Clomipramine versus haloperidol in the treatment of autistic disorder: a double-blind, placebo-controlled, crossover study

Pharmacological management in children and adolescents with pervasive developmental disorder

OBJECTIVE

Pervasive developmental disorder (PDD) is associated with emotional and behavioural problems. There is no pharmacological cure for PDD, but some comorbidities and dysfunctional behaviours in PDD can be managed pharmacologically. The aim of the present study was to provide a better understanding of the efficacy and limitations in the currently available agents.

METHODS

Electronic literature searches were conducted from the following sources: MEDLINE, Cochrane Library, PSYARTICLES and PsycINFO. Search terms included, but were not limited to, 'autism', 'PDD', 'autism spectrum disorder' ('ASD'), and 'pharmacological management'.

RESULTS

A range of pharmacological agents are available for the management of various dysfunctional symptoms in PDD. Broadly speaking, these agents help in the management of repetitive stereotyped behaviours, anxiety, aggression/irritability/self-injurious behaviour, hyperactivity/inattention and in sleep.

CONCLUSIONS

There is a paucity of systemic, well-conducted trials on the use of pharmacological agents in the management of PDD, and more research in this area is warranted.

The role of antipsychotics in the management of behavioural symptoms in children and adolescents with autism

Autistic disorder or autism is a serious childhood-onset disorder that affects all areas of development, particularly in the areas of language, communication and reciprocal social interaction. Patients with autistic disorder typically demonstrate repetitiveness and a restricted repertoire of behaviour. Additionally, they also have a number of disruptive symptoms that may be reduced by drug treatment, including severe tantrums, hyperactivity and lability. Antipsychotic drugs are the agents that are the most critically studied as treatments for reducing symptoms. Both first- and second-generation antipsychotics have shown safety and efficacy in short- and long-term studies in autism. The most studied antipsychotic drugs include haloperidol and risperidone, although studies of other antipsychotic drugs are underway. Safety concerns associated with treatment include the risk of drug-related dyskinesias, which is greater with the first-generation drugs, and the risk of weight gain and associated metabolic problems (i.e. increases in glucose and lipids), which is greater with second-generation agents. Prescription of antipsychotic drugs requires careful monitoring because of these safety risks and the likelihood of long-term use. Drug administration should be initiated at low dosages and subsequent dosage changes should be based on tolerability and clinical response.

Lack of efficacy of citalopram in children with autism spectrum disorders and high levels of repetitive behavior: citalopram ineffective in children with autism

CONTEXT

Selective serotonin reuptake inhibitors are widely prescribed for children with autism spectrum disorders.

OBJECTIVES

To determine the efficacy and safety of citalopram hydrobromide therapy for repetitive behavior in children with autism spectrum disorders.

DESIGN

National Institutes of Health-sponsored randomized controlled trial.

SETTING

Six academic centers, including Mount Sinai School of Medicine, North Shore-Long Island Jewish Health System, University of North Carolina at Chapel Hill, University of California at Los Angeles, Yale University, and Dartmouth Medical School.

PARTICIPANTS

One hundred forty-nine volunteers 5 to 17 years old (mean [SD] age, 9.4 [3.1] years) were randomized to receive citalopram (n = 73) or placebo (n = 76). Participants had autistic spectrum disorders, Asperger disorder, or pervasive developmental disorder, not otherwise specified; had illness severity ratings of at least moderate on the Clinical Global Impressions, Severity of Illness Scale; and scored at least moderate on compulsive behaviors measured with the Children's Yale-Brown Obsessive Compulsive Scales modified for pervasive developmental disorders.

INTERVENTIONS

Twelve weeks of citalopram hydrobromide (10 mg/5 mL) or placebo. The mean (SD) maximum dosage of citalopram hydrobromide was 16.5 (6.5) mg/d by mouth (maximum, 20 mg/d).

MAIN OUTCOME MEASURES

Positive response was defined by a score of much improved or very much improved on the Clinical Global Impressions, Improvement subscale. An important secondary outcome was the score on the Children's Yale-Brown Obsessive Compulsive Scales modified for pervasive developmental disorders. Adverse events were systematically elicited using the Safety Monitoring Uniform Report Form.

RESULTS

There was no significant difference in the rate of positive response on the Clinical Global Impressions, Improvement subscale between the citalopram-treated group (32.9%) and the placebo group (34.2%) (relative risk, 0.96; 95% confidence interval, 0.61-1.51; P > .99). There was no difference in score reduction on the Children's Yale-Brown Obsessive Compulsive Scales modified for pervasive developmental disorders from baseline (mean [SD], -2.0 [3.4] points for the citalopram-treated group and -1.9 [2.5] points for the placebo group; P = .81). Citalopram use was significantly more likely to be associated with adverse events, particularly increased energy level, impulsiveness, decreased concentration, hyperactivity, stereotypy, diarrhea, insomnia, and dry skin or pruritus.

CONCLUSION

Results of this trial do not support the use of citalopram for the treatment of repetitive behavior in children and adolescents with autism spectrum disorders. Trial Registration clinicaltrials.gov Identifier: NCT00086645.

Child and adolescent psychopharmacology update

Understanding pediatric psychopharmacology often is an important part of the practice of a general psychiatrist, as a substantial number of children and adolescents are affected by a major psychiatric illness. A general psychiatrist should consider some key issues before he or she begins prescribing psychotropic medications to children and adolescents. Some agents that are effective in adults may not be effective in youths, and similarly, medications that are well tolerated in adults may be associated with accentuated or additional risks when prescribed to young people. This article is an effort to summarize the recent advances in medication therapy of the pediatric population and bring the general psychiatrist up to date on the evidence-based psychopharmacologic treatment of children and adolescents.

Racial/ethnic disparities in the identification of children with autism spectrum disorders

OBJECTIVES

We sought to examine racial and ethnic disparities in the recognition of autism spectrum disorders (ASDs).

METHODS

Within a multisite network, 2568 children aged 8 years were identified as meeting surveillance criteria for ASD through abstraction of evaluation records from multiple sources. Through logistic regression with random effects for site, we estimated the association between race/ethnicity and documented ASD, adjusting for gender, IQ, birthweight, and maternal education.

RESULTS

Fifty-eight percent of children had a documented autism spectrum disorder. In adjusted analyses, children who were Black (odds ratio [OR] = 0.79; 95% confidence interval [CI] = 0.64, 0.96), Hispanic (OR = 0.76; CI = 0.56, 0.99), or of other race/ethnicity (OR = 0.65; CI = 0.43, 0.97) were less likely than were White children to have a documented ASD. This disparity persisted for Black children, regardless of IQ, and was concentrated for children of other ethnicities when IQ was lower than 70.

CONCLUSIONS

Significant racial/ethnic disparities exist in the recognition of ASD. For some children in some racial/ethnic groups, the presence of intellectual disability may affect professionals' further assessment of developmental delay. Our findings suggest the need for continued professional education related to the heterogeneity of the presentation of ASD.

Psychopharmacologic interventions for repetitive behaviors in autism spectrum disorders

This article provides an overview of psychopharmacological treatments for repetitive behaviors in autism spectrum disorders (ASDs) in the context of current conceptualizations of this understudied core symptom domain. The available literature on the widely used selective serotonin reuptake inhibitors (SSRIs), including fluvoxamine, fluoxetine, citalopram, escitalopram, and sertraline, are reviewed. In addition to SSRIs, research on effects of other pharmacologic interventions such as divalproex sodium, risperidone, and the neuropeptide oxytocin are presented. To date, data are mixed for interventions commonly prescribed in clinical practice and suggest several areas of investigation in advancing research on the medication management of repetitive behaviors.

Pharmacological treatment options for autism spectrum disorders in children and adolescents

Autism and other pervasive developmental disorders (PDDs) are frequently associated with dysfunctional behaviors and are characterized by deficits in socialization, communication, and behavioral rigidity. Despite the absence of a pharmacological cure for PDDs, many of the dysfunctional, coinciding behaviors may be treated pharmacologically. This article reviews what is known about the efficacy and tolerability of pharmacological interventions for the treatment of children and adolescents suffering from autistic spectrum disorders.

Psychopharmacology of aggression in children and adolescents with autism: a critical review of efficacy and tolerability

BACKGROUND

Autism is characterized by a clinical triad of symptoms that affect social, language, and behavioral domains. Aggression and self-injury may be associated symptoms of autism and can result in significant harm to those affected as well as marked distress for their families. The precise nature of the relationship between aggressive or self-injurious behavior (SIB) and autism remains unclear and as a result, these symptoms are treated with a broad range of pharmacological approaches. This review seeks to systematically and critically examine the evidence for the pharmacological management of aggression and SIB in children with autism spectrum disorders.

METHOD

The entire PubMed database was searched for English language biomedical articles on clinical trials with medication in autism spectrum disorders. Studies were selected based on the following inclusion criteria: (1) randomized placebo-controlled trials; (2) a sample population that included children and adolescents; (3) at least one standardized assessment of aggression as a primary outcome measure of the study.

RESULTS

Twenty one trials with 12 medications were identified. Five medications produced significant improvement as compared to placebo, including tianeptine, methylphenidate, risperidone, clonidine, and naltrexone. Only risperidone and methylphenidate demonstrate results that have been replicated across at least two studies.

CONCLUSIONS

Although many medications have been studied under placebo-controlled conditions, few produce significant improvement. Additional placebo-controlled trials are needed to increase the number of therapeutic options available in the treatment of aggression in autism.

The status of pharmacotherapy for autism spectrum disorders

The use of pharmacologic agents as a component of treatment for children and adults with autism spectrum disorders is common and a substantial body of literature describing controlled and open-label clinical trials now exists to guide clinical practice. Empiric evidence of efficacy of risperidone, methylphenidate and some selective serotonin re-uptake inhibitors for maladaptive behaviors commonly associated with autism spectrum disorders has increased substantially in recent years. Preliminary controlled trials of valproate, atomoxetine, alpha-2 adrenergic agonists and olanzapine are promising. In addition to traditional psychotropic medications, investigators have examined the potential role of a variety of agents with glutamatergic or cholinergic mechanisms, and the results warrant further investigation. Although psychotropic medications are effective in treating some important associated behaviors, evidence of significant impact on the core features of autism spectrum disorders is very limited.

Drug therapy for attention-deficit/hyperactivity disorder-like symptoms in autistic disorder

Problems of inattention and hyperactivity affect one half of individuals with autistic disorder. Care must be taken to ensure that inattention and hyperactivity are not manifestations of other behavioural pathology seen in association with autistic disorder, as this will affect treatment decisions. The prescribing of psychotropic agents to individuals with autistic disorder is increasing but the evidence base is limited, with some exceptions, to uncontrolled studies. Substantial benefit in reducing inattention and hyperactivity is seen with atypical antipsychotics such as risperidone and quetiapine, although weight gain and sedation are common side effects. Moderate benefit is derived from methylphenidate, atomoxetine, some anticonvulsant medications, guanfacine and donepezil. Data show dexamphetamine, clonidine, clomipramine, mirtazapine, and fluoxetine are of unlikely benefit.

Disparities in diagnoses received prior to a diagnosis of autism spectrum disorder

This study estimated differences by ethnicity in the diagnoses assigned prior to the diagnosis of autism. In this sample of 406 Medicaid-eligible children, African-Americans were 2.6 times less likely than white children to receive an autism diagnosis on their first specialty care visit. Among children who did not receive an autism diagnosis on their first visit, ADHD was the most common diagnosis. African-American children were 5.1 times more likely than white children to receive a diagnosis of adjustment disorder than of ADHD, and 2.4 times more likely to receive a diagnosis of conduct disorder than of ADHD. Differences in diagnostic patterns by ethnicity suggest possible variations in parents' descriptions of symptoms, clinician interpretations and expectations, or symptom presentation.

[Prescription of psychotropic drugs in paediatry: approved indications and therapeutic perspectives]

In France, psychotropic drugs may be classified in four categories according to their official data. The first category corresponds to psychotropic drugs with an approved indication available in paediatry. Theyare old agents (e.g. haloperidol, amitriptyline, benzodiazepines...) with the exception of methylphenidate (hyperactivity). The second one corresponds to pharmacological agents approved for some indications obtained with adults but not for a1l (i.e. restricted indication: e.g. sertraline approved in paediatry only for OCD but not for depression, risperidone approved only for the treatment of disruptive behaviors in children with subaverage IQs). For the third category, the psychotropic agent is either contraindicated or unadvised under the age of 15 or 18 years, by lack of data (e.g. most of SSRI or atypical antipsychotic drugs). For the last category, official data available in brief summaries offer no information on paediatric use and consequently their administration does not appear possible. Up to now, no approved use has been delivered to injection route (IM or IV) in France, except for an IM formulation of zuclopenthixol. Prescribing psychotropic drug has to respect good practices including close psychological and somatic monitoring that associates the young patient and his relative (psycho-education program). Particular key-points should be taken into consideration (i.e. pharmacokinetic and physiological specificities, risk of false passage under the age of 6 years with capsules or tablets, presence of alcohol in some oral solution or bitter aroma...). Beside these official data, many studies have been published but must be carefully interpreted according to their level of pertinence. Meta-analysis gather all randomised controlled trials published or not, analyse their specific pertinence and thus provide clinically relevant elements. Randomised controlled trials present clinical interest but key-points in study design must be checked (e.g. number of patients, inclusion and exclusion criteria, length of the study and clinical relevance of clinical scales...). Other studies like open trials or clinical cases do not offersufficient guarantees. Some randomised controlled trials of clinical relevance have been carried out in this population with new pharmacological classes (eg SSRI, atypical antipsychotic drugs) and may lead to extended indications in children and adolescents. According to bibliographic and official data, the main criteria in the prescribing choice may take into consideration the following sis stressing a poor benefit/risk ratio. SSRI may offer better prospects but their use has not been approved in this indication, until now. In OCD, sertraline shows great interest to enhance clinical response and represents the molecule of reference. No drug has been approved for mood disorders in children or adolescent, in France, contrary to USA where lithium can be administered over the age of 12 years. In addition, antiepileptic drugs like carbamazepine or divalproate have conducted to clinical improvement in some studies. Benzodiazepines, hydroxyzine and meprobamate use should be strictly restricted in case of anxiety symptoms but are the only agents approved in this indication despise promising results obtained with SSRI. Transitory insomnia may take advantage of alimemazine prescription (approved use over the age of 36 months). Some typical neuroleptics are indicated in tics or in behaviour disorders associated to autism or related syndromes but present clinical limitations and poor tolerability. Promising clinical trials (randomised or not) have been conducted with new atypical antipsychotic drugs like risperidone. In conclusion, present data available for paediatric use of psychotropic agents emphasizes that safety and effectiveness are not always well established in particular for the treatment of chronic disorders (long term tolerability assessment). Moreover, studies should be carried out to specify factors promoting adherence and quality of life for this young population in order to optimise clinical benefit of drug prescription.

The use of selective serotonin reuptake inhibitors in autism and related disorders

This paper reviews the published literature on the use of selective serotonin reuptake inhibitors (SSRIs) for the treatment of symptoms associated with autistic disorder and other pervasive developmental disorders (PDDs) in both children and adults. To date, placebocontrolled studies of SSRIs have involved only fluvoxamine (in children and adults) and fluoxetine (in children). Open-label and retrospective studies of all other SSRIs in PDDs have also been published that suggest effectiveness. Despite these positive reports, there continues to be questions about the tolerability and appropriate dosing of SSRIs in children with PDDs. Because of the limited number of placebo-controlled studies, definitive conclusions about the role SSRIs should play in the clinical treatment of children with PDDs cannot be drawn. Larger, placebo-controlled studies of SSRIs are needed to guide clinical treatment.

Advances in drug treatments for children and adolescents with autism and other pervasive developmental disorders

Autism is a disorder characterised by abnormalities in language and social development, and repetitive behaviours. Antipsychotics, including haloperidol and risperidone, are the most widely studied drugs for reducing symptoms in children and adolescents with autism. When administered at relatively low dosages, antipsychotics have been shown to reduce repetitive behaviours (stereotypies) and social withdrawal, as well as a number of related symptoms, such as hyperactivity, aggression, self-abusive behaviour, temper tantrums, lability of mood and irritability. Adverse effects of antipsychotics include sedation, dizziness, increased appetite, weight gain, changes in the electrocardiogram parameters, drooling, hyperprolactinemia and a risk of drug-related dyskinesias. Other agents have been less well studied for the treatment of autism, but there are suggestive data regarding their safety and efficacy. Of these agents, a number have been investigated, based on theories about the aetiology of autism, including SSRIs and naltrexone, although the efficacy of these agents has been limited. Stimulant drugs have been shown to reduce hyperactivity and improve focus, but they may cause behavioural worsening, weight loss and stereotypies de novo. Secretin is a treatment that has received much media attention after reports of efficacy from small open studies, but all controlled studies have failed to show any benefit. In autism, alternative treatments have also been used, but none have shown benefit in well-designed studies.

AEDs and psychotropic drugs in children with autism and epilepsy

The efficacy of antiepileptic drugs (AEDs) and psychotropic medications in children with autism is limited to the treatment of seizures or to specific behaviors such as irritability, impulsivity, hyperactivity, repetitive behaviors, or aggression. The reliability and value of the available data--to determine the efficacy of these medications in autism--are limited by lack of controlled clinical trials, the small number of subjects, the heterogeneity of the population studied, and the brief duration of most drug trials. Indeed, few controlled clinical trials using AEDs in autism, with or without seizures, have been conducted. Because some AEDs also have a positive effect on mood, the benefits that children with autism sometimes obtain from these medications may not be due to the treatment of the abnormal electrical activity or the seizures per se but to an effect on common neuronal systems responsible for both behavior and epilepsy. The relationship between epilepsy and autism, and specifically the effects that abnormal electrical activity may have on the developing brain, may provide some valuable insights into the type of studies that are needed to help us understand the pathophysiology of autism.

A review of the growing evidence base for pediatric psychopharmacology

This article provides an update of pediatric psychopharmacologic treatment evidence and focuses on six classes of medications in pediatric populations: psychostimulants, mood stabilizers, SSRIs, tricyclic antidepressants, antipsychotic agents, and other agents. The evidence is organized by disorder so that it is most useful to practicing clinicians. We begin each section with a brief introduction and summary of the findings published before January 1998. Priority is given to clinical trials that use random assignment and use of a comparison group (ie, placebo-control, head-to-head comparison, or cross-over design). Serious concerns remain about the efficacy and safety of many of these agents for use in children and adolescents. While a great progress is being made, there is clearly much work left to be done.

Management of hyperactivity and other acting-out problems in patients with autism spectrum disorder

Hyperactivity/impulsivity, aggression, self injury, and irritability are disruptive behaviors that frequently accompany autism spectrum disorders (ASD). The psychostimulants and atypical antipsychotics have been used with some success to manage hyperactivity, but neither drug group is fully satisfactory and clinical response to the stimulants varies. For other disruptive symptoms (irritability, aggression, self injury), both older antipsychotics and newer atypical antipsychotics have been shown to have helpful effects. Because of potential side effects, atypical antipsychotics should ordinarily be preferred over older agents. A small group of studies suggests that selective serotonin reuptake inhibitors may be helpful in managing symptoms related to aggression, self injury, and the like. A small and largely imperfect literature suggests that beta blockers, mood stabilizers, and alpha-2 agonists may also have some role for treating such symptoms. More research is needed on the management of all of these target symptoms, both for new agents (e.g., atomoxetine) and for established psychoactive medicines.

Molecular analysis of nicotinic receptor expression in autism

Autism is a developmental disorder of unknown aetiopathology and lacking any specific pharmacological therapeutic intervention. Neurotransmitters such as serotonin, gamma-aminobutyric acid (GABA) and acetylcholine have been implicated. Abnormalities in nicotinic acetylcholine receptors have been identified including cortical loss of binding to the alpha4/beta2 subtype and increase in cerebellar alpha7 binding. Receptor expression (mRNA) has not so far been systematically examined. This study aims to further explore the role of nicotinic receptors in autism by analysing nicotinic receptor subunit mRNA in conjunction with protein levels and receptor binding in different brain areas. Quantitative RT-PCR for alpha4, alpha7 and beta2 subunit mRNA expression levels; alpha3, alpha4, alpha7 and beta2 subunit protein expression immunochemistry and specific radioligand receptor binding were performed in adult autism and control brain samples from cerebral cortex and cerebellum. Alpha4 and beta2 protein expression and receptor binding density as well as alpha4 mRNA levels were lower in parietal cortex in autism, while alpha7 did not change for any of these parameters. In cerebellum, alpha4 mRNA expression was increased, whereas subunit protein and receptor levels were decreased. Alpha7 receptor binding in cerebellum was increased alongside non-significant elevations in mRNA and protein expression levels. No significant changes were found for beta2 in cerebellum. The data obtained, using complementary measures of receptor expression, indicate that reduced gene expression of the alpha4beta2 nicotinic receptor in the cerebral cortex is a major feature of the neurochemical pathology of autism, whilst post-transcriptional abnormalities of both this and the alpha7 subtype are apparent in the cerebellum. The findings point to dendritic and/or synaptic nicotinic receptor abnormalities that may relate to disruptions in cerebral circuitry development.

Disordered gambling in adolescents : epidemiology, diagnosis, and treatment

Rapid expansion of legalized gambling has been associated with increased rates of gambling disorders among adults and adolescents worldwide. Epidemiologic studies suggest that, in North America, up to 6% of adults and 20% of adolescents have a gambling problem. Despite increasing prevalence rates of gambling disorders, little research is available on how to treat such disorders in adolescents. Much of what is known about how to treat adolescent problem and pathological gambling comes from research on psychosocial and psychopharmacologic treatments for adult pathological gambling. Risk factors for adolescent gambling disorders include male gender, alcohol and drug use, deviant peers, family history of gambling, and impulsive behavior. While several risk factors characterize disordered gambling among adolescents, the extent to which these characteristics are related remains to be determined. In terms of screening for adolescent problem and pathological gambling, several instruments designed to reflect the Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria for pathological gambling are available. Psychosocial approaches used to treat adult pathological gambling include Gamblers Anonymous, cognitive-behavioral therapy (CBT), and motivational enhancement therapy (MET). Among adolescents, CBT as well as an eclectic therapy have been helpful in reducing problematic gambling behavior. In terms of pharmacotherapy, three classes of psychotropic drugs have been used to treat adult pathological gambling - serotonin reuptake inhibitors, opioid antagonists, and mood stabilizers. While some of these pharmacotherapies have been efficacious in treating adult pathological gambling, additional double-blind, placebo-controlled studies are needed to determine the long-term effectiveness of these treatments. No known study has evaluated the use of psychopharmacologic agents in treating adolescent pathological gambling. Possible reasons for the lack of research on treatment for adolescent gambling disorders include lack of motivation to pursue treatment, feelings of self-control, and negative perception of therapy. Referrals from parents, teachers, and peers of adolescents, as well as community outreach programs, may be useful in successfully deriving a treatment population. Clinicians are advised to be sensitive to behavioral risk factors and to screen for disordered gambling in high risk adolescents. A combination of CBT and MET, as well as medication for any comorbid psychiatric condition, is recommended.

Antipsychotic medication for challenging behaviour in people with learning disability

BACKGROUND

The term 'challenging behaviour', in the absence of psychiatric disorder, encompasses a wide range of behaviours that may be harmful to people or property, may be difficult to manage and may limit access to community facilities. Antipsychotic medications have been used to modify such behaviours in people with learning disability, but there is little evidence to suggest that the benefits outweigh the risks.

OBJECTIVES

To determine the effectiveness of antipsychotic medication for people with learning disability and challenging behaviour without additional mental illness.

SEARCH STRATEGY

Biological Abstracts, the Cochrane Library, EMBASE, MEDLINE, PsycINFO and BIOSIS were searched. Further references were sought from published trials and pharmaceutical companies. Trials were reliably identified and data extracted.

SELECTION CRITERIA

All randomised controlled trials of antipsychotic medication versus placebo.

DATA COLLECTION AND ANALYSIS

Reviewers independently evaluated and analysed data on an intention to treat basis. Data were evaluated at 4, 8 and 12 weeks as longer follow-up data were not available. Reviewers assumed that those subjects lost to follow-up had a bad outcome.

MAIN RESULTS

Only nine randomised controlled trials could be included in the analyses. These provided no evidence of whether antipsychotic medication helps or harms adults with learning disability and challenging behaviour.

REVIEWERS' CONCLUSIONS

There are limited data on this important issue and more research is urgently needed.

Strategies for pharmacologic treatment of high functioning autism and Asperger syndrome

The treatment of complex, polymorphous disorders like HFA/AS always brings a particular challenge to pharmacotherapy. Additionally, the specific characteristics presented by HFA/AS introduce unique complications to patient care and place unusual demands on a clinician's skill and experience. To provide safe and effective treatment, the clinician must understand the core features of the disorder and the manifestations of the condition in his or her patient. Furthermore, a thorough understanding of the family, school, and community resources and limitations is necessary. Once an assessment has been made, focusing on target symptoms provides a crucial framework for care. Knowing manifestations of symptoms and characterizing their distribution and behavior in that patient is most important. For patients with HFA/AS it is particularly essential to coordinate behavioral and pharmacologic objectives. The target symptoms should be tracked carefully and placed into a priority system that is based on the risks and disability they create for the patient. The skill of pharmacotherapy also means setting out realistic expectations, keeping track of the larger systems of care at school and home, and collaboration with parents and care providers. There is an expanding range and pace of biologic and intervention research into HFA/AS. The genetic work has produced exciting leads that are likely to be helpful to future generations [82-84], but the task of clinicians is to tend to today's patients. As we discover more about the complex neural circuitry subserving repetitive behaviors, reward systems, and social cognition, there are good reasons to believe our treatments will become more sophisticated and specific. Psychopharmacology is also moving to design medications that target more specific populations of receptor and brain functions. This is likely to produce medicines that have fewer side effects, are more effective, and are more symptom-specific. Pharmacotherapy is not the ultimate treatment for HFA/AS but it has a definite place. Medication can be a critical element in a comprehensive treatment plan. There is a wider range of medications with more specific biologic effects than ever before. For patients with HFA/AS these newer agents are safer and less disruptive. When paired with clinicians who are becoming more skilled at recognizing and managing symptoms, patients have a greater opportunity to reach their potential and lead pleasurable lives.

The pharmacological treatment of autistic spectrum disorders

What role do medications play in the overall treatment of autistic spectrum disorders? In this review, the decision-making process involving identifying symptoms, initiating a pharmacological intervention, and monitoring that process is discussed. A review of the literature with an emphasis on controlled trials in autistic spectrum disorders is also undertaken.