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AUTISTIC DISORDER
Autism involves impaired social interaction, impaired communication and lack of developmentally appropriate behavior, interests or activities.
Deficit in social skills eg abnormal eye contact, failure to orient name, failure to use gestures to point or show, lack of interactive play, failure to smile, lack of sharing & interest in other children, and often withdrawn and spends hours in solitary play with restrictive or repetitive interests and behaviors.
Impaired social interaction showed as impairment in joint attention, deficits in empathy for what another person might be feeling and deficits in understanding what another person might be thinking.
Autistic child also presents with deficit in language and communication (eg nonverbal or having some speech), aberrant play skills (eg little symbolic play, preoccupation with parts of objects), variation in intellectual functioning, heightened awareness to stimuli and lowered sensitivity to stimuli.

Principles of Therapy

  • There is no pharmacologic cure for autism
  • Medications are most beneficial when used in conjunction with developmental, educational, behavioral & habilitative therapies
  • There is no single medication that consistently benefits all patients with autism spectrum disorder (ASD)

Indications

  • If presenting with comorbid psychiatric or neurodevelopmental conditions
  • For short to medium term intervention for specific severe symptoms
  • For aggressive or self-injurious behavior
  • For anxiety, depression, tics, obsessive-compulsive behaviors, hyperactivity, sleep disorders

Goals

  • Minimize core symptoms
  • Facilitate access to intervention
  • Maximize benefits of nonmedical intervention
  • Improves the patient’s & the family’s quality of life

Pharmacotherapy

Atypical Antipsychotics

Aripiprazole

  • Approved for the short-term treatment of irritability in autistic children 6-17 years of age
  • Studies showed improvement in challenging behavior & repetitive behavior

Risperidone

  • Approved for the short-term treatment of irritability, hyperactivity & stereotypic behavior in autistic children 5-16 years of age
  • Has less extrapyramidal effects than typical antipsychotics
  • Children may gain weight w/in the first few months of treatment
  • Prolactin levels may rise but w/ no clinical effects seen
  • Based on controlled trial, Risperidone did not significantly improve the social interaction & communicative impairment
    • Further research is needed to identify effective treatment for the core social & communication deficits

Conventional Antipsychotics

  • Eg Haloperidol, Chlorpromazine
  • Haloperidol is being considered in the management of temper tantrums, aggression, hyperactivity, withdrawal & stereotypical behavior
  • Limitation of use is due to sedation, irritability & extrapyramidal dyskinesia

Selective Serotonin Reuptake Inhibitors (SSRI)

  • Eg Fluoxetine, Fluvoxamine
  • Studies have shown that Fluoxetine improved the mood of adolescent & adult patients & reduced ritualistic or repetitive behavior
  • Fluvoxamine has been shown to be effective in the treatment of obsessive-compulsive disorder (OCD), refractory depression & social phobia
  • Fluvoxamine has been considered for repetitive thought & maladaptive behavior but it can cause occasional worsening of hyperactivity in patients

Non-Pharmacological Therapy

Early Developmental Intervention

  • Intervention programs for autistic toddlers commonly involve the following:
    • A predictable program with routine that should stress the ability to pay attention to other people, imitate others, use of preverbal & verbal communication, play & social interaction
    • Systematic individual teaching of skills to support the child’s specific needs
    • Functional approach to dealing with the child’s problematic behavior
    • Family involvement
  • There is evidence that if intensive early intervention is done on children diagnosed before 5 years, a better outcome is expected

Educational Systems

  • Help autistic children from the age of 3-21 years
  • Individualize the intervention & consider the patient’s developmental status, (eg specific strengths & deficits)
  • Usually includes speech therapy with use of visual cues
    • Shows improvement in the expressive language at 4 years of age if speech therapy is given between 2-3 years of age
  • For the minimally speaking child, alternative-augmentative communication systems may be recommended because these may stimulate speech acquisition in non-verbal children & enhance expression in verbal children
  • Other communication interventions includes: Responsive Education & Prelinguistic Milieu Teaching (RPMT), Reciprocal Imitation Training (RIT), Picture Exchange Communication System (PECS)
  • Occupational therapy gives assessment & intervention to maximize daily living activities
    • Sensory Integration Therapy (SIT)
    • Perceptual Motor Training
  • Social skills should be taught
    • Use strategies to minimize maladaptive behavior & encourage compliance
    • Social skill taught explicitly through modeling & feedback
  • Positive reinforcement should be applied
  • Involvement of the parents is critical
  • Parents & caregivers should be encouraged to share information about special educational needs with school personnel for better planning of intervention & support

Behavioral Management

  • Notable treatment approach to autistic disorder is Applied Behavior Analysis (ABA)
  • Most effective when started early & applied consistently
  • Reinforce proper desirable behavior using behavioral psychologic theory
    • Implement behavioral training & management protocols at home & school
  • Should be initiated after complete assessment of the child’s behavioral characteristics & environment
  • Positive reinforcement strategy should be used
  • Parents, caregivers & teachers should be trained to consistently implement the behavioral strategy in all of the child’s environments
  • Social competence should be developed as part of behavioral rehabilitation plan

Early intensive behavioral & developmental approach

  • UCLA/Lovaas
  • Early start Denver model
  • Parent training approaches
  • Discrete Trial Training (DTT)
  • Pivotal Response Training (PRT)

Social skills approach

  • Social skills training

Play/Interaction-based approach

  • Joint attention intervention
  • Symbolic play & play-based interventions

Behavioral intervention for commonly associated symptoms

  • Cognitive behavioral therapy for anxiety or anger management
  • Sleep workshop for sleep disturbances
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