Alpha-2 Agonist Use in Children with Autism

Autism spectrum disorder (ASD) is frequently associated with symptoms of hyperactivity and anxiety which can interfere with the child’s response to social and educational interventions. Treating these hyperarousal states may improve adaptive functioning and ability to learn. While alpha-2 agonists are not typically considered first-line treatments for hyperactivity or anxiety, they may be effective alternatives when first-line medications are poorly tolerated. [Handen: 2011] [Fankhauser: 1992] [Jaselskis: 1992]
Adverse effects of alpha-2 agonists include sedation, irritability, hypotension, bradycardia, and electrocardiogram changes. Hypertension may occur if discontinued abruptly. [Daviss: 2008]
Guidelines for the initiation and adjustment of alpha-2 agonists in children with ASD:
  • Clonidine Note: useful for delayed sleep onset as well [Ming: 2008]
    • Start with ½ of a 0.1 mg tablet (0.05 mg) at bedtime.
    • Add ¼ to ½ tablet in the morning once the evening dose is tolerated.
    • Noon and afternoon doses may be added. Each may be titrated up to 0.1 mg.
    • Bedtime dose may be increased to 0.2 mg as needed for sleep onset. [Palumbo: 2008]
  • Guanfacine Note: has a longer half-life than clonidine and it is less sedating
    • Start at 0.5 mg twice daily.
    • Maximum dose is 3 mg/day [Handen: 2008]
  • Monitor blood pressure and heart rate.
  • Consider obtaining an EKG if an alpha-2 agonist is to be added to a stimulant.
  • Oral ingestion of patch formulation may cause life-threatening arrhythmia. Do not use in patients at risk for removing and ingesting patch.
  • Alpha-2 agonists may precipitate depression in patients at risk for depression.
  • Avoid abrupt discontinuation of alpha-2 agonists as this may result in hypertension. Rebound hypertension may be avoided by tapering the medication over the course of 2 weeks.
  • Longer acting alpha-2 agonists have been FDA approved for treatment of ADHD symptoms in children and adolescents (Kapvay and Intuniv). Though these medications may have fewer side effects than the shorter acting formulations, these have not been studied in the ASD population to date.
  • As with typically developing children, target behaviors in the home and school should be identified at the onset of treatment and monitored for treatment effectiveness. Establish a plan with the family for follow-up. Use rating scales such as the NICHQ Vanderbilt Assessment Scale - Parent Informant (PDF Document 105 KB), Vanderbilt ADHD Diagnostic Teacher Rating Scale - Initial Assessment (PDF Document 43 KB), or the Nisonger Child Behavior Rating Form (NCBRF) (NCBRF) to get an objective measure of problem behaviors. The NCBRF is a standardized scale for assessing child and adolescent behavior. Scales are available for typically developing children as well as for those with disabilities. They may be downloaded free of charge.
Overdose or misuse of these medications may be life-threatening. Keep this and other medications out of reach from the patient and other children in the household.


Information & Support

For Professionals

Vanderbilt ADHD Diagnostic Teacher Rating Scale - Initial Assessment (PDF Document 43 KB)
A 40-questions assessment designed to identify behavior problems and performance impairments in school children; contains scoring information.

NICHQ Vanderbilt Assessment Scale - Parent Informant (PDF Document 105 KB)
A 2-page assessment designed to identify ADHD related behavior problems and performance impairments in school children; also screens for anxiety, depression, oppositional defiant, and conduct disorders.

Nisonger Child Behavior Rating Form (NCBRF)
A standardized tool used in assessing child and adolescent behaviors.

Authors & Reviewers

Current Authors and Reviewers:
Authors: Tara Buck, MD
Deborah Bilder, MD
Catherine Jolma, MD
Reviewer: Mary Steinmann, MD

Page Bibliography

Daviss WB, Patel NC, Robb AS, McDermott MP, Bukstein OG, Pelham WE Jr, Palumbo D, Harris P, Sallee FR.
Clonidine for attention-deficit/hyperactivity disorder: II. ECG changes and adverse events analysis.
J Am Acad Child Adolesc Psychiatry. 2008;47(2):189-98. PubMed abstract

Fankhauser MP, Karumanchi VC, German ML, Yates A, Karumanchi SD.
A double-blind, placebo-controlled study of the efficacy of transdermal clonidine in autism.
J Clin Psychiatry. 1992;53(3):77-82. PubMed abstract

Handen BL, Sahl R, Hardan AY.
Guanfacine in children with autism and/or intellectual disabilities.
J Dev Behav Pediatr. 2008;29(4):303-8. PubMed abstract

Handen BL, Taylor J, Tumuluru R.
Psychopharmacological treatment of ADHD symptoms in children with autism spectrum disorder.
Int J Adolesc Med Health. 2011;23(3):167-73. PubMed abstract

Jaselskis CA, Cook EH Jr, Fletcher KE, Leventhal BL.
Clonidine treatment of hyperactive and impulsive children with autistic disorder.
J Clin Psychopharmacol. 1992;12(5):322-7. PubMed abstract

Ming X, Gordon E, Kang N, Wagner GC.
Use of clonidine in children with autism spectrum disorders.
Brain Dev. 2008;30(7):454-60. PubMed abstract

Palumbo DR, Sallee FR, Pelham WE Jr, Bukstein OG, Daviss WB, McDermott MP.
Clonidine for attention-deficit/hyperactivity disorder: I. Efficacy and tolerability outcomes.
J Am Acad Child Adolesc Psychiatry. 2008;47(2):180-8. PubMed abstract