Medical Management in ASC

Autism Management:

General principles of management: Autism Spectrum Condition (ASC) can present substantial barriers to normal daily functioning and the approach to its management is a combination of symptom modification together with the removal of these barriers wherever possible.

Pharmacological Interventions:

No medication has any direct effect on the triad of impairment (social challenges, restricted interests/behaviours and communication problems) in ASC and the place of medication is therefore mainly in alleviating associated conditions and problems. The risks should always be looked at in balance with the small potential benefits.

Additional cautions are advised when using any medications in autism because of the increased likelihood of unpredictable effects in this group of patients.

1. Antipsychotics: There is some suggestion that risperidone or aripiprazole may be useful in the management of aggression, tantrums and self-injury.
2. Stimulants: Autistic children and co-existing ADHD respond to stimulant medications in a similar way to those with ADHD alone like Methylphenidate.
3. Antidepressants: Small evidence supports the use for low mood, but also for some improvements in repetitive behaviours with Selective Serotonin Reuptake Inhibitors (SSRIs). Antidepressants commonly used for co-morbidities with ASC like sertraline for anxiety disorders & depression.
4. Melatonin: To improve sleep. Whilst little official information exists about its safety profile and dosing, it appears to be safe and effective in autistic children who have sleep-wake cycle problems that fail to respond to behavioural intervention.

Antidepressants in ASC for Anxiety and Depression
 

SSRI (Selective Serotonin Reuptake Inhibitor): are sometimes an effective treatment for severe Anxiety and depression in Autism.
 

SSRI treatment of Anxiety and Depression commonly used in children are Fluoxetine, Sertraline, fluvoxamine and escitalopram.
 

SSRI treatment of Anxiety and Depression in adults are Fluoxetine, Escitalopram, fluvoxamine, Paroxetine and Sertraline.

Catatonia and ASC
 

There are various theories about the relationship between catatonia in autistic children and adults. Catatonia can be defined as a group of symptoms that usually involve difficulties in movement and behaviour (Diagnostic and Statistical Manual of Mental Disorders-IV DSM-IV: American Psychiatric Association, 2013). The Overlap in the clinical pictures of catatonia, autism and parkinsonism raises the question as to whether they are all part of a continuously distributed array of disorders of movement and volition related to the extrapyramidal system. Some individuals show a tendency to passivity in social interactions before the onset of catatonia, suggesting a difficulty in initiating motor activity as a possible neuropathology in the three conditions, although autism is also a social and cognitive condition (Wing & Shah, 2000).

Treatment of catatonia is lorazepam
 

Self-injurious behaviour in ASC:

Self-injurious behaviour (SIB) includes slapping, punching, banging and biting. In practice, the most common causes of self-injury are pain and low mood.

The presence of SIB points to particular genetic syndromes that are more common in patients with a lower than average IQ. The majority of SIBs can be managed using behavioural approaches and treating anxiety; however, when SIBs are more serious and these strategies prove ineffective, pharmacotherapy may be an option, although the evidence base is lacking.

Prescribing standards

When discussing potentially prescribing medication off-licence, it is important to:

• Explain to the patient and carers that the medication is not licenced for the intended use

• Explain the intended benefits and possible side-effects

• Ensure the patient/carer is in complete agreement before prescribing

• Provide them with information leaflets, if available.

Documentation

The discussion must be clearly documented in the patient's notes. The Royal College of Psychiatrists provides four standards that should be followed in its FR/ID/09 practice guidelines (RCPsych, 2016).

• Pharmacological approaches should not routinely be used to treat the core features of autism and should never be used in isolation.

• The common associated symptoms of irritability, stereotypies and compulsions, hyperactivity and ADHD, and sleep difficulties can potentially be treated pharmacologically. The ABC is a caregiver-scored report of behaviour commonly used.

• The stereotypies seen in ASD differ from those seen in OCD as they often have a sensory basis and can in fact calm the person down. The evidence base for selective serotonin reuptake inhibitors (SSRIs) is variable.

• When prescribing off-licence, it is important to follow the four standards set out in the Royal College of Psychiatrists' FR/ID/09 practice guidelines (RCPsych, 2016).