Đánh giá
Determine the presence of other medical conditions associated with autism spectrum disorder, such as Fragile X syndrome, tuberous sclerosis, mitochondrial disorders, Soto syndrome, inborn error of metabolism that may require treatment, and fetal alcohol syndrome. Confirm the presence of comorbidity that may require treatment, such as seizure disorder, intellectual disability, attention-deficit hyperactivity disorder (ADHD), sleep problems, feeding problems, and deficits in motor coordination. A complete audiologic assessment should be made to obtain hearing status, including middle ear function.
Nguyên tắc điều trị
There is no pharmacological cure for autism. Medications are most beneficial when used in conjunction with developmental, educational, behavioral, and rehabilitative therapies. There is no single medication that consistently benefits all patients with autism spectrum disorder. Treatment should be individualized based on the patient’s needs, response, and presence of co-existing conditions. Therapy should be initiated at a low dose.
Indications for Pharmacological Therapy
Pharmacological therapy should be given in the following: If presenting with comorbid psychiatric or neurodevelopmental conditions; for short- to medium-term intervention for specific severe symptoms; for aggressive or self-injurious behavior; and for anxiety, depression, tics, obsessive-compulsive behaviors, hyperactivity, and sleep disorders.
Goals of Pharmacological Therapy
The goals for pharmacological treatment include minimizing disruptive or disturbing symptoms, facilitating access to intervention, maximizing benefits of non-medical intervention, maximizing functional independence, and improving the patient’s and the family’s quality of life.
Pharmacological therapy
Atypical Antipsychotics
Aripiprazole
Autism Spectrum Disorder_Management 1
Aripiprazole is approved for the short-term treatment of irritability in autistic children 6-17 years of age. Studies showed improvement in challenging behavior and repetitive behavior.
Risperidone
Risperidone is approved for the short-term treatment of irritability, hyperactivity, and stereotypic behavior in autistic children 5-16 years of age. This has lesser extrapyramidal effects than typical antipsychotics. Children may gain weight within the first few months of treatment. Prolactin levels may rise but with no clinical effects seen. Improvement in repetitive behavior, social withdrawal, and hyperactivity was observed in several studies.
Conventional Antipsychotics
Example drugs: Chlorpromazine, Haloperidol
Haloperidol is being considered in the management of temper tantrums, aggression, hyperactivity, withdrawal, and stereotypical behavior. Haloperidol is approved for use in children and adolescents with autism and with persistent, severe aggression by the European Medicines Agency (EMA) when other therapies fail or with intolerable side effects. Limitation of use is due to sedation, irritability, and extrapyramidal dyskinesia.
Selective Serotonin Reuptake Inhibitors (SSRIs)
Autism Spectrum Disorder_Management 2Example drugs: Fluoxetine, Fluvoxamine
Studies have shown that Fluoxetine improved the mood of adolescent and adult patients and reduced ritualistic or repetitive behavior. Fluvoxamine has been shown to be effective in the treatment of obsessive-compulsive disorder (OCD), refractory depression, and social phobia in adults. Fluvoxamine has been considered for repetitive thought and maladaptive behavior, but it can cause occasional worsening of hyperactivity in patients.
Other Agents
Methylphenidate is the first-line treatment in patients with attention deficit/hyperactivity disorder (ADHD) on the autism spectrum. Treatment with Atomoxetine may be considered in children and adolescents with ADHD on the autism spectrum if Methylphenidate therapy was unsuccessful or contraindicated. Gaunfacine may be used as a third-line treatment in case of treatment failure with Methylphenidate and Atomoxetine. Melatonin is an option for patients with sleep issues if psychosocial intervention shows no improvement, to be used in conjunction with psychosocial interventions.
Investigative Agents
Various clinical studies are being conducted to prove the therapeutic effects of Oxytocin on patients with autism spectrum disorder. Oxytocin therapy may have the potential to improve social responsiveness based on several studies.
Nonpharmacological
Parent and Caregiver Education
The parents or caregivers will remember the manner by which they were informed of the diagnosis and present the diagnosis in a sensitive, unrushed manner without interruption. Allocate enough time for parent or caregiver counseling. Inform the parents or caregivers that autism varies widely in presentation, severity of behavior, intelligence, and prognosis. Creating a network with other parents of autistic children may be done. Genetic counseling before subsequent pregnancy is important. The prevalence of abnormality in subsequent children is higher when language delays, OCD, or social deficits are present. The parents or caregivers should be informed of available interventions and their role. Family and caregivers should be trained to continue to teach the child and improve the child’s compliance.
Developmental Intervention
Early Developmental Intervention
Intervention programs for autistic toddlers commonly involve the following: A predictable program with a routine that should stress the ability to pay attention to other people, imitate others, and use preverbal and verbal communication; play and social interaction; systematic individual teaching of skills to support the child’s specific needs; a functional approach to dealing with the child’s problematic behavior; and family involvement. There is evidence that if intensive early intervention is done on children diagnosed before 5 years of age, a better outcome is expected.
Educational Systems
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Education systems help autistic children from the ages of 3-21 years old. Individualize the intervention and consider the patient’s developmental status (ie specific strengths and deficits). This usually includes speech therapy with the use of visual cues. This shows improvement in the expressive language at 4 years of age if speech therapy is given between 2-3 years of age. For the minimally speaking child, alternative and augmentative communication (AAC) systems may be recommended because these may stimulate speech acquisition in non-verbal children and enhance expression in verbal children. Other communication interventions include Responsive Education and Prelinguistic Milieu Teaching (RPMT), Reciprocal Imitation Training (RIT), and Picture Exchange Communication System (PECS).
Occupational therapy gives assessment and intervention to maximize daily living activities such as Sensory Integration Therapy (SIT) and perceptual motor training. Social skills should be taught by using strategies to minimize maladaptive behavior and encourage compliance. Social skills are taught explicitly through modeling and feedback. Positive reinforcement should be applied, and involvement of the parents is critical. Parents and caregivers should be encouraged to share information about special educational needs with school personnel for better planning of intervention and support.
Cognitive Therapy
Cognitive remediation therapy, cognitive flexibility training, cognitive enhancement therapy, and other cognitive impairment interventions may be adapted into the patient's training program.
Complementary and Alternative Treatments
Music therapy and visual motor exercises may be considered. There is a moderate level of evidence for an increased chance of global improvement, improved quality of life, and reduced total autism severity with music therapy. Emerging evidence states that visual motor exercises have the potential to improve social communication and reduce repetitive behaviors.
Physical exercise may help improve inhibitory control, cognitive flexibility, and working memory. A healthy diet composed of a variety of fresh foods is encouraged. Those individuals who exhibit signs and/or symptoms of vitamin and/or mineral deficiencies should be evaluated, treated, and monitored.
Behavioral Management
A notable treatment approach to autism spectrum disorder is Applied Behavior Analysis (ABA). This is most effective when started early and applied consistently. Reinforce proper desirable behavior using behavioral psychological theory. Implement behavioral training and management protocols at home and school. This should be initiated after complete assessment of the child’s behavioral characteristics and environment. A positive reinforcement strategy should be used. Parents, caregivers, and teachers should be trained to consistently implement the behavioral strategy in all of the child’s environments. Social competence should be developed as part of the behavioral rehabilitation plan.
Early Intensive Behavioral and Developmental Approach
The following are the early intensive behavioral and developmental approaches: UCLA/Lovaas; Early Intensive Behavioural Intervention (EIBI); Naturalistic Developmental Behavioural Interventions (NDBIs); early start Denver model; parent training approaches; Discrete Trial Training (DTT); and Pivotal Response Training (PRT).
Social Skills Approach
Social skills training focuses on developing effective communication skills, enhancing social interaction skills, improving conversation skills, including both its initiation and continuance, cultivating the ability to understand and empathize with the feelings and perspectives of others, building self‑awareness and self‑regulation skills, and promoting emotional understanding and control. This includes Social Cognition and Interaction Training (SCIT), Education and Enrichment of Relational Skills (PEERS), Assistive Soft Skills and Employment Training (ASSET), and Emotion Regulation Therapy (ERT).
Play/Interaction-Based Approach
Autism Spectrum Disorder_Management 4
The play or interaction-based approach includes joint attention intervention and symbolic play and play-based interventions.
Behavioral Intervention for Commonly Associated Symptoms
Cognitive behavioral therapy (CBT) for anxiety or anger management and a sleep workshop for sleep disturbances may also be done.