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Treating Irritability of ASD

Risperidone (Risperdal®), Aripiprazole (Abilify®) and generic forms belong to a group of medications called “atypical antipsychotics” or “second-generation antipsychotics.”

How do I decide if my child should take medication to treat irritability?

Autism spectrum disorder (ASD) is a condition related to brain development with core features affecting a person’s social communication and interaction, as well as experiencing restrictive and repetitive behaviours. There are no medications available which treat core features of ASD.

Medications such as risperidone and aripiprazole are the best studied medication targeting irritability and aggression in children with ASD.

Many factors are considered before prescribing medication including an assessment of impact on learning, socialization, health, safety, quality of life, and overall functioning. Behavioural interventions should be implemented before starting medication whenever possible.

My child is not psychotic. Why are we considering an “antipsychotic” medication to treat irritability?

Medications are used to treat multiple conditions. Medication classes are often named by the condition which they were first approved to treat. Risperidone and aripiprazole were first approved to treat psychosis, and are called antipsychotic medications.

Health Canada has not approved any medication for treatment of irritability of ASD, including risperidone and aripiprazole. However, many studies show they are effective treatments. When potential benefits outweigh risks, these medications can be prescribed “off label.” Learn more about off-label use:

How do I know if the medication is working?

It can be a challenge to determine if your child’s medication is working. Your doctor may ask you to record the number of behaviour outbursts your child has each week or month over several months, the intensity of the behaviour outburst on a scale of 1-10 (1=mild and 10=severe) and the number of “rescue/as needed” medication doses used over this period.

Risperidone and aripiprazole are expected to start working within 1-2 weeks. It is also helpful to have a record of behaviour outbursts for a few weeks prior to starting medication to compare to, in order to decide if medication is working.

Do children with ASD tolerate medications the same as typically developing children?

Children and youth with ASD may sometimes be more sensitive to some medication effects compared to typically developing children. Your child may have more side effects when starting a new medication, changing the dose, or coming off a medication.

Medication changes are made slowly over time for children with ASD to help limit these side effects. Ask your doctor or pharmacist if your child starts any new medication (new prescriptions, over the counter products, or natural health products) to make sure it is safe to take with their other medications.

Are there long-term side effects that I should be aware of prior to my child starting an antipsychotic medication?

It is important to understand the long-term risks of medication use and how these can be managed.

  • Antipsychotics may cause metabolic side effects including significant weight gain and effects on blood pressure, blood sugar, cholesterol and hormones. It is recommended that all patients have metabolic screening before starting medication and be re-checked during treatment over time. This includes measuring height, weight, waist circumference, blood pressure and blood tests. Ask your doctor for suggestions on how to make it as easy as possible for your child to have blood tests.
  • Antipsychotics are associated with a rare side effect called “neuroleptic malignant syndrome.” Symptoms include severe muscle stiffness, high fever, sweating, increased or irregular heart beat and increased blood pressure.
  • Long-term antipsychotic use increases the risk of a movement side effects called “tardive dyskinesia” (TD). TD may appear as repetitive, flicking movements of the face, neck, tongue, fingers or toes. The symptoms may be troubling for family members and your child. TD is usually reversible if caught early. It is important to notify your doctor immediately if you notice your child has any abnormal body movements.

Can I change the dose of my child’s medication if necessary?

Changes to your child’s medication, dose, or frequency are possible with medical supervision and guidance. Do not increase, decrease, or suddenly stop taking this medication without discussing it with your doctor.

If your child stops taking an antipsychotic medication suddenly, their symptoms may return or they may have a bad reaction. Bad reactions may include:

  • Nausea, vomiting or diarrhea
  • Dizziness, difficulty sleeping or restlessness
  • Repetitive, jerking movements that occur in the face, neck, tongue, fingers or toes temporarily (called “withdrawal dyskinesia”)
  • Agitation, confusion, anxiety, drooling and trouble sleeping (called “cholinergic rebound”)

Your doctor or pharmacist will help you to reduce your child’s dose slowly or change medications safely to prevent or minimize the side effects listed above.

Why is my child prescribed several medications? Should I be concerned?

It is estimated that half of children living with ASD take medication to treat different symptoms such as irritability, aggression, hyperactivity, anxiety, and oppositional behaviors.

Antipsychotics, ADHD medications, and antidepressants (for example, selective serotonin reuptake inhibitors (SSRIs)) are some of the most commonly used medications for these symptoms. Sometimes more than one medication is needed to help your child function at their best.

Working with your healthcare team, it is important to review your child’s medication list over time to make sure they experience the most benefit and least side effects.

Learn more about antipsychotic medications used to treat irritability:

My child tried an antipsychotic medication and it did not work. Can we try anything else?

Although aripiprazole and risperidone are the most effective medicines for irritability of ASD, other treatment options include valproic acid or divalproex (Depakene®/Epival®), clonidine (Catapres®/Dixarit®) and topiramate (Topamax®). These medications can be prescribed instead of, or sometimes in combination with an antipsychotic medication.

Each medication has its own benefits and risks which is why it is important to discuss alternatives with your doctor to determine the next best treatment option for your child.

My child is experiencing symptoms of anxiety and sleep disturbances. Could this be contributing to their irritability?

It is important that any physical and/or mental health conditions that may be contributing to your child’s irritability are managed before starting a medication. Physical conditions include sleep disturbances, gastrointestinal disorders, pain conditions, and medication side effects. Mental health conditions include anxiety, attention-deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), mood and psychotic disorders. If your child continues to experience symptoms of irritability after all other conditions have been managed, your doctor may prescribe medication if the benefits outweigh the risks.

TIP: See the Kelty Mental Health Atypical Antipsychotic & Metabolic Monitoring document.

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