Autism and Repetitive and Restricted Behaviors 4/22/2021

In this discussion of Autism Spectrum Disorder (ASD), we will review the latest evidence in treatment for repetitive behaviors.  Individuals and families impacted by ASD can present with a range of challenges and needs, it is important for providers to be familiar with a range of interventions and supports.  Most particularly, youth with ASD can exhibit various forms of agitation, aggression, self-harm, pacing, handing flapping and other repetitive movements.

Not all of these behaviors cause distress or create challenges, and some in fact may be soothing for the child, so it is important to listen to youth and their care givers: what are the needs that they see?  If parents or youth believe that repetitive behaviors are causing problems or dysfunction here are some considerations.

Medications may have a role, but can also have side effects.  A recent meta-analysis of 64 randomized control trials look at the role of medication for the treatment of “stereotyped movements or speech, an insistence on sameness, extremely narrow interests, and/or atypical sensory responses.” (Zhou et al., 2021).   This study found that the effect size of anti-psychotic medications (aripiprazole, risperidone and others) was “small”.  There was preliminary evidence for the use of a number of other medications (with variable presumed mechanisms of action) including: bumetanide, divalproex, folinic acid, and guanfacine.  Antidepressants “did not have evidence for benefit”.  Other treatments lacking evidence included oxytocin, omega-3 fatty acids, methylphenidate, naltrexone, atomoxetine, secretin, NAC, and vitamin D.

Behavioral interventions are most successful when they can enhance communication, identify underling causes of stress or anxiety and target these (Boyd et al., 2012).  Recent literature has found that Applied Behavioral Analysis may be most effective with socialization, communication and expressive language, but less so with repetitive behaviors (Yu et al., 2020).  Sensory sensitivities may lead to repetitive behaviors, so youth should be considered for occupational therapy, which can help with practical solutions to diminish or acclimate to sensory stimuli, subsequently decreasing repetitive behaviors.

In review:

  • Target repetitive behaviors if family and youth identify this as a problem, or there is objective evidence that said behaviors are causing dysfunction
  • Recent data supports use of antipsychotics, alpha agonists, divalproex, folinic acid, though side effects should always be carefully monitored and these risks need to be weighed against the degree of benefit achieved with their use
  • ABA, OT, Therapy for anxiety and depression should be considered when appropriate. While these will not directly target repetitive behaviors, they may assist with overall levels of anxiety and distress and thus may help decrease repetitive and restrictive behaviors over time.

References:

http://www.smartcarebhcs.org/autism-and-aggression-10-22-2020/

Boyd BA, McDonough SG, Bodfish JW. Evidence-based behavioral interventions for repetitive behaviors in autism. J Autism Dev Disord. 2012 Jun;42(6):1236-48. doi: 10.1007/s10803-011-1284-z. PMID: 21584849; PMCID: PMC3709868.

Yu Q, Li E, Li L, Liang W. Efficacy of Interventions Based on Applied Behavior Analysis for Autism Spectrum Disorder: A Meta-Analysis. Psychiatry Investig. 2020 May;17(5):432-443. doi: 10.30773/pi.2019.0229. Epub 2020 May 8. PMID: 32375461; PMCID: PMC7265021.

Zhou MS, Nasir M, Farhat LC, Kook M, Artukoglu BB, Bloch MH. Meta-analysis: Pharmacologic Treatment of Restricted and Repetitive Behaviors in Autism Spectrum Disorders. J Am Acad Child Adolesc Psychiatry. 2021 Jan;60(1):35-45. doi: 10.1016/j.jaac.2020.03.007. Epub 2020 May 6. PMID: 32387445.

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