Professional Corner

Education Before Medication

By Abigail Scott

Education, not medication, is the ultimate key to managing autism, according to Isabelle Rapin, MD, professor of neurology and pediatric neurology in the Saul R. Korey Department of Neurology at the Albert Einstein College of Medicine in the Bronx.

"I don't think medication is the key thing for autism," she said. "The key is to educate these children, and that is where the speech-language pathologist plays a major role."

Children with autism have underlying communication disorders that need to be addressed by speech-language pathologists, Dr. Rapin stated. Medication serves to minimize undesirable behaviors and make children more accessible to behavioral and communication interventions.

Pharmacological intervention can open a window of opportunity for children with autism, according to Roberto F. Tuchman, MD, executive medical director of the Dan Marino Center at Miami Children's Hospital in Miami, FL.

Once conditions such as epilepsy, attention deficit hyperactivity disorder (ADHD), and depression are managed with medication, speech-language pathologists and other allied health professionals may be better able to address communication, learning, and behavior.

Clinicians working with children who have autism need to know what medications a child is taking and why. Any medication needs to be used for a specific purpose.

"In autism a primary problem is joint attention, and the physician or neurologist may prescribe neurostimulant drugs," observed Dr. Rapin.

A child who has a bipolar disorder that interferes with therapy or progress in the classroom may benefit from serotonin reuptake inhibitors such as Prozac. These medications are also effective in reducing rigidity and perseveration.

Highly aggressive behavior and attention problems may be reduced with medications such as propranolol or resipiradone. Examples of other medications commonly used to remediate concomitant conditions are naltrexone for self-injurious behavior and anti-convulsants for epileptic seizures.

Health care professionals need to be aware of any side effects that may occur with the drugs. Many drugs are effective for acute symptoms of a disorder by should not be given indefinitely. For example, haloparidol, which may be prescribed for aggressiveness, can result in tardive dyskinesia if given for long periods of time. Less severe side effects of medications prescribed for conditions that occur with autism include changes in alertness and sleep patterns and dry mouth.

Speech-language pathologists need to develop a rapport with the physicians who prescribe medications for children they are treating.

"The speech-language pathologist spends more time with the child on an ongoing basis and may have a lot to bring to the table," in discussions with physicians and psychologists, observed Dr. Tuchman. Physicians and neurologists should only prescribe medication for children with autism if they are enrolled in a strong behavioral or communication program.

"Autism is the ultimate communication disorder, and many behaviors are associated with lack of communication skills," he said.

A clinician who works with a child making no progress should assess whether the barrier to communication or learning could be due to biological problems.

"You have to have a definite goal in mind when you prescribe medication and not give it with the idea of curing autism," said Dr. Rapin.

Selecting an effective medication to help elicit desired behavior in children with autism may require a lot of trial and error. Most pharmaceutical companies do not test drugs in children, and many of the medications used for conditions such as autism are not approved for children by the US Food and Drug Administration. Only recently was the issue raised of testing these types of medications on children.

Sometimes clinicians do not know whether improved behavior is attributable to medication, behavioral intervention, or the child outgrowing negative behavior.

"It is hard to determine which treatments is the effective one," Dr. Rapin stated.

Educators also need to be aware of any medications used with these children and the potential impact of the drugs on learning.

"Teachers should know what the medicine is used for and what outcomes can be realistically expected. Medicines are only there to help create a better situation and not to replace learning," Dr. Tuchman emphasized.

A "halo effect" may result if a teacher knows a child is taking medication, according to Dr. Rapin.

Speech-language pathologists and physicians should keep detailed records of behavioral and pharmaceutical interventions to assess the potential effectiveness of medication on autistic symptoms, she said. "If you don't, you will never know what you are doing."


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