AN OVERVIEW OF THE MAIN
Autism therapies attempt to lessen the deficits
and family distress associated with Autism Spectrum Disorders (ASD),
and to increase the quality of life and functional independence
of autistic individuals, especially children. No single treatment
is best and treatment is typically tailored to the child's needs.
Treatments fall into two major categories: educational interventions
and medical management. Training and support is also given to families
of those with Autism Spectrum Disorder.
Intensive, sustained special education programs
and behavior therapy early in life can help children acquire self-care,
social, and job skills. Available approaches include applied
behavior analysis, which focuses on teaching tasks one-on-one using
the behaviorist principles of stimulus, response and reward,
and cognitive therapies based on comprehensive programs in treatment
centers. Educational interventions have some effectiveness in
children; the limited research on the effectiveness of adult
residential programs shows mixed results.
Medications are often used to treat problems associated
with Autism Spectrum Disorder. More than half of U.S. children diagnosed
with Autism Spectrum Disorder are prescribed psychoactive drugs
or anticonvulsants, with the most common drug classes being antidepressants,
stimulants, and antipsychotics.
However, there is scant reliable research about the effectiveness
or safety of drug treatments for adolescents and adults with Autism
Spectrum Disorder. A person with Autism Spectrum Disorder
may respond atypically to medications, the medications can have
adverse side effects, and no known medication relieves autism's
core symptoms of social and communication impairments.
Many alternative therapies and interventions are
available. Few are supported by scientific studies.
Treatment approaches lack empirical support in quality-of-life contexts,
and many programs focus on success measures that lack predictive
validity and real-world relevance. Scientific evidence appears
to matter less to service providers than program marketing, training
availability, and parent requests. Even if they do not help,
conservative treatments such as changes in diet are probably harmless
aside from their bother and cost. Dubious invasive treatments
are a much more serious matter: for example, in 2005, botched chelation
therapy killed a five-year-old autistic boy.
Treatment is expensive; indirect costs are
more so. A U.S. study estimated the average additional lifetime
cost due exclusively to autism to be $3.2 million in 2003 U.S. dollars
for an autistic individual born in 2000, with about 10% medical
care, 30% nonmedical care such as child care and education, and
60% the lost economic productivity of individuals and their parents.
Legal rights to treatment are complex, vary with location and age,
and require advocacy by caregivers. Publicly supported programs
are often inadequate or inappropriate for a given child, and unreimbursed
out-of-pocket medical or therapy expenses are associated with likelihood
of family financial problems. After childhood, key treatment
issues include residential care, job training and placement, sexuality,
social skills, and estate planning.
Educational interventions attempt to help children
not only to learn academic subjects and gain traditional readiness
skills, but also to communicate functionally and spontaneously,
socialize with skills such as joint attention, gain cognitive skills
such as symbolic play, reduce disruptive behavior, and generalize
by applying learned skills to new situations. Several model programs
have been developed, which in practice often overlap and share many
early intervention that does not wait for a definitive
intense intervention, at least 25 hours/week, 12 months/year;
low student/teacher ratio;
family involvement, including training of parents;
interaction with neurotypical peers;
structure that includes predictable routine and clear physical boundaries
to lessen distraction; and
ongoing measurement of a systematically planned intervention, resulting
in adjustments as needed.
Several educational intervention methods are available, as discussed
below. They can take place at home, at school, or at a center devoted
to autism treatment. A 2007 study found that augmenting a center-based
program with weekly home visits by a special education teacher improved
cognitive development and behavior. Intensive, sustained special
education programs and behavior therapy early in life can help children
acquire self-care, social, and job skills; claims that intervention
by age two to three years is crucial are not substantiated.
Applied behavior analysis
Interventions based on applied behavior analysis
(ABA) focus on teaching tasks one-on-one using the behaviorist principles
of stimulus, response and reward, and on reliable measurement
and objective evaluation of observed behavior. There is wide
variation in the professional practice of behavior analysis and
among the assessments and interventions used in school-based ABA
programs. Many interventions rely heavily on discrete trial
teaching (DTT) methods, which use stimulus-response-reward techniques
to teach foundational skills such as attention, compliance, and
imitation. However, children have problems using DTT-taught skills
in natural environments. In functional behavior analysis, a common
assessment technique, a teacher formulates a clear description of
a problem behavior, identifies antecedents, consequents, and other
environmental factors that maintain the behavior, develops hypotheses
about what motivates the behavior, and collects observations to
test the hypotheses. A few more-comprehensive ABA programs use
multiple assessment and intervention methods individually and dynamically.
ABA has demonstrated effectiveness in several
controlled studies: children have been shown to make sustained gains
in academic performance, adaptive behavior, and language, with outcomes
significantly better than control groups. For example, a 2005
California study found that early intensive behavior analytic treatment,
a form of ABA, was substantially more effective for preschool children
with autism than the mixture of methods provided in many programs.
However, a 2007 British study found that home-based early intensive
behavioral interventions, another ABA form, was no more effective
than nursery-based eclectic programs.
TEACCH, which has come to be called "structured teaching",
emphasizes structure by using organized physical environments, predictably
sequenced activities, visual schedules and visually structured activities,
and structured work/activity systems where each child can practice
various tasks. Parents are taught to implement the treatment
at home. A 1998 controlled trial found that children treated with
a TEACCH-based home program improved significantly more than a control
Floortime was developed by Stanley Greenspan.
The intervention focuses on facilitating attachment between the
child with autism and the parent through the act of play. The parent
follows the child's lead and joins with the child in his or her
preferred activity, even if the activity would be considered peculiar.
Relationship Development Intervention
Relationship Development Intervention (RDI) is
a treatment program developed by Dr. Steven E. Gutstein. Rather
than teaching specific skills that are seen as lacking, RDI focuses
primarily on building a general "dynamic intelligence"
believed to underlie the acquisition of social skills demonstrated
in neurotypical children. It also focuses on the building blocks
of motivation by developing episodic memory (seen as impaired in
autism) and filling it with the child's own personal stories of
competence and mastery. RDI emphasizes declarative (as opposed to
imperative) communication, and aims for an appropriate balance of
verbal and nonverbal communication.
Dr. Gutstein claims that 70% of his patients improved
their ADOS diagnostic category within 18 months and that a similar
proportion are able to enter school without a shadow teacher or
other personal assistant, though to date there is no peer-reviewed
published research on the RDI protocol.
Communication interventions fall into two major
categories. First, many autistic children do not speak, or have
little speech, or have difficulties in effective use of language.
Interventions that attempt to improve communication are commonly
conducted by speech and language therapists, and work on joint attention,
communicative intent, and alternative or augmented communication
methods such as visual methods. Little solid research supports
the efficacy of speech therapy for autism. A 2006 study reported
benefits both for joint attention intervention and for symbolic
play intervention, and a 2007 study found that joint attention
intervention is more likely than symbolic play intervention to cause
children to engage later in shared interactions.
Second, social skills treatment attempts to increase
social and communicative skills of autistic individuals, addressing
a core deficit of autism. A wide range of intervention approaches
is available, including modeling and reinforcement, adult and peer
mediation strategies, peer tutoring, social games and stories, self-management,
pivotal response therapy, video modeling, direct instruction, visual
cuing, circle of friends, and social-skills groups. A 2007 meta-analysis
of 55 studies of school-based social skills intervention found that
they were minimally effective for children and adolescents with Autism Spectrum Disorder, and a 2007 review found that social skills training has
minimal empirical support for children with Asperger syndrome or
Unusual responses to sensory stimuli are more
common and prominent in autistic children, although there is no
good evidence that sensory symptoms differentiate autism from other
developmental disorders. Several therapies have been developed
to treat Sensory
Integration Dysfunction. Some of these treatments (for example,
sensorimotor handling) have a questionable rationale and no empirical
evidence. Other treatments (for example, prism lenses, physical
exercise, and auditory integration training) have had studies with
small positive outcomes, but few conclusions can be made about them
due to methodological problems with the studies. Although replicable
treatments have been described and valid outcome measures are known,
gaps exist in knowledge related to sensory integration dysfunction
Therapy in education
Children with autism are affected by their symptoms
every day, which set them apart from unaffected students. Because
of problems with receptive language and theory of mind, they can
have difficulty understanding some classroom directions and instruction,
along with subtle vocal and facial cues of teachers. This inability
to fully decipher the world around them often makes education stressful.
Teachers need to be aware of a student's disorder, and ideally should
have specific training in autism education, so that they are able
to help the student get the best out of his or her classroom experiences.
Some students learn more effectively with visual
aids as they are better able to understand material presented visually.
Because of this, many teachers create “visual schedules” for their
autistic students. This allows students to concretely see what is
going on throughout the day, so they know what to prepare for and
what activity they will be doing next. Some autistic children have
trouble going from one activity to the next, so this visual schedule
can help to reduce stress.
Research has shown that working in pairs may be
beneficial to autistic children. Autistic students have problems
not only with language and communication, but with socialization
as well. By facilitating peer interaction, teachers can help their
students with autism make friends, which in turn can help them cope
with problems or understand the world around them. This can help
them to become more integrated into the mainstream environment of
A teacher's aide can also be useful to the student.
The aide is able to give more elaborate directions that the teacher
may not have time to explain to the autistic child and can help
the child to stay at an equivalent level to the rest of the class
through the special one-on-one instruction. However, some argue
that students with one-on-one aides may become overly dependent
on the help, thus leading to difficulty with independence later
There are many different techniques that teachers
can use to assist their students. A teacher needs to become familiar
with the child’s disorder to know what will work best with that
particular child. Every child is going to be different and teachers
have to be able to adjust with every one of them.
Students with Autism Spectrum Disorders sometimes
have high levels of anxiety and stress, particularly in social environments
like school. If a student exhibits aggressive or explosive behavior,
it is important for educational teams to recognize the impact of
stress and anxiety. Preparing students for new situations, such
as through writing social stories, can lower anxiety. Teaching social
and emotional concepts using systematic teaching approaches such
as The Incredible 5-Point Scale or other cognitive behavioral strategies
can increase a student's ability to control excessive behavioral
Animal-assisted therapy, where an animal such
as a dog becomes a basic part of a person's treatment, is a controversial
treatment for some symptoms. A 2007 meta-analysis found that animal-assisted
therapy is associated with a moderate improvement in autism spectrum
symptoms. Reviews of published dolphin-assisted therapy (DAT)
studies have found important methodological flaws and have concluded
that there is no compelling scientific evidence that DAT is a legitimate
therapy or that it affords any more than fleeting improvements in
Affective computing devices, typically with image
or voice recognition capabilities, have been proposed to help autistic
individuals improve their social communication skills. These devices
are still under development. Robots have also been proposed as educational
aids for autistic children.
Son-Rise is a home-based program with emphasis
on eye contact, accepting the child without judgment, and engaging
the child in a noncoercive way. Proponents claim that children will
decide to become non-autistic after parents accept them for who
they are and engage them in play. The program was started by the
parents of Raun Kaufman, who is claimed to have gone from being
autistic to normal via the treatment in the early 1970s. No
independent study has tested the efficacy of the program, but a
2003 study found that involvement with the program led to more drawbacks
than benefits for the involved families over time, and a 2006
study found that the program is not always implemented as it is
typically described in the literature, which suggests it will be
difficult to evaluate its efficacy.
Patterning is a set of exercises that attempts
to improve the organization of a child's neurologic impairments.
It has been used for decades to treat children with many unrelated
neurologic disorders, including autism. The therapy is based on
oversimplified theories and is not supported by carefully designed
Parent mediated interventions
Parent mediated interventions offer support and
practical advice to parents of autistic children. Randomized
and controlled studies suggest that parent training leads to reduced
maternal depression, improved maternal knowledge of autism and communication
style, and improved child communicative behavior. A 2006 randomized
controlled trial (RCT) found that a 20-week parent education and
behavior management (PEBM) program provided significant improvements
in parental mental health and well-being, particularly for parents
with preexisting mental health problems.
Drugs, supplements, or diets are often used to
alter physiology in an attempt to relieve common autistic symptoms
such as seizures, sleep disturbances, irritability, and hyperactivity
that can interfere with education or social adaptation or (more
rarely) cause autistic individuals to harm themselves or others.
There is plenty of anecdotal evidence to support medical treatment;
many parents who try one or more therapies report some progress,
and there are a few well-publicized reports of children who are
able to return to mainstream education after treatment, with dramatic
improvements in health and well-being. However, this evidence may
be confounded by improvements seen in autistic children who grow
up without treatment, by the difficulty of verifying reports of
improvements, and by the lack of reporting of treatments' negative
outcomes. Only a very few medical treatments are well supported
by scientific evidence using controlled experiments.
Medications are often used to treat problems associated with Autism Spectrum Disorder.
More than half of U.S. children diagnosed with Autism Spectrum Disorder are prescribed
psychoactive drugs or anticonvulsants, with the most common drug
classes being antidepressants, stimulants, and antipsychotics.
Research has focused on atypical antipsychotics,
especially risperidone, which has the largest amount of evidence
that consistently shows improvements in irritability, self-injury,
aggression, and tantrums associated with Autism Spectrum Disorder. In the United
States, risperidone is approved for treating symptomatic irritability
in autistic children and adolescents aged 5–16 years. In short-term
trials (up to 6 months) most adverse events were mild to moderate,
with weight gain, drowsiness, and high blood sugar requiring monitoring.
Its long term efficacy and safety have not been fully determined.
Other drugs are prescribed off-label in the U.S.,
which means they have not been approved for treating Autism Spectrum Disorder. Some selective
serotonin reuptake inhibitors (SSRIs) and dopamine blockers can
reduce some maladaptive behaviors associated with Autism Spectrum Disorder. The limited
data for SSRIs suggest that they may be helpful for obsessions/compulsions,
but that children may have a worse response than adults and may
suffer more adverse affects, such as suicidal impulses. One study
found that the psychostimulant methylphenidate was efficacious against
hyperactivity associated with Autism Spectrum Disorder, though with less response than
in neurotypical children with ADHD. A 1998 study of the hormone
secretin reported improved symptoms and generated tremendous interest,
but several controlled studies since have found no benefit.
There is scant reliable research about the effectiveness
or safety of drug treatments for adolescents and adults with Autism Spectrum Disorder.
Results of the handful of randomized control trials that have been
performed suggest that risperidone, the SSRI fluvoxamine, and the
typical antipsychotic haloperidol may be effective in reducing some
behaviors, that haloperidol may be more effective than the tricyclic
antidepressant clomipramine, and that the opiate antagonist naltrexone
hydrochloride is not effective. A person with Autism Spectrum Disorder may respond
atypically to medications, the medications can have adverse side
effects, and no known medication relieves autism's core symptoms
of social and communication impairments.
Many parents give their children vitamin and other nutritional supplements
in an attempt to treat autism or to alleviate its symptoms. The
range of supplements given is wide; few are supported by scientific
data, but most have relatively mild side effects.
Nutritional supplementation with high dose pyridoxine
(vitamin B6) and magnesium (HPDM) is claimed to alleviate the symptoms
of autism and is one of the most popular complementary and alternative
medicine choices for autism. Three small randomized controlled trials
have studied this therapy; the smallest one (with 8 individuals)
found improved verbal IQ in the treatment group and the other two
(with 10 and 15 individuals, respectively) found no significant
difference. Due to the limited data it is difficult to tell
whether this treatment approach has effects greater than placebo.
The short-term side effects seem to be mild, but there may be significant
long-term side effects, as high doses of pyridoxine cause peripheral
neuropathy in adults, high doses of magnesium can cause reduced
heart rate and weakened reflexes, and high magnesium concentrations
are associated with seizures. Magnesium should always be taken
along with high doses of pyridoxine to prevent side effects such
as irritability and sensitivity to sound.
Dimethylglycine (DMG) is hypothesized to improve
speech and reduce autistic behaviors, and is a commonly used
supplement. Two double-blind, placebo-controlled studies found
no statistically significant effect on autistic behaviors, and
reported few side effects. No peer-reviewed studies have addressed
treatment with the related compound trimethylglycine.
Vitamin C decreased stereotyped behavior in a
small 1993 study. The study has not been replicated, and vitamin
C has limited popularity as an autism treatment. High doses might
cause kidney stones or gastrointestinal upset such as diarrhea.
Probiotics containing potentially beneficial bacteria
are hypothesized to relieve some symptoms of autism by minimizing
yeast overgrowth in the colon. The hypothesized yeast overgrowth
has not been confirmed by endoscopy, the mechanism connecting yeast
overgrowth to autism is only hypothetical, and no clinical trials
to date have been published in the peer-reviewed literature. No
negative side effects have been reported.
Melatonin is sometimes used to manage sleep problems
in developmental disorders. One small open trial found a statistically
significant reduction in sleep latency in children with Autism Spectrum Disorder. Adverse
effects are generally reported to be mild, including drowsiness,
headache, dizziness, and nausea; however, an increase in seizure
frequency is reported among susceptible children.
Several other supplements have been hypothesized
to relieve autism symptoms, including carnosine, cyproheptadine,
D-cycloserine, folic acid, glutathione, metallothionein promoters,
oxytocin, polyunsaturated fatty acids (PUFA) such as omega-3 or
omega-6 fatty acids, tryptophan, tyrosine, thiamine (see Chelation
therapy), vitamin B12, and zinc. None of these have reliable scientific
evidence of efficacy or safety in treatment of autism.
Atypical eating behavior occurs in about three-quarters of children
with Autism Spectrum Disorder, to the extent that it was formerly a diagnostic indicator.
Selectivity is the most common problem, although eating rituals
and food refusal also occur; this does not appear to result
in malnutrition. Although some children with autism also have gastrointestinal
(GI) symptoms, there is a lack of published rigorous data to support
the theory that autistic children have more or different GI symptoms
than usual; studies report conflicting results, and the relationship
between GI problems and Autism Spectrum Disorder is unclear.
In the early 1990s it was hypothesized that autism
can be caused or aggravated by opioid peptides like casomorphine
that are metabolic products of gluten and casein. Based on this
hypothesis, diets that eliminate foods containing either gluten
or casein, or both, are widely promoted, and many testimonials can
be found describing benefits in autism-related symptoms, notably
social engagement and verbal skills. Studies supporting these claims
have had significant flaws, so the data are inadequate to guide
Other elimination diets have also been proposed,
targeting salicylates, food dyes, yeast, and simple sugars. No scientific
evidence has established the efficacy of such diets in treating
autism in children. An elimination diet may create nutritional deficiencies
that harm overall health unless care is taken to assure proper nutrition.
Based on the speculation that heavy metal poisoning
may trigger the symptoms of autism, particularly in small subsets
of individuals who cannot excrete toxins effectively, some parents
have turned to alternative medicine practitioners who provide detoxification
treatments via chelation therapy. However, evidence to support this
practice has been anecdotal and not rigorous. There is strong epidemiological
evidence that refutes links between environmental triggers, in particular
thimerosal containing vaccines, and the onset of autistic symptoms.
No scientific data supports the claim that the mercury in the vaccine
preservative thiomersal causes autism or its symptoms, and
there is no scientific support for chelation therapy as a treatment
Chelation therapy can be hazardous. In August
2005, botched chelation therapy killed a 5-year-old autistic boy,
a nonautistic child died in February 2005 and an nonautistic adult
died in August 2003. These deaths were due to cardiac arrest caused
by hypocalcemia during chelation therapy.
Thiamine tetrahydrofurfuryl disulfide (TTFD) is
hypothesized to act as a chelating agent in children with autism.
A 2002 pilot study administered TTFD rectally to ten autism spectrum
children, and found beneficial clinical effect. This study has
not been replicated and a 2006 review of thiamine by the same author
did not mention thiamine's possible effect on autism. There
is not sufficient evidence to support the use of thiamine (vitamin
B1) to treat autism.
Hyperbaric oxygen therapy
Hyperbaric oxygen therapy (HBOT) can compensate
for decreased blood flow by increasing the oxygen content in the
body. It has been postulated that HBOT might relieve some of the
core symptoms of autism. However, scientific evidence is lacking
for the use of HBOT to treat autism.
Stem cell therapy
Mesenchymal stem cells and cord blood CD34+ cells have been proposed
to treat autism, but this proposal has not been tested.
Approximately twelve research studies are published each week on
autism therapies. Three major barriers inhibit transfer of this
information from the laboratory to the child:
Treatment providers do not routinely turn to treatments
that have been validated scientifically.
A large minority of patients (actually parents of patients) resist
therapies that have been scientifically validated.
Even scientifically validated therapies are not universally effective.
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