New Practice Guidelines for Autism

Deborah Brauser

January 29, 2014

An evidence-based, multipart, multidisciplinary treatment plan for children and adolescents with autism spectrum disorder (ASD) is among the primary recommendations from a new practice parameter released by the American Academy of Child and Adolescent Psychiatry (AACAP).

Based on almost 200 studies, these clinical guidelines will replace those released in 1999 on how to assess and manage children with ASD. Other key recommendations include that medications be used "judiciously" and that prescribing be guided by best evidence.

In addition, the new practice parameter calls for physical examinations and genetic testing, and asks clinicians to look out for comorbid and co-occurring issues.

"The goal of this parameter is really to raise the standard of care for children and adolescents with autism," coauthor Matthew Siegel, MD, director of the Developmental Disorders Program at Spring Harbor Hospital in Westbrook, Maine, and clinical investigator at the Maine Medical Center Research Institute, told Medscape Medical News.

"The number 1 take-away is that these children must have a multidisciplinary treatment plan that considers areas of communication and socialization, behavioral challenges, and medical, comorbid, and occupational needs," added Dr. Siegel, who is also a member of the AACAP Committee on Quality Issues.

He noted that "it was not that long ago" when a single clinician, whether a psychiatrist, neurologist, or primary care physician, would see a child with autism and then diagnose and treat them themselves.

"But we've now seen that this is a disorder that touches multiple areas of functioning. So to give children the best chance for a good outcome, it's not acceptable to operate from a single viewpoint."

The practice parameter is published in the February issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

"Woefully Out of Date"

According to the authors, there have been "several thousand research and clinical articles" published since the release of the first practice parameter in 1999. In addition, the diagnostic criteria for ASD have changed.

Dr. Matthew Siegel

"Practice parameters are important because they really guide practice both in the United States and, in the case of child psychiatry, internationally. Because of that, they take an enormous amount of work and effort. And the one for autism was woefully out of date," said Dr. Siegel.

"The field has moved forward significantly. So there was a real need to revise and update this parameter and bring recommended practices in line with the best research and outcomes currently available."

Dr. Siegel spent significant time during the past 5 years researching and developing the new parameter.

"These guidelines are not just about people's opinions about what's best in the treatment and assessment of children with autism. But rather, it represents a very rigorous systematic review of all research that was publicly available for the past 20 years," he explained.

The investigators reviewed data for 9581 studies published between 1991 and March 2013 before selecting 186 for full-text examination. The body of research for this set of guidelines was performed under the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) because the DSM-5 was not released until May 2013.

"It will be some years before the implication of these changes for autism prevalence [based on the DSM-5 criteria] and other facets of assessment and treatment can be fully assessed," write the authors.

"We can only work off the evidence base we have. But we also recognize that this shift in diagnostic definition is occurring," added Dr. Siegel.

Assessment Recommendations

There are 3 recommendations for assessment of ASD in the new parameter. First, psychiatric and developmental assessments of young children should routinely include questions about core symptoms of ASD, including any unusual or repetitive behaviors.

Second, a thorough evaluation should be performed if a screening shows significant ASD symptomatology, based on DSM-5 diagnostic criteria. In addition, consideration should be made of possible comorbid diagnoses.

Third, clinicians should coordinate a multidisciplinary assessment of these children, including a physical examination, a hearing screen, communication and psychological tests, and genetic testing, "which may include G-banded karyotype, fragile X testing, or chromosomal microarray."

"These tests currently detect known abnormalities clearly associated with increased rates of ASD," write the authors. Additional evaluations should be conducted if the child has a history of regression, dysmorphology, or staring spells.

Psychological assessment should include measures of cognitive ability, adaptive skills, intelligence, and unusual abilities, such as detailed drawings or calendar calculations.

"Psychological tests clarify areas of strength and weakness useful in designing intervention programs and may need to include instruments valid for a nonverbal population."

Other assessments should include communication measurements, occupational and physical therapy evaluations, and sleep variables. For all of the measures listed, the authors note that "it is optimal" that coordination occur among all members of the multiple disciplines.

"While not every practitioner around the country, due to geographic location, will have access to experts in the areas we've recommended, they should always be thinking about how the child is being served in those different areas," said Dr. Siegel.

Treatment Plans

For treating children and adolescents with ASD, the new practice parameter also provides 4 primary recommendations for clinicians:

  1. Help families obtain "appropriate, evidence-based, and structured" educational and behavioral interventions.

  2. Offer pharmacotherapy when there is a specific target symptom or comorbid condition.

  3. Maintain an active role in long-term treatment planning.

  4. Inquire about the use of alternative/complementary treatment.

Under the first recommendation, the authors suggest that applied behavioral analysis (ABA) programs such as early intensive behavioral intervention have been shown to be effective, especially for treating specific problem behaviors.

They also highlight benefits of communication interventions and a highly structured, individualized educational program.

As for pharmacotherapy, "the parameter really highlights the limited benefits and significant limitations of pharmacologic treatments for autism at this time," said Dr. Siegel.

"It encourages people to consider medication but to look beyond it and move past the idea that a medication alone is going to be the answer," he said.

"After reviewing all the evidence, the parameter clearly states that medication can be an important tool to address either co-occurring psychiatric or behavioral disorders or specific problems, such as aggression. But it's only 1 tool in the toolbox."

Bottom Line

There are now plans for new updates to be released in 5 years, based on studies using criteria from the DSM-5, reported Dr. Siegel. He also noted that the current parameter points out a lack of research in the areas of co-occurring psychiatric disorders.

"In other words, there's still a huge need to better understand how one can best screen, diagnose, and treat in children the disorders you see in all people. At this time, we do not have any widely disseminated measures that have been validated for this population," he explained.

"And frequently, these co-occurring conditions keep children from benefitting from their education program interventions."

But for now, the new guidelines are designed to provide updated, best-evidence recommendations.

"AACAP Practice Parameters are developed to assist clinicians in psychiatric decision making," write the authors, adding that they are not intended to define the sole standard of care.

"The ultimate judgment regarding the care of a particular patient must be made by the clinician in light of all of the circumstances presented by the patient and his or her family, the diagnostic and treatment options available, and available resources," they conclude.

The authors have reported no relevant financial relationships.

J Am Acad Child Adolesc Psychiatry. 2014;53:237-257. Full text

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