Autism therapies

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A young child points, in front of a woman who smiles and points in the same direction.
A three-year-old with autism points to fish in an aquarium, as part of an experiment on the effect of intensive shared-attention training on language development.[1]

Autism therapies attempt to lessen the deficits and abnormal behaviours associated with autism and other autism spectrum disorders (ASD), and to increase the quality of life and functional independence of autistic individuals, especially children. Treatment is typically catered to the child's needs. Treatments fall into two major categories: educational interventions and medical management. Training and support are also given to families of those with ASD.[2]

Studies of interventions have methodological problems that prevent definitive conclusions about efficacy.[3] Although many psychosocial interventions have some positive evidence, suggesting that some form of treatment is preferable to no treatment, the methodological quality of systematic reviews of these studies has generally been poor, their clinical results are mostly tentative, and there is little evidence for the relative effectiveness of treatment options.[4] Intensive, sustained special education programs and behavior therapy early in life can help children with ASD acquire self-care, social, and job skills,[2] and often can improve functioning, and decrease symptom severity and maladaptive behaviors;[5] claims that intervention by around age three years is crucial are not substantiated.[6] Available approaches include applied behavior analysis (ABA), developmental models, structured teaching, speech and language therapy, social skills therapy, and occupational therapy.[2] Educational interventions have some effectiveness in children: intensive ABA treatment has demonstrated effectiveness in enhancing global functioning in preschool children,[7] and is well established for improving intellectual performance of young children.[5] Neuropsychological reports are often poorly communicated to educators, resulting in a gap between what a report recommends and what education is provided.[8] The limited research on the effectiveness of adult residential programs shows mixed results.[9]

Many medications are used to treat problems associated with ASD.[10] 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.[11] Aside from antipsychotics,[12] there is scant reliable research about the effectiveness or safety of drug treatments for adolescents and adults with ASD.[13][14] A person with ASD may respond atypically to medications, the medications can have adverse effects, and no known medication relieves autism's core symptoms of social and communication impairments.[15]

Many alternative therapies and interventions are available, ranging from elimination diets to chelation therapy. Few are supported by scientific studies.[16][17][18][19][20] 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.[21] Scientific evidence appears to matter less to service providers than program marketing, training availability, and parent requests.[22] Even if they do not help, conservative treatments such as changes in diet are expected to be harmless aside from their bother and cost.[23] Dubious invasive treatments are a much more serious matter: for example, in 2005, botched chelation therapy killed a five-year-old boy with autism.[24]

Treatment is expensive;[25] indirect costs are more so. For someone born in 2000, a U.S. study estimated an average discounted lifetime cost of $4.05 million (2014 dollars, inflation-adjusted from 2003 estimate[26]), with about 10% medical care, 30% extra education and other care, and 60% lost economic productivity.[27] A UK study estimated discounted lifetime costs at ₤1.56 million and ₤1 million for an autistic person with and without intellectual disability, respectively[28] (2014 pounds, inflation-adjusted from 2005/06 estimate[29]). Legal rights to treatment are complex, vary with location and age, and require advocacy by caregivers.[30] 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;[31] one 2008 U.S. study found a 14% average loss of annual income in families of children with ASD,[32] and a related study found that ASD is associated with higher probability that child care problems will greatly affect parental employment.[33] After childhood, key treatment issues include residential care, job training and placement, sexuality, social skills, and estate planning.[30]

Historical approach[edit]

Before autism was well understood, children in Britain and America would often be put in institutions on the instruction of doctors and the parents told to forget about them. Observer journalist Christopher Stevens, father of an autistic child, reports how a British doctor told him that after a child was admitted, usually "nature would take its course" and the child would die due to the prevalence of tuberculosis.[34]

Educational interventions[edit]

Educational interventions attempt to help children not only to learn academic subjects and gain traditional readiness skills, but also to improve functional communication and spontaneity, enhance social skills such as joint attention, gain cognitive skills such as symbolic play, reduce disruptive behavior, and generalize learned skills by applying them to new situations. Several model programs have been developed, which in practice often overlap and share many features, including:[2]

  • early intervention that does not wait for a definitive diagnosis;
  • intense intervention, at least 25 hours per week, 12 months per year;
  • low student/teacher ratio;
  • family involvement, including training of parents;
  • interaction with neurotypical peers;
  • social stories, ABA and other visually based training;[35]
  • 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; they can be done by parents, teachers, speech and language therapists, and occupational therapists.[2][36] A 2007 study found that augmenting a center-based program with weekly home visits by a special education teacher improved cognitive development and behavior.[37]

Studies of interventions have methodological problems that prevent definitive conclusions about efficacy.[3] Although many psychosocial interventions have some positive evidence, suggesting that some form of treatment is preferable to no treatment, the methodological quality of systematic reviews of these studies has generally been poor, their clinical results are mostly tentative, and there is little evidence for the relative effectiveness of treatment options.[4] Concerns about outcome measures, such as their inconsistent use, most greatly affect how the results of scientific studies are interpreted.[38] A 2009 Minnesota study found that parents follow behavioral treatment recommendations significantly less often than they follow medical recommendations, and that they adhere more often to reinforcement than to punishment recommendations.[39] Intensive, sustained special education programs and behavior therapy early in life can help children acquire self-care, social, and job skills,[2] and often improve functioning and decrease symptom severity and maladaptive behaviors;[5] claims that intervention by around age three years is crucial are not substantiated.[6]

In the U.S., under IDEA compliance, public schools are required to employ high qualified staff. A Certified Autism Specialist has a masters degree, two years career experience working with the autism population, earns 14 continuing education hours in autism every two years, and is registered with International Institute of Education [40]

Applied behavior analysis[edit]

Further information: Applied behavior analysis

Applied behavior analysis (ABA) is the applied research field of the science of behavior analysis, and it underpins a wide range of techniques used to treat autism and many other behaviors and diagnoses,[41] including those who are patients in rehab or who need to have their behavior changed. ABA-based interventions focus on teaching tasks one-on-one using the behaviorist principles of stimulus, response and reward,[42] and on reliable measurement and objective evaluation of observed behavior.[2] There is wide variation in the professional practice of behavior analysis and among the assessments and interventions used in school-based ABA programs.[43] Moreover, ABA—which uses stimulus control, data collection, functional analysis, replacement behavior strategies, and reinforcement—was once called behavior modification; the latter only used reinforcement and punishment to change behavior. Early research had noted behavior modification as being an effective early, curricular-based therapy for ASD children.

Early intensive behavioral intervention[edit]

Many behavioral 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.[44] However, children have problems using DTT-taught skills in natural environments.[2] These students are also taught with naturalistic teaching procedures to help generalize these skills. In functional assessment, a common technique, a teacher formulates a clear description of a problem behavior, identifies antecedents, consequences, and other environmental factors that influence and maintain the behavior, develops hypotheses about what occasions and maintains the behavior, and collects observations to support the hypotheses.[2] A few more-comprehensive ABA programs use multiple assessment and intervention methods individually and dynamically.[43]

ABA-based techniques have 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.[2] A 2009 review of educational interventions for children, whose mean age was six years or less at intake, found that the higher-quality studies all assessed ABA, that ABA is well-established and no other educational treatment is considered probably-efficacious, and that intensive ABA treatment, carried out by trained therapists, is demonstrated effective in enhancing global functioning in pre-school children.[7] These gains maybe complicated by initial IQ.[45] A 2008 evidence-based review of comprehensive treatment approaches found that ABA is well established for improving intellectual performance of young children with ASD.[5] A 2009 comprehensive synthesis of early intensive behavioral intervention (EIBI), a form of ABA treatment, found that EIBI produces strong effects, suggesting that it can be effective for some children with autism; it also found that the large effects might be an artifact of comparison groups with treatments that have yet to be empirically validated, and that no comparisons between EIBI and other widely recognized treatment programs have been published.[46] A 2009 systematic review came to the same principal conclusion that EIBI is effective for some but not all children, with wide variability in response to treatment; it also suggested that any gains are likely to be greatest in the first year of intervention.[6] A 2009 meta-analysis concluded that EIBI has a large effect on full-scale intelligence and a moderate effect on adaptive behavior.[47] However, a 2009 systematic review and meta-analysis found that applied behavior intervention (ABI), another name for EIBI, did not significantly improve outcomes compared with standard care of preschool children with ASD in the areas of cognitive outcome, expressive language, receptive language, and adaptive behavior.[48] Applied behavior analysis is cost effective for administrators [49]

Recently behavior analysts have built comprehensive models of child development (see Behavior analysis of child development) to generate models for prevention as well as treatment for autism.

Pivotal response therapy[edit]

Pivotal response therapy or treatment (PRT) is a naturalistic intervention derived from ABA principles. Instead of individual behaviors, it targets pivotal areas of a child's development, such as motivation, responsivity to multiple cues, self-management, and social initiations; it aims for widespread improvements in areas that are not specifically targeted. The child determines activities and objects that will be used in a PRT exchange. Intended attempts at the target behavior are rewarded with a natural reinforcer: for example, if a child attempts a request for a stuffed animal, the child receives the animal, not a piece of candy or other unrelated reinforcer.[50]

Aversive therapy[edit]

The Judge Rotenberg Educational Center uses aversion therapy, notably contingent shock (electric shock delivered to the skin for a few seconds), to control the behavior of its patients, many of whom are autistic. The practice is controversial[51] and has not been popular or used elsewhere since the 1990s.

Communication interventions[edit]

The inability to communicate, verbally or non-verbally, is a core deficit in Autism. Children with Autism are often engaged in repetitive activity or other behaviors because they cannot convey their intent any other way. They do not know how to communicate their ideas to caregivers or others. Helping a child with Autism learn to communicate their needs and ideas is absolutely core to any intervention. Communication can either be verbal or non-verbal. Children with Autism require intensive intervention to learn how to communicate their intent.

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.[52] Social skills have been shown to be effective in treating children with autism.[52] Interventions that attempt to improve communication are commonly conducted by speech and language therapists, and work on joint attention, communicative intent, and alternative or augmentative and alternative communication (AAC) methods such as visual methods.[53] AAC methods do not appear to impede speech and may result in modest gains.[54] A 2006 study reported benefits both for joint attention intervention and for symbolic play intervention,[55] 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.[56]

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.[57] 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,[58] and a 2007 review found that social skills training has minimal empirical support for children with Asperger syndrome or high-functioning autism.[18]

SCERTS[edit]

The SCERTS model[59] is an educational model for working with children with autism spectrum disorder (ASD). It was designed to help families, educators and therapists work cooperatively together to maximize progress in supporting the child.

The acronym refers to the focus on:

  • SC - social communication - the development of functional communication and emotional expression.
  • ER - emotional regulation - the development of well-regulated emotions and ability to cope with stress.
  • TS - transactional support - the implementation of supports to help families, educators and therapists respond to children's needs, adapt the environment and provide tools to enhance learning.

Computer-assisted therapy for reasoning about communicative actions[edit]

Many remediation strategies have not taken into account that people with autism suffer from difficulties in learning social rules from examples. Computer-assisted autism therapy has been proposed to teach not simply via examples but to teach the rule along with it.[60] A reasoning rehabilitation strategy, based on playing with a computer based mental simulator that is capable of modeling mental and emotional states of the real world, has been subject to short-term and long-term evaluations.[61] The simulator performs the reasoning in the framework of belief-desire-intention model. Learning starts from the basic concepts of knowledge and intention and proceeds to more complex communicative actions such as explaining, agreeing, and pretending.

Relationship based, developmental models[edit]

Relationship based models give importance to the relationships that help children reach and master early developmental milestones. These are often missed or not mastered in children with ASD. Examples of these early milestones are engagement and interest in the world, intimacy with a caregiver, intentionality of action.

Relationship Development Intervention[edit]

Relationship development intervention[62] is a family-based treatment program for children with autism spectrum disorder (ASD). This program is based on the belief that the development of dynamic intelligence (the ability to think flexibly, take different perspectives, cope with change and process information simultaneously) is key to improving the quality of life of children with autism.

Floortime/DIR[edit]

Main article: Floortime

The Floortime/DIR (Developmental, Individual Differences based, Relationship based ) approach is a developmental intervention to autism developed by Stanley Greenspan and Serena Weider. This approach is based on the idea that the core deficits in autism are individual differences in the sensory system, motor planning problems, difficulties in communication and relation to others, and the inability to connect ones desire to intentional action and communication. When addressed through a combination of sensory support and DIR/Floortime techniques, the facilitator is playfully obstructive to redirect the child to play and relate to their therapist. The primary goal of Floortime is to improve the child's cognitive, language, and social abilities.[63] However, these claims should be regarded with some scepticism, owing to a lack of independent scientific research into the efficacy of the floortime approach.

The DIR model is based on the model of a developmental 'tree', the central notion being that Autistic children have yet to master certain early developmental milestones, or 'branches' of the tree, which are as follows:

  • Stage One: Regulation and Interest in the World: Being calm and feeling well enough to attend to a caregiver and surroundings. Have shared attention.
  • Stage Two: Engagement and Relating: Interest in another person and in the world, developing a special bond with preferred caregivers. Distinguishing inanimate objects from people.
  • Stage Three: Two way intentional communication: Simple back and forth interactions between child and caregiver. Smiles, tickles, anticipatory play.
  • Stage Four: Social Problem solving: Using gestures, interaction, babble to indicate needs, wants, pleasure, upset. Get a caregiver to help with a problem. Using pre-language skills to show intention.
  • Stage Five: Symbolic Play: Using words, pictures, symbols to communicate an intention, idea. Communicate ideas and thoughts, not just wants and needs.
  • Stage Six: Bridging Ideas: This stage is the foundation of logic, reasoning, emotional thinking and a sense of reality.[64]

Exponents of the floortime approach argue that children with ASD struggle with or have missed some of these vital developmental stages. An introduction to DIR/Floortime can be found in the book - Engaging Autism: Using the Floortime Approach to Help Children Relate, Communicate, and Think, by Stanley Greenspan, M.D. and Serena Wieder, PhD.

The P.L.A.Y. Project (or PLAY Project)[edit]

Main article: The P.L.A.Y. Project

The P.L.A.Y. Project (or PLAY Project) [65](an acryonym for PLAY and Language for Autistic Youngsters) is a community-based, national autism training and early intervention program established in 2001 by Richard Solomon, MD.[66] Based on the DIR® (Developmental, Individualized, Relationship-based) theory of Stanley Greenspan MD, the program is designed to train parents and professionals to implement intensive, developmental interventions for young children (18 months to 6 years) with autism. The program is operating in nearly 100 agencies worldwide including 25 states and in 5 countries outside of the U.S. (Australia, Canada, England, Ireland and Switzerland). The PLAY Project has been operating since 2001 from its headquarters in Ann Arbor, MI.

In September 2009, The P.L.A.Y. Project received a $1.85 million grant [67] from the National Institute of Mental Health (NIMH) to conduct a three-year controlled, clinical study of the P.L.A.Y. Project model. Drawing participants from five Easter Seals autism service locations, the study compares the outcomes of 60 children who participate in The P.L.A.Y. Project with the outcomes of 60 children who receive standard community interventions, making it the largest study of its kind. Before and after the 12-month intervention, each child is assessed with a battery of tests to measure developmental level, speech and language, sensory-motor profile, and social skills.

The results of previous research on the program were published by the peer-reviewed British journal, Autism [68] (May, 2007).

Son-Rise[edit]

Main article: Son-Rise

Son-Rise is a home-based program that emphasizes on implementing a color- and sensory-free playroom. Before implementing the home-based program, an institute trains the parents how to accept their child without judgment through a series of dialogue sessions. Like Floortime, parents join their child's ritualistic behavior for relationship-building. To gain the child's "willing engagement", the facilitator continues to join them only this time through parallel play. 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.[69] 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,[70] 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.[71]

TEACCH[edit]

Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH), which has come to be called "structured teaching", emphasises 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.[2] 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.[72] A 2013 meta-analysis compiling all the clinical trials of TEACCH indicated that it has small or no effects on perceptual, motor, verbal, cognitive, and motor functioning, communication skills, and activities of daily living. There were positive effects in social and maladaptive behavior, but these required further replication due to the methodological limitations of the pool of studies analysed.[73]

Sensory integration[edit]

Main article: Sensory processing

Unusual responses to sensory stimuli are more common and prominent in children with autism, although there is not good evidence that sensory symptoms differentiate autism from other developmental disorders.[74] Several therapies have been developed to treat Sensory processing disorder.[75] Some of these treatments (for example, sensorimotor handling) have a questionable rationale and have no empirical evidence. Other treatments have been studied, with small positive outcomes, but few conclusions can be drawn due to methodological problems with the studies. These treatments include prism lenses, physical exercise, auditory integration training, and sensory stimulation or inhibition techniques such as "deep pressure"—firm touch pressure applied either manually or via an apparatus such as a hug machine or a pressure garment.[76] Weighted vests, a popular deep-pressure therapy, have only a limited amount of scientific research available, which on balance indicates that the therapy is ineffective.[77] Although replicable treatments have been described and valid outcome measures are known, gaps exist in knowledge related to Sensory processing disorder and therapy.[78] Because empirical support is limited, systematic evaluation is needed if these interventions are used.[79]

The term Multisensory integration in simple terms means the ability to use all of ones senses to accomplish a task. Occupational Therapists sometimes prescribe sensory treatments for children with Autism however in general there has been little or no scientific evidence of effectiveness.[76]

A 2008 book My Stroke of Insight by Jill Bolte Taylor gives some insight, from a brain researcher's point of view, on what sensory processing disorder feels like. Other books on sensory integration include The Out of Sync Child - Recognizing and Coping with Sensory Processing Disorder by Carol Kranowitz and Lucy Jane Miller.

Animal-assisted therapy[edit]

Animal-assisted therapy, where an animal such as a dog or a horse 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.[80] 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.[81]

Neurofeedback[edit]

Neurofeedback attempts to train individuals to regulate their brainwave patterns by letting them observe their brain activity more directly. In its most traditional form, the output of EEG electrodes is fed into a computer that controls a game-like audiovisual display. Neurofeedback has been evaluated with positive results for ASD, but studies have lacked random assignment to controls.[82]

Patterning[edit]

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 several unrelated neurologic disorders, including autism. The method, taught at the The Institutes for the Achievement of Human Potential, is based on oversimplified theories and is not supported by carefully designed research studies.[83]

Packing[edit]

In packing, children are wrapped tightly for up to an hour in wet sheets that have been refrigerated, with only their heads left free. The treatment is repeated several times a week, and can continue for years. It is intended as treatment for autistic children who harm themselves; most of these children cannot speak. Similar envelopment techniques have been used for centuries, such as to calm violent patients in Germany in the 19th century; its modern use in France began in the 1960s, based on psychoanalytic theories such as the theory of the refrigerator mother. Packing is currently used in hundreds of French clinics. There is no scientific evidence for the effectiveness of packing, and some concern about risk of adverse health effects.[84]

Transcranial magnetic stimulation[edit]

Transcranial magnetic stimulation, which is a somewhat well established treatment for depression, has been proposed, and used, as a treatment for autism.[85] A review published in 2013, however, found insufficient evidence to support its widespread use for autism spectrum disorders.[86]

Environmental enrichment[edit]

Environmental enrichment is concerned with how the brain is affected by the stimulation of its information processing provided by its surroundings (including the opportunity to interact socially). Brains in richer, more-stimulating environments, have increased numbers of synapses, and the dendrite arbors upon which they reside are more complex. This effect happens particularly during neurodevelopment, but also to a lesser degree in adulthood. With extra synapses there is also increased synapse activity and so increased size and number of glial energy-support cells. Capillary vasculation also is greater to provide the neurons and glial cells with extra energy. The neuropil (neurons, glial cells, capillaries, combined together) expands making the cortex thicker. There may also exist (at least in rodents) more neurons.

Research on nonhuman animals finds that more-stimulating environments could aid the treatment and recovery of a diverse variety of brain-related dysfunctions, including Alzheimer's disease and those connected to aging, whereas a lack of stimulation might impair cognitive development.

Research on humans suggests that lack of stimulation (deprivation—such as in old-style orphanages) delays and impairs cognitive development. Research also finds that higher levels of education (which is both cognitively stimulating in itself, and associates with people engaging in more challenging cognitive activities) results in greater resilience (cognitive reserve) to the effects of aging and dementia.

Massage therapy[edit]

A review of massage therapy as a symptomatic treatment of autism found limited evidence of benefit. There were few high quality studies, and due to the risk of bias found in the studies analyzed, no firm conclusions about the efficacy of massage therapy could be drawn.[87]

Music[edit]

Music therapy uses the elements of music to let people express their feelings and communicate. Two small studies have reported short-term improvement in verbal and gestural communication skills of children with autism from a week's work of daily sessions; no significant effects on behavior problems were observed.[88]

Parent mediated interventions[edit]

Parent mediated interventions offer support and practical advice to parents of autistic children.[53] A 2002 Cochrane Review found only two relevant studies, with small numbers of participants, and no clinical recommendations could be made due to these limitations.[89] A very small number of randomized and controlled studies suggest that parent training can lead to reduced maternal depression, improved maternal knowledge of autism and communication style, and improved child communicative behavior, but due to the design and number of studies available, definitive evidence of effectiveness is not available.[90]

Medical management[edit]

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.[91] 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.[92] Only a very few medical treatments are well supported by scientific evidence using controlled experiments.[91]

Prescription medication[edit]

Many medications are used to treat problems associated with ASD.[10] 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.[11] Only the antipsychotics have clearly demonstrated efficacy.[12]

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.[93] Risperidone is approved by the Food and Drug Administration (FDA) for treating symptomatic irritability in autistic children and adolescents.[12] In short-term trials (up to six months) most adverse events were mild to moderate, with weight gain, drowsiness, and high blood sugar requiring monitoring; long term efficacy and safety have not been fully determined.[94] It is unclear whether risperidone improves autism's core social and communication deficits.[12] The FDA's decision was based in part on a study of autistic children with severe and enduring problems of tantrums, aggression, and self-injury; risperidone is not recommended for autistic children with mild aggression and explosive behavior without an enduring pattern.[95]

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.[12] Aripiprazole may be effective for treating autism, but is also associated with side effects, such as weight gain and sedation.[96] Some selective serotonin reuptake inhibitors (SSRIs) and dopamine blockers can reduce some maladaptive behaviors associated with ASD.[97] Although SSRIs reduce levels of repetitive behavior in autistic adults,[98] a 2009 multisite randomized controlled study found no benefit and some adverse effects in children from the SSRI citalopram, raising doubts whether SSRIs are effective for treating repetitive behavior in autistic children.[99] A further study of related medical reviews determined that the prescription of SSRI antidepressants for treating autistic spectrum disorders in children lacked any evidence, and could not be recommended.[100] One study found that the psychostimulant methylphenidate was efficacious against hyperactivity associated with ASD, though with less response than in neurotypical children with ADHD.[13] Of the many medications studied for treatment of aggressive and self-injurious behavior in children and adolescents with autism, only risperidone and methylphenidate demonstrate results that have been replicated.[101] A 1998 study of the hormone secretin reported improved symptoms and generated tremendous interest, but several controlled studies since have found no benefit.[102] Oxytocin may play a role in autism and may be an effective treatment for repetitive and affiliative behaviors;[103] two related studies in adults found that oxytocin decreased repetitive behaviors and improved interpretation of emotions, but these preliminary results do not necessarily apply to children.[104] An experimental drug STX107 has stopped overproduction of metabotropic glutamate receptor 5 in rodents, and it has been hypothesized that this may help in about 5% of autism cases, but this hypothesis has not been tested in humans.[104]

Aside from antipsychotics,[12] there is scant reliable research about the effectiveness or safety of drug treatments for adolescents and adults with ASD.[13] Results of the handful of randomized controlled 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.[14] In small studies, memantine has been shown to significantly improve language function and social behavior in children with autism.[105][106] Research is underway on the effects of memantine in adults with autism spectrum disorders.[107] A person with ASD may respond atypically to medications and the medications can have adverse side effects.[15][108]

Dietary supplements[edit]

Many parents give their children dietary 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.[17][91]

A review found some low-quality evidence to support the use of vitamin B6 in combination with magnesium at high doses, but the evidence was equivocal and the review noted the possible danger of fatal hypermagnesemia.[109] A Cochrane Review of the evidence for the use of B6 and magnesium found that "[d]ue to the small number of studies, the methodological quality of studies, and small sample sizes, no recommendation can be advanced regarding the use of B6-Mg as a treatment for autism."[110]

Dimethylglycine (DMG) is hypothesized to improve speech and reduce autistic behaviors,[17] and is a commonly used supplement.[91] Two double-blind, placebo-controlled studies found no statistically significant effect on autistic behaviors,[17] and reported few side effects. No peer-reviewed studies have addressed treatment with the related compound trimethylglycine.[91]

Vitamin C decreased stereotyped behavior in a small 1993 study.[111] 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.[91]

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.[91]

Melatonin is sometimes used to manage sleep problems in developmental disorders. 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.[17] Several small RCTs have indicated that melatonin is effective in treating insomnia in autistic children, but further large studies are needed.[112] A 2013 literature review found 20 studies that reported improvements in sleep parameters as a result of melatonin supplementation, and concluded that "the administration of exogenous melatonin for abnormal sleep parameters in ASD is evidence-based."[113]

Although omega-3 fatty acids, which are polyunsaturated fatty acids (PUFA), are a popular treatment for children with ASD, there is very little high-quality scientific evidence supporting their effectiveness,[114][115] and further research is needed.[2]

Several other supplements have been hypothesized to relieve autism symptoms, including BDTH2,[116] carnosine, cholesterol,[117] cyproheptadine, D-cycloserine, folic acid, glutathione, metallothionein promoters, other PUFA such as omega-6 fatty acids, tryptophan, tyrosine, thiamine (see Chelation therapy), vitamin B12, and zinc. These lack reliable scientific evidence of efficacy or safety in treatment of autism.[17][91]

Diets[edit]

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;[118] 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;[119] studies report conflicting results, and the relationship between GI problems and ASD is unclear.[2]

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.[120] 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 these data are inadequate to guide treatment recommendations.[23][121]

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.[17] For example, a 2008 study found that autistic boys on casein-free diets have significantly thinner bones than usual, presumably because the diets contribute to calcium and vitamin D deficiencies.[122]

Chelation therapy[edit]

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. Strong epidemiological evidence refutes links between environmental triggers, in particular thiomersal containing vaccines, and the onset of autistic symptoms. No scientific data supports the claim that the mercury in the vaccine preservative thiomersal causes autism[123] or its symptoms,[124] and there is no scientific support for chelation therapy as a treatment for autism.[125][126]

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.[127] 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.[128] There is not sufficient evidence to support the use of thiamine (vitamin B1) to treat autism.[17]

Chiropractic[edit]

Chiropractic is an alternative medical practice whose main hypothesis is that mechanical disorders of the spine affect general health via the nervous system, and whose main treatment is spinal manipulation. A significant portion of the profession rejects vaccination, as traditional chiropractic philosophy equates vaccines to poison.[129] Most chiropractic writings on vaccination focus on its negative aspects,[130] claiming that it is hazardous, ineffective, and unnecessary,[129] and in some cases suggesting that vaccination causes autism[130] or that chiropractors should be the primary contact for treatment of autism and other neurodevelopmental disorders.[131] Chiropractic treatment has not been shown to be effective for medical conditions other than back pain,[132] and there is insufficient scientific evidence to make conclusions about chiropractic care for autism.[133]

Craniosacral therapy[edit]

Craniosacral therapy is an alternative medical practice whose main hypothesis is that restrictions at cranial sutures of the skull affect rhythmic impulses conveyed via cerebrospinal fluid, and 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.[134] There is no scientific support for major elements of the underlying model,[135] there is little scientific evidence to support the therapy, and research methods that could conclusively evaluate the therapy's effectiveness have not been applied.[134] No published studies are available on the use of this therapy for autism.[16]

Electroconvulsive therapy[edit]

Studies indicate that 12–17% of adolescents and young adults with autism satisfy diagnostic criteria for catatonia, which is loss of or hyperactive motor activity. Electroconvulsive therapy (ECT) has been used to treat cases of catatonia and related conditions in people with autism. However, no controlled trials have been performed of ECT in autism, and there are serious ethical and legal obstacles to its use.[136]

Hyperbaric oxygen therapy[edit]

A boy with ASD, and his father, in a hyperbaric oxygen chamber.

One small 2009 double-blind study of autistic children found that 40 hourly treatments of 24% oxygen at 1.3 atmospheres provided significant improvement in the children's behavior immediately after treatment sessions but this study has not been independently confirmed.[137] More recent, relatively large-scale controlled studies have also investigated HBOT using treatments of 24% oxygen at 1.3 atmospheres and have found less promising results. A 2010 double-blind study compared HBOT to a placebo treatment in children with autistic disorder. Both direct observational measures of behavioral symptoms and standardized psychological assessments were used to evaluate the treatment. No differences were found between the HBOT group and the placebo group on any of the outcome measures.[138] A second 2011 single-subject design study also investigated the effects of 40 HBOT treatments of 24% oxygen at 1.3 atmospheres on directly observed behaviors using multiple baselines across 16 participants. Again, no consistent outcomes were observed across any group and further, no significant improvements were observed within any individual participant.[139] Together these studies suggest that HBOT at 24% oxygen at 1.3 atmospheric pressure does not result in a clinically significant improvement of the behavioral symptoms of autistic disorder.

Nonetheless, news reports and related blogs indicate that HBOT is used for many cases of children with autism. HBOT can cost up to $150 per hour with individuals using anywhere from 40 to 120 hours as a part of their integrated treatment programs. In addition, purchasing (at $8,495–27,995) and renting ($1,395 per month) of the HBOT chambers is another option some families use.[139] When considering the financial and time investments required in order to participate in this treatment and the inconsistency of the present findings, HBOT seems to be a riskier and thus, often less favorable alternative treatment for autism. Further studies are needed in order for practitioners and families to make more conclusive and valid decisions concerning HBOT treatments.[140]

Prosthetics[edit]

Unlike conventional neuromotor prostheses, neurocognitive prostheses would sense or modulate neural function in order to physically reconstitute cognitive processes such as executive function and language. No neurocognitive prostheses are currently available but the development of implantable neurocognitive brain-computer interfaces has been proposed to help treat conditions such as autism.[141]

Affective computing devices, typically with image or voice recognition capabilities, have been proposed to help autistic individuals improve their social communication skills.[142] These devices are still under development. Robots have also been proposed as educational aids for autistic children.[143]

Stem cell therapy[edit]

Mesenchymal stem cells and cord blood CD34+ cells have been proposed to treat autism, but this proposal has not been tested.[144] They may represent a future treatment.[145] Since immune system deregulation has been implicated in autism, mesenchymal stem cells show the greatest promise as treatment for the disorder. Changes in the innate and adaptive immune system have been observed. Those with autism show an imbalance in CD3+, CD4+, and CD8+ T cells, as well as in NK cells.[146] In addition, peripheral blood mononuclear cells (PBMCs) overproduce IL-1β.[146] MSC mediated immune suppressive activity could restore this immune imbalance.

Alternative medicine[edit]

Acupuncture has not been found to be helpful.[147]

Religious interventions[edit]

The Table Talk of Martin Luther contains the story of a twelve-year-old boy who may have been severely autistic.[148] According to Luther's notetaker Mathesius, Luther thought the boy was a soulless mass of flesh possessed by the devil, and suggested that he be suffocated.[149] In 2003, an autistic boy in Wisconsin suffocated during an exorcism in which he was wrapped in sheets.[150] Some Pentecostal and charismatic Christians believe that autism is the result of a "generational curse" visited upon a child for the sins of a parent, and can be cured through repentance and divine healing.

Ultraorthodox Jewish parents sometimes use spiritual and mystical interventions such as prayers, blessings, recitations of religious text, amulets, changing the child's name, and exorcism.[151]

One study has suggested that spirituality and not religious activities involving the mothers of autistic children were associated with better outcomes for the child.[152]

Anti-cure perspective[edit]

Further information: Autism rights movement

The exact cause of autism is unclear, yet some organizations advocate researching a cure. Some autism rights organizations view autism as a way of life rather than as a disease and thus advocate acceptance over a search for a cure.[153][154]

See also[edit]

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