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Autism Spectrum Disorders and Psychiatry: Update on Diagnostic and Treatment Considerations: Page 4 of 6

Autism Spectrum Disorders and Psychiatry: Update on Diagnostic and Treatment Considerations: Page 4 of 6

Questions to consider before making diagnosis of ASD in toddlers & childrenTable 1 – Questions to consider before making a diagnosis of ASD in to...
Intervention models derived from Applied Behavior AnalysisTable 2 – Intervention models derived from Applied Behavior Analysis

 

Treatment

Treatment should follow from and be based on a thorough assessment. In addition to characterizing ASD symptomatology, to best inform treatment, an initial assessment should provide information about comorbidities, cognition, academic performance, social behavior, communication skills, and independent living skills. There is no single treatment appropriate for every individual with ASD, and it remains difficult to predict which patients will benefit most from treatment and in which ability domains. The best course of action is to account for age, symptoms, and functioning level when planning treatment.

Across all age ranges, interventions must intensively address the individual’s most pressing needs. At the same time, progress should be monitored so that interventions can be started, adjusted, or discontinued in a way that is developmentally sensitive, supports the patient, and allows for emerging independence.

Behavioral and therapeutic interventions

Early, intensive, individualized behavioral intervention is highly recommended for toddlers and young children with ASD. Traditional guidelines recommended 25 or more hours per week of direct intervention between a child and a trained clinician3; newer models increasingly utilize parents in the role of interventionist to maximize the number of engaged, face-to-face hours a child receives.4

Applied Behavior Analysis (ABA), derived from early studies done at UCLA by Ivar Lovaas, has been shown to be effective.5 More recently, ABA approaches have evolved to include increasingly developmentally based and naturalistic models (Table 2).6-8 Although more randomized clinical trials are needed—including direct comparisons between active interventions—given the benefits of early intensive interventions for young children with ASD, the ABA approach remains a best-practice recommendation.9

As children age, a variety of behavioral, therapeutic, academic, and often psychopharmacological interventions may be necessary. Most children will need a combination of supports, which may change across development and settings. Many children will require speech and language therapy to help them develop basic expressive and receptive language. Some will need intensive speech and behavioral interventions that target the development of alternative communication systems (eg, sign language, picture exchange) when language does not emerge. Even among children with ASD and higher cognitive and language skills, speech and language therapy is often recommended to hone pragmatic skills. Supplemental use of visual communication strategies (eg, picture schedules) is often helpful in conjunction with verbal communication interventions and supports.

Teaching and rehearsing social rules and scripts—first in therapeutic settings and then in more naturalistic settings—are effective for many children. Several manualized social skills programs, such as the Program for Education and Enrichment of Relational Skills (PEERS),10 have been developed to structure social skills interventions.

Behavioral interventions for children with ASD—both clinician- and parent-mediated—help build skills for the classroom, increase on-task behavior, ease difficulties with transitions and changes in routine, build social and communication skills, improve executive functioning, and decrease challenging behaviors.11-13 Functional behavioral analyses can be helpful for identifying behavioral treatment goals and appropriate ways to address them across settings. Overall, intervention plans are best designed when they use strengths (eg, cognitive skills) to compensate for weaknesses, while simultaneously employing additional external supports to facilitate learning and socialization.

For adolescents and adults, support is usually necessary for transitioning from school to community and vocational settings. Many families require assistance to connect with disability services and to consider housing and support options, such as group home settings. Mental health clinicians can be helpful in supporting discussions of long-term planning, legal guardianship, and reasonable expectations for an individual’s work and day-to-day living plans.

 
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