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 Table of Contents  
REVIEW ARTICLE
Year : 2017  |  Volume : 15  |  Issue : 1  |  Page : 17-27

Management of autism spectrum disorder: A case-based overview


Department of Developmental Pediatrics, Developmental Paediatrics Unit, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication17-Feb-2017

Correspondence Address:
Beena Koshy
Department of Developmental Pediatrics, Developmental Paediatrics Unit, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-4651.200302

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  Abstract 

The management of autism spectrum disorder requires a multidisciplinary team (MDT) comprising parents, therapists, psychologists, special educators, and medical specialists. Therapy is aimed at helping the child acquire functional skills in daily living, to minimize the core features of autism, and eliminate behaviors that are unhelpful or disruptive. The child must be adequately assessed by every member of the MDT to formulate an intervention plan which is then brought together to tailor a specific treatment plan for each child. The involvement of the parents or caretakers in the entire process is critical. The plan should address multiple areas such as communication, social skills, behavior, daily living, motor skills, and learning early and intensive treatment has been shown to be much more effective than treatment that is delayed. The child's progress should be monitored and documented, and only then can the intervention model's effectiveness be gauged.

Keywords: Autism, autism evaluation, autism management, multi-disciplinary team


How to cite this article:
Oommen SP, Bhattacharyya S, Koshy B, Roshan R, Samuel L, Preethi R. Management of autism spectrum disorder: A case-based overview. Curr Med Issues 2017;15:17-27

How to cite this URL:
Oommen SP, Bhattacharyya S, Koshy B, Roshan R, Samuel L, Preethi R. Management of autism spectrum disorder: A case-based overview. Curr Med Issues [serial online] 2017 [cited 2019 Mar 19];15:17-27. Available from: http://www.cmijournal.org/text.asp?2017/15/1/17/200302

Case scenario

Rehan (not real name), a 2½-year-old boy, was brought to the unit by his parents. His mother's antenatal period, his birth, and the postnatal period were unremarkable. The parents were both professionals who were at work throughout the day, and Rehan has spent most of the time with the live-in maid. Since early infancy, he had been exposed to the television and thereafter to mobile phones and spent almost all his waking hours watching cartoons. The parents tried to play with him when they got back home in the evening, but he preferred playing with the mobile phone.

During the previous year, his parents had noticed that Rehan was different from other children. Although his motor development was normal, he still had not started speaking or communicating. He seemed quite happy to be left alone and preferred to watch his cartoons or play with cars. He would not respond when called, but would immediately respond, by running to them when the parents asked him if wanted “chocolates or chips.” He primarily used proximity to communicate his needs and often took his mother to what he wanted and waited, or he used her hand as a tool and put her hand on the object he wanted. His parents also noticed he spoke to himself while playing and used words which were apparently meaningless. But whenever they tried to communicate with him, he would turn his face away. They were also concerned about his hyperactivity. His parents described him as being in his “own little world.” He had difficulties in tolerating crowds or closed spaces. He spent much of his time engaged in repetitive behaviors (e.g., opening and shutting door, spinning, rubbing his head in a sandbox, eating dirt, dropping objects, and clapping on hearing the sound). He also loved to line up all his toys, and if interrupted, he would throw a tantrum. He did not engage in reciprocal, pretend or imaginative play, and avoided the company of other children.


  Introduction Top


Autism is characterized by deficits in three “core areas” - communication (both verbal and nonverbal), social interaction, and behavior (which is restricted and repetitive). The severity of difficulties in these three areas varies between individuals. On one end of the spectrum is “high functioning” individuals who have normal or above normal intelligence, excellent language abilities but may have difficulties in understanding facial expressions or some gestures and appear aloof but are reasonably independent in their personal life and professional careers. On the other end of the spectrum is “low functioning” individuals who have severe intellectual disability, minimal skills in communication, who may engage in self-injuring behavior such as repeatedly banging their heads on the floor and require constant support in activities of daily living (dressing, feeding, going to the toilet, bathing, etc.). Furthermore, most individuals with autism have other associated comorbidities such as intellectual disability, seizure disorder, psychiatric illnesses, sleep disorders, and sensory abnormalities which further complicate their underlying disorder. These comorbidities and the autistic symptoms of the individual change through their lifetime, and the management is long drawn out and complicated.

Goals of therapy in autism

The management of autism spectrum disorder (ASD) requires a multidisciplinary team (MDT) comprising parents, therapists, psychologists, special educators, and medical specialists.[1] The primary goals of management are to:[2]

  • Help the child acquire functional skills - in daily living, in social interaction, and to communicate
  • Minimize the core features of autism and eliminate behaviors that are unhelpful or disruptive
  • Identify and treat comorbid conditions
  • Apply the learned skills to daily life situations in ways that are socially appropriate – generalization
  • Demystify autism to the family member and alleviate their distress.



  Intervention (Or Therapy) Models in Autism Top


There are numerous intervention plans (or models). Since each child is different and unique, the interventions which are suggested for the child must be tailor-made for the child's situation taking into consideration the child's developmental abilities, verbal and communication skills, level of cognition, parental insight and motivation, and most importantly, the availability of resources to carry out the plan. Some intervention models are “behavioral,” and they focus on teaching the child proper behavior while minimizing inappropriate ones (like the Applied Behavior Analysis [ABA]). Others are “relational” and use relationship building skills to improve the child's functioning. Others are “educational” and emphasize the importance of teaching skills that help a child learn better in school (like TEACHH). Still others focus on specific skills such as speech, self-care, sensory integration, improving social skills, and independence in daily living skills. However, most places have an “eclectic” model, in which components of the various models mentioned above are incorporated.

For the purpose of this article, we will limit ourselves to the assessment and the initial interventions of a child with autism. We will discuss the assessment and the subsequent interventions through a case study of a child who was brought to the Developmental Pediatrics Unit and was evaluated by the MDT.


  Assessment Top


Interdisciplinary assessment process

Rehan was initially seen in the outpatient department by the developmental pediatrician. The diagnosis of autism was established using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V) criteria.[3] Medical comorbidities were ruled out. He underwent an ophthalmic evaluation to rule out any refractive errors, and a formal hearing assessment to rule out any hearing difficulty. Since there was no history suggestive of a metabolic disorder (global regression in milestones, seizures, or vomiting), neurometabolic tests were not done. Electroencephalogram was done since there was a history of a recent change in his behavior pattern.[4] Neuroimaging was not done since there were no localizing neurologic signs or symptoms [Figure 1]. He was then referred to the MDT of the unit for a detailed evaluation.
Figure 1: Medical evaluation of a child with autism.

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The detailed evaluation was done over a few days by the MDT comprising a psychologist, occupational therapist, speech-language pathologist, nurses, and doctors.[5],[6],[7] Before the evaluation, detailed information about the child's development, behavior, and the environment at home was collected by the team members.

Play-based assessment

The first part of the evaluation was “play-based observations” by the MDT [Table 1] when the child and his caregivers were observed in a play room through a one-way mirror. The playroom is stocked with toys that are developmentally appropriate to elicit various skills. Rehan and his parents were led into the playroom. Inside the room, there are also various kinds of textures on the wall and the floor, bright lights of different colors, and bells of different intensities which are used to gauge the responses to sensory stimuli.
Table 1: The multidisciplinary team

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He was allowed a few minutes of free play (playing undisturbed on his own) to get adjusted to the new surroundings. After few minutes of free play, when Rehan became with familiar with the environment, one of the team members entered the room and started interacting with him. The play time was then structured by the team member, and he was given only one toy at a time, and his access to the other toys was restricted, to avoid any distraction. [Table 2] gives a list of the toys which are usually used in a child of Rehan's age.
Table 2: Toys used to assess developmental skills

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During the play-based evaluation which lasted about 20 min, the team members observed Rehan's behavior to assess his developmental abilities, social interaction, communication abilities, motor skills, cognitive abilities, manner of play, organizational skills, and responses to various sensory stimuli.[8] Rehan's behavior was also monitored for atypical behaviors [9] associated with autism [Table 3]. To a lesser extent, the parent's behavior and interactions were also observed to assess the general quality of the parent–child relationship and the parent's abilities to read the child's cues and provide support.
Table 3: Checklist of atypical behavior to observe in play-based assessments for toddlers and young children with autism

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Valuable information about the child's developmental abilities and autistic features was obtained by the MDT by observing Rehan's skills in playing. Following the play-based observations, each member of the team (psychologist, occupational therapist, and speech therapist) spent several one-to-one sessions with the child and the parent over the next few days. During these sessions, formal assessments were done, and more information about the child and the environment was collected from the parent. A list of the standardized assessments used in the unit is shown in Appendix 1 [Additional file 1].

[Additional file 2]

[Additional file 3]


  Intervention Top


Individualized learning plan

After the team deliberated on their individual findings, they jointly designed a set of intervention recommendations and gave the parents an individualized learning plan [10] which incorporated their individual plans [Table 4]. Interventions suggested would begin at the current developmental skills of the child and sequentially new developmental skills would be introduced. Rehan would be reassessed every 3–6 months to ascertain his developmental progress and once the developmental skills are mastered new interventions would be recommended. The plan was parent-centric, and therefore, the team members demonstrated each item on the plan to Rehan's parents and made sure the parents understood and were confident in implementing it. One of the important instructions given to parents of autistic children is to reduce the exposure to media (TV, computers/laptops, and the mobile phones). Increased exposure to visual media has been shown to reduce the language abilities and social interaction of children.[11]
Table 4: Assessment and intervention plans by the multidisciplinary team

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The team recommended that Rehan receives early intervention services in a one-to-one setting, with a MDT of professionals (psychologist/special teacher, occupational therapist, and speech therapist) for the next 1–2 years. If available it would be beneficial, if the child is referred to a structured program for autistic children like ABA or TEACHH.[12],[13],[14],[15]

The “Tested and True” features of early intervention which work in autism [8]

When parents of children who have just been diagnosed to have autism are asked to continue with an autism intervention program, they are likely to be overwhelmed by the numerous claims and virtues of the various programs. However, there are a few “tested and true” facts [8] which have been shown to work in autism and are successful irrespective of the type of intervention:

  1. Interventions should be started as soon as the diagnosis of autism is made since it is now proven that children who receive therapy early generally do better that those in whom it was started later [16],[17]
  2. Those who are on intensive therapy (defined as at least 25 h a week), throughout the year have better outcomes [18]
  3. Parents (and if possible other family members) should always be part of the process and should be involved in the therapy. Involvement of parents has been shown to improve the outcomes [19],[20]
  4. The interventions should be developmentally appropriate (should be planned and executed according to the child's developmental abilities) and the goals should be clear
  5. The ideal learning environment should have a low student–to-teacher ratio (2:1 or less)
  6. The plan should address multiple areas such as communication, social skills, behavior, daily living, motor skills, and learning (since most of these areas are involved in children with autism). A good intervention plan should, therefore, have the following components in its curriculum:

    1. Focus on improving the child's ability to attend to the environment (improve the child's attention)
    2. Interventions to improve verbal and motor imitation and social skills
    3. Interventions to facilitate language acquisition and communication
    4. Intervention strategies to increase the child's ability to use toys in functionally appropriate ways and promote the use of symbolic play
    5. Interventions to improve social interaction with others (teaching turn-taking, reciprocal play, and improving peer interactions)


  7. A good plan should allow other people besides the therapists to reinforce new skills in the usual daily routines of the child's life (generalizing new skill)
  8. There should be ample opportunities for the child to interact with peers with typical development
  9. The intervention plans should be “structured” – the routines should be predictable, there should be lot of visual input (since autistic children are better visual learners and respond to visual inputs – such as gestures, pictures, rather than auditory input like verbal instruction)
  10. The child's progress should be monitored and documented and only then can the intervention model's effectiveness be gauged.


Complementary and alternative medicine

It is likely that in the course of a chronic disorder such as autism parents will look for nonconventional therapies. Complementary and alternative medicine (CAM) represents a large and diverse group of health-care systems, practices, and products that are based on philosophies and techniques other than those used in conventional medicine. Many of these treatment modalities are popular.[21],[22] However, most of them have not undergone scientific scrutiny such as the conventional treatments mentioned above and are usually based on anecdotal evidence with insufficient data to endorse on their usefulness.[23]

One of the most popular CAM treatments is gluten-free/casein-free (GFCF) diet. It is believed that by eliminating foods containing gluten and casein, the symptoms of autism would diminish. However, many studies have now shown that GFCF diets do not improve social skill or communication or help with sleep or reduce hyperactivity in children with autism.[24],[25] Other dietary interventions include supplementing the diet with B6 (pyridoxine), magnesium, omega-3-fatty acids, probiotics, multivitamins, and amino acids. None of these have strong evidence of usefulness in the treatment of autism. Other treatments which are controversial because of lack of evidence include auditory integration, behavioral optometry, craniosacral therapy, chelation, hyperbaric oxygen, and secretin. Yoga as treatment for autism is quite popular; however, there are still no well-designed studies on its usefulness although it is quite safe.[26]
Figure 2: Shape-sorter puzzle.

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Figure 3: Pretend/make-believe play (setting a table to serve tea).

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Figure 4: (a) Playing with coloured blocks (b) Introducing size and colours.

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Figure 5: Visual attention-visually colourful toys can improve attention.

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Figure 6: Pretend/make-believe play (Taking care of a baby).

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Figure 7: Hand skills-encouraging fine motor activity.

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Family support

Professionals often view the parents of the autistic child as caretakers or cotherapists only and expect them to continue to implement the programs frequently at the expense of other priorities and the other members of the family. Having a child with autism places profound and unrelenting stress on the parents and the family as a unit.[27] Families also experience stress because of the lack of financial and other resources. Therefore, supporting the family throughout their journey of bringing up a child with autism is paramount in the management of children with autism.[28]


  Recovery and Prognosis in Autism Top


The major question in the mind of any parent of a child with autism is whether the child will improve with treatment, whether they will be independent and be able to go to school. While therapy may not result in a child with autism attaining to all the developmental abilities appropriate for his/her age, significant improvement is possible.

Recent studies have shown that with early diagnosis and intervention, 3%–25% of children with autism can lose their diagnosis of autism.[38],[39] Recovery, also termed as optimal outcome (OO), was defined as previously having had clearly defined ASD, but currently no longer meeting criteria (DSM-5) for any ASD. Individuals in the OO group had skills in facial recognition, socialization, communication, and formal language tests comparable to those with normal development.[38],[38],[40]

There are some factors identified that favor a positive or a less favorable outcome [Table 7].[38] While early identification and intervention is a factor that favors a good outcome, treatment should not be withheld from those diagnosed late in childhood or as adults.
Table 5: Sensory integration therapy

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Table 6: Alternate/augmentative communication

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Table 7: Factors affecting outcome in autism spectrum disorder

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  Conclusion Top


In conclusion, autism is a complex neurodevelopmental disorder that affects several developmental domains – language and communication, social interactions, behavior, and often times there are multiple comorbidities. In the management of autism, there is no “one-size fits all” approach and the interventions should address the multiple areas of concern. Helping the parents and other caregivers understand the complexity of the disorder is imperative in the management of autism.
Figure 8: Sensory intergration therapy.

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Figure 9: Introducing PECS (picture exchange communication system).

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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