An effective treatment program will build on the child's interests, offer a predictable schedule, teach tasks as a series of simple steps, actively engage the child's attention in highly structured activities, and provide regular reinforcement of behavior. Parental involvement has emerged as a major factor in treatment success. Parents work with teachers and therapists to identify the behaviors to be changed and the skills to be taught. Recognizing that parents are the child's earliest teachers, more programs are beginning to train parents to continue the therapy at home.
As soon as a child's disability has been identified, instruction should begin. Effective programs will teach early communication and social interaction skills. In children younger than 3, appropriate interventions usually take place in the home or a child-care center. These interventions target specific deficits in learning, language, imitation, attention, motivation, compliance, and initiative of interaction. Included are behavioral methods, communication, and occupational and physical therapy along with social-play interventions. Children older than 3 usually have school-based individualized special education. The child may be in a segregated class with other autistic children or in an integrated class with children without disabilities for at least part of the day. See the educational section below for more information.
Before spending time and money and possibly delaying progress, the family of an autistic child should evaluate the findings of objective reviewers. Following are some of the approaches that have not been shown to be effective in treating the majority of children with autism:
Facilitated communication: The theory is that by supporting a nonverbal child's arms and fingers so that he can type on a keyboard, the child will be able to type out his inner thoughts. Several scientific studies prove that the typed messages actually reflect the thoughts of the person providing the support.
Holding therapy: The theory is that the parents should hug the child for long periods of time, even if the child resists, to encourage a bond. There is no scientific evidence to support that this creates a bond between parent and child.
Auditory integration training: In this therapy, a child listens to a variety of sounds in order to improve language comprehension. This method is supposed to help people with autism receive more balanced sensory input from their environment. When tested using scientific procedures, the method was shown to be no more effective than listening to music.
Dolman/Delcato method: This treatment has people crawl and move as they did at each stage of early development, in an attempt to learn missing skills. There is no scientific support for this method.
Scientists have found that while no medication can correct the impairments underlining autism, medications are often used to treat behavioral problems, such as aggression, self-injurious behavior, and severe tantrums, that keep the person with ASD from functioning more effectively at home or school. The medications used are those that have been developed to treat similar symptoms in other disorders, such as OCD and depression.
A child with ASD may not respond to medications in the same way as typically developing children. It is important that parents work with a doctor who has experience with children with autism. A child should be monitored closely while taking a medication. The doctor will prescribe the lowest dose possible to be effective. Ask the doctor about any side effects the medication may have and keep a record of how your child responds to the medication. It will be helpful to read the patient insert that comes with your child's medication. Some people keep the patient inserts in a small notebook to be used as a reference. This is most useful when several medications are prescribed.
Anxiety and depression. The selective serotonin reuptake inhibitors (SSRIs) are the medications most often prescribed for symptoms of anxiety, depression, and/or obsessive-compulsive disorder (OCD). Only one of the SSRIs, fluoxetine (Prozac®), has been approved by the FDA for both OCD and depression in children age 7 and older. Three that have been approved for OCD are fluvoxamine (Luvox®), age 8 and older; sertraline (Zoloft®), age 6 and older; and clomipramine (Anafranil®), age 10 and older (Newschaffer, 2003). Treatment with these medications can be associated with decreased frequency of repetitive, ritualistic behavior and improvements in eye contact and social contacts. The FDA is studying and analyzing data to better understand how to use the SSRIs safely, effectively, and at the lowest dose possible.
Please note that a "black box" warning was issued in 2004 (and modified in 2007 to include young adults up to 25) for all antidepressant drugs by the Food and Drug Administration (FDA) after a thorough review of data. The warning emphasizes that children, adolescents, and young adults taking antidepressants should be closely monitored, especially during the initial weeks of treatment, for worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations.
Behavioral problems. Antipsychotic medications have been used to treat severe behavioral problems. These medications work by reducing the activity of the neurotransmitter dopamine in the brain. Among the older, typical antipsychotics, such as haloperidol (Haldol®), thioridazine, fluphenazine, and chlorpromazine, haloperidol was found in more than one study to be more effective than a placebo in treating serious behavioral problems. However, haloperidol, while helpful for reducing symptoms of aggression, can also have adverse side effects, such as sedation, muscle stiffness, and abnormal movements.
A study on atypical antipsychotics conducted by the NIMH-supported Research Units on Pediatric Psychopharmacology (RUPP) Autism Network showed that risperidone was effective and well tolerated for the treatment of severe behavioral problems in children with autism (RUPP, 2002). The most common side effects were increased appetite, weight gain, and sedation. On October 6, 2006, the U.S. Food and Drug Administration (FDA) approved risperidone (Risperdal®) for the symptomatic treatment of irritability in autistic children and adolescents, ages 5 to 16. The approval is the first for the use of a drug to treat behaviors such as irritability, aggression, deliberate self-injury, and temper tantrums, all associated with autism in children. Further long-term studies are needed to determine any long-term side effects. Other atypical antipsychotics that have been studied recently with encouraging results are olanzapine (Zyprexa®) and ziprasidone (Geodon®) which has not been associated with significant weight gain.
Seizures. Seizures are found in one in four persons with ASD, most often in those who have low IQ or are mute. They are treated with one or more anticonvulsants, including such medications as carbamazepine (Tegretol®), lamotrigine (Lamictal®), topiramate (Topamax®), and valproic acid (Depakote®). The level of the medication in the blood should be monitored carefully and adjusted so that the lowest effective amount possible is used. Although medication usually reduces the number of seizures, it cannot always eliminate them.
Inattention and hyperactivity. Stimulant medications such as methylphenidate (Ritalin®), used safely and effectively in persons with attention-deficit/hyperactivity disorder, have also been prescribed for children with autism. These medications may decrease impulsivity and hyperactivity in some children, especially those higher functioning children.
Several other medications have been used to treat ASD symptoms; among them are other antidepressants, naltrexone, lithium, and some of the benzodiazepines such as diazepam (Valium®) and lorazepam (Ativan®). The safety and efficacy of these medications in children with autism has not been proved. Since people may respond differently to different medications, your child's unique history and behavior will help your doctor decide which medication might be most beneficial.
Options in Education
For every child eligible for special programs, each state guarantees special education and related services. The Individuals with Disabilities Education Act (IDEA) is a federally mandated program that assures a free and appropriate public education for children with diagnosed learning deficits. Usually children are placed in public schools and the school district pays for all necessary services. These will include, as needed, services by a speech therapist, occupational therapist, school psychologist, social worker, school nurse, or aide.
By law, public schools must prepare and carry out a set of instruction goals, or specific skills, for every child in a special education program. The list of skills is known as the child's Individualized Education Program (IEP). The IEP is an agreement between the school and the family on the child's goals. When your child's IEP is developed, you will be asked to attend the meeting. There will be several people at this meeting, including a special-education teacher, a representative of the public schools who is knowledgeable about the program, other individuals invited by the school or by you (you may want to bring a relative, a child-care provider, or a supportive close friend who knows your child well). Parents play an important part in creating the program, as they know their child and his or her needs best. Once the IEP is developed, an annual meeting is scheduled to review your child's progress and make any alterations to reflect his or her changing needs.
If your child is under 3 years of age and has special needs, he or she should be eligible for an early intervention program; these programs are available in every state. Early intervention services are provided by workers qualified to care for toddlers with disabilities and are usually in the child's home or a place familiar to the child. The services provided are written into an Individualized Family Service Plan (IFSP) that is reviewed at least once every six months. The plan will describe services that will be provided to the child but will also describe services for parents to help them in daily activities with their child and for siblings to help them adjust to having a brother or sister with ASD.
The Teen Years
Adolescence is a time of stress and confusion, even for children with no significant brain disorder, and autistic children carry with them special challenges. Like all children, they need help in dealing with their budding sexuality. While some behaviors improve in the teenage years, some get worse. Increased autistic or aggressive behavior may be one way some teens express their newfound tension and confusion.
The teenage years are also a time when children become more socially sensitive and aware. At the age that most teenagers are concerned with acne, popularity, grades and dates, teens with autism may become painfully aware that they are different from their peers. They may notice that they lack friends and, unlike their schoolmates, they aren't dating or planning for a career. For some, the sadness that comes with such realization urges them to learn new behaviors.
Autism in Adulthood
A few cities are exploring ways to help autistic people hold meaningful jobs and live and work within the wider community. Innovative programs enable the autistic adult to live and work in mainstream society, rather than be limited to a segregated environment.
Nevertheless, communication and social problems often cause difficulties in many areas of life. Adults with ASD will continue to need encouragement and moral support in their struggle for an independent life.
Many people with ASD are capable of employment in sheltered workshops under the supervision of managers trained in working with persons with disabilities. A nurturing environment at home, at school, and later in job training and at work, helps persons with ASD continue to learn and to develop throughout their lives.
Living Arrangements for the Adult with an Autism Spectrum Disorder
Independent living. Some adults with ASD are able to live entirely on their own. Others can live semi-independently in their own home if they have assistance with solving major problems, such as personal finances or dealing with the government agencies that provide services to persons with disabilities. This assistance can be provided by family, a professional agency, or another type of provider.
Living at home. Government funds are available for families that choose to have their adult child with ASD live at home. These programs include Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), Medicaid waivers, and others. Information about these programs is available from the Social Security Administration (SSA). An appointment with a local SSA office is a good first step to take in understanding the programs for which the young adult is eligible.
Foster homes and skill-development homes. Some families open their homes to provide long-term care to unrelated adults with disabilities. If the home teaches self-care and housekeeping skills and arranges leisure activities, it is called a "skill-development" home.
Supervised group living. Persons with disabilities frequently live in group homes or apartments staffed by professionals who help the individuals with basic needs. These often include meal preparation, housekeeping, and personal-care needs. Higher-functioning persons may be able to live in a home or apartment where staff only visit a few times a week. These persons generally prepare their own meals, go to work, and conduct other daily activities on their own.
Institutions. Although the trend in recent decades has been to avoid placing persons with disabilities into long-term-care institutions, this alternative is still available for persons with ASD who need intensive, constant supervision. Unlike many of the institutions of past eras, today's facilities view residents as individuals with human needs and offer opportunities for recreation and simple but meaningful work.
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