Autism and Parent Training

ByDr. Berney

Autism and Parent Training

I was not sure what I wanted to discuss for my first, truly mental health related post.  There are many “hot topics” out there right now and there is so much to say about them all.  Nonetheless, as I was making my decision, I was reading in the Journal of the American Academy of Child and Adolescent Psychiatry, which is THE JOURNAL for child and adolescent psychiatry.  In the Journal’s December 2010 issue (yes, you will have somewhat of a jump start by reading this post) there is an article written by researchers at the NIMH Research Units on Pediatric Psychopharmacology (RUPP) Autism Network.  In this article, the authors describe the results of a study meant to compare the benefits of medication alone to medication plus parent training in reducing the behavioral issues associated with Autism, PDD-NOS, and Asperger’s Disorder (if you do not know the differences between these diagnoses, keep checking this site, as I will be posting other threads to describe them in more detail).  In this post I will review the article as well as give you my own impressions and views.

In the article, the authors reported that there has been a significant increase in the use of medication in children with Autism and Autistic Spectrum Disorders (ASD) over the past few years.  In fact, research suggests that 45 to 83% of individuals with ASD are prescribed medications.  The most common medications prescribed are selective serotonin reuptake inhibitors (SSRI; e.g., Prozac), antipsychotics (e.g., Risperdal and Abilify), alpha 2 adrenergic agonists (e.g., Clonidine), psychostimulants (e.g., Ritalin), and anticonvulsants (i.e., Depakote).  While most of these medications are used “off label” (meaning that they are not FDA approved for children with ASD), in October 2006, the FDA has approved the use of Risperdal (risperidone) for use in children with ASD who exhibit maladaptive and aggressive behaviors.  Further, in November 2009 (just a few weeks ago) the FDA approved Abilify (aripiprazole) for use in ASD related irritability.  Unfortunately, while these medications to be beneficial, research has shown that there are no lasting benefits once the medication is discontinued.

<<I want to add a brief note here.  The last statement I made, regarding the lack of continued benefit once the medication is discontinued, should not be surprising to anyone.  Medications do not teach skills.  Medications do not teach right from wrong.  All that medication does is make you “available.”  I will spend more time on this issue in another post, but the primary purpose of medication is to stop a particular behavior or set of behaviors.  Medication, in and of itself, does not teach appropriate behaviors!>>

Because medication has no long lasting gains once it is stopped, the researchers at RUPP Autism Network conducted a study to determine the benefits of adding a Parent Training (PT) program to the treatment of children with ASD.  In this study, 124 children between the ages of 4 and 13 years participated.  To be included in the study, the children had to have a diagnosis of Autism, PDD-NOS, or Asperger’s Disorder.  In addition to other inclusion and exclusion criteria, the participants had to demonstrate clinically significant behavior problems.

As part of the 24-week study, all of the children were prescribed risperidone (though a few were changed to Abilify during the study as a result of poor response), but only a portion of the participants also received PT.  This design allows for comparisons between two groups; the group where the children were just getting medication (MED) and the combination group where the children were getting medication and the parents were receiving PT (COMB).  The researchers used multiple rating scales to assess behavioral issues, which were administered throughout the study to measure changes in the severity of the child’s behavior.  Through this research study, the researchers hoped to demonstrate that risperidone treatment coupled with PT would be superior to risperidone treatment alone in reducing serious behavior problems in children with ASD.

The results of this study are very promising.  Children in both groups demonstrated improved compliance, as reported by their parents.  However, the COMB group reported greater improvements in compliance than those seen in the MED group.  That is, although all of the children demonstrated improvement, children whose parents were in the PT program demonstrated greater improvement.  Even more exciting was the fact that the children in the COMB group showed greater reduction in irritability.  Again, although all of the children demonstrated less irritability, the children whose parents received the PT demonstrated the greatest improvement.

This study demonstrated, yet again, the benefits of behavioral and psychological treatments in the management of challenging behaviors.  While medication is a useful tool for treating troublesome behaviors and emotions, the addition of psychological treatment (in the form of parent training, behavioral support, and therapy) results in greater, longer-lasting benefits.  I frequently recommend my patients to prescribing physicians to determine if medication could be helpful for them.  While I do not believe that medication is a “cure-all,” it has its place in helping the patient become “available” to the treatment I am providing.  Once the patient has benefitted from my treatment, there is the potential that the medication can be reduced or even completely stopped.  While all patients cannot be taken off of their medications, the additional benefits of psychological support are clear and well worth the additional treatment.  Now, if only we could get the insurance companies to agree…

Here is the reference for those of you who would like to see the full article:

Aman, MG; McDougle, CJ; Scahill, L; Handen, B; Arnold, LE; Johnson, C; et.al. (2009). Medication and Parent Training in Children with Pervasive Developmental Disorders and Serious Behavior Problems: Results From a Randomized Clinical Trial. Journal of the American Academy of Child & Adolescent Psychiatry. 48 (12), p. 1143-1154.