Should a patient with severe autism requiring medication be referred to neurology or psychiatry?

Refer to Psychiatry for Medication Management in Severe Autism

A patient with severe autism requiring medication should be referred to psychiatry, specifically to a child and adolescent psychiatrist (CAP) or a psychiatrist with specialized training in developmental neuropsychiatry. 1

Rationale for Psychiatry Referral

Scope of Practice and Expertise

• Child and adolescent psychiatrists are explicitly within their scope of practice to provide high-quality psychiatric care for patients with autism spectrum disorder and intellectual/developmental disabilities. 1
• Psychiatry is the appropriate specialty because medication management in autism targets comorbid psychiatric disorders and specific behavioral symptoms (irritability, aggression, hyperactivity, anxiety, sleep disturbances) rather than neurological conditions. 1, 2
• Some institutions offer advanced training programs in developmental neuropsychiatry for psychiatrists who specialize in this population. 1

Medication Expertise

• The most commonly used and FDA-approved medications for autism are psychotropic agents managed by psychiatrists:
  • Risperidone and aripiprazole (FDA-approved for irritability in ASD ages 6-17) 2, 3
  • Methylphenidate for ADHD symptoms 2
  • SSRIs for anxiety and repetitive behaviors 2
  • Melatonin for sleep disturbances 2
• These medications require psychiatric expertise for proper selection, dosing, and monitoring of behavioral and emotional symptoms. 1

When Specialized Referral is Needed

Consider Subspecialty Psychiatry Referral When:

• The patient has treatment-refractory cases that don't respond to initial interventions. 1
• There is need for referral to a psychiatrist specializing in the intellectual/developmental disability population. 1
• The patient requires specialized psychiatric treatment programs or settings (e.g., specialized inpatient units for severe behavioral disturbance). 1
• A developmental-behavioral pediatrician with psychiatric medication expertise may also be appropriate in some cases. 1

Neurology is NOT the Primary Referral

Neurology Would Only Be Appropriate If:

• The patient has comorbid seizure disorder requiring neurological management (present in some autism cases). 1
• There are specific neurological symptoms separate from the behavioral/psychiatric manifestations of autism.
• In such cases with medical comorbidities like seizures, medication regimen consolidation should be considered (choosing medications that address multiple issues). 1

Critical Treatment Principles

Medication Should Target Specific Symptoms:

• Medication choice must proceed from diagnosis of a DSM-5 psychiatric disorder as part of a comprehensive treatment plan. 1
• Prescribing for behavioral problems alone (aggression, self-injury, property destruction) should be minimized when possible because these may stem from various disorders or factors (ADHD, anxiety, medical issues, communication deficits). 1
• Medication targeting behavioral problems is best limited to patients who:
  • Pose risk of injury to self or others 1
  • Have severe impulsivity 1
  • Are at risk of losing access to important services (foster home, school, residential placement) 1
  • Have failed other treatments 1

Essential Caveats:

• Psychotropic medications should never substitute for appropriate behavioral and educational services. 1
• Combining medication with parent training is moderately more efficacious than medication alone for serious behavioral disturbance. 2
• Regular monitoring using standardized rating scales is essential for assessing treatment response. 2