SECOND OF 2 PARTS
Evidence supports the crucial role of early intervention and nonpharmacologic approaches
A large percentage of individuals with autism spectrum disorder (ASD) experience persisting significant social deficits in adulthood,1 which often leads to isolation, depressive symptoms, and poor occupational and relationship functioning.2,3 Childhood is a vital time for making the most significant and lasting changes that can improve functioning of individuals with ASD. Psychiatrists and other physicians who treat children are in a key role to influence outcomes of children at risk for or diagnosed with ASD.
This article provides updates on various aspects of ASD diagnosis and treatment (based on available evidence up to March 2020). Part 1 (Current Psychiatry, March 2022) focused on early detection and diagnosis. Here in Part 2, I describe an overview of treatment strategies. Given the vast nature of the topic and the abundance of research that has emerged in the field of ASD over the last several years,4 providing an exhaustive review of each of the aspects discussed here is not within the scope of this article.
A comprehensive approach is essential
Multiple treatment modalities have been recommended for ASD.5 It is essential to address all aspects of ASD through cognitive, developmental, social-communication, sensory-motor, and behavioral interventions. Nonpharmacologic interventions are crucial in improving long-term outcomes of children with ASD.6
Nonpharmacologic treatments
Nonpharmacologic interventions commonly utilized for children with ASD include behavioral therapies, other psychological therapies, speech-language therapy, occupational therapy, educational interventions, parent coaching/training, developmental social interventions, and other modalities of therapy that are delivered in school, home, and clinic settings.5,7
A recent study examining ASD treatment trends via caregivers’ reports (N = 5,122) from the SPARK (Simons Foundation Powering Autism Research for Knowledge) cohort in the United States reported that 80% of children received speech-language therapy or occupational therapy; 52% got both.5 The study revealed that approximately one-quarter utilized 3 therapies simultaneously; two-thirds had utilized 3 or more therapies in the previous year.5
Interventions for children with ASD need to be individualized.1,8 Evidence-based behavioral interventions for ASD fall into 2 broad categories: Applied Behavior Analysis (ABA), and Naturalistic Developmental Behavioral Interventions (NDBI). Traditionally, ABA has been a key model, guiding treatment for enhancing social-communicating skills and lowering maladaptive behaviors in ASD.9 ABA follows a structured and prescribed format,10,11 and has been shown to be efficacious.1,7 More recently, NDBI, in which interventions are “embedded” in the natural environment of the young child and more actively incorporate a developmental perspective, has been shown to be beneficial in improving and generalizing social-communication skills in young children with ASD.7,11
Early Start Denver Model (ESDM) is an intensive, naturalistic behavioral intervention4 that has been shown to be efficacious for enhancing communication and adaptive behavior in children with ASD.7,8,12 A multisite randomized controlled trial (RCT) by Rogers et al12 that examined the efficacy of ESDM in 118 children (age 14 to 24 months) with ASD found the treatment was beneficial and superior compared with a “community intervention” group, in regards to language ability measured in time by group analyses.The ESDM intervention in this study involved weekly parent coaching for 3 months, along with 24 months of 15 hours/week of one-on-one treatment provided by therapy professionals.12
Reciprocal imitation training (RIT) is another naturalistic intervention that has shown benefit in training children with ASD in imitation skills during play.13 Studies have found that both RIT and ESDM can be parent-implemented, after parents receive training.13,14
Parent-mediated, parent-implemented interventions may have a role in improving outcomes in childhood ASD,7,15 particularly “better generalization and maintenance of skills than therapist-implemented intervention” for lowering challenging behaviors and enhancing verbal and nonverbal communication.16
Various social skills interventions have also been found effective for children with ASD.1 Such interventions are often provided in the school setting.7 Coordination with the child’s school to discuss and advocating for adequate and suitable interventions, educational services, and placement is an essential aspect of ASD treatment.7
Two other school-based, comprehensive treatment model interventions—Learning Experiences and Alternative Programs for Preschoolers and their Parents (LEAP), and TEACCH—have some evidence of leading to improvement in children with ASD.7,17
Some studies have found that music therapy may have high efficacy for children with ASD, even with smaller length and intensity of treatment, particularly in improving social interaction, engagement with parents, joint attention, and communication.3,18 Further research is needed to conclusively establish the efficacy of music therapy for ASD in children and adolescents.
A few studies have assessed the long-term outcomes of interventions for ASD; however, more research is needed.19 Pickles et al19 conducted a follow-up to determine the long-term effects of the Preschool Autism Communication Trial (PACT), an RCT of parent-mediated social communication therapy for children age 2 to 4 with ASD. The children’s average age at follow-up was 10 years. The authors found a significant long-term decrease in ASD symptoms and enhancement of social communication with parents (N = 152).19
Technology-based interventions, including games and robotics, have been investigated in recent years, for treatment of children with ASD (eg, for improving social skills).20
Research suggests that the intensity (number of hours) and duration of nonpharmacologic treatments for ASD is critical to improving outcomes (Box1,3,5,7,10,16).
Box
Nonpharmacologic interventions for ASD: How much is needed?
A higher intensity of nonpharmacologic intervention (greater number of hours) has been associated with greater benefit for children with autism spectrum disorder (ASD), in the form of enhancements in IQ and adaptive behavior.1,10,16 In the United States, the intensity of interventions commonly ranges from 30 to 200 or more minutes per week.3 This may mean that a child with ASD who is receiving 30 minutes of speech therapy at school and continues to exhibit significant deficits in speech-language or social-communication may likely benefit from additional hours of speech therapy and/or social-communication skill training, and should be referred accordingly, even for private therapy services if needed and feasible.7 Guidelines created through a systematic review of evidence recommend at least 25 hours per week of comprehensive treatment interventions for children with ASD to address language, social deficits, and behavioral difficulties.1 The duration of intervention has also been shown to play a role in outcomes.1,3,10 Given the complexity and extent of impairment often associated with ASD, it is not surprising that in recent research examining trends in ASD treatment in the United States, most caregivers reported therapy as ongoing.5 The exact intensity and duration of nonpharmacologic interventions may depend on several factors, such as severity of ASD and of the specific deficit being targeted, type of intervention, and therapist skill. The quality of skills of the care provider has also been shown to affect the benefits gained from the intervention.3
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