From the Guidelines
Treating aggression in autism requires a comprehensive approach that combines behavioral strategies, environmental modifications, and sometimes medication, with a focus on identifying triggers, implementing Applied Behavior Analysis (ABA), and considering medications like Risperidone and aripiprazole for severe cases, as recommended by the American Academy of Child and Adolescent Psychiatry 1. When managing aggression in individuals with autism, it's crucial to start by identifying triggers for aggressive behavior through careful observation and documentation. This can be achieved by:
- Implementing behavioral interventions such as Applied Behavior Analysis (ABA), which uses positive reinforcement to encourage appropriate behaviors 1
- Creating a structured, predictable environment with visual schedules and clear communication methods tailored to the individual's needs
- Addressing physical discomfort, sensory sensitivities, and communication barriers, which often underlie aggressive behaviors For severe aggression that poses safety risks, medications may be considered, including:
- Risperidone (0.5-3mg daily) and aripiprazole (2-15mg daily), which are FDA-approved for irritability and aggression in autism, typically started at low doses and gradually increased 1
- Alpha-2 agonists like guanfacine (1-4mg daily) or clonidine (0.1-0.4mg daily), which can help with impulsivity and hyperactivity Medication should always complement behavioral approaches, not replace them, and regular monitoring for side effects is essential, with periodic attempts to reduce medication when possible 1. Additionally, teaching alternative communication methods and coping strategies gives individuals better ways to express needs and frustrations. Parent and caregiver training in behavior management techniques is also vital for consistent implementation of strategies across settings, as recommended by the Lancet Neurology 1. Early intervention, combining developmental and behavioral approaches, is also crucial for children under 3 years of age, as stated in the Pediatrics journal 1.
From the FDA Drug Label
The efficacy of RISPERIDONE in the treatment of irritability associated with autistic disorder was established in two 8-week, placebo-controlled trials in children and adolescents (aged 5 to 16 years) who met the DSM-IV criteria for autistic disorder. The ABC-I subscale measured the emotional and behavioral symptoms of autism, including aggression towards others, deliberate self-injuriousness, temper tantrums, and quickly changing moods.
Risperidone is effective in treating aggression in autism, as measured by the Aberrant Behavior Checklist-Irritability subscale (ABC-I). The results of two 8-week, placebo-controlled trials in children and adolescents (aged 5 to 16 years) showed that risperidone significantly improved scores on the ABC-I subscale compared with placebo 2.
- Key points:
- Risperidone is indicated for the treatment of irritability associated with autistic disorder, including symptoms of aggression towards others.
- Efficacy was established in three short-term trials in children and adolescents (ages 5 to 17 years) 2.
- The high dose of risperidone (1.25 mg per day for patients weighing 20 to < 45 kg, and 1.75 mg per day for patients weighing > 45 kg) demonstrated efficacy in a 6-week, multicenter, randomized, double-blind, placebo-controlled, fixed-dose study 2.
From the Research
Treating Aggression in Autism
- Aggression is a common and debilitating problem in individuals with autism spectrum disorders (ASD) 3
- Treating aggression in ASD is a high priority, but there is a limited number of studies addressing treatment 3
- A review of studies on treating aggression in ASD found that various interventions have been used, including pharmacological and behavioral interventions 3
Pharmacological Interventions
- Atypical antipsychotics, such as risperidone, may be effective in reducing irritability and aggression in individuals with ASD 4, 5
- Selective serotonin reuptake inhibitors (SSRIs) may be effective in reducing symptoms of anxiety and depression in individuals with ASD, but their effectiveness in reducing aggression is unclear 6, 7
- Other pharmacological interventions, such as propranolol, fluvoxamine, and dextromethorphan/quinidine, may also be effective in reducing aggression in individuals with ASD 4
Behavioral Interventions
- Behavioral interventions, such as functional assessment-informed behavioral interventions, may be effective in reducing aggression in individuals with ASD 4
- Multisensory environments and vigorous aerobic exercise may also be effective in reducing aggression in individuals with ASD 4