Pharmacological Management of Autism Associated Behaviors

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The following course content

Introduction   

When hearing the phrase autism spectrum disorder, what comes to mind? If you’re an advanced practice registered nurse (APRN) with prescriptive authority, you’ve definitely heard of autism and ASD before. Even as a nurse or maybe before nursing school, conversations about autism, prescription drug use, and more existed every so often. Presently, patients seek guidance and information on various health topics from APRNs, including medication management before, during, and after their ASD diagnosis. The information in this course will serve as a valuable resource for APRNs with prescriptive authority of all specialties, education levels, and backgrounds to learn more about medications used to manage autism-associated behaviors and mood disturbances.    

Defining Autism Spectrum Disorder (ASD) 

What Is ASD?  

Autism spectrum disorder (ASD) is a neurodevelopmental chronic health condition that involves repetitive behaviors, social interaction difficulties, mood disturbances, and behavioral challenges. ASD has been referred to as autism, Asperger’s, and other names over the past century. Health conditions like Asperger’s have been retired, and people are now diagnosed with being on the autism spectrum. ASD has grown in popularity as a medical diagnosis over the past decade among children, adults, and geriatric populations. ASD has also been subject to much more research currently than prior because of growing awareness of neurodivergent and psychosocial behaviors. While ASD is a complex chronic neurodevelopmental condition, millions of people remain undiagnosed and undertreated for this condition. The cause of ASD is not known, as there are many theories for its causation, ranging from genetics to environmental exposure and trauma. Because of the complex, emerging psychosocial and neurodevelopment needs of patients with ASD, pharmacological management of autism-associated behaviors is a must for APRNs (1,2,3,4,5,6). 

How Prevalent is ASD? 

The true prevalence of ASD is not known, as millions of people with ASD are misdiagnosed or unable to seek professional health care services. Many people with ASD self-diagnose themselves as a result of lack of access to health care and lack of trust in the medical system. Some studies indicate that ASD has a prevalence on 1 in 68 among children; however, many people receive an ASD diagnosis in adulthood and as a geriatric patient as well. In addition, ASD has historically been viewed as a “white male” condition, leaving many women and people of color undiagnosed because of social stigmas that ASD only affects certain races or genders. Because of varying access to care and provider knowledge and education on ASD, the true prevalence of ASD is yet to be determined (1).  

What Are Some ASD Signs and Symptoms? 

Most people with ASD symptoms have symptoms by age two. Common ASD signs and symptoms include: social interaction impairment, irritability, complications with expressing or receiving language, repetitive behaviors (also known as “stimming”), general loss of interest in objects and the environment, or mood changes with changes in schedule or routine. For these signs and symptoms to be considered for ASD, they must interfere with the patient’s ability to work, go to school, or function interpedently. That said, it is important to consider the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) Criteria for Childhood Disintegrative Disorder Diagnosis via the World Health Organization (WHO) and the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). The DSM-5 criteria for ASD states that for an ASD diagnosis, there must be: Deficits in social interaction and communication; Restricted interests, repetitive behavior, and activities; Symptoms impair everyday functioning (1,2,3,4,5,6). 

What Are ASD Risk Factors? 

Risk factors for ASD are still unknown. Some research suggests that ASD has a genetic and environmental exposure component, whereas other research suggests that ASD is also defined by social norms of a community as well. Further research is needed to determine the exact risk factors and causation of ASD (1,2,3,4,5,6).  

What If ASD Is Left Untreated? 

If ASD is left untreated or unmanaged, patients can experience mood disturbances and changes in behavior that can negatively influence their health, quality of life, ability to participate in society, go to school, work, and more. While some people have ASD on a milder spectrum than others, some people have more pronounced and more severe mood disturbances and behavioral changes that can severely influence their quality of life. Given the complexities of mental and neurodevelopmental health and the emerging research with ASD, it is important to note several ways to manage mood disturbances and changes in behavior in patients with ASD (1,2,3,4,5,6). 

Defining ASD Medications 

What Are ASD Medication Options? 

There are several prescription and over the counter (OTC) medication options that can be used to manage autism-associated behaviors and mood disturbances. It is important to note that there is no medication to cure or treat ASD alone, as medications are given to manage ASD’s symptoms. When considering which medications to prescribe or discuss with a patient, it is important to consider patient characteristics, age, insurance, administration route, cost, patient preference, and prior experiences on medications. Common prescriptions for ASD behavior or mood management include antipsychotics, selective serotonin reuptake inhibitors (SSRIs), stimulants, anxiolytics, tricyclic antidepressants (TCAs), alpha adrenergic receptor agonists, and cannabidiols. OTC medication options such as melatonin, n-acetylcysteine, and sulforaphane are also possible management options (1,2,3,4,5,6). 

How and Where Are ASD Medications Used? 

Medications to manage autism-associated behaviors and mood disturbances are used in a variety of clinical settings, such as hospitals, outpatient clinical settings, correctional facilities, pediatric facilities, and more. Most medications are administered by mouth. Depending on the dosage and severity of ASD mood disturbances and behaviors and patient clinical presentation, some people might need IV medication to manage their autism-associated behaviors (1,2,3,4,5,6).  

What Are the Clinical Criteria for Prescribing ASD Medications? 

Clinical criteria for prescribing medications to manage autism-associated behaviors and mood disturbances significantly varies on the patient population. While there are general guidelines on ASD from the DSM-V and other organizations with clinical guidelines, there is no definitive one way to prescribe medications for ASD. In fact, ASD behavior changes and mood disturbances can go undetected and unmedicated for many years, whereas other people have earlier medication interventions.  

In addition, patient history, clinical presentation, and other factors can be used to determine first-line medication management for ASD mood disturbances and behavior changes. In general, first-line medication options for ASD mood disturbances and behaviors include antipsychotics and antidepressants starting with the lowest dose possible and adjusting dosages depending on patient response to medication therapy. Also, other medications can be used simultaneously or one at a time to gauge patient response. Depending on patient history and clinical presentation, non-pharmacological methods, such as therapy, might be considered as well (1,2,3,4,5,6). 

What Is the Average Cost for ASD Medications? 

Cost for medications to manage autism-associated behaviors and mood changes can significantly vary depending on the type of medication, insurance, dosage, administration route, frequency, and other factors. Cost is among a leading reason why many patients cannot maintain their medication regime (7). If cost is a concern for your patient, consider reaching out to your local pharmacies or patient care teams to find cost effective solutions for your patients.  

ASD Medication Pharmacokinetics 

Health care provider professional discretion and patient condition should guide therapy. Consider reviewing a patient’s medication history, clinical presentation, and health history prior to prescribing ASD medications. Consider consulting with a mental health specialist or other relevant clinical staff regarding ASD medication management. It is recommended to start on the lowest dosage possible and titrate upwards or add another medication to manage autism-associated behaviors and mood changes. Alternatives to ASD medications include trying another pharmacological option or encouraging a lifestyle modification, such as stress reduction techniques or therapy. 

Antipsychotics 

Presently, aripiprazole and risperidone are FDA approved antipsychotics that are FDA approved for autism-associated irritability. Risperidone is FDA approved for patients ages 5 and older. Other antipsychotic medications, such as quetiapine or ziprasidone, can be considered for ASD-related behaviors and mood changes, though limited evidence suggests they are effective for management of ASD-related mood changes and behaviors. Antipsychotics are typically given via pill, but can be administered via intramuscular (IM) injection as well (1,2,3,4,5,6,8,9). 

• Method of Action: All antipsychotic medications have some degree of dopamine receptor antagonistic properties. Aripiprazole is a quinolinone antipsychotic medication with partial agonistic properties at the dopamine and 5HT-1a receptors and acts an antagonist at the 5HT2A receptor. Second-generation antipsychotic medications, such as risperidone, have some dopamine antagonist properties and acts as an antagonist at the serotonin receptor 5HT2A (8,9). 

• Side Effects: Even though antipsychotics can possibly help with irritability for patients with ASD, antipsychotic medications have several severe side effects. Possible side effects of aripiprazole include extrapyramidal symptoms (EPS), such as tremor and repetitive movements, metabolic syndromes, such as changes in cholesterol, sexual dysfunction, gastrointestinal (GI) upset, electrolyte imbalances, changes in menstrual cycles, fatigue, sleep pattern changes, increase compulsive, possible-manic urges, and weight changes.  

Children and the elderly are particularly more prone to these side effects because of their pharmacodynamic effects on the body. Possible side effects of risperidone are the same as for aripiprazole. However, risperidone has an FDA warning about its use in elderly patients, as risperidone can possibly cause dementia-related psychosis. In addition, antipsychotic medications pose the risk of serotonin syndrome and neuroleptic malignant syndrome (NMS), both of which can be life-threatening if left untreated and undetected (8,9).  

It is important to monitor patient side effects to determine if risks outweigh the benefits and to adjust the medication regime as needed. Because of the high risk of adverse side effects, it is often recommended to perform a baseline bloodwork of lipids, a complete blood count (CBC), a comprehensive metabolic panel (CMP), and fasting glucose reading to determine a patient’s baseline lab values (1,8,9).  

Selective Serotonin Reuptake Inhibitors 

Selective serotonin reuptake inhibitors, known as SSRIs, are a type of pharmacological drug class. SSRIs have existed for the past several decades as a class of prescription medications that can manage major depressive disorder (MDD) and other mental health conditions. While SSRIs are FDA approved to manage obsessive-compulsive disorder (OCD), panic disorder (PD), post-traumatic stress disorder (PTSD), and social anxiety disorder (SAD), they are not FDA approved for ASD-related mood changes or behavioral changes. That said, SSRIs can be used in conjunction with other medications or independently to help managed ASD-related behaviors (1,2,3,4,5,6,10,11). Common SSRIs include paroxetine, sertraline, citalopram, escitalopram, vilazodone, and fluoxetine.  

• Pharmacokinetics: SSRIs can be prescribed for the oral route and are available via capsule, tablet, or liquid suspension/solution. SSRIs can be taken at any time of day. They can be taken with or without food; though vilazodone, in particular, is recommended to take with food. SSRIs are metabolized by and known to affect the cytochrome P450 system. CYP2D6 inhibitors include escitalopram, citalopram, sertraline, paroxetine, and fluoxetine. Fluoxetine and fluvoxamine are inhibitors of CYP2C19. Fluvoxamine is an inhibitor of CYP1A2. Consider reviewing a patient’s medication history and health history prior to prescribing SSRIs (10,11).  

• Method of Action: SSRI method of action has been subject to several studies, especially in the last few years. Serotonin is a neurotransmitter that plays a role in mood and other bodily functions. It can be measured in plasma, blood, urine, and CSF; it is important to note that serotonin is rapidly metabolized to 5-hydroxyindoleacetic acid (5-HIAA). SSRIs work by inhibiting the reuptake of serotonin at certain chemical receptors, thereby increasing serotonin activity and concentration. SSRIs inhibit the serotonin transporter (SERT) at the presynaptic axon terminal. While research suggests that SSRI can increase serotonin levels, there is still mixed evidence on the exact method of action for SSRIs. As a result, it is important to counsel patients that SSRIs can take a few weeks to provide a therapeutic response and to monitor mood and symptoms while taking SSRIs (10,11). 

• Side Effects: Fortunately, SSRIs are known to have less side effects than other drug classes of antidepressants, such as monoamine oxidase inhibitors (MAOIs) or tricyclic antidepressants (TCAs).  

The most commonly known side effects of SSRIs include weight gain, sleep changes, headache, gastrointestinal issues, drowsiness, orthostatic hypotension, and sexual function changes. Sleep changes can include an increased desire to sleep, increasing in time sleeping, or insomnia. Gastrointestinal issues can include an upset stomach, nausea, or dry mouth. Mood changes, such as anxiety, can also be a possible side effect as well. Sexual function changes can include erectile dysfunction, libido changes, impaired orgasmic response, and vaginal dryness (10,11). 

There are more serious possible side effects of SSRIs as well. For instance, SSRIs have the possible side effect of QT prolongation, which, if left untreated or undiagnosed, can lead to fatal cardiac arrythmias. In particular, the SSRI citalopram has been shown to have more of a risk for QT prolongation compared to other SSRIs. Also, like any other medication that can possibly increase levels of serotonin in the body, there is a possibility of serotonin syndrome as a complication of SSRI use.  

• Black Box Warning: In 2004, the FDA issued a black box warning for SSRIs and other antidepressant medications because of the possible increased risk of suicidality in pediatric and young adult (up to age 25) populations. When considering SSRI use in patients under 25, having a conversation with the patient about risks versus benefits must be considered. However, in the past several years since the FDA’s warning, there is no clear evidence showing a correlation between SSRIs and the increased risk of suicidality (10,11). 

Stimulants 

Stimulants refer to a drug class in which these medications increase the activity of someone’s central nervous system (CNS). Stimulants are not FDA approved to manage ASD-related mood changes or behaviors, but, depending on someone’s ASD behaviors or mood, stimulants can help with functioning and improving quality of life. Common stimulants include caffeine, amphetamines, methylphenidate, ephedrine, cocaine, pseudoephedrine, and modafinil. For ASD-related behaviors and mood changes, the most commonly prescribed stimulant is amphetamine. It is recommended to start on the lowest dosage possible and titrate upwards or add another medication to ASD-related mood changes and behaviors (1,2,3,4,6,12,13). 

• Method of Action: Stimulants work by increasing the amounts of dopamine, norepinephrine, and sometimes serotonin in the synaptic cleft through a variety of mechanisms. While stimulants are used more frequently presently, there exact method of action still remains to be determined (12,13). 

• Side Effects: Stimulants can have side effects of trouble sleeping, delayed in height growth (especially in young children), appetite changes, headache, dry mouth, changes in blood pressure, changes in heart rate, and irritability (12,13).  

Anxiolytics 

Anxiolytic medications are medications that are used to manage anxiety and anxiety-related symptoms. Examples of anxiolytic medications include buspirone, alprazolam, and chlordiazepoxide. Buspirone is most the most commonly prescribed anxiolytic medication for people with ASD, but it is important to note that anxiolytic medications are not FDA approved for ASD-related behaviors and mood changes (1,2,3,14,15). 

It is recommended to start on the lowest dosage possible and titrate upwards or add another medication to manage ASD-related behaviors and mood changes. If you are considering prescribing anxiolytic medications other than buspirone, you will need a DEA license and comply with your state’s regulations regarding prescribing controlled substances.  

• Method of Action: Buspirone is classified in the azapirone drug class with anxiolytic drug features. Buspirone is a partial serotonin agonist and acts as a weak dopamine antagonist. Buspirone has no effect on GABA receptors. Other anxiolytics, such as diazepam, have activity on the GABA receptors (14,15). Further research is needed to determine the true role of anxiolytic medications’ method of actions.   

• Side Effects: Most common side effects of buspirone include fatigue, dizziness, abnormal dreams, mood changes, changes in vision, chest pain, GI upset, and muscular pain. Other anxiolytic medications have similar side effects, but can have more severe side effects of sleepiness and impaired memory and judgment (14,15).  

Tricyclic Antidepressants 

Tricyclic antidepressants (TCAs) are a medication drug class used to manage depression. Common TCAs include amitriptyline, imipramine, desipramine, and doxepin. It is important to note that TCAs are not FDA approved to manage ASD-related behaviors or mood changes. They are often prescribed to manage mood among people with ASD (1,2,3,4,16). 

• Method of Action: TCAs have a method of action of tempering with five neurotransmitter pathways. TCAs inhibit serotonin and norepinephrine reuptake within the presynaptic terminals, resulting in elevated concentrations of these neurotransmitters within the synaptic cleft. Also, TCAs influence activity on the postsynaptic cholinergic, muscarinic, and histamine receptors. The molecular structure of each receptor significantly impacts TCA’s affinity for each of these receptors. Because of TCAs affect on several neurotransmitter pathways, TCAs have a wide side effect profile (16).  

• Side Effects: Most common side effects of TCAs include dizziness, headache, fatigue, dry mouth, constipation, changes in blood pressure, QTc prolongation, cardiac complications, changes in appetite, weight changes, and urinary retention (16). 

Alpha-Adrenergic Receptor Agonists 

Commonly prescribed alpha-adrenergic receptor agonists used to help with ASD behaviors and mood changes include clonidine and guanfacine. These medications are not FDA approved to manage ASD-related mood changes or behaviors, but can provide some symptomatic relief for ASD-related behaviors (1,2,3,4,17,18).  

• Method of Action: Clonidine and guanfacine have a method of action of stimulating the alpha-2 receptors throughout the body. This stimulation allows for activation of nerve and brain activity within the body, influencing bodily sensations such as pain and blood pressure (17,18).  

• Side Effects: Most common side effects of clonidine and guanfacine include GI upset, headache, mood changes, dry mouth, sexual dysfunction, sedation, changes in blood pressure (most likely hypotension), changes in heart rate (most likely bradycardia), and syncope (17,18). 

Melatonin  

Melatonin is an OTC supplement and also naturally occurs in the body as a hormone. Melatonin is not FDA approved to manage ASD-related mood changes or behaviors, but some studies indicate that melatonin can be helpful for sleep and possible mood concerns among people with ASD (1,2,3,4,5,19).  

• Method of Action: Melatonin has a method of action of inhibiting wake-promoting signals through interactions with its MT1 and MT2 receptors. As a result of inhibiting these signals in these receptors, the person starts to feel sleepy and rests (19). 

• Side Effects: Most common side effects of melatonin include headaches, GI upset, and excessive sleepiness. Generally, melatonin is a well-tolerated OTC medication with few side effects (19). 

N-Acetylcysteine 

N-Acetylcysteine is an OTC supplement and also FDA approved to manage acetaminophen toxicity. Melatonin is not FDA approved to manage ASD-related mood changes or behaviors, but there has been growing speculation of the role of N-Acetylcysteine in ASD behaviors. That said, research is needed to determine the role of N-Acetylcysteine in ASD behaviors and moods. However, many people still use N-Acetylcysteine to manage ASD symptoms, so that is something to keep in mind (1,2,3,4,5,20). 

• Method of Action: N-Acetylcysteine has a method of action of binding to toxic metabolites and searches for free radicals. N-Acetylcysteine also increases oxygen delivery to tissues, increases ATP production in the mitochondria, and alters the microvascular tone to increase blood flow and oxygen delivery to the liver and other major organ systems. This is why N-Acetylcysteine is considered the main drug used for suspected acetaminophen toxicity (20). 

• Side Effects: Most common side effects of N-Acetylcysteine include GI upset, headache, and acid reflux (20). 

Sulforaphane 

Sulforaphane is an OTC supplement and also found in many vegetables, such as broccoli and cauliflower. Sulforaphane is not FDA approved to manage ASD-related mood changes or behaviors, but there has been growing speculation of the role of sulforaphane in ASD behaviors. That said, most research on sulforaphane and ASD shows little evidence that sulforaphane is beneficial to people with ASD. Knowing this, many people still use sulforaphane to manage ASD symptoms, so that is something to keep in mind (1,2,3,4,5,21,22). 

• Method of Action: Sulforaphane has a method of action of detoxifying carcinogens through various reactive oxidative stress pathways, of which research is still being done to determine the exact pathway (21,22).  

• Side Effects: Most common side effects of sulforaphane include heartburn and GI upset (21,22).  

Cannabidiol 

Cannabidiol is a recreational drug and prescription medication. Cannabidiol is not FDA approved to manage ASD-related mood changes or behaviors, but some studies indicate that cannabidiol can be helpful for social interactions and possible mood concerns among people with ASD (1,2,3,4,5,24,25). Given the nature and politicalization of cannabidiol, please refer to your state’s protocol and legislation for APRNs’ scope of work to prescribe, recommend, and monitor the use of cannabidiol in patients.  

• Method of Action: Cannabidiol has a method of action of stimulating two cannabinoid receptors within the endocannabinoid system. This system is a complex network of organs throughout the body, expressing the cannabinoid receptors and playing a homeostatic role (24,25).  

• Side Effects: Most common side effects of cannabidiol include changes in heart rate, changes in mood, changes in appetite, changes in breathing, and GI upset (24,25). 

Non-Pharmacological Management Options for ASD 

While there are several pharmacological options to manage ASD-related mood changes and behaviors, there are many non-pharmacological options to consider as well. Psychotherapy, speech therapy, occupational therapy, and physical therapy are all possible options for those living with ASD to manage their moods and behaviors (1,2,3,4,5,6). 

Nursing Considerations 

What Is the Nurses’ Role in Patient Education and Medication Management? 

Nurses remain the most trusted profession for a reason, and APRNs are often pillars of patient care in several health care settings. Patients turn to nurses for guidance, education, and support. While there is no specific guideline for the APRN role in ASD medication education and management, here are some suggestions to provide quality care for patients currently seeking and taking medications to manage ASD mood disturbances and behaviors (1,2,3,4,5,6,11,23,24,25).  

1. Take a detailed health history. Often times, neurodevelopmental and psychiatric health history can be obtained in a hastily manner in health care settings, especially in primary care or emergent care settings. Sometimes, behavioral or psychological health is not taken seriously. Ask patients about their history and family history of psychiatric or neurodevelopmental health conditions. If a patient is complaining of symptoms that could be related to ASD, such as trouble with social interactions, mood changes, or behavioral concerns, inquire more about those complaints. Ask about how long the symptoms have lasted, what treatments have been tried, if these symptoms interfere with their quality of life, and if anything alleviates any of these symptoms. If you feel like a patient’s complaint is not being taken seriously by other health care professionals, advocate for that patient to the best of your abilities.  
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3. Review medication history at every encounter. Often times, in busy clinical settings, reviewing health records can be overwhelming. Millions of people take medications for various reasons, and people’s medication histories can look similar over time. Ask each patient about how they are feeling on the medication, if their symptoms are improving, and if there are any changes to medication history, including OTC medication use.  
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5. Answer Questions. Be willing to answer questions about ASD and medication options. There are many people who do not know about medication side effects, risk factors to be aware of, and lifestyle changes that can influence ASD. Be willing to be honest with yourself about your comfort level discussing topics and providing education on ASD.  
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7. Communicate the plan of care. All staff involved should be informed of the plan of care for continuity of care. For several patients, especially for patients with ASD, care often involves a team of nurses, psychiatrists, behavioral health specialists, pharmacies, and more. Ensure that patients’ records are up to date for ease in record sharing and continuity of care. 
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9. Engage in self-learning. Stay up to date on continuing education related to ASD medications, as evidence-based information is always evolving and changing. You can then present your new learnings and findings to other health care professionals and educate your patients with the latest information. 

How Can Nurses Identify if Someone has ASD?  

Unfortunately, it is not possible to look at someone with the naked eye and determine if they have ASD. While some people might have notable ASD-related symptoms, such as repetitive behaviors or emotional outbursts, the most common visible symptom for many people with ASD is no symptom. APRNs can identify and diagnose if someone has ASD by performing a mental health examination, a psychiatric evaluation, or a neuropsychological assessment. APRNs can provide quality care by completing health history, listening to patient’s concerns, and offering medication and lifestyle management (1,2,3,4,5,6).  

What Should Patients Know About Medications Used to Manage ASD Mood Disturbances and Behaviors?  

Patients should know that anyone has the possibility of developing ASD, as more research is being done to determine the exact cause for ASD, such as genetics, lifestyle, or environmental exposures. Patients should be aware that if they notice any changes in their mental health, experience any sudden emotional or behavioral changes, or feel like something is a concern, they should seek medical care. For several reasons, people are hesitant to seek medical care because of fear, shame, cost, and embarrassment. However, as more research and social movements discuss ASD more openly, there is more space and awareness for adequate ASD management (1,2,3,4,5,6,24,25).  

Nurses should also teach patients to advocate for their own health in order to avoid untreated or undetected ASD and unwanted side effects of medications. Here are important tips for patient education in the inpatient or outpatient setting.  

• Tell the health care provider of any existing medical conditions or concerns (need to identify risk factors) 

• Tell the health care provider of any existing lifestyle concerns, such as alcohol use, other drug use, sleeping habits, diet, stress levels (need to identify lifestyle factors that can influence ASD-related medication use and ASD management) 

• Tell the nurse of health care provider if you experience any pain that increasingly becomes more severe or interferes with your quality of life 

• Keep track of your health, medication use, and health concerns via an app, diary, or journal (self-monitoring for any changes) 

• Tell the health care provider right away if you are having thoughts of hurting yourself or others (possible increased risk of suicidality) 

• Take all prescribed medications as indicated and ask questions about medications and possible other treatment options, such as non-pharmacological options or surgeries 

• Tell the health care provider if you notice any changes while taking medications or on other treatments to manage autism-associated behaviors and mood changes (potential worsening or improving health situation)  

Research Findings 

There is extensive publicly available literature on medications via the National Institutes of Health and other evidence-based journals. If a patient is interested in participating in clinical trial research, they can seek more information on clinical trials from local universities and health care organizations. 

Case Studies 

Case Study 1: Susie 

Susie is an 8-year-old at the pediatrician’s office with her mom. She arrives to her annual pediatric exam for her flu shot, and Susie’s mom discusses some concerns about her behavior. Susie’s mom states that Susie is doing well in elementary school, but is having a hard time socializing with some children. She is excelling at tasks and doing well academically, but she has been fixated on some tasks recently and has been more easily irritable. Susie has no known health history, no medications given in the past year, and has met all her developmental milestones so far. Susie’s mom states that she has been doing some reading online and thinks that Susie might be autistic. Susie is in the patient room playing with some toys as you talk to her mother. 

• What are some specific questions you’d want to ask about her health? 

• What are some health history questions you’d want to highlight? 

• What lab work would you suggest to perform?  

• What would be your referrals? 

Susie’s mom agrees to take Susie to a pediatric psychiatrist for a full evaluation to determine the cause for her behaviors. Susie’s mom is concerned about possible medications and lifestyle management, as she is a single mother recently going through a divorce with Susie’s father. A few months later, Susie and her mom are back in the office after seeing the pediatric psychiatrist. Susie’s bloodwork showed no abnormalities, but Susie’s mom has some concerns. Susie’s irritability has been increasing, and her teachers are starting to notice.  

Last week, the pediatric psychiatrist suggested starting Susie on a low-dose aripiprazole, but Susie’s mom wants a second opinion. She did her own research about aripiprazole and realized it’s an antipsychotic medication. Susie’s mom says, “She’s so young, and I don’t know if I want to start her on a psych med so early. What if she becomes addicted?” Susie is reading a book in the patient room with her mom.  

• How would you discuss hesitancy to take antipsychotic medication in pediatric populations? 

• What lifestyle changes or at-home monitoring would you recommend?   

• What are some risk factors Susie has for irritability in a young child? 

• What are some patient education points to discuss about unmanaged ASD in children? 

You talk to Susie and her mom, and Susie states that she does not want to try any new medications that will “make her feel different.” Susie’s mom agrees. Susie’s mom wants to try another medication option that is possibly less severe and safer for children. Susie’s mom also wants to know if there are any non-prescription options she can try for Susie as well.  

• What are some patient education talking points you would discuss with Susie about ASD? 

• What sort of behavioral health concerns do you have about Susie?  

• What would be your pharmacological recommendations presently? 

Case Study 2: Beth 

Beth is a 24-year-old woman working as an engineer. She arrives to her consultation with you as the APRN for an initial appointment. She arrives to this appointment because her therapist suggested that she might have a neurodevelopmental or psychiatric concern that needs further attention. Beth tells you that she gets irritable easily, can be aggressive at times, has extreme sensitivity to loud noises, and has trouble distinguishing social cues. Beth tells you that she has been doing some research about mental health, and she thinks she might have symptoms of ASD. Beth reports taking sertraline 25 mg by mouth daily and is in therapy for PTSD related to sexual assault which occurred six months ago. Her vitals are within normal limits.  

• What are some specific questions you’d want to ask about her health? 

• What are some health history questions you’d want to highlight? 

• What lab work would you suggest to perform?  

• What would be your initial ASD management protocol? 

Beth states she has never taken any prescription medication long-term before, as she just started taking sertraline within the past few months from her primary care provider. She wants to know if sertraline can also help with ASD and if there are other medications she can take as well, as she wants to make sure she can still work and function. She is concerned that ASD is interfering with her ability to work and how she can monitor herself and her health at home. After your discussion and consultation with Beth, you diagnose her with ASD.  

• What lifestyle changes or at-home monitoring would you recommend?   

• What are some risk factors Beth has for ASD? 

• What are some first-line options for managing ASD with multiple medications?  

Beth sees you a few months later and is now taking sertraline 25 mg daily and aripiprazole 2mg since she wanted to start on the lowest dose of an antipsychotic medication possible. Beth states that she is feeling better, but the two medications make her very sleepy. She states that she is less irritable and reports doing better mentally with the help of her therapist as well. She reports doing better at work and sleeping better. Beth would like to continue this medication regime, but wants to know if this can affect her fertility, as she would like to have children in the future.  

• How would you discuss the influence of sertraline and aripiprazole on future fertility? 

• How would you discuss the role of ASD and genetics? 

• How would you educate Beth on serotonin syndrome? 

• What would be your next steps for Beth? 

Conclusion

Autism spectrum disorder is a serious health condition affecting millions of people of all ages and can influence someone’s ability to work, function, go to school, and engage in social interactions. There are several medication options that can be used to help manage ASD-related mood changes and behaviors, but there is no cure for ASD. Clinical presentation and symptom management for ASD can vary widely. Education and awareness of different medication options and different clinical presentations of ASD can influence the lives of many people in a healthy way.  

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