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Original Question

An 11-year-old girl with autism spectrum disorder is referred to child psychiatry by her pediatrician with a request for recommendations on medication management of her escalating aggression. She has always had some minor, manageable aggression but she has significantly worsened in the last two months. She is at risk of losing her school placement due to physical aggression toward teachers and peers. Her parents are considering residential placement but they would prefer to maintain her at home. The patient’s current medications include amphetamine (D, L) started at 6 years of age for impulsivity without much benefit, guanfacine added at 8 years of age to also help with impulsivity with only modest benefit, and fluoxetine added two months ago to target depression that was manifesting primarily as irritability. Other than a new paraprofessional at school at about that time, no other environmental triggers were identified. Fluoxetine was increased to 40 mg two weeks ago due to ongoing irritability and the significant escalation in her aggressive behavior over the past two months. She has always struggled with transitions, changes in routine, rigid thinking, and misinterpretation of social cues. However, these difficulties now seem to cause nearly constant irritability and trigger acts of aggression. Which of the following would be the best first step to recommend to the pediatrician? Add low-dose risperidone Discontinue fluoxetine Immediately stop all medications Refer to beha

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