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Medical interventions in ASD

The Child Neurology Division, Department of Pediatrics All India Institute of Medical Sciences, New Delhi provides evidence based practices to parents of children with autism, so that they are empowered to take informed decisions.

Management of Autism spectrum disorder (ASD)

The following focuses on the medical management of Autism.

Intervention targets

Main intervention targets in the management of the autism are listed below :

  1. Core features: Social interaction, Communication & Stereotypy
  2. Non-core features: Irritability, Aggression, Insomnia, Self-injury
  3. Comorbid states: such as obsessive-compulsive disorder, Attention deficit hyperactivity disorder, depression and anxiety, GI disturbances, epilepsy, sensory issues etc.
  4. Activities of daily living leading to independence
  5. Quality of life: individual and family

Health promotion and hygiene

  1. Health promotion and disease prevention is of prime importance as any other normal child.
  2. Immunizations schedule to be discussed with the parents and informed decisions need to be taken about vaccinations.
  3. Although many vaccines and contents of vaccines were implicated in causation of autism in the past, current recommendation is provide the same vaccination schedule as a normal child.
  4. Macro-nutrition and micro-nutrition (Autistic kids are known to have meal time tantrums, extreme food selectivity and ritualistic eating behaviors).
  5. Physical growth to be regular monitored (They are known to have abnormal growth trajectory).
  6. Personal Hygiene (Dental, Genital, Menstrual hygiene in adolescent girls).

Personal Hygiene

A child with autism needs to be told that his/her body changes and it is important to wash properly everyday and wear neat clothes.They need to wash their hair and face - this seemingly simple thing can be extremely difficult due to sensory processing issues. Also it is important to brush teeth twice a day and shave regularly. Charts or picture sequences in the bathroom can be used which show the sequence of personal hygiene tasks and chart when they have completed the tasks each day. Favorable behavior should be rewarded.

When discussing menstrual management with a girl with ASD remember that the material needs to be age and developmentally appropriate. Explain what will happen and how to manage. Inform that it will happen to her each month. Dates on a calendar or in some other visually appropriate way. Demonstrate with actual pads how to unwrap, place a pad in underwear and dispose of a pad. A visual activity sequence for changing a pad may be useful. Let the girl know she can talk or ask questions about menstruation with the mother or trusted female in private place and time.

Masturbation

It can be a tricky subject for parents and care givers to deal with, but if young people with ASD are not properly informed about masturbation it can become a problem. Boys will often masturbate at inappropriate times and places if they do not understand that this is a private activity. Masturbation needs to be dealt with in positive light free from stigma and myth. Masturbation is not often discussed with girls, but it can be a way for girls to express their sexuality in a private and healthy way. Discuss masturbation in the context that it is-private touching that should happen in a private place such as a bedroom or bathroom with the door shut.Visual cue cards may be needed depending on the person’s level of functioning to remind the person to go to their room and close the door/curtains and to clean up afterwards.

Self-esteem

It is essential that every individual should have good self-esteem and  a positive self-image. You can build up your child‘s self esteem by promoting self–hygiene, grooming, dress, encouraging sports, healthy diet and sleep.

Sexuality

It is important to realize that young people with ASD also become sexually active, as they have biological functions as others, but they lack the required maturity. They are more likely to involve in inappropriate sexual behavior. They are more vulnerable to sexual abuse and discrimination. It is crucial that they receive adequate and correct information to handle this aspect of their life appropriately and safely. They should be imparted good sexual education.

To summarize, children and young people with autism need factual information about their bodies, puberty, hygiene and sexuality. They need to know when to say NO and how to stay safe.

Co –morbidities in autism

Epilepsy

Seizures are common, seen in about 11% of children with autism. In the management of epilepsy in autism, the same principles are followed as any other case of epilepsy. Compliance with medication is an issue. Parents need to take extra care in ensuring the regular and timely medications.

Sleep disturbances

Some children with autism suffer from sleep disturbances in the form of poor sleep efficiency and prolonged time taken to sleep. A drug called melatonin has been shown to be of proven benefit in improving sleep efficiency and decreasing the time taken by your child to go into sleep. In children who take a long time to go to sleep and have sleep disturbances, you can consult with your doctor on suitable medication.

Challenging behaviors

In case of a sudden onset of worsening of  behavioral symptoms, such as aggressive or self-injurious behavior, a source of pain or discomfort should be sought for.

Evidence based therapies for behavioral problems

Intervention Conclusion (Cochrane Evidence)
Risperidone
  • Some evidence of the benefits in irritability, repetition and social withdrawal
  • Side effects: Weight gain
Tricyclic antidepressants
  • TCAs block noradrenaline and serotonin reuptake their impact on serotonin, used in the treatment of autistic symptoms and comorbidities
  • Further research is required before TCAs can be recommended
Aripiprazole
  • Can be effective in treating some behavioral aspects of ASD in children.
  • After treatment children showed less irritability, hyperactivity, and stereotypies
  • Side effects : weight gain, sedation, drooling, and tremor
Selective serotonin
  • Fluoxetine, fluvoxamine, fenfluramine and citalopram
  • Depression, anxiety and obsessive- compulsive behaviours
  • No evidence of effect of SSRIs in children

Methylphenidate for core and ADHD-like symptoms in ASD aged 6 to 18 years

  • In ADHD, this has been shown to reduce impulsivity and increase attention

Points to note

  1. Rule out any treatable medical causes and modifiable
  2. environmental factors
  3. A therapeutic trial of medication should generally be considered if the behavioral symptoms cause significant impairment in functioning and are sub optimally responsive to behavioral interventions
  4. Hence, parents should not be insistent on demanding medications like sedative agents or anti-psychotics before considering the above mentioned points
  5. Over the counter or self medications should be strictly avoided

Source : Autism Awareness: Bringing them in the mainstream

 
 
 

 



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