BHIPP Bulletin

Volume 11, Issue 1

July 2025

This month's BHIPP Bulletin is a contribution from

Rheanna Platt, MD, Associate Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine and BHIPP Consultant.

As implied in the name, Autism Spectrum Disorders (ASD) are heterogeneous in their presentation; though, by definition include components of stereotyped behaviors or movements, restricted range of interests, difficulties with social connectedness, and sensory sensitivities. In addition to the core features of ASD, there are often co-occurring symptoms and/or disorders, including hyperactivity, impulsivity, irritability, anxiety, sleep difficulties, or mood symptoms. Individuals with ASD are at increased risk for a range of comorbid disorders, including ADHD, anxiety, and mood disorders.   

When ASD symptoms or associated symptoms/disorders are impairing, psychopharmacologic treatment may be one part of the overall treatment approach. Importantly, prior to considering psychopharmacologic treatment, behavioral approaches should be considered, as behavioral treatments (e.g., applied behavior analysis) can be very effective. However, when behaviors or functional impairments are severe and/or not responsive to behavioral interventions (or behavioral interventions are not available), medication can be considered. In this newsletter, we will review psychopharmacologic treatments for patients with ASD. Many of the recommendations/information below are based on recent reviews of psychopharmacology management in ASD.^1-4   

Common indications for medication include severe aggressive outbursts (toward self or others), impulsivity, hyperactivity, repetitive behavior, anxiety, and irritability. In general, the same medications are used for similar symptoms (e.g., stimulants to treat hyperactivity) in those with ASD as those without. However, those with ASD may be more sensitive to medication side effects and in some cases, features of ASD may worsen with pharmacologic treatment of some symptoms. For example, in some cases, treatment of ADHD symptoms with stimulants can increase repetitive behaviors in ASD, or patients can have paradoxical/unexpected reactions to medications. As such, it is recommended to start at lower doses of medications when they are used.

Medications for Irritability and Aggression

As with neurotypical patients, behavioral approaches are generally recommended prior to psychopharmacologic approaches. As noted above, understanding the precipitant of irritability or aggressive outbursts is important in guiding medication treatment. For example, if an aggressive outburst occurs in the context of anxiety (e.g., aggression in the context of being confronted with a feared situation) or irritability occurs in the context of depression, a low dose SSRI might be considered. Whereas if aggression occurs in the context of hyperactivity/impulsivity, a stimulant or alpha agonist might be considered. While aripiprazole (Abilify) and risperidone (Risperdal) have FDA approval for irritability and aggression in patients with ASD, assessing whether symptoms might be treated with other classes of medication (e.g., SSRI, stimulant, alpha agonist) is recommended given the side effect burden of antipsychotic medications. 

Medications for Hyperactivity/Impulsivity

ADHD frequently co-occurs with ASD, and sensory-seeking behavior may occur in both disorders. For hyperactivity/impulsivity symptoms that are impairing, psychopharmacologic treatment is similar in those with ASD as without, with primary options including stimulants, alpha agonists, and atomoxetine. Patients should be monitored for adverse effects, including irritability, social withdrawal, and an increase in restricted and repetitive behaviors. Guanfacine has also been studied in children with ASD, with doses up to 3mg/day being relatively well-tolerated.¹

Medications for Restricted and Repetitive Behaviors

A recent meta-analysis of studies examining medication treatment of restricted and repetitive behaviors (e.g., stereotyped movements or speech, restricted interests, rigidity/ritualistic behaviors) noted that studies to date have shown, at best, relatively small effects of medications on these behaviors, with antipsychotic medications demonstrating the best evidence.⁴ As noted above, given their side effect profile, antipsychotic medications should only be considered with significant impairment. Of note, though rigidity/ritualistic behaviors can also be a feature of OCD, SSRIs do not show evidence of benefit for restricted and repetitive behaviors associated with ASD.⁴ 

Medications for Other Symptoms

Dysregulated sleep is common in ASD. As with ADHD, when psychopharmacologic intervention is required (e.g., behavioral interventions have not been effective), melatonin has shown some benefit in patients with ASD. There is currently limited evidence for use of other medications in the treatment of sleep difficulties for those with ASD. 

Anxiety and depressive disorders are more prevalent in youth with ASD relative to the general population, though can be challenging to diagnose if communication abilities are significantly impaired. There is some evidence for the use of SSRIs when medication is indicated, though as with other medications, the effects of these medications in children with ASD may be less than in neurotypical children. 

As always, if you have questions about the behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at 

855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.

We will keep you informed about all our services and training events through our website (www.mdbhipp.org) and monthly e-newsletters. Additionally, BHIPP is on LinkedIn and Facebook. We invite you to follow us there to stay up-to-date on upcoming training events, pediatric mental health research, and resources for providers, families and children.