3.5 BALANCING RISK AND BENEFIT IN MANAGING IRRITABILITY AND AGITATION IN AUTISM SPECTRUM DISORDER

Abstract

This presentation aims to provide a systematic approach to the assessment of irritability and agitation symptoms in autism spectrum disorder (ASD) and to review the existing evidence for effective (and ineffective) treatments for irritability and agitation in ASD, highlighting both potential benefits and risks. A practice pathway, developed by expert consensus, for the assessment and management of irritability and problem behavior, will provide the organizing framework for the discussion. Systematic reviews and meta-analyses will provide an overview of the literature, with supplementation from individual randomized controlled trials. Clinical case examples will be used to highlight key concepts in assessment and treatment. Irritability and agitation are common but nonspecific outcomes of multiple underlying areas of difficulty, from pain to family conflict to communication difficulties. It is therefore critical to systematically evaluate potential contributions from the medical, psychiatric, psychosocial, communication, and behavioral domains for the individual patient. This multimodal assessment approach, combined with a careful evaluation of the severity and risk of the problem behavior, guides a multidisciplinary treatment approach. With regard to psychopharmacology in particular, the evidence of benefit for a medication must be carefully balanced with the potential risk that must be actively managed. Vignettes from clinical practice demonstrate the choice points for the use of particular behavioral and medication treatments in the management of irritability and agitation. Careful evaluation of irritability, agitation, and accompanying aggression in ASD requires integrating information across domains and settings. A systematic approach to assessment allows the child and adolescent psychiatrist or allied professional to consider each domain and develop an initial formulation that can be refined by response to intervention. Successful treatment will likewise require collaboration across disciplines, ranging from the management of medical problems to improving communication tools to optimizing behavioral management. In the real world, we must all balance risk and benefit to appropriately manage irritability and agitation in ASD.