Autism: Treatment

General Standards of Care

Treatment approaches are evolving as more is learned about autism. There are many therapeutic programs, both conventional and complementary, that focus on replacing dysfunctional behaviors and developing specific skills.

As a parent, it's natural to want to do something immediately. However, it is important not to rush in with changes. Your child may have already learned to cope with his or her current environment and immediate changes could be stressful. You should investigate various treatment approaches and gather information concerning various options before proceeding with your child's treatment.

You will encounter numerous accounts from parents about successes and failures with many of the treatment approaches mentioned. You will also discover that professionals differ in their theories of what they feel is the most successful treatment for autism. It can be frustrating! But you will learn to sift through them and make rational, educated decisions on what is appropriate for your child. You live with your child every day and you know his/her needs. And in time, you will come to know his/her autism. Trust your instincts as you explore various options.

Again, please keep in mind that the descriptions of treatment approaches provided here are for informational purposes only. They are meant to give you an overview of an approach. The ASA does not endorse any specific treatment or therapy. For more information about ASA's policy on options, click here.

During your research, you will hear about many different treatment approaches, such as auditory training, discrete trial training, vitamin therapy, anti-yeast therapy, facilitated communication, music therapy, occupational therapy, physical therapy, and sensory integration. These approaches can generally be broken down into three categories:

• Behavioral and Communication Approaches
• Biomedical and Dietary Approaches
• Complementary Approaches

Some of these treatment approaches have research studies that support their efficacy; others do not. Some parents will only want to try treatment methods that have undergone research and testing and are generally accepted by the professional community. But keep in mind that scientific studies are often difficult to do since each individual with autism is different.

For other parents, formal testing might not be a pre-requisite for them to try a treatment with their child. Even for those treatments with "scientific" proof, we recommend that the family or caregiver investigate all options available to determine the appropriateness for their child.

Experts agree though that early intervention is important in addressing the symptoms associated with autism. The earlier treatment is started, the better the chance the child will reach normal functioning levels. Many of the approaches described can be used on children as young as age 2 or 3. They may also continue to be used in conjunction with special education programs or traditional elementary school for children who are mainstreamed.

Understanding and Evaluating Your Options

Treatment approaches are constantly evolving as more is learned about the autism spectrum. There are many therapeutic programs, both conventional and complementary, that focus on replacing dysfunctional behaviors and developing specific skills.

As a parent, it's natural to want to do something immediately. The literature states time and time again the importance of early treatment for individuals on the autism spectrum. However, it does no good to push ahead with a treatment that is not appropriate for the individual or one that may be harmful. You also must consider the larger implications of beginning a new treatment as sudden changes or unexpected different expectations could be stressful and confusing for your child. Various treatment approaches should be investigated and information gathered concerning various options before proceeding with any child's treatment.

Parents will encounter numerous accounts from other parents about successes and failures with many of the treatment approaches mentioned. Professionals also differ in their theories of what they feel is the most successful treatment for autism. Parents must learn to sift through the information, examine options with a critical eye and make rational, educated decisions on what is appropriate given the individual circumstance. Parents live with the individual on the spectrum every day and best know his/her needs and the unique ways that autism impacts their lives. Parents must be empowered to trust their instincts as various options are explored, considered and implemented.

The descriptions of treatment approaches serve as overviews only and should always be followed with contact with qualified professionals and discussed with parents or individuals on the spectrum who have personal experiences with these approaches.

Learning/Behavioral

When families first receive a diagnosis on the autism spectrum for their son or daughter, it is not long before they are bombarded with literature that focuses on “cure” or “recovery.” For many, this goal becomes the single focus of any programming efforts. As the years progress, many families view the absence of a cure as tantamount to catastrophe. Since there is currently no known or reliably effective cure for autism, should this goal be our sole or primary focus? The desperation families feel in the absence of a cure highlights an urgent need to develop a model for successfully “living with autism” even as we pursue a model for helping individuals “recover” from autism (Carr, 2007a).

The good news is that, through carefully designed support for positive, constructive behavior (hence, the term “positive behavior support”), it is possible to repair and enhance the quality of life for people with autism and their families (Carr et al., 2002). A support model mirrors the field of general medicine in which many chronic conditions are also not curable at present. For example, people with diabetes, arthritis, AIDS, cancer and heart disease are often not cured and, yet, with support and appropriate management, they can live fulfilling lives. So, too, can people with autism and their families.

- from “Positive Behavioral Supports: Creating Meaningful Life Options for People with ASD” by Edward G. Carr, Ph.D., and Cathy L. Pratt, Ph.D, featured Volume 49 of the Autism Advocate, issue no. 4. To read the article in its entirety.

Biomedical

Autism is a spectrum disorder with a variety of options for treatment for individuals across the lifespan. Professionals and families have found that a combination of approaches may be effective in treating symptoms and behaviors that make it hard for individuals with autism to function. These treatment options may include psychosocial and pharmacological interventions.

While there are no drugs, vitamins or special diets that can correct underlying neurological problems associated with autism, parents and professionals have found that some drugs used for other disorders are sometimes effective in treating some aspects of behaviors associated with autism.

Changes to diet and the addition of certain vitamins or minerals may also help with behavioral issues. For more then a decade, there have been claims by parents and some professionals that adding essential vitamins such as B6 and B12 and removing gluten and casein from a child's diet may improve digestion, allergies and sociability. Not all researchers and experts agree about whether these therapies are effective or scientifically valid.

Medications

There are a number of medications, developed for other conditions, which have been found effective in treating some of the symptoms and behaviors frequently found in individuals with ASD. Some of these behaviors include: hyperactivity, impulsivity, attention difficulties, and anxiety. The goal of these medications is to reduce these behaviors to allow the individual with ASD to take advantage of educational and behavioral treatments.

When medication is being discussed or prescribed, it's important to as the following questions:

• What is its safety record for children on the autism spectrum?
• What is the appropriate dosage?
• How is it administered (pills, liquid)?
• What are the long-term consequences of taking the medication?
• Are there possible side effects?
• How will monitoring occur and by whom?
• What laboratory tests are required before starting the drug and during treatment?
• Are there possible interactions with other drugs, vitamins or foods?

Given the complexity of medications, drug interactions, and the unpredictability of how each patient may react to a particular drug, parents should seek out and work with a medical doctor with expertise in the area of medication management and experience with individuals with ASD.

What Medications are Available?

The ASA does not endorse any specific medication or type of treatment approach. ASA recommends that all options available are investigated to determine the approach that is most appropriate. People on the spectrum, parents and professionals must be empowered to critically examine the wide variety of options available to determine associated threats and opportunities and, therefore, make informed decisions. The information provided here is meant as an overview of the types of medications sometimes prescribed. Be sure to consult a medical professional for more information.

There are a number of medications frequently used for individuals with autism to address certain behaviors or symptoms. Some have studies to support their use, while others do not. Serotonin re-uptake inhibitors have been effective in treating depression, obsessive-compulsive behaviors and anxiety that present in some individuals with ASD. Researchers who have consistently found elevated levels of serotonin in the bloodstream of one-third of individuals with autism feel that these drugs could potentially reverse some of the symptoms of serotonin dysregulation in autism. Three drugs that have been studied are clomipramine (Anafranil), fluvoxamine (Luvox) and fluoxetine (Prozac). Studies have shown that they may reduce the frequency and intensity of repetitive behaviors, and may decrease irritability, tantrums and aggressive behavior. Some children have also shown improvements in eye contact and responsiveness.

Other drugs, such as Elavil, Wellbutrin, Valium, Ativan and Xanax have not been studied as much but may have a role in treating behavioral symptoms. However, all these drugs have potential side effects, which should be discussed with qualified professionals before treatment is started.

Anti-psychotic medications have been the most widely studied of the psychopharmacologic agents in autism over the past 35 years. Originally developed for treating schizophrenia, these drugs have been found to decrease hyperactivity, stereotypical behaviors, withdrawal and aggression in individuals with autism. Four that have been approved by the FDA are clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa) and quetiapine (Seroquel). Only risperidone has been investigated in a controlled study of adults with autism and was approved in 2006 by the FDA for the treatment of autism. Like the antidepressants, these drugs all have potential side effects, including sedation, which need to be carefully monitored by a qualified professional with experience in autism.

Stimulants, such as Ritalin, Adderall and Dexedrine, used to treat hyperactivity in children with ADHD, have also been prescribed for children with ASD. Although few studies have been done, anecdotal evidence shows these medications may increase focus and decrease impulsivity and hyperactivity in autism, particularly in children who are not as severely affected as others. However, dosages need to be carefully monitored because behavioral side effects are often dose-related.

Increased use of medications to treat autism spectrum disorders has highlighted the need for more studies of these drugs in children. The National Institute of Mental Health has established a network of Research Units on Pediatric Psychopharmacology (RUPPs) that combines expertise in psychopharmacology and psychiatry.

If you are considering the use of medications, contact a medical professional experienced in treating individuals on the autism spectrum to learn of possible side effects and discuss potential benefit. People with ASD may have very sensitive nervous systems and the normally recommended dosage may need to be adjusted. Even the use of large doses of vitamins should be under the supervision of a medical doctor.

Vitamins and Minerals

For over a decade, claims have been made that vitamin and mineral supplements may improve the symptoms of autism in a natural way. While not all researchers agree about whether these therapies are scientifically proven, many parents and an increasing number of physicians report improvement in people with ASD when using individual or combined nutritional supplements.

Malabsorption problems and nutritional deficiencies have been addressed in several as-of-yet unreplicated studies. A few studies suggest that intestinal disorders and chronic gastrointestinal inflammation may reduce the absorption of essential nutrients and cause disruptions in immune and general metabolic functions that are dependent upon these essential vitamins. Other studies have shown that some children on the autism spectrum may have low levels of vitamins A, B1, B3, and B5, as well as biotin, selenium, zinc, and magnesium; while others may have an elevated serum copper to plasma zinc ratio, suggesting that they may benefit by avoiding copper and taking extra zinc to boost their immune system. Other studies have indicated a need for more calcium. There are several laboratories that test for nutritional deficiencies, but many insurance companies will not pay for these tests.

Perhaps the most common vitamin supplement used for individuals with ASD is vitamin B, which plays an important role in creating enzymes needed by the brain. In several studies on the use of vitamin B and magnesium (which is needed to make vitamin B effective), almost half of the individuals with autism showed improvement. The benefits include decreased behavioral problems, improved eye contact, better attention span, and improvements in learning. Other research studies have shown that other supplements may help symptoms as well. Cod liver oil supplements (rich in vitamins A and D) have resulted in improved eye contact and behavior of children with autism. Vitamin C helps in brain function and deficiency symptoms like depression and confusion. Increasing vitamin C has been shown in a clinical trial to improve symptom severity in children with ASD.

Using Vitamins and Minerals

If you are considering the addition of vitamins or minerals to your child's diet, a laboratory and clinical assessment of nutritional status is highly recommended. The most accurate method for measuring vitamin and mineral levels is through a blood test. It is also important to work with someone knowledgeable in nutritional therapy. While large doses of some vitamins and minerals may not be harmful, others can be toxic. Once supplements are chosen, they should be phased in slowly (over several weeks) and then the effects should be observed for one to two months.

Dietary Interventions

Individuals with ASD may exhibit low tolerance or allergies to certain foods or chemicals. While not a specific cause of autism, these food intolerances or allergies may contribute to behavioral issues. Many parents and professionals have reported significant changes when specific substances are eliminated from the child's diet.

Individuals on the autism spectrum may have trouble digesting proteins such as gluten. Research in the U.S. and England has found elevated levels of certain peptides in the urine of children with ASD, suggesting the incomplete breakdown of peptides from foods that contain gluten and casein. Gluten is found in wheat, oats and rye, and casein in dairy products. The incomplete breakdown and the excessive absorption of peptides may cause disruption in biochemical and neuroregulatory processes in the brain, affecting brain functions. Until there is more information as to why these proteins are not broken down, the removal of the proteins from the diet is the only way to prevent further neurological and gastrointestinal damage.

It is important not to withdraw gluten/casein food products at once from a child's diet, as there can be withdrawal symptoms. Parents wishing to pursue a gluten/casein free diet should consult a gastroenterologist or nutritionist, who can help ensure proper nutrition. For information about implementing a gluten/casein free diet, go to http://www.gfcfdiet.com/. Additional information about gluten-free foods can be found at http://www.celiacsociety.org/. The ASA magazine, Autism Advocate, also has a regular feature of recipes for those with special dietary needs.

Some hypothesize that children with ASD have what is referred to as a "leaky gut" -- tiny holes in their intestinal tract that may be caused by an overgrowth of yeast. Some believe that this overgrowth may contribute to behavioral and medical problems in individuals on the spectrum, such as confusion, hyperactivity, stomach problems, and fatigue. The use of nutritional supplements, anti-fungal drugs and/or a yeast-free diet may reduce behavioral problems. However, caution should be paid to the fact that just as antibiotics can lead to bacterial resistance, antifungals can lead to fungal resistance.

Complementary Approaches

While early educational intervention is key to improving the lives of individuals with ASD, some parents and professionals believe that other treatment approaches may play an important role in improving communications skills and reducing associated behavioral symptoms. These complementary therapies may include music, art or animal therapy and may be done on an individual basis or integrated into an educational program. All of them can help by increasing communication skills, developing social interaction, and providing a sense of accomplishment. They can provide a non-threatening way for a child on the autism spectrum to develop a positive relationship with a therapist in a safe environment.

Art and music are particularly useful in sensory integration, providing tactile, visual and auditory stimulation. Music therapy is good for speech development and language comprehension. Songs can be used to teach language and increase the ability to put words together. Art therapy can provide a nonverbal, symbolic way for the child to express him or herself.

Animal therapy may include horseback riding or swimming with dolphins. Therapeutic riding programs provide both physical and emotional benefits, improving coordination and motor development, while creating a sense of well-being and increasing self-confidence. Dolphin therapy was first used in the 1970s by psychologist David Nathanson. He believed that interactions with dolphins would increase a child's attention, enhancing cognitive processes. In a number of studies, he found that children with disabilities learned faster and retained information longer when they were with dolphins, compared to children who learned in a classroom setting.

Again, as with all other therapy or treatment approaches, it is important to gather information and make an informed decision. Keep in mind, however, with most complementary approaches there will be little scientific research that has been conducted to support the particular therapy.