PFA Tips: Medication Management and ASD (Part 1)

In my article, “Explaining the Autistic Brain”, I discussed generally what medication management means in the setting of the autistic brain. The key question was: how do we manage the underlying cognitive and emotional data dysregulation of ASD and the overload that it brings to daily experience?

Autism does not need to be fixed
The brain of the autistic individual is a complex and fascinating – and yes, at times, a challenging – place. Trained as an adult psychiatrist, I have only over the past several years begun to appreciate the diverse experiences of these patients and to adapt my prescribing practices to better fit how they see the world.

Let’s begin with an important premise: ASD does not need to be fixed. Autistics are not broken. To some degree, the challenges that they struggle with most arise from their interactions with a neurotypical world that fails to understand or adapt to their unique ways of perceiving and reacting to life.

That being said – and to be very realistic and practical about how we might help from a medication management perspective – there are specific kinds of dysregulation – cognitive, emotional, sensory – that can plague the person as they try to meet the demands in the social, family, educational and employment parts of their lives.

The medication management relationship
The medication management relationship is a critical part of the autistic’s mental health care. Summarizing briefly:
1. The med manager should have extensive experience working with the neurodivergent population and be familiar with the cognitive, emotional and sensory nuances that mark these wonderful brains.
2. The med manager should communicate in concrete terms and with precision about detail. Use of visual aids is recommended for patients who are visual processors.
3. Medication must be viewed as a necessary but not sufficient part of a wrap-around treatment plan. The med manager should have at their disposal a network of health care professionals able to address the person’s complex needs.
4. Work with the autistic patient around rigid perceptions that might block the understanding of treatment alternatives.
5. When gathering data about treatment and side effects, the med manager must be sensitive to challenges with interoception. If a patient responds “I don’t know” to a question about the impact of a medication, they are not being stubborn. They might truly not know. Sensitive, nuanced questioning rooted in concrete detail, perhaps with assistance from a collateral source, might be the only way to get these questions answered.
6. Med managers should lean towards specific, close-ended questions. Open-ended questions require subtle social and emotional interpretations that don’t come easily to the autistic brain. Learn to speak the language of your patient’s brain.

Treating Emotional Dysregulation/Anxiety
Let’s start with some examples:
Suzanne is an autist who struggles with packing her suitcase for a long trip. The idea that she has to organize a set of items for a 1 week vacation completely overwhelms her, and she copes by avoiding the task, smoking weed to manage her anxiety and fighting with her parents when they offer to help.

Craig can get through about 4 hours of high school before he becomes exhausted. “People feel too close, I don’t like interacting. Staying focused on school tasks is really hard.” He frequently feels panicked, desperate and hopeless. When he gets home, he needs a 2 hour nap before he can even think about starting his homework. Getting to school the next day is always a problem and he has missed a lot of class because of this.

Craig and Suzanne demonstrate how the autist struggles to manage the huge amounts of data that rush through their brain every second of every day. As a result of the effort required to simply stay on course while trying to function, several key psychological symptoms develop: fatigue with the need for long and frequent breaks; anxiety; depression; and even symptoms that look “psychotic” but are complex sensory processing issues with no other psychotic symptoms present.

Two key medication management principles come into play here: heal the brain and calm the brain. The class of psychiatric drugs that we call antidepressants – such as Prozac, Cymbalta, Wellbutrin – actually serve to heal the brain by reducing inflammatory processes (naturally occurring processes that can “run too hot” and decrease the brain’s ability to function optimally); and by growing new nerve cells (neurogenesis) to build a stronger physical organ. When the brain is strong, it regulates mood, anxiety and rumination (sticky thoughts or loop thinking) much better.

But antidepressants work slowly over several weeks, and there are times when the person who feels overloaded and stressed out needs a short-term rescue remedy in order to calm the brain and get through the day. These antianxiety medications can come from several classes – atypical antipsychotics (e.g., Abilify), benzodiazepines (e.g., Ativan) or mood stabilizers (e.g., Neurontin). All of these are strong medications with the potential to not only help the individual improve their quality of life and manage their symptoms, but also with the risk of a variety of side effects that need to be carefully managed.

A good medication manager will carefully review the benefits and risks of each of these options, help you make the best decision for you and work with you to monitor both the pros and cons of taking the medication.

Treating Executive Function/ADHD
Alyssa has the classic symptoms of inattentive ADHD – struggles to focus in class, to get started on homework, to plan for the future and to keep her time and things organized. She loves to learn, but school has been a constant frustration for her. She feels that she has to work twice as hard to get the grades that her peers find it so easy to achieve.

James is a bright individual diagnosed with both autism and ADHD who has had a lifetime challenge with managing his stuttering. “My thoughts rush through my head and I can’t keep up with them, so I end up spilling over my words.”

Most people with autism struggle with dysfunction in the prefrontal cortex of the brain – the seat of the executive functions. When this part of the brain is challenged, we label the impairments as ADHD. Symptoms of impaired initiation, motivation, focus, planning, follow through, impulse control, emotional regulation and foresight contribute to significant problems in social, academic and employment settings and lead frequently to setbacks and failures that can contribute to an overall sense of hopelessness, anxiety and learned helplessness.

It is therefore critical that these issues be adequately diagnosed and treated if the autist is to have the opportunity to maximize their potential for developing robust cognitive and emotional skills for life.

Over many years of treating patients with ADHD/executive dysfunction, I have found stimulant medications such as the methylphenidates (e.g., Ritalin) or amphetamines (e.g., Adderall) to be overall the safest, best tolerated and most effective choices for an initial medication trial. Problems do exist for some patients with these medications and the use of non-stimulant drugs can also provide effective treatment for ADHD.

James provides a good example of how stimulant medications can be effective tools for improving functioning for the autist. James’ “freight train of thoughts” is a common occurrence for people with executive dysfunction. His stuttering – stumbling over his words – was a reflection of how he “stumbled over his thoughts.” Although not a complete solution, the stimulant medication improved the functioning of James’ prefrontal cortex, allowing it to slow the flow of ideas and helping him slow and better organize his speech.

An important takeaway here is that in order to manage these complex symptoms, medication management may be a necessary but, by itself, not a sufficient tool. In this case, support from a speech pathologist to provide specific exercises was required for the best resolution of his speech challenges.

And so it is with much of the treatment of cognitive and emotional symptoms that go hand in hand with autism: complex brain and psychological conditions require complex and complementary treatment combinations to achieve optimal resolution of symptoms and maximum improvement in functioning.

It is important for the patient and medication manager to define clearly beforehand the specific, concrete target symptoms to be treated with these medications. This might include such things as focus better in class, improve my grades, not have as much “ADHD noise” in my head, follow through on projects, be generally more productive at work and so on.

Many neurodivergent individuals have challenges with interoception – the ability to scan one’s inner environment, detect cognitive and emotional data, name those phenomena and report out. So the patient and medication manager need to be particularly careful to identify the “red flag” symptoms to be treated with the medication. Coaching the patient to attend to these cues helps build clinical success and satisfaction with the medication process and improves adherence to medication regimens.

Additional Resources

PFA Tips: Medication Management and ASD (Part 2)

PFA Tips: Explaining the Autistic Brain

Healthcare PFA Tips

Pathfinders for Autism Online Provider Database

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