Judith Aronson-Ramos, M.D.
www.draronsonramos.com
 Robert
Hendren – 1st genetic vulnerability 2nd
GxE 3rd lack of EI
 Immune Abnormalities
 Oxidative Stress
 Disturbed Methylation
 Mitochondrial Dysfunction
 FFA Metabolism
 Excitatory-Inhibitory Balance
 Hormonal effects
 May culminate in ASD in genetically
susceptible individuals
We are treating “target symptoms” not the core
deficits of Autism
 Two FDA approved medications in ASD –
Risperidone (2006) , Aripiprazole (2009) approved for “irritability – aggression, self
injury, tantrums
 Ongoing research into new medications which
effect balance of excitatory vs. inhibitory brain
signaling
 Targets using effects on specific syndromes such
as Fragile x, Retts, TS – reversal of symptoms
 Research Conundrum - Targeting causes of Autism
in specific syndromes will likely be most
transformative vs. targeting general brain
circuitry (not causes) which will likely be less
effective but will help more individuals

 ADHD
medications
 SSRI and other anti-depressants
 Antipsychotics – mostly second generation
 Mood stabilizers
 Anti-epileptics
 Less commonly – antibiotics, antivirals,
antifungals
 DSM
5 – we can now have ASD with ADHD
 Very high percentage of ASD individuals also
have ADHD
 Stimulants – Methylphenidates,
Amphetamines
 Non-stimulants – Clonidine, Guanfacine, and
extended release forms – Intuniv (guanfacine
er) and Kapvay (clonidine er)
 Strattera (Atomoxetine)
 Dosage
range can be different with
stimulants – always start low and go slow
 Exacerbation of anxiety is common
 Increased perservations, obsessions, getting
stuck, hyper focus
 Some individuals respond optimally
 ASD with ADHD is different than ADHD alone –
internal vs external distractions
 Evidence base – “moderate strength”
 Research –RCT with methylphenidate in ASD
less benefit and more side effects than ADHD
alone
Alpha agonists hold tremendous promise –
Guanfacine, Intuniv (Guanfacine ER), Clonidine,
Kapvay (Clonidine ER)
 Data pending – some unpublished studies showing
strong benefit for inattention, hyperactivity and
impulsivity – little benefit for agitation and
irritability
 Can be used in combination with stimulants very
effectively
 Short acting forms great in young children with
ASD
 Side effects – often more manageable than
stimulants

 Strattera
(Atomoxetine) – stand alone
medication
 Research has shown very small effect sizes in
ADHD
 One positive study in ASD in 2012 still only
21% of patients improved
 Not clinically effective to treat anxiety
 Not as robust as stimulants for hyperactivity
and impulsivity
 Niche medication
The SSRI medications are only FDA approved for
depression and OCD – Sertraline, Fluoxetine,
Citalopram, Escitalopram, Fluvoxamine
 One SSRI is FDA approved for anxiety
(Duloxetine) but all SSRIs are used for anxiety
 There are no positive research studies for
benefit in ASD – HOWEVER may reflect flaws of
research – heterogeneity of ASD
 Very commonly used in ASD for coexisting
depression, anxiety, and ocd
 Safe and well tolerated
 “Activation”- moody, aggressive, irritable, manic
- more common in ASD
 Low doses to start a must

Two FDA approved medications – Aripiprazole
(Abilify) and Risperidone (Risperdal)
 Indication is irritability, aggression, agitation
 Clinically we see they also show benefit for
hyperactivity, defiance, and stereotyped
behaviors
 Doses may be lower than other psychiatric
disorders
 Side effects are a serious concern – weight gain,
hyperprolactinemia, sedation, extrapyramidal
symptoms (movement related -tardive, dystonia,
akathesia)
 ? Brain atrophy

Miscellaneous antidepressants – Wellbutrin,
Effexor, Cymbalta
 Antipsychotics – Geodon, Zyprexa, Seroquel,
Haldol
 Anti-Epileptics – Lamictal, Trileptal, Tegretol,
Topamax, Depakote
 Mood Stabilizers –Lithium, Neurontin
 Virtually every psychotropic med has been tried
in someone somewhere
 If you of your child is being properly managed by
a physician and is doing well on these
medications there is no cause for alarm – there is
value in case report and clinical experience

 NOT
every child or individual with ASD will
benefit from medication
 A large % of individuals with ASD will trial
medication in their lifetime
 Pharmacotherapy should never be considered
the first line treatment in ASD
 Published medical evidence is limited –
strength of evidence is summarized below
 Risperidone and Aripiprazole – HIGH
 Stimulants – MODERATE
 SSRI -INSUFFICENT
Disappointments with Fragile X – drugs that
inhibit MGLUR5, Arbaclofen, Namenda
 Medications to treat core symptoms of ASD
 Oxytocin, Gaba/Glutamate Modulators, Mtor
inhibitors (TS), IGF 1 (Rett),
Dcycloserine/Amantadine (NMDA)
 Placebo effect in autism mediation trials can be
as high as 30-40 % (Secretin)
 Complication of subgroups of responders
 With increasing knowledge of both neurobiology,
genetics, and autism risk factors, more
medications are likely to emerge
 Pharmacogenetics – not ready for primetime

 No
one specific diet has been validated with
research to be beneficial in ASD
 Most data is anecdotal, case reports, basic
science, published studies not peer reviewed
 Emerging information showing healthy eating
impacts general well being - foundation for
healthy psycho-social functioning
 Validated diets: No dyes, preservatives,
pesticide residue – ADHD; ? - GFCF
 Popular diets: GFCFSFCFYF
 Elimination with food diary more informative
than lab testing
 To
test true allergy measure IGE reaction to
food (RAST, CAP-RAST), skin prick, oral
challenge
 Unproven is food sensitivity testing – IGG,
provocation/neutralization, and others
 Complications of interpretation – cross
reactivity of proteins, outgrowing allergies,
difficulties of interpretation
 Food allergy tests can be helpful, but
decisions regarding what tests to perform
and how to interpret them are complex,
costly, elimination diets may be as effective
 ASD
complications with nutrition – picky and
restricted, rigid, carbohydrate cravers, poor
self regulation, sensory issues (texture,
smell, look, temperature)
 Behavioral issues with food – parents
indulging, children demanding
 Effects of nutrition on well being not easily
quantified or measured, invariably multiple
factors contribute to behavior and emotional
regulation
 Self determination and control in changing
dietary habits are beneficial
Research can lag and dietary information has
always been slow in coming from medical
community, BUT this does not mean every new
diet is viable
 New thinking about plant based diets,
cholesterol and the myth of low fat, sugar vs fat
in obesity, antioxidants, diet and chronic disease
 Limitations of laboratory testing in guiding
dietary choices needs to be understood
 Work with nutritionists and allergists
 Examples of dietary manipulations without lab
tests - Rotation diet, Elimination diets, followed
by challenge
 Hypoallergenic diets – rice, lamb, chicken,
pears, apples, non-gluten grains (quinoa, millet,
amaranth), beans and legumes AVOID peanuts,
eggs, corn, wheat, fish, or dairy











First Do No Harm
Any product used needs third party analysis –
www.consumerlabs.com, USP(US pharmacopeia), NSF
(nat’l science found.), GMP (good manuf practices)
etc.
Fallacy of thinking you can just take a supplement to
replace what is “missing”
Fat vs water soluble vitamins, making expensive urine
Dietary anti-oxidants v. glutathione, sulforaphane
GI issues -probiotics – 4 billion CFU (?enzymes)
Omega 3 Fatty Acids – EPA:DHA (3:2) 1-3 g per day
Multi-Vitamin/multi-mineral support– Vitamin D
Maybe worth trying mitochondrial support,
sulforophane, glutathione, B12 shots (3
x/week/6weeks), NAC, Melatonin
Previously popular – IVIG, Chelation, HBOT
Eat whole foods, avoid snack/junk foods,
additives and sugar, monitor intake, healthy fats
 3-4 servings of veg (not corn, potato), 1-2 fruit,
colorful, organic (dirty 12)
 3 servings of protein (clean)- meat, poultry, fish
alternatives (myco, soy etc.), nuts, beans
 With very picky eaters work with preferred foods
and maximize nutritional value
 Work with sensory related food issues (texture,
smell, temperature, color)
 Zone approach, eat in reverse
 Use a food diary
 When trying special diets keep other variables
constant, blind observers, adequate trial (1-2mo)

Healthy Diet
 2Multivitamin/Mineral supplement, Omega 3
FA, Probiotic, Vitamin D
 Consider GFCF trial, elimination and
rotation diets, food diary
 Lab testing: general metabolic panel, lipids,
iron, CBC, thyroid, R/O Celiac, CMA, FragileX
 http://autism.asu.edu/ Dr John Adams ASU

Companies with a track record (Klaire,
Jameison, Nordic Naturals, Solgar, Life
Extension)
 MD’s with a track record –Andrew Weil, Sandy
Newmark, *Amen, *Perlmutter
 Martha Herbert M.D., The Autism Revolution
 Follow the latest research www.sfari.org,
www.autismspeaks.org
 Cheapest not always best
 Nutraceuticals are an emerging industry
 Beware of conflicts of interest in buying products
from clinicians

Choose brands labeled with the NSF
International, US Pharmacopeia, Natural
Products Association, or Consumer Lab seal
www.consumerlabs.com, GMP-Good
Manufacturing Practices
 These insignia verify that the supplement
actually contains the ingredients stated on the
label, and that the product doesn’t contain any
contaminants or potentially harmful ingredients.
 Be wary of supplements produced outside the
United States. Many are not regulated and some
may contain toxic ingredients.

 Meditation,
Yoga, Mindfulness Based Stress
Reduction (MBSR)
 Attention strengthening interventions
utilizing neuroplasticity – Cogmed,
Neuro/Biofeedback, C8 sciences, Lumosity
 Cognitive Behavioral Therapy
 Hippotherapy
 Art therapy
 Pet therapy
 ???transcranial magnets, sensory therapies
(mendability.com)
 Nutrition
& Supplements
 Exercise
 Sleep
 School
& Work
 Clean Environment – avoid toxins – cleaning
products, hygiene products, household
exposures
 Therapy
 Meaningfulness – work, volunteerism, school
 Psychopharmacology +/-