Dr Pru Allington-Smith has been a Consultant Child Psychiatrist for those with learning disabilities since 1998, working for Coventry and Warwickshire Partnership NHS Trust. Last November, AuKids attended her workshop on medication at the Autism West Midlands conference ‘Exploring Autism Interventions’. In this feature, we share some of her responses to the key questions surrounding medication for autism.
Q: What sort of problems associated with autism can medication help with?
A: One in four of the population will suffer from significant mental illness at some point in their lives, but in people with autism, anxiety disorders, OCD and depression are more common than in the general population. Eighty per cent of the children who I see at CAMHS also have autism. It’s not surprising that some of the key aspects of autism, such as social difficulties, can eventually have a big knock-on impact on mental health. Medication can be helpful in some circumstances for these issues, but would rarely be our first port of call.
Q: Can you medicate for difficulties that are part of the autism itself, such as repetitive behaviour?
A: There are no medications that treat autism itself. Most medications that are used reduce anxiety, which is often associated with distress and with behavioural problems in autism
Q: At what stage would you consider trying medication?
A: Medication is very much the last option. Looking at how the individual communicates is important and for some children, sensory strategies can be very helpful. It is also important to consider whether the physical environment someone is in could be contributing to their problems.
In anxiety disorders and depression, talking therapies such as CBT (Cognitive Behavioural Therapy) can help children to retrain unhelpful thoughts. The benefit of these interventions is that unlike many of the medications, they can result in life-long positive changes. Some versions of CBT can be done online which tends to appeal to older youngsters with autism.
The drawback of these is that this sort of training can be impossible for someone with learning difficulties, or who has trouble transferring skills. Psychological therapies usually require 8-10 weekly sessions. Plus, if someone has severe depression, they may not be able to do the therapy.
Q: I would be worried about giving medication to my child. At what age is it safe?
A: All medications must be tailored to the individual but it would be highly unusual to consider medication below the age of 6 years and mostly children are much older. The only exception is Melatonin for sleep.
Q: At what stage would you suggest medicating for anxiety?
A: Anxiety disorders can present as generalised anxiety – feeling very anxious most of the time – which is very common in autism. Then there’s simple phobias and panic attacks for which medication is not recommended. When other behavioural interventions like the ones I’ve mentioned aren’t working, medication can be helpful when there are severe problems – and can be used in conjunction with other therapies. Severe problems might include self injury, severe aggression or anxiety so severe that the individual cannot go out or function in the community.
Q: How do we know when to treat depression?
A: We say that depression turns from being ‘down in the dumps’ to a clinical diagnosis when feelings of profound sadness present most of the time for at least three weeks. It may be in response to something in particular, or there may be no discernible cause. What we look for is loss of interest in activities, poor concentration and poor sleep. It may be associated with anxiety and irritability. Depression in children with autism isn’t always obvious; it can manifest itself as a child being disruptive or self-injuring. Again, unless the depression was severe, we would try other routes before medicating
Q: Is OCD part of autism or not – and can we medicate for it?
A: OCD is a form of anxiety disorder which is associated with repetitive thoughts and behaviours. It’s present in 2-3% of the population but is much more common in autism. Autistic rituals can be a sign of OCD and clinicians have a dilemma over whether to diagnose it separately or to put it down to being part of autism. We tend to diagnose it separately when it is experienced as distressing and tiring, and is seriously interfering with daily life.
We’ve all had that ‘I’ve left the oven on’ feeling once or twice, but in OCD this type of checking behaviour is sustained. It can also show itself through intrusive thoughts about having done something wrong, when you haven’t, or in having to perform certain rituals before you can do an activity. Again, this is common in autism, but intervention will depend on how disruptive to a person’s life that behaviour is. We can medicate for OCD, but again some psychological therapies are also very helpful and would be tried first. Medication rarely treats symptoms on its own.
Q: Who can tell me whether my child needs medication?
A: Your GP can refer you to your local CAMHS (Children and Adolescent Mental Health Services) team. In my CAMHS team, we have mental health nurses, a speech and language therapist, an occupational therapist trained in sensory integration and a clinical psychologist. It is the job of the team’s child psychiatrist to work out whether an illness is physical or mental. Psychiatrists are medical doctors who have then specialised in psychological disorders, so can prescribe medication. They have the training to detect any physical disorders which can be associated with mental health problems. They also have some training in psychological therapies.
Psychological therapies will take you down a non-medication route first. A Clinical Psychologist is a professional who has a Psychology Degree and further extensive training in Clinical Psychology, working with people who have mental health problems and/or behavioural problems.
Q: What are the drawbacks of medication?
A: Medication can be helpful, but:
· It generally only works while you take it
· Side effects are common
· It may lose its effect after taking it for a while
Q: In your view, should we medicate for autism?
A: For most mental health issues, I would always try behavioural measures first. We need to bear in mind that all medications have side effects and these can end up as problematic as the issue itself, so there are always risks with medication and it isn’t a decision to be taken lightly. If other measures haven’t worked and a person’s quality of life is in jeopardy, then medication can be appropriate. But it will need to be monitored very closely and you must immediately tell your GP if your child is experiencing side effects.
This is particularly problematic with non-verbal children, who may not be able to report what they’re experiencing.
A BRIEF GUIDE TO MEDICATION:
For generalised anxiety disorder:
Benzodiazepines such as Diazepam and Lorazepam work by affecting the brain’s GABA receptors. They reduce brain activity to reduce anxiety and cause sedation. Over time, though, the brain is able to bypass them. This medication only works while you are taking it. Side effects are common and it may lose effect after a while. Drugs like Diazepam and Lorazepam are addictive and become less effective the more you take them. They are best avoided.
Beta blockers were originally used to treat high blood pressure and heart arrhythmias. They block the body’s response to anxiety and are designed to keep the heart rate steady. These can be effective for generalised anxiety disorder. Side effects can include low blood pressure, cold hands and feet and a heart rate that is too slow.
For depression, anxiety and OCD:
SSRI drugs (selective serotonin reuptake inhibitors), such as Fluoxetine, Sertraline and Citalopram are anti-depressants that also help anxiety. They work by increasing the levels of the chemical Serotonin in the brain (by preventing its reabsorption). They are relatively safe but side effects can include nausea and headache initially. Very rarely, they can make people more agitated. These medications can also be useful in severe depression and in OCD, although in OCD large doses are sometimes required to help. In depression, treatment for at least 18 months is usually advised. For anxiety and OCD, treatment can be longer. Some people experience great difficulty coming off the medication.
Which drug to use will depend on the particular symptoms of the patient, for instance someone who experiences a lot of physical symptoms of anxiety, such as a racing heart, might respond to a beta blocker.
Risperidone, Aripiprazole and the older drug Haloperidol are some examples of anti-psychotic drugs which in standard doses are used to treat Schizophrenia and Bipolar disorder. In small doses they can help severe anxiety, but there are many potential side effects.
ADHD is present in about 1 in 5 children with autism. Half of children will grow out of ADHD by their late teens; half still benefit from treatment as adults. Drug treatment is usually recommended with ADHD that has a significant impact on learning and wellbeing. Treatment is usually with either the stimulant medications Methyl Phenidate and Dexamphetamine or the non-stimulant Atomoxetine.
For sleep onset disorders:
Sleep issues are very common in children with autism, who often say that their thoughts won’t calm down enough for them to settle to sleep. Most children are sleeping well by teenage years and many non-drug interventions given by sleep counsellors can be very helpful.
If severe enough, sleep issues can be treated with Melatonin. Melatonin is a hormone produced in the Pineal Gland in the brain. The hormone is regulated through light coming through the eyes and when levels are high, the brain tells us we need to sleep. It may be produced less in children with autism or not be produced at the right time. Although Melatonin is a safe drug, it is only licensed for older adults so you need a specialist to prescribe it. If children go to sleep well but are waking during the night, it is better to use behaviour interventions.
Sleep Difficulties and Autism Spectrum Disorders: A Guide for Parents and Professionals by Kenneth J. Aitken, published by Jessica Kingsley Publishing. www.jkp.com
Breaking Free from OCD, A CBT Guide for Young People and Their Families by Jo Derisley, Isobel Heyman, Sarah Robinson and Cynthia Turner, published by Jessica Kingsley Publishing.