Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

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preschool children ages 12 months to 5 years (or equivalent developmental age)

1st line – behavioral and parent-mediated intervention(s) for core features of ASD

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preschool children ages 12 months to 5 years (or equivalent developmental age)
1st line – 

behavioral and parent-mediated intervention(s) for core features of ASD

Interventions for the core features of ASD in children are often mediated or delivered by parents, using child-initiated teaching episodes or naturally occurring opportunities, and play to deliver learning. 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.[147]

Early interventions for ASD typically begin at (or before) preschool age, and may take place as early as 12 months. There is emerging evidence that early intervention is beneficial, and results in improved long-term cognition, language, and behavior, although the strength of evidence is limited due to methodologic concerns.[157][158][159][160] 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.[141]  However, longitudinal studies and data on long-term outcome following interventions are lacking, and no comparative studies between interventions have been reported. Little evidence exists about which interventions are best for particular groups. 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. 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.[161][162][150][163]

The following therapies are examples of early educational and behavioral interventions used with young 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 local protocols and guidelines. Below are some examples of commonly used interventions, listed in alphabetical order.

Social communication interventions

The Early Start Denver Model (ESDM), frequently used in the US, is based on developmental and applied behavioral analytic (ABA) 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 behaviors, although interpretation is limited by methodological weaknesses within some of the studies.[164][165][166] One multi-site randomized 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.[167]

The More Than Words (Hanen program) is 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.[168] 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 in communication at 9 months.[169] However, there is consensus opinion that it is likely to be of value in children with ASD.

High-intensity 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 behaviors or overactivity. The program reinforces positive behaviors and dissuades the child from engaging in negative behaviors (often repetitive interests). The program is initially taught on a one-to-one basis and is time-intensive (up to 40 hours per week) and expensive.[170] Research evidence is limited, with few RCTs.[171] One 2018 Cochrane review, looking at early, intensive behavioral interventions (based on ABA principles) in children under the age of 6, found weak evidence that this approach is an effective behavioral treatment for some children with ASD. The evidence was weak as it mostly came from small studies, only one of which was an RCT.[172] 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.[173][174] 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.[175] One criticism of ABA is that it does not generalize beyond the specific skills trained, limiting its usefulness as a standalone intervention.

Joint Attention, Symbolic Play, and Engagement Regulation (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 with joint attention and play skills across a number of studies.[148][176][177][178][179][180]

Learning Experiences and Alternative Program for Preschoolers and their Parents (LEAP) 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 preschoolers with ASD, but there is insufficient evidence to determine whether it provides benefits in other core ASD symptoms.[181][182] 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.

Preschool 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 behavior after 1 year, and also after 6 years following treatment.[149][153]

Interventions used to manage ritualistic and repetitive patterns of behavior are generally the same as those used to manage challenging behavior, such as positive behavioral support techniques (see ‘Interventions for challenging behavior’ below).

Plus – input from early educational services

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preschool children ages 12 months to 5 years (or equivalent developmental age)
Plus – 

input from early educational services

Treatment recommended for ALL patients in selected patient group

Nursery schools, preschools, and other early years educational establishments may assist with and use some of the behavioral interventions for core features of ASD described above.

Plus – family support and education

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preschool children ages 12 months to 5 years (or equivalent developmental age)
Plus – 

family support and education

Treatment recommended for ALL patients in selected patient group

Family members of children with ASD often benefit from forums where they can learn more about the disorder, its associated problems, and strategies to manage difficulties. Parent support groups exist for this purpose. In addition, local ASD-specific organizations often run workshops for parents/carers.

Autism organizations include:

Autism Society of America Opens in new window

Autism Speaks Opens in new window

National Autistic Society Opens in new window

In some cases, parental counseling may also be appropriate.

The family should be made aware of provisions they may be entitled to by law, such as an individualized educational plan or social care services. There may also be financial entitlements, such as disability tax credits.

Consider – multidisciplinary therapies

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preschool children ages 12 months to 5 years (or equivalent developmental age)
Consider – 

multidisciplinary therapies

Treatment recommended for SOME patients in selected patient group

Multidisciplinary therapies such as speech-language therapy, occupational therapy, and physical therapy may be required, tailored to the needs of the individual child.

Speech-language therapy is the most commonly identified intervention in children with ASD.[292] Strategies include reinforcing sound repetition and word use, in a similar way to early speech development strategies in typically developing children.[293] A substantial minority (around 30% of children with ASD) will never acquire verbal speech.[294]

In the US, around two thirds of preschoolers with ASD are reported to receive occupational therapy services.[296] 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 behaviors.[297] Sensory-based therapies are commonly requested by caregivers, although evidence supporting their use is currently limited.[292][297][298][299] More rigorous research is needed into effective interventions for heterogeneous sensory symptoms.[300] Toe walking is common in children with ASD. Interventions for this, such as passive stretching, orthotics, and casting, may be required.[29]  

Children with low muscle tone or developmental co-ordination disorder may benefit from physical therapy 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.[29]

Consider – total communication approach

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preschool children ages 12 months to 5 years (or equivalent developmental age)
Consider – 

total communication approach

Treatment recommended for SOME patients in selected patient group

The total communication approach refers to the use of a variety of communication methods to optimize a person’s ability to communicate with others.

Some examples of alternative and augmentative communication methods (used with or without speech and nonverbal 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 behaviorally based program 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.[285][285][286]​​​ Research has demonstrated some benefits of using PECS in children with ASD with little or no functional speech.[288] 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 behaviors.[289]​ It appears to have a neutral effect on spoken language development.[290]

Sign language (e.g., Makaton) is another alternative communication strategy, and there is emerging evidence in favor of speech-generating devices (e.g., smartphones with communication applications) in facilitating requesting communication among minimally verbal people with ASD, although the effects on spoken language is unknown.[291]​​

Consider – behavioral interventions for challenging behavior

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preschool children ages 12 months to 5 years (or equivalent developmental age)
Consider – 

behavioral interventions for challenging behavior

Treatment recommended for SOME patients in selected patient group

Routine assessment and care planning should ensure that a strategy is in place to assess for, mitigate, and manage the risk factors for challenging behavior, including communication difficulties, coexisting physical disorders, pain, mental health problems (e.g., mood or anxiety disorders), changes to the child's usual routine, changes to the child's physical environment (e.g., lighting or noise levels), or mistreatment or abuse by others.[192]

If the management of known triggers or underlying causes is ineffective, or if it is not possible to identify a trigger for the behavior, the next step is a psychosocial intervention informed by a functional assessment of the child’s behavior.[192] Positive behavioral support is a person-centered framework for managing challenging behaviors in people with ASD and 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 behavior 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.[205] [ Cochrane Clinical Answers logo ] ​​ A specialist (e.g., care provider organisation or health professional) carries out a thorough assessment of the behavior(s), and formulates an overview of the causes. This guides the creation of a positive behavior support plan, outlining key strategies for prevention and behavioral management approaches to attempt should challenging behaviors occur (e.g., teaching new skills, such as communication skills, modifying the environment or routine, distraction from challenging behavior, or positive reinforcement of more appropriate behaviors).

Although medication (e.g., an antipsychotic) is sometimes used in older children for the management of very challenging behavior not responsive to behavioral management, it is not typically used in this age group.

Consider – behavioral intervention for coexisting emotional and behavioral problems

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preschool children ages 12 months to 5 years (or equivalent developmental age)
Consider – 

behavioral intervention for coexisting emotional and behavioral problems

Treatment recommended for SOME patients in selected patient group

Children under 5 years may sometimes manifest symptoms suggestive of a comorbid psychiatric condition. However, in practice, children in this age group are much less likely to receive a formal psychiatric diagnosis given that suggestive features, such as fears and tantrums, can be considered to be part of typical early child development. When emotional and behavioral problems in young children are severe enough to warrant intervention, behavioral and family focused approaches are typically favored, and medication is much less likely to be recommended.

Clinical practice may vary internationally, and clinicians should consult relevant local and national guidance for specific approaches.

Consider – management of coexisting ADHD

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preschool children ages 12 months to 5 years (or equivalent developmental age)
Consider – 

management of coexisting ADHD

Treatment recommended for SOME patients in selected patient group

Some children under 5 years may meet diagnostic criteria for ADHD. For all children under 5 with ADHD, UK guidance recommends offering nonpharmacologic management first-line (e.g., ADHD-focused group parent training plus environmental modifications). If after this ADHD symptoms are still causing a significant impairment across different settings, seeking specialist advice (ideally from a tertiary service) is recommended.[271]

Consider – management of eating and drinking difficulties

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preschool children ages 12 months to 5 years (or equivalent developmental age)
Consider – 

management of eating and drinking difficulties

Treatment recommended for SOME patients in selected patient group

For preschool children with ASD who are experiencing eating and drinking difficulties, the initial approach includes identification and management of underlying or contributing problems, such as GERD (if present, referral to a gastroenterologist may be required), dental pain, food allergies, lactose intolerance, constipation, or oral-motor difficulties (if present, referral for speech or occupational therapy assessment is required).[29]

Offer advice on behavioral approaches to optimize 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. Dietitian input may be beneficial here.[29]

Children with severe problems (e.g., severe vomiting, pica, or aversions) are likely to require referral to a speech or occupational therapist.

Consider – management of sleep disturbance

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preschool children ages 12 months to 5 years (or equivalent developmental age)
Consider – 

management of sleep disturbance

Treatment recommended for SOME patients in selected patient group

For young children with sleep disturbance, assess for any potential underlying reasons (e.g., restless leg syndrome, fears/anxieties associated with bedtime and sleep, and any underlying medical conditions, such as asthma, eczema, or GERD).[29] Ask about environmental factors (e.g., screen time before bed and the child’s bedtime routine) as this may also help guide behavioral approaches to sleep disturbance. Potential challenges to behavioral 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.[256] 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.[257] The addition of visual schedules may be beneficial.[256] Tool kits covering behavioral 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 behavioral interventions, melatonin is sometimes prescribed by a specialist.[258][259][260]​ Evidence (from five small studies) supports this use.[258] In one trial, melatonin was found to reduce sleep latency (falling asleep) but had less effect on the overall duration of sleep.[259] 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][258]​​ Melatonin, preferably combined with a behavioral 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][262]​ 

Dosing should be initiated under specialist guidance and careful monitoring is required in this age group.

Primary options

melatonin: consult specialist for guidance on dose

school-age children ages 5 to 18 years (or equivalent developmental age)

1st line – behavioral and parent-mediated intervention(s) for core symptoms of ASD

Back
ONGOING
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school-age children ages 5 to 18 years (or equivalent developmental age)
1st line – 

behavioral and parent-mediated intervention(s) for core symptoms of ASD

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. 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.[147]

The following therapies are examples of behavioral and parent-mediated interventions used for the core symptoms of ASD. Longitudinal studies and data on long-term outcome following interventions are lacking, and no comparative studies between interventions have been reported. Little evidence exists about which interventions are best for particular groups. In practice, a combination of approaches may be used. Practice varies widely according to region and country, and clinicians will need to refer to local protocols and guidelines. Below are some examples of commonly used interventions, listed in alphabetical order.

Social communication interventions

The Children’s Friendship Training program (CFT) 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.[183][184] CFT is associated with modest gains in social play skills.[185] 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 program has been adapted for adolescents, with some positive results.[186]

Peer-mediated interventions are varied, and 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.[187] However, more research is required on the effectiveness of social communication interventions in children with ASD who are not high-functioning.[188]

High-intensity applied behavioral analysis (ABA) often begins in preschool age children (see above) but programs may continue for older children.

Treatment and Education of Autistic- and Communications-related Handicapped Children (TEACCH) is a structured, developmental teaching program that 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.[189] 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.[190] 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.[191]

Interventions used to manage ritualistic and repetitive patterns of behavior are generally the same as those used to manage challenging behavior, such as positive behavioral support techniques (see ‘Interventions for challenging behavior’ below).

Plus – input from educational services

Back
ONGOING
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school-age children ages 5 to 18 years (or equivalent developmental age)
Plus – 

input from educational services

Treatment recommended for ALL patients in selected patient group

Schools may assist with and use some of the behavioral interventions for the core features of ASD described above.

Plus – family support and education

Back
ONGOING
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school-age children ages 5 to 18 years (or equivalent developmental age)
Plus – 

family support and education

Treatment recommended for ALL patients in selected patient group

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 support groups exist for this purpose. In addition, local ASD-specific organizations often run workshops for parents/carers.

Autism organizations include:

Autism Society of America Opens in new window

Autism Speaks Opens in new window

National Autistic Society Opens in new window

In some cases, parental counseling may also be appropriate.

The family should be made aware of provisions they may be entitled to by law, such as an individualized educational plan or social care services. There may also be financial entitlements, such as disability tax credits.

Consider – multidisciplinary therapies

Back
ONGOING
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school-age children ages 5 to 18 years (or equivalent developmental age)
Consider – 

multidisciplinary therapies

Treatment recommended for SOME patients in selected patient group

Multidisciplinary therapies, such as speech-language therapy, occupational therapy, and physical therapy, may be required, as tailored to the needs of the individual child.

Speech-language therapy is the most commonly identified intervention in children with ASD.[292] Strategies include reinforcing sound repetition and word use, in a similar way to early speech development strategies.[293] A substantial minority (around 30% of children with ASD) will never acquire verbal speech.[294] Be aware that phrase speech may develop at least up until the age of 10 years, especially in children with preserved nonverbal communication and social interaction skills.[295] In older children and adolescents who are verbal, speech and language therapy may be beneficial to 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).  

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 behaviors.[297] Sensory-based therapies are commonly requested by caregivers, although evidence supporting their use is currently limited.[292][297][298][299]

Children with low muscle tone or developmental co-ordination disorder may benefit from physical therapy 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.

Consider – total communication approach

Back
ONGOING
|
school-age children ages 5 to 18 years (or equivalent developmental age)
Consider – 

total communication approach

Treatment recommended for SOME patients in selected patient group

The total communication approach refers to the use of a variety of communication methods to optimize a person’s ability to communicate with others.

Some examples of alternative and augmentative communication methods (used with or without speech and nonverbal 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 behaviorally based program 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.[285][286][287] Research has demonstrated some benefits of using PECS in children with ASD with little or no functional speech.[288] 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 behaviors.[289] It appears to have a neutral effect on spoken language development.[290]

Sign language (e.g., Makaton) is another alternative communication strategy, and there is emerging evidence in favor of speech-generating devices (e.g., smartphones with communication applications) in facilitating requesting communication among minimally verbal people with ASD, although the effects on spoken language is unknown.[291]

Consider – interventions for challenging behavior

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ONGOING
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school-age children ages 5 to 18 years (or equivalent developmental age)
Consider – 

interventions for challenging behavior

Treatment recommended for SOME patients in selected patient group

Routine assessment and care planning should ensure that a strategy is in place to assess for, mitigate, and manage the risk factors for challenging behavior, which include communication difficulties, coexisting physical disorders, pain, mental health problems (e.g., mood or anxiety disorders), changes to the person’s usual routine, changes to the person's physical environment (e.g., lighting or noise levels), or mistreatment or abuse by others.[192]  

If the management of known triggers or underlying causes is ineffective, or if it is not possible to identify a trigger for the behavior, the next step is a psychosocial intervention informed by a functional assessment of the child’s behavior.[192] Positive behavioral support is a person-centered framework for managing challenging behaviors in people with ASD and other intellectual and developmental disabilities. There is moderate-certainty evidence that it reduces aggressive behavior 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.[205] [ Cochrane Clinical Answers logo ] ​​ A specialist (e.g., care provider organisation or health professional) carries out a thorough assessment of the behavior(s), and formulates an overview of the causes. This guides the creation of a positive behavior support plan, outlining key strategies for prevention and behavioral management approaches to attempt should challenging behaviors occur (e.g., teaching new skills, such as communication skills, modifying the environment or routine, distraction from challenging behavior, or positive reinforcement of more appropriate behaviors).

If behavioral approaches are ineffective in isolation, or not possible to deliver due to the severity of the behavior, 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][192]​ 

Pharmacologic treatment for challenging behavior is associated with adverse effects, including an increased risk of mortality.[211][212] It should only be started by a specialist (e.g., pediatrician, neurologist, or child or adolescent psychiatrist), following careful consideration and management of any reversible underlying causes; particular care is required if the child with ASD is minimally verbal. Appropriate documentation is necessary before starting an antipsychotic to manage challenging behavior. This documentation should include the rationale for the drug (which should be explained to the child [if feasible] and everyone else 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.[210] 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]

Risperidone may be considered for older children with very challenging behaviors that do not respond to the management of comorbidities and behavioral 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 behaviors such as aggression, deliberate self-injury, and temper tantrums) in children and adolescents with ASD.[29] Two randomized controlled trials have found risperidone to be effective in terms of behavior improvement when compared with placebo in children with ASD and challenging behavior. Adverse effects (including weight gain and sedation) may outweigh benefits.[213][214] Clear goals are required to allow the evaluation of medication efficacy, and the patient's weight and blood pressure need monitoring.[215][216][217][218][219] In one randomized 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 (including the US) for the symptomatic treatment of irritability in children and adolescents with ASD, based on the results of two randomized trials.[220] However, there is no evidence for the longer term use of this medication, and, as with risperidone, after a period of stabilization the necessity for continuation should be re-evaluated.[220] Potential benefits of aripiprazole are weighed against the risk of side effects, which include sedation, fatigue, and increased appetite.[221] 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 hyperprolactinemia.[103] 

Primary options

risperidone: consult specialist for guidance on dose

OR

aripiprazole: consult specialist for guidance on dose

Consider – management of coexisting depression

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school-age children ages 5 to 18 years (or equivalent developmental age)
Consider – 

management of coexisting depression

Treatment recommended for SOME patients in selected patient group

Direct evidence on treatments for depression in children 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]

For children with ASD, first-line management of depression includes supportive therapy and cognitive behavioral therapy (CBT), although in practice, CBT may be difficult or impossible to carry out in some children with intellectual disability.[29][103]

Pharmacologic treatment for depression in children with ASD should only be considered by a specialist.[225] 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.[226][103] One large, systematic review looking at safety of psychotropic medications in children and adolescents without ASD found that fluoxetine emerged as a relatively safe option in this age group.[227] SSRIs should be used with caution in youths with ASD, as there appears to be an increased risk of behavioral activation (characterized by a cluster of symptoms that include increased activity level, impulsivity, insomnia, or disinhibition in the absence of mania).[233]

Children with ASD should only be prescribed psychotropic medication if clinically indicated, and require regular and timely monitoring and review (including for effectiveness and for adverse effects). Treatment should be 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 a learning disability, autism, or both. NHS England: STOMP and STAMP Opens in new window

Primary options

fluoxetine: consult specialist for guidance on dose

Consider – management of coexisting anxiety

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school-age children ages 5 to 18 years (or equivalent developmental age)
Consider – 

management of coexisting anxiety

Treatment recommended for SOME patients in selected patient group

Extrapolation from general pediatric guidance on managing anxiety is recommended.[29]

There is good evidence in favor of CBT for school-age children with ASD without intellectual disability who have comorbid anxiety.[234][235][236]​​ CBT delivered by nonclinicians within alternative settings (e.g., within schools) may also be effective, potentially widening access to CBT treatment programs.[237][238] Some children with anxiety related to uncertainty may benefit from the introduction of routine or structure.[239] Virtual reality environment (VRE) interventions show promise for phobias in older children, and have entered routine clinical practice in some centers.[240] Other newer, nonpharmacologic 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 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.

For older children with anxiety, benzodiazepines, such as lorazepam or diazepam, are also sometimes used for the short-term management of anxiety when other medications have been nonefficacious 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.

Children with ASD should only be prescribed psychotropic medication if clinically indicated, and require regular and timely monitoring and review (including for effectiveness and for adverse effects). Treatment should be 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 a learning disability, autism, or both. NHS England: STOMP and STAMP Opens in new window

Primary options

fluoxetine: consult specialist for guidance on dose

OR

sertraline: consult specialist for guidance on dose

Secondary options

risperidone: consult specialist for guidance on dose

Tertiary options

lorazepam: consult specialist for guidance on dose

OR

diazepam: consult specialist for guidance on dose

Consider – management of coexisting OCD

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school-age children ages 5 to 18 years (or equivalent developmental age)
Consider – 

management of coexisting OCD

Treatment recommended for SOME patients in selected patient group

For children with comorbid OCD-related disorders, behavioral 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 be difficult or not possible to carry out in some children with intellectual disability.[29][249][250]​​

If pharmacologic treatment is required, there is preliminary RCT evidence that fluoxetine is effective in the short-term in reducing obsessive compulsive behaviors in children and adolescents with ASD, although interpretation is limited due to methodological concerns.[251] Buspirone may be useful in the management of repetitive patterns of behavior among younger children, as evidenced by the results from one randomized controlled trial of children ages 2 to 6 years.[252] 

Children with ASD should only be prescribed psychotropic medication if clinically indicated, and require regular and timely monitoring and review (including for effectiveness and for adverse effects). Treatment should be 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 a learning disability, autism, or both. NHS England: STOMP and STAMP Opens in new window

Primary options

fluoxetine: consult specialist for guidance on dose

Secondary options

sertraline: consult specialist for guidance on dose

Tertiary options

buspirone: consult specialist for guidance on dose

Consider – management of coexisting ADHD

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ONGOING
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school-age children ages 5 to 18 years (or equivalent developmental age)
Consider – 

management of coexisting ADHD

Treatment recommended for SOME patients in selected patient group

Behavioral strategies in the classroom include educational, language modifications, breaking down tasks into manageable units, and taking regular breaks for activity.[29] Other behavioral approaches to ADHD in the general pediatric population include group parent training and/or individual psychological treatments; as a guide, exclusively nonpharmacologic treatment for ASD is more likely to be appropriate in the first instance for younger children, and in those with milder symptoms.[270][271] 

Pharmacologic treatment may be considered by a specialist as part of the overall management plan, if problems persist in spite of behavioral management strategies.[29] Note that children with ASD may be at increased risk of adverse effects from pharmacologic treatment; careful prescribing, slow titration, and regular monitoring is required.[272][273] 

Methylphenidate may be used for ADHD that cannot be managed behaviorally, that interferes with learning potential, or that causes significant difficulties at home or school. However, the evidence in favor of its use in ASD is low in quality, and is based on short-term trials only.[274] 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).[272] 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 nonstimulant 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.[275][276][277] It appears to be more effective when combined with parent training.[278][279] It appears to be similarly effective to methylphenidate for children with ASD and symptoms of ADHD.[273] Adverse effects include nausea, fatigue, and sleeping difficulties.[276] 

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.[280][281]​ Guanfacine appears to be similarly effective to clonidine (and to methylphenidate).[282] Side effects of guanfacine include drowsiness, irritability, reduced blood pressure, and bradycardia. Note that there are no data to support combining ADHD treatments. 

Children with ASD should only be prescribed psychotropic medication if clinically indicated, and require regular and timely monitoring and review (including for effectiveness and for adverse effects). Treatment should be 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 a learning disability, autism, or both. NHS England: STOMP and STAMP Opens in new window

Primary options

methylphenidate: consult specialist for guidance on dose

Secondary options

atomoxetine: consult specialist for guidance on dose

OR

clonidine: consult specialist for guidance on dose

OR

guanfacine: consult specialist for guidance on dose

Consider – management of eating and drinking difficulties

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school-age children ages 5 to 18 years (or equivalent developmental age)
Consider – 

management of eating and drinking difficulties

Treatment recommended for SOME patients in selected patient group

The initial approach includes identification and management of underlying or contributing problems, such as GERD (if present, referral to a gastroenterologist may be required), dental pain, food allergies, lactose intolerance, constipation, or oral-motor difficulties (if present, referral for speech or occupational therapy assessment is required).[29]

Offer advice on behavioral approaches to optimize mealtime structure and predictability, and 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. Dietitian 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. 

Consider – management of sleep disturbance

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school-age children ages 5 to 18 years (or equivalent developmental age)
Consider – 

management of sleep disturbance

Treatment recommended for SOME patients in selected patient group

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 GERD).[29] Ask about environmental factors (e.g., screen time before bed and the child’s bedtime routine) as this may also help guide behavioral approaches to sleep disturbance. Potential challenges to behavioral 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.[256] 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.[257] The addition of visual schedules may be beneficial.[256] Tool kits covering behavioral 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 behavioral interventions, melatonin is frequently prescribed.[258][259][260]​ Evidence (from five small studies) supports this use.[258] In one trial, melatonin was found to reduce sleep latency (falling asleep) but had less effect on the overall duration of sleep.[259] 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][258]​​ Melatonin, preferably combined with a behavioral 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][262]​ 

Dosing should be initiated under specialist guidance.

Primary options

melatonin: consult specialist for guidance on dose

adults

1st line – non-pharmacologic treatment for core symptoms of ASD

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adults
1st line – 

non-pharmacologic treatment for core symptoms of ASD

Some people with ASD are able to function successfully without treatment, whereas others require intermittent or lifelong support and care. Management approaches are individualized and aim to optimize 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).

Postdiagnostic support: a number of charities offer support to adults newly diagnosed with ASD, including organized social groups and activities, which may be online or face to face. Autism Society of America Opens in new window Adults with ASD may also require an assessment of their support requirements.

Transition to adulthood: care of young people moving from pediatric to adult services requires careful planning to ensure a smooth transition.[104][192]  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.[192]

Employment support: among transition-age adolescents and young adults, vocational support or support during continuing education may be beneficial (e.g., an individual supported employment program); such programs can improve employment and job retention.[104][193] For older adults, support in the community through involvement in social or other groups, or through mentoring in jobs, may be valuable.

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

Social learning programs aim to improve social interaction by applying behavioral therapy techniques within a social learning framework, using video-modeling, peer feedback, and imitation. However, no method of social skills program has robust evidence in terms of its effectiveness.[103][194]​​[195]​ Observational study evidence suggests that social skills groups may be effective at improving social interaction, but RCT evidence for their efficacy is currently lacking.[196][197]​ 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.[198] 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.[199] 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 programs, that aim to improve recognition of other people's facial expressions.[200][201]​ There is evidence of the effectiveness of the Let's Face It! package in people with ASD.[202]

Behavioral 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 program based on behavioral principles.[104] However, high-quality evidence on the effectiveness of this type of program is lacking.[103]

Cognitive behavioral interventions: cognitive behavioral therapy (CBT) may be beneficial for adults at risk of victimization by teaching decision-making and problem-solving skills; however, evidence in favor of this approach is not specific to people with ASD.[104][203][204] In addition, CBT may not be suitable for some people with intellectual disability.

Plus – family support and education

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adults
Plus – 

family support and education

Treatment recommended for ALL patients in selected patient group

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 organizations often run workshops for parents/caregivers.

Autism organizations include:

Autism Society of America Opens in new window

Autism Speaks Opens in new window

National Autistic Society Opens in new window

In some cases, parental counseling may be appropriate.

The family should be aware of provisions they may be entitled to by law, such as an individualized educational plan or social care services. There may also be financial entitlements such as disability tax credits.

Adults with ASD may require help regarding vocational options and independent living provision. A variety of vocational treatment approaches exist; however, studies looking at their efficacy are generally of poor quality.[307]

Consider – multidisciplinary therapies

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adults
Consider – 

multidisciplinary therapies

Treatment recommended for SOME patients in selected patient group

For adults, therapies include speech-language therapy, occupational therapy, and physical therapy. Speech-language therapy may help with pragmatics of the give-and-take of normal conversation. Occupational therapy and physical therapy will help for poor sensory integration and motor co-ordination. Sustained continuous therapy is more effective than episodic programing.[301]

Consider – total communication approach

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adults
Consider – 

total communication approach

Treatment recommended for SOME patients in selected patient group

The total communication approach 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 nonverbal communication, are outlined here.

The Picture Exchange Communication System (PECS) is used alongside structured teaching methods to assist the person to request and communicate their needs. Although more frequently used for children, it may also be used for adults with communication difficulties or intellectual disability. PECS uses a behaviorally based program to teach the people to exchange a picture card for something they like and want. Objects, pictures, or symbols may be used, according to the person's developmental level.[287][285][286]​​​​​​​​​​​​ It provides a method of communication for people who are unable to communicate verbally, and there may be some positive effect on social communication and challenging behaviors.[289]​​​ 

Sign language (e.g., Makaton) is another alternative communication strategy, and there is emerging evidence in favor of speech-generating devices (e.g., smartphones with communication applications) in facilitating requesting communication among minimally verbal people with ASD.[291]​​​

Consider – management of challenging behavior

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adults
Consider – 

management of challenging behavior

Treatment recommended for SOME patients in selected patient group

Routine assessment and care planning should ensure that a strategy is in place to assess for, mitigate, and manage the risk factors for challenging behavior, which include communication difficulties, coexisting physical disorders, pain, mental health problems (e.g., mood or anxiety disorders), changes to the person’s usual routine, changes to the person's physical environment (e.g., lighting or noise levels), or mistreatment or abuse by others.[192]  

If the management of known triggers or underlying causes is ineffective, or if it is not possible to identify a trigger for the behavior, the next step is a psychosocial intervention informed by a functional assessment of the child’s behavior.[192] 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 behaviors; in these situations, clinicians should consider making a referral for assessment.

Positive behavioral support is a person-centered framework for managing challenging behaviors in people with ASD and other intellectual and developmental disabilities. There is moderate-certainty evidence that it reduces aggressive behavior 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.[205] [ Cochrane Clinical Answers logo ] ​​ A specialist (e.g., care provider organisation or health professional) carries out a thorough assessment of the behavior(s), and formulates an overview of the causes. This guides the creation of a positive behavior support plan, outlining key strategies for prevention and behavioral management approaches to attempt should challenging behaviors occur (e.g., teaching new skills, such as communication skills, modifying the environment or routine, distraction from challenging behavior, or positive reinforcement of more appropriate behaviors).

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, applied behavioral analysis (ABA) techniques may be used for any physical aggression or inappropriate sexualized behavior occurring as the result of the ASD itself. ABA interventions aim to identify the antecedents, the exact characteristics of the behavior, and the consequences of the behavior; this is used to guide behavior-modifying strategies. Social Stories™ are often written to facilitate adaptive patterns of behavior, but their efficacy is not well established.[207][208] However, their ease of implementation justifies their continued use in clinical practice.

If behavioral approaches are ineffective in isolation, or not possible to deliver due to the severity of the behavior, medication to manage symptoms may be required, especially if symptoms are severe (e.g., aggression or self-injury).​[29][104][192]

Pharmacologic treatment is associated with a risk of adverse effects, and should only be started by a specialist (e.g., a psychiatrist, neurologist, or learning disabilities specialist), 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 treatment, including a rationale for the drug (which should be explained to the person and everyone involved in their care), a plan for monitoring and for how long the drug should be taken, and for how the treatment should be reviewed and stopped.[210] 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]

Among adults there is some evidence that risperidone is effective for the treatment of irritability and challenging behavior.[218][222]​​​ In clinical practice, risperidone is generally used in conjunction with behavioral 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.[218] 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.[218]

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

Primary options

risperidone: consult specialist for guidance on dose

OR

aripiprazole: consult specialist for guidance on dose

Secondary options

olanzapine: consult specialist for guidance on dose

OR

quetiapine: consult specialist for guidance on dose

Tertiary options

haloperidol: consult specialist for guidance on dose

Consider – management of coexisting depression

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adults
Consider – 

management of coexisting depression

Treatment recommended for SOME patients in selected patient group

Direct evidence on treatments for depression in 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.[103][224]

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. There is some evidence that cognitive behavioral therapy (CBT) may reduce depressive symptoms in adults with ASD, although in practice, CBT programs for people with ASD often focus on anxiety or aggression, rather than depression alone.[228][229] Low-intensity psychological therapy (i.e., low intensity CBT with behavioral activation) and mindfulness-based therapies also show promise.[230][231] Social and vocational skills programs may also reduce depressive symptoms in young people and adults with ASD, even though this is not their primary focus.[232]

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 behavioral activation characterized by a cluster of symptoms that include increased activity level, impulsivity, insomnia, or disinhibition in the absence of mania.[233]

Dosing should only be initiated under specialist guidance.

Primary options

fluoxetine: consult specialist for guidance on dose

OR

sertraline: consult specialist for guidance on dose

Consider – management of coexisting anxiety

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adults
Consider – 

management of coexisting anxiety

Treatment recommended for SOME patients in selected patient group

For adults, cognitive behavioral therapy (CBT) can help with concurrent anxiety.[241][242][243][244] There is emerging evidence that anxiety may present differently in autism, when compared with people without ASD, and that it may warrant tailored interventions.[245] For specific subtypes of anxiety (e.g., phobias) virtual reality environment interventions show promise, and have entered routine clinical practice in some centers.[246] 

Pharmacologic therapy may be considered as part of an overall treatment plan. There is some evidence from small studies that SSRIs are associated with a modest improvement in symptoms in adults with ASD with 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).[146][222][247][248]​​​

For both adults and older children with anxiety, benzodiazepines such as lorazepam or diazepam are sometimes used for the short-term management of anxiety when other medications have been nonefficacious or poorly tolerated. These require careful specialist monitoring and should only be used for a very short period (typically less than 2-4 weeks). There is no data supporting their use however.

Primary options

fluoxetine: consult specialist for guidance on dose

OR

sertraline: consult specialist for guidance on dose

OR

fluvoxamine: consult specialist for guidance on dose

Secondary options

lorazepam: consult specialist for guidance on dose

OR

diazepam: consult specialist for guidance on dose

Consider – management of coexisting OCD

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adults
Consider – 

management of coexisting OCD

Treatment recommended for SOME patients in selected patient group

For adults with ASD, cognitive behavioral therapy (CBT) can help with concurrent obsessive OCD, although it may not be possible to carry out CBT for some people with intellectual disability.[241][250]

Pharmacologic 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.[222][247][248]​​ The SSRIs fluoxetine and fluvoxamine may be helpful for repetitive behaviors, in conjunction with behavioral interventions such as CBT.[253][254]​ These medications must be started at very low doses and titrated slowly.[255] 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.

Primary options

fluoxetine: consult specialist for guidance on dose

OR

fluvoxamine: consult specialist for guidance on dose

Consider – management of coexisting ADHD

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adults
Consider – 

management of coexisting ADHD

Treatment recommended for SOME patients in selected patient group

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 pharmacologic treatments as first-line, in part due to lack of evidence for the efficacy of nonpharmacologic treatments.[270][271] For adult ADHD in general, stimulant drugs are recommended first-line.[270][271] 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.[283][284][276] 

Given the relative absence of data, treatment should be considered on a case by case basis, and dosing initiated under specialist guidance.

Consider – management of sleep disturbance

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adults
Consider – 

management of sleep disturbance

Treatment recommended for SOME patients in selected patient group

Evaluate and address underlying causes; if sleep disturbance persists after this, follow guidance on sleep disturbance in the general adult population. Generally, a behavioral intervention should be considered first in adults with ASD, although data on ASD-specific approaches are currently lacking.[263] 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.[264][265][266][267][268]

There is very limited evidence for the use of melatonin for adults with ASD.[269] 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 pharmacologic 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]

Dosing should be initiated under specialist guidance.

Primary options

melatonin: consult specialist for guidance on dose

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