Parent training key to improved treatment of behavior problems in children with autism

The serious behavior problems that can occur in children with autism and related conditions can be reduced with a treatment plan that includes medication combined with a structured training program for parents, according to Yale University researchers and their colleagues.

Published in the December 2009 issue of the Journal of the American Academy of Child and Adolescent Psychiatry, the study was conducted by the National Institute of Mental Health (NIMH) Research Units on Pediatric Psychopharmacology (RUPP) Autism Network. The 24-week, three-site trial was conducted at Yale, Ohio State University and Indiana University. Lawrence Scahill, professor at Yale School of Nursing and the Yale Child Study Center, is principal investigator at the Yale site.

Results from a 2002 RUPP report showed that the antipsychotic medication risperidone (Risperdal) reduced such behavioral problems as tantrums, aggression and self-injury in children with autism. However, most children's symptoms returned when the medication was discontinued after six months of effective treatment. Also, risperidone is associated with adverse effects such as weight gain, which can lead to obesity and related health problems.

In this new study, the RUPP group tested the benefits of medication alone compared to medication plus a parent training program that actively involves parents in managing their children's severely disruptive and noncompliant behaviors. In a series of 14 sessions over six months, parents were taught to reduce their children's challenging behavior and to enhance daily living skills.

The study included 124 children ages 4 to 13 with pervasive developmental disorders (PDD) such as autism, Asperger's or related disorders accompanied by tantrums, aggression and self-injury. The children were randomly given a combination of risperidone and parent training, or risperidone only.

Although both groups improved over the six-month trial, the group receiving combination therapy showed greater reduction in disruptive behavior, tantrums and aggression compared to the group receiving medication only. The combination therapy group also ended the trial taking an average dose of 1.98 milligrams (mg) per day of risperidone, compared to 2.26 mg per day in the medication-only group—a 14 percent lower dose. However, children in both groups gained weight, indicating "a need to learn more about the metabolic consequences of medications like risperidone," noted Scahill.

"The results show that the parent training intervention can be delivered in a reliable manner and results were the same across all sites," said Scahill. "This is important because it shows that the intervention is exportable—and ready for dissemination."

The RUPP group is expecting to launch a multi-site parent training study in preschool-age children with pervasive developmental disorders. "We hope to show that these behavioral problems can be reduced in children without medication—if intervention starts early," Scahill said. "Future studies may also look for ways in which the parent training program can be used in schools and community clinics."

The work was funded, in part, by the Yale Clinical and Translational Science Award (CTSA) grant from the National Center for Research Resources at the National Institutes of Health.

Other principal investigators in this NIMH-funded trial included Michael Aman from Ohio State University and Christopher McDougle, M.D. from Indiana University.