Objective Impairments associated with attention-deficit/hyperactivity disorder (ADHD) and noncompliance are prevalent in children with autism spectrum disorder (ASD). However, ADHD response to stimulants is well below rates in typically developing children, with frequent side effects. Group studies of treatments for noncompliance are rare in ASD. We examined individual and combined-effectiveness of atomoxetine (ATX) and parent training (PT) for ADHD symptoms and noncompliance. Method In a 3-site, 10-week, double-blind, 2×2 trial of ATX and PT, 128 children (ages 5–14) with ASD and ADHD symptoms were randomized to ATX, ATX+PT, placebo+PT, or placebo. ATX was adjusted to optimal dose (capped at 1.8 mg/kg/day) over 6 weeks and maintained for 4 additional weeks. Nine PT sessions were provided. Primary outcome measures were the parent-rated DSM ADHD symptoms on the Swanson, Nolan and Pelham (SNAP) scale and Home Situations Questionnaire (HSQ). Results On the SNAP, ATX, ATX+PT and placebo+PT were each superior to placebo (effect sizes 0.57–0.98), with p-values of 0.0005, 0.0004 and 0.025, respectively. For noncompliance, ATX and ATX+PT were superior to placebo (effect sizes 0.47–0.64; p values of .03 and .0028, respectively). ATX was associated with decreased appetite but otherwise well-tolerated. Conclusion Both ATX and PT resulted in significant improvement on ADHD symptoms while ATX (both alone and combined with PT) was associated with significant decreases on measures of noncompliance. ATX appears to have a better side effects profile than psychostimulants in the population with ASD.

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This review summarizes the pharmacokinetic characteristics, pharmacodynamic properties, common side effects, and clinical advantages and disadvantages associated with atomoxetine (ATX) treatment in typically developing children and adults with ADHD. Then the clinical research to date in developmental disabilities (DD), including autism spectrum disorders (ASD), is summarized and reviewed. Of the 11 relevant reports available, only two were placebo-controlled randomized clinical trials, and both focused on a single DD population (ASD). All trials but one indicated clinical improvement in ADHD symptoms with ATX, although it was difficult to judge the magnitude and validity of reported improvement in the absence of placebo controls. Effects of ATX on co-occurring behavioral and cognitive symptoms were much less consistent. Appetite decrease, nausea, and irritability were the most common adverse events reported among children with DD; clinicians should be aware that, as with stimulants, irritability appears to occur much more commonly in persons with DD than in typically developing individuals. Splitting the dose initially, starting below the recommended starting dose, and titrating slowly may prevent or ameliorate side effects. Patience is needed for the slow build-up of benefit. Conclusions: ATX holds promise for managing ADHD symptoms in DD, but properly controlled, randomized clinical trials of atomoxetine in intellectual disability and ASD are sorely needed. Clinicians and researchers should be vigilant for emergence of irritability with ATX treatment. Effects of ATX on cognition in DD are virtually unstudied.

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Objective We previously reported a 2×2 randomized clinical trial of individual and combined treatment with atomoxetine (ATX) and parent training (PT) for attention-deficit/hyperactivity disorder (ADHD) symptoms and behavioral noncompliance in 128 children with autism spectrum disorder, ages 5–14 years. We now describe a 24-week extension of treatment responders and non-responders. Method One-hundred seventeen participants from the acute trial (91%) entered the extension; 84 of these were in two subgroups: (1) “treatment responders” (n=43) from all four groups in the acute trial, seen monthly for 24 weeks, and (2) “placebo nonresponders” (n=41), treated with open-label ATX for 10 weeks. Participants originally assigned to PT continued in PT during the extension; the remainder served as controls. Primary outcome measures were parent-rated Swanson, Nolan and Pelham ADHD scale and Home Situations Questionnaire. Results Sixty percent (26/43) of treatment responders in the acute trial, including 68% of responders originally assigned to ATX, still met response criteria at the end of extension. The response rate of placebo nonresponders treated with 10-week open-label ATX was 37% (15/41), similar to the acute trial. Children receiving open-label ATX+PT were significantly more likely to be ADHD responders (53% vs 23%) and noncompliance responders (58% vs 14%) than those receiving open-label ATX alone. Conclusion Most ATX responders maintained their responses during the extension. PT combined with ATX in the open-label trial appeared to improve ADHD and noncompliance outcomes more than ATX alone.