Evidence Based Management of Autism Spectrum Disorder

Outline of Presentation

  • Prologue
  • Goals of treatment
  • Therapies: evidence
  • Medical management
  • Anecdotal treatment
  • Complimentary and Alternative Medicine
  • Summary


  • ASDs are not “curable,” hence chronic management across life span is necessary
  • Variable outcomes & dynamic behavioral characteristics
  • Most children with ASDs remain within spectrum as adults
  • Need constant support with independent living, employment & social relationships

Intervention Targets

  • Core features: Social interaction, Communication & Stereotypy
  • Non-core features or challenging behaviors: Irritability, Aggression, Hyperactivity, Insomnia, Self-injury
  • Co morbid states: such as OCD, depression and anxiety, GI disturbances, epilepsy etc
  • Activities of daily living
  • Quality of life: individual and family
  • Facilitating development and learning, promoting socialization, reducing maladaptive behaviors,
  • Without causing adverse effect

ASD: Management

Educational Interventions / Behavioral Strategies / Rehabilitative Therapies

Different guiding principles

  • Academic learning, socialization-communication, managing extreme behaviors, daily-living skills, play and leisure skills
  • Involvement of therapist, parents and school teachers
  • Frequency, intensity ?
  • Does one type fits everybody ? Combinations & ideal prescription ?
  • Complete psychological assessment: IQ / Behavior mapping / Sensory issues / co-morbidities / RRB
  • Involvement of family, availability, affordability ?

Pick & Choose

Educational Interventions & Principles

Applied Behavior Analysis

  • Interventions that are based on principles of learning derived from research to systematically change behavior
  • Early intensive behavioral treatment: substantial, sustained gains in cognitive ability, language, and adaptive behavior
  • Also some measures of social behavior

ABA: Evidence

Sensory Integration Therapy

  • Hypothesis: Impairment in sensory information processing in ASD
  • Based on Ayres' Theory of sensory integration
  • Play activities specifically designed to restore effective neurological processing by enhancing vestibular, proprioceptive and tactile systems
  • Sensory diet: Specifically designed plan of biochemical and neurological inputs to promote and facilitate function

Sensory Diet

  • Biochemical inputs:
    • Sleep
    • Nutrition
    • Neurological inputs:
      • Vestibular
      • Proprioceptive
      • Tactile
      • Auditory
      • Visual

Sensory Integration Therapy: Evidence

  • 4 studies: Significant improvement in several autistic core symptoms
  • Limitations
      • Two studies used a standardized form of  therapy
      • Lack of standardized outcome measures
      • Lack of well-defined control group
      • Recommended by NICE guidelines, 2013

ASD: Medical Management

  • Routine care: immunization, growth, nutrition, hygiene
  • Psychopharmacology: core symptoms, associated symptoms and psychiatric illnesses
  • Co morbidities: epilepsy, GI, behavior, psychiatric illnesses, sleep (identification & treatment)


  • Pharmacologic interventions may be considered for maladaptive behaviors such as aggression, self injurious behavior
  • Repetitive behaviors (eg: perseveration, obsessions, compulsions, and stereotypic movements)
  • Sleep disturbance, mood lability, irritability, anxiety, hyperactivity, inattention, destructive behavior, or other disruptive behaviors
  • Repetitive behavior, obsessive-compulsive symptoms, stereotypic movement disorder: SSRIs (fluoxetine, fluvoxamine, citalopram), Atypical antipsychotic agents (risperidone, aripiprazole, olanzapine), Valproic acid
  • ADHD: stimulants, atypical antipsychotic, clonidine
  • Aggression, self injury: atypical antipsychotic, VPA, LEV, SSRIs
  • Anxiety and depression: SSRIs

Pharmacologic Interventions: Evidence

1 α2 adrenergic agonist (clonidine), 1 psychostimulant (methylphenidate), and 1 tricyclic antidepressant (tianeptine) demonstrated moderate effect sizes in decreasing ABC-I.

GI Disturbances

  • Gastrointestinal symptoms (including abnormal stool pattern, frequent constipation, frequent vomiting, and frequent abdominal pain) reported in 70% of children with ASDs
  • High rates of lymphoid nodular hyperplasia & histologically subtle esophagitis, gastritis, duodenitis, and colitis
  • Routine specialized gastroenterological testing for asymptomatic children is not recommended
  • Occult gastrointestinal discomfort should be considered in a child who presents with a change in behavior, such as outbursts of aggression or self-injury
  • Effective management may provide global benefit

PEDIATRICS Volume120, Number5, November 2007

Sleep Disturbances

  • Estimated prevalence of 50% to 80%
  • In a study at AIIMS, it was found that sleep problems affect upto 58 % of children with autism.
  • Polysomnography studies show that children with ASD have altered sleep architecture includingshorter total sleep time and longer sleep latency than typically developing peers

Pediatrics. 2016;137(S2)

Sleep Disturbances: Melatonin

  • Abnormality of melatonin regulation in children with ASDs
  • Clinical studies have shown some benefit
    • Small randomized, placebo-controlled trials showed increased sleep duration and reduced sleep latency
    • Retrospective study of 107 children showed only 3 with side effects of daytime sleepiness and enuresis (Andersen, 2008)
  • Recommendation: 1-3 mg 30 minutes prior to bedtime

EEG Abnormalities: Treat or Not

  • Epileptiform abnormalities: 10% to 72% patients
  • No well designed, controlled trials have defined a role for antiepileptic drug therapy for symptoms of ASD
  • In absence of clinical epilepsy, treatment of  epileptiform activity with AEDs has not been demonstrated to reverse the symptoms of ASD

Epilepsia, 48 (Suppl. 9):33–35, 2007

Management Guidelines for CSWS

Veggiotti P et. al. Journal of Clinical Neurophysiology, February 2016

Anecdotal Therapies

  • IV Secretin
  • Intranasal Oxytocin
  • Chelation: DMSA and others
  • HBOT
  • Mesenchymal stem cell transplant (umb cord or peripheral), fetal stem cell

Anecdotal Therapies: Evidence

What is CAM?

  • “A group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine”
  •  “A broad domain of healing resources that encompasses all health modalities, and practices other than those intrinsic to the politically dominant health systems of a particular society or culture in a given historical period”
  • ASD: Vitamins, minerals, exclusion diets, yoga, music therapy………..
  • Lack of “Gold Standard”

Who uses CAM?

  • CAM perceived as “natural”, without side effects
  •  > 75% chose CAM based on perception of
    safety, absence of side effects or prior
    experience with side effects
  • Internet and media
  • Recommendations by friends or families
    of other children with ASD

Hanson et al. Use of CAM among children diagnosed with ASD.
J Autism Dev Disord. 2007

Types of CAM

Biologically Based Treatments
  • Dietary interventions
  • Vitamin supplements
  • Herbal remedies
  • Chelation
  • HBOT
Non Biologically Based Treatments
  • Mind-body medicine (i.e., prayer, yoga,  meditation, music, dance, and art)
  • Manipulative and body-based practices (i.e., massage, chiropractic care, acupuncture, patterning)

How to Handle CAM?

    • AAP Committee on Children with Disabilities
    • CAM interventions should be discussed in a nonjudgmental manner
    • Treating physician should provide “balanced advice about therapeutic options” and information about potential risks

CAM: Evidence

CAMs that may be used

Recommendations: Sensory integration therapy

Experimental, Individual basis

  • Pet therapy
  • Drama therapy
  • Music therapy
  • Massage
  • Yoga


  • Educational intervention if initiated early and intensive, have shown some benefit
  • Resperidone and Aripiprazole is recommended for Irritability and problem behaviors in ASD
  • Melatonin is effective for sleep disturbances
  • CAM should be looked at with open mind and weighed appropriately

Thank You

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