Sections

Treatment

Approach Considerations

Individual intensive interventions, including behavioral, educational, and psychological components, are the most effective treatments of ASD. 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 ASD is crucial because it allows for early identification of these patients. The American Academy of Pediatrics recommends referral for specialized diagnostic and therapeutic interventions as soon as symptoms or signs of ASD appear.^{[157, 1]}

Individuals with ASD typically benefit from behaviorally oriented therapeutic programs developed specifically for this population. Children with ASD 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 ASD. 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 ASD. 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 ASD.^[10]

Limited, largely anecdotal evidence suggests that dietary measures may be helpful in some children with ASD. 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 ASD. The project has identified established, emerging, and unestablished treatments. Early identification of children with ASD followed by prompt institution of intensive interventions^[158]facilitates optimal outcomes.^[159]

Inpatient Psychiatric Care

In December 2015, an expert panel released 11 consensus statements on best practices for inpatient care of children with ASD. The panel recommends that children with ASD or intellectual disability (ID) can be treated in general inpatient psychiatric units, with specific accommodations. The recommendations also set out the information that should be obtained from children on admission, including the child's preferences, means of communication, reinforcement items, and sensory sensitivities. Also emphasized is the importance of screening for co-occurring medical and psychiatric conditions.^[160]

Special Education

Special education is central to the treatment of ASD. 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 ASD or a related condition. Intensive behavioral interventions, instituted as early as possible, are indicated for every child in whom ASD is suspected.^{[161, 162]}

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 ASD 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 ASD 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 spectrum disorder include the following:

Assisted communication - Using keyboards, letter boards, word boards, and other devices (eg, the Picture Exchange Communication System^[163]), 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 ASD, including those with comorbid anxiety disorders.^[8]

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 ASD, showed significant improvements in IQ, adaptive behavior, and autism diagnosis compared with children who received intervention commonly available in the community.^[164]A follow-up electroencephalographic study showed normalized patterns of brain activity in the ESDM group.151 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.^[165]

Cognitive behavior therapy (CBT)

Cognitive behavior therapy (CBT) is a technique that has been valuable for people with anxiety disorders, including social anxiety disorder. Individuals with ASD and social anxiety underwent CBT to address negative thoughts and social situations provoking anxiety to develop effective behavioral techniques. CBT represents a promising psychological treatment for people with ASD and social anxiety.^[166]

Family therapy

Living with a person with ASD can be stressful for family members. Talking therapy to ameliorate conflicts among people with ASD and other family members has been reported to be beneficial to people with ASD and to family members. Research is needed to assess family therapy for people with ASD.^[167]

Mind-body exercise

Practices such as Qigong benefit children with ASD by reducing the severity of sensory, behavioral, and language dysfunction.^{[168, 169]}

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 compared with those without frequent symptoms.^{[170, 171]}

Individuals with or without ASD 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.^[172]

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 ASD. 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.^[173]

Additionally, preclinical and clinical studies indicate that dietary phenols alleviate symptoms of ASD.^[174]

Pharmacologic Treatment

Although 70% of children with ASD receive medications, only limited evidence exists that the beneficial effects outweigh the adverse effects.^[175]No pharmacologic agent is effective in the treatment of the core behavioral manifestations of ASD, but drugs may be effective in treating associated behavioral problems and comorbid disorders.^{[176, 177]}

The second-generation antipsychotic agents risperidone and aripiprazole provide beneficial effects on challenging and repetitive behaviors in children with ASD, although these patients may experience significant adverse effects.^[178]Risperidone and aripiprazole have been approved by the US Food and Drug Administration (FDA) for irritability associated with ASD. The second-generation antipsychotic agent ziprasidone may help to control aggression, irritability, and agitation.^[179]

Serotonergic drugs are reportedly beneficial for improving behavior in ASD. 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 ASD and related conditions. Beneficial effects on children and adolescents with ASD have been reported with fluoxetine,^[180]escitalopram,^[181]and citalopram.^{[182, 183]}

On the other hand, a multicenter, randomized, controlled trial by King and colleagues in 149 children with ASD 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).^[184]

Serotonin syndrome

Children with ASD 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.

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Adverse effects and treatment efficacy

Children with ASD 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.^{[185, 186]}Additionally, Kem et al noted priapism in an adolescent with ASD who was treated with trazodone.^[187]

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 ASD. 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.^[188]

Experimental Approaches

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

Transcranial magnetic stimulation

Repetitive transcranial magnetic stimulation has been reported to alleviate repetitive behaviors and improve social functioning in ASD.^[189]

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 ASD. This led to several scientific studies of secretin for children with ASD.^{[190, 191, 192]}However, 2 reviews of these trials failed to demonstrate that secretin had a beneficial effect on these children.^{[193, 194]}

Hyperbaric oxygen therapy

Beneficial effects from hyperbaric oxygen therapy have been reported in 6 patients with ASD. 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 ASD.^{[195, 196]}

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 ASD 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

University of Maryland Medical Center

737 West Lombard Street, First Floor

Baltimore, MD 21201

Phone: 410-706-2300

Fax: 410-706-5770

URL: http://www.medschool.umaryland.edu/pediatrics/Divisions/Division-of-Behavioral--Developmental-Pediatrics/

Yale Developmental Disabilities Clinic

Yale Child Study Center

Yale University School of Medicine

350 George Street, 2nd Floor

New Haven, CT 06511

Phone: 203-785-3420

URL: www.autism.fm

Seaver Autism Center for Research and Treatment

Icahn School of Medicine at Mount Sinai

Department of Psychiatry

Mount Sinai School of Medicine, Box 1230

One Gustave L Levy Place

New York, NY 10029

Phone: 212-241-0961

Email: theseavercenter@mssm.edu

URL: https://icahn.mssm.edu/research/seaver

Center for Autism and Related Disorders

Kennedy Krieger Institute

Creamer Family Building

3901 Greenspring Avenue

Baltimore, MD 21211

URL: https://www.kennedykrieger.org/patient-care/centers-and-programs/center-for-autism-and-related-disorders

Division of Child and Adolescent Psychiatry

Neuropsychiatric Hospital

University of California at Los Angeles

760 Westwood Plaza, Room 48-240

Los Angeles, CA 90024-1759

Phone: 310-825-9989 (800-825-9989 from outside 310)

URL: https://people.healthsciences.ucla.edu/institution/groups-detail?group_id=12516

Medical Investigation of Neurodevelopmental Disorders (MIND) Institute

University of California Davis Medical Center

2825 50th Street

Sacramento, CA 95817

Phone: 916-703-0280

URL: https://health.ucdavis.edu/mindinstitute/contactus/index.html

Strong Center for Developmental Disabilities

Department of Pediatrics

Children's Hospital at Strong

University of Rochester Medical Center

601 Elmwood Ave, Box 671

Rochester, NY 14642

URL: https://www.urmc.rochester.edu/strong-center-developmental-disabilities/contact-us.aspx

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 ASD.
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

Guidelines

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Media Gallery

The significance of answers to individual Autism Screening Checklist items is as follows: Item 1- A "yes" occurs in healthy children and children with some pervasive developmental disorders; a "no" occurs in children with autism, Rett syndrome, and other developmental disorders. Item 2 - A "yes" occurs in healthy children, not children with autism. Item 3 - A "yes" occurs in healthy children and children with Asperger syndrome (ie, high-functioning autism); a "no" occurs in children with Rett syndrome; children with autism may elicit a "yes" or a "no"; some children with autism never speak; some children with autism may develop speech normally and then experience a regression with the loss of speech. Item 4 - A "yes" occurs in healthy children and children with Asperger syndrome and some other pervasive developmental disorders; a "no" occurs in children with developmental disorders; children with autism may elicit a "yes" or a "no." Items 5-10 - Scores of "yes" occur in some children with autism and in children with other disorders. Item 11 – A "yes" occurs in healthy children; a "no" occurs in some children with autism and in children with other disorders. Items 12, 13 - Scores of "yes" occur in some children with autism and in children with other disorders. Items 14-19 - Scores of "yes" occur in children with schizophrenia and other disorders, not in children with autism, Asperger syndrome, or other autism spectrum disorders. The higher the total score for items 5-10, 12, and 13 on the Autism Screening Checklist, the more likely the presence of an autism spectrum disorder.
Serotonin syndrome checklist.

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Author

James Robert Brasic, MD, MPH, MS, MA Assistant Professor, Russell H Morgan Department of Radiology and Radiological Science and Neurology, Division of Nuclear Medicine and Molecular Imaging, Assistant Professor, Department of Neurology, Johns Hopkins University School of Medicine

James Robert Brasic, MD, MPH, MS, MA is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Neurology, International Parkinson and Movement Disorder Society, Society for Neuroscience, Society of Nuclear Medicine and Molecular Imaging

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Johns Hopkins University School of Medicine<br/>Serve(d) as a speaker or a member of a speakers bureau for: Society of Nuclear Medicine and Molecular Imaging, Maryland Regional Council of Child and Adolescent Psychiatry<br/>Received research grant from: National Institutes of Health, Johns Hopkins University School of Medicine, Intellectual & Developmental Disabilities Research Center (U54 HD079123) at the Kennedy Krieger Institute<br/>Received income in an amount equal to or greater than $250 from: Gerson Lehrman Group; Guidepost<br/>Received royalty from Medscape for other.

Coauthor(s)

Farzaneh Farhadi, MD Postdoctoral Research Fellow, Johns Hopkins Hospital

Disclosure: Nothing to disclose.

Tarek Elshourbagy, MBBCh Intern, Kasr Alainy Medical School, Cairo University, Egypt; Research Physician, Department of Radiology, Johns Hopkins University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgements

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Acknowledgments

This publication was made possible by the Johns Hopkins Institute for Clinical and Translational Research (ICTR) which is funded in part by Grant Number UL1 TR003098 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the Johns Hopkins ICTR, NCATS or NIH. This research is also supported by the Radiology Bridge Funding Initiative to Stimulate and Advance Research (RAD BriteStar Bridge) Award of the Johns Hopkins University School of Medicine and the Intellectual and Developmental Disabilities Research Center (U54 HD079123) at the Kennedy Krieger Institute of Johns Hopkins Medical Institutions in Baltimore, Maryland.

Autism Spectrum Disorder Treatment & Management