Autism Treatment & Management
- Author: James Robert Brasic, MD, MPH; Chief Editor: Caroly Pataki, MD more...
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 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 teach effective ways to modify these challenging behaviors. Parents 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. Adverse effects of interventions must be balanced against potential benefits. In particular, venlafaxine may increase high-intensity aggression in some adolescents with autism.[94]
Special Education
Special education is central to the treatment for 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 and related conditions. Intensive behavioral interventions, instituted as early as possible, are indicated for every child in whom autistic disorder is suspected.
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. These requirements for free appropriate public education apply even if the local public school lacks specialized programs.
Pediatricians and parents cannot assume that the community school will provide satisfactory education for a child with autistic disorder and related conditions. 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 and related conditions. 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, Behavior, and Physical Therapies
Speech, behavior, and physical therapies that are reported to help some individuals with autism include the following:
- Facilitated communication, using keyboards, letter boards, word boards, and other devices, 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 are reported to help some people with autistic disorder
Dietary Modification
Individuals with autistic disorder and related conditions need 3 well-balanced meals a day. 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 persons with autistic disorder and related conditions.
Physical Activity
Exercise is often therapeutic for individuals with autistic disorder. A regular program of activity prescribed by a physical therapist may be helpful.
Specialist Resources
Children with autism and related conditions typically benefit from intensive, thorough evaluations 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
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
Pharmacologic Treatment
Although 70% of children with autism spectrum disorders receive medications, scant evidence exists that the beneficial effects outweigh the adverse effects.[96] 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. Although children with autism spectrum disorders may experience significant adverse effects, risperidone and aripiprazole provide beneficial effects on challenging and repetitive behaviors.[97] Serotonergic drugs and opioid antagonists, including naltrexone, are reportedly beneficial for this purpose.
Ziprasidone may help to control aggression, irritability, and agitation.[98] Risperidone and aripiprazole have been approved by the FDA for irritability associated with autistic disorder. Hyperactivity often improves with methylphenidate therapy. Additionally, treatments are indicated for the underlying condition. For example, children with biotin-responsive infantile encephalopathy improve with the addition of biotin.
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,[99] escitalopram,[100] and citalopram[101, 102] .
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).[103] Multiple controlled randomized clinical trials have failed to demonstrate a beneficial effect of secretin for children with autism spectrum disorders.[104]
Children with autistic disorder are at risk to develop 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. 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. Additionally, Kem et al noted priapism in an adolescent with autism who was treated with trazodone.[105]
Experimental Approaches
Various interventions, including chiropractic manipulations, are reported to help with autistic disorder. The results of individual case reports cannot be generalized to the overall autistic population. However, scientific research is needed to investigate whether treatments are generally helpful.
Secretin therapy
Several anecdotal reports suggested that secretin, a gastrointestinal hormone, was an effective intervention for the symptoms of autism. This led to several scientific studies of secretin for autism spectrum disorders.[106, 107, 108] A review of 16 clinical trials for 900 children demonstrated no effect of single or multiple doses of secretin on social interaction, communication, and repetitive behaviors for autism spectrum disorders. Thus, there is no scientific evidence that secretin produces beneficial effects for children with autism spectrum disorders.[109]
Hyperbaric oxygen therapy
Beneficial effects of 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.
Research Studies and Clinical Trials
In New York, New York, Abigail Connolly is investigating connections among pragmatic language and behavioral needs of children with autism spectrum disorders, maternal stress, and family functioning. Further information may be obtained from her at ConnollyCUNY@aol.com.
Trials sponsored by the National Institutes of Health are listed at http://clinicaltrials.gov. Research studies at the intramural program of the National Institute of Mental Health (NIMH) are listed at http://intramural.nimh.nih.gov/pdn/. The NIMH can be reached by telephone at 301-435-7962.
Clinical trials for fragile X syndrome are listed at http://www.fraxa.org/ra_Paribello.aspx.
Consultations
Neuropsychological consultation can be helpful to assess intelligence. Deficits in simple and complex problem-solving tasks, both verbal and nonverbal, are likely to be demonstrated on the Wisconsin Card Sorting Test, the Trail Making Test, and the Stanford-Binet Intelligence Test.
Metabolic consultation may help identify any deficiencies.
Immunologic consultation may be useful to rule out immune abnormalities. The possible benefits must be weighed against the risks of experimental treatments such as intravenous (IV) immunoglobulin therapy.
Otolaryngologic consultation may be indicated to rule out deficits in the auditory apparatus. Additionally, audiography is indicated to rule out hearing deficits.
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 is indicated to evaluate tics and other movement disorders when present.
Infectious disease consultation may be helpful to rule out bacterial or fungal infections.
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