autistic%20disorder
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to point or show, lack of interactive play, failure to smile, lack of sharing & interest in other children, and often withdrawn and spends hours in solitary play with restrictive or repetitive interests and behaviors.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 pharmacological cure for autism
  • Medications are most beneficial when used in conjunction with developmental, educational, behavioral and 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 disruptive/disturbing symptoms
  • Facilitate access to intervention
  • Maximize benefits of nonmedical intervention
  • Improves the patient’s and 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 and repetitive behavior

Risperidone

  • Approved for the short-term treatment of irritability, hyperactivity and stereotypic behavior in autistic children 5-16 years of age
  • Has less extrapyramidal effects than typical antipsychotics
  • Children may gain weight within the first few months of treatment
  • Prolactin levels may rise but with no clinical effects seen
  • Improvement in repetitive behavior, social withdrawal and hyperactivity were observed in several studies

Conventional Antipsychotics

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

Selective Serotonin Reuptake Inhibitors (SSRI)

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

Investigative Agents

  • Various clinical studies are being conducted to prove the therapeutic effects of Oxytocin on patients with autism spectrum disorder
    • Oxytocin therapy may have the potential to improve social responsiveness based on several studies
  • Methylphenidate is another agent undergoing clinical trials, showing potential in controlling joint attention and self-regulation behaviors, but further studies are needed to conclude its use for the treatment of autism

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 and verbal communication, play and 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 and consider the patient’s developmental status, (eg specific strengths and 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 and enhance expression in verbal children
  • Other communication interventions includes: Responsive Education and Prelinguistic Milieu Teaching (RPMT), Reciprocal Imitation Training (RIT), Picture Exchange Communication System (PECS)
  • Occupational therapy gives assessment and intervention to maximize daily living activities
    • Sensory Integration Therapy (SIT)
    • Perceptual Motor Training
  • Social skills should be taught
    • Use strategies to minimize maladaptive behavior and encourage compliance
    • Social skill taught explicitly through modeling and feedback
  • Positive reinforcement should be applied
  • Involvement of the parents is critical
  • Parents and caregivers should be encouraged to share information about special educational needs with school personnel for better planning of intervention and support

Behavioral Management

  • Notable treatment approach to autistic disorder is Applied Behavior Analysis (ABA)
  • Most effective when started early and applied consistently
  • Reinforce proper desirable behavior using behavioral psychologic theory
    • Implement behavioral training and management protocols at home and school
  • Should be initiated after complete assessment of the child’s behavioral characteristics and environment
  • Positive reinforcement strategy should be used
  • Parents, caregivers and 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 and 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 and 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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