Key takeaways
- Safety first. Medical assessment, communication support, and treatment can all start at the same time.
- A change from someone’s usual baseline is a clue. Look for pain, illness, sleep loss, and medicine effects.
- No family should have to finish a long behavior checklist before getting urgent care.
- Risperidone and aripiprazole are approved for irritability associated with autistic disorder in children and teens. That is not approval to treat autism itself.
- Being quieter because of sedation is not a good outcome. Judge alertness and daily life, not just fewer incidents.
- Monitoring is part of the treatment, not an optional extra.
If someone is getting hurt, the first goal is safety and relief. A good plan asks two questions at once. What might be driving this change? And what can reduce the danger now? Medical assessment, communication support, and treatment can all start together. No family should have to complete a long behavior checklist before receiving urgent care.
Seek emergency care now for any of these:
- Severe injury
- Altered awareness
- A seizure that will not stop
- Not being able to keep fluids down
- Escalation that puts someone in immediate danger
Call 911 when emergency help is needed. Explain how the person communicates, what their sensory needs are, and what usually helps. A routine medication visit is not a substitute for emergency assessment.
Outside an emergency, the next step is a coordinated plan with a clear target. “Stop being difficult” is not a clinical goal. “Reduce head injuries and make it possible to eat with less distress” is a goal a person and a team can review.
Describe the injury, then ask what changed
Aggression describes an action that may hurt another person. Self-injury describes an action that harms the person’s own body. Neither word explains why it happened. Neither is a character trait, or proof of what someone intended.
Describe what you saw without guessing at motives. Was there biting, hitting, scratching, head banging? What injury happened? Was this new, more frequent, or harder to interrupt than usual? What changed around that time in sleep, health, demands, relationships, or medicine?
Include the autistic person’s own account. Speech, typing, pictures, gestures, an AAC system, and supported choices can all add information. Ask about pain and fear in a way they can answer. A supporter may spot patterns, but their explanation should not simply replace the person’s own message.
Repeated self-injury and suicidal behavior are different questions. Both can be present at once. Do not assume a nonspeaking person has no suicidal thoughts. Do not assume every repeated injury means a wish to die. Clinicians should ask directly about wanting to die, thoughts of suicide, and immediate safety, using communication the person can access. In the United States, you can call or text 988 for suicide and emotional crisis support. Use emergency services for immediate medical danger.
Look for pain and illness while support begins
A change from baseline can point to a treatable problem. Constipation, reflux, dental pain, infection, and poor sleep all deserve attention when the history suggests them. Puberty, menstrual discomfort, a recent illness, and difficulty communicating a basic need can matter too. Seizures or another neurologic problem need assessment when the events suggest that. 1
Bring an accurate list of medicines, supplements, recent changes, and missed doses. A medicine can cause restlessness, sleep loss, or other distress. Withdrawal can change behavior too. Do not test that idea by stopping a prescribed medicine on your own.
The social setting matters. Ask about bullying, trauma, overwhelming noise, instructions nobody made accessible, the loss of a trusted person, or repeated demands with no way to ask for help. A person can have pain and an unsafe environment at the same time.
This does not mean everyone needs the same blood tests, scan, or EEG. A clinician uses the history and examination to choose. It also does not mean a medical cause must be found before distress is taken seriously.
What a functional assessment can add
A functional behavioral assessment looks at the pattern around an action. What tends to happen before? What happens after? What need might the person be trying to meet, escape, obtain, or communicate? The aim is to understand the context and build a safer, more effective way to meet that need.
Suppose, in a hypothetical example, hitting often starts when a noisy task begins and stops when the task ends. That pattern may point toward changing the task and building a reliable way to ask for a break. It does not prove the person is manipulating anyone. It also does not rule out a headache, a hearing problem, or anxiety about the task.
Functional communication training teaches a usable way to express a need, with partners who respond to that message. A small randomized trial in young children found benefit from specialist coaching delivered to parents by telehealth. That was an organized treatment package. It is not a reason for a family to provoke dangerous behavior to find out what it means. 2
Useful supports are often simple. Fewer demands at once. More recovery time. A pain scale the person can use. A transition they can predict. Communication that stays within reach even during distress. Caregiver coaching can help adults respond the same way each time. The plan has to fit the household’s time, resources, and ability to keep everyone safe.
In a larger trial, parent training improved some outcomes more than parent education did. But the differences on the main parent-rated scales did not reach the study’s own threshold for a clinically important difference. Another study found added benefit from combining medicine with parent training on some measures, but not all. These findings support offering practical help while checking what actually changes at home. They do not support promising that one method solves every crisis. 3 4
Do not treat a worksheet as instructions for restraint, seclusion, punishment, withholding basic needs, or ignoring a dangerous injury. Ask the treating team for a safety plan built for this person, and for training that fits the situation.
When medication enters the discussion
Medication may be considered when severe irritability, aggression, or self-injury causes serious distress or risk. That is especially so when other supports have not been enough, or cannot safely take effect on their own. Urgent severity can change the pace. The decision should still name the target and keep medical and environmental causes in view.
Risperidone and aripiprazole have U.S. oral-product indications for irritability associated with autistic disorder in children and adolescents. The label’s word “irritability” covers a studied cluster: aggression toward others, deliberate self-injury, temper tantrums, and quickly changing moods. It is not approval to treat autism itself, or to make a person appear less autistic. 5 6
The ages need care. The current RISPERDAL label states that efficacy was established in three short-term trials in children and adolescents aged 5 to 17 years. Within those, the label summarizes the two original trials as ages 5 to 16; one of them enrolled ages 5 to 16 and the other ages 5 to 12. A later trial covered ages 5 to 17. Older summaries often just say 5 to 16. ABILIFY’s autism-related irritability evidence and pediatric labeling cover ages 6 to 17. All of this concerns specific oral products. It does not establish an autism indication for every injectable product, or for adults. Adult use for this target is off-label. 5 6
In the pivotal risperidone trial, 34 of 49 children receiving risperidone met the study’s response threshold, compared with 6 of 52 receiving placebo. That threshold combined a behavior-rating change with a clinician improvement rating. It did not mean recovery from autism, an end to all injury, or restored quality of life. Weight gain was greater with risperidone during the short trial. 7
Aripiprazole also improved irritability ratings in short pediatric trials, with side effects including weight gain and sedation. Those were different studies in different groups. Their percentages cannot tell you which drug would work better for one particular person. A small head-to-head comparison found improvement with both and some difference in weight gain, but it was far smaller than planned. It does not name a winner. 8 9
Count benefit in the person’s life
A shared medicine trial starts with an observable target and a baseline. How often are injuries happening? How serious are they? Can the person get back to meals, school, work, rest, or activities they choose? What improvement would matter to them?
Being quieter because of sedation is not enough. A person who stops hitting but is too sleepy to communicate or take part may still be carrying a heavy treatment burden. Ask separately about distress, injury, alertness, and access to daily life.
| Part of the decision | Details |
|---|---|
| A new change | What the clinician checks: Health, pain, sleep, medicines, context Support that can begin: Communication access and a safer setting How the plan gets reviewed: Does treating a contributor reduce distress? |
| A repeated pattern | What the clinician checks: What happens before and after; unmet needs Support that can begin: A reliable way to ask for help or a break How the plan gets reviewed: Does the safer response hold across settings? |
| Serious ongoing risk | What the clinician checks: Severity, urgency, past care, preferences Support that can begin: Coordinated safety and caregiver support How the plan gets reviewed: Is the likely benefit worth the burden? |
| A medication trial | What the clinician checks: A defined target and a baseline Support that can begin: Other helpful supports continue How the plan gets reviewed: Are injury and daily function improving without unacceptable effects? |
Agree the review date when treatment starts. Ask who will track benefit, who receives concerns, and what happens if the person cannot tolerate the monitoring plan. A blood draw may need preparation, communication support, or a different setting. Trouble accessing monitoring deserves problem-solving, not blame.
Monitoring is part of treatment
Both drugs can affect weight, appetite, blood sugar, and lipids. Both can cause movement problems, sedation, and blood-pressure symptoms. Risperidone can raise prolactin, a hormone that may affect menstrual patterns, breast symptoms, and sexual function. Aripiprazole can cause akathisia, a distressing inner restlessness that can look like worsening agitation. Its label also describes impulse-control problems in some people. Individual history decides which risks matter most. 5 6
The table below is for discussion with a clinician. It does not set a testing schedule. The prescriber should choose and document follow-up based on the drug, the person, current guidance, and what they find. 1
| Stage | Topics for the clinician to plan |
|---|---|
| Before or at treatment start | Current medicines; medical and family history; height, weight, growth pattern; blood pressure and pulse; movement examination; metabolic testing appropriate to the plan |
| Planned follow-up | Target symptom and participation; appetite, weight, growth; alertness and sleep; movement symptoms; blood pressure; repeat glucose and lipid testing as indicated; drug-specific hormone concerns |
| Contact the prescriber promptly | New restlessness or unusual movements; troubling sleepiness; rapid appetite or weight change; marked thirst or urination; menstrual, breast, sexual, or impulse-control changes |
| Emergency assessment | Fever with severe stiffness or decline, altered awareness, severe injury, or another medical emergency |
Improvement still needs reassessment
Longer use is not automatically wrong, and improvement is not a reason to stop without a plan. In a risperidone discontinuation study, selected children who had already responded were more likely to relapse when switched to placebo. That concerns prior responders under research supervision. It cannot determine how long any one person needs treatment. 10
An aripiprazole maintenance study did not show a statistically significant difference on its main time-to-relapse outcome. That does not prove the drug never helps maintain benefit, or that stopping and continuing are equivalent. It leaves uncertainty that belongs in the review conversation. 11
As health, communication, and circumstances change, ask whether the current medicine still earns its place. Any change should be supervised. The goal is the least burdensome care that keeps the person safe and lets them take part in life.
Frequently asked questions
Do we have to try behavior therapy before medicine? Not always. Severity and urgency change the order. Supports and medical assessment can start at the same time as a medication discussion.
Does risperidone treat autism? No. It is approved for irritability associated with autistic disorder, which is a specific cluster of aggression, self-injury, tantrums, and rapidly changing mood. It is not a treatment for autism itself.
Which is better, risperidone or aripiprazole? The studies cannot answer that for one person. They enrolled different children and used different measures. The one direct comparison was far too small to settle it.
My child got calmer but sleeps all day. Is that success? No. Sedation is a burden, not a benefit. Report it, and ask the prescriber to review the target and the dose.
What blood tests are needed? That is the prescriber’s decision, based on the drug and the person. Ask what will be checked, when, and what would change the plan.
Related reading on NP FADY
- Autism medication: a parent’s map of the evidence
- Meltdown, tantrum, and shutdown in autism
- Missed conditions and medication targets
- When movement and speech change: catatonia in autism
References
1. Hyman SL, Levy SE, Myers SM; AAP Council on Children With Disabilities, Section on Developmental and Behavioral Pediatrics. Identification, Evaluation, and Management of Children With Autism Spectrum Disorder. Pediatrics. 2020;145:e20193447. DOI 10.1542/peds.2019-3447. DOI.
2. Lindgren S, Wacker D, Schieltz K, et al. A Randomized Controlled Trial of Functional Communication Training via Telehealth for Young Children with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders. 2020;50:4449–4462. DOI 10.1007/s10803-020-04451-1. DOI.
3. Bearss K, Johnson C, Smith T, et al. Effect of Parent Training vs Parent Education on Behavioral Problems in Children With Autism Spectrum Disorder: A Randomized Clinical Trial. JAMA. 2015;313:1524–1533. DOI 10.1001/jama.2015.3150. DOI.
4. Aman MG, McDougle CJ, Scahill L, et al. Medication and Parent Training in Children With Pervasive Developmental Disorders and Serious Behavior Problems: Results From a Randomized Clinical Trial. Journal of the American Academy of Child and Adolescent Psychiatry. 2009;48:1143–1154. DOI 10.1097/CHI.0b013e3181bfd669. DOI.
5. Janssen Pharmaceuticals, Inc. RISPERDAL (risperidone) tablets, orally disintegrating tablets, and oral solution: prescribing information. DailyMed. Updated May 28, 2026. Source.
6. Otsuka America Pharmaceutical, Inc. ABILIFY (aripiprazole) tablets: prescribing information. DailyMed. Updated January 29, 2025. Source.
7. McCracken JT, McGough J, Shah B, et al.; Research Units on Pediatric Psychopharmacology Autism Network. Risperidone in Children with Autism and Serious Behavioral Problems. New England Journal of Medicine. 2002;347:314–321. DOI 10.1056/NEJMoa013171. DOI.
8. Marcus RN, Owen R, Kamen L, et al. A Placebo-Controlled, Fixed-Dose Study of Aripiprazole in Children and Adolescents With Irritability Associated With Autistic Disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 2009;48:1110–1119. DOI 10.1097/CHI.0b013e3181b76658. DOI.
9. DeVane CL, Charles JM, Abramson RK, et al. Pharmacotherapy of Autism Spectrum Disorder: Results from the Randomized BAART Clinical Trial. Pharmacotherapy. 2019;39:626–635. DOI 10.1002/phar.2271. DOI.
10. Research Units on Pediatric Psychopharmacology Autism Network. Risperidone Treatment of Autistic Disorder: Longer-Term Benefits and Blinded Discontinuation After 6 Months. American Journal of Psychiatry. 2005;162:1361–1369. DOI 10.1176/appi.ajp.162.7.1361. DOI.
11. Alfaro C; U.S. Food and Drug Administration, Center for Drug Evaluation and Research. Clinical Review: sNDA 021436 S-036, ABILIFY (aripiprazole), Irritability Associated with Autistic Disorder (maintenance), study CN138603. Review completed February 26, 2014. Source.
This article is for education. It does not diagnose a condition, replace individual care, or promise services. Do not start, stop, or change any medicine without your prescribing clinician. Reading this does not create a clinician-patient relationship. Evidence checked September 8, 2026.
If you or someone you know is in crisis
- Call 911 or go to your nearest emergency room for any life-threatening emergency.
- 988 Suicide & Crisis Lifeline — call or text 988, or chat at 988lifeline.org, available 24/7, free and confidential. En español: marque 988 y oprima 2, o envíe AYUDA al 988. Deaf or hard of hearing: 988 videophone (ASL) or TTY 711 then 988. Veterans: 988 and press 1, or text 838255.
- Crisis Text Line — text HOME to 741741.
- The Trevor Project (crisis support for LGBTQ+ young people) — call 1-866-488-7386, or text START to 678-678.
- National Sexual Assault Hotline (RAINN) — call 1-800-656-HOPE (4673) or text HOPE to 64673; free, confidential, 24/7. Online chat at RAINN.org/hotline.
- National Domestic Violence Hotline — call 1-800-799-SAFE (7233) or text START to 88788; 24/7, help in 200+ languages. Online chat at TheHotline.org. If your phone or computer may be monitored, calling from a safer device is an option.
- Riverside County — Inland SoCal Crisis Helpline 951-686-HELP (4357), 24/7 (Inland SoCal United Way / 211+, in partnership with RUHS-BH); Community Access, Referral, Evaluation and Support (CARES) Line 800-499-3008, 24/7.
- San Bernardino County — Access Unit (Behavioral Health Helpline) 888-743-1478, 24/7; Mobile Crisis/CCRT 800-398-0018 (24/7, all ages) or text 909-420-0560. Arrowhead Regional Medical Center (ARMC) has a dedicated walk-in adolescent psychiatric ER (ages 13–17).
- Children under 13 — call 911 for immediate danger, contact your county's mobile crisis team (they respond to all ages), or go to the nearest pediatric emergency room.
- California Peer-Run Warm Line (non-crisis — someone to talk to) — call or text 1-855-600-WARM (9276); daytime and evening hours, not a 24/7 line.
- NP Fady (non-emergency) — for routine scheduling or questions, call (909) 707-6261. This line is not monitored for emergencies.