Autism Spectrum Disorders - Treatment & Management

Educational and behavioral interventions remain the cornerstone of management of autism spectrum disorders and may lead to significant improvement in cognition, communication, adaptive skills, and social skills. Several types of educational models have been developed and may be categorized as: behavior analytic, developmental, and structured teaching. While these models differ significantly, they often share common goals and behavioral techniques.

• Applied Behavioral Analysis (ABA) relies on the use of experimental psychology techniques to increase the frequency of desired behaviors and decrease the frequency of undesired or maladaptive behaviors. Teaching sessions are highly structured and behavioral data is methodically collected. When initiated early and conducted in an intense fashion (30-40 hours per week), ABA-based interventions have shown effectiveness in leading to sustained cognitive gains, improved communication, improved academic functioning, and better global outcomes. Critics of ABA interventions suggest that skills taught by this method do not generalize well to the natural environment and that the difficulty in implementing such an intense treatment program in a young population is prohibitive. Newer approaches using basic ABA methodology with more emphasis on teaching in the natural environment (Natural Environment Training, Applied Verbal Behavior) have been designed to address issues of generalizability and encourage the spontaneous use of communication.
• Developmental Models. Developmental or relationship-based models are based on the use of developmental theory to design interventions that target the core deficits of autism. Examples include the developmental, individual-difference, relationship-based model (DIR) and the relationship-development intervention (RDI). These interventions are often attractive to families because they are play-based and can readily be taught to family members. The empiric evidence supporting developmental strategies is limited.
• Structured Teaching. The TEACCH method (Treatment and Education of Autistic and related Communication-handicapped CHildren) emphasizes organization of the physical environment, predictable routine sequence with flexible routines, structured work and activity sessions, visual schedules and visually structured activities. While it has not been as rigorously studied as ABA, TEACCH is supported by a small body of empiric evidence indicating improvements when a TEACCH-based home program is implemented in addition to school programming. [Ospina: 2008]
  
  

Various social skills interventions have been developed to address the core deficits in social development faced by children on the autism spectrum. Social skills interventions, carried out individually or in small groups, may involve the use of social stories, video modeling, or playgroups in which adult facilitators prompt appropriate interactions between participants with positive reinforcement for spontaneous appropriate interactions. A review article by Bellini and Peters provides detailed information regarding different approaches to social skills training. [Bellini: 2008]

Subspecialist Collaborations and Other Resources

Individuals with autism spectrum disorders are at risk for psychiatric comorbidities, such as anxiety disorders, mood disorders, and attention deficit disorder with or without hyperactivity. Often, such disorders may present with aggression, irritability, or self-injurious behavior. A detailed symptom history, including problem behaviors, antecedents, and consequences, should be obtained to identify the underlying disorder.

An anxiety disorder should be considered in a child with aggression or irritability associated with changes in routine, transitions between activities, separation from a caregiver, or interruption of repetitive or obsessive behaviors. Also consider anxiety in the child who demonstrates acute changes in behavior associated with discrete situations that may cause fear. Management of anxiety may include both behavioral and pharmacologic approaches

• Behavioral strategies
  • Visual schedules. The use of visual or picture-based schedules may be beneficial in reducing anxiety and undesired behaviors surrounding transitions and changes in routine. Photographs, simple drawings, or computer-generated pictures may be used for visual schedules. Families and educators may also download simple drawings for schedule use from the website Do 2 Learn. Access to all pictures on the site may be obtained for an annual fee. This site also contains a free section with extensive schedule materials for safety issues and activities of daily living.
  • Social Stories describe situations in terms of relevant social cues, perspectives, and common responses in a specifically defined style and format. When designed and used properly, they can be useful in helping individuals understand situations that cause anxiety and to respond with more appropriate behaviors. The concept of the Social Story was developed by Carol Gray in 1991. For more information, visit The Gray Center Website.
• Medications for the treatment of anxiety
  • While selective serotonin-reuptake inhibitors (SSRIs) are frequently used to treat anxiety in children with ASDs, they do not treat the core symptoms of autism (language delay, social delay, and restrictive interests/repetitive behavior). Their use is supported by several randomized, controlled trials that have shown improvements in irritability and depressive symptoms, tantrums, anxiety, aggression, difficulty with transitions, and some aspects of social interactions and language. SSRIs may cause nausea, drowsiness, gastrointestinal disturbance, agitation, behavioral activation, suicidal ideation, sleep disturbance or other symptoms. SSRI use in children with autism and other neurodevelopmental disabilities provides detailed information regarding the use and adjustment of SSRI medications in individuals with autism and other neurodevelopmental disabilities. [Kolevzon: 2006]
  • Alpha-2 agonists may reduce symptoms of anxiety, hyperactivity, and irritability. They may be particularly helpful in patients who experience behavioral activation with SSRIs. Alpha-2 agonists may cause more somnolence than SSRIs. Additional possible adverse effects include, but are not limited to, dry mouth, hypotension, constipation, irritability, and cardiac arrhythmia. Alpha-2 agonist use in children with autism provides additional information. [Handen: 2008] [Ming: 2008]
  • Benzodiazepines. Though they should not be used as a first-line agent in the chronic management of anxiety, long-acting benzodiazepines (such as clonazepam) may be beneficial in individuals who do not tolerate alpha-2 agonists or SSRIs.
  • Atypical antipsychotic medications. The antipsychotic medications risperidone and aripiprazole have received US Food and Drug Administration approval for the treatment of the symptoms of irritability and aggression in children and adolescents age 6 and older with ASDs. This class of medication should not be considered first-line in the approach to anxiety in the patient on the autism spectrum. If a detailed symptom history reveals that irritable and aggressive behavior may be due to underlying anxiety, then an SSRI or alpha-2 agonist may be more appropriate. Antipsychotic medications may be useful, however, if a patient does not tolerate treatment with and SSRI or alpha-2 agonist. These medications may cause appetite increase and weight gain, insulin resistance, dylipidemia, hyperprolactinemia, extrapyramidal symptoms, tardive dyskinesia, neuroleptic malignant syndrome, QTc prolongation, seizures, anticholinergic symptoms, and sedation. Patients may experience akathisia ("inner restlessness") when doses are titrated up or down. Upon discontinuation, these medications should be tapered over months to avoid excessive akathisia. Atypical antipsychotic medication use in children and adolescents with autism provides further information. [Luby: 2006] [Williams: 2006] [McDougle: 2005] [Owen: 2009]
    
    
• Depression. Individuals with ASDs may experience depressive symptoms. When considering a diagnosis of depression, take a behavioral history to establish a baseline for the child's disruptive or maladaptive behavior. Compare the patient's current state to his or her baseline, with particular attention to crying spells, enjoyment of activities, interest in being around others, sleep patterns, appetite, and energy level. Note the intensity, frequency, and duration of related maladaptive behaviors. Establish behavioral treatment targets based on the behavioral history obtained.
  • SSRIs are the recommended medication for depression in individuals with ASD. SSRI use in children with autism and other neurodevelopmental disabilities provides detailed information regarding their use and adjustment in individuals with autism and other neurodevelopmental disabilities.

• Attention-deficit hyperactivity disorder. Individuals with ASDs may also experience symptoms of inattention and hyperactivity, which can impair their ability to acquire new skills and function in the home and school environments. While stimulant medications such as methylphenidate are effective in some children with ASDs and ADHD symptoms, the response rate is lower than that in typically-developing children with isolated ADHD and the potential for adverse effects is higher. Pharmacologic treatment of hyperactivity and inattentiveness in autism spectrum disorders offers further information.

These recommendations are intended as guidelines for the approach to psychiatric comorbidities in individuals with ASDs. Practitioners should only prescribe medications with which they are familiar, including knowledge of indications and contraindications, potential adverse effects, drug-drug interactions, dosing, and monitoring recommendations. Consultation with a pediatric psychiatrist should be considered if a practitioner is unfamiliar or uncomfortable with the use of such medications. If regular psychiatric care is not available, consider co-management or phone consultation with a child psychiatrist experienced in the management of children with ASDs.

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Sleep problems are very common in individuals with ASDs and may significantly impact behavior and family functioning. Sleep problems in this population are often behaviorally mediated or related to poor sleep hygiene. Other potential causes of sleep disruption include obstructive sleep apnea, gastroesophageal reflux, periodic limb movement disorder, and circadian rhythm disturbance. If sleep problems are reported, a detailed history should be obtained, including details of sleep onset and duration, nighttime wakenings, snoring and restlessness, and nightmares. The details of the sleep history should guide management strategies.

• Behavioral management is often effective and should be considered first-line treatment. [Johnson: 2008]
• Melatonin may be effective if a circadian rhythm disturbance is suspected or sleep onset is delayed [Andersen: 2008].
• Clonidine may be effective in reducing sleep latency and nighttime wakenings [Ming: 2008].
• Low iron stores have been associated with periodic limb movement disorder (PLMD)/restless leg syndrome. If sleep is described as restless, consider obtaining a CBC and serum ferritin. Iron supplementation in individuals with PLMD and low serum ferritin may lead to significant sleep improvement. [Dosman: 2007].
  • Sleep disorders in children with autism provides additional guidelines for the basic management of disordered sleep.

Subspecialist Collaborations and Other Resources

If sleep problems persist after behavioral management techniques have been implemented, medications such as melatonin and clonidine may be of benefit in cases of prolonged sleep latency or frequent nighttime wakenings. Consider referral for to a sleep medicine specialist for further evaluation and consideration of a sleep study if sleep problems continue.

The primary care provider should inquire about the communication methods used by the patient with autism and involvement in private or school-based speech therapy services. Many children on the autism spectrum initially learn to communicate using nonverbal methods such as American Sign Language, the Picture Exchange Communication System (PECS), a communication board, or a combination of methods. The use of non-verbal communication methods does not inhibit the development of spoken language and should not be discouraged. Older non-verbal individuals may benefit from an assistive communication device. A speech and language pathologist can assist in teaching nonverbal communication modalities and perform evaluations for assistive communication devices, if appropriate.

Subspecialist Collaborations and Other Resources

In the United States, many children on the autism spectrum are treated with complementary and alternative medicine (CAM). Nearly one-third of children have been treated with some form of CAM by the time an ASD is diagnosed. Because the use of these treatments is so prevalent, the primary care physician should be aware of popular treatments, as well as potential benefits and risks. Most of these treatments have not been rigorously tested for safety and efficacy. The clinician must, however, remain open to discussing CAM therapies with families and provide information so that families can make informed decisions regarding their use. Association for Science in Autism Treatment provides a comprehensive list of CAM treatments used in autism, with references to evidence that may help guide treatment decisions. [Levy: 2008] [Weber: 2007]

Some individuals on the autism spectrum show extreme food selectivity and/or oral texture issues. Obtaining a dietary history can help identify those individuals who are at risk for nutritional deficiency and guide dietary intervention and supplementation, if needed.

The gluten-free, casein-free (GFCF) diet is a popular alternative treatment. It has been suggested that the proteins gluten and casein cause or exacerbate features of autism, after they are absorbed across a damaged or "leaky" gut, by acting upon the central nervous system as opiate-like neuropeptides. While anecdotal reports have indicated some success with the implementation of the GFCF diet, several small studies have not shown significant improvements in language or behavior with the diet. Families who desire to try the GFCF diet should be counseled regarding the need for calcium and vitamin D supplementation. Recent evidence suggests diminished bone cortical thickness in boys on the autism spectrum, particularly those on the GFCF diet. [Hediger: 2008] In addition, protein intake should be monitored, as many young children obtain a great deal of their protein from dairy products.

Subspecialist Collaborations and Other Resources

For Professionals

Autism (OMIM)
from Online Mendelian Inheritance in Man, supported by the National Center for Biotechnology Information; provides extensive, detailed background on genetic studies related to autism.

Autism Overview (GeneReviews)
From genetests.org, extensive clinical review with focus on heritable causes and candidate genes.

Autism Spectrum Disorders Knowledge Path
This site from the Maternal & Child Health Library at Georgetown provides many links to other sites that address autism including links for professionals and families.

For Parents and Patients

Books on Autism Spectrum Disorders ( 24 KB) contains a list of books recommended as general information for patients and families affected by autism spectrum disorders.

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