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Autism Treatment & Management

Approach Considerations

Individual intensive interventions, including behavioral, educational, and psychological components, are the most effective treatments of autistic disorder. Beginning the treatment early in infancy increases the likelihood of a favorable outcome. Thus, regular screening of infants and toddlers for symptoms and signs of autistic disorder is crucial because it allows for early identification of these patients.

Individuals with autism spectrum disorder and unspecified pervasive developmental disorder typically benefit from behaviorally oriented therapeutic programs developed specifically for this population. Autistic children should be placed in these specialized programs as soon as the diagnosis is entertained.

Parents, teachers, pediatricians, and other health care providers are advised to seek the assistance of people who are familiar with early intervention programs for children with autistic disorder. The Autism Society can help parents to obtain appropriate referrals for optimal interventions.

Parents understandably become exhausted by the relentless performance of challenging behaviors by their child with autism. A specially trained educator or behavioral psychologist can help to teach them effective ways to modify these challenging behaviors. Parents also frequently benefit from temporary respite from the child.

The possible benefits from pharmacotherapy must be balanced against the likely adverse effects on a case-by-case basis. In particular, venlafaxine may increase high-intensity aggression in some adolescents with autism.^[8]

Limited, largely anecdotal evidence suggests that dietary measures may be helpful in some children with autism. Avoidance of certain foods, notably those containing gluten or casein, and supplementation with specific vitamins and minerals have reportedly proved helpful in select cases.

The National Autism Center has initiated the National Standards Project, which has the goal of establishing a set of evidence-based standards for educational and behavioral interventions for children with autism spectrum disorders. The project has identified established, emerging, and unestablished treatments.

Special Education

Special education is central to the treatment of autistic disorder. Although parents may choose to use various experimental treatments, including medication, they should concurrently use intensive individual special education by an educator familiar with instructing children who have autistic disorder or a related condition. Intensive behavioral interventions, instituted as early as possible, are indicated for every child in whom autistic disorder is suspected^{[118, 119]} .

The Education for All Handicapped Children Act of 1975 requires free and appropriate public education for all children, regardless of the extent and severity of their handicaps. Amendments to the Education of the Handicapped Act of 1986 extended the requirement for free and appropriate education to children aged 3-5 years.

Pediatricians and parents cannot assume, however, that their community’s school will provide satisfactory education for a child with autistic disorder or a related condition. The Individuals with Disabilities Education Act authorized states to determine how to provide educational services to children younger than 3 years. Pediatricians and parents need to determine the best way to proceed with local agencies.

Legal assistance may be necessary to influence a board of education to fund appropriate education for a child with autistic disorder or a related condition. The Autism Society maintains a Web site and offers a toll-free hotline (1-800-3-AUTISM/1-800-328-8476). This resource provides information and referral services to the public.

Speech, Behavioral, Occupational, and Physical Therapies

Therapies that are reported to help some individuals with autism include the following:

• Assisted communication - Using keyboards, letter boards, word boards, and other devices (eg, the Picture Exchange Communication System ^[120] ), with the assistance of a therapist
• Auditory integration training - A procedure in which the individual listens to specially prepared sounds through headphones
• Sensory integration therapy - A treatment for motor and sensory motor problems typically administered by occupational therapists
• Exercise and physical therapy - Exercise is often therapeutic for individuals with autistic disorder; a regular program of activity prescribed by a physical therapist may be helpful

In addition, social skills training helps some children with autism spectrum disorder, including those with comorbid anxiety disorders.^[7] Children with autism spectrum disorder and comorbid attention deficit hyperactivity disorder may not benefit from social skills training.^[7]

In a 2-year randomized, controlled trial, children who received the Early Start Denver Model (ESDM), a comprehensive developmental behavioral intervention for improving outcomes of toddlers diagnosed with autism spectrum disorder, showed significant improvements in IQ, adaptive behavior, and autism diagnosis compared with children who received intervention commonly available in the community.^[121] A follow-up electroencephalographic study showed normalized patterns of brain activity in the ESDM group.^[122]

In contrast, a 12-week study of parent-delivered ESDM intervention found no effect on child outcomes compared with usual community treatment. However, starting intervention at an earlier age and providing a greater number of intervention hours both related to the degree of improvement in children's behavior.^[123]

Diet

When compared with their typically developing (TD) peers, children with ASD are significantly more likely to experience GI problems and food allergies. According to one study, children with ASD were 6 to 8 times more likely to report frequent gas/bloating, constipation, diarrhea, and sensitivity to foods than TD children. Researchers also discovered a link between GI symptoms and maladaptive behavior in children with ASD. When these children had frequent GI symptoms, they showed worse irritability, social withdrawal, stereotypy, and hyperactivity scores compared with those without frequent symptoms.^{[124, 125]}

Individuals with autistic disorder or a related condition need 3 well-balanced meals daily. Dietary consultation may be useful to evaluate the benefits of special diets, including those lacking gluten and casein. Vitamin B-6 and magnesium are among the vitamins and minerals hypothesized to help some patients.^[126]

In a randomized, double-blind, placebo-controlled trial, 3 months of treatment with a vitamin/mineral supplement produced statistically significant improvement in the nutritional and metabolic status of children with autism. In addition, the supplement group had significantly greater improvements than did the placebo group in its Parental Global Impressions-Revised (PGI-R) Average Change scores.^[127]

Pharmacologic Treatment

Although 70% of children with autism spectrum disorder receive medications, only limited evidence exists that the beneficial effects outweigh the adverse effects.^[128] No pharmacologic agent is effective in the treatment of the core behavioral manifestations of autistic disorder, but drugs may be effective in treating associated behavioral problems and comorbid disorders.^{[129, 130]}

The second-generation antipsychotic agents risperidone and aripiprazole provide beneficial effects on challenging and repetitive behaviors in children with autism spectrum disorder, although these patients may experience significant adverse effects.^[131] Risperidone and aripiprazole have been approved by the US Food and Drug Administration (FDA) for irritability associated with autistic disorder. The second-generation antipsychotic agent ziprasidone may help to control aggression, irritability, and agitation.^[132]

Serotonergic drugs are reportedly beneficial for improving behavior in autism. Hyperactivity often improves with methylphenidate therapy.

Additionally, treatments may be indicated for an underlying condition. For example, children with biotin-responsive infantile encephalopathy improve with the addition of biotin.

SSRIs

Selective serotonin reuptake inhibitors (SSRIs) are widely prescribed for children with autism and related conditions. Beneficial effects on children and adolescents with autism and other pervasive developmental disorders have been reported with fluoxetine,^[133] escitalopram,^[134] and citalopram^{[135, 136]} .

On the other hand, a multicenter, randomized, controlled trial by King and colleagues in 149 children with autism spectrum disorders found no difference between citalopram and placebo among children rated as much improved or very much improved. Participants in the treatment arm received liquid citalopram daily for 12 weeks at a mean maximum daily dose of 16.5 mg (maximum 20 mg). Nearly all the citalopram recipients reported adverse effects (eg, impulsiveness, hyperactivity, diarrhea).^[137]

Serotonin syndrome

Children with autistic disorder are at risk of developing a serotonin syndrome when treated with serotonergic agents. Therefore, children who are treated with serotonergic agents should be evaluated at baseline before beginning treatment and then regularly evaluated for symptoms of a serotonin syndrome using the serotonin syndrome checklist. See the image below for a printable version.

Serotonin syndrome checklist.

Adverse effects and treatment efficacy

Children with autistic disorder appear sensitive to medication and may experience serious adverse effects that outweigh any beneficial effects. For example, children may develop catatonia when treated with haloperidol and other traditional neuroleptics.^{[138, 139]} Additionally, Kem et al noted priapism in an adolescent with autism who was treated with trazodone.^[140]

Practice guidelines from the American Academy of Pediatrics stress the importance of having some quantifiable means of assessing the efficacy of medication used for the treatment of children with autism. Validated, treatment-sensitive rating scales that have been used in clinical practice to measure the effects of treatment on maladaptive behavior include the Clinical Global Impression Scale, the Aberrant Behavior Checklist, and the Nisonger Child Behavior Rating Form.^[141]

Experimental Approaches

Various interventions, including chiropractic manipulations, are reported to help with autistic disorder. The results of individual case reports, however, cannot be generalized to the overall autistic population; scientific research is needed to investigate whether treatments truly are generally helpful.

Secretin therapy

Several anecdotal reports suggested that secretin, a gastrointestinal hormone that may function as a neurotransmitter, was an effective intervention for the symptoms of autism. This led to several scientific studies of secretin for children with autism spectrum disorders.^{[142, 143, 144]} However, 2 reviews of these trials failed to demonstrate that secretin had a beneficial effect on these children.^{[145, 146]}

Hyperbaric oxygen therapy

Beneficial effects from hyperbaric oxygen therapy have been reported in 6 patients with autism. The risks of this procedure must be weighed against the benefits for individual patients. Controlled clinical trials and other studies are needed to confirm the potential value of this intervention.

Intranasal oxytocin

Research suggests that administration of a single intranasal dose of the hormone oxytocin increases activity in brain regions associated with reward, social perception, and emotional awareness and temporarily improves social information processing in children with autism spectrum disorder (ASD).^{[147, 148]}

In the study of 17 high-functioning children and adolescents with ASD, brain centers associated with reward and emotion recognition responded more during social tasks when children received oxytocin instead of a placebo.

Although behavioral studies in children and adults suggest that a single dose of intranasal oxytocin improves social interaction and comprehension of affective speech, results from clinical trials examining the effect of daily administration of the drug have been mixed.

Specialist Resources

Children with autism and related conditions typically benefit from intensive, thorough evaluation performed by experienced professionals. Intensive diagnostic evaluation and treatment are accomplished quickly and effectively by well-trained clinicians at well-staffed centers. Valuable resources are listed below.

Division of Developmental and Behavioral Pediatrics

Pediatric Ambulatory Center

University of Maryland Medical Center

700 West Lombard St

Baltimore, MD

Phone: 410-328-5437

Developmental Disabilities Clinic

Child Study Center

Yale University School of Medicine

230 South Frontage Rd

PO Box 207900

New Haven, CT 06520-7900

Phone: 203-785-2510 (For appointments, call 203-785-2874.)

Fax: 203-737-4197

Developmental Disorders Clinic

The Harris Center for Developmental Studies

Section of Child and Adolescent Psychiatry

Department of Psychiatry

The University of Chicago

5841 South Maryland Ave MC3077

Chicago, IL 60637

Seaver Autism Research Center

Department of Psychiatry

Mount Sinai School of Medicine, Box 1230

One Gustave L Levy Place

New York, NY 10029-6574

Phone: 212-241-2994

Bellevue Hospital Center

462 First Ave

New York, NY 10016-9103

Phone: 212-562-4504

Center for Autism and Related Disorders

Kennedy Krieger Institute

Pierce Building, Third Floor

3825 Greenspring Avenue

Baltimore, MD 21211

Phone: 410-404-6252

Fax: 443-923-7695

Division of Child Psychiatry

New York State Psychiatric Institute, Room 2521

722 West 168th St

New York, NY 10032

Phone: 212-543-5280, 212-543-6782, 212-579-5557

Fax: 212-543-5966

Division of Child and Adolescent Psychiatry

Department of Psychiatry

University of California at Los Angeles

760 Westwood Plaza, Room 48-270

Los Angeles, CA 90095

Phone: 310-825-0470

Fax: 310-206-4446

Medical Investigation of Neurodevelopmental Disorders (MIND) Institute

University of California Davis Medical Center

4860 Y Street, Room 3020

Sacramento, CA 95817

Phone (toll-free): 888-883-0961

Phone: 916-734-5153

Strong Center for Developmental Disabilities

Department of Pediatrics

Children's Hospital at Strong

University of Rochester Medical Center

601 Elmwood Ave

Rochester, NY 14642

Phone: 716-275-2100

Consultations

Neuropsychological consultation can be helpful to assess intelligence. Deficits in simple and complex problem-solving tasks (verbal and nonverbal), are likely to be demonstrated on the following tests:

• Wisconsin Card Sorting Test
• Trail Making Test
• Stanford-Binet Intelligence Test

Other consultations include the following:

• Ophthalmologic consultation - May be indicated to rule out a treatable visual deficit; special lenses are reported to help some individuals with autistic disorder
• Neurologic consultation with a movement disorder specialist - Indicated to evaluate tics and other movement disorders when present
• Infectious disease consultation - May be helpful to rule out bacterial or fungal infections
• Metabolic consultation - May help to identify any deficiencies
• Immunologic consultation - May be useful to rule out immune abnormalities; the possible benefits of experimental treatments, such as intravenous (IV) immunoglobulin therapy, must be weighed against the risks of experimental treatments
• Otolaryngologic consultation - May be indicated to rule out deficits in the auditory apparatus; additionally, audiography is indicated to rule out hearing deficits