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5336 A Rational Approach to Psychopharmacology for Children and Adolescents with ASD [ASHA Session]

Saturday, July 9, 2011: 10:45 AM-12:00 PM
Sun D (Gaylord Palms Resort and Convention Center)
Disruptive behavior is common in children with ASD. In this session the presenters describe underlying neuropsychological and neurophysiologic deficits commonly encountered in ASD (cognitive rigidity, dysregulation of attention, arousal, and sensory processing), and the different pathways by which these deficits culminate in disruptive behavior. Using this framework, participants will be able to “reason backwards” from the observed disruptive behavior to consider its primary cause(s), and use this knowledge as the basis for instituting behavioral and pharmacologic interventions.  

Best practices

This session will advance best practices in the care of children with ASD, by providing an analytical approach to the management of disruptive behavior. Rather than replacing existing descriptive schemas (functional behavioral assessment, e.g.), our approach integrates behavioral and neurophysiologic perspectives into a unified whole that can be applied by practitioners across multiple disciplines working with children with ASD plus disruptive behavior.

Session Content

ASD is diagnosed on the basis of symptoms in four domains: socialization, language, repetitive behavior, and sensory processing. Beneath these symptoms lie a constellation of neuropsychological and neurophysiologic deficits, including cognitive rigidity, dysregulation of attention, dysregulation of arousal, and dysregulation of sensory processing. In this session, we will discuss the ways in which these underlying deficits give rise to various forms of maladaptive behavior seen in children with ASD, often culminating in disruptive behavior.  Armed with this analytical framework, the participant will be able to “reason backwards” from the observed maladaptive behavior, tracing that behavior to its underlying neurophysiologic source (or sources), permitting a rational approach to behavior management and the use of psychopharmacological agents.

We start by arranging cognitive rigidity, regulation of attention, regulation of arousal, and regulation of sensory input around the face of a clock, with disruptive behavior (operationally defined as property destruction, aggression, and self-injurious behavior) at the center of the dial. (This will be easier to grasp during the session, where graphics are available; see Coplan, 2010, chapter 12.)

First, we consider cognitive rigidity. Cognitive rigidity may be operationally defined as difficulty shifting from one behavior or mode of thinking to another. Cognitive rigidity underlies the “insistence on sameness” seen in children with ASD. Cognitive rigidity is located at 12 o’clock.

Next, we consider regulation of attention. Normally, we alternate between paying attention (for example, maintaining focus on the road ahead when we are driving an automobile), and breaking away (in this example, shifting our attention away from the road, in order to focus on a different stimulus, such as the sound of an approaching ambulance. Once we have localized the position and direction of movement of the ambulance, we break away from that stimulus, and resume attending to the road ahead.). Ordinarily, we shift effortlessly between attending and breaking away. However, in ASD this mechanism is “sticky.” Instead of attending and shifting in the normal fashion, children with ASD get stuck at both extremes, unable to maintain focus one minute, and unable to break away the next. The classical description of ASD evokes an image of perseveration (a child stuck at the computer for hours, etc.) In actuality, children on the spectrum often bounce back and forth between perseveration and inattention.  Normally-regulated attention is located at 3 o’clock on the dial; we place perseveration at 2 o’clock, and inattention at 4 o’clock.

Next, we consider arousal.  “Arousal” refers to our state of readiness to deal with perceived threats. Watching an exciting basketball game, or being cut off in traffic, increase our state of arousal, triggering the “fight or flight” response, with increased heart and respiratory rate, and hypervigilance. Alternatively, we occasionally lapse into a state of decreased arousal (when relaxed after a meal, or when listening to a boring speech, for example).  Normally, we oscillate between states of mildly increased and mildly decreased arousal, generally coming to rest in the middle: a calm and alert state. The point at which people transition from calm and alert to aroused - the “arousal threshold” – varies from one individual to another. Some people have a very high threshold for arousal, remaining calm no matter how stressful the external circumstances. Other people have a very low threshold for arousal, becoming excited after minimal provocation. As we saw with the regulation of attention, the thermostat that regulates arousal can malfunction children with ASD: Some children manifest a chronically decreased arousal threshold, becoming hypervigilant after minimal provocation - the parents have to “walk on eggshells” to avoid triggering agitated and disruptive behavior.  Alternatively, some children manifest hypo-arousal, and seem to be chronically lethargic.  We locate the arousal mechanism at 6 o’clock on the dial. Hyper-arousal is located above the 6, part-way towards the center of the dial, where disruptive behavior is located. Hypo-arousal is located just below the 6 (further removed from the center of the dial and disruptive behavior).

Regulation of arousal is closely tied to regulation of the sleep/wake cycle; children with a decreased threshold for arousal during the daytime also frequently have difficulty falling asleep, and frequent night-waking. We place regulation of sleep at 7 o’clock on the dial.

The final major neurophysiologic mechanism to be addressed is sensory processing. As with the arousal threshold, we all have differing thresholds for perception of sensory input. Some persons are slightly more sensitive to sensory input (i.e., have a decreased sensory threshold), and some persons are slightly less sensitive (i.e., have increased sensory threshold). In neither instance, however, is the deviation from the norm disabling.  In contrast, children on the spectrum may manifest highly increased, decreased, or variable sensory thresholds, to different classes of stimuli. An increased sensory threshold is believed to underlie the tendency to sensory-seeking behavior: ordinary sensory experiences are blunted and distant, leading to a craving for input. Conversely, a decreased threshold is believed to underlie sensory-avoidant behavior: normally innocuous stimuli are perceived in an exaggerated, unpleasant fashion, and the child seeks to avoid them. Normal regulation of sensory input goes at 9 o’clock. A decreased sensory threshold (heightened perception of stimuli, sensory-avoidant behavior) goes at 8; an increased sensory threshold (blunted perception; sensory-seeking behavior) goes at 10.

The following table attempts to convey the idea, within the technical limitations of the submission process (text only; no figures):



Cognitive Rigidity



Increased Threshold





Sensory Regulation


Disruptive Behavior


Regulation of Attention

Decreased Threshold







Increased arousal





Regulation of Arousal





Decreased arousal



 Once we have our “map,” we will discuss how these deficits act, singly or in combination, to give rise to maladaptive behavior, including disruptive behavior.

The upper right-hand quadrant of our clock encompasses rigid and perseverative behavior. Cognitive rigidity (12 o’clock) gives rise to a strong notion of how things are “supposed to be.” If the child’s ability to execute his or her intended routines is blocked, or if the child’s expectations are not met (taking a promised trip to the zoo, for example), disruptive behavior may ensue. Visual schedules, verbal preparation for change, anxiety-reduction techniques, and SSRIs can all be helpful in managing cognitive rigidity.  In addition to acting directly, cognitive rigidity can interact synergistically with perseveration (2 o’clock). Perseveration is more automatic than cognitive rigidity, and consists of repeating the same act over and over, but without the emotional perception that things “should” or “must” be a certain way. For example, on the Bender-Gestalt Test (copying geometric shapes with pencil and paper), one of the stimulus cards consists of a row of dots.  The child with perseveration may begin at one edge of the paper, fill the width of the paper with dots, and then continue right off the paper, making dots until reaching the edge of the table.  There is no indication that the child feels that the dots “should” continue. The child’s brain is simply “stuck” on the motor activity. Cognitive rigidity and perseveration are thus quite different, but it’s easy to see that they can reinforce one another.  The same techniques as described for cognitive rigidity alone are useful in dealing with this combination of issues.

The lower right-hand quadrant of the clock encompasses inattention (4 o’clock) and hyperarousal (just above the 6). In neurotypical children, the stimulants (methylphenidate, dextroamphetamine) are the first-line drugs for treatment of inattention. However, stimulants carry the potential of making cognitive rigidity, perseveration, and agitation worse. For this reason, we prefer the alpha-2 agents (guanfacine) as the drug of first choice when treating inattention / impulsivity in children on the spectrum.  A decreased arousal threshold can lead directly to agitated, disruptive behavior: once the fight-or-flight sequence is launched, the child may “go after” a specific target, including  property, adults, peers, or self-injury. This is different from the purposeless, emotionally neutral impulsivity and hyperactivity of a child with inattention. Limitation of external stimuli, alpha-2-agonists (guanfacine), and atypical neuroleptics (risperidone, aripiprazole) are useful in the management of decreased arousal threshold. Glutamate inhibitors hold great promise.

As we saw with cognitive rigidity and perseveration, inattention and hyperarousal can also interact.  Along with implementing behavioral measures (limitation of stimuli, use of positive reinforcement, avoidance of negative reinforcement of escape behavior), we typically suggest guanfacine first, and then add an atypical neuroleptic if necessary. Parents and clinicians need to be careful when treating this combination of features. We have seen children who were put on stimulants for “hyperactivity” wind up in the emergency room with an episode of acute agitation.

The lower left-hand quadrant of the clock, comprising hyper-arousal (above the 6), poor sleep (7 o’clock on the dial), and decreased sensory threshold (8 o’clock), is a setup for disruptive behavior.

Dysregulation of sleep, with prolonged time to the onset of sleep, shortened duration of sleep, with frequent night-waking and early morning rising, is common in children with ASD, especially children with agitated behavior. Melatonin often provides substantial benefit for disordered sleep. It is important for the parents to practice good sleep hygiene, with a regular bed-time routine, and fastidious avoidance of reinforcement of maladaptive behavior (such as permitting the child to sleep in bed with them.  Along with the measures already described for decreased arousal threshold and dysregulation of sleep, Occupational Therapy and a “sensory diet” may improve quality of life for children with impaired sensory processing.

The upper left-hand quadrant of the clock contains children with an increased sensory threshold (decreased perception of stimuli). One theory holds that children in this quadrant engage in stereotypies and self-injurious behavior as a way of obtaining sensory input. Pharmacologic agents, such as endorphin receptor blockers, have produced inconsistent results. This brings us full circle, back to the 12 o’clock position on the dial.

The final slide in this presentation shows all of the above processes in an interactive fashion, enabling the participant to see how each of the individual neurophysiologic deficits acts directly, as well as in concert with adjacent points on the clock face, to give rise to maladaptive behavior, including disruptive behavior. We will also discuss the relationship between biologically based maladaptive behavior, and behaviors that are sustained via positive and negative environmental reinforcement.


Coplan, J. (2010). Making sense of Autistic Spectrum Disorders: Creating the Brightest Future for Your Child with ASD by Finding the Best Treatment Options. New York, Bantam-Dell Press.

Learning Objectives:

  • Be able to distinguish between cognitive rigidity and perseveration
  • Be able to discuss the difference between impulsivity and agitation
  • Be able to discuss the relationship between disordered arousal and disordered sleep
  • Be able to discuss the various behavioral consequences of disordered sensory processing
  • Be able to identify four neuropsychological or neurophysiologic deficits commonly seen in children with ASD

Content Area: Current Biomedical Research


James Coplan, M.D.
Developmental Pediatrician
Neurodevelopmental Pediatrics of the Main Line, PC

James Coplan holds sub-specialty certification in Neurodevelopmental Disabilities and Developmental-Behavioral Pediatrics, and is an author. He is a member of the Child Neurology Society, and is a Clinical Associate Professor of Child Psychiatry at the University Of Pennsylvania School Of Medicine.