In a recent study involving 9,013 adults with intellectual disability and 32,242 adults without intellectual disability, there was an increased risk of movement side effects, which included among others, neuroleptic malignant syndrome, a rare but potentially deadly side effect, (Rory Sheehan, Laura Horsfall, Andre Strydom, David Osborn, Kate Walters, Angela Hassoitis, "Movement Side Effects of Antipsychotic Drugs in Adults with and without Intellectual Disability: UK Population-based Cohort Study," BMJ Open 7, (2017): e017406, doi:10.1136/bmjopen-2017-017406). Neuroleptic malignant syndrome consists of fever, rigidity and autonomic dysregulation- which is part of the nervous system. Neuroleptic malignant syndrome was three times more common in individuals with intellectual disability compared to individuals without intellectual disability. The rate of parkinson symptoms and akathisia was also increased. Akathisia, a feeling of restlessness and need to move constantly, sometimes manifests itself with increased levels of agitation, which may result in increased dosages of medication. People with intellectual disability may not be able to disclose symptoms, resulting in missing their diagnoses. This is another reason why we need ABA to treat behaviors rather than drugs.
FDA Accelerated Approvals Based on Poor Evidence of Effectiveness and Safety
In a recent study examining accelerated approvals between 2009 and 2013, less than half (42%) showed efficacy in post approval trials which were completed at least 3 years after approval, and studies done before and after approvals had limitations in study designs and end points used, (Huseyin Naci, Katelyn R. Smalley, Aaron S. Kesselheim, "Characteristics of Preapproval and Postapproval Studies for Drugs Granted Accelerated Approval by the US Food and Drug Administration," JAMA 318, no. 7 (August 15, 2017): 626-636, doi:10.1001/jama.2017.9415). Accelaterd approvals are granted for drugs purported to treat serious or life-threatening conditions. From 2009 to 2013, 22 drugs received accelated approval for 24 indications. 14 of the 24 indications had not completed all the postapproval requirements. Some comfirmatory studes showed either no benefit, were terminated or delayed by over a year. In fact, five years after approval, 8 indications were still lacking evidence in confirmatory studies. Clinical trials that the FDA accepted were not blinded, meaning people knew if they were being treated or not, and were not randomized, meaning the subjects were not randomly put into different groups to compare treatment. In fact, comparator groups were not required. Furthermore, studies that go through the accelerated approval process only require surrogate outcome measures, that may not necessarily be predictive of better outcomes. For example, body mass index, as a surrogate measure for body fat, might be inaccurate, as muscle and bone mass also contribute to body mass index. In addition, for standard approvals, the FDA requires psychiatry medications to be tested against a placebo, and will not accept using an active comparator instead. Of course, it would be unethical for individuals with life-threatening behaviors to be placed on placebos. Therefore, results might not be able to be generalized to individuals with severe behaviors.
Going Green = Lower Autism Risk
Recent research has shown a higher risk of autism with exposure to traffic related air pollution and a new study showed a lower risk of autism with increased amounts of green space, specifically tree cover when there was high road density. (Lucio G. Costa, Yu-Chi Chang, Toby B. Cole, "Developmental Neurotoxicity of Traffic-Related Air Pollution: Focus on Autism," Current Environmental Health Reports 4, no.2 (June 2017): 156-165, doi:10.1007/s40572-017-0135-2; Jianyong Wu, Laura Jackson, "Inverse Relationship Between Urban Green Space and Childhood Autism in California Elementary School Districts," Environment International 107, (October 2017): 140-146, doi:10.1016/j.envint.2017.07.010). The latter study included autism prevalence in 543 of 560 public elementary school districts in California. Besides air pollution, noise may also be a factor. Both children with autism and individuals exposed to high levels of traffic related air pollution exhibit elevated levels of inflammation, including in the brain. In individuals who are genetically susceptible to autism, air pollution may be a contributing factor. For this and many other reasons, life may be easier by going green.
Autism: Preventing Hospitalization with ABA
A recent study comparing 218 psychiatrically hospitalized individuals with autism with 255 individuals also with autism who were not hospitalized, ages 4-20, showed five predictors of hospitalization, (Giulia Righi, Jill Benevides, Carla Mazefsky, Matthew Siegel, Stephen J. Sheinkoph, and Eric M. Morrow, "Predictors of Inpatient Psychiatric Hospitalization for Children and Adolescents with Autism Spectrum Disorder," Journal of Autism and Developmental Disorders, published online ahead of print, (May 23, 2017), doi:10.1007/s10803-017-3154-9). These include adaptive functioning, autism spectrum disorder symptom severity, presence of a mood disorder, sleep problems, and living with a single caregiver, which is indicative of limited support. Adaptive functioning, autism symptoms, mood instability and sleep problems can all be improved with ABA. For example, a well done stimulus preference assessment to determine effective positive reinforcers, learning to wait for reinforcement with gradual time increases, or learning to use functional communication tokens to request breaks can all improve mood. Parent training is supportive as well. This research shows among other reasons why effective ABA is cost effective.
ADHD Too or Just Autism?
According to a study, children with autism may be falsely diagnosed with ADHD as diagnostic criteria overlap, (Benjamin E. Yerys, Jenelle Nissley-Tsiopinis, Ashley de Marchena, Marley W. Watkins, Ligia Antezana, Thomas J. Power, and Robert T. Schultz, "Evaluation of the ADHD Rating Scale in Youth with Autism," Journal of Autism and Developmental Disorders, 47, no. 1 (January 2017): 90-100, doi:10.1007/s10803-106-2933-z). This is particularly concerning as individuals with autism may be placed on medications with potentially harmful side effects unnecessarily. ADHD diagnostic symptoms such as being "easily distracted," "does not seem to listen when spoken to directly," or "has difficulty sustaining attention in tasks or play activities," may well be part of autism social impairments and not ADHD. Until we have effective rating scales for individuals who have autism to find out if ADHD is also present, we must be very cautious that individuals with autism are not being falsely diagnosed with ADHD.