An Update on Autism -- Perspectives and Treatment

From Medscape Neurology & Neurosurgery

Andrew N. Wilner, MD

An Autism Update: Introduction

Autism is a common disorder of children that presents with a spectrum of neurobehavioral and cognitive disorders, particularly problems with socialization, communication, and repetitive behaviors. There are no biologic markers for autism. The diagnosis is clinical, based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM IV).[1] Lack of timely development of language, or regression in communication skills, are indications for an evaluation for autism (Table 1). Multiple diagnostic tools are available to assist clinicians in the assessment of a child with suspected autism (Table 2).

Table 1. Absolute Indications for Autism Evaluation
No babbling, pointing, or other gesture by 12 months
No single words by 16 months
No 2-word spontaneous (not echolalic) phrases by 24 months
Any loss of any language or social skills at any age

Data from the American Psychiatric Association.[1]

Table 2. Diagnostic Tools
Diagnostic Parental Interviews
The Gilliam Autism Rating Scale
The Parent Interview for Autism
The Pervasive Developmental Disorders Screening Test-Stage 3
The Autism Diagnostic Interview-Revised
Diagnostic Observation Instruments
The Childhood Autism Rating Scale
The Screening Tool for Autism in 2-Year-Olds
The Autism Diagnostic Observation Schedule-Generic

Data from the American Psychiatric Association.[1]

Like epilepsy, autism is a not a single syndrome. There is no cure, but early intervention can improve quality of life. The devastating nature of the disorder has attracted many unproven approaches, providing many opportunities for misguided, expensive, and potentially harmful "alternative" treatments.

An Update on Treatment

Medscape: What is the treatment for autism?

Dr. Goldstein: There are very little data concerning efficacy of behavioral treatments for autism. Most rely on close personal interactions between therapists/teachers and the children. Medications may be used to treat abnormal behaviors, but there are no medications that address the underlying disorder.

Dr. Chez: Treatment is purely symptomatic. For example, I sometimes use risperidone, which is US Food and Drug Administration approved for children with autism with aggressive behavior. We need more controlled studies of treatments. Clinical trials are now ongoing for memantine, an N-methyl-D-aspartic acid and glutamate antagonist that plays a role in brain neurogenesis, epilepsy, learning, and neuroglial inflammation, all of which may be important in autism. Designer drugs based on single gene defects, and stem cells are some other possibilities for the future.

Dr. Pellock: Autism has many faces and treatment must be individualized to each child. When children are referred with autism, they need a comprehensive evaluation to identify symptoms and developmental delays that may accompany autism. Treatment goals need to be identified. For example, is the therapy to decrease impulsiveness, hyperactivity, improve sleep, or treat seizures? The biggest issue is usually behavior. Children need behavioral controls throughout the day to learn which behaviors are acceptable and which are not to allow them to achieve to the best of their ability within the school system. A comprehensive, multimodal approach is necessary. Educational and environmental treatments are frequently at least as important, if not more important, than medications.
Conclusions

Autism remains a frustrating and challenging problem for many children and their families. While the experts do not agree on all of the details regarding management, all children with symptoms suggestive of autism should receive a comprehensive evaluation by a pediatric neurologist or other expert to determine whether the child has autism or another developmental disorder. If autism is diagnosed, the child’s behavioral, communication, and cognitive problems should be identified, as well as comorbidities such as epilepsy, sleep disorders, and gastrointestinal problems, so that a comprehensive treatment plan can be implemented. Early diagnosis and intervention offer children with autism the best opportunity to improve their social integration and quality of life.


http://www.medscape.com/viewarticle/726778?src=mp&spon=9&uac=71630FV