Medication and Autism

Let me start by saying that I am a doctor, but one of the law, not medicine. I have no training whatsoever in the care of people, other than learning what works best when my wife has a cold. I don't even have credentials from a cheesy online medical school program. I am trained as a lawyer, and work as a real estate developer in my 40 hour a week job. So, me speaking on the subject of the use of medications in managing autism is hazardous. First rule of thumb - rely on your child's doctor and autism treatment team for decisions about care. But, that doesn't mean you can't take an active part in making decisions, with your doctor, about the appropriateness of a particular approach to treatment involving medication, or that I can't air some thoughts about the use of medication in managing illness.

The Problem of Modern Medicine

 I am generally suspicious of reliance on medication to treat chronic illness. When we humans evolved, we didn't have drugs available to us, and we were generally fine. I am all in favor of vaccines, and antibiotics that treat actual infections, and medications that treat acute, active illness of the type our ancestors suffered from in our past. But, medication to treat the types chronic illness we suffer from today is another matter. One researcher whose name I don't recall wrote in a journal article that medicine was an artificial attempt to substitute a pill for a normal human environment. I agree wholeheartedly. Medication, related to chronic disease, is largely a crutch that encourages us to behave badly. It is a substitute to getting off the sofa and eating correctly. It is a way of delegating the control of our own health to someone, a 'trained expert', such that we can ignore our own health, behave horribly knowing that we are doing so, and take the pills she gives us to treat the heartburn, the loss of circulatory function, and the lung cancer.

The other problem with managing chronic illness with medication, particularly in children, is that medications that manipulate neurotransmitter levels in the brain, which is how pretty much all medicines used to treat psychological disorders work, change the brain over time in a way that modifies the effects of the medications. Sometimes, the brain gets used to the medicine, such that more mediicine is required to get the same effect (think about how alcohol works in people who drink a lot). In other cases, the medicine just stops working, or works differently, depending on a complex, and largely not understood, interaction between neurotransmitter levels, receptor number and sensitivity, and other factors. And, all of this is complicated by the fact that the brain of a child is constantly changing at they mature. For instance, the main inhibitory neurotransmitter in children and adults is largely excitatory prenatally and in early postnatal life. If you read the treatment history of autistic children being treated with medication, you usually see a constantly evolving treatment regime, with multiple medicines being taken at any one point in time. Many have been on literally dozens of medicines by the time they hit their teen years. It is expensive, time consuming, frustrating, and generally not terribly effective. And, I believe it distracts from what the family really should be doing related to the child.

The underlying problem is that modern medicine has been transformed largely into a pharmacological agent delivery system. The pharma companies have essentially taken over the practice of medicine. They have, over decades and through their many agents and vast resources, rewritten the curricula of medical schools to equate treatment with pharmacology. They dominate medical trade associations. They use huge amounts of cash to buy influence with practicing physicians and researchers. And, there is no countervailing influence to their power. They have essentially stripped from physician training subjects such as nutrition, relaxation, and adaptive coping. Stress, particularly chronic stress, has never been a concept medicine has embraced because its non-specificity is poorly addressed by the statistical models that establish causation; it is a topic largely ignored in medical school. Hence, the modern doctor, despite the best of intentions, is not armed with tools to treat chronic disease other than with pharmacology. I just finished a 1,000 page textbook on bipolar disorder by a leading expert in the field. It was a brilliant book. There was a 250 page section on treatment options. About two paragraphs discussed the mandatory eat better, get your sleep, and get some exercise message. The remaining 249.5 pages spelled out in enormous detail the pharmacological interventions available and the hundreds of studies that support them. This is the filter through which modern medicine is practiced, to our great detriment. An article that discusses this issue in the context of the care of nursing home patients is the following: www.nytimes.com/2008/06/24/health/24deme.html.

A Nod to Reality

Let me start by acknowledging the great challenges at living healthy lives, and helping those around you live healthy lives, in America and other western cultures. The food that is affordable and available is of poor nutritional quality. Our lives are filled with stress and time constraints because of how we live our lives, particularly related to the car. We are inundated with media messages encouraging us to take very poor care of ourselves. We have been born into a culture in which convenience through products is maximized and movement is minimized. We have limited control or influence over the actions and choices of those around. A teenager does not choose where they are going to live. A parent can't always controls the food their toddler likes. And, the hours one needs to work are normally controlled by higher powers.

That being said, I think we all can do better related to adaptive coping. In a perfect world, if we all ate good diets, and exercised, and controlled our stress, and spent lots of time doing things we enjoy, and followed the advice my health guide, I think much of the chronic disease we humans experience would simply disappear or would be seriously attenuated. Autism rates would plummet. We would all be a lot happier. Now, I know that is not going to happen. But, that does not mean I, or we, can't strive for that.

However, choices associated with medication need to be made cognizant of the world in which we live today, knowing what the past leading up to today looked like. If adaptive coping related to you child is something you have challenges accomodating, because of your schedule, or your habits, or your inability to control your child's behaviors, or your financial resources, then you will need to evaluate the use of medicine in light of your reality. If medicaid can pay for medicines that calm your child and reduce the daily meltdowns, and this relieves financial and psychological burdens upon that otherwise you could not deal with, then you will need to make choices informed by that reality.

My Recommendations 

I advocate strong efforts at adaptive coping as the vanguard of treatment of any disease or disorder, including autism - I believe my guide to coping with autism, plus my daily health planner, offer good guidance towards this end. As a supplement to adaptive coping for autistic children, immediately after diagnosis I recommend engaging with professionals in seeking autism treatment options, some of which are compiled on my Treatment page, many of which have been shown to reduce autistic symptoms. These two options, in my unprofessional opinion, offer you the best long term shot at maximizing the abilities and happiness of your autistic child. Medication is very appropriate as an adjunct to these efforts to deal with a changing situation, such as your child entering a deep depressive phase, as a way of stopping a downward spiral and causing a return to equilibrium. Beyond this, and subject to my thoughts above, I think you need to seriously consider and question the wisdom of following the advice of a physician to enter into a long term program to manage autism through pharmacology. And, I would seek out and talk to other families who have used long term medication for the treatment of their children. They are experts as well.

If medication is used in the treatment of your child, there are a few points of which you should be aware.

First, pretty much all psychological medications work through increasing neural inhibition (equivalent to decreasing neural excitation) - see the subpage to this page discussing this topic. Some work through a brain wide increase in inhibition that is highly non-specific, such as valium and alcohol. Other work on very specific neural circuits, such as selective serotonin reuptake inhibitors (SSRI'S), which focus on regulating serotonin levels in the amygdala, which causes an increase in the release of GABA, which is the brain's main inhibitory neurotransmitter. My theory indicates that this would be a way to treat a disorder of neural excitation such as autism - and experimental results show some level of effectiveness for many drugs including anti- convulsants and anti-depressants. However, pharmacological treatments bears the risks described above. And, this type of treatment bears the risk of simply masking the underlying problem by just knocking the kid out and making them passive. This may help your daily life, as the number of melt downs and other problematic behaviors may be reduced, but it is not necessarily improving the life of your child and the course of their condition. And, once you start on the course of medication management, it is very hard to get off that merry-go-round because of the changes that have occurred in the brain during treatment. I believe that aggressive pursuit of adaptive coping and professional treatment can create authentic and real improvement in your child's short term behaviors and long term prognosis.

Second, autistic individuals are reported to respond to medications differently than normal people. Sometimes, the medicine has exactly the opposite effect of what you would expect. For instance, in many persons with autism, caffeine acts as a behavioral depressant. Also, sometimes small doses work as expected but the results become abnormal as dosage increases. So, if you are going to use medication, start with very low doses and watch intensely, documenting behavioral changes as you start to step up the dosage.


Your Contact Information

Your Feedback