Approach

ASD is a lifelong neurodevelopmental condition that increasingly is being viewed as an example of neurological and cognitive variation among people. It is clinically very heterogeneous; although typically associated with disabilities and everyday challenges, ASD may also be associated with considerable cognitive strengths and talents.[141] Claims of a ‘cure’ for ASD are without foundation, and indeed the concept of a cure is controversial for some people on the autism spectrum and for their families.

ASD is associated with functional difficulties and a reduced quality of life compared with the general population. The aims of treatment are to maximise functional independence and quality of life, and to minimise distress by supporting learning, social communication, and cognitive skills, and by managing any co-occurring physical or mental health problems.[142] Care should be multidisciplinary, collaborative, and tailored to the specific needs of the person with ASD (and their carers) as these needs change across their lifespan.[143]

Within this topic, we present an approach to the management of both:

  • Core symptoms of ASD (e.g., social communication difficulties and repetitive behaviours)

    • This is always non-pharmacological in nature.

  • Some key coexisting conditions (e.g., insomnia, ADHD, anxiety, and depression)

    • As a general, best practice principle, non-pharmacological treatments are considered first, and only augmented with pharmacological treatment (e.g., psychotropic medication) where there is an inadequate treatment response, or if a rapid response to treatment is required

    • It is important that people with ASD are only prescribed psychotropic medication when clinically indicated, that they receive regular and timely monitoring and review (including for effectiveness and for adverse effects), and that treatment is discontinued if no longer required. The NHS in the UK has published guidance and resources to support treatment and appropriate medication for children and young people with an intellectual disability, autism, or both. NHS England: STOMP and STAMP Opens in new window

Family support and education

Care and support for families and carers is vital. Clinicians should offer families, partners, and/or carers of people with ASD an assessment of their own needs, including support in their caring role, and including respite care and emergency plans. Family members of people with ASD often benefit from forums where they can learn more about the disorder, its associated problems, and strategies to manage difficulties. Parent or spouse support groups exist for this purpose. In addition, local ASD-specific organisations often run workshops for parents/carers.

Autism organisations include:

In some cases, parental counselling may also be appropriate.

The family should be made aware of provisions they may be entitled to by law, such as an individualised educational plan or social care services. There may also be financial entitlements, such as disability tax credits. However, although specific support measures may be recommended by a healthcare professional, in practice, funding is often under external control (e.g., local or state authority), frequently limiting the practical help available to patients and their families.

Parent-mediated or -delivered intervention

Interventions for the core features of ASD in children of all ages are often mediated or delivered by parents, using child-initiated teaching episodes or naturally occurring opportunities and play to deliver learning. They typically focus on parent-child interaction, joint attention, and engagement. Parents are trained by professionals, who support them to a varying degree. Training sessions may be delivered in the home, clinic, school or other community setting, or remotely via telehealth.[144]

There is evidence that parent-mediated interventions improve parent-child interaction and may also improve child language comprehension, as well as reducing core ASD symptom severity.[145][146][147][148][149] There is also some evidence for improved core ASD symptoms at long-term follow-up.[150][151][152] One randomised trial found a parent training programme to be superior to parent education for the management of challenging behaviour.[153]

Early interventions for ASD in pre-schoolers

Early interventions for ASD typically begin at (or before) pre-school age, and may take place as early as 12 months. There is evidence that early intervention for children with ASD is beneficial, and results in improved long-term cognition, language, and behaviour, although the strength of evidence is limited due to methodological concerns.[154][155][156][157] In particular, it appears that interventions started before the age of 3 may have a greater positive effect than those started after the age of 5.[139]

Longitudinal studies and data on long-term outcome following interventions are lacking. For some children, improvements in outcome may be moderate, and there is no way of ascertaining whether a particular group of children may benefit from a specific intervention. In addition to considering the possible adverse effects of treatment, the wider costs of interventions are considered. Many interventions are expensive, and costs may not necessarily be covered by state funding. Some interventions are administered by (or in conjunction with) parents and may be carried out in the home. Consideration of the direct financial costs, indirect costs (through possible lost earnings), and the impact on relationships within the family must be balanced against likely and possible improvements in outcome for the person with ASD.[158][159][148][160]

The following therapies are examples of early educational and behavioural interventions used with pre-school children with ASD. In practice, a combination of approaches may be used. Practice varies widely according to region and country, and clinicians will need to refer to their local protocols and guidelines. Below are some examples of commonly used interventions, listed in alphabetical order.

Early Start Denver Model (ESDM)

ESDM intervention is based on developmental and applied behavioural analytical principles and is delivered by trained therapists and parents. A number of systematic reviews suggest overall positive results; ESDM appears to be associated with improvements in certain specific domains, such as cognition, language, and adaptive behaviours, although interpretation is limited by methodological weaknesses within some of the studies.[161][162][163] One multi-site randomised controlled trial (RCT) found that early age at the beginning of treatment, and more hours of total treatment, were associated with improved outcomes in toddlers.[164]

More Than Words (Hanen programme)

Designed to help the parents of all children <6 years of age who are experiencing difficulties in social interaction and communication. Parents learn a number of strategies that help to improve their child's communication and interaction.[165] Research evidence is limited; one RCT found no effects of treatment on children’s outcomes, either immediately or 5 months after treatment, but did find gains on communication at 9 months.[166] However, there is consensus opinion that it is likely to be of value in children with ASD.

High-intensity applied behavioural analysis (ABA)

A behavioural programme for treating young children (age 2 to 3 years at the start of intervention) with ASD. ABA may be used if it is considered that the child would benefit from a heavily structured environment, with the use of a reward system to lessen the impact of either repetitive behaviours or overactivity. The programme reinforces positive behaviours and dissuades the child from engaging in negative behaviours (often repetitive interests). Traditionally, most early intensive behavioural interventions were based on ABA principles; however, the emphasis has since moved away from a structured ABA approach towards a more naturalistic approach.[143]

The programme is initially taught on a one-to-one basis and is time-intensive (up to 40 hours per week) and expensive.[167] Research evidence is limited, with few RCTs.[168] One 2018 Cochrane review, looking at early, intensive behavioural interventions (EIBI) based on ABA principles in children under 6 years, found weak evidence that this approach is an effective behavioural treatment for some children with ASD. The interventions were associated with improvements in adaptive behaviour, IQ, and language skills. However, no improvement was seen in the core symptoms of ASD. The evidence was weak as it mostly came from small studies, only one of which was an RCT.[169] There is some evidence to suggest that children who receive more hours per week of ABA, or more intensive ABA therapy, experience better developmental outcomes than those receiving fewer hours or lower intensity treatment.[170][171] In spite of the limited evidence base for ABA, clinical experience has led to consensus opinion that it is likely to be of some benefit in children with ASD.[172] One criticism of ABA is that it does not generalise beyond the specific skills trained, limiting its usefulness as a standalone intervention.

Joint Attention, Symbolic Play, and Engagement Regulation (JASPER)

JASPER is one example of a caregiver-mediated, play-based intervention. It aims to improve early joint attention and thus promote language and cognitive abilities later on. It is used in some parts of the US and Canada. This approach is associated with improvements in joint attention and play skills across a number of studies.[145][173][174][175][176][177]

Learning Experiences and Alternative Program for Preschoolers and their Parents (LEAP)

This programme combines ABA principles with special and general educational techniques; small groups of children with ASD are taught alongside small groups of peers without autism. There is some high-quality RCT evidence that LEAP improves the social communication skills of some pre-schoolers with ASD, but there is insufficient evidence to determine whether it provides benefits in other core ASD symptoms.[178][179] It is one of a number of educational interventions for children with ASD; however, more research is required to assess the comparative effectiveness of available interventions.

Pre-school Autism Communication Trial (PACT)

There is some RCT evidence to suggest that this parent-mediated social communication therapy for young children with autism is associated in improvements in communication and repetitive behaviour after 1 year, and also after 6 years following treatment.[146][150]

Social communication interventions to manage core symptoms of ASD in school-age children (5-18 years)

Below are some examples of commonly used interventions, in alphabetical order.

Children’s friendship training programme (CFT)

This parent-assisted programme is one example of a group-based social skills intervention. There is some evidence that this general type of intervention improves social skills and wellbeing in cognitively-able children with ASD, although the improvement varies according to how performance is measured.[180][181] CFT is associated with modest gains in social play skills.[182] It typically involves groups of children, with or without typically developing peers, where social skills are taught through instruction, rehearsal, role-play, and performance feedback. The CFT programme has been adapted for adolescents, with some positive results.[183]

Peer-mediated interventions

Peer-mediated social communication interventions often involve free-play sessions between a child with ASD, and a child without ASD who has had preparatory training. These interventions improve social communication skills in high-functioning children with ASD.[184] However, more research is required on the effectiveness of social communication interventions in children with ASD who are not high-functioning.[185]

High-intensity ABA

See section on high-intensity ABA in pre-school children above. High-intensity ABA often begins in pre-school-age children, but programmes may continue for older children.

Treatment and education of autistic- and communications-related handicapped children (TEACCH)

This structured, developmental teaching programme provides continuity in the classroom setting, with the aim of improving developmental skills in order to enable children to learn. It is one example of an educational intervention for children with ASD. Parents are trained in TEACCH methods, and schooling at home is supplemented by day therapy, or by special schooling given by professionals.[186] There is limited research evidence supporting this treatment; it is associated with a small but measurable benefit in perceptual, motor, verbal, and cognitive skills in students with ASD.[187] Consensus opinion is that it is likely to be beneficial in some children with ASD, but more research is needed on the comparative effectiveness of educational interventions. There is some evidence to suggest that TEACCH is particularly effective for children with ASD who have greater cognitive delays.[188]

Non-pharmacological approaches/considerations in adults

Some adults with ASD are able to function successfully without treatment, whereas others require intermittent or lifelong support and care. Management approaches are individualised and aim to optimise personal functioning and increase quality of life. Note that psychological approaches may also be required as part of the management of co-occurring conditions (see below).

Post-diagnostic support

Adults with ASD may require an assessment of their support requirements. A number of charities offer support to adults newly diagnosed with ASD, including organised social groups and activities, which may be online or face to face. National Autistic Society Opens in new window

Transition to adulthood

Care of young people moving from paediatric to adult services requires careful planning to ensure a smooth transition.[104][189] If continuing treatment is necessary, an assessment is required, taking into account the young person’s personal, educational, occupational, social, and communication functioning, as well as any coexisting conditions.[189]

Employment support

Among transition-age adolescents and young adults, vocational support or support during continuing education may be beneficial (e.g., via an individual supported employment programme); such programmes can improve employment and job retention.[104][190] For older adults, support in the community through involvement in social or other groups, or through mentoring in jobs, may be valuable.

Social skills programmes

UK guidelines recommend individual or group social learning programmes for adults with ASD who experience difficulties with social interaction (with a mild to moderate intellectual disability or no intellectual disability).[104]

Social learning programmes aim to improve social interaction by applying behavioural therapy techniques within a social learning framework (e.g., by using video-modelling, peer feedback, and imitation). However, no method of social skills programme has robust evidence in terms of its effectiveness.[103][191]​​[192]​ Observational study evidence suggests that social skills groups may be effective at improving social interaction, but RCT evidence for their efficacy is currently lacking.[193][194]​ The Program for the Education and Enrichment of Relational Skills (PEERS) group model has been shown in one RCT to improve social skills in young adults with ASD.[195] One strategy is for people with ASD to meet up for social activities, thereby reducing isolation and empowering better social inclusion. A carer-assisted social skills intervention is another approach, with some evidence of efficacy.[196] In adults with ASD without intellectual disability (or with a mild to moderate intellectual disability) who are socially isolated, UK guidance recommends structured group leisure activities.[104]

There are also computer-based training packages, such as the Let's Face It! or Mind Reading, that aim to improve recognition of other people's facial expressions.[197][198] There is evidence of the effectiveness of the Let's Face It! skills battery in people with ASD.[199]

Behavioural and life skills interventions

For adults with ASD who need help with the general activities of daily living, UK guidelines recommend a structured, predictable training programme based on behavioural principles.[104] However, high-quality evidence on the effectiveness of this type of programme is lacking.[103]

Cognitive behavioural interventions

Cognitive behavioural therapy (CBT) may be beneficial for adults at risk of victimisation by teaching decision-making and problem-solving skills; however, evidence in favour of this approach is not specific to people with ASD.[104][200][201] In addition, CBT may not be suitable for some people with intellectual disability.

Management of challenging behaviour (all ages)

Routine assessment and care planning should ensure that a strategy is in place to assess for, mitigate, and manage the risk factors for challenging behaviour, which include (but are not limited to):[189][104]

  • Communication difficulties

  • Coexisting physical disorders

  • Pain

  • Mental health problems (e.g., mood or anxiety disorders)[32][103]

  • Changes to the person’s usual routine

  • Changes to the person's physical environment, such as lighting or noise levels

  • Mistreatment or abuse by others.

If the management of known triggers or underlying causes is ineffective, or if it is not possible to identify a trigger for the behaviour, the next step is a psychosocial intervention informed by a functional assessment of the child or adult’s behaviour.[104][189]​​​ In adults, physical aggression can occur in the context of any disruption of routine, during transition times, or when attempts are made to limit the pursuit of a particular interest. Social misunderstandings can also result in problematic behaviours; in these situations, clinicians should consider making a referral for assessment. Positive behavioural support is a person-centred framework for managing challenging behaviours in people with ASD, as well as other intellectual and developmental disabilities, and is becoming increasingly popular within the UK, Canada, and Australia. There is moderate-certainty evidence that it reduces aggressive behaviour in people with intellectual disabilities in the short term according to one Cochrane review, although there is less certainty about the evidence in the medium and long term, particularly in relation to other outcomes such as quality of life.[202] [ Cochrane Clinical Answers logo ]

A specialist (e.g., care provider organisation or health professional) carries out a thorough assessment of the behaviour(s), and formulates an overview of the causes. This guides the creation of a positive behaviour support plan, outlining key strategies for prevention and behavioural management approaches to attempt should challenging behaviours occur.

These strategies may include:[203]

  • Teaching new skills, such as communication skills

  • Modifying the environment or routine

  • Distraction from challenging behaviour

  • Positive reinforcement of more appropriate behaviours.

For adults with ASD without an intellectual disability, or with a mild to moderate intellectual disability, who have problems with anger and aggression, UK guidelines recommend offering an anger management intervention adjusted to the person’s individual needs.[104] In particular, ABA techniques may be used for any physical aggression or inappropriate sexualised behaviour occurring as the result of the ASD itself. ABA interventions aim to identify the antecedents, the exact characteristics of the behaviour, and the consequences of the behaviour; this is used to guide behaviour-modifying strategies. Social Stories™ are often written to facilitate adaptive patterns of behaviour, but their efficacy is not well established.[204][205] However, their ease of implementation justifies their continued use in clinical practice.

If behavioural approaches are ineffective in isolation, or not possible to deliver due to the severity of the behaviour, medication to manage symptoms may be required for some older children and adults, especially if symptoms are severe (e.g., aggression or self-injury).​[29][104][189]​ There is evidence of widespread prescribing of psychotropic medications for people with intellectual disability (including those with ASD) as a management strategy for challenging behaviour; in some regions this is off-label, although in the US, there is Food and Drug Administration approval for risperidone and aripiprazole for this indication.[206] This carries the potential for overuse; such treatment is commonly associated with adverse effects.[143] Pharmacological treatment for challenging behaviour should only be started by a specialist (e.g., paediatrician, neurologist, or psychiatrist) following careful consideration and management of any reversible underlying causes; particular care is required if the person with ASD is minimally verbal. Appropriate documentation is necessary before starting an antipsychotic to manage challenging behaviour. This should include a rationale for the drug (which should be explained to the person and everyone involved in their care), a plan for monitoring its use, how long it should be taken for, and how the treatment should be reviewed and stopped.[207] Periodic attempts to reduce the daily dosage and to discontinue use are recommended, to either confirm the need for continuing treatment, or to establish that treatment is no longer required.[103]

For children with ASD, the estimated pooled prevalence of adverse events due to antipsychotics is around 50%; this is frequently associated with discontinuation.[208] Prescription of antipsychotics for children and youths without psychosis is associated with increased mortality, underscoring the need for careful prescribing and monitoring.[209]

Risperidone may be considered for older children with very challenging behaviours that do not respond to the management of comorbidities and behavioural techniques. It is generally not used in young children. Risperidone was the first medication approved in the US for the symptomatic treatment of irritability (including challenging behaviours such as aggression, deliberate self-injury, and temper tantrums) in children and adolescents with ASD.[29] Two randomised controlled trials have found risperidone to be effective in terms of behaviour improvement when compared with placebo in children with ASD and challenging behaviour. Adverse effects (including weight gain and sedation) may outweigh benefits.[210][211] Clear goals are required to allow the evaluation of medication efficacy, and the patient's weight and blood pressure need monitoring.[212][213][214][215][216] In one randomised clinical trial, long-term treatment with risperidone was associated with a two- to fourfold increase in serum prolactin levels, compared with placebo. The long-term consequences of this are unclear.

Aripiprazole has approval in some countries for the symptomatic treatment of irritability in children and adolescents with ASD, based on the results of two randomised trials.[217] However, there is no evidence for the longer term use of this medication, and, as with risperidone, after a period of stabilisation the necessity for continuation should be re-evaluated.[217] Potential benefits of aripiprazole are weighed against the risk of side effects, which include sedation, fatigue, and increased appetite.[218] Given that there has been no increase in serum prolactin noted in studies of aripiprazole, it may be preferable to risperidone in cases where there are concerns about hyperprolactinaemia.[103]

Among adults, there is some evidence that risperidone is effective for the treatment of irritability and challenging behaviour.[215][219] In clinical practice, risperidone is generally used in conjunction with behavioural therapy. Aripiprazole may be considered as an alternative to risperidone, according to UK guidance.[103] Both olanzapine and quetiapine are also used in clinical practice, but prescribing is off-label and the evidence is less strong.[215] Previous studies have also shown the effectiveness of haloperidol for the same symptoms, although the adverse effects are marked and its use is not recommended first line.[220]

Any pharmacological treatment should be used cautiously, under specialist guidance, with careful monitoring for adverse effects.[103]

Management of coexisting conditions

While no medication is available to treat ASD's core difficulties, medication is sometimes used for both adults and children in the management of the symptomatic manifestations of ASD and its comorbidities.[29][103]​​[104][189]

In the first instance, when a person presents with a behavioural difficulty or with symptoms suggestive of a psychiatric disorder, clinicians should evaluate and manage any physical, psychosocial, and environmental triggers.[143] Non-pharmacological options are typically considered first.

Management of coexisting depression

Direct evidence on treatments for depression in children and adults with ASD is lacking; careful extrapolation is required from guidance on depression in the general population, with moderations made based on individual patient needs and characteristics.[29][103][221]

For children with ASD, first-line management of depression includes supportive therapy and CBT.[29][103]

Pharmacological treatment for depression in children with ASD should only be considered by a specialist.[222] Children with ASD may be at increased sensitivity to side effects of selective serotonin-reuptake inhibitors (SSRIs), and so slow and careful titration is recommended.[103][223]​​ One large, systematic review looking at safety of psychotropic medications in children and adolescents without ASD found that, of the six antidepressants studied, fluoxetine emerged as a relatively safe option in this age group.[224] SSRIs do not treat the core features of ASD, but may lessen anxiety or depression. One large, high-quality study found no evidence for the efficacy of citalopram in the treatment of repetitive behaviours.[223]

For adults, adopt a stratified approach to the treatment of depression, according to the severity of symptoms. Refer to the relevant local or national guidance on the management of depression in the general population, including consideration of psychosocial approaches to treatment. There is some evidence that CBT may reduce depressive symptoms in adults with ASD without intellectual disability, although in practice, CBT programmes for people with ASD often focus on anxiety or aggression, rather than depression alone.[225][226] Low-intensity psychological therapy (i.e., low intensity CBT with behavioural activation) and mindfulness-based therapies also show promise.[227][228] Social and vocational skills programmes may also reduce depressive symptoms in young people and adults with ASD, even though this is not the primary focus of these programmes.[229]

If required, SSRIs should be used with caution in people with ASD (in particular young adults) as there appears to be an increased risk of behavioural activation characterised by a cluster of symptoms that include increased activity level, impulsivity, insomnia, or disinhibition in the absence of mania.[230] Treatment should only be initiated under specialist guidance.

Management of coexisting anxiety

For children, extrapolation from general guidance on managing anxiety is recommended.[29] There is good evidence in favour of CBT for school-age children with ASD (without intellectual disability) who have comorbid anxiety.[231][232][233]​​ CBT delivered by non-clinicians within alternative settings (e.g., within schools) may also be effective, potentially widening access to CBT treatment programmes.[234][235] Some children with anxiety that is related to uncertainty may benefit from the introduction of routine or structure.[236] Virtual reality environment (VRE) interventions show promise for phobias in older children, and have entered routine clinical practice in some centres.[237] Other newer, non-pharmacological approaches to anxiety in children with ASD, such as neurofeedback and digitally delivered approaches to self-regulation, are currently under evaluation.[29]

Psychotropic medication may be considered by a specialist as part of the overall treatment plan for anxiety in children (e.g., if there is inadequate response to first-line treatment).[29] UK guidelines recommend considering a cautious trial of an SSRI for anxiety, followed by risperidone if there is poor response.[103] In practice, risperidone is typically only used for short-term symptomatic relief of anxiety, and only under specialist guidance. Benzodiazepines, such as lorazepam or diazepam, are sometimes used for the short-term management of anxiety in older children, in cases where other medications have been non-efficacious or poorly tolerated. These medications require careful specialist monitoring and should only be used for a very short period (typically less than 2-4 weeks). However, there are no data supporting their use. 

For adults, CBT can help with concurrent anxiety, although CBT may not be possible for some people with intellectual disability.[238][239][240][241]​ There is emerging evidence that anxiety may present differently in autism, when compared with people without ASD, and that it may warrant tailored interventions.[242] For specific subtypes of anxiety (e.g., phobias) VRE interventions show promise, and have entered routine clinical practice in some centres.[243]

If pharmacological therapy is required for adults, there is some evidence from small studies that SSRIs are associated with a modest improvement in symptoms in adults with ASD who have anxiety disorders. This improvement is predominantly limited to obsessive compulsive symptoms, and there is insufficient evidence to suggest efficacy in reducing autism-related anxiety (e.g., fear of uncertainty or change, or sensory overload).[143][219][244][245]​​​

Benzodiazepines, such as lorazepam or diazepam, are sometimes used for the short-term management of anxiety when other medications have been non-efficacious or poorly tolerated. These require careful specialist monitoring and should only be used for a very short period (typically less than 2-4 weeks). However, there are no data supporting their use.

Management of coexisting obsessive compulsive disorder (OCD)

For children, extrapolation from general guidance on managing OCD is recommended.[29] For children with comorbid OCD-related disorders, behavioural approaches such as CBT (including exposure and response prevention) are recommended first-line, although CBT may be less effective in young people with ASD, compared with those without ASD. Evidence of efficacy in children with intellectual disability is currently lacking, and CBT may not be suitable for some children with intellectual disability.[29][246][247]

If pharmacological treatment is required, there is preliminary RCT evidence that fluoxetine is effective in the short-term in reducing obsessive compulsive behaviours in children and adolescents with ASD. However, interpretation is limited due to methodological concerns.[248] Buspirone may be useful in the management of repetitive patterns of behaviour among younger children, as evidenced by the results from one RCT of children aged 2 to 6 years.[249]

For adults with ASD, CBT can help with concurrent obsessive OCD but its usefulness may be limited for some people with intellectual disability.[238][247]​​

Pharmacological therapy may be considered as part of an overall treatment plan for OCD in adults. SSRIs are associated with a modest improvement in adults with obsessive compulsive symptoms.[219][244][245]​​ In particular, the SSRIs fluoxetine and fluvoxamine may be helpful for repetitive behaviours, in conjunction with behavioural interventions such as CBT.[250][251]​ These medications must be started at very low doses and titrated slowly.[252] Dosing should be initiated under specialist guidance, and careful monitoring for worsening of anxiety symptoms is required. There is currently insufficient evidence to recommend risperidone in the treatment of OCD.

Management of sleep disturbance

For children with sleep disturbance, assess for any potential underlying reasons (e.g., restless leg syndrome, anxiety or other mood disorders, and underlying medical conditions, such as asthma, eczema, or GORD).[29] Ask about environmental factors (e.g., screen time before bed and the child’s bedtime routine) as this may also help guide behavioural approaches to sleep disturbance. Potential challenges to behavioural approaches to sleep disturbance include some core features of ASD, such as difficulty with emotional regulation (e.g., ability to calm self), difficulty transitioning from activities to sleep, and difficulties in communication which may affect a child’s understanding of parental sleep expectations.[253] However, in general, parent-implemented strategies, such as establishing a clear bedtime routine and ensuring that the child sleeps in their own bed, appear to be successful when consistently implemented.[254] The addition of visual schedules may be beneficial.[253] Tool kits covering behavioural approaches to sleep disturbance are available. Autism Speaks: sleep strategies for children with autism Opens in new window

For sleep-onset difficulties in children who are unresponsive to the management of underlying causes and behavioural interventions, melatonin is frequently prescribed.[255][256][257]​ Evidence (from five small studies) supports this use.[255] In one trial, melatonin was found to reduce sleep latency (falling asleep) but had less effect on the overall duration of sleep.[256] Nonetheless, many parents report that melatonin helps their child. It appears to be associated with minimal to no side effects in the short term, although a possible increase in the frequency of nightmares has been noted, possibly due to an increase in total REM sleep.[29][255]​​ There is RCT evidence that melatonin combined with CBT is superior to melatonin only, CBT only, and placebo in reducing symptoms of insomnia.[258] Therefore, melatonin, preferably combined with a behavioural intervention, appears to be a safe and effective option for sleep difficulties in children with ASD, although its long-term safety is currently unclear.[103][259]

For adults with ASD, after evaluating and addressing underlying causes, follow guidance on sleep disturbance in the general adult population. Generally, a behavioural intervention should be considered first in adults with ASD, although data on ASD-specific approaches are currently lacking.[260] For the general adult population, CBT for insomnia (CBT-i) is recommended first-line for chronic insomnia; face to face CBTi and computer-based CBTi (digital or dCBTi) appear to be equally effective.[261][262][263][264][265]

There is very limited evidence for the use of melatonin for adults with ASD.[266] Given that it appears to be a safe and effective treatment in children, it is worth considering an early trial of melatonin in adults with sleep disturbance. Otherwise, if pharmacological treatment is required, follow general guidance on managing sleep disorders in adults. Slow and cautious titration of pharmacotherapy is required due to a potential increased risk of adverse effects in people with ASD.[103] As for all adults with insomnia, prolonged treatment with benzodiazepines or related GABA-agonists is not recommended due to the risk of tolerance and side-effects.[103]

Management of coexisting attention deficit hyperactivity disorder (ADHD)

Within the classroom, strategies include educational modifications and careful use of language that is tailored to the child’s understanding. Other behavioural strategies include breaking down tasks into manageable units and taking regular breaks for activity.[29] Other behavioural approaches to ADHD in the general paediatric population include group parent training and/or individual psychological treatments; as a guide, exclusively non-pharmacological treatment for ASD is more likely to be appropriate in the first instance for younger children, and in those with milder symptoms.[267][268]

Pharmacological treatment for children with ASD and comorbid ADHD may be considered as part of the overall management plan, if problems persist in spite of behavioural management strategies.[29] Children with ASD may be at increased risk of adverse effects from pharmacological treatment; therefore, careful prescribing, slow titration, and regular monitoring is required.[269][270]

Methylphenidate may be used for ADHD that cannot be managed behaviourally, that interferes with learning potential, or that causes significant difficulties at home or school. However, the evidence in favour of its use in ASD is low in quality, and is based on short-term trials only.[271] It is less frequently effective in the treatment of children with ASD (approximately 30% respond) than in children with ADHD without ASD (approximately 70% to 80% respond).[269] The most commonly reported side effects in children with ASD include decreased appetite, sleeping difficulties, abdominal discomfort, social withdrawal, irritability, and emotional outbursts.[103] Weight and blood pressure monitoring is required.

Atomoxetine is a non-stimulant alternative to methylphenidate, and is recommended by a number of treatment guidelines as a second-line option for children with ASD and comorbid symptoms of ADHD.[29][103] Limited RCT evidence supports its use for this indication; it appears to be associated with an improvement in hyperactivity and possibly also inattention.[272][273][274] It appears to be more effective when combined with parent training.[275][276] It appears to be similarly effective to methylphenidate for children with ASD and symptoms of ADHD.[270] Adverse effects include nausea, fatigue, and sleeping difficulties.[273]

The alpha-adrenergic agonists clonidine and guanfacine are also recommended by treatment guidelines as alternative second-line options for children with ASD and comorbid ADHD symptoms, based on limited evidence.[29][103]​​ Reported side effects for clonidine include sedation, drowsiness, fatigue, and reduced activity.[277][278]​ Guanfacine appears to be similarly effective to clonidine (and to methylphenidate).[279] Side effects of guanfacine include drowsiness, irritability, reduced blood pressure, and bradycardia. Note that there are no data to support combining ADHD treatments. 

Other medications (e.g., atypical antipsychotics) are sometimes used within clinical practice to target hyperactivity, but there is limited evidence for this use, and they are not recommended within this topic.[29] For adults, cautious extrapolation from guidance on ADHD in the general adult population is recommended, taking into account the potential for an increased risk of adverse effects.[103] Adult ADHD treatment guidelines typically recommend pharmacological treatments as first-line, in part due to lack of evidence for the efficacy of non-pharmacologic treatments.[267][268] For adult ADHD in general, stimulant drugs are recommended first-line.[267][268] To date, there have been no RCTs on medications for ADHD in adults with ASD. There is some evidence for the efficacy of some agents, such as methylphenidate or atomoxetine, for the treatment of symptoms of ADHD in patients with ASD.[280][281][273]

Treatment should be considered on a case by case basis, and initiated under specialist guidance.

Management of eating and drinking difficulties

In children, problems may include:[29]

  • Food sensitivity based on colour, taste, smell, texture, or temperature

  • Rituals regarding presentation

  • Compulsive eating of certain foods, including non-food items (pica)

  • Behavioural refusal (e.g., holding food in the mouth, volitional gagging, emesis)

  • Delayed oral motor development in children with developmental delays.

Some behavioural problems involving eating may persist into adolescence.

The initial approach includes identification and management of underlying or contributing problems, such as:[29]

  • GORD (if present, referral to a gastroenterologist may be required)

  • Dental pain

  • Food allergies

  • Lactose intolerance

  • Constipation

  • Oral-motor difficulties (if present, referral for speech or occupational therapy assessment is required).

Offer advice on behavioural approaches to optimise mealtime structure and predictability, and to reduce distraction. Children with ASD may need to be offered new foods multiple times in order to become familiar with them. Consider whether children with selective diets require vitamin fortification (e.g., for poor vitamin D or calcium intake), taking into account the levels of food fortification in your country of practice. Dietician input may be beneficial.[29] Children with severe problems (e.g., severe vomiting, pica, or aversions) are likely to require referral to a speech or occupational therapist. 

Total communication approach

This refers to the use of a variety of communication methods to optimise a person’s ability to communicate with others. Some examples of alternative and augmentative communication methods, used with or without speech and non-verbal communication, are outlined here.

The Picture Exchange Communication System (PECS) is used alongside structured teaching methods to assist children to request and communicate their needs. PECS uses a behaviourally based programme to teach the child to exchange a picture card for something they like and want. Objects, pictures, or symbols may be used, according to the developmental level of the child.[282][283][284] Research has demonstrated some benefits of using PECS in children with ASD with little or no functional speech.[285] It provides a method of communication for children who are unable to communicate verbally, and there may be some positive effect on social communication and challenging behaviours.[286] It appears to have a neutral effect on spoken language development.[287]

Sign language (e.g., Makaton) is another alternative communication strategy, and there is emerging evidence in favour of speech-generating devices (e.g., smartphones with communication applications) in facilitating requesting communication among minimally verbal people with ASD, although the effect on spoken language is unknown.[288]

Multidisciplinary therapies

For children, options include speech-language therapy, occupational therapy, and physiotherapy. Speech-language therapy is the most commonly identified intervention in children with ASD.[289] Strategies include reinforcing sound repetition and word use, in a similar way to early speech development strategies.[290] A substantial minority (around 30% of children with ASD) will never acquire verbal speech.[291] Be aware that phrase speech may develop at least up until the age of 10 years, especially in children with preserved non-verbal communication and social interaction skills.[292] In older children and adolescents who are verbal, speech and language therapy may be beneficial. It can help with deficits in pragmatic language, which may negatively affect social interaction with peers and adults and in educational settings (e.g., literal interpretation of language and difficulty understanding the intent of others). 

Children with low muscle tone or developmental co-ordination disorder may benefit from physiotherapy and/or occupational therapy; it can assist them with gross motor impairment and fine motor and adaptive skills, such as self-care, toy use, and handwriting. In the US, around two thirds of pre-schoolers with ASD are reported to receive occupational therapy services.[293] Occupational therapists may offer sensory-based interventions to address symptoms, such as increased sensitivity to sound, which may be distressing for the child and related to repetitive or challenging behaviours.[294] Sensory-based therapies are commonly requested by caregivers, although evidence supporting their use is currently limited.[289][294][295][296] More rigorous research is needed into effective interventions for heterogeneous sensory symptoms.[297] Toe walking is common in children with ASD. Interventions for this, such as passive stretching, orthotics, and casting, may be required.[29]

For pre-school and school-age children, educational services play a key role assisting with, and using, behavioural interventions (e.g., for core features of ASD).

For adults, therapies include speech-language therapy, occupational therapy, and physiotherapy. Speech-language therapy may help with pragmatics of the give-and-take of normal conversation. Occupational therapy and physiotherapy will help for poor sensory integration and motor co-ordination. Sustained continuous therapy is more effective than episodic programming.[298]

Hormones, diet, lifestyle, or other alternative options

There is no robust evidence that lifestyle options (e.g., nutritional supplements) result in improved outcome or lessen core features of ASD.[29][158]​​ Some interventions pursued by people with ASD or their families (e.g., chelation, hyperbaric oxygen therapy, and sex-hormone inhibiting drugs) have substantial evidence of harm.[299] Systematic reviews have concluded that there is no evidence that single or multiple doses of intravenous secretin are effective for the treatment of ASD.[300][301]​ There is no evidence supporting exclusion diets.[302] Despite this; however, some parents are keen to pursue these. Parents and children should be supported in maintaining good nutrition and a healthy weight if exclusion diets are followed; dietician input may be helpful here.

Clinicians must be clear about the evidence (or lack thereof) for specific treatment approaches used by families, and must clearly advocate against any intervention that may be harmful.

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