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Published scientific evidence for behavioral, medical interventions in autism sparse

Monday, October 13 2008 | Comments

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What's This? By Patrice LaVigne

The prevalence of autism spectrum disorder is rising, so pediatricians need to be aware of the growing evidence that supports the use of both behavioral and medical interventions to treat autism, according to Dr. Scott Myers, a pediatrician who specializes in neurodevelopmental disabilities at Geisinger Medical Center in Danville, Pennsylvania.

Overall, Dr. Myers noted there are very few well-rounded studies that demonstrate efficacy of behavioral or pharmacologic interventions to treat autism. Instead, pediatricians must rely on evidence-based data, which is still sometimes plagued by weak design, including small study populations and lack of a control group.

Nonetheless, Dr. Myers said educational interventions represent the primary "cornerstones of management" in autism and aim to alleviate impairment in social interactions, communication deficits, and maladaptive behaviors, thus improving and maintaining functional independence and quality of life.

Any intervention, he stressed, "should be based on assessment of existing skills and formulation of individualized goals and objectives" for each child. Specifically, the programs should include "a high degree of structure" and should "measure and document the child's progress so that you can make adjustments to the strategy."

Dr. Myers highlighted some of the most common approaches in educational interventions. Applied behavior analysis (ABA), for example, is a popular method used to encourage socially useful behaviors and discourage problematic behaviors. There are many types of ABA-based interventions, such as discrete trial training, incidental teaching, and pivotal response training.

"These interventions have the strongest empirical support in peer-reviewed literature," Dr. Myers said. "It doesn't mean they're the only thing that's good or they're for everyone, but as far as what research has been done and what's out there in literature, there's really no question that the documentation is best for ABA interventions."

Several approaches are categorized as developmental models, such as the Denver Model, the DIR (Developmental, Individual-Difference, Relationship-based)/Floortime Model, LEAP (Learning Experiences: an Alternative Program for Preschoolers and Parents), and SCERTS (Social Communication, Emotional Regulation, and Transactional Support). These models, in contrast to the ABA-based models, focus on remediating deficits in pivotal developmental skills that affect social communication and emotional relationships, Dr. Myers said.

Overall, he noted that at this point, the evidence-based data are still questionable to fully support the developmental interventions. In particular, many of the interventions lack strongly designed studies--including no control group--or no peer-reviewed research at all, and it is clear that more analysis is necessary. For example, he described the Denver Model, which has been around for a long time. He said there have been various papers describing improvements in certain skills with the Denver Model. Now, the National Institutes of Health (NIH) is funding a study to prospectively evaluate 108 children aged 12 to 24 months at enrollment. The children will be randomized to receive the Early Start Denver Model, an intensive intervention program that combines ABA strategies with relationship-based approaches from the Denver Model, or standard community care. The study is expected to be completed in December 2012.

Another approach is TEACCH (Treatment and Education of Autistic and related Communication-handicapped CHildren), which emphasizes visual instruction in an organized environment and is routine-oriented but also allows for flexibility.

"Although the studies [for TEACCH] are primarily uncontrolled, there is a fair amount of evidence that this strategy is in widespread use," Dr. Myers said.

Speech and language therapy is "almost always" an important component of autism treatment and is supported by recent reviews demonstrating efficacy, he noted. This intervention mostly focuses on didactic and naturalistic behavioral methods, sign language, and augmentative communication techniques to teach communication.

A number of approaches are included within the social skills instruction category, which aims to teach children to initiate social interaction. He added that there is some objective evidence to support certain ABA-based social skills instruction.

According to Dr. Myers, there are no data on the effectiveness of occupational therapy in autism, but pediatricians can recommend it as a way to remediate deficits in neurological processing that affect self-care skills and academic performance.

Lastly in terms of behavioral interventions, Dr. Myers stressed that there are a number of other "inadequately evaluated" examples, such as art, music, and vision therapies, that should not be recommended based on the available evidence.

"The field [of behavioral therapy] is relatively early in the process of determining which interventions are most effective and how much improvement can reasonably be expected," he cautioned.

Medical interventions in autism, Dr. Myers continued, are sometimes necessary when the child presents with challenging behaviors, such as aggression, self-injury, and anxiety. He stressed that the treating physician must review other medical conditions that may prompt or exacerbate the abnormal behaviors. Based on his own experience, he said dental and stomach problems are often the culprits instead of the autism.

If medical treatments are necessary to treat the autism symptoms, physicians should feel comfortable with the drugs they prescribe and expect high adverse effect rates. Risperidone is the only Food and Drug Administration-approved therapy for autism symptoms, and studies of the drug indicate improvements in restrictive, repetitive, stereotyped behavior in children with autism but show no significant impact on social interaction and communication deficits.

There are also off-label options, Dr. Myers said. Data are sparse, but available, for the use of selective norepinephrine reuptake inhibitors, antidepressants, atypical antipsychotics, and anticonvulsants. Some inadequately evaluated medical therapy options include antiviral agents, antioxidants, and gluten-free/casein-free diets. Dr. Myers noted that the dietary approach is popular, though unsupported, and the NIH is funding a study to assess the use of this method in children with autism.

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