Game Changers in Pediatrics 2011

Laurie Scudder, DNP, PNP

Disclosures

November 23, 2011

In This Article

Autism Spectrum Disorders: A Growing Population of Kids

In April 2011, the Agency for Healthcare Quality and Research released Therapies for Children With Autism Spectrum Disorders: Comparative Effectiveness Review Number 26, which was developed by the Vanderbilt Evidence-Based Practice Center.[7]Three systematic reviews developed in conjunction with this research and focusing on specific therapies for autism spectrum disorders (ASDs) were published the same day in Pediatrics.[8,9,10] Earlier this year, Medscape spoke with Jeremy Veenstra-VanderWeele, MD, Assistant Professor of Psychiatry, Pediatrics, and Pharmacology and Director, Treatment Resistant Autism Consultation Clinic at the Treatment and Research Institute for Autism Spectrum Disorders, Vanderbilt Kennedy Center for Research on Human Development, Nashville, Tennessee, and an author for all of these papers about this research and the implications for primary care. –The bottom line is that early behavioral intervention looks hopeful, albeit without complete data, and the risk for harm appears lower than the risk with a medication.

Unfortunately, these treatments are both expensive and time consuming. While there is evidence that there is an effect, the data do not allow for a hard determination about particular therapies. Additionally, it appears that the earlier intervention begins, the better. However, despite a growing body of knowledge about the early signs of ASDs, the average age of diagnosis is over 3 years for children with autistic disorder, and closer to 4 years for those with pervasive developmental disorder-not otherwise specified.[11] Children with Asperger's disorder are typically not diagnosed before school entry. Pharmacotherapy may be useful in the management of selected symptoms but all agents have adverse effects and they should probably only be prescribed by people who see more children with ASDs.

Other key findings:

  • Atypical antipsychotics may be useful in treating aberrant behaviors, which may be associated with ASDs though side effects can be substantial. These agents should be reserved for cases in which someone is at risk from aggression or self-injury or when individuals are very impaired from these behaviors.

  • Current diagnostic guidelines do not allow for the diagnosis of ADHD in the context of ASDs. However, that may change and one study of use of methylphenidate in kids with ASD and hyperactivity did find evidence of efficacy.

  • Studies to date of use of selective serotonin reuptake inhibitors have not demonstrated any benefit to use of these agents in treating repetitive behaviors associated with ASD.

  • There is no reason to use secretin for the treatment of children with ASDs.

  • There are not enough data to provide guidance on whether parent training, in general, is helpful and which specific parent trainings may be most beneficial.

Why Is This a Game Changer?

Game changer may be a stretch -- but these documents represent the most comprehensive examination of data to date. They point to the need for early recognition and referral of children with suspected ASDs. For the average child with an ASD who is under 5 years of age, the inconclusive data available suggests that the best approach is to pursue early intensive behavioral intervention. Additionally, refer children for specific treatment of any speech problem that the child may have to improve communication with the spoken word or to use alternative communication strategies, such as picture cards or a computer-based communication system. The best approach is to address the specific difficulties, knowing that the data aren't strong enough to be totally confident. Interventions should then be chosen that have the best evidence of benefit and the least chance of harm.

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