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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 individual'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 on the autism spectrum acquire self-care, social, and job skills,[1] and often can improve functioning, and decrease symptom severity and maladaptive behaviors;[2] there are widespread claims that intervention by age two to three years is crucial,[3] but this view has not been substantiated.[4] Available approaches include applied behavior analysis, developmental models, structured teaching, speech and language therapy, social skills therapy, and occupational therapy.[1] Educational interventions have some effectiveness in children: intensive Applied behavior analysis (ABA) treatment has demonstrated effectiveness in enhancing global functioning in preschool children,[5] and is well-established for improving intellectual performance of young children.[2] The limited research on the effectiveness of adult residential programs shows mixed results.[6]

A wide variety of medications are used to treat problems associated with ASD.[7] More than half of children in the United States diagnosed with autism spectrum disorders (ASDs) are prescribed psychoactive drugs or anticonvulsants, with the most common drug classes being antidepressants, stimulants, and antipsychotics.[8] Aside from antipsychotics,[9] there is scant reliable research about the effectiveness or safety of drug treatments for adolescents and adults with ASD.[10][11] 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 neurological, social and communication impairments.[12]

Many alternative therapies and interventions are available, ranging from dietary intervention to chelation and neurofeedback. Few are supported by scientific studies.[13][14][15][16][17][18] 'Alternative' treatment approaches lack empirical support in quality-of-life contexts, and many such programs focus on success measures that lack predictive validity and real-world relevance.[19] Scientific evidence appears to matter less to service providers than program marketing, training availability, and parent requests.[20] Even if they do not help, conservative treatments such as changes in diet are expected to be harmless aside from their bother and cost.[21] Dubious invasive treatments are a much more serious matter: for example, in 2005, botched chelation therapy killed a five-year-old autistic boy.[22]

Treatment is expensive;[23] 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% non-medical care (such as child care and education), and 60% the lost economic productivity of individuals and their parents.[24] Legal rights to treatment are complex, vary with location and age, and require advocacy by caregivers.[25] 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;[26] a 2008 U.S. study found a 14% average loss of annual income in families of children with ASD.[27] After childhood, key treatment issues include residential care, job training and placement, sexuality, social skills, and estate planning.[25]

Educational interventions

Educational interventions attempt to help children not only to learn academic subjects and gain traditional readiness skills, but also to facilitate functional communication and spontaneity, to enhance social skills such as joint attention, to gain cognitive skills such as symbolic play, to reduce disruptive behavior, and to generalize upon behavioral advances 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; they can be done by parents, teachers, speech and language therapists, and occupational therapists.[1][28] A 2007 study found that augmenting a center-based program with weekly home visits by a special education teacher improved cognitive development and behavior.[29] Intensive, sustained special education programs and behavior therapy early in life can help children acquire self-care, social, and job skills,[1] and often improve functioning and decrease symptom severity and maladaptive behaviors;[2] claims that intervention by age two to three years is crucial[3] are not substantiated.[4]

Applied behavior analysis

Further information: 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,[30] 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.[31] 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 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.[1] A few more-comprehensive ABA programs use multiple assessment and intervention methods individually and dynamically.[31]

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] A 2008 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.[5] A 2008 evidence-based review of comprehensive treatment approaches found that ABA is well-established for improving intellectual performance of young children with ASD.[2] A 2008 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.[32]

Pivotal response therapy

Main article: Pivotal response therapy

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.[33]

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.[34]

DIR/Floortime

The DIR/Floortime model uses a framework based on developmental approaches, individual differences, and relationships. It targets autism's core impairment of social reciprocity with a variety of therapies, including sensory-motor, language, social functioning, occupational, and speech therapy, along with family support and floortime play sessions; the therapies are tailored to the individual child. Published scientific evidence is lacking for this approach.[1]

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 augmentative and alternative communication (AAC) methods such as visual methods.[35] Little solid research supports the efficacy of speech therapy for autism;[36] AAC methods do not appear to impede speech and may result in modest gains.[37] A 2006 study reported benefits both for joint attention intervention and for symbolic play intervention,[38] 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.[39]

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.[40] 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,[41] and a 2007 review found that social skills training has minimal empirical support for children with Asperger syndrome or high-functioning autism.[16]

Sensory integration

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.[42] Several therapies have been developed to treat Sensory Integration Dysfunction.[43] Some of these treatments (for example, sensorimotor handling) have a questionable rationale and lack supporting 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.[44] 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.[45] Although replicable treatments have been described and valid outcome measures are known, gaps exist in knowledge related to sensory integration dysfunction and therapy.[46] Because empirical support is limited, systematic evaluation is needed if these interventions are used.[47]

Animal-assisted therapy

Animal-assisted therapy, where an animal such as a dog becomes a basic part of a person's treatment, is a common treatment for some symptoms. A 2007 meta-analysis found that animal-assisted therapy is associated with a moderate improvement in autism spectrum symptoms.[48] 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.[49]

Hippotherapy, which involves the use of a horse as a therapy tool in physical, occupational or speech-language therapy, is another common animal-assisted therapy for which the research base is growing.

Neurofeedback

Neurofeedback has been hypothesized to improve focusing and decrease anxiety in individuals with ASD. One pilot study investigated this hypothesis in ten 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.[50]

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 non-coercive 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.[51] 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,[52] 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.[53]

Packing

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; the modern application is based on refrigerator mother theories. Packing is currently used in hundreds of French clinics. There is no scientific evidence for the effectiveness of packing.[54]

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 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.[55]

Parent mediated interventions

Parent mediated interventions offer support and practical advice to parents of autistic children.[35] 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.[56] A 2006 randomized controlled trial (RCT) found that a twenty-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.[57] A 2008 pilot trial of Parent-Child Interaction Therapy, a parent coaching intervention model, for boys aged 5–12 with high-functioning ASD and behavioral problems, found increases in child adaptability and reductions in parent perceptions of child problem behaviors.[58]

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.[59] 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.[60] Only a very few medical treatments are well supported by scientific evidence using controlled experiments.[59]

Prescription medication

Many medications are used to treat problems associated with ASD.[7] 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.[8] Only the antipsychotics have clearly demonstrated efficacy.[9]

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.[61] In the United States, risperidone has been approved by the Food and Drug Administration (FDA) for treating symptomatic irritability in autistic children and adolescents.[9] 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 demonstrated.[62] It is unclear whether risperidone improves autism's core social and communication deficits.[9] 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.[63]

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.[9] Some selective serotonin reuptake inhibitors (SSRIs) and dopamine blockers can reduce some maladaptive behaviors associated with ASD.[64] 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.[10] One study found that the psychostimulant methylphenidate was efficacious against hyperactivity associated with ASD, though with less response than in neurotypical children with ADHD.[10] 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.[65] A 1998 study of the hormone secretin reported improved symptoms and generated tremendous interest, but several controlled studies since have found no benefit.[14] Oxytocin may play a role in autism and may be an effective treatment for repetitive and affiliative behaviors;[66] 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.[67] 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.[67]

Aside from antipsychotics,[9] there is scant reliable research about the effectiveness or safety of drug treatments for adolescents and adults with ASD.[10] 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.[11] 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.[12][68]

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.[59][13]

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 ten and fifteen individuals, respectively) found no significant difference.[13] Due to the limited data it is difficult to tell whether this treatment approach has effects greater than placebo.[14] 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,[13] high doses of magnesium can cause reduced heart rate and weakened reflexes,[15] and high magnesium concentrations are associated with seizures.[17] Magnesium should always be taken along with high doses of pyridoxine to prevent side effects such as irritability and sensitivity to sound.[14]

Dimethylglycine (DMG) is hypothesized to improve speech and reduce autistic behaviors,[13] and is a commonly used supplement.[59] Two double-blind, placebo-controlled studies found no statistically significant effect on autistic behaviors,[13] and reported few side effects. No peer-reviewed studies have addressed treatment with the related compound trimethylglycine.[59]

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.[59]

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.[59]

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.[13] A 2008 open trial found that melatonin appears to be a safe and well-tolerated treatment for insomnia in children with ASD. and suggested controlled trials to determine efficacy.[69]

Omega-3 fatty acids, which are polyunsaturated fatty acids (PUFA), were found to reduce hyperactivity in children with ASD in a 2007 double-blind, placebo-controlled trial of small groups of children,[70] suggesting that further research is needed.[1]

Several other supplements have been hypothesized to relieve autism symptoms, including carnosine, cholesterol,[71] 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.[59][13]

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;[72] this does not appear to result in malnutrition. Although some children with autism also have gastrointestinal (GI) symptoms (controversy has surrounded the related diagnosis of autistic enterocolitis), there is a lack of published rigorous data to support the theory that autistic children have more or different GI symptoms than usual;[73] 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.[74] 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.[21]

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.[13] 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.[75]

Cannabis

It has been speculated that THC, the main active ingredient in cannabis, counteracts inhibitory mechanisms underlying autism.[76]

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 epidemiological evidence that refutes links between environmental triggers, in particular thimerosal containing vaccines, and the onset of autistic symptoms. No scientific data supporting the claim that the mercury in the vaccine preservative thiomersal causes autism[77] or its symptoms,[78] and there is no scientific support for chelation therapy as a treatment for autism.[36] Citing possible harm to research subjects, such research studies have not been funded by the U.S. government.

Chelation therapy can be hazardous when performed incorrectly. In August 2005, botched chelation therapy killed a five-year-old autistic boy; a nonautistic child died in February 2005; and a nonautistic adult died in August 2003. These deaths were due to cardiac arrest caused by hypocalcemia during chelation therapy.[22]

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.[79] 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.[80] There is not sufficient evidence to support the use of thiamine (vitamin B1) to treat autism.[13]

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.[81] There is no scientific support for major elements of the underlying model,[82] there is little scientific evidence to support the therapy, and research methods that could conclusively evaluate the therapy's effectiveness have not been applied.[81]

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.[83] However, scientific evidence is lacking for the use of HBOT to treat autism.[17]

Prosthetics

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 protheses are currently available but the development of implantable neurocognitive brain-computer interfaces has been proposed to help treat conditions such as autism.[84]

Affective computing devices, typically with image or voice recognition capabilities, have been proposed to help autistic individuals improve their social communication skills[85]. These devices are still under development. Robots have also been proposed as educational aids for autistic children.[86]

Stem cell therapy

Mesenchymal stem cells and cord blood CD34+ cells have been proposed to treat autism, but this proposal has not been tested.[87]

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:[88]

  • 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.

References

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Further reading

See also


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