Interventions for autism spectrum disorders (ASD)

Todd Kopelman, PhD, Scott Lindgren, PhD, and David Wacker, PhD
Center for Disabilities and Development
University of Iowa Children’s Hospital

Introduction

Substantial progress has been made in identifying interventions that address the core deficits of ASDs and improve the quality of life for many individuals with an autism spectrum diagnosis.

Identifying appropriate interventions can be an overwhelming and frustrating experience for parents. A recent Google search using the term “autism treatment” revealed over 750,000 results! Unfortunately, many of these “treatments” are costly, have limited scientific support, and may result in families failing to seek out interventions that are more likely to have beneficial effects.

In 2009, the National Autism Center released The National Standards Report, a comprehensive review of the level of scientific evidence available to support applied treatments for individuals with ASDs. Based on a review of the research evidence, treatments were separated into three categories:

1. Established
2. Emerging
3. Not established

The authors of the report noted that the majority of the established treatments were developed in the field of Applied Behavior Analysis (ABA). The following is a brief overview of ABA treatments as well as information about selected other treatments for autism that have received support in the research literature.

Applied behavior analysis (ABA)

ABA is the scientific study of the influence of environmental events on a range of socially significant behaviors. The term ‘ABA’ does not refer to any specific program or procedure. Instead, ABA is used more generally to describe programs that adhere to the following principles:

1. An emphasis on observable behaviors
2. The systematic analysis and measurement of relations between environment and behavior
3. The use of single-subject design to show the relation between behavior and the environment
4. A focus on behaviors of social relevance

Within the field of autism, ABA programs typically focus on teaching new skills and generalizing the use of these skills across different settings, reinforcing desirable behaviors, and decreasing behaviors of concern. ABA procedures are used with children with ASDs to teach specific academic and vocational skills; to increase speech, social skills, and play skills; and to decrease problem behaviors. Multiple studies published over the past four decades have demonstrated that many children who receive intensive ABA interventions make substantial growth in their learning, adaptive skills, and behaviors.

The specific approaches used in ABA programs vary. Some ABA programs focus on teaching specific skills through the use of massed learning trials, with trials conducted between a therapist and a child at a table. Recently, a greater emphasis has been placed on blending ABA principles into developmentally sequenced, play-based programs that are implemented in naturalistic settings. For challenging behaviors, the most common approach is to first conduct a functional analysis, an assessment of the environmental events that elicit and maintain problem behavior. After the function(s) for the problem behavior has been identified, the child is then taught to communicate for desired outcomes and to replace problem behavior with equivalent communications (e.g., to request a toy or a break from work).

Visual supports

Many children with an ASD diagnosis experience difficulties in the areas of receptive and expressive language, attention, and memory. For many children with this learning profile, the use of visual supports has been shown to have a positive effect on learning, behavior, and social skills. Examples of visual interventions with research support include the use of schedules, story-based instruction, picture exchange systems, and structured teaching (e.g., TEACCH Autism Project). In many cases, visual supports are used as a package along with other interventions.

Other therapies

Social skills training is important in reducing social deficits in ASDs, and effective approaches include ABA methods, peer-based intervention strategies, and social skills groups. Use of cognitive behavior therapy, especially structured “self-management” programs designed for higher functioning children/adolescents or adults with ASD, can support management of anxiety, depression, anger control, and social skill development. Targeted therapies (e.g., speech/language, OT) can be used to increase communication skills and to improve independence in activities of daily living. Although many children with ASD have “sensory” issues that interfere with learning or social behavior, the theories behind sensory integration (SI) therapy for ASD lack scientific support. Despite this fact, some of the activities emphasized in “sensory” therapy may help children to become more physically active, to accept a wider range of sensory experiences, or to be more receptive to reinforcement for desired behavior when used as part of a comprehensive ASD intervention program.

Medical treatment

Medications are sometimes used to target symptoms experienced by some children with ASDs. Currently, one medication, risperidone, has received approval from the Food and Drug Administration (FDA) for the treatment of irritability (including aggression, self-injury, and tantrums) in children with ASDs between the ages of 5 and 16 years. Although risperidone is the only FDA-approved medication, there are other medications with fewer side effects that may often be tried first. Other medications are often prescribed on an “off-label” basis to target symptoms such as aggression, depression, anxiety, obsessive-compulsive tendencies, sleep difficulties, and attention deficits. The term “off-label” means drugs that are typically prescribed one way, but are now being used to treat something else. Children with ASDs may not respond to medications in the same way as typically developing children. It is important for parents to work closely with a provider with expertise in the field of autism to closely monitor response to the medication. Additional medical care may be needed to manage problems with seizures, gastrointestinal problems, and dietary imbalances. Genetic testing using microarray analyses is also now being recommended for children with ASDs.

Complementary and alternative medicine (CAM) treatments

It has been estimated that around 30 percent of parents with a child with autism choose to use complementary and alternative medicine (CAM). Common examples of CAM’s include melatonin, a gluten-free, casein-free (GFCF) diet, different enzymes and vitamins (e.g., B6, Magnesium, B12, probiotics), and body-based systems such as deep pressure. Research has found that melatonin can help children with ASDs to fall asleep. At this time, limited research exists to support the efficacy of other CAM’s. Some approaches, such as chelation (the administration of medication to help the body excrete heavy metals) lack scientifically valid research to support their efficacy and can pose serious safety concerns. Parents considering CAM’s are encouraged to consult closely with their child’s healthcare provider to receive up-to-date information about the intervention so that appropriate monitoring and evaluation can occur.

General intervention guidelines

Treatment is likely to be most effective when it is individualized and when it is conducted as soon as possible after concerns are noted. Before treatment begins, it is therefore important to conduct a comprehensive assessment of the child’s developmental status. Key members of the assessment team often include a developmental pediatrician or other healthcare provider with expertise in autism, a speech and language pathologist, a psychologist, an educational consultant, and an occupational therapist. Results from the evaluation can be used by parents and the school team to develop a treatment program that is tailored to the child’s strengths and needs. As is true for any child with a serious neurodevelopmental disability, providing a “medical home” that can ensure care coordination, parent training, and family support is critically important to a comprehensive plan of care. For adolescents and adults with ASD, vocational training, job coaching, and interventions to improve social and behavioral adjustment are crucial to support independence in living and working in community settings. Although distinctions have been made between ASD services that are “habilitative” (building new skills) or “rehabilitative” (restoring lost skills), legal decisions have questioned the use of these distinctions. Current thinking supports the need for preventive, medical, and remedial services when these interventions have been recommended by a health care practitioner for the reduction of a physical or mental disability and for ensuring the best possible level of functioning. Whenever possible, recommended services should be based on proven interventions with a strong evidence base.