Biological Therapies

Autistic Disorder

No specific pharmacotherapy exists for the core symptoms of autistic disorder; however, it is not

uncommon for a child with autistic disorder to exhibit symptoms of impulsivity and inattention,

compulsive and ritualistic behaviors, irritability, temper outbursts with or without self-injurious

behaviors, and anxiety symptoms. Pharmacologic agents currently receiving the most attention in

the treatment of autistic disorder are atypical antipsychotics, such as risperidone, olanzapine, and

aripiprazole, glutaminergic agents, and SSRI antidepressants. A large multisite study is

underway to gain evidence for optimal treatments for autistic disorders.

The behavioral problems of children with autistic disorder range from mild to very severe. In

past studies, antipsychotic agents, including risperidone and haloperidol, have been used with

varying degrees of success in reducing temper tantrums, aggression, stereotypies, self-injurious

behavior, and hyperactivity. Haloperidol is much less frequently chosen compared with the

atypical antipsychotic agents because of the increased risks of extrapyramidal symptoms and,

withdrawal dyskinesia. SSRIs, including fluoxetine, and citalopram have been studied in autistic

disorder, because of the association between the compulsive behaviors in OCD and stereotypic

behaviors common in children with autism. To date, clomipramine (Anafranil) and fluoxetine

have shown promise in ending stereotypies and other behaviors in autistic children and adults.

The opioid antagonists naloxone (Narcan) and naltrexone have not proved effective in

diminishing self-injurious behavior in children with autistic disorder. A variety of agents,

including β-adrenergic receptor antagonists (beta blockers), lithium, and anticonvulsants are

used in clinical practice to ameliorate the multiple symptoms seen in children with pervasive

disorder. Stimulants are often tried to reduce hyperactivity and inattentiveness in children with

autism.

Attention-deficit/hyperactivity disorder often coexists with oppositional defiant disorder or

conduct disorder. With concurrent externalizing psychiatric disorders, the risks of aggressive

behaviors, including impulsive or reckless behavior, may emerge. Stimulants have been found to

reduce aggression in children with ADHD who are impulsive, but it is not a first-line treatment

for dangerous, repeated episodes of assaultive or explosive outbursts. Atomoxetine (Strattera) is

typically the second line of pharmacologic therapy for ADHD in children who do not respond to

stimulants. Bupropion has been shown to be effective in some children with ADHD who either

cannot tolerate stimulants or atomoxetine because of side effects or for whom other agents are

ineffective. A few studies have shown that clonidine (Catapres), an α-adrenergic agonist agent,

has some success in ADHD. Guanfacine (Tenex), another α-adrenergic agonist, has also been

used in clinical practice for children and adolescents with ADHD who do not respond to the

stimulants. Antipsychotics are not indicated in the treatment of ADHD, unless accompanied by

psychosis, given the risks of sedation and tardive dyskinesia. ADHD often precedes and coexists

with tic disorders.

The dietary management of hyperactivity has historically received public attention, but

controlled studies have not substantiated its benefit.

Obsessive-Compulsive Disorder

Current literature has provided evidence from randomized clinical trials of efficacy and safety of

fluoxetine, fluvoxamine, and sertraline as first-line agents for children and adolescents with

OCD. The POTS of CBT, sertraline, and their combination for children and adolescents with

OCD has shown that CBT combined with sertraline resulted in the best outcome for children and

adolescents with OCD compared with medication or therapy alone. Previously, clomipramine

was proved effective in diminishing obsessions and compulsions in children and adolescents, but

although clomipramine is often well tolerated, the SSRIs have a more favorable adverse-effect

profile and appear to be as effective as clomipramine.