Irritability, Agitation and Agression in Persons with ASD: The ATN Pathway for Evaluation and Individualized Treatment Planning

Background: Irritability, agitation, and aggression (IAA) are the most common of the concerning problem behaviors that may develop in persons with autism spectrum disorder (ASD). Given the serious adverse impact of IAA on learning, social development and community participation, the human cost of delayed or ineffective treatment for IAA in ASD is high. The Autism Speaks Autism Treatment Network (AS-ATN) Psychopharmacology Committee, composed of specialists in the treatment of ASD and co-occurring conditions, was charged with the task of developing a practice pathway for planning the treatment of  IAA behavior in a person with ASD.

Objectives: The goal is to maximize the efficiency and effectiveness of treatment for IAAwhile minimizing risk for the individual patient.

Methods: Systematic literature review, monthly to biweekly committee teleconferences for discussion. The committee noted that until recently, treatment approaches to  IAA has been mostly either  psychopharmacological or behavioral.  The basic premise of the psychopharmacological approach has been that IAA reflects underlying CNS dysfunction which can be alleviated  by medications that affect neurotransmitters. The basic premise of the behavioral approach has been that IAA reflects learned behavior that can be diminished by removing  reinforcers of that behavior and where needed substituting more adaptive behaviors. Both approaches have made important contributions to the treatment of IAA, in ASD but are not successful in all cases.  The committee noted that work over the past decade has suggested a third possible approach, whose basic premise is that  IAA is a natural nonspecific, human behavioral response to a perceived danger (threat) to the self. The threat can be in the form of change/uncertainty (psychosocial stressors)  unmet needs (due to skills deficits of the individal or a deficient environment),  or physical or mental pain/discomfort (medical or psychiatric conditions).  Growing evidence, to be reviewed in this presentation,  suggests that effectively removing the threat (by addressing the underlying problem) can result in rapid and sustained remission of IAA in some persons with ASD.

Results: The consensus view of the Committee was that the most efficient and effective treatment plan for IAA in a given individual with ASD logically flows from a systematic assessment of all factors potentially contributing to IAA in that person. The evaluation pathway assesses factors in five domains (psychosocial stressors, functional communication deficits, medical conditions including medication side effects, psychiatric conditions and maladaptive patterns of reinforcement). The treatment plan then aims to address all the relevant factors either sequentially or simultaneously in order to effect the most rapid and enduring remission possible. The pathway is designed to ensure that all potentially treatable factors contributing to IAA behavior in a given person are systematically considered before psychotropic medication or behavioral treatment is used, but does allow that in some circumstances  psychotropic medications or behavioral interventions should be used first.

Conclusions: This ATN pathway has the potential to maximize the efficiency and effectiveness of treatment for IAA while minimizing risk for the individual patient.