What is the recommended treatment plan for a patient with autism spectrum disorder (ASD) who has shown significant improvements in communication, eye contact, and social engagement, but still exhibits aggressive behaviors and self-injurious behaviors?

Treatment Plan for ASD with Persistent Aggressive and Self-Injurious Behaviors

Continue the current intensive behavioral intervention program while adding risperidone 0.5-3.5 mg/day (weight-adjusted) to specifically target the daily aggressive behaviors and self-injurious behaviors that persist despite significant therapeutic progress. 1

Pharmacological Management for Target Behaviors

Initiate risperidone as first-line pharmacotherapy for irritability, aggression, and self-injurious behaviors:

• Start at 0.25 mg/day if weight < 20 kg or 0.5 mg/day if weight ≥ 20 kg, administered twice daily 1
• Titrate to clinical response over 1-2 weeks, with typical effective doses ranging 0.5-3.5 mg/day (mean modal dose approximately 1.9 mg/day or 0.06 mg/kg/day) 1
• FDA-approved specifically for irritability associated with autistic disorder in children ages 5-17 years, with demonstrated large effect size (standardized mean difference of 1.1) for reducing aggression and self-injury 2, 3
• Monitor for adverse effects including weight gain (33% experience >7% weight gain), somnolence (most common, typically early-onset and transient with median duration 16 days), increased appetite, and extrapyramidal symptoms 1, 4

Combining medication with behavioral interventions is more efficacious than medication alone for decreasing serious behavioral disturbance. 2

Behavioral Intervention Optimization

Maintain and intensify current Applied Behavioral Analysis (ABA)-based interventions:

• Continue speech therapy twice weekly and occupational therapy once weekly, as these services are demonstrating measurable progress in communication and adaptive functioning 4
• Implement functional behavioral assessment specifically targeting the 1-2 daily aggressive episodes and self-injurious behaviors during frustration to identify antecedents and develop replacement behaviors 4, 5
• Use differential reinforcement techniques to systematically reward alternative communication attempts when frustration occurs, rather than aggressive or self-injurious responses 6
• Apply forward or backward chaining with reinforcement for multistep tasks to reduce frustration-related behavioral episodes 4, 6

The family's extensive intervention efforts have prevented adaptive functioning scores from falling significantly lower, demonstrating the critical importance of maintaining current intensity. 4

Communication Support Strategies

Address the functional communication deficits that likely contribute to frustration-based behaviors:

• Despite the patient's rejection of tablet-based AAC devices, re-introduce alternative augmentative communication modalities including Picture Exchange Communication System (PECS), activity schedules, or voice output communication aids with different form factors 4, 6
• The rejection behavior itself warrants functional analysis—throwing and stomping devices may indicate sensory aversion, motor difficulties, or learned escape behavior that can be systematically addressed 4
• Explicitly teach functional communication for expressing frustration, needs, and wants through structured teaching sessions, capitalizing on the emerging ability to use phrases and scripts 4
• Continue speech/language therapy with emphasis on pragmatic language skills and social reciprocity, as language delays directly correlate with behavioral dysregulation 4, 6

Addressing Underlying Cognitive and Processing Deficits

Implement environmental supports for working memory and processing speed deficits common in ASD:

• Use visual schedules, planners, and timers throughout the school and home environment to reduce organizational demands that trigger frustration 4, 5
• Ensure educators and therapists gain attention before giving instructions, speak slowly without infantilizing, use repetition, and minimize multistep directives 4
• Teach chains of behaviors using systematic prompting and reinforcement to allow success in complex tasks that might otherwise overwhelm processing capacity 4, 5

Monitoring and Assessment

Establish systematic monitoring using standardized measures:

• Use the Aberrant Behavior Checklist-Irritability subscale (ABC-I) to quantify changes in aggression, self-injury, and tantrums at baseline and every 2-4 weeks during medication titration 1, 2
• Track frequency, intensity, and duration of aggressive and self-injurious episodes daily to assess treatment response 6
• Monitor weight, appetite, and sedation closely given the high incidence of these adverse effects in pediatric populations on risperidone 1
• Assess for tardive dyskinesia at each visit, though incidence is low (0.1% in pediatric trials) 1

Comorbidity Screening

Screen systematically for psychiatric comorbidities that may exacerbate behavioral symptoms:

• Evaluate for depression (20% prevalence in ASD vs 7% in general population), anxiety (11% vs 5%), and sleep disturbances (13% vs 5%) using standardized rating scales 2, 6, 3
• The constipation history and pica behaviors (eating rocks/sand) warrant ongoing medical monitoring, as gastrointestinal issues can increase behavioral dysregulation 4
• Assess for ADHD symptoms, as attentional difficulties are frequent in autism and may present as frustration intolerance; if present, consider methylphenidate 0.3-0.6 mg/kg/dose 2-3 times daily after behavioral symptoms stabilize 2, 6

Family Support and Coordination

Acknowledge and support the mother's role as primary coordinator while ensuring sustainability:

• Active family involvement as co-therapists is essential for generalization of skills across settings and increases intervention time beyond formal therapy sessions 4, 2
• The mother's cautious optimism and realistic expectations are appropriate given the slower-than-anticipated progress; continue supporting goal-setting that balances hope with evidence-based timelines 4
• Consider respite services or additional family support given the intensive coordination demands and daily behavioral challenges 4

Educational Program Considerations

Optimize the current special education services:

• The 5-day-per-week school attendance with IEP, one teacher, and two paraprofessionals provides appropriate structure; ensure behavioral intervention plan is integrated into IEP with consistent strategies across home and school 4, 6
• Coordinate medication management with school staff to monitor behavioral changes and adverse effects during school hours 2
• Continue organized playdates and deliberate teaching of social skills, as peer-mediated interventions show improvement in interaction with generalization to new settings 4

Critical Pitfalls to Avoid

• Do not delay pharmacotherapy while waiting for behavioral interventions alone to address daily aggression and self-injury; the evidence supports combined treatment as superior to either alone 2
• Do not abandon AAC device trials based on initial rejection; systematic desensitization and functional analysis of rejection behaviors can lead to successful implementation for substantial functional communication needs 4, 6
• Do not attribute all behavioral symptoms to autism without screening for treatable comorbidities like depression or anxiety that may present as increased irritability and aggression 2, 6
• Do not use risperidone doses below the effective range; a controlled trial demonstrated that low-dose risperidone (0.125-0.175 mg/day) was ineffective, while higher doses (1.25-1.75 mg/day) showed significant efficacy 1