Behavioural treatments for autism
The most effective treatment for autism is early and intensive behaviour therapy, or Applied Behavioural Analysis (ABA), preferably starting before 4 years of age. Individual or small group sessions are best and, if possible, the intervention should take place for at least 20 hours per week.
Behaviour therapy consists of rewarding the desired behaviour, such as appropriate social interaction and language, and eliminating undesired behaviours, such as spinning, hand flapping and self-injury. As such, these interventions are highly individualized to target the child’s specific needs. An important part of ABA is that sessions are highly organized, and skills are taught in small steps, mastered, and then generalized – generalizing learned skills to other similar situations is much more difficult for children with ASD to do than for neurotypical children.
Behaviour therapy has been shown to improve children’s social and intellectual skills. It is recommended that this intensive early behavioural therapy is continued for at least 3-4 years, until the child is able to cope in an educational setting.
TEACCH (Treatment and Education of Autism and related Communications-handicapped Children) is another widely used method of teaching children with ASD. This method takes advantage of the fact that children with ASD are better at understanding visual information than spoken instructions. TEACCH uses strategies such as picture schedules and highly structured learning sessions that are broken down into manageable, visually organized steps.
Ineffective or unproven treatments
Dietary interventions are popularly prescribed for autism. Elimination diets, such as diets free of casein (found in dairy products) or gluten (found in wheat products), may help for a small subset of children, but have not been proven to be effective by randomized, controlled-trial studies.
A popular technique in the 1990s, facilitated communication, has been proven to be ineffective. The premise of facilitated communication is that children with autism do not have problems with language or social functioning, but purely with motor control with impedes their ability to speak. Facilitated communication claimed that children with autism could therefore communicate with their family with the help of a facilitator guiding the child’s hand across a keyboard. However, it has repeatedly been shown that the resulting communication is because of the facilitator’s unintentional control over the child’s hand.
Sensory-motor integration targets sensory hypersenstivity (e.g., touch, sound) in children with autism. Treatments include spinning children on chairs, deep-pressure massage, and brushing the skin with a soft-bristle brush in order to calm children. However, carefully controlled studies have not found sensory integration therapies to be effective.
No controlled studies have been done on the effectiveness of auditory integration therapy or music therapy.
Pharmacological treatments should not be used on their own, but are effective in reducing anxiety and problem behaviours so that learning is not hindered. Pharmacological interventions include antipsychotics, such as haloperidol (Haldol) and risperidone (Risperdal), to manage aggressiveness and irritability, and reduce self-injurious and stereotyped behaviours; and methylphenidate (Ritalin, Concerta) to reduce inattention, impulsivity and hyperactivity. Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), cetalopram (Celexa) and sertraline (Zoloft), are often used to reduce anxiety and repetitive behaviours, although evidence for its effectiveness has been mixed.
Between 7 and 14% of children with autism also have epilepsy. Anti-epileptic medication can help to control seizures. There are many anticonvulsant drugs available, and the doctor will work with the family to find the best medication for the child that both reduces seizures effectively and has the least side-effects.
Update: September, 2011. Autism Speaks has compiled a booklet to help parents who are considering medication to help with unwanted or harmful behaviour. Please let them know if you find it useful!
Ineffective or unproven treatments
Popular medical treatments that have not been proven to be effective or safe include (1) vitamin and mineral supplements, most often vitamin B6 together with magnesium, but also vitamin B12, vitamin C, and folic acid; (2) the antioxidant dimethylglycine, purported to increase immune system functioning and mental alertness; and (3) famotide (Pepcid), which is given to reduce stomach acid production. There has been no support for the effectiveness of these treatments, some of which can have serious side-effects, such as liver and kidney damage or peptic ulcers.
What are the favourable signs for best outcome?
Predictors of recovery include relatively high intelligence, receptive language, verbal and motor imitation, and motor development. Earlier age of diagnosis and initiation of treatment, and a diagnosis of Pervasive Developmental Disorder-Not Otherwise Specified are also favourable signs. Joint attention, pretend play, and social development may also contribute to recovery. Overall symptom severity did not influence recovery. The presence of seizures, mental handicap and genetic syndromes are unfavourable signs.
What treatments best predict favourable outcome?
Controlled studies that report the most recovery use behavioural treatment techniques that reward social interactions. Examples of these techniques are intensive practice of weak skills, preventing interfering behaviours, enrichment of the child’s environment, reducing stress and anxiety, and using reinforcements that guide the child’s attention outward into the physical and social environment. These efforts appear most promising when implemented early in life, even before the autistic symptoms have fully presented. Bio-medical intervention, such as good nutrition and getting enough sleep, are also associated with positive outcomes.
Children who recover from ASD are still vulnerable to residual problems, however, such as higher-order communication deficits, tics, depression, ADHD and phobias.
That a significant amount of children with ASD show such positive outcomes is a very hopeful sign. More research is certainly needed into how interventions affect behaviour and the brain.
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