Handling aggression in autistic children

 The mother of my patient looked exhausted as she entered my clinic. Her autistic child had been shouting for the past half an hour while waiting. She had run out into the road several times and been brought in willy nilly, hitting her mother repeatedly.

How does one handle this constant aggression, high decibel crying and defiant behaviour. There are no simple answers.

There are 2 basic strategies. Non pharmacological and pharmacological.https://dx.doi.org/10.2147%2FNDT.S84585

There are many fancy names for the non-drug methods. Functional behavioural assessment, reinforcement strategies, functional communication training.

What it boils down to is - deep observation, analysis and intervention.

Practically speaking these are the steps you must run through.

1. Decide the most disturbing/ destructive behaviour you want to target.

2. Ask the child's parent to record the number of times he/she demonstrates the particular behaviour.

3. Each time record additional information- when, where, with whom the behaviour occurs.

4. Write down what happens just before ( trigger) and just after (consequence) the behaviour.

5. Analyse why this behaviour occurs. The most common causes are - escape ( need to get away from some activity/place/person) , avoidance (of a situation/activity),  attention seeking, other gain, self stimulation. This is called the function of the behaviour.

6. Deciding a program. 

For eg if the child starts hitting her mother whenever she is asked to do some writing- the plan would be to break up the disagreeable activity say writing into tiny portions. After just a little bit of writing she must be allowed to stop (escape) and given her reward ( say- juice or play with her favourite toy). Slowly the duration of the disagreeable take may be increased and each time rewarded.

What you are basically trying to do is to replace the 'function' of the challenging behaviour with your intervention and if required teach a more appropriate behaviour.

What are the drugs which have helped?

Risperidone is the go-to drug for most pediatric neurologists dealing with autism. You can start with 0.25 mg/ day and slowly titrate upto 3 mg. Sedation, weight gain and hyperprolactinemia are the side effects you will be watching for.

Aripiprazole works a little differently from risperidone which is a pure D2 receptor antagonist. Interestingly Aripiprazole modulates the degree of blockage depending on the initial level of dopamine in the brain. When dopamine levels are high it blocks the D2 receptor and when it is low it works as an agnist at the D2 receptor. It probably has lower extrapyramidal symptoms because of its antagonism of the 5HT2A receptor. It is also less sedative and is considered to have lesser weight gain than resperidone.

However a head to head trial with risperidone  (BAART trial) has shown risperidone was more effective than Aripiprazole though weight gain  was lesser in the latter. https://doi.org/10.1002/phar.2271

Valproate has been used to treat the behavioural swings in autism but there is no robust scientific data to support its use.

3 small trials using 600-900 mg/day of N acetyl cysteine have shown a significant reduction of challenging behaviours in autism and need more evaluation.