Autism. Treatment

Behavior therapy

Behavior therapy, which uses specific behavior modification procedures, may be helpful in establishing desired behaviors and eliminating problem behaviors in autistic children. After a behavioral analysis is performed, techniques such as shaping or prompting are used to develop desired responses, which are then reinforced by increasingly mature rewards. However, autistic children may fail to generalize the learned responses to other situations. In one study, very young autistic children who took part in an intensive behavioral program during which they received 40 or more hours of one-to-one behavioral treatment for two or more years showed significant improvement in I.Q. and higher levels of adaptive functioning than a control group of autistic children that did not receive the intensive treatment. By the end of the treatment period the experimental group included a subgroup of eight (42 percent) normal-functioning children who were able to be enrolled in regular classes. By contrast, no child in the control group achieved a favorable outcome.

Psychotherapy

With the recognition of the biological basis of autistic disorder came the realization that psychodynamic psychotherapy in young autistic children, including unstructured play therapy, was not appropriate. Individual psychotherapy, with or without medication, may be appropriate for higher-functioning persons who, as they get older, may become anxious or depressed as they become aware of their differences and difficulties in relating to others.

Psychopharmacological treatment

In a subgroup of autistic children with target symptoms, such as temper tantrums, aggressiveness, self-injury, hyperactivity, and stereotypies, appropriate psychoactive agents may be an important part of a comprehensive treatment program. Clinical and laboratory monitoring is recommended throughout pharmacotherapy. Periodic drug withdrawal (every six months) is recommended to assess whether there is continued need for treatment.

ANTIPSYCHOTICS

It was hypothesized that the stereotypies and hyperactivity seen in many autistic children were a function of increased dopaminergic activity. That was the rationale for the use of antipsychotics, which block dopamine receptors, in autistic children. In individually regulated doses of 0.25 to 4.0 mg a day, or from 0.016 to 0.217 mg/kg a day, the high-potency antipsychotic haloperidol proved more effective than placebo in reducing target symptoms. Side effects of sedation and neuroleptic-induced dystonia were seen at doses above therapeutic doses. No negative effect on learning or cognition was found, and in two studies haloperidol was shown to facilitate language development and learning in the laboratory. In one study that assessed the interaction of haloperidol and behavior therapy, the combination of the two treatments was superior to either treatment alone in facilitating speech acquisition. The efficacy of haloperidol is maintained over time, and the drug is especially effective in children who are angry, irritable, and emotionally labile. Tardive dyskinesia remains a significant untoward effect of antipsychotic treatment, with 29.27 percent of children who participated in a prospective study of haloperidol developing dyskinesias; 79.2 percent developed dyskinesia during drug withdrawal and 20.8 percent developed dyskinesia while taking the drug. Because stereotypies and dyskinesias often occur in the same body areas, particularly in the orofacial area, differentiating the two may be difficult, especially when stereotypies that had been suppressed by antipsychotic treatment reemerge on drug withdrawal. Therefore, it is important to make baseline ratings of abnormal movements in autistic children before commencing treatment with antipsychotics or any psychoactive agent.

In a double-blind, placebo-controlled study pimozide (Orap) (1.0 to 9.0 mg a day), another high-potency antipsychotic, was shown to be as effective as haloperidol in decreasing maladaptive behaviors. Pimozide may be more effective than haloperidol in treating hypoactive or normoactive autistic children, who frequently experience sedation on low doses of haloperidol without showing a decrease in maladaptive behaviors. The daily dosage should not exceed 0.3 mg/kg because of potential cardiotoxicity.

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