JADD - Medication or Behavior Therapy ？

秋爸爸

J Autism Dev Disord (2008) 38:1197–1198 / 2008年8月

Ask the Expert
How Do I Decide Whether or Not to Use Medication for My Child with Autism? Should I Try Behavior Therapy First?
Lawrence Scahill1

Journal of Autism and Developmental Disorders
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Dear Editor:

The decision of whether to use medication or behavioral intervention in the treatment of a child with autism may be difficult in some cases and always deserves careful consideration. There is solid consensus that all children with autism need education including enriched environments for learning, speech and language training and instruction to promote social and daily living skills. There is less agreement and even controversy on the role of medication in children with autism. For example, many clinicians and parents advocate behavioral intervention rather than medication. Despite the lack of consensus on how and when to use medication in children with autism, medication use in children with autism has steadily risen over the past decade. This undisputed rise in medication use has occurred in the face of inconsistent evidence that commonly used medications are indeed effective. At the same time, the term “behavior therapy” encompasses a wide range of techniques and interventions––not all of which have supportive evidence. Thus, parental uncertainty about the use of medication or behavioral intervention in children with autism is understandable.

Recent events have brought the dilemma of medication versus behavior therapy back to center stage. In late 2006, the US Food and Drug Administration (FDA) approved the use of risperidone for the treatment of tantrums, aggression, and self-injury in children with autism indicating that this medication is safe and effective for these target problems. More recently an article published in the British journal, Lancet, showed that risperidone was no better than placebo for aggression in a group of intellectually disabled adults (Tyrer et al. 2008). At first look, it may seem difficult to reconcile the FDA approval (which was based on positive results from previous studies) and the results of the study in Lancet. Upon closer examination, however, it is possible to sort this out.

The Research Units on Pediatric Psychopharmacology (RUPP) Autism Network conducted a multisite study that was evaluated by the FDA in the decision to approve risperidone (RUPP Autism Network, 2002, 2005). In our study, risperidone was compared to placebo in 101 children with autism accompanied by severe and enduring problems of tantrums, aggression, and self-injury. By contrast, the study in Lancet included adults and only a small minority had a diagnosis of autism (Tyrer et al. 2008). Perhaps more importantly, it is not clear that the adults in the Lancet study had both severe and enduring problems with aggression. These two points have implications for the decision to use medication for aggression in children with autism. First, a medication, such as risperidone should not be used in children with mild aggression and explosive behavior that does not have an enduring pattern. Although risperidone is usually well-tolerated, it is a potent medication that may have adverse effects. In addition, if the problem behaviors are mild and not enduring, it may be difficult to determine whether the medication is actually working. Here, we may draw an analogy with fever. If a child with a low grade fever is treated with a medication––it may be difficult to detect change and even more difficult to tell if any change was due to the medication or simple passage of time. Parents and clinicians should avoid being in the position of having a child with autism on medication and being uncertain if it is working or not.

Before putting a child with autism on a medication, such as risperidone, the clinical assessment should establish the severity and pattern of the behavioral problems. A careful clinical assessment will also consider what previous treatments have been tried and are currently in place. In some cases, it may become apparent that the aggressive and explosive behavior emerged recently suggesting that it is response to new environmental demands or in response to a health problem––such as an abscessed tooth. A medication, such as risperidone should be reserved for children with moderate or greater levels of aggression, tantrums or self-injury for whom other treatments including behavior therapy have been tried and been shown to be ineffective. Finally, in children with severe behavioral problems, it may not be a matter of selecting medication or behavior therapy. Rather, it may be useful to combine medication and behavior therapy. We are now conducting a study to examine the combined effects of risperidone and a behavioral intervention.

Acknowledgments  This work was supported by U10MH66764 (P.I., L. Scahill). The author would like to acknowledge the following: Allison Gavaletz, Erin Kustan.


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References
Research Units on Pediatric Psychopharmacology (RUPP) Autism Network. (2002). Risperidone in children with autism for serious behavioral problems. New England Journal of Medicine, 347(5), 314–321.
   
Research Units on Pediatric Psychopharmacology (RUPP) Autism Network. (2005). Risperidone treatment of autistic disorder: longer term benefits and blinded discontinuation after six months. American Journal of Psychiatry, 162, 1361–1369.
   
Tyrer P., Oliver-Africano, P. C., Ahmed, Z., et al. (2008). Risperione, haloperidol and placebo in the treatment of aggressive and challenging behavior in patients with intellectual disability: a randomized trial. Lancet, 371, 57–64.

仰望山林

在青春期如果出现严重的情绪和行为问题，应该适当使用Risperidone.

daisy４

秋爸爸，我的公公看了你们在央视的节目，但只看了上集没有看到你们送去训练，现在我的孩子也确症是自闭症，而且跟你其中一个很像，也喜欢旋转，能转一百多圈而不晕，喜欢旋转的东西，不会正常玩玩具，不怕危险等等，但我公公拒绝承认，还认为我送去训练是浪费钱，他们要把孩子接回老家去，还说我没有带好，看书太多陷进去了．我真不知要怎样说服他们．我的孩子现在一岁九个月了，目前在深圳莲塘训练．我昨天才请训练班的家长们一起说服他爸爸认清事实．我不想我的孩子耽误[EM12]

jiajunmei

  顶一下，秋爸的好文章，确实对临床药物干预的指证有一些参考价值

RICHARD妈咪

秋爸爸一位好爸爸，你的孩子有你一定会康复，你是我们的榜样，我们要让我们的天使再次展翅，一定可以。

ajajaj

多谢分享！
我上周五刚刚看了DAN!医生，他又推荐一种新药，叫Namenda. 是UC Davis (Univ. of CA)一个儿科医生实践了4年我的医生才开始使用的。那个儿科医生有各自闭症的女儿。这是我的DAN!推荐的第一个non-label的drug. 我儿子平时吃的都是supplements。
我个人是医学盲，凭直觉和父母的反馈为孩子作决定。我想其实像ABA, RDI等等这些行为干预也没一种完全治愈自闭症的，对一个孩子完全生效的方法对另一个孩子无效很正常，同理适用于听统感统训练以及生化治疗。能让生活保持平衡是我们这种家庭最大的挑战，在我们能够掌控的大前提下，我不拒绝使用任何一种可以帮助孩子的方法，而且它们之间不是exclusive的，都可以同时进行，所以没必要比较和坚决倡导一种方法。用管理学的角度讲，这叫risk management，既衡量利弊。

老枪

英文，看不懂。

First, a medication, such as risperidone should not be used in children with mild aggression and explosive behavior that does not have an enduring pattern. Although risperidone is usually well-tolerated, it is a potent medication that may have adverse effects. In addition, if the problem behaviors are mild and not enduring, it may be difficult to determine whether the medication is actually working. Here, we may draw an analogy with fever. If a child with a low grade fever is treated with a medication––it may be difficult to detect change and even more difficult to tell if any change was due to the medication or simple passage of time. Parents and clinicians should avoid being in the position of having a child with autism on medication and being uncertain if it is working or not.

是不是说：对于有中度攻击行为或者偶尔出现一下的严重攻击行为的自闭症小孩，像risperidone利培酮（这个已经算有名了）这样的药最好别用。就像轻度发烧，你去用一种不确定疗效的药去治，然后退烧了---你不应该由此就满世界地去宣传，说你发现了神药。谁知道呢？也许仅仅是时间推移，自己退烧了。
？？

关于利培酮，以前和平祝有过一个帖子

http://www.elimautism.org/leadbbs/a/a.asp?B=83&ID=248490&p=2&q=1&r=40062

老枪

http://news.yahoo.com/s/ap/20081002/ap_on_he_me/med_cold_medicines

小孩（2-6岁）感冒咳嗽，吃药还是不吃？医生说，不要吃，养养多休息，多喝流质，自然会好。不仅如此，一些儿科医生还要求FDA禁止药店出售小儿感冒止咳药。FDA最近驳回了这一请求，原因在于：虽然小儿感冒药的确缺乏数据支持其有效性，但如果禁售，可能会导致有的家长给小孩吃大人药从而引起更严重的后果。


WASHINGTON - A top government health official Thursday rejected pediatricians' calls for an immediate ban on over-the-counter cough and cold medicines for young children, saying it might cause unintended harm.

But Food and Drug Administration officials at a public hearing also said they were uncomfortable with the lack of solid scientific data to support continued use of OTC remedies with youngsters, particularly from ages 2-6.

A ban — as sought by leading pediatricians' groups — might only drive parents to give adult medicines to their youngsters, said Dr. John Jenkins, who heads the FDA's Office of New Drugs.

"That is a concern for us," said Jenkins. "We do not want to do something that we think will have a positive impact, only to have an unintended negative. That could be an even worse situation."

With a new cold season coming, pediatricians are urging the government to demand a recall of over-the-counter cough and cold medicines for children younger than 6. The effectiveness of the medicines in children was never proven, critics say, and problems with the drugs send thousands of kids to the emergency room every year.

"When a treatment is ineffective, its risks — unless zero — always exceed its benefits," Dr. Michael Shannon of Children's Hospital in Boston told the FDA panel.

"We don't see a public health emergency here as far as an inherent risk of the products," said the FDA's Jenkins.

But he agreed with critics who say there's no proof the medicines work in kids. "We don't see that adequate evidence of efficacy has been demonstrated in children to date," said Jenkins. Clinical studies to try to settle the issue could take years to complete, and may not provide clear answers.

"It really is a conundrum for us," said Jenkins.

Parents might also be frustrated by the conflicting advice.

The American Academy of Pediatrics says OTC products are ineffective for treating coughs and colds in children under 6, and should not be given because of the risk of serious side effects — a conclusion seconded last year by a panel of outside advisers to the FDA. But the FDA's own advice is that parents should not give the medications to tots under 2 — a position shared by the drug companies.

In January, FDA officials said they expected to decide by spring on recommendations for youngsters up to 11. Now the agency is seeking more advice from doctors, industry and consumers — and officials are not giving a timetable for a decision.

U.S. families spend at least $286 million a year on such cough and cold remedies for children, according to the Nielsen Co. market research firm. In any given week the medicines are used by an estimated 10 percent of all children, with the biggest exposure among 2- to 5-year-olds, a recent Boston University report found.

But colds usually clear up on their own after a few days. Many doctors say rest and plenty of fluids are what it takes to get over a cold.

The industry says OTC medicines have been used for decades in treating kids' colds and are safe for those older than 2. Nonetheless, manufacturers are planning to carry out new studies involving the most common ingredients in the medications. The companies voluntarily stopped selling cough and cold medicines for babies and toddlers last fall.

It turns out that when the FDA set standards for cough and cold medicines some 30 years ago, no separate studies were done for kids.

Cough and cold medicines send about 7,000 children to hospital emergency rooms each year with symptoms ranging from hives and drowsiness to unsteady walking. Low doses of a medicine are not likely to cause a problem; the main risk comes from unintentional overdoses.

The same ingredients usually are found in different products. For example, giving a child a cough syrup and a decongestant could inadvertently lead to an overdose.

The Consumer Healthcare Products Association, which represents the manufacturers, says preventable errors are the problem, not the safety of the ingredients in the medicines. The industry is starting an educational campaign aimed at parents, doctors and day care providers on the importance of following directions and storing medicines in places where kids cannot get at them.

"The data clearly show a majority of adverse events are direct result of misuse of our products," said Linda Suydam, who heads the industry group.

Baltimore health commissioner Dr. Joshua Sharfstein sought to reassure FDA officials worried about unintended consequences if the government moves to restrict the medications and parents start dispensing adult drugs to their preschoolers. Sharfstein said the state of Maryland saw an immediate benefit after OTC cough and cold remedies for tots were removed from store shelves last fall. Calls to poison control about problems with the medicines involving children younger than 2 dropped by 40 percent, from 99 to 60, in the first six months of this year when compared with 2007. Calls involving children 2 to 6 also dropped, but by much less.

"The feared increases in poisonings simply did not happen," said Sharfstein. "In fact, the opposite occurred."