Reducing Repetitive Behaviors with Meds: Not the Goal?
Published June 02, 2009 @ 01:25PM PT
The anti-depressant Celexa for autistic children has been found to be no more effective than a placebo. Indeed, use of the medication was found to have sufficient risks that outweigh any benefits, according to the "largest published study of medication versus dummy pills for autism," yesterday's Associated Press reported.
In the study (published in the Archives of General Psychiatry and funded by the NIH), 149 children aged 5 to 17 were randomly given either up to 20 milligrams daily of Celexa for 12 weeks or a placebo. While about one-third of the participants "showed substantial improvement," most of the children showed "little or no improvement or got worse," with adverse effects including "increased energy level, impulsiveness, decreased concentration, hyperactivity, stereotypy, diarrhea, insomnia, and dry skin or pruritus." Celexa (a selective serotonin reuptake inhibitor (SSRI) ) has been found to increase the "risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) and other psychiatric disorders."
I've read a number of book chapters and articles and heard presentations by physicians about medication for autistic children. All have had a very standard feeling, with the same medications listed, described, responses in the children duly noted, and a call for being very attentive to the particular needs and responses of one's own child (well of course!) added. With studies about the use of medications often inconclusive at best, hearing the observations of parents of their children on certain meds, and of individuals on the spectrum regarding their own experiences, is not only helpful, it's necessary. I really appreciated the responses to a recent post concerning medication and, in particular, Risperdal. It's not an easy topic to bring up and parents are certainly in need of information.
It's noted (as in this Wall Street Journal article) that Celexa has been used "'to reduce repetitive behaviors that are a key characteristic of autism and are a significant reason why this class of antidepressants is prescribed." My son has been taking another SSRI, Zoloft, for some time. "Reducing repetitive behaviors" was not the reason an SSRI was prescribed for him: He started taking this particular medication to help him deal with anxiety, which we'd often noted as preceding self-injurious behaviors, but not for helping to "manage" repetitive vocalizing or pacing or the like.
I recognize I'm talking about a different medication. The "repetitive behaviors" that my son has are not dangerous to him or anyone else, and often serve as ways for him to self-calm and to alleviate his anxiety. Perhaps "reducing repetitive behaviors" (provided, again, that they are not dangerous to anyone, including the individual engaged in them) isn't something that needs to be targeted?
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Comments (11)
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Kristina is a Classics professor in Jersey City, New Jersey, a blogger (formerly at AutismVox), a translator (of Virgil), and an advocate every day for her son, Charlie.
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I am a physician, though not a pediatrician. You are very, very correct in requiring patients and parents be very aware of the RESULTS that are expected from, especially psychologically based medications.Thant being said, and not being aware of this particular study, I would like to make some generalizations. It is wonderful that there is more and more research being done on autism. When discussing trials of medications, however, in which there are older VERY VERY inexpensive generica types...vs. NEW expensive types... and the two (or in this case four) medications have few differences, I am always very leary of any 'benefit' ascribed by researchers PAID BY THE DRUG companies to perform this 'research.'
Just as a given, we mostly expect about a 30% good effect from the 'placebo' effect only, so I see little true benefit here.
Now in addressing the use of any of these FOUR medications (all SSRI's, Prozac, Paxil, Zoloft and Celexa), in adults there are some significant differences. But they are very individual.I would chose Zoloft for people who had a blue, low energy depression.... and that needed to be titrated to a very indiviiidual dose. Paxil for people who had an anxious deperession..given at bedtime, even more helpful.
Then CELEXA came out. Not knowing its balance of energizing vs stabilizing, I saved it for people not better two weeks after beginning one of the others. Then, at four weeks let them chose which seemed more helpful. 80% stayed with Celexa, so then I used it first line often.
Now, however, we have known for many years that there are types of psychological disorders that react the 'opposite' or paradoxically to medications. Hyperactivity disorder the primary one. In these children medications that for others are stimulating...like caffiene or adrenaline feels to us...for them are calming and soothing.
There are some similarities in lack of concentration and hyparactive motion patterns in autism..so it would not surprise me at all to find that say.. Zoloft is calming instead of energizing.
Whatever you decide to try, be sure you know the GOAL you want to achieve, and monitor the drugs progress accordingly.
Posted by Lee Dorsey on 06/02/2009 @ 02:11PM PT
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thank you, this is very helpful......figuring out medication for Charlie has often seemed a process of stumbling in the dark. I have wondered about him having "paradoxical" reactions to medications (some that are supposed to make him drowsy have had the opposite effect).
I guess our goal has been to get his self-injurious and aggressive behaviors under control, so he'd be more in a position to learn (including, to learn better strategies for dealing with whatever he's trying to communicate with those behaviors). Anxiety has been something we've often noted as a precursor to the behaviors.
Posted by Kristina Chew on 06/02/2009 @ 03:46PM PT
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Thank you for your helpful information- sometimes it feels like doctors and parents are just shooting in the dark (so to speak), when it comes to medications for autistic people, so it is always good to hear from well-informed professionals. My son's been on and off medication for years, but it's been mainly to try to increase his impulse control as he's aggressive and self-injurious. Sometimes medication will work for a time, and sometimes it doesn't.
But I have what is probably a stupid question...does the placebo affect still "work" on people who may not even understand what medication is? I'm pretty sure that my son has no idea why sometimes he takes pills, and sometimes he doesn't, (or even what the difference is between a pill or a piece of candy), so I'm curious if there have any been any studies done to measure the placebo effect on people who may not understand even what a pill is. Sorry if that's an idiotic question :-)
Thanks for your input.
Posted by Jen Niebler on 06/03/2009 @ 03:38AM PT
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I'm taking Celexa (Citolopram) now. They made me increase it to 20 mg see if it would help with my IBS.
It doesn't stop me from rocking back and forth and handflapping when i'm happy though.
I don't understand the problem with repetative behaviours since even non-autistic people have them. Why are they a big deal?
Aggression is something that would be more of an actual problem to deal with.
I hope you can find a good solution to help.
Posted by Shondolyn (Synesthesia) Gibson on 06/02/2009 @ 06:21PM PT
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In her book, "The Fabric of Autism," Judith Bluestone explains that repetitive behaviors actually release endorphins in autistic persons. She talks about how when she suppresses her stims in order for her to present at conferences or work in therapy sessions with clients, that she often comes home and sort of has a stim explosion in order to "reset" her body and her sensory systems.
I am of the frame of mind that as long as the behavior is not harmful to the individual or to anyone else, and as long as it does not interfere with things necessary for daily life such as sleep and eating, then let it be. Benign repetitive behaviors can be a way of him attempting to self regulate and self soothe.
Posted by ASD momNC on 06/02/2009 @ 08:17PM PT
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I think the repetitive behaviors hinder my son´s development because he´s so focused and preoccupied with those thoughts and actions that he misses or avoids important information and stimulation from his environment. Repetitive behaviors aren´t just things like rocking and flapping, but repetitive play like watching the same video scene over and over or scripting the same sentence 100 times or re-enacting the same movie scene 80 times in a row. Repetitive behaviors some times are OCD symptoms that need to be addressed.
Posted by Leila * on 06/03/2009 @ 06:04AM PT
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Those would fall into the category of "interferes with life," and I agree, need to be treated.
We don't interfere with our son's stims, to a point. Meaning, he can't take stimmy objects into the classroom, he can't stim at the dinner table if it's loud and intrusive to those around him, he can't stim intead of sleeping, etc.. When he first started OT, the therapists had to clear the sensory gym of all things with wheels when my son came in for therapy, because he would stim instead of focusing on the task at hand.
I'm pretty liberal with not breaking stims, but like you so well articulated, there are definitely stims that need to/have to be broken from time to time.
Posted by ASD momNC on 06/03/2009 @ 12:27PM PT
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I guess on stereotypic or repetitive behavior, our take currently is--is it interfering, restricting, or just annoying, if that?
I'm a nailbiter (embarrassing), grind my teeth, and sometimes find myself needing to move around to really listen--off and on. My husband taps tables and rocks his knee up and down at times, (and yeah, sometimes it's annoying). He also says he needs sometimes to "move around to really listen". My daughter does neither, but she does some handflapping and pacing and almost always rocks if there's music on. Is it annoying, depends--they get "looks" from people who don't know her. Is it interfering or escalating? Nope. Should these be "treated"? I don't know, but my tendency in the absence of a compelling reason to do so is...no. If there was a compelling reason, I might feel and approach it differently.
I asked her recently why she was flapping her hands--the answer was, "I like flapping.". Why? "It makes me feel happy". Seemed pretty honest and reasonable. So we talk about how it might be perceived, and when and where it might not be a good idea, but that answer stays in my head.
Posted by Regina Claypool-Frey on 06/03/2009 @ 04:34PM PT
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My teeth grinding needs to be treated. Only because it's ruining my teeth and causing me agonizing TMJ pain.
Posted by Shondolyn (Synesthesia) Gibson on 06/03/2009 @ 04:38PM PT
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Well, I'm real sorry about that Shondolyn; I hope you can get treatment. So far I don't have either issue, but certainly those are possibilities, that might push me to more closely look at the options. So far it's more of a habit for me.
Take care.
Posted by Regina Claypool-Frey on 06/03/2009 @ 05:00PM PT
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In thinking about what repetitive behaviors Charlie has, it occurred to me that the behaviors of most concern in his case---SIBs---can occur repeatedly (he'll bang his head not one time, but a couple of times). But it is not that he has SIBs every day all the time; there've been periods when this has occurred, but that is not at all the case now.
As he's gotten older, I would say that Charlie has learned to "go easier" on his perseverating and has learned to stop doing it (or at least let it taper off) without getting very upset.
Posted by Kristina Chew on 06/03/2009 @ 05:51PM PT
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