Autism Spectrum Disorders
This section contains a review of treatments that have been used in individuals with Autism Spectrum Disorders (ASD). The review includes conventional treatments that are often covered on other websites, some integrative therapies that may offer potential benefit, and a couple of alternative therapies that pose some risk.
ASD symptoms and severity vary from patient to patient. Thus, there is no right way to treat ASD. Our purpose is not to endorse or suggest the use of specific therapies, but to provide information about the evidence, or lack thereof, along with potential risks/benefits of various treatment modalities. We recommend, as always, that you talk to your family's healthcare providers about any options you are interested in pursuing.
What are autism spectrum disorders?
Individuals with ASD have difficulty with social interactions and communication, as well as restricted, repetitive behaviors, interests, or activities. These symptoms usually appear before age three. ASD is thought of as a "spectrum" disorder; different people with ASD may have very different symptoms, levels of severity, strengths, and challenges.
Rate of ASD
The rate of children diagnosed with ASD is increasing. The Centers for Disease Control and Prevention (CDC) reports that one in 110 children in the U.S. is affected by ASD. This rate has increased since 2002, when it was one in 166, or since 1999, when it was one in 1,000. Much of this increase is explained by changes in diagnostic practice, including:
- Broadening the definition of ASD to include higher-functioning children
- Increased accuracy in the diagnosis of ASD (particularly for children who previously may have been diagnosed with intellectual disability)
- Increased awareness of the disorder
- Earlier identification of young children
However, we cannot rule out that there is a true increase in the risk for ASD.
There is an increasing body of evidence to show that ASD is a neurobiological disorder resulting from several causes, but with a strong genetic basis. However, to date, no biological marker exists to "diagnose" ASD.
A diagnosis of ASD is based on behavioral criteria requiring extensive neuropsychological evaluation, which assesses cognitive, developmental, and language abilities, as well as adaptive behaviors or life skills.
What are the conventional treatments for autism spectrum disorders?
While the following section focuses on children, a great number of individuals diagnosed with ASD are reaching adolescence and adulthood. Many ASD characteristics require continuous support over a lifetime. As the ASD population ages, there is a growing need for resources to serve adolescents and adults with ASD.
Behavioral and Educational Interventions
There are many behavioral and educational approaches for individuals with ASD. The best known is Applied Behavior Analysis (ABA), which is well-supported by evidence. ABA focuses on systematically encouraging (and reinforcing) positive, functional behaviors, while reducing negative or nonfunctional ones, often by teaching a more appropriate replacement skill.
Many studies have shown that children who receive intensive early intervention services—especially those who receive at least two years of intensive intervention prior to entering elementary school—experience significant gains in functional communication, cognitive skills, and behavior and need fewer support services in school.
Developmental models are another common intervention approach. These models aim to meet the child at his or her development level and use the child's current strengths to build new skills. Relationship-based models often engage parents and focus on fostering genuine relationships and creating a desire and ability to live in a changing environment. Many approaches now incorporate both ABA and developmental or "relationship-based" models.
Social Skills Interventions
There are many social skills interventions for individuals with ASD, but designing research to measure the effectiveness of these interventions is challenging, and there is not much supporting research evidence. Social skills groups that include typically developing children have the most research support. A few examples of social skills strategies include:
- Social skills groups - individuals with ASD practice social skills with each other and/or other children on a regular basis.
- Social StoriesTM - teachers, therapists, clinicians, and caregivers use stories and drawings to build social understanding.
- Hidden Curriculum - teachers and clinicians directly point out "unspoken" social rules.
- Social scripts - teachers and clinicians give individuals with ASD "scripts" for common social situations.
- Computers and other technology - teachers and clinicians use videos, software, or virtual-reality programs to teach complex social skills, such as recognition of emotions in facial expressions and tone of voice.
Individuals with ASD have challenges communicating with others. A certified speech-language pathologist may work on skills such as:
- Non-verbal communication - teaching communication through gestures, a picture exchange system (such as PECS), an electronic talking device, or another alternative or augmentative communication tool.
- Pragmatics - helping individuals understand when and how to use language socially.
- Conversation skills - practicing back-and-forth exchanges, such as turn-taking or joint attention.
- Concepts - helping individuals understand abstract concepts.
Occupational therapists help individuals with ASD interact with the world around them. One aspect of occupational therapy is Sensory Integration, which allows the child to interact more effectively by addressing limitations he or she might have in processing information and integrating sensory information.
For example, an occupational therapist may help individuals with ASD by:
- Leading activities that help improve attention and awareness (when the individual is theorized to be "under-reactive") or reduce overall arousal (in the case of "hyper-arousal").
- Facilitating play that teaches and helps individuals with ASD to participate in communication with others.
- Teaching strategies to help transition from one place or activity to the next.
- Developing adaptive techniques and strategies to get around apparent disabilities (e.g., keyboarding or using a weighted pencil to facilitate handwriting).
Such sensory approaches try to help manage symptoms of ASD, which are highly complex and variable from patient to patient. Due to the complexity of both ASD and sensory-based approaches, the research base for these approaches is limited.
Antipsychotic drugs: Some atypical antipsychotics are used to treat irritability and behavioral problems, such as aggression, self-injury, and rapid mood swings. Risperdone (RisperdalTM) which was approved by the FDA in 2006 for irritability (aggression, self-injury, temper tantrums, and rapid mood changes) in individuals with ASD, is the best studied. Recent studies suggest Risperidone may be associated with improved overall functioning and social responsiveness; however, it has associated side effects of weight gain and adverse metabolic effects (increasing the potential risk of high cholesterol or diabetes).
Alpha-adrenergic agonists: Limited (and often very small) studies of Clonidine and Guanfacine report improvements in behaviors such as hyperactivity, impulsivity, stereotypies, self-stimulation, inappropriate speech, irritability, aggression, and oppositional behavior as a frequent side effect in individuals with ASD.
Mood stabilizers: These drugs—such as Divalproex sodium (Valproic Acid), Lamotrigine (Lamictal), or Topiramate (Topomax)—are most commonly used to treat seizures, bipolar disorder, and some behavioral symptoms. Some studies have started to assess behavior changes associated with these medications with mixed outcomes. Such medications are occasionally tried on a case-by-case basis.
Antidepressants: Tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) have not been clearly beneficial for individuals with ASD and are sometimes associated with side effects. However, SSRIs are sometimes used to target specific symptoms such as aggression, self-injurious behavior, and anxiety.
Stimulants: Individuals with ASD often have significant problems with inattention, hyperactivity, and impulsivity. The Diagnostic and Statistical Manual (DSM) provides diagnosis criteria for both ASD and Attention Deficit Hyperactivity Disorder (ADHD). Because DSM rules exclude adding an ADHS diagnosis when an ASD diagnosis has already been made, the prevalence of ADHD in children and youth with ASD is unknown.
Available research tells us that stimulants tend to produce highly variable responses in children with both ASD and ADHD symptoms. On average, the response in children with ASD may be less favorable than in typically developing children, and there may be a greater chance of side effects. This said, stimulants may still be a reasonable first therapeutic choice for previously untreated children with ASD and uncomplicated ADHD. As with any individual with ADHD, stimulant treatment should be implemented in increments using systematic monitoring for improvements and side effects (such as insomnia, abdominal pain, headache, and loss of appetite).
Anticonvulsants: Individuals with ASD have a higher incidence of seizures and epilepsy compared to the general population and may require anticonvulsant medication to treat seizures.
Sleep medications: Individuals with autism have higher rates of sleep disturbance compared to the general population. Some medications used to treat sleep disturbances include: clonidine, trazodone, melatonin, and antihistamines. Studies have demonstrated that individuals with ASD may have abnormal production of melatonin, and preliminary studies have shown melatonin to be a safe and effective sleep aid in children with ASD. Interestingly, in an open-label study with 33 subjects, the restless sleep of children with ASD and iron deficiency improved with iron supplementation.
Gastrointestinal agents: While yet controversial and difficult to assess, many studies point to an increased incidence of gastrointestinal issues (such as chronic diarrhea, constipation, or acid reflux disease) in individuals with ASD. It is thought that reducing these symptoms may allow a child to gain maximum benefit from behavioral and educational therapies. Medications such as probiotics, ranitidine (Zantac), or famotidine (PepcidTM) may be prescribed for specific gastrointestinal conditions.
Probiotics have been shown to have a positive effect on diarrhea. While probiotics may improve gastrointestinal function (for example, decreasing diarrhea), studies have not evaluated whether probiotics are associated with core ASD symptoms (such as social interactions or communication). More than 12 well-designed randomized controlled research studies failed to demonstrate any effect of secretin, a gastrointestinal hormone, on ASD symptoms.
What are some integrative therapies and healing practices commonly used in individuals with ASD?
Some experts and parents believe that children with ASD do not break down or process the nutrients they consume in expected ways. To address this, providers sometimes recommend a daily multi-vitamin, especially if the children:
- Have self-restricted diets
- Follow a specific diet (for example, if a child is consuming a diet free of casein, a multi-vitamin may be necessary to ensure adequate vitamin D and calcium intake.)
- Have chronic diarrhea, constipation, or gastrointestinal inflammation
The use of mega-dose vitamins and nutritional supplements beyond a multi-vitamin are not fully supported for routine use. Below is a list of some vitamins and supplements that have been recently studied regarding their use with individuals with ASD.
- Vitamin B6 and Magnesium (Mg) - Studies of B6 and Mg are limited and have conflicting results. Recent good quality research by Tolbert and Findling found that B6 and magnesium did not result in statistically significant effects. Hence the evidence is not adequate to make clinical recommendations. A recent study focusing on children with Asperger's Syndrome and PDD-NOS (Pervasive Developmental Disorder-Not Otherwise Specified), found that Vitamin B6 appeared to increase verbal IQ scores, but it showed no improvements in social functioning.
- Vitamin B12, Folinic Acid, Dimethylglycine (DMG), and Glutathione - Preliminary research suggests that individuals with ASD have impairments in methylation and sulfation, meaning that the cells do not receive the proper instructions to develop. The supplements listed above have shown some improvements in these cellular processes, per several research studies.
- Vitamins C, E, Selenium, and Glutathione - Oxidative stress (an increase in toxins, such as free radicals, and a decrease in the body's ability to detoxify or repair damages caused by these free radicals) has been shown to be elevated in individuals with ASD. Oxidative stress is significant because this renders the central nervous system exquisitely sensitive to free radical attack. The vitamins and supplements listed above have been used in an attempt to reduce oxidative stress. One double-blind, placebo-controlled study by Dolske showed a decrease in stereotypic behaviors after use of vitamin C, which was hypothesized to regulate dopamine. This study was small and has not been replicated.
- L-carnitine - It has been suggested by Lombardi that there is an increased prevalence of mitochondrial disorders (disorders affecting the mitochondria or "energy powerhouses" inside of cells) in individuals with ASD. Both mitochondrial disorders and ASD are complex disorders that are challenging to diagnose, making research difficult and the relationship unclear. While one case series by Filipek suggested that children with ASD may have low carnitine, treatments targeting mitochondrial function (such as L-carnitine) are not currently indicated as standard treatment for individuals with ASD.
- Amino Acids and Carnosine - Amino acids used as alternative treatments in ASD include taurine, lysine, or GABA, but they lack research. One by Chez found that L-carnosine improved participants' language and Autism symptoms on the Gilliam Autism Rating Scale and Receptive One-Word Picture Vocabulary Test.
- Vitamin A - Megson hypothesizes that vitamin A may be associated with ASD symptoms because it is necessary for functioning of the receptors critical for sensory perception, attention, and language processing. However, vitamin A for individuals with ASD has not been studied in clinical trials. Note that vitamin A in high doses has potential for toxicity.
- Vitamin D and Calcium - Milk products are a major source of vitamin D and calcium. Providers should evaluate vitamin D and calcium intake in individuals with ASD because: 1) many individuals with ASD consume a specific casein-free diet and 2) individuals with ASD may consume less dairy regardless of imposed dietary limitations. While there have been no controlled trials of vitamin D or Calcium related to Autism symptoms, some experts have suggested that vitamin D deficiency could be a contributing factor to ASD and to the higher rate of educational ASD services for children of Somali descent who are at higher risk for vitamin D deficiency.
- Zinc - It is hypothesized that individuals with ASD have an increased prevalence of abnormal zinc-copper balance and abnormal metallothionein function (metallothionein is a protein that binds to and is involved in zinc and copper regulation). However, there are no controlled trials involving zinc and Autism symptoms.
- Iron - Iron is necessary for normal neurodevelopment. A few studies, such as one by Dosman in 2006, suggest that children with ASD have a higher rate of iron deficiency compared to children without Autism. Dosman's 2007 study also suggested that iron deficiency in ASD is related to sleep disturbances. Although one clinical trial by Konofal suggested the iron supplements could have promising effects on ADHD symptoms, no clinical trials have tested the effects of iron supplementation on individuals with ASD.
Essential Fatty Acids (Omega 3)
Research on Omega-3 fatty acids is preliminary but encouraging. These "essential" fatty influence various central nervous and immune system biochemical processes. Experts, such as Young and Richardson, also believe that Omega-3 fatty acids play a role in various neuropsychiatric or brain disorders. The current U.S. diet is thought to include too many Omega-6s and too few Omega-3s. Somewhat conflicting studies by Sliwinski and Vancassell have shown that children with autism may have increased or decreased levels of Omega-3s compared to children without ASD.
Recent studies by Amminger, Bell, and Patrick have found that increasing Omega-3s in the diet is associated with improvements in people with ASD, particularly in hyperactivity and repetitive behaviors, as well as cognitive and motor skills, concentration, eye contact, sociability, and sleep. (And one study based on parental report suggested that infants who received essential fatty acid supplements in their breast milk or formula were less likely to develop ASD.)
The food a person eats affects the body in many ways. Many children with ASD follow specific diets, often because caregivers report that dietary interventions correlate with improvements in behaviors or medical symptoms (such as reflux, diarrhea, abdominal pain, or eczema). Some commonly followed diets include:
- Casein-free diet - Casein is a protein found in milk; this diet eliminates milk and all by-products of milk.
- Gluten-free diet - Gluten is a protein found in many grains; this diet eliminates such grains.
- Feingold diet - Eliminates additives and chemicals.
- Specific carbohydrate diet - Removes specific carbohydrates, including all grains, lactose, and sucrose.
- Yeast-free diet - Eliminates yeast and sugar.
Kvinsberg's 2002 study suggested that a gluten-free casein-free (GFCF) diet in individuals with autism reduces autistic traits; other studies have found no significant difference. Larger randomized controlled trials of GFCF diets are currently underway. While no evidence-based studies have evaluated their efficacy, digestive enzymes are often used for the purpose of aiding in digestion of proteins such as gluten and casein. Families choosing to utilize a GFCF diet should ensure adequate nutrition with particular attention to protein, vitamin D, and calcium.
Mind-body approaches aim to support the body through various methods, including decreasing anxiety and self-regulation techniques. Some of the following examples are supported by preliminary studies but are all still considered experimental: yoga, music therapy, craniosacral massage, massage, aromatherapy, therapeutic touch, pet therapy (e.g. horses, dogs), and auditory integration.
Other alternative therapies
Below are a couple of alternative therapies with limited supporting evidence that pose significant risks.
The connection between the immune system and ASD is being studied. It has been reported that children with ASD are more likely to have infectious and allergy-related disorders, and many abnormalities have been reported related to the functioning of the immune system. Some immune system-altering medications used by children with ASD include: intravenous immunoglobulins (IVIG), anti-viral medications, anti-fungal medications, and steroids. IVIG is not FDA-approved for autism; it is costly and may carry risks of headaches, anaphylactic shock, meningitis, or infectious disease. While one study by Sandler reported short-term behavioral improvements in 11 children taking vancomycin, further studies are not available.
It should be noted that while anti-infectives are frequently used in general medical practice for things such as ear infections, all come with potential side effects, such as rash, allergy, disruption of gastrointestinal flora, or liver damage. Long-term steroids carry many potential risks, including bone fractures, effects on height and metabolism, and immunosupression.
Hyperbaric oxygen therapy (HBOT)
The use of HBOT in individuals with ASD has been suggested for its ability to increase blood flow in the brain, reduce inflammation, and reduce oxidative stress. A preliminary multi-site randomized controlled trial by Rossingol revealed significant improvements in overall functioning, receptive language, social interaction, eye contact, and sensory/cognitive awareness after HBOT in individuals with autism. However, a subsequent similar study by Granpeesheha did not find HBOT to be effective in multiple assessments. HBOT carries significant potential risks, including ear pain and oxygen toxicity, and it can be expensive. Further investigation is necessary to determine safety and efficacy.
Some experts and partents theorize that individuals with ASD have less capacity to clear heavy metals or are more susceptible to the effects of heavy metals on immune function and the central nervous system. Chelation therapy involves the use of agents to remove heavy metals from the body. No controlled studies have evaluated the safety or efficacy of chelation in individuals with ASD. Chelation carries serious risks of vomiting, netropenia, and death. One death occurred in a child with autism due to hypocalcemia (low serum calcium levels in the blood) resulting from the inappropriate use of EDTA (a chelator). Deaths attributed to chelation complications have also occurred in individuals without ASD.
How to combine integrative therapies and healing practices in ASD
Central Place of Care or Health Home: It is critical to have a working relationship with a provider, or team of providers, who can help you navigate through the numerous therapies and treatments for ASD. At least one central provider or team should know all the therapies and treatments used by you or your child. The provider can be a conventional physician, nurse practitioner, therapist, or other professional who is philosophically aligned with your perspective on the disease.
Collect Data: People with ASD are unique individuals and may respond to treatments differently. It is important to monitor progress with a new treatment or therapy. Work with a professional to choose target behaviors or symptoms (e.g., improved eye contact, less diarrhea, etc.) and specific methods to rate these target behaviors (such as a 1-5 rating scale on a calendar). Collect data before and after you make the treatment change. Make only one change at a time. Consider not telling (blinding) one parent, a therapist, or teacher about the treatment and asking for their evaluation of the child. Work with a professional to review the data and evaluate whether the treatment correlates with improvements.
Consider External Factors: Recognize all the factors that could influence your treatment trial. Take natural child development into account and recognize that all children go through stages during which they gain new skills or may focus less on other skills previously acquired. Additionally, all people have "good days" and "bad days." People are also influenced by their environment (i.e., a disrupted schedule due to the holidays, less sunlight in the wintertime, a new teacher, etc.). Recognize that these typical stages of development and "ups and downs" may correlate with a new treatment. Parents' feelings of anxiety or hope can also influence their perception of the "results" or their treatment of the child. Ensure that your treatment trial is long enough to account for these types of normal variation.
Educate Yourself: Learn all you can about treatments and, in addition to proposed benefits, be sure to inquire about potential risks, such as cost, time, or side effects. Use the same instincts you have developed as a consumer to make judgments about potential "hype." Ask about the evidence behind a treatment, realizing that while randomized controlled clinical trials are the highest level of evidence, they are challenging to conduct in individuals with ASD.