Parameters for the assessment and treatment of Autism Spectrum Disorder (2/2)

Part 2: Recommendations of the American Academy of Child and Adolescent Psychiatry for the Evaluation and Treatment of Autism Spectrum Disorder[1. Free translation]

EVIDENCE BASIS FOR PRACTICE¹

The parameters recommended below are supported by empirical and clinical data:

• The clinical standard (CS): The recommendations provided are based on rigorous empirical evidence (meta-analyses, systematic reviews, controlled trials, or overwhelming clinical consensus).
• The clinical guideline (CG): It applies to recommendations that are based on strong empirical evidence (uncontrolled clinical trials, cohort studies, case-control studies).
• The clinical option (CO): These are recommendations based on emerging empirical evidence (uncontrolled trials, case series, or clinical opinions without clinical evidence and/or consensus).
• Not Endorsed (NR): It is applied when it is known that the practices are ineffective or contraindicated.

The strength of empirical evidence is scored, in descending order, as follows:

• (ECC), When there are controlled clinical trials in which subjects have been randomly assigned to at least two treatment conditions.
• (EC), when clinical trials exist but have not been randomly assigned to two different treatment conditions.
• (IN), for uncontrolled trials and subjects assigned to a single treatment.
• (SC), when there are only a series of cases or a single case.

EVALUATION

Recommendation 1. Both developmental and psychiatric assessments should routinely include questions about ASD symptoms.. (EC). 

Screening should include inquiries about core ASD symptoms, including those related to sociability, repetitive behaviors, and unusual behaviors. Assessment tools have been designed to be useful to clinicians.

Of the instruments listed in Table 1, some are implemented by the clinician or other caregivers. They can be applied to very young children, to preschoolers, when the diagnosis is considered first. In some cases, they may be relevant for older children, especially when they are not significantly intellectually impaired and whose social impairment is usually diagnosed later.

Recommendation 2. When screening indicates significant symptoms of ASD, a complete evaluation should be performed to determine the presence of ASD. (EC).

Currently, there are no biological markers for diagnosis; it is the result of a careful clinical evaluation. A standard psychiatric evaluation should be performed, including an interview with the child, the family, and a review of their medical history. Both the history and the examination must strictly adhere to the DSM-5 criteria. It is important to keep in mind that DSM-5 symptoms are age-independent, so in younger children, the evaluation should be approached with greater caution, as some symptoms may appear later.

Special attention must be paid to the differential diagnosis and the changes that occur with evolution.

The history should include a review of behavioral and educational interventions, information on family history, and relevant psychosocial aspects. It is very important to assess for possible comorbidities.

Patient observation should focus on broad areas of social interaction, restrictive behaviors, and repetitive behaviors. Both the patient's age and developmental stage may necessitate modifications to the assessment procedures. The clinician should also consider ethnic, cultural, or socioeconomic factors that may influence the assessment.

The assessment tools listed in Table 1 may vary in their usefulness to the clinician. Some require prior training. They are useful tools, but they do not replace clinical judgment.

Recommendation 3Clinicians should coordinate an appropriate multidisciplinary assessment in children with ASD. (EC).

All children with ASD should undergo a medical evaluation that includes a physical examination, hearing test, Wood's lamp examination for signs of tuberous sclerosis, and genetic testing, including karyotyping, Fragile X syndrome, and chromosomal microarray analysis. The latter has been recommended by geneticists as a standard screening test for children with learning disabilities and/or ASD. These tests are revealing abnormalities clearly associated with the increasing prevalence of ASD (in a sample of children with ASD, 2,5% showed chromosomal abnormalities, 0,57% Fragile X syndrome, and 24% chromosomal microarray abnormalities). Maternal duplications of 15q11-13 and duplications and deletions of chromosome 16p11.2, as well as other genetic variations of uncertain significance, are particularly well-known. When these abnormalities are detected, further genetic evaluation and genetic counseling are recommended.

When unusual clinical aspects are detected, further evaluation is recommended. A wide variety of diseases exist that should require additional investigation: infections (encephalitis or meningitis), endocrine disorders (hypothyroidism), metabolic disorders (homocystinuria), traumatic injuries (head injuries), toxic disorders (fetal alcoholism), or genetic disorders (chromosomal abnormalities).

Some developmental disorders, especially Landau-Kleffner syndrome, which, if suspected, can be ruled out with an EEG. When present, it often coexists with marked aphasia.

Genetic or neurological consultations, neuroimaging, EEG and additional laboratory tests should be performed when justified by relevant data that emerged during the evaluation.

Psychological assessment, including cognitive and adaptive skills, is indicated for treatment planning and to help address social and communication difficulties related to overall development. Standard intelligence tests often yield mixed results. Isolated abilities may be found. In high-achieving children, areas of special interest may emerge, and an obsession with these areas can interfere with learning. Psychological examination clarifies strengths and weaknesses, which is very useful in intervention programs. These programs should include instruments valid for nonverbal individuals.

The communication assessment includes measures of language comprehension and expression, as well as vocabulary (especially pragmatic aspects). Occupational and physical therapy assessments should be conducted to evaluate sensory and motor difficulties. Finally, it is advisable to assess sleep quality.

When the treatment of a patient involves professionals from multiple disciplines, it is advisable to coordinate the intervention between several professionals.

TREATMENT

Recommendation 4Clinicians should assist families in obtaining appropriate, evidence-based educational and behavioral interventions for patients with ASD. (EC).

Structured educational and behavioral interventions have proven effective in patients with ASD. Many studies have been conducted using controls or single-subject methods. Randomized controlled trials are scarce, ultimately highlighting the difficulties in assigning controls.

Another problem observed is the lack of attention paid to characterizing the subjects, generalizing the results, and ensuring adherence to the implemented treatment. Despite these difficulties, some overall treatments have proven effective, although none has shown to be superior.

1. Behavioral treatment

El Applied Behavioral Analysis  (ABA) is based on the learning paradigm. Many holistic interventions have been proposed, although the best known is the Early Intensive Behavioral Intervention for young children  by Lovaas. A meta-analysis indicates its effectiveness in young children. However, rigorous research is needed before the results can be disseminated.

Behavioral techniques have proven effective, especially when maladaptive behaviors interfere with the implementation of comprehensive programs. In these situations, a functional analysis of the target behavior is conducted, the reinforcers that maintain it are identified, and then various behavioral techniques are applied. ABA techniques have frequently been used for specific behavioral problems. They have also proven effective in improving certain academic skills, daily living skills, communication, and social skills. It is very important to seek the generalizability of the results.

2. Communication

This is the most important focus of therapeutic efforts. It is implemented through individualized educational programs in coordination with a speech-language pathologist. Children who are nonverbal can be assisted with various forms of alternative communication, such as sign language, communication boards, visual aids, pictograms, and other augmentative and alternative communication (AAC) techniques.

Where language exists, efforts are focused on improving its pragmatic aspects. There are quite a few programs available to improve these pragmatic aspects.

3. Educational

There is a general consensus that patients with ASD need structured educational programs and specific instruction. Programs that have proven effective are those that are specifically planned, intensive, individualized, and delivered by an experienced, interdisciplinary team with family involvement, with the aim of generalizing the skills acquired.

The child's strengths and weaknesses must be identified, with a clear description of the intervention, goals, and objectives. Of course, the intervention should be monitored to assess progress. Typically, each program is geared toward specific goals: improving verbal and non-verbal communication, academic skills, or social and psychomotor skills. With younger children, it is common to work with parents to improve aspects related to the home environment.

4. Other interventions

Although there is insufficient evidence for other interventions, it appears that behavioral-cognitive intervention It may be useful in dealing with anxiety and anger in high-achieving children.

El auditory integration training, the sensory integration therapy, the massages, Although methodologically weak, they present limited evidence.

Other interventions whose effectiveness has not been proven are described.

Recommendation 5. Drug treatment may be offered for specific symptoms or comorbidity. (GC). Pharmacology in patients with ASD helps to maximize the effectiveness of other interventions by managing severe behaviors. Targeted behaviors for pharmacotherapy include anxiety, depression, aggression, self-harm, hyperactivity, inattention, obsessive-compulsive rituals, repetitive behaviors, stereotypies, and sleep problems.

The FDA has approved the following for autism: risperidone and the aripiprazole in the treatment of aggression, irritability, and tantrums. Table 3 lists the different drugs used and their level of evidence.

When we combine parental intervention with medication, the results are better. In patients without language, the results should be reported by caregivers. There are several scales available to assess outcomes and side effects.

Recommendation 6.(GC)Clinicians should maintain an active long-term role during planned and supportive treatment, both to the family and the individual.

Children and their families need ongoing support and assistance. To achieve this, clinicians should develop long-term partnerships. This is absolutely essential for younger children. During school age, both behavioral and pharmacological interventions become more relevant. During adolescence, it is necessary to address career paths, autonomy, and sexuality.

Patients who experience parental divorce/separation face greater challenges.

Recommendation 7. (OC). Clinicians should inquire about possible alternative or complementary treatments and be prepared to assess the potential risks and benefits.

Suelen treatments without empirical evidence and are followed by some parents. Most of them, although they offer no benefits, also do not carry significant risks: In some, it has been shown that don't work, , the B6, magnesium, or intravenous administration of secretin. In others no scientific evidenceas the gluten-free diet, casein-free diet, Omega 3 and oral human immunoglobulin.

Some treatments present risks for the patient: the use of the chelation therapy for the elimination of heavy metals (high mortality and morbidity). It is important that parents can express their questions about these alternatives. Parents should increase their knowledge about treatments with empirical evidence.

1. Fred Volkmar et al. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Autism Spectrum Disorder. J. Am. Acad.Child Adolesc. Psychiatry, 2014;53(2):237–257 [↩]