Autism therapies

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Autism therapies attempt to lessen the deficits and family distress associated with autism spectrum disorders (ASD), and to increase the quality of life and functional independence of autistic individuals, especially children. No single treatment is best and treatment is typically tailored to the child's needs. Treatments fall into two major categories: educational interventions and medical management. Training and support is also given to families of those with ASD.[1]

Intensive, sustained special education programs and behavior therapy early in life can help children acquire self-care, social, and job skills.[1] Available approaches include applied behavior analysis, which focuses on teaching tasks one-on-one using the behaviorist principles of stimulus, response and reward,[2] and cognitive therapies based on comprehensive programs in treatment centers.[3] Educational interventions have some effectiveness in children;[2][4] the limited research on the effectiveness of adult residential programs shows mixed results.[5]

Medications are often used to treat problems associated with ASD. More than half of U.S. children diagnosed with ASD are prescribed psychoactive drugs or anticonvulsants, with the most common drug classes being antidepressants, stimulants, and antipsychotics.[6] Aside from antipsychotics,[7] there is scant reliable research about the effectiveness or safety of drug treatments for adolescents and adults with ASD.[8][9] A person with ASD may respond atypically to medications, the medications can have adverse side effects, and no known medication relieves autism's core symptoms of social and communication impairments.[10]

Many alternative therapies and interventions are available. Few are supported by scientific studies.[11][12][13][14][15][16] Treatment approaches lack empirical support in quality-of-life contexts, and many programs focus on success measures that lack predictive validity and real-world relevance.[17] Scientific evidence appears to matter less to service providers than program marketing, training availability, and parent requests.[18] Even if they do not help, conservative treatments such as changes in diet are probably harmless aside from their bother and cost.[19] Dubious invasive treatments are a much more serious matter: for example, in 2005, botched chelation therapy killed a five-year-old autistic boy.[20]

Treatment is expensive;[21] indirect costs are more so. A U.S. study estimated the average additional lifetime cost due exclusively to autism to be $3.2 million in 2003 U.S. dollars for an autistic individual born in 2000, with about 10% medical care, 30% nonmedical care such as child care and education, and 60% the lost economic productivity of individuals and their parents.[22] Legal rights to treatment are complex, vary with location and age, and require advocacy by caregivers.[23] Publicly supported programs are often inadequate or inappropriate for a given child, and unreimbursed out-of-pocket medical or therapy expenses are associated with likelihood of family financial problems.[24] After childhood, key treatment issues include residential care, job training and placement, sexuality, social skills, and estate planning.[23]

Educational interventions

Educational interventions attempt to help children not only to learn academic subjects and gain traditional readiness skills, but also to communicate functionally and spontaneously, socialize with skills such as joint attention, gain cognitive skills such as symbolic play, reduce disruptive behavior, and generalize by applying learned skills to new situations. Several model programs have been developed, which in practice often overlap and share many features, including:[1]

  • early intervention that does not wait for a definitive diagnosis;
  • intense intervention, at least 25 hours/week, 12 months/year;
  • low student/teacher ratio;
  • family involvement, including training of parents;
  • interaction with neurotypical peers;
  • structure that includes predictable routine and clear physical boundaries to lessen distraction; and
  • ongoing measurement of a systematically planned intervention, resulting in adjustments as needed.

Several educational intervention methods are available, as discussed below. They can take place at home, at school, or at a center devoted to autism treatment. A 2007 study found that augmenting a center-based program with weekly home visits by a special education teacher improved cognitive development and behavior.[25] Intensive, sustained special education programs and behavior therapy early in life can help children acquire self-care, social, and job skills;[1] claims that intervention by age two to three years is crucial[26] are not substantiated.[27]

Applied behavior analysis

Interventions based on applied behavior analysis (ABA) focus on teaching tasks one-on-one using the behaviorist principles of stimulus, response and reward,[2] and on reliable measurement and objective evaluation of observed behavior.[1] There is wide variation in the professional practice of behavior analysis and among the assessments and interventions used in school-based ABA programs.[28] Many interventions rely heavily on discrete trial teaching (DTT) methods, which use stimulus-response-reward techniques to teach foundational skills such as attention, compliance, and imitation. However, children have problems using DTT-taught skills in natural environments.[1] In functional behavior analysis, a common assessment technique, a teacher formulates a clear description of a problem behavior, identifies antecedents, consequents, and other environmental factors that maintain the behavior, develops hypotheses about what motivates the behavior, and collects observations to test the hypotheses.[1] A few more-comprehensive ABA programs use multiple assessment and intervention methods individually and dynamically.[28]

ABA has demonstrated effectiveness in several controlled studies: children have been shown to make sustained gains in academic performance, adaptive behavior, and language, with outcomes significantly better than control groups.[1] For example, a 2005 California study found that early intensive behavior analytic treatment, a form of ABA, was substantially more effective for preschool children with autism than the mixture of methods provided in many programs.[2] However, a 2007 British study found that home-based early intensive behavioral interventions, another ABA form, was no more effective than nursery-based eclectic programs.[4]

TEACCH

Main article: TEACCH

TEACCH, which has come to be called "structured teaching", emphasizes structure by using organized physical environments, predictably sequenced activities, visual schedules and visually structured activities, and structured work/activity systems where each child can practice various tasks.[1] Parents are taught to implement the treatment at home. A 1998 controlled trial found that children treated with a TEACCH-based home program improved significantly more than a control group.[29]

Floortime

Main article: Floortime


Floortime was developed by Stanley Greenspan. The intervention focuses on facilitating attachment between the child with autism and the parent through the act of play. The parent follows the child's lead and joins with the child in his or her preferred activity, even if the activity would be considered peculiar.

Relationship Development Intervention

Relationship Development Intervention (RDI) is a treatment program developed by Dr. Steven E. Gutstein. Rather than teaching specific skills that are seen as lacking, RDI focuses primarily on building a general "dynamic intelligence" believed to underlie the acquisition of social skills demonstrated in neurotypical children. It also focuses on the building blocks of motivation by developing episodic memory (seen as impaired in autism) and filling it with the child's own personal stories of competence and mastery. RDI emphasizes declarative (as opposed to imperative) communication, and aims for an appropriate balance of verbal and nonverbal communication.

Dr. Gutstein claims that 70% of his patients improved their ADOS diagnostic category within 18 months and that a similar proportion are able to enter school without a shadow teacher or other personal assistant, though to date there is no peer-reviewed published research on the RDI protocol.

Communication interventions

Communication interventions fall into two major categories. First, many autistic children do not speak, or have little speech, or have difficulties in effective use of language. Interventions that attempt to improve communication are commonly conducted by speech and language therapists, and work on joint attention, communicative intent, and alternative or augmented communication methods such as visual methods.[30] Little solid research supports the efficacy of speech therapy for autism.[31] A 2006 study reported benefits both for joint attention intervention and for symbolic play intervention,[32] and a 2007 study found that joint attention intervention is more likely than symbolic play intervention to cause children to engage later in shared interactions.[33]

Second, social skills treatment attempts to increase social and communicative skills of autistic individuals, addressing a core deficit of autism. A wide range of intervention approaches is available, including modeling and reinforcement, adult and peer mediation strategies, peer tutoring, social games and stories, self-management, pivotal response therapy, video modeling, direct instruction, visual cuing, circle of friends, and social-skills groups.[34] A 2007 meta-analysis of 55 studies of school-based social skills intervention found that they were minimally effective for children and adolescents with ASD,[35] and a 2007 review found that social skills training has minimal empirical support for children with Asperger syndrome or high-functioning autism.[14]

Sensory integration

Unusual responses to sensory stimuli are more common and prominent in autistic children, although there is no good evidence that sensory symptoms differentiate autism from other developmental disorders.[36] Several therapies have been developed to treat Sensory Integration Dysfunction.[37] Some of these treatments (for example, sensorimotor handling) have a questionable rationale and no empirical evidence. Other treatments (for example, prism lenses, physical exercise, and auditory integration training) have had studies with small positive outcomes, but few conclusions can be made about them due to methodological problems with the studies.[38] Although replicable treatments have been described and valid outcome measures are known, gaps exist in knowledge related to sensory integration dysfunction and therapy.[39]

Therapy in education

Children with autism are affected by their symptoms every day, which set them apart from unaffected students. Because of problems with receptive language and theory of mind, they can have difficulty understanding some classroom directions and instruction, along with subtle vocal and facial cues of teachers. This inability to fully decipher the world around them often makes education stressful. Teachers need to be aware of a student's disorder, and ideally should have specific training in autism education, so that they are able to help the student get the best out of his or her classroom experiences.

Some students learn more effectively with visual aids as they are better able to understand material presented visually. Because of this, many teachers create “visual schedules” for their autistic students. This allows students to concretely see what is going on throughout the day, so they know what to prepare for and what activity they will be doing next. Some autistic children have trouble going from one activity to the next, so this visual schedule can help to reduce stress.

Research has shown that working in pairs may be beneficial to autistic children. Autistic students have problems not only with language and communication, but with socialization as well. By facilitating peer interaction, teachers can help their students with autism make friends, which in turn can help them cope with problems or understand the world around them. This can help them to become more integrated into the mainstream environment of the classroom.

A teacher's aide can also be useful to the student. The aide is able to give more elaborate directions that the teacher may not have time to explain to the autistic child and can help the child to stay at an equivalent level to the rest of the class through the special one-on-one instruction. However, some argue that students with one-on-one aides may become overly dependent on the help, thus leading to difficulty with independence later on.

There are many different techniques that teachers can use to assist their students. A teacher needs to become familiar with the child’s disorder to know what will work best with that particular child. Every child is going to be different and teachers have to be able to adjust with every one of them.

Students with autism spectrum disorders sometimes have high levels of anxiety and stress, particularly in social environments like school. If a student exhibits aggressive or explosive behavior, it is important for educational teams to recognize the impact of stress and anxiety. Preparing students for new situations, such as through writing social stories, can lower anxiety. Teaching social and emotional concepts using systematic teaching approaches such as The Incredible 5-Point Scale or other cognitive behavioral strategies can increase a student's ability to control excessive behavioral reactions.

Animal-assisted therapy

Animal-assisted therapy, where an animal such as a dog becomes a basic part of a person's treatment, is a controversial treatment for some symptoms. A 2007 meta-analysis found that animal-assisted therapy is associated with a moderate improvement in autism spectrum symptoms.[40] Reviews of published dolphin-assisted therapy (DAT) studies have found important methodological flaws and have concluded that there is no compelling scientific evidence that DAT is a legitimate therapy or that it affords any more than fleeting improvements in mood.[41]

Prosthetics

Affective computing devices, typically with image or voice recognition capabilities, have been proposed to help autistic individuals improve their social communication skills. These devices are still under development. Robots have also been proposed as educational aids for autistic children.[42]

Neurofeedback

Neurofeedback has been hypothesized to improve focusing and decrease anxiety in individuals with ASD. One pilot study investigated this hypothesis in 10 adolescent boys diagnosed with Asperger syndrome. Five boys dropped out during the study; results on the remaining boys were positive but were not statistically significant.[43]

Son-Rise

Main article: Son-Rise

Son-Rise is a home-based program with emphasis on eye contact, accepting the child without judgment, and engaging the child in a noncoercive way. Proponents claim that children will decide to become non-autistic after parents accept them for who they are and engage them in play. The program was started by the parents of Raun Kaufman, who is claimed to have gone from being autistic to normal via the treatment in the early 1970s.[44] No independent study has tested the efficacy of the program, but a 2003 study found that involvement with the program led to more drawbacks than benefits for the involved families over time,[45] and a 2006 study found that the program is not always implemented as it is typically described in the literature, which suggests it will be difficult to evaluate its efficacy.[46]

Patterning

Patterning is a set of exercises that attempts to improve the organization of a child's neurologic impairments. It has been used for decades to treat children with many unrelated neurologic disorders, including autism. The therapy is based on oversimplified theories and is not supported by carefully designed research studies.[47]

Parent mediated interventions

Parent mediated interventions offer support and practical advice to parents of autistic children.[30] Randomized and controlled studies suggest that parent training leads to reduced maternal depression, improved maternal knowledge of autism and communication style, and improved child communicative behavior.[48] A 2006 randomized controlled trial (RCT) found that a 20-week parent education and behavior management (PEBM) program provided significant improvements in parental mental health and well-being, particularly for parents with preexisting mental health problems.[49]

Medical management

Drugs, supplements, or diets are often used to alter physiology in an attempt to relieve common autistic symptoms such as seizures, sleep disturbances, irritability, and hyperactivity that can interfere with education or social adaptation or (more rarely) cause autistic individuals to harm themselves or others.[50] There is plenty of anecdotal evidence to support medical treatment; many parents who try one or more therapies report some progress, and there are a few well-publicized reports of children who are able to return to mainstream education after treatment, with dramatic improvements in health and well-being. However, this evidence may be confounded by improvements seen in autistic children who grow up without treatment, by the difficulty of verifying reports of improvements, and by the lack of reporting of treatments' negative outcomes.[51] Only a very few medical treatments are well supported by scientific evidence using controlled experiments.[50]

Prescription medication

Medications are often used to treat problems associated with ASD. More than half of U.S. children diagnosed with ASD are prescribed psychoactive drugs or anticonvulsants, with the most common drug classes being antidepressants, stimulants, and antipsychotics.[6] Only the antipsychotics have clearly demonstrated efficacy.[7]

Research has focused on atypical antipsychotics, especially risperidone, which has the largest amount of evidence that consistently shows improvements in irritability, self-injury, aggression, and tantrums associated with ASD.[52] In the United States, risperidone is approved for treating symptomatic irritability in autistic children and adolescents aged 5–16 years. In short-term trials (up to 6 months) most adverse events were mild to moderate, with weight gain, drowsiness, and high blood sugar requiring monitoring. Its long term efficacy and safety have not been fully determined.[53] It is unclear whether risperidone improves autism's core social and communication deficits.[7]

Other drugs are prescribed off-label in the U.S., which means they have not been approved for treating ASD. Large placebo-controlled studies of olanzapine and aripiprazole were underway in early 2008.[7] Some selective serotonin reuptake inhibitors (SSRIs) and dopamine blockers can reduce some maladaptive behaviors associated with ASD.[54] The limited data for SSRIs suggest that they may be helpful for obsessions/compulsions, but that children may have a worse response than adults and may suffer more adverse affects, such as suicidal impulses.[8] One study found that the psychostimulant methylphenidate was efficacious against hyperactivity associated with ASD, though with less response than in neurotypical children with ADHD.[8] A 1998 study of the hormone secretin reported improved symptoms and generated tremendous interest, but several controlled studies since have found no benefit.[12]

There is scant reliable research about the effectiveness or safety of drug treatments for adolescents and adults with ASD.[8] Results of the handful of randomized control trials that have been performed suggest that risperidone, the SSRI fluvoxamine, and the typical antipsychotic haloperidol may be effective in reducing some behaviors, that haloperidol may be more effective than the tricyclic antidepressant clomipramine, and that the opiate antagonist naltrexone hydrochloride is not effective.[9] A person with ASD may respond atypically to medications, the medications can have adverse side effects, and no known medication relieves autism's core symptoms of social and communication impairments.[55]

Supplements

Many parents give their children vitamin and other nutritional supplements in an attempt to treat autism or to alleviate its symptoms. The range of supplements given is wide; few are supported by scientific data, but most have relatively mild side effects.[50][11]

Nutritional supplementation with high dose pyridoxine (vitamin B6) and magnesium (HPDM) is claimed to alleviate the symptoms of autism and is one of the most popular complementary and alternative medicine choices for autism. Three small randomized controlled trials have studied this therapy; the smallest one (with 8 individuals) found improved verbal IQ in the treatment group and the other two (with 10 and 15 individuals, respectively) found no significant difference.[11] Due to the limited data it is difficult to tell whether this treatment approach has effects greater than placebo.[12] The short-term side effects seem to be mild, but there may be significant long-term side effects, as high doses of pyridoxine cause peripheral neuropathy in adults,[11] high doses of magnesium can cause reduced heart rate and weakened reflexes,[13] and high magnesium concentrations are associated with seizures.[15] Magnesium should always be taken along with high doses of pyridoxine to prevent side effects such as irritability and sensitivity to sound.[12]

Dimethylglycine (DMG) is hypothesized to improve speech and reduce autistic behaviors,[11] and is a commonly used supplement.[50] Two double-blind, placebo-controlled studies found no statistically significant effect on autistic behaviors,[11] and reported few side effects. No peer-reviewed studies have addressed treatment with the related compound trimethylglycine.[50]

Vitamin C decreased stereotyped behavior in a small 1993 study. The study has not been replicated, and vitamin C has limited popularity as an autism treatment. High doses might cause kidney stones or gastrointestinal upset such as diarrhea.[50]

Probiotics containing potentially beneficial bacteria are hypothesized to relieve some symptoms of autism by minimizing yeast overgrowth in the colon. The hypothesized yeast overgrowth has not been confirmed by endoscopy, the mechanism connecting yeast overgrowth to autism is only hypothetical, and no clinical trials to date have been published in the peer-reviewed literature. No negative side effects have been reported.[50]

Melatonin is sometimes used to manage sleep problems in developmental disorders. One small open trial found a statistically significant reduction in sleep latency in children with ASD. Adverse effects are generally reported to be mild, including drowsiness, headache, dizziness, and nausea; however, an increase in seizure frequency is reported among susceptible children.[11]

Several other supplements have been hypothesized to relieve autism symptoms, including carnosine, cyproheptadine, D-cycloserine, folic acid, glutathione, metallothionein promoters, oxytocin, polyunsaturated fatty acids (PUFA) such as omega-3 or omega-6 fatty acids, tryptophan, tyrosine, thiamine (see Chelation therapy), vitamin B12, and zinc. None of these have reliable scientific evidence of efficacy or safety in treatment of autism.[50][11]

Diets

Further information: Gluten-free, casein-free diet

Atypical eating behavior occurs in about three-quarters of children with ASD, to the extent that it was formerly a diagnostic indicator. Selectivity is the most common problem, although eating rituals and food refusal also occur;[56] this does not appear to result in malnutrition. Although some children with autism also have gastrointestinal (GI) symptoms, there is a lack of published rigorous data to support the theory that autistic children have more or different GI symptoms than usual;[57] studies report conflicting results, and the relationship between GI problems and ASD is unclear.[1]

In the early 1990s it was hypothesized that autism can be caused or aggravated by opioid peptides like casomorphine that are metabolic products of gluten and casein.[58] Based on this hypothesis, diets that eliminate foods containing either gluten or casein, or both, are widely promoted, and many testimonials can be found describing benefits in autism-related symptoms, notably social engagement and verbal skills. Studies supporting these claims have had significant flaws, so the data are inadequate to guide treatment recommendations.[19]

Other elimination diets have also been proposed, targeting salicylates, food dyes, yeast, and simple sugars. No scientific evidence has established the efficacy of such diets in treating autism in children. An elimination diet may create nutritional deficiencies that harm overall health unless care is taken to assure proper nutrition.[11]

Chelation therapy

Based on the speculation that heavy metal poisoning may trigger the symptoms of autism, particularly in small subsets of individuals who cannot excrete toxins effectively, some parents have turned to alternative medicine practitioners who provide detoxification treatments via chelation therapy. However, evidence to support this practice has been anecdotal and not rigorous. There is strong epidemiological evidence that refutes links between environmental triggers, in particular thimerosal containing vaccines, and the onset of autistic symptoms. No scientific data supports the claim that the mercury in the vaccine preservative thiomersal causes autism[59] or its symptoms,[60] and there is no scientific support for chelation therapy as a treatment for autism.[31]

Chelation therapy can be hazardous. In August 2005, botched chelation therapy killed a 5-year-old autistic boy, a nonautistic child died in February 2005 and an nonautistic adult died in August 2003. These deaths were due to cardiac arrest caused by hypocalcemia during chelation therapy.[20]

Thiamine tetrahydrofurfuryl disulfide (TTFD) is hypothesized to act as a chelating agent in children with autism. A 2002 pilot study administered TTFD rectally to ten autism spectrum children, and found beneficial clinical effect.[61] This study has not been replicated and a 2006 review of thiamine by the same author did not mention thiamine's possible effect on autism.[62] There is not sufficient evidence to support the use of thiamine (vitamin B1) to treat autism.[11]

Craniosacral therapy

Craniosacral therapy is based on the theory that restrictions at cranial sutures of the skull affect rhythmic impulses conveyed via cerebrospinal fluid. Practitioners, who include physical therapists, chiropractors, dentists, osteopaths, medical, and naturopathic physicians, hypothesize that gentle pressure on external areas can improve the flow and balance of the supply of this fluid to the brain, relieving symptoms of many conditions.[63] There is no scientific support for major elements of the underlying model,[64] there is little scientific evidence to support the therapy, and research methods that could conclusively evaluate the therapy's effectiveness have not been applied.[63]

Hyperbaric oxygen therapy

Hyperbaric oxygen therapy (HBOT) can compensate for decreased blood flow by increasing the oxygen content in the body. It has been postulated that HBOT might relieve some of the core symptoms of autism.[65] However, scientific evidence is lacking for the use of HBOT to treat autism.[15]

Stem cell therapy

Mesenchymal stem cells and cord blood CD34+ cells have been proposed to treat autism, but this proposal has not been tested.[66]

Research

Approximately twelve research studies are published each week on autism therapies. Three major barriers inhibit transfer of this information from the laboratory to the child:

  • Treatment providers do not routinely turn to treatments that have been validated scientifically.
  • A large minority of patients (actually parents of patients) resist therapies that have been scientifically validated.
  • Even scientifically validated therapies are not universally effective.[67]

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