medication use among children with autism spectrum disorders. Journal of Child and Adolescent Psychopharmacology, 17(3), 348-355. doi:i:10.1089/cap.2006.17303. Parent Guide to Therapies. (n.d.). Retrieved October 2013, from Raising Children Network Australia: http://raisingchildren.net.au/parents_guide_to_therapies/parents_guide_to_therapies.html Research Autism. (2013). Interventions, Treatments and Therapies for Autism. Retrieved from Research Autsim: http://researchautism.net/pages/autism_treatments_therapies_interventions/