Understanding the Brain

Autism therapies

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Autism therapies attempt to lessen the deficits and family distress associated with autism and other 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 are also given to families of those with ASD.[1]

Studies of interventions have methodological problems that prevent definitive conclusions about efficacy.[2] Although many psychosocial interventions have some positive evidence, suggesting that some form of treatment is preferable to no treatment, the methodological quality of systematic reviews of these studies has generally been poor, their clinical results are mostly tentative, and there is little evidence for the relative effectiveness of treatment options.[3] Intensive, sustained special education programs and behavior therapy early in life can help children with ASD acquire self-care, social, and job skills,[1] and often can improve functioning, and decrease symptom severity and maladaptive behaviors;[4] claims that intervention by around age three years is crucial are not substantiated.[5] Available approaches include applied behavior analysis (ABA), developmental models, structured teaching, speech and language therapy, social skills therapy, and occupational therapy.[1] Educational interventions have some effectiveness in children: intensive ABA treatment has demonstrated effectiveness in enhancing global functioning in preschool children,[6] and is well-established for improving intellectual performance of young children.[4] Neuropsychological reports are often poorly communicated to educators, resulting in a gap between what a report recommends and what education is provided.[7] The limited research on the effectiveness of adult residential programs shows mixed results.[8]

Many medications are used to treat problems associated with ASD.[9] More than half of U.S. children diagnosed with ASD are prescribed psychoactive drugs or anticonvulsants, with the most common drug classes being antidepressants, stimulants, and antipsychotics.[10] Aside from antipsychotics,[11] there is scant reliable research about the effectiveness or safety of drug treatments for adolescents and adults with ASD.[12][13] A person with ASD may respond atypically to medications, the medications can have adverse effects, and no known medication relieves autism's core symptoms of social and communication impairments.[14]

Many alternative therapies and interventions are available, ranging from elimination diets to chelation therapy. Few are supported by scientific studies.[15][16][17][18][19] 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.[20] Scientific evidence appears to matter less to service providers than program marketing, training availability, and parent requests.[21] Even if they do not help, conservative treatments such as changes in diet are expected to be harmless aside from their bother and cost.[22] Dubious invasive treatments are a much more serious matter: for example, in 2005, botched chelation therapy killed a five-year-old boy with autism.[23]

Treatment is expensive;[24] indirect costs are more so. For someone born in 2000, a U.S. study estimated an average discounted lifetime cost of $

  1. REDIRECT Template:Format price (2014 dollars, inflation-adjusted from 2003 estimate[25]), with about 10% medical care, 30% extra education and other care, and 60% lost economic productivity.[26] A UK study estimated discounted lifetime costs at ₤
  2. REDIRECT Template:Format price and ₤
  3. REDIRECT Template:Format price for an autistic person with and without intellectual disability, respectively[27] (2014 pounds, inflation-adjusted from 2005/06 estimate[28]). Legal rights to treatment are complex, vary with location and age, and require advocacy by caregivers.[29] 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;[30] one 2008 U.S. study found a 14% average loss of annual income in families of children with ASD,[31] and a related study found that ASD is associated with higher probability that child care problems will greatly affect parental employment.[32] After childhood, key treatment issues include residential care, job training and placement, sexuality, social skills, and estate planning.[29]

Educational interventions

Educational interventions attempt to help children not only to learn academic subjects and gain traditional readiness skills, but also to improve functional communication and spontaneity, enhance social skills such as joint attention, gain cognitive skills such as symbolic play, reduce disruptive behavior, and generalize learned skills by applying them to new situations. Several model programs have been developed, which in practice often overlap and share many features, including:[1]

  • early intervention that does not wait for a definitive diagnosis;
  • intense intervention, at least 25 hours per week, 12 months per 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; they can be done by parents, teachers, speech and language therapists, and occupational therapists.[1][33] A 2007 study found that augmenting a center-based program with weekly home visits by a special education teacher improved cognitive development and behavior.[34]

Studies of interventions have methodological problems that prevent definitive conclusions about efficacy.[2] Although many psychosocial interventions have some positive evidence, suggesting that some form of treatment is preferable to no treatment, the methodological quality of systematic reviews of these studies has generally been poor, their clinical results are mostly tentative, and there is little evidence for the relative effectiveness of treatment options.[3] Concerns about outcome measures, such as their inconsistent use, most greatly affect how the results of scientific studies are interpreted.[35] A 2009 Minnesota study found that parents follow behavioral treatment recommendations significantly less often than they follow medical recommendations, and that they adhere more often to reinforcement than to punishment recommendations.[36] Intensive, sustained special education programs and behavior therapy early in life can help children acquire self-care, social, and job skills,[1] and often improve functioning and decrease symptom severity and maladaptive behaviors;[4] claims that intervention by around age three years is crucial are not substantiated.[5]

Applied behavior analysis

Lovaas

Applied behavior analysis (ABA) is the applied research field of the science of behavior analysis, and it underpins a wide range of techniques used to treat autism and many other behaviors and diagnoses.[37] ABA-based interventions focus on teaching tasks one-on-one using the behaviorist principles of stimulus, response and reward,[38] and on reliable measurement and objective evaluation of observed behavior.[1] There is wide variation in the professional practice of behavior analysis and among the assessments and interventions used in school-based ABA programs.[39] 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.[40] However, children have problems using DTT-taught skills in natural environments.[1] These students are often taught with Natural language procedures to help lessen problems from DTT. In functional assessment, a common technique, a teacher formulates a clear description of a problem behavior, identifies antecedents, consequents, and other environmental factors that influence and maintain the behavior, develops hypotheses about what occasions and maintains the behavior, and collects observations to support the hypotheses.[1] A few more-comprehensive ABA programs use multiple assessment and intervention methods individually and dynamically.[39]

ABA-based techniques have 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.[1] A 2009 review of educational interventions for children, whose mean age was six years or less at intake, found that the higher-quality studies all assessed ABA, that ABA is well-established and no other educational treatment is considered probably-efficacious, and that intensive ABA treatment, carried out by trained therapists, is demonstrated effective in enhancing global functioning in pre-school children.[6] These gains maybe complicated by initial IQ.[41] A 2008 evidence-based review of comprehensive treatment approaches found that ABA is well-established for improving intellectual performance of young children with ASD.[4] A 2009 comprehensive synthesis of early intensive behavioral intervention (EIBI), a form of ABA treatment, found that EIBI produces strong effects, suggesting that it can be effective for some children with autism; it also found that the large effects might be an artifact of comparison groups with treatments that have yet to be empirically validated, and that no comparisons between EIBI and other widely recognized treatment programs have been published.[42] A 2009 systematic review came to the same principal conclusion that EIBI is effective for some but not all children, with wide variability in response to treatment; it also suggested that any gains are likely to be greatest in the first year of intervention.[5] A 2009 meta-analysis concluded that EIBI has a large effect on full-scale intelligence and a moderate effect on adaptive behavior.[43] However, a 2009 systematic review and meta-analysis found that applied behavior intervention (ABI), another name for EIBI, did not significantly improve outcomes compared with standard care of preschool children with ASD in the areas of cognitive outcome, expressive language, receptive language, and adaptive behavior.[44] Applied behavior analysis is cost effective for administrators [45]

Recently behavior analysts have built comprehensive models of child development (see Behavior analysis of child development ) to generate models for prevention as well as treatment for autism.

Pivotal response therapy

Pivotal response therapy or treatment (PRT) is a naturalistic intervention derived from ABA principles. Instead of individual behaviors, it targets pivotal areas of a child's development, such as motivation, responsivity to multiple cues, self-management, and social initiations; it aims for widespread improvements in areas that are not specifically targeted. The child determines activities and objects that will be used in a PRT exchange. Intended attempts at the target behavior are rewarded with a natural reinforcer: for example, if a child attempts a request for a stuffed animal, the child receives the animal, not a piece of candy or other unrelated reinforcer.[46]

Aversion therapy

The Judge Rotenberg Educational Center uses aversion therapy, notably contingent shock (electric shock delivered to the skin for a few seconds), to control the behavior of its patients, many of which are autistic. The practice is controversial.[47]

Communication interventions

The inability to communicate, verbally or non-verbally, is a core deficit in Autism. Children with Autism are often engaged in repetitive activity or other behaviors because they cannot convey their intent any other way. They do not know how to communicate their ideas to caregivers or others. Helping a child with Autism learn to communicate their needs and ideas is absolutely core to any intervention. Communication can either be verbal or non-verbal. Children with Autism require intensive intervention to learn how to communicate their intent.

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.[48] Social skills have been shown to be effective in treating children with autism.[48] Interventions that attempt to improve communication are commonly conducted by speech and language therapists, and work on joint attention, communicative intent, and alternative or augmentative and alternative communication (AAC) methods such as visual methods.[49] Little solid research supports the efficacy of speech therapy for autism;[50] AAC methods do not appear to impede speech and may result in modest gains.[51] A 2006 study reported benefits both for joint attention intervention and for symbolic play intervention,[52] 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.[53]

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.[54] A 2007 meta-analysis of 55 studies of school-based social skills intervention found that they were minimally effective for children and adolescents with ASD,[55] and a 2007 review found that social skills training has minimal empirical support for children with Asperger syndrome or high-functioning autism.[17]

Speech therapy

Picture Exchange Communication System

SCERTS

Social Communication/ Emotional Regulation/ Transactional Support.[56]

Relationship based, developmental models

Relationship based models give importance to the relationships that help children reach and master early developmental milestones. These are often missed or not mastered in children with ASD. Examples of these early milestones are engagement and interest in the world, intimacy with a caregiver, intentionality of action.

Relationship Development Intervention

Floortime/DIR

The Floortime/DIR (Developmental, Individual Differences based, Relationship based ) approach is a developmental intervention to autism developed by Stanley Greenspan and Serena Weider. Its core precept is to understand the child's sensory differences, follow the child's lead and use these to encourage children with ASD to climb up the developmental ladder. This approach is based on the idea that the core deficits in autism are individual differences in the sensory system, motor planning problems, the inability to relate and the inability to connect ones desire to intentional action and communication. When addressed through a combination of sensory support and DIR/Floortime techniques, children can become more social, less repetitive and also develop symbolic abilities.[57]

The DIR model is based on the idea that due to individual processing differences children with ASD do not master the early developmental milestones that are the foundations of learning. DIR outlines six core developmental stages that children with ASD have often missed or not mastered:

  • Stage One: Regulation and Interest in the World: Being calm and feeling well enough to attend to a caregiver and surroundings. Have shared attention.
  • Stage Two: Engagement and Relating: Interest in another person and in the world, developing a special bond with preferred caregivers. Distinguishing inanimate objects from people.
  • Stage Three: Two way intentional communication: Simple back and forth interactions between child and caregiver. Smiles, tickles, anticipatory play.
  • Stage Four: Social Problem solving: Using gestures, interaction, babble to indicate needs, wants, pleasure, upset. Get a caregiver to help with a problem. Using pre-language skills to show intention.
  • Stage Five: Symbolic Play: Using words, pictures, symbols to communicate an intention, idea. Communicate ideas and thoughts, not just wants and needs.
  • Stage Six: Bridging Ideas: This stage is the foundation of logic, reasoning, emotional thinking and a sense of reality.

Most typically developing children have mastered these stages by age 5 years. However, children with ASD struggle with or have missed some of these vital developmental stages. When these foundational abilities are strengthened through the child's lead and through meaningful play with a caregiver, children begin to climb up the developmental ladder. An introduction to DIR/Floortime can be found in the book - Engaging Autism: Using the Floortime Approach to Help Children Relate, Communicate, and Think. By Stanley Greenspan, M.D. and Serena Wieder, PhD.

The P.L.A.Y. Project (or PLAY Project)

The P.L.A.Y. Project (or PLAY Project) [58](an acryonym for PLAY and Language for Autistic Youngsters) is a community-based, national autism training and early intervention program established in 2001 by Richard Solomon, MD.[59] Based on the DIR® (Developmental, Individualized, Relationship-based) theory of Stanley Greenspan MD, the program is designed to train parents and professionals to implement intensive, developmental interventions for young children (18 months to 6 years) with autism. The program is operating in nearly 100 agencies worldwide including 25 states and in 5 countries outside of the U.S. (Australia, Canada, England, Ireland and Switzerland). The PLAY Project has been operating since 2001 from its headquarters in Ann Arbor, MI.

In September 2009, The P.L.A.Y. Project received a $1.85 million grant [60] from the National Institute of Mental Health (NIMH) to conduct a three-year controlled, clinical study of the P.L.A.Y. Project model. Drawing participants from five Easter Seals autism service locations, the study compares the outcomes of 60 children who participate in The P.L.A.Y. Project with the outcomes of 60 children who receive standard community interventions, making it the largest study of its kind. Before and after the 12-month intervention, each child is assessed with a battery of tests to measure developmental level, speech and language, sensory-motor profile, and social skills.

The results of previous research on the program were published by the peer-reviewed British journal, Autism [61] (May, 2007).

Son-Rise

Son-Rise is a home-based program that emphasizes eye contact, accepting the child without judgment, and joining in with the child's repetitive and restricted behaviors. 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.[62] 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,[63] 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.[64]

TEACCH

Treatment and education of autistic and related communication handicapped children (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.[1] 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 group.[65]

Sensory integration

Unusual responses to sensory stimuli are more common and prominent in children with autism, although there is not good evidence that sensory symptoms differentiate autism from other developmental disorders.[66] Several therapies have been developed to treat Sensory Integration Dysfunction.[67] Some of these treatments (for example, sensorimotor handling) have a questionable rationale and have no empirical evidence. Other treatments have been studied, with small positive outcomes, but few conclusions can be drawn due to methodological problems with the studies. These treatments include prism lenses, physical exercise, auditory integration training, and sensory stimulation or inhibition techniques such as "deep pressure"—firm touch pressure applied either manually or via an apparatus such as a hug machine or a pressure garment.[68] Weighted vests, a popular deep-pressure therapy, have only a limited amount of scientific research available, which on balance indicates that the therapy is ineffective.[69] Although replicable treatments have been described and valid outcome measures are known, gaps exist in knowledge related to sensory integration dysfunction and therapy.[70] Because empirical support is limited, systematic evaluation is needed if these interventions are used.[71]

The term Sensory integration in simple terms means the ability to use all of ones senses to accomplish a task. For children with Autism, there is usually a problem with integrating these senses and simple tasks as the one described are difficult.

Occupational Therapy is commonly prescribed for children with Autism. Occupational therapists certified in Sensory Integration are a key component of any Autism intervention program. A recent book My Stroke of Insight by Jill Bolte Taylor gives some insight, from a brain researcher's point of view, on what sensory dysfunction feels like. Other books on sensory integration include The Out of Sync Child - Recognizing and Coping with Sensory Processing Disorder by Carol Kranowitz and Lucy Jane Miller.

Massage therapy

A review of massage therapy as a symptomatic treatment of autism found limited evidence of benefit. There were few high quality studies, and due to the risk of bias found in the studies analyzed, no firm conclusions about the efficacy of massage therapy could be drawn.[72]

Music

Music therapy uses the elements of music to let people express their feelings and communicate. Two small studies have reported short-term improvement in verbal and gestural communication skills of children with autism from a week's work of daily sessions; no significant effects on behavior problems were observed.[73]

Animal-assisted therapy

Animal-assisted therapy, where an animal such as a dog or a horse 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.[74] 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 mood.[75]

Neurofeedback

Neurofeedback attempts to train individuals to regulate their brainwave patterns by letting them observe their brain activity more directly. In its most traditional form, the output of EEG electrodes is fed into a computer that controls a game-like audiovisual display. Neurofeedback has been evaluated with positive results for ASD, but studies have lacked random assignment to controls.[76]

Patterning

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 several unrelated neurologic disorders, including autism. The method, taught at the The Institutes for the Achievement of Human Potential, is based on oversimplified theories and is not supported by carefully designed research studies.[77]

Packing

In packing, children are wrapped tightly for up to an hour in wet sheets that have been refrigerated, with only their heads left free. The treatment is repeated several times a week, and can continue for years. It is intended as treatment for autistic children who harm themselves; most of these children cannot speak. Similar envelopment techniques have been used for centuries, such as to calm violent patients in Germany in the 19th century; its modern use in France began in the 1960s, based on psychoanalytic theories such as the theory of the refrigerator mother. Packing is currently used in hundreds of French clinics. There is no scientific evidence for the effectiveness of packing, and some concern about risk of adverse health effects.[78]

Parent mediated interventions

Parent mediated interventions offer support and practical advice to parents of autistic children.[49] 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.[79] A Cochrane Review (2002) of the evidence found two relevant research items, and observed "intensive intervention (involving parents, but primarily delivered by professionals) was associated with better child outcomes on direct measurement than were found for parent-mediated early intervention, but no differences were found in relation to measures of parent and teacher perceptions of skills and behaviours".[80] A 2006 randomized controlled trial (RCT) found that a twenty-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.[81] Parent child interaction therapy is a model that has demonstrated success with children with oppositional defiant disorder that has recently been applied to children with autism.[82] A 2008 pilot trial of Parent-Child Interaction Therapy, a parent coaching intervention model, for boys aged 5–12 with high-functioning ASD and behavioral problems, found increases in child adaptability and reductions in parent perceptions of child problem behaviors.[83]

Medical management

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.[84] 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.[85] Only a very few medical treatments are well supported by scientific evidence using controlled experiments.[84]

Prescription medication

Many medications are used to treat problems associated with ASD.[9] More than half of U.S. children diagnosed with ASD are prescribed psychoactive drugs or anticonvulsants, with the most common drug classes being antidepressants, stimulants, and antipsychotics.[10] Only the antipsychotics have clearly demonstrated efficacy.[11]

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 ASD.[86] Risperidone is approved by the Food and Drug Administration (FDA) for treating symptomatic irritability in autistic children and adolescents.[11] In short-term trials (up to six months) most adverse events were mild to moderate, with weight gain, drowsiness, and high blood sugar requiring monitoring; long term efficacy and safety have not been fully determined.[87] It is unclear whether risperidone improves autism's core social and communication deficits.[11] The FDA's decision was based in part on a study of autistic children with severe and enduring problems of tantrums, aggression, and self-injury; risperidone is not recommended for autistic children with mild aggression and explosive behavior without an enduring pattern.[88]

Other drugs are prescribed off-label in the U.S., which means they have not been approved for treating ASD. Large placebo-controlled studies of olanzapine and aripiprazole were underway in early 2008.[11] Some selective serotonin reuptake inhibitors (SSRIs) and dopamine blockers can reduce some maladaptive behaviors associated with ASD.[89] Although SSRIs reduce levels of repetitive behavior in autistic adults,[90] a 2009 multisite randomized controlled study found no benefit and some adverse effects in children from the SSRI citalopram, raising doubts whether SSRIs are effective for treating repetitive behavior in autistic children.[91] A further study of related medical reviews determined that the prescription of SSRI antidepressants for treating autistic spectrum disorders in children lacked any evidence, and could not be recommended.[92] One study found that the psychostimulant methylphenidate was efficacious against hyperactivity associated with ASD, though with less response than in neurotypical children with ADHD.[12] Of the many medications studied for treatment of aggressive and self-injurious behavior in children and adolescents with autism, only risperidone and methylphenidate demonstrate results that have been replicated.[93] A 1998 study of the hormone secretin reported improved symptoms and generated tremendous interest, but several controlled studies since have found no benefit.[94] Oxytocin may play a role in autism and may be an effective treatment for repetitive and affiliative behaviors;[95] two related studies in adults found that oxytocin decreased repetitive behaviors and improved interpretation of emotions, but these preliminary results do not necessarily apply to children.[96] An experimental drug STX107 has stopped overproduction of metabotropic glutamate receptor 5 in rodents, and it has been hypothesized that this may help in about 5% of autism cases, but this hypothesis has not been tested in humans.[96]

Aside from antipsychotics,[11] there is scant reliable research about the effectiveness or safety of drug treatments for adolescents and adults with ASD.[12] 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.[13] A person with ASD 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.[14][97]

Dietary supplements

Many parents give their children dietary 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.[16][84]

A review found some low-quality evidence to support the use of vitamin B6 in combination with magnesium at high doses, but the evidence was equivocal and the review noted the possible danger of fatal hypermagnesemia.[98] A Cochrane Review of the evidence for the use of B6 and magnesium found that "[d]ue to the small number of studies, the methodological quality of studies, and small sample sizes, no recommendation can be advanced regarding the use of B6-Mg as a treatment for autism."[99]

Dimethylglycine (DMG) is hypothesized to improve speech and reduce autistic behaviors,[16] and is a commonly used supplement.[84] Two double-blind, placebo-controlled studies found no statistically significant effect on autistic behaviors,[16] and reported few side effects. No peer-reviewed studies have addressed treatment with the related compound trimethylglycine.[84]

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.[84]

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.[84]

Melatonin is sometimes used to manage sleep problems in developmental disorders. 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.[16] A 2008 open trial found that melatonin appears to be a safe and well-tolerated treatment for insomnia in children with ASD. and suggested controlled trials to determine efficacy;[100] a small 2009 retrospective study had similar results for adults.[101]

Although omega-3 fatty acids, which are polyunsaturated fatty acids (PUFA), are a popular treatment for children with ASD, there is very little scientific evidence supporting their effectiveness,[102] and further research is needed.[1]

Several other supplements have been hypothesized to relieve autism symptoms, including BDTH2,[103] carnosine, cholesterol,[104] cyproheptadine, D-cycloserine, folic acid, glutathione, metallothionein promoters, other PUFA such as omega-6 fatty acids, tryptophan, tyrosine, thiamine (see Chelation therapy), vitamin B12, and zinc. These lack reliable scientific evidence of efficacy or safety in treatment of autism.[16][84]

Diets

Atypical eating behavior occurs in about three-quarters of children with ASD, to the extent that it was formerly a diagnostic indicator. Selectivity is the most common problem, although eating rituals and food refusal also occur;[105] 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;[106] studies report conflicting results, and the relationship between GI problems and ASD is unclear.[1]

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.[107] 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 these data are inadequate to guide treatment recommendations.[22][108]

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.[16] For example, a 2008 study found that autistic boys on casein-free diets have significantly thinner bones than usual, presumably because the diets contribute to calcium and vitamin D deficiencies.[109]

Chelation therapy

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. Strong epidemiological evidence 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[110] or its symptoms,[111] and there is no scientific support for chelation therapy as a treatment for autism.[50]

Chelation therapy can be hazardous. In August 2005, an incorrect form of EDTA used for chelation therapy resulted in hypocalcemia, causing cardiac arrest that killed a five-year-old autistic boy.[23]

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.[112] 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.[113] There is not sufficient evidence to support the use of thiamine (vitamin B1) to treat autism.[16]

Chiropractic

Chiropractic is an alternative medical practice whose main hypothesis is that mechanical disorders of the spine affect general health via the nervous system, and whose main treatment is spinal manipulation. A significant portion of the profession rejects vaccination, as traditional chiropractic philosophy equates vaccines to poison.[114] Most chiropractic writings on vaccination focus on its negative aspects,[115] claiming that it is hazardous, ineffective, and unnecessary,[114] and in some cases suggesting that vaccination causes autism[115] or that chiropractors should be the primary contact for treatment of autism and other neurodevelopmental disorders.[116] Chiropractic treatment has not been shown to be effective for medical conditions other than back pain,[117] and there is insufficient scientific evidence to make conclusions about chiropractic care for autism.[118]

Craniosacral therapy

Craniosacral therapy is based on the theory that restrictions at cranial sutures of the skull affect rhythmic impulses conveyed via cerebrospinal fluid, and that gentle pressure on external areas can improve the flow and balance of the supply of this fluid to the brain, relieving symptoms of many conditions.[119] There is no scientific support for major elements of the underlying model,[120] there is little scientific evidence to support the therapy, and research methods that could conclusively evaluate the therapy's effectiveness have not been applied.[119] No published studies are available on the use of this therapy for autism.[15]

Electroconvulsive therapy

Studies indicate that 12–17% of adolescents and young adults with autism satisfy diagnostic criteria for catatonia, which is loss of or hyperactive motor activity. Electroconvulsive therapy (ECT) has been used to treat cases of catatonia and related conditions in people with autism. However, no controlled trials have been performed of ECT in autism, and there are serious ethical and legal obstacles to its use.[121]

Hyperbaric oxygen therapy

A boy with ASD, and his father, in a hyperbaric oxygen chamber.

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. A small 2009 double-blind study of autistic children found that 40 hourly treatments of 24% oxygen at 1.3 atmospheres provided significant improvement in the children's behavior immediately after treatment sessions. The study has not been independently confirmed; further studies are planned or in progress.[122]

Prosthetics

Unlike conventional neuromotor prostheses, neurocognitive prostheses would sense or modulate neural function in order to physically reconstitute cognitive processes such as executive function and language. No neurocognitive prostheses are currently available but the development of implantable neurocognitive brain-computer interfaces has been proposed to help treat conditions such as autism.[123]

Affective computing devices, typically with image or voice recognition capabilities, have been proposed to help autistic individuals improve their social communication skills.[124] These devices are still under development. Robots have also been proposed as educational aids for autistic children.[125]

Stem cell therapy

Mesenchymal stem cells and cord blood CD34+ cells have been proposed to treat autism, but this proposal has not been tested.[126]

Transcranial Magnetic Stimulation

Transcranial Magnetic Stimulation is a noninvasive method to cause depolarization or hyperpolarization in the neurons of the brain. TMS uses electromagnetic induction to induce weak electric currents using a rapidly changing magnetic field; this can cause activity in specific or general parts of the brain with minimal discomfort, allowing the functioning and interconnections of the brain to be studied. A variant of TMS, repetitive transcranial magnetic stimulation (rTMS), has been tested as a treatment tool for various neurological and psychiatric disorders including migraines, strokes, Parkinson's disease, dystonia, tinnitus, depression and auditory hallucinations. TMS has been demonstrated to improve discriminatory sensory processing[127][128] and novelty processing [129] as well as social functioning [130] in ASD. TMS has the potential to become an important therapeutic tool in ASD treatment and has shown significant benefits in treating core symptoms of ASD with few, if any side effects.

Religious interventions

The Table Talk of Martin Luther contains the story of a twelve-year-old boy who may have been severely autistic.[131] According to Luther's notetaker Mathesius, Luther thought the boy was a soulless mass of flesh possessed by the devil, and suggested that he be suffocated.[132] In 2003, an autistic boy in Wisconsin suffocated during an exorcism in which he was wrapped in sheets.[133] Some Pentecostal and charismatic Christians believe that autism is the result of a "generational curse" visited upon a child for the sins of a parent, and can be cured through repentance and divine healing.

Ultraorthodox Jewish parents sometimes use spiritual and mystical interventions such as prayers, blessings, recitations of religious text, holy water, amulets, changing the child's name, and exorcism.[134]

One study has suggested that spirituality and not religious activities involving the mothers of autistic children were associated with better outcomes for the child.[135]

Anti-cure perspective

The exact cause of autism is unclear, yet some organizations advocate researching a cure. Some autism rights organizations view autism as a way of life rather than as a disease and thus advocate acceptance over a search for a cure.[136][137]

See also

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