Can Antipsychotic Medication Help My Child?
Parents of children with autism are faced with many difficult decisions on how to best help their child. There is a variety of options to consider, including educational programming, behavioral treatments, alternative therapies, obtaining further assessments -- the list goes on and on. This article is meant to help parents considering whether to try treatment with antipsychotic medication.
As researchers who conduct studies of such medications, we are frequently faced with parents asking the question: “Will treatment with antipsychotic medication help my child?” Of course, we cannot say for sure that a medication will or will not help an individual child. The best available information to use to form opinions regarding possible benefits comes from double-blind and placebo-controlled studies. We know from our studies, and the studies of others, what potential benefits and side effects are likely.
Antipsychotic medications can be divided into two broad categories. The first group is referred to as the first-generation, or the conventional, agents. First-generation agents are, in general, the antipsychotic medications that appeared on the scene beginning in the 1950s through the 1970s. They include chlorpromazine (Thorazine) and haloperidol (Haldol). A characteristic of the first-generation agents was that they more commonly caused some very unpleasant side effects, collectively known as extrapyramidal symptoms. (See below for more discussion.)
The second group is referred to as the second-generation, or the atypical, agents. They include aripiprazole (Abilify), olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), and ziprasidone (Geodon). The second-generation agents, apart from the medication clozapine, came on the market later, beginning in the 1990s. They are atypical in that they cause fewer extrapyramidal side effects. However, they often cause more weight gain than the first-generation agents, though this can depend on the exact medication.
Currently, the two best-studied medications in autism include a first-generation agent, haloperidol (Haldol), and a second-generation agent, risperidone (Risperdal). Other second-generation medications, including aripiprazole (Abilify) and olanzapine (Zyprexa), continue to be studied. Both haloperidol and risperidone are similarly effective in reducing symptoms in autism such as tantrums and aggression, hyperactivity, repetitive behaviors (i.e., stereotypies or “self-stim”), and irritable or quickly changing moods.
Haloperidol is approved by the Food and Drug Administration for reducing severe behavioral disorders in children older than 3 years, but the diagnosis of autism is not included in the approval language. Risperidone is approved for treating irritability associated with autism in children aged 5–16 years, and is the only medication that currently includes the diagnosis of autism in its labeling.
In considering whether antipsychotic medication can be useful for the treatment of children and adolescents with autism, it is important to understand that these medications do not cure the core deficits of autism. They will not, for example, suddenly improve a child’s social understanding. What they can do is help to alleviate symptoms associated with autism -- symptoms that can interfere with a child’s quality of life and ability to benefit from other therapies such as behavioral approaches to symptom reduction, educational programming, speech therapy, and occupational therapy. The antipsychotics have been shown to help with disruptive behaviors such as hyperactivity, temper tantrums, and irritability. They also often improve sleep in children who are not sleeping or who have frequent awakenings. In addition, they can reduce repetitiveness, including repetitive motor behaviors such as arm flapping, twirling, toe walking, and pacing. The amount of improvement in any individual can vary from no improvement to marked improvement. As with any medication, some individuals may even seem to worsen with antipsychotic medication treatment. That individuals react to medication treatment differently must be kept in mind.
Most often, the initial dosage of medication used is on the low end for several reasons. First of all, many side effects, such as sedation (i.e., sleepiness), are most often seen when medication is initiated. Starting with a low dosage minimizes many side effects, and they can be less frequent or notable after an adjustment period. Second, there is no way to know what dosage will be effective. In some cases individuals may respond to the lowest dose, which can be determined only by starting with a low dosage. However, it is possible that the medication will be effective only once higher dosages are used, a judgment that may require several dosage increases. It is important to remember that when a medication is not effective at a low dosage, it still may be effective once the dosage is increased to a higher level.
No discussion of medication treatment would be complete without a consideration of side effects. Every medication comes with the risk of side effects. Not all individuals experience side effects, but it is important to know what can occur so that side effects can be identified and, if necessary, the medication dosage lowered or the medication discontinued. The extrapyramidal side effects mentioned earlier are fairly specific to antipsychotic medications.
Extrapyramidal side effects involve problems with motor movement. They include:
- Dystonic reactions. Prolonged contractions of muscles, including any muscles such as those in the neck or arms, or even the muscles around the eye (in which case the individual seems to have a fixed gaze upward).
- Medication-induced parkinsonism. Characterized by a stiff gait and a tremor.
- Akathisia. Restlessness and possibly increased motor activity (which can be hard to judge in those who are already hyperactive).
- Dyskinesia. Abnormal involuntary movement that can affect any muscle of the body, often involving the facial area and the tongue.
The first three types -- dystonic reactions, medication-induced parkinsonism, and akathisia -- are direct effects of medication and lessen if dosage is decreased. If it becomes necessary to discontinue the medication, these side effects will go away. Actually, dystonic reactions can be treated with medication, and diphenhydramine (Benadryl) is often administered for this purpose. The fourth extrapyramidal side effect, dyskinesia, is the result of long-term antipsychotic exposure, and there is a risk that dyskinesias will be permanent. Dyskinesias were more of a concern with the first-generation antipsychotic medications, as they occur in less than 1% of patients taking second-generation agents.
The side effects that have caused the most concern with the second-generation antipsychotics, however, are increased appetite and weight gain. Weight gain is related to increased risk for developing diabetes and cardiovascular diseases such as hypertension and heart disease. A number of other side effects can occur, but a full discussion is beyond the scope of this article. They include sedation, constipation, sensitivity to sunlight, increased thirst, increased urination, and fever.
Because of the risk of side effects, a careful assessment of the individual must be made before antipsychotic medication is started. This assessment should include measuring height, weight, blood pressure, and pulse. Blood glucose and lipid levels also should be obtained. The individual should be examined for any abnormal movement or tics because they can be hard to distinguish from dyskinesias once medication has begun. All of these assessments are necessary to judge possible side effects such as the development of abnormal movements, weight gain, and changes in blood glucose and lipids. These assessments need to be repeated during treatment to monitor for changes that may be related to medication.
In summary, antipsychotics may be useful for reducing certain symptoms in individuals with autism and can be an important adjunct to other ongoing therapies. At times, the use of antipsychotic medications can permit the individual to gain more benefit from other therapies, and permit the individual to be included in a less restrictive setting. Antipsychotic medications are most helpful for reducing disruptive and aggressive behaviors, as well as rigid and repetitive behaviors. When antipsychotic medications are administered, there needs to be careful monitoring for side effects. And don’t forget: The decision to try a medication is not a permanent decision. If the medication is not helpful, it can be discontinued.