A recent guest on Uniquely Human: The Podcast, Dr. Joshua Feder discussed appropriate use of medications, "...seeing them only as part of more comprehensive plans for supporting autistic & neurodivergent individuals and not as isolated treatments." Here are the highlights and helpful takeaways from episode 66 that we are excited to share with you!

                    IMPORTANT NOTE: The primary purpose of Uniquely Human: The Podcast is to educate and inform. The views expressed during all episodes are solely those of the individuals involved and do not constitute educational or medical advice. Listeners should consult with professionals familiar with each individual or family for specific guidance. Uniquely Human: The Podcast is produced by Elevated Studio. Music is graciously provided by Matt Savage of Savage Records. 

Take it Away…

Treatment philosophy:

A question that comes up frequently with any of these medications or any kind of biomedical treatment is, “Are you treating autism, or are you helping a person to better regulate so that some of the symptoms we associate with autism are lessened?” This is exactly the point! The goal is to help people live happier, more functional lives. It's not to “treat autism.”

Dr. Feder stresses, “I’m not thinking about autism as a disorder. I'm thinking about neurodiversity and the necessity of neurodiversity— to have all the different people who do all the different things in our world.”

• When you can include a child, teen, or young adult in their own treatment plan, including medicines and other options, they have more buy-in and have better outcomes.
• When it comes to interventions, the primary focus should be on helping people become more regulated. Yet the vast majority go straight to the most aggressive option: the two FDA-approved antipsychotic class medications, Risperidone and Aripiprazole.
• Dr. Feder writes books on medication to encourage responsible use, which often means trying non-medication approaches first when possible as well as also thinking about when to reduce or discontinue medications when possible. The second edition of his highly popular Child Medication Fact Book for Psychiatric Practice is coming out in early 2023 and includes treatment algorithms for various psychiatric situations.

Start with non-medication approaches:

Dr. Feder believes that medications are meant to help a good plan work better, not as a solution to replace a bad plan. The H.A.L.T.(Hungry-Angry-Lonely-Tired) mnemonic is a good way to help parents remember to think beyond their child’s behavior and ask, “What’s going on behind my child’s behavior?” Once we determine this, then parents can begin to address it in a holistic manner.

To that, Dr. Feder has developed 14 steps that start with naturalistic, sensory developmental interventions. (This is where his treatment algorithm comes in, which will be described in his upcoming 2^nd edition of Child Medication Fact Book for Psychiatric Practice.)

It’s not that medications should never be used. It’s about minimizing the use of antipsychotic medications and trying other options first when possible (and watching for toxic side effects when you do need to use them).

Treat Co-occurring conditions before going to antipsychotics:

It is usually best to treat any co-occurring conditions such as depression, anxiety, ADHD, and insomnia before targeting irritability related to autism. Especially since those other conditions are likely making the irritability worse, those conditions are treatable, and the treatments are typically less toxic than antipsychotic medications.

Dr. Feder emphasizes that when addressing co-occurring conditions, it’s important to use naturalistic, parent-mediated, developmental interventions that support connection, co-regulation, and connection.

If you still have difficulty with irritability, combine naturalistic approaches with other therapies (e.g., speech-language therapy and occupational therapy). This transdisciplinary, integrative approach focuses not only on the sensory-motor needs of the child but also looks at things like comprehension and hunger and how they may be contributing to the child’s dysregulation.

He also discussed the following:

• A common co-occurring condition with autism is insomnia. Telling people to practice good sleep hygiene is good advice, but most families already know what you should and shouldn’t do when it comes to sleep habits; it’s a matter of enacting it.  
• ‍Cognitive Behavioral Therapy for Insomnia (CBTI) is a much more individualized approach to help families identify and shift thoughts, feelings, and behaviors that drive insomnia.
• Most autistic individuals also have symptoms of ADHD and stimulant-type medications are typically the first line of therapy. They work just as well as they do for non-autistic individuals and with no greater frequency of side effects. Use enough to help a child learn better but remember that if given too high of a dose, learning may not improve even though the child may seem a lot calmer.

It's important to note that the main concern with stimulant medications, especially in adults, is the impact on blood pressure and cardiac-related issues.

‍Responsible use of antipsychotic medications in autism:

There is an important role for antipsychotic class medications as part of a comprehensive treatment plan because some people truly benefit from them. Without these medications, some individuals become violent and a danger to themselves or others. For example:

• In schizophrenia, these medications may be critical for daily function. But even in cases where it is necessary, there are plenty of people who could use less.
• Risperidone and aripiprazole are the only two medications approved by the FDA for the treatment of irritability in autism. There are many side effects of these medications including neurotoxicity and metabolic problems.
• While aripiprazole is promoted as having fewer metabolic side effects, many children have significant weight gain on this medication. If you use aripiprazole or risperidone, consider pairing them with metformin to reduce the likelihood of weight gain.
• Some similar medications such as lurasidone or ziprasidone have better metabolic outcomes, but they all have the potential for neurotoxicity.
• Although these medications may be incredibly helpful in very dire circumstances, we need to keep asking ‘how long should this person stay on them?‘

Meaningful outcomes:

How we measure the effectiveness of the medicine is the bottom line. Many people associate a meaningful outcome with a child who behaves according to the norms of a dominant culture. Dr. Feder is more interested in functional outcomes such as whether a person can connect with others to get things done and to have fun.

These are the things that contribute to a meaningful outcome: The ability to engage in a meaningful flow of interaction through which growing, learning, communicating, and problem-solving take place, as well as the ability to self-regulate and build trusting relationships with people. 

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About Dr. Joshua Feder

Dr. Joshua Feder is a child and family psychiatrist in Solana Beach, California, and Editor-in-Chief at the Carlat Child Psychiatry Report. He serves as medical director at Positive Development, providing affordable developmental relationship-based support for autistic and neurodivergent children and their families. Dr. Feder co-wrote the first American Academy of Child and Adolescent Psychiatry Practice Parameter on the assessment and treatment of autism spectrum disorder and engages in research at a number of universities, including the University of California at San Diego, San Diego State, and University and Fielding Graduate University. Dr. Feder helps run the Autism Is inclusion program, the only active anti-bullying program certified by the state of California Department of Education. Dr. Feder has produced over 150 peer reviewed articles and he is the author of Prescribing Psychotropics and The Child Medication Fact Book for Psychiatric Practice.

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