Medication
Usage: Risk versus Benefit Decisions
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There
has been much publicity lately about the hazards associated with certain
medications such as antidepressants and pain-relieving drugs for arthritis. It
has raised concern among parents whose children already use medications, and
has made more ardent skeptics of those who already hesitate to use drugs with
their child.
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All
medications have risks. When making decisions about medication usage, the
benefits should clearly - not marginally - outweigh the risks. Common sense
dictates that drugs with a higher risk of bad side-effects should be used more
carefully than drugs with a low risk. A reasonable approach is to try drugs
with a lower risk of side effects first.
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To
approach medication decision-making in a logical manner, it is best to adhere
to the following three principles. These principles assume that non-drug approaches
have been tried FIRST and proved unsuccessful in alleviating the challenge. A
child should NOT be given medication as the first course of treatment when
presenting behavioral challenges. Exhaust other treatments first.
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Try
one medication at a time so you can judge its effect. Do not change educational
programs or diet at the same time a new drug is cried. Allow a few weeks to a
month between starting a medication and changing some other part of the individual's
program. Keeping a journal of the child's behaviors, demeanor, and levels of
activity can be helpful in spotting possible side effects and/or assessing the
degree of improvement, if any.
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An
effective medication should have an OBVIOUS BENEFICIAL EFFECT. Giving a child a
powerful drug that renders him only slightly less hyper would probably not be
worth the risk. A drug that just takes the edge off his hyperactivity, but
makes him very lethargic, would be equally bad. I am really concerned about the
growing number of powerful drugs being prescribed to young children. In little
kids, I recommend trying one of the special diets and Omega-3 (fish oil
supplements first, before giving the child powerful drugs.
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If
an individual has been on a medication that is working really well it is
usually not worth the risk to change it for a new medication. Newer is not
always better. Pharmaceutical companies promote their new drugs while they
still have patents. After a drug goes generic, they no longer promote it. Many
of the older generic drug are very effective and cheap. However, use care when
switching brands of generics. Find a brand that works well and stay with it;
The way the pills are manufactured may affect how fast they dissolve, which may
change the way the drug works.
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To
make good decisions, parents need to know ALL the risks involved with the major
classes of medications. The following section summarizes the uses and risks
associated with the six most commonly used medications.
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1
Antidepressants (both SSRIs-selective serotonin reuptake inhibitors such as
Prozac - and older tricyclics) should be given at lower doses to people on the
spectrum than to the general population. Some individuals with ASD need only
one-quarter to one-half the normal starter dose. Giving too high a dose of an
antidepressant causes many problems such as insomnia and agitation. The correct
low dose can have very positive effects. I know many design professionals who
take Prozac and they have done some of their best work while taking it.
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However;
I have heard several complaints about memory problems with Paxil (paroxenne),
Prozac (fluoxetine) or Zoloft (sertraline) would probably be better choices. In
a meta-analysis Prozac came out hs having the best evidence for use in
individuals with autism when compared to other SSRIs. However, if you are
taking Paxil and doing well, it would probably be best to keep taking it.
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Antidepressants
work really well for anxiety, panic attacks, obsessive compulsive disorder (OCD),
social anxiety, and racing thoughts. _Most antidepressants have a
"black-box" warning of a slightly increased risk of suicidal thinking
during the early period of use - the first eight weeks on the drug. Doctors
usually prefer to try SSRIs first because they are safer. Tricyclics can cause
heart problems in some susceptible individuals.
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2.
Atypicals. Some examples are Risperdal (risperidone), Seroquel (quetiapine),
and Abilify (aripiprazole). The side effects of these drugs are high. They
include weight gain, increased risk for diabetes, and tardive dyskinesia
(Parkinson's Shaker) Tardive dyskinesia sometimes causes permanent damage that
may continue after the medication is stopped. There is no black-box warning on
the labels of these drugs, but the long term risks are actually greater than
those associated with antidepressants. Gaining 100 pounds can seriously
compromise health, impair mobility, and contribute to social ostracism and low
self-esteem. The risks continue and tend to get worse the longer the drug is
taken. Low doses of atypicals should be used.
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These
drugs are effective for controlling very severe aggression in older children
and adults. Behavioral interventions should be used first before employing
atypicals to control aggression. The balance between risk versus benefit favors
using the atypicals for individuals with severe symptoms. For those with milder
symptoms, the risks are too high. Similarly, powerful drugs in the atypical
class should not be used as sleep aids or for attention problems because they
have too many severe side effects.
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3.
Stimulants. Some examples are Ritalin (Methylphenidate) and Adderall
(combination of Dextroamphetamine and Amphetamine). These drugs are normally
prescribed for children and adults with ADHD. Stimulants usually make children
with autism who have had speech delay worse. However, they often improve
individuals with mild autism or Asperger's where there is no speech delay.
Compared to the atypicals, stimulants have fewer long-term side effects, but
they should be avoided in individuals who have either diagnosed or suspected
heart problems. The effects of stimulants are immediate and will become obvious
after one or two doses. Other types of medicines require several weeks or more
to evaluate.
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4.
Anti-convulsants. These drugs were originally developed for treating epilepsy
and seizures. They are also very effective for controlling aggression and
stabilizing mood. Anti-convulsants are likely to be effective if aggression
starts suddenly, almost like flicking a light switch. The rage may appear to
come "out of the blue," with little or no provocation. It may be
triggered by a tiny seizure activity that is difficult to detect. Risperdal or
one of the other atypicals may work better for aggression that is more directed
at certain people. Mark Goodman, a psychopharmacologist in Kansas reports that
Lamictal (lamotrigine) is often very effective for aggression in autistic
adolescents. Other anti-convulsants that often work well are Topamax
(ropirarnate) and Depakote (divalproex sodium).
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The
main disadvantage of anti-convulsants is that blood tests have to be done to
make sure they are not damaging the liver in susceptible individuals. If a skin
rash develops within six months after starting an anti-convulsant, the drug
must be stopped immediately. Most problems with rashes occur in the first two
to eight weeks. If the person continues to take the drug, the rash can be
fatal. Many individuals tolerate anti-convulsants really well, provided they have
no liver or rash problems within the first year of taking these drugs. Careful
monitoring will prevent dangerous side effects because the person can be taken
off the drug before it causes permanent damage.
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5.
Blood Pressure Medications. This class of drugs was originally developed for
treating high blood pressure. They have strong anti-anxiety and calming
properties. I know design professionals who had terrible problems with anxiety
and drug addiction who completely got their lives turned around by taking a low
dose of Prozac along with the beta-blocker Propranolol. Propranolol is an old
generic that is being rediscovered. The Army is doing research with Propranolol
as a treatment for post traumatic stress disorder. It blocks the huge fear
response that veterans experience during a "flashback." Propranolol
may help control rage in nonverbal individuals who are hot and sweaty and often
sound like they are out of breath.
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Other
blood pressure medications may also be helpful for calming or helping a child
get to sleep. Catapres (clonidine) works well as a sleep aid. Blood pressure
medications have fewer long-term side effects compared to the atypicals such as
Risperdal or Abilify.
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Since
they are blood pressure pills, they could cause fainting if the person's blood
pressure gets too low. When any blood pressure medication is first started,
individuals should avoid driving until they know how they will react to the
medication.
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6.
Benzodiazepines. These medications are used for anxiety, but they have many
disadvantages. They have huge abuse potential and getting off the drug may be
very difficult to do once started. Some of the most common ones are Xanax
(alprazolam), Valium (diazepam), and Klonopm (clonazepam) Usually an
antidepressant such as Prozac (fluoxetine) or Zoloft (sertraline), or a blood
pressure medication is better for long-term management of anxiety. Dr. John
Ratey at Harvard University usually avoids the benzodiapozines when treating
individuals on the autism spectrum.
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Old
Versus New
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Many
new atypicals and antidepressants are coming on the market all the time. Some
of these have minor advantages compared to older drugs. Many of them are slight
chemical modifications of older drugs. Often the older drugs will work just as
well and they are available in cheap generics. At the time of revising this
chapter, there were no totally new types of conventional pharmaceuticals on the
market or in the research pipeline awaiting FDA approval. Today there are effective
generic drugs available for all classes of conventional pharmaceuticals used in
the treatment of individuals with autism.
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In
terms of real risk, the antidepressants and blood pressure medications are
safer for long-term health. However, there are some situations where the
benefits of Risperdal far outweigh the risk. It is a very effective drug for
controlling rage. If it enables a teenager to attend school, live in a group
home, or have enough self-control to learn other cognitive forms of behavior
management, It would be worth the risk.
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Parents
must logically assess the risk-benefit ratio when contemplating any form of
medication usage with their child. Discuss the medication thoroughly with the
child's doctor. Ask the doctor to provide you with a list of possible side effects
of the medication. Do some research of your own on the internet to determine
how widely and/or effectively the medication has been used with people with
ASD. This is especially true when medication is suggested for use with younger
children. Both doctors and parents must avoid increasing drug doses or adding
another medication every time there is a crisis. I have talked to parents where
their child was taking eight different medications and the child was a sedated
zombie.
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When
medications are used carefully and conservatively, they can help normalize
function. When medications are just thrown at problems without using logical
thinking, the child can be so drugged that he or she may not be able to
function.
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Temple
Grandin "The Way I See It: A Personal Look at Autism &
Asperger's" (2011)
