Autism Spectrum Disorders

Number: 0648

Policy

1. Aetna considers autism spectrum disorder (ASD) evaluation and diagnosis medically necessary when developmental delays or persistent deficits in social communication and social interaction across multiple contexts have been identified and when the evaluation is performed by the appropriate certified/licensed health care professional.

   The following services may be included in the assessment and treatment of the member's condition:

   1. ASD specific developmental evaluation
   2. Cognitive and adaptive behaviors evaluations
   3. Speech, language and comprehensive communication evaluation by speech-language pathologist.
   4. Formal audiological hearing evaluation including frequency-specific brainstem auditory evoked response (see CPB 0181 - Evoked Potential Studies) or otoacoustic emissions. 
   5. Measurement of blood lead level if the child exhibits developmental delay and pica, or lives in a high-risk environment (see CPB 0553 - Lead Testing).  Additional periodic lead screening can be considered if the pica persists.
   6. Genetic testing specifically high resolution chromosome analysis (karyotype) and DNA analysis for fragile X syndrome in the presence of mental retardation (or if mental retardation can not be excluded) if there is a family history of fragile X or mental retardation of undetermined etiology, or if dysmorphic features are present (see CPB 0140 - Genetic Testing).
   7. Comparative genomic hybridization (CGH), when medical necessity criteria are met in CPB 0787 - Comparative Genomic Hybridization.
   8. Medical evaluation (complete medical history and physical examination, including neurologic evaluation).
   9. Parent and/or child interview (including siblings of children with autism).
   10. Quantitative plasma amino acid assays to detect phenylketonuria.
   11. Selective metabolic testing if the child exhibits any of the following:
       
       
       1. Clinical and physical findings suggestive of a metabolic disorder
          
          
          1. Cyclic vomiting, recurrent vomiting and dehydration
          2. Early seizure,
          3. Lethargy;
          4. Hearing impairment;
          5. Hypotonia;
          6. Visual impairment; or
          7. Unusual odor; or
             
             
       2. Dysmorphic or coarse features; or
       3. Evidence of mental retardation or mental retardation can not be ruled out; or
       4. Occurrence or adequacy of newborn screening for a birth defect is questionable.
           
   12. Genetic counseling for parents of a child with autism (see CPB 0189 - Genetic Counseling).
   13. Electroencephalogram (EEG) for clinical spells that might represent seizures.
   14. Physical therapy (PT) and/or occupational therapy (OT) evaluations for sensorimotor deficits.
   15. Sleep-deprived EEG study only if the child exhibits any of the following conditions:
       
       
       1. Clinical seizures; or
       2. High suspicion of subclinical seizures; or
       3. Symptoms of developmental regression (clinically significant loss of social and communicative function) at any age, but especially in toddlers and pre-schoolers.
           
   16. Video-EEG when criteria are met in CPB 0322 - Electroencephalographic (EEG) Video Monitoring.

   17. Pharmacotherapy for management of co-morbidities.

       Note: Coverage of pharmacotherapy is subject to the member's specific benefits for drug coverage.  Please check benefit plan descriptions. Information on pharmacotherapy options for autism can be found in the Background section below.

   18. Behavior modification, for management of behavioral co-morbidities.

       Note: Interventions for behavioral co-morbidities are covered under the member's behavioral health benefits.  Please check benefit plan descriptions.

   19. Intensive educational interventionsFootnotes* in which the child is engaged in systematically planned and developmentally appropriate educational activity toward identified objectives, including services rendered by a speech-language pathologist to improve communication skills.

       Footnotes* Notes:

       1. Many Aetna plans exclude coverage of educational services.  Speech therapy provided in educational settings would be excluded under these plans.  Please check benefit plan descriptions for details;
       2. There is insufficient evidence for the superiority of any particular intensive educational intervention strategy (such as applied behavior analysis, structured teaching, or developmental models) over other intensive educational intervention strategies. (see CPB 0554 - Applied Behavior Analysis)

   20. Alternative and augmentative communication aids (e.g., sign language, flashcards, communication boards, etc.) if demonstrated as effective for the individual with PDD.  Note: Some plans exclude coverage of “communication aids.”  Please check benefit plan descriptions for details.

   21. Physical and occupational therapy for co-morbid physical impairments.

   22. Medical therapy or psychotherapy, as indicated for co-morbid medical or psychological conditions.

       Note: Psychotherapy is covered under the member's behavioral health benefits.  Please check benefit plan descriptions.

2. Aetna considers the following procedures and services experimental and investigational because the peer-reviewed medical literature does not support the use of these procedures and services in the assessment and treatment of autism and other pervasive developmental disorders:

   Assessment

   1. Allergy testing (including food allergy for gluten, casein, candida, and other molds; allergen specific IgG and IgE)
   2. Blood tests for metabolomic analyses (e.g., NPDX ASD ADM Panel I by NeuroPointDX)
   3. Celiac antibody testing
   4. Ciliary neurotrophic factor (as a biomarker for ASD)
   5. GABA receptor polymorphisms testing
   6. Electronystagmography (in the absence of dizziness, vertigo, or balance disorder)
   7. Erythrocyte glutathione peroxidase studies
   8. Event-related brain potentials
   9. Genetic panels other than CGH (e.g., the Fulgent ASD panel, the Greenwood Genetic Center's Syndromic Autism Panel, and the MitoMed-Autism Assay)
   10. Genetic testing for DRD2, HTR2C, MTHFR, RELN, SLC25A12 and UGT2B15 for diagnosis of autism and other pervasive developmental disorders and their drug treatment
   11. Hair analysis for trace elements (see CPB 0300 - Hair Analysis)
   12. Homocysteine testing (see CPB 0763 - Homocysteine Testing)
   13. Intestinal permeability studies
   14. Latent class analysis (for determination of psychosis-related clinical profiles in children with autism spectrum disorders)
   15. Magnetoencephalography/magnetic source imaging (see CPB 0279 - Magnetic Source Imaging/Magnetoencephalography)
   16. Micronutrients (ie, trace elements, trace minerals or vitamin) level testing
   17. Neuroimaging studies such as CT, functional MRI (fMRI), MRI, MRS (see CPB 0202 - Magnetic Resonance Spectroscopy (MRS)), PET (see CPB 0071 - Positron Emission Tomography (PET)), and SPECT (see CPB 0376 - Single Photon Emission Computed Tomography (SPECT))
   18. Nutritional testing (e.g., testing for arabinose and tartaric acid)
   19. Olfactory function testing
   20. Provocative chelation tests for mercury
   21. Serum cytokine and growth factor levels
   22. Stool analysis
   23. Tests for glutamatergic candidate genes
   24. Tests for immunologic or neurochemical abnormalities
   25. Tests for micronutrients such as vitamin levels
   26. Tests for mitochondrial disorders including lactate and pyruvate
   27. Tests for amino acids (except quantitative plasma amino acid assays to detect phenylketonuria), fatty acids (non-esterified), organic acids, citrate, silica, urine vanillylmandelic acid
   28. Tests for heavy metals (e.g., antimony, arsenic, barium, beryllium, bismuth, mercury)
   29. Tests for trace metals (e.g., aluminum, cadmium, chromium, copper, iron, lead, lithium, magnesium, manganese, nickel, selenium, zinc)
   30. Thyroid function testing
   31. Tympanometry (in the absence of hearing loss)
   32. Urinary peptide testing
   33. Whole-exome sequencing

   Note: Neuropsychological or psychological testing (see CPB 0158 - Neuropsychological and Psychological Testing) beyond standardized parent interviews and direct, structured behavioral observation is rarely considered medically necessary for the diagnosis of pervasive developmental disorders.

   Treatment

   1. Acupuncture
   2. Anti-fungal medications (e.g., fluconazole, ketoconizole, metronidazole, nystatin)
   3. Anti-viral medications (e.g., acyclovir, amantadine, famciclovir, isoprinosine, oseltamivir, valacyclovir)
   4. Auditory integration training (auditory integration therapy) (see CPB 0256 - Sensory and Auditory Integration Therapy)
   5. BioMat
   6. Chelation Therapy (see CPB 0234 - Chelation Therapy)
   7. Cognitive rehabilitation (see CPB 0214 - Cognitive Rehabilitation)
   8. Electro-convulsive therapy (for the treatment of autistic catatonia)
   9. Elimination diets (e.g., gluten and milk elimination)
   10. Facilitated communication
   11. Emotion recognition training
   12. Herbal remedies (e.g., astragalus, berberis, echinacea, garlic, plant tannins, uva ursi)
   13. Floor time therapy
   14. GABAergic agents (e.g., acamprosate, arbaclofen, and valproic acid)
   15. Hippotherapy (See CPB 0151 - Hippotherapy)
   16. Holding therapy
   17. Immune globulin infusion
   18. Manipulative therapies
   19. Massage therapy
   20. Music therapy and rhythmic entrainment interventions
   21. Memantine
   22. Neurofeedback/EEG biofeedback (see CPB 0132 - Biofeedback)
   23. Nutritional supplements (e.g., dimethylglycine, glutathione, magnesium, megavitamins, omega-3 fatty acids, and high-dose pyridoxine)
   24. Nutritional therapy (e.g., casein-free and gluten-free diets, ketogenic and modified Atkins diets)
   25. Oxytocin
   26. Quantum Reflex Integration
   27. Secretin infusion
   28. Sensory integration therapy (see CPB 0256 - Sensory and Auditory Integration Therapy)
   29. Stem cell transplantation
   30. Systemic hyperbaric oxygen therapy (see CPB 0172 - Hyperbaric Oxygen Therapy (HBOT))
   31. Tomatis sound therapy
   32. Transcranial direct current stimulation
   33. Vestibular stimulation
   34. Vision therapy (see CPB 0489 - Vision Therapy)
   35. Vitamins and minerals (calcium, germanium, magnesium, manganese, selenium, tin, tungsten, vanadium, zinc, etc.).
   36. Weighted blankets or vests.

Background

Autism spectrum disorders (ASD) are a group of biologically based chronic neurodevelopmental disorders characterized by impairments in two major domains: 1) deficits in social communication and social interaction and 2) restricted repetitive patterns of behavior, interests and activities. The exact cause is unknown, but is believed to have many factors, including a strong genetic component.

Signs and symptoms of ASD generally appear prior to three years of age and include difficulties with language, deficient social skills and restricted or repetitive body movements and behaviors. Autism and other autism spectrum disorders (ASD) may be suspected by the following symptoms: any loss of any language or social skills at any age; no 2-word spontaneous (not just echolalic) phrases by 24 months; no babbling by 12 months; no gesturing (e.g., pointing, waving bye-bye) by 12 months; or no single words by 16 months.

Autism spectrum disorders (ASD) include autism, Rett syndrome, childhood disintegrative disorder and Asperger’s syndrome, and are chronic life-long conditions.  Autism has been estimated to affect approximately 1 in 1,000 children in the United States, and other pervasive developmental disorders have been estimated to affect approximately 2 in 1,000 children in the United States.  Based on recent prevalence estimates of 10 to 20 cases per 10,000 individuals, between 60,000 and 115,000 children under the age of 15 years meet diagnostic criteria for autism.

There is no cure for ASD. However, there is a consensus that treatment must be individualized depending upon the specific strengths, weaknesses and needs of the child and family. Early diagnosis and early intensive treatment have the potential to affect outcome, particularly with respect to behavior, functional skills and communication. There is increasing evidence that intervention is more effective when initiated as early as possible.

Diagnosis and treatment of ASD may involve a variety of tools. Developmental screening, usually performed during a routine well child exam, identifies atypical (unusual) behaviors such as social, interactive and communicative behaviors that are delayed, abnormal or absent. Once identified, a comprehensive multidisciplinary assessment is recommended in order to make an accurate and appropriate diagnosis.

Appropriate certified/licensed healthcare professionals for evaluation and management of autism include the following: board certified behavioral analyst; developmental pediatrician; neurologist; occupational therapist; physical therapist; primary care provider; psychiatrist; psychologist; or speech-language pathologist and audiologist. 

According to the American Academy of Neurology (AAN)'s practice parameter, Screening and Diagnosis of Autism (Filipek et al, 2000), autism is characterized by severe deficiencies in reciprocal social interaction, verbal and non-verbal communication, and restricted interests.  It usually commences before the age of 3 years and lasts over the whole lifetime.  Early signs that distinguish autism from other atypical patterns of development include poor use of eye gaze, lack of gestures to direct other people's attention (especially to show things of interest), decreased social responsiveness, and lack of age-appropriate play with toys (especially imaginative use of toys).  A typical symptom of autism is absence of speech development, observed from infancy, taking the form of complete mutism at later stages.  It has been emphasized that most pathological symptoms of autism result from altered perception of external stimuli, which arouse fear and anxiety.  Currently, there are no biological markers for autism and there is no proven cure for this disorder.

Because there are no biological markers for autism, screening must focus on behavior.  Studies comparing autistic and typically developing children demonstrated that problems with eye contact, orienting to one’s name, joint attention, pretend play, imitation, non-verbal communication, and language development are measurable by 18 months of age.  These symptoms are stable in children from toddler age through preschool age.  Retrospective analysis of home videotapes also has identified behaviors that distinguish infants with autism from other developmental disabilities as early as 8 months of age.

Current screening methods may not identify children with milder variants of autism, those without mental retardation or language delay, such as verbal individuals with high-functioning autism and Asperger’s disorder, or older children, adolescents, and young adults.

There are relatively few appropriately sensitive and specific autism screening tools for infants and toddlers, and this continues to be the current focus of many research centers.  The Checklist for Autism in Toddlers (CHAT) for 18-month-old infants, and the Autism Screening Questionnaire for children 4 years of age and older, have been validated on large populations of children.  However, it should be noted that the CHAT is less sensitive to milder symptoms of autism, as children later diagnosed with PDD-NOS, Asperger’s, or atypical autism did not yield positive results on the CHAT at 18 months.

The AAN’s practice parameter noted that specific neuropsychological impairments can be identified, even in young children with autism, that correlate with the severity of autistic symptoms.  Performance on tasks that rely on rote, mechanical, or perceptual processes are typically spared; deficient performance exists on tasks requiring higher-order conceptual processes, reasoning, interpretation, integration, or abstraction.  Dissociations between simple and complex processing are reported in the areas of language, memory, executive function, motor function, reading, mathematics, and perspective-taking.  However, there is no reported evidence that confirms or excludes a diagnosis of autism based on these cognitive patterns alone.

The AAN’s practice parameter recommended that diagnosis of autism should include the use of standardized parent interviews regarding current concerns and behavioral history related to autism, and direct, structured observation of social and communicative behavior and play.  Recommended instruments for parental interviews include the Gilliam Autism Rating Scale, Parent Interview for Autism, Pervasive Developmental Disorders Screening Test–Stage 3, and Autism Diagnostic Interview–Revised.  Recommended instruments for observation include the Childhood Autism Rating Scale, Screening Tool for Autism in Two-Year-Olds, and Autism Diagnostic Observation Schedule-Generic.  The AAN practice parameter did not recommend that neuropsychological testing be used for the diagnosis of autism, but insteadshould be performed as needed, in addition to a cognitive assessment, to assess social skills and relationships, educational functioning, problematic behaviors, learning style, motivation and reinforcement, sensory functioning, and self-regulation.

Similarly, the American Academy of Child And Adolescent Psychiatry (AACAP)’s practice parameter for the assessment and treatment of autism recommended neuropsychological testing only when the clinical context indicates that it may be helpful.  Psychological testing is recommended in the AACAP practice parameter to assess for cognitive and intellectual functioning, in order to determine eligibility and plan for educational and other services.

Mental retardation (IQ less than 70) is associated with 70 % of cases of autism and seizures with 33 % of cases.  Furthermore, the recurrence risk for siblings is about 3 to 5 %, corresponding to an incidence 75 times greater than that in the general population.  These features, in conjunction with the increased number of male patients (3:1 male:female ratio), suggest a genetic predisposition.  On the other hand, parallel evidence of immune abnormalities in autistic patients argues for an implication of the immune system in pathogenesis.  Additionally, some neurological disorders such as tuberous sclerosis, neurofibromatosis, fragile X syndrome, Rett syndrome and phenylketonuria may also be associated with autistic features. In these cases, autism is defined as "secondary".

The AAN's practice parameter Screening and Diagnosis of Autism (Filipek et al, 2000) recommended genetic testing in children with autism, specifically high resolution chromosome analysis (karyotype) and DNA analysis for fragile X syndrome in the presence of mental retardation (or if mental retardation can not be excluded), if there is a family history of fragile X or undiagnosed mental retardation, or if dysmorphic features are present.  However, there is little likelihood of positive karyotype or fragile X testing in high-functioning autism.

An assessment prepared for the Agency for Healthcare Research and Quality (Sun, et al., 2015) on genetic testing for developmental disability, intellectual disability and autism spectrum disorders concluded that "little evidence from controlled studies exists to directly link genetic testing to health outcomes. Published studies have reported superior diagnostic yields of newer genetic tests (e.g., aCGH) in identifying DD-related genetic abnormalities, and some have identified the impact of the tests on medical management (e.g., medical referrals, diagnostic imaging, further laboratory testing). However, these findings are not sufficient for drawing a conclusion that use of the tests will lead to improved health outcomes ...."

1. lethargy, cyclic vomiting, or early seizure, or
2. dysmorphic or coarse features, or
3. evidence of mental retardation, or
4. mental retardation can not be ruled out, or
5. occurrence or adequacy of newborn screening for a birth defect is questionable. 

The AAN also recommended lead screening if the child exhibits developmental delay and pica.

Epileptiform abnormalities on electroencephalography (EEG) are common in children with autism spectrum disorders (ASDs), with reported frequencies ranging from 10 % to 72 % (AAP, 2007).  Some studies have suggested that epileptiform abnormalities on EEG and/or epilepsy are more common in the subgroup of children with ASDs who have a history of regression, whereas other studies have not demonstrated this association.  Autistic regression with epileptiform abnormalities on EEG has been compared by analogy with Landau-Kleffner syndrome and electrical status epilepticus in sleep, but there are important differences between these conditions, and the treatment implications are unclear (AAP, 2007).  Whether subclinical seizures have adverse effects on language, cognition, and behavior is debated, and there is no evidence-based recommendation for the treatment of children with ASDs and epileptiform abnormalities on EEG, with or without regression.  A report from the American Academy of Pediatrics (AAP, 2007) states that universal screening of patients with ASDs by EEG in the absence of a clinical indication is not currently supported.  The report states, however, that because of the increased prevalence of seizures in this population, a high index of clinical suspicion should be maintained, and EEG should be considered when there are clinical spells that might represent seizures.

Localized structural and functional brain correlates of PDD have yet to be established.  Structural neuroimaging studies performed in autistic patients have reported abnormalities such as increased total brain volume and cerebellar abnormalities.  However, none of these abnormalities fully account for the full range of autistic symptoms.  Functional neuroimaging has demonstrated temporal lobe abnormalities and abnormal interaction between frontal and parietal brain areas.  However, the value of functional neuroimaging such as positron emission tomography (PET), single photon emission computed tomography (SPECT) and functional magnetic resonance imaging (fMRI) in diagnosing autism has not been established.  Functional neuroimaging techniques are at the early stage of identifying abnormalities at the neurotransmitter and systems levels.  Further studies with well-defined patient populations and appropriate activation paradigms will better elucidate the pathophysiology of this disorder.

1. the patient has clinical seizures or suspicion of subclinical seizures; or
2. a history of regression (clinically significant loss of social and communicative function) at any age, but especially in toddlers and pre-schoolers. 

Moreover, the AAN considered event-related potentials and magnetoencephalography to be research tools, which have no evidence of routine clinical utility (Filipek et al, 2000).

Philip and colleagues (2012) stated that recent years have seen a rapid increase in the investigation of ASD through the use of fMRI.  These investigators performed a systematic review and ALE meta-analysis of fMRI studies of ASD.  A disturbance to the function of social brain regions is among the most well replicated finding.  Differences in social brain activation may relate to a lack of preference for social stimuli as opposed to a primary dysfunction of these regions.  Increasing evidence points towards a lack of effective integration of distributed functional brain regions and disruptions in the subtle modulation of brain function in relation to changing task demands in ASD.  The authors stated that limitations of the literature to date include the use of small sample sizes and the restriction of investigation to primarily high-functioning males with autism.

1. allergy testing (especially food allergy for gluten, casein, candida, and other molds),
2. erythrocyte glutathione peroxidase studies,
3. hair analysis,
4. intestinal permeability studies,
5. stool analysis, and
6. tests for celiac antibodies, immunologic or neurochemical abnormalities, micronutrients such as vitamin levels, mitochondrial disorders including lactate and pyruvate, thyroid function, and urinary peptides.

Hair Analysis is a test in which a sample of an individual's hair, typically from the back of the neck, is sent to a laboratory for measurement of its mineral content. The AAN (Filipek et al, 2000) found inadequate supporting evidence for hair analysis for treatment of autism.

Autistic patients may suffer from gastrointestinal disturbances such as abdominal pains, diarrhea, and the so-called leaky-gut syndrome.  Secretin, a hormone produced by the pancreas to stimulate the production of gastric juices, has been used to aid digestion before intestinal biopsy or endoscopy. Secretin is a hormone made in the duodenum which causes the stomach to make pepsin, the liver to make bile and the pancreas to make a digestive juice. Early case studies suggested that secretin improved gastrointestinal symptoms as well as behavior, eye contact, alertness, and expressive language in autistic children.  However, such claims are not borne out by recent well-designed studies.

A randomized, double blind, placebo-controlled, cross-over study (Corbett et al, 2001) investigated the effect of a single intravenous dose of porcine secretin on autistic children.  The authors found that significant differences were not observed on the majority of the dependent variables.  Statistically significant differences were observed on measures of positive affect and activity level following secretin infusion.  In general, autistic children did not demonstrate the improvements described in the initial retrospective report.  This is in agreement with the findings of Owley and colleagues (2001) who reported that there was no evidence for efficacy of secretin in a multi-center, randomized, placebo-controlled, double-blind trial.  In a single-blinded, prospective, open-label study, Lightdale and associates (2001) reported that intravenous secretin had no effects in a 5-week period on the language and behavior of 20 children with autism and gastrointestinal symptoms.

The National Academy of Sciences (NAS) (2001) has stated that there is no known cure for autism, and that “[e]ducation, both directly of children, and of parents and teachers, is currently the primary form of treatment for autistic spectrum disorders.”  The National Academy of Sciences recommends that educational services begin as soon as a child is suspected of having autistic spectrum disorder, and that those services should include a minimum of 25 hours a week, 12 months a year, in which the child is engaged in systematically planned and developmentally appropriate educational activity toward identified objectives.  Brasic (2003) has stated that, while parents may choose to utilize a variety of experimental treatments including medication, they should concurrently utilize intensive individual special education by an educator familiar with instructing children with autistic disorder and related conditions.

The NAS report concluded that “there is little evidence concerning the effectiveness of discipline-specific therapies, and there are no adequate comparisons of different comprehensive treatments.  However, there is substantial research supporting the effectiveness of many specific therapeutic techniques and of comprehensive programs in contrast to less intense, nonspecific interventions.”  “The consensus across programs is generally strong concerning the need for: early entry into an intervention program; active engagement in intensive instructional programming for the equivalent of a full school day, including services that may be offered in different sites, for a minimum of 5 days a week with full-year programming; use of planned teaching opportunities, organized around relatively brief periods of time for the youngest children (e.g., 15- to 20-minute intervals); and sufficient amounts of adult attention in one-to-one or very small group instruction to meet individualized goals.”

The NAS report concluded that functional communication training has been shown to be effective in treatment of autism: “There is strong empirical support for the efficacy of functional communication training to replace challenging behaviors.  This approach includes a functional assessment of the particular behavior to determine its function for a child (e.g., desire for tangible or sensory item, attention, or to escape a situation or demand) and teaching communication skills that serve efficiently and effectively as functional equivalents to challenging behaviors, a method that has been documented to be the most effective for reductions in challenging behavior (Horner et al, 1990; see Horner et al, 2000).”

The NAS report also concluded that there is evidence to support the use of augmentative and alternative communication strategies (AAC) in children with autism.  “For children with autism who do not acquire functional speech or have difficulty processing and comprehending spoken language, augmentative and alternative communication (AAC) and assistive technology (AT) can be useful components of an educational program.”  “AAC is defined as ’an area of clinical practice that attempts to compensate (either temporarily or permanently) for the impairment and disability patterns of individuals with severe expressive communication disorders’ (American Speech-Language-Hearing Association, 1989).  AAC may involve supporting existing speech or developing independent use of a non-speech symbol system, such as sign language, visual symbols (pictures and words) displayed on communication boards, and voice output devices with synthesized and digitized speech.  AT is any commercial, hand-made, or customized device or service used to support or enhance the functional capabilities of individuals with disabilities.  AT includes computer-assisted instruction, mobility devices, high and low technology adaptations and AAC.” 

A structured evidence assessment of interventions in alternative and augmentive communication (ACC) (training to compensate for the impairment and disability patterns) in persons with severe expressive communication disorders (including autism, mental retardation, and other disabilities) concluded that ACC interventions are effective in terms of behavior change, generalization, and, to a lesser degree, maintenance (Schlosser and Lee, 2000). 

A number of discipline-specific intensive intervention programs have been advocated for the treatment of autism, including Lovaas therapy, the Rutgers Program, the LEAP Program, the Denver Program, the Autism Pre-school Program, and TEACCH Program.  The objectives of treatment are to improve the child's early social communication and social interaction skills, leading to the potential development of play and flexibility of behavior.  The NAS (2001) concluded that, although there is substantial research supporting the effectiveness of comprehensive programs in contrast to less intense, non-specific interventions, “there is little evidence concerning the effectiveness of discipline-specific therapies, and there are no adequate comparisons of different comprehensive treatments.”   

Lovaas therapy is a method of early behavioral intervention for the treatment of PDD.  It entails the employment of intensive teaching techniques designed to reinforce appropriate social behaviors in children with autism and related disorders.  Every task (trial) consists of a directive to the patient, a response from the patient, and a reaction from the therapist.  The patient learns to respond in a manner that generates reinforcement reaction from the therapist.  Lovaas therapy is usually practiced 30 to 40 hours a week.

1. choice of outcome measure,
2. criteria for subject selection and the intellectual level of the subjects, and
3. method for assigning subjects to control groups. 

These methodological problems made it difficult to ascertain the effects of early behavioral intervention on autistic children.  Recent reviews suggested that there is no available treatment that meets criteria for well-established or probably efficacious treatment; and that more research is needed to refine current behavioral treatment approaches.

Delprato (2001) compared discrete trial training (Lovaas Therapy) and normalized behavioral language intervention for young children with autism.  The author reported that in studies with language criterion responses, normalized language training was more effective than discrete trial training.  Furthermore, in studies that assessed parental affect, normalized treatment yielded more positive affect than discrete trial training.

Boyd and Corley (2001) reported the outcome survey of early intensive behavioral intervention (EIBI) programs for young children with autism in a community setting.  Based on both individual case reviews and parent questionnaires, they found that these programs failed to support any instances of "recovery", but yielded a high degree of parental satisfaction.  Moreover, a follow-up inquiry into the type of services each child was receiving in his or her post-EIBI setting documented continued dependence on extensive educational and related developmental services, suggesting that the promise of future treatment sparing did not materialize.  The authors concluded that there is a need for further research designed to document the effectiveness of services provided to young children with autism.

The Alberta Heritage Foundation for Medical Research (AHFMR) evaluated the effectiveness of intensive intervention programs for children with autism (Ludwig and Harstall, 2001).  These programs range from strict operant discrimination learning such as Lovaas therapy to broader applied behavior analysis such as the Rutgers Program to more developmentally oriented programs such as the Denver Program and the Treatment and Education of Autistic and Communication Handicapped Children (TEACCH) Program.  Furthermore, these treatment programs vary in their intensity from 40 hours per week for Lovaas Therapy and the Rutgers Program to a range of 15 hours per week for the LEAP Program.

1. studies on Lovaas therapy were methodologically flawed.  ECRI concluded that Lovaas Therapy appears to increase scores on IQ tests and behavioral adaptation, at least in some children with autism.  However, given the designs and methodological flaws of the studies, it could not be determined if the changes in IQ and functional parameters could be attributed to the Lovaas therapy.  BCOHTA concluded that the original Lovaas study as well as other follow-up studies were still inadequate to establish the degree to which this form of therapy resulted in "normal" children, and
2. there is insufficient evidence to establish a relationship between amount (intensity and duration) of any intensive intervention treatment program and outcomes measures (intelligence tests, language development, adaptive behavior tests).

Smith (1999) evaluated the evidence supporting intensive intervention programs for autism.  Smith noted that most reports of major gains made by children with autism have “withered under scrutiny”.  Smith emphasized the need to validate the long-term benefits of these intervention programs.  Smith noted that most studies of specific intensive intervention programs do not provide data on the children’s progress following termination of treatment.  Smith noted that this is a critical omission because even if treatment is successful while ongoing, the benefits may not be durable.  Smith concluded that methodological weaknesses in the research hinder us from drawing conclusions from existing early intervention studies.

An assessment of intensive intervention programs for autism by the Canadian Coordinating Office for Health Technology Assessment (CCOHTA) (McGahan, 2001) concluded that “there are few published controlled primary studies regarding the efficacy of behavioral interventions; most have methodological flaws that make interpretation of results difficult.  Study design in this area could benefit from the inclusion of an adequate control group and the application of consistent outcome measures used for all children enrolled in a study, administered by the same, blinded assessor at the beginning and end of the study.”

In assessing the evidence supporting specific intensive intervention programs for children with autism, the NAS (2001) concluded that “[a]s a group, these studies show that intensive early interventions with children with autistic spectrum disorders makes a clinically significant difference for many children …. However, each of the studies has methodological weaknesses, and most of the reports were descriptive rather than evaluations with controlled experimental research designs.  There are virtually no data on the relative merit of one model over another, either overall or as related to individual differences in children …. In sum, it appears that a majority of children participating in comprehensive behavioral interventions made significant progress in at least some developmental domains, although methodological limitations preclude definitive attributions of that progress to specific intervention procedures”.

A New Zealand Health Technology Assessment (Doughty, 2004) reviewed the conclusions of 5 recently published systematic evidence reviews of intensive behavioral interventions for autism-spectrum disorders.  The assessment found that all of these systematic evidence reviews draw attention to the lack of well-conducted research on early intervention for autism in young children.  The assessment found that all of the systematic evidence reviews reached the same conclusion, that “to date there is insufficient evidence to allow conclusions to be drawn about best practice. Furthermore, researchers have yet to establish a relationship between the amount (per day and total duration) of any form of early comprehensive treatment programme and overall outcome.”  The New Zealand Health Technology Assessment also reviewed recently published primary research on intensive behavioral interventions for autism.  The assessment found that, despite the relatively large volume of studies published and extent of interest of a variety of stakeholders in the effectiveness of interventions for young children with autism, only 5 primary studies published since 2000 met selection criteria for relevance and methodological quality.  The assessment concluded that these studies provide preliminary evidence suggesting that early intervention (note this includes different types of behavioral intervention, across different settings) may lead to selected gains in a number of specific domains.  The report concluded, however, that “further research is required to address the methodological limitations of existing studies and replicate their findings. In particular studies with larger sample sizes (from multisite collaborations using identical methods and outcome measures) are required to provide greater statistical power and more precise estimates of effectiveness.”

A position statement on early intervention for autism from the Canadian Paediatric Society (2004) reviewed the published literature on intervention programs, and concluded that the evidence for these programs is "weak" and "suboptimal".

More recently, an assessment by the Scottish Intercollegiate Guidelines Network (SIGN, 2007) stated that "[a]ll studies included in this review [of applied behavior analysis] were marked by considerable methodological flaws and there was also a concern that many had enrolled high functioning children with autism, making it difficult to generalise from the conclusions".  The review concluded that a causal relationship can not be established between a particular program of intensive behavioral intervention and the achievement of "normal functioning".  SIGN concluded that "[t]he Lovaas programme should not be presented as an intervention that will lead to normal functioning".  SIGN also noted that a comprehensive literature search did not find any good quality evidence for other intensive behavioral interventions.

A systematic evidence review and metanalysis found inadequate evidence that applied behavior intervention programs have better outcomes than standard care for children with autism (Spreckley and Boyd, 2009).  The authors reviewed systematic reviews and randomized or quasirandomized controlled trials of applied behavioral interventions delivered to preschool children with autism spectrum disorder.  Quantitative data on cognitive, language, and behavior outcomes were extracted and pooled for meta-analysis.  The authors reported that thirteen studies met the inclusion criteria.  Six of these were randomized comparison trials with adequate methodologic quality.  Meta-analysis of 4 studies concluded that, compared with standard care, applied behavioral intervention programs did not significantly improve the cognitive outcomes of children in the experimental group.  There was no additional benefit over standard care for expressive language, for receptive language, or adaptive behavior.  The authors concluded that there is inadequate evidence that applied behavioral interventions have better outcomes than standard care for children with autism.  The authors stated that appropriately powered clinical trials with broader outcomes are required.

An special report on applied behavior analysis for autism spectrum disorders by the BlueCross BlueShield Association Technology Evaluation Center (BCBSA, 2009) found that the strongest evidence of effectiveness came from 2 randomized controlled clinical trials (Smith et al, 2000; Sallows and Graupner, 2005); however, weaknesses in research design, differences in the treatments and outcomes compared, and inconsistent results mean that the impact of applied behavior analysis versus other treatments on outcomes for children with autism can not be determined.  The report stated that, given the lack of a definitive evidence on the relative effectiveness of applied behavior analysis, one can not answer the question of whether there are characteristics of children that predict a greater likelihood of success.  The assessment also stated that the findings on whether more intense treatment leads to better outcomes were inconsistent, and no conclusions can be drawn.

The BlueCross BlueShield Association's special report on "Early Intensive Behavioral Intervention Based on Applied Behavior Analysis among Children with Autism Spectrum Disorders" (2010) stated that overall, the quality and consistency of results of this body of evidence are weak.  Consequently, no conclusions can be drawn from this literature on how well early intensive behavioral intervention (based on applied behavior analysis or ABA; hereafter referred to as “EIBI”) works.  Weaknesses in research design and analysis, as well as inconsistent results across studies, undermine confidence in the reported results.  It is important to distinguish between certainty about ineffectiveness and uncertainty about effectiveness.  Based on the weakness of the available evidence, we are uncertain about the effectiveness of EIBI for autism spectrum disorders (ASDs).  Furthermore, the authors stated that the variability of presentation and progression among children with ASDs, as well as potential differences in delivery of behavioral interventions, make this topic challenging to study.  Nevertheless, given the importance of caring for children with ASDs, additional research is needed to identify those characteristics of treatment -- content, technique, intensity, starting and ending age, etc. -- that maximize its effectiveness.  Because of the challenges in launching a very large randomized controlled trial (RCT) and the ethical necessity to provide some treatment to the control group, this body of research needs to be built piece by piece, with a series of studies that investigate different components of the larger research question.  For this to be effective, however, the overall quality of studies needs to be improved, including a greater emphasis on RCTs, where at all possible; substantially larger sample sizes; uniformity of outcomes evaluated and instruments used to measure them; and consistent treatments that do not vary widely within treatment groups (i.e., experimental or control group).

The cost of continuing the current course of assuming that EIBI works may not be obvious.  EIBI is costly financially for society and requires a large time commitment from children, their families, and their teachers or therapists.  However, these programs may not appear to pose any harm for the children themselves.  Nevertheless, the opportunity costs could be high, indeed, of providing sub-optimal care to these children, simply because we as a society do not know what works best.  The children may be treated with an intervention that is not as effective as the alternatives.  And if we accept an intervention because it seems to work, without solid evidence, research on the alternatives or on how it can be improved is likely to be stifled.

Other interventions that have little or insufficient evidence of effectiveness in the treatment of children with autism are auditory integration training (also referred to auditory integration therapy, [AIT]), cognitive rehabilitation, facilitated communication, gluten and milk elimination diets, holding therapy, immune globulin therapy, music therapy, nutritional supplements (e.g., megavitamins, high-dose pyridoxine and magnesium, dimethylglycine), sensory integration therapy, and vision therapy.

Facilitated Communication is a method of providing assistance to a nonverbal individual by typing words using a typewriter, computer keyboard or other communication device. An assessment of interventions for autism conducted by the NAS (2001) concluded that there is insufficient evidence of the effectiveness of facilitated communication (FC) for autism.  The NAS report stated: “There are over 50 research studies of FC with 143 communicators.  Based on these research studies, the American Speech-Language-Hearing Association (1994) has stated that there is a lack of scientific evidence validating FC skills and a preponderance of evidence of facilitator influence on messages attributed to communicators (ASHA Technical Report, 1994).  Thus, there is now a large body of research indicating that FC does not have scientific validity.”

The AAP (2001) stated that available information does not support the claims of proponents that FC is effective in the treatment of autism, and considered it experimental.  In a review on autism, Levy and colleagues (2009) stated that popular biologically based treatments include anti-infectives, chelation medications, gastrointestinal medications, hyperbaric oxygen therapy, off-label drugs (e.g., secretin), and intravenous immunoglobulins.  Non-biologically based treatments include AIT, chiropractic therapy, cranio-sacral manipulation, FC, interactive metronome, and transcranial stimulation.  However, few studies have addressed the safety and effectiveness of most of these treatments.

Chelation Therapy is treatment that aims at lowering levels of mercury, lead or other heavy metals in the body. Medication is taken on a regular schedule that chelates (binds with) the metal to lessen its toxic effect on the body. In a review on autism, Levy and colleagues (2009) found that few studies have addressed the safety and effectiveness of chelation therapy for autism 

Sensory Integration Therapy is a method to improve the way the brain processes and organizes external stimuli, such as touch, movement, body awareness, sight and sound. The NAS report (2001) concluded that there is insufficient evidence of the effectiveness of sensory integration therapy for autism.  By focusing a child on play, sensory integration therapy emphasizes the neurological processing of sensory information as a foundation for learning of higher-level skills.  The goal is to improve subcortical (sensory integrative) somatosensory and vestibular functions by providing controlled sensory experiences to produce adaptive motor responses.  The hypothesis is that, with these experiences, the nervous system better modulates, organizes, and integrates information from the environment, which in turn provides a foundation for further adaptive responses and higher-order learning.  The NAS report states, however, that “[t]here is a paucity of research concerning sensory integration treatments in autism …. These interventions have also not yet been supported by empirical studies.”  In addition, the AAP (2001) stated that research data supporting the effectiveness of sensory integration therapy in managing autistic children is scant.

Auditory Integration Training (AIT) is a procedure for reducing painful hypersensitivity to sound. The NAS report (2001) concluded that there is insufficient evidence of the effectiveness of AIT in autism.  Proponents of auditory integration therapy suggest that music can “massage” the middle ear (hair cells in the cochlea), reduce hyper-sensitivities and improve overall auditory processing ability.  The NAS concluded that “auditory integration therapy has received more balanced investigation than has any other sensory approach to intervention, but in general studies have not supported either its theoretical basis or the specificity of its effectiveness.”  Based on a lack of clearly demonstrated effectiveness, the AAP (2001) also recommended against the use of AIT for autism.

A Cochrane review (Sinha et al, 2011) reviewed the evidence for AIT and other sound therapies for autism, and concluded that there is “no evidence that auditory integration therapy or other sound therapies are effective as treatments for autism spectrum disorders.”  The evidence review identified 6 relatively small studies of AIT and one of Tomatis therapy met the inclusion criteria for AIT.  These largely measured different outcomes and reported mixed results.  The report found that, of the seven studies including 182 participants that have been reported to date, only two (with an author in common), involving a total of 35 participants, report statistically significant improvements in the auditory intergration therapy group and for only two outcome measures.

Vision therapy is a primarily optometric treatment method that focuses on neurological and muscular function and the brain-eye connection for developing efficient visual skills and processing. Orthoptics is a component of vision therapy. Orthoptics is therapy limited in scope to eye muscle training, typically for straightening eye gaze so that both eyes appear to be looking toward the same direction. After initial training, the individual performs the eye exercises at home. The NAS concluded that there is insufficient evidence of the effectiveness of vision therapy for autism.  “A variety of visual therapies (including oculomotor exercises, colored filters, i.e., Irlen lenses, and ambient prism lenses) have been used with children with autism in attempts to improve visual processing or visual spatial perception.  There are no empirical studies regarding the efficacy of the use of Irlen lenses or oculomotor therapies specifically in children with autism …. As with auditory integration therapy, studies have not provided clear support for either its theoretical or its empirical basis.”

Other therapies involving sensory stimulation have insufficient evidence of effectiveness for treatment of autism, including holding therapy and vestibular stimulation. Holding Therapy is a practice that consists of forced holding by a therapist or parent until the child stops resisting, eye contact is made or a fixed time period has elapsed. Vestibular Stimulation is the input the body receives when experiencing movement or gravity.

Bell (2004) assessed the evidence for the effectiveness of music therapy for autism for the Wessex Institute for Health Research and Development, and concluded that there is insufficient evidence to support its use.  The assessment concluded that children with autism may demonstrate slight improvements in speech and imitation during music therapy sessions, but the clinical importance of these changes may be negligible.  The assessment found that the impact of music therapy on behavior and social functioning is unclear, and the long-term effects are uncertain.  The assessment also stated that it is unclear whether music therapy is better than other forms of behavioral therapy for children with autism.  The assessment stated that these conclusions are limited by the poor quality of the evidence, in particular the biased selection of the children, the small numbers involved, the contamination effect of the crossover design of many of the studies, the uncertain relevance of many of the outcome measures and the short follow-up.  The assessment concluded “[w]ithout further research, no recommendation about the clinical effectiveness of music therapy for autism can be made.”

The AAP stated that speech therapy and physical therapy play important roles in the comprehensive, interdisciplinary management of children with autistic spectrum disorder (2001).  An assessment by the National Initiative for Autism: Screening and Assessment (NIASA) (National Autistic Society, 2003) stated that children with co-morbid specific developmental disorders will require additional therapeutic services.  “These services include speech and language therapy for augmented communication programmes, physiotherapy and occupational therapy for visual perceptual problems, fine and gross motor co-ordination difficulties including with writing, unusual sensory responses, self-care skills and provision of equipment and environmental adaptations.”  However, there is a lack of high-quality evidence for speech/language therapy for autism.  The evidence for the effectiveness of speech/language therapy for autism is derived from case reports, single-case research designs, small-scale studies, and anecdotal reports. 

Physical therapy for children with autistic spectrum disorders focuses on developing strength, coordination and movement (CARD, 2001).  Therapists work on improving gross motor skills, such as running, reaching, and lifting.  This therapy is concerned with improving function of the body's larger muscles through physical activities including exercise and massage.  Occupational therapists commonly focus on improving fine motor skills, such as brushing teeth, feeding, and writing, or sensory motor skills that include balance (vestibular system), awareness of body position (proprioceptive system), and touch (tactile system).

Immune globulin infusions are concentrated antibodies administered intravenously to treat certain infectious diseases or boost the immune system response. The AAP (2001) has concluded that there is no scientific evidence to justify the use of infusions of immune globulin in treating autism.

Cognitive Rehabilitation is a systematic, goal oriented treatment program to improve cognitive (mental/intellectual) function and functional abilities (memory, judgment, perception and reasoning). The bulk of the evidence supporting cognitive rehabilitation for autism comes from case studies, anecdotal evidence and expert opinion.  The effectiveness of cognitive rehabilitation in treating autism has not been critically evaluated in well-designed studies.

In a Cochrane review on the use of music therapy for the treatment of autistic spectrum disorders, Gold et al (2006) stated that published studies were of limited applicability to clinical practice.  However, the findings indicate that music therapy may help children with autistic spectrum disorder to improve their communicative skills.  The authors noted that more research is needed to examine whether the effects of music therapy are enduring, and to investigate the effects of music therapy in typical clinical practice.

In a Cochrane review, Millward et al (2008) noted that it has been suggested that peptides from gluten and casein may have a role in the origins of autism and that the physiology and psychology of autism might be explained by excessive opioid activity linked to these peptides.  Research has reported abnormal levels of peptides in the urine and cerebrospinal fluid of people with autism.  These investigators examined the effectiveness of gluten and/or casein free diets as an intervention to improve behavior, cognitive and social functioning in individuals with autism.  The authors concluded that research has shown of high rates of use of complementary and alternative therapies for children with autism including gluten and/or casein exclusion diets.  However, current evidence for the effectiveness of these diets is poor.  They stated that large scale, good quality randomized controlled trials are needed.  This is in agreement with the observations of Curtis and Patel (2008) who stated that larger studies are needed to determine optimum multi-factorial treatment plans for autism and attention deficit hyperactivity disorder involving nutrition, environmental control, medication, as well as behavioral/education/speech/physical therapies.

The Tomatis sound therapy has been used to improve language skills in children with autism.  It entails the use classical music that includes complex rhythms, melodies and harmonic relationships known to create improved brain function.  The music is filtered with a device that Dr. Alfred Tomatis invented and called the Electronic Ear.  The filtering or "gating", which the Electronic Ear provides, creates a gymnastic program that activates and rehabilitates the middle ear muscles and the whole auditory system.  Programs are progressively filtered to gradually awaken the ear and auditory system to the full range of high frequencies.

Corbett et al (2008) examined the effects of the Tomatis sound therapy on language skills in children with autism utilizing a randomized, double-blind, placebo-controlled, cross-over design.  The results indicated that although the majority of the children demonstrated general improvement in language over the course of the study, it did not appear to be related to the treatment condition.  The percent change for Group 1 (placebo/treatment) for treatment was 17.41 %, and placebo was 24.84 %.  Group 2 (treatment/placebo) showed -3.98 % change for treatment and 14.15 % change for placebo.  The results reflect a lack of improvement in language using the Tomatis sound therapy for children with autism.

Hyperbaric Oxygen Therapy is a mode of treatment in which an individual breathes 100% oxygen at greater than normal atmospheric pressure. Rossignol and associates (2009) performed a multi-center, randomized, double-blind, controlled trial to evaluate the effectiveness of hyperbaric treatment in children with autism.  A total of 62 children with autism were recruited from 6 centers, aged 2 to 7 years (mean of 4.92 +/- 1.21 years).  Subjects were randomly assigned to 40 hourly treatments of either hyperbaric treatment at 1.3 atmosphere (atm) and 24 % oxygen (treatment group, n = 33) or slightly pressurized room air at 1.03 atm and 21 % oxygen (control group, n = 29).  Outcome measures included Clinical Global Impression (CGI) scale, Aberrant Behavior Checklist (ABC), and Autism Treatment Evaluation Checklist (ATEC).  After 40 sessions, mean physician CGI scores significantly improved in the treatment group compared to controls in overall functioning (p = 0.0008), receptive language (p < 0.0001), social interaction (p = 0.0473), and eye contact (p = 0.0102); 9/30 children (30 %) in the treatment group were rated as "very much improved" or "much improved" compared to 2/26 (8 %) of controls (p = 0.0471); 24/30 (80 %) in the treatment group improved compared to 10/26 (38 %) of controls (p = 0.0024).  Mean parental CGI scores significantly improved in the treatment group compared to controls in overall functioning (p = 0.0336), receptive language (p = 0.0168), and eye contact (p = 0.0322).  On the ABC, significant improvements were observed in the treatment group in total score, irritability, stereotypy, hyperactivity, and speech (p < 0.03 for each), but not in the control group.  In the treatment group compared to the control group, mean changes on the ABC total score and sub-scales were similar except a greater number of children improved in irritability (p = 0.0311).  On the ATEC, sensory/cognitive awareness significantly improved (p = 0.0367) in the treatment group compared to the control group.  Post-hoc analysis indicated that children over the age of 5 years and children with lower initial autism severity had the most robust improvements.  Hyperbaric treatment was safe and well-tolerated.  The authors concluded that children with autism who received hyperbaric treatment at 1.3 atm and 24 % oxygen for 40 hourly sessions had significant improvements in overall functioning, receptive language, social interaction, eye contact, and sensory/cognitive awareness compared to children who received slightly pressurized room air.

Moreover, the authors stated that because this study was not designed to measure the long-term outcomes of hyperbaric treatment in children with autism, additional studies are needed to determine if the significant improvements observed in this study last beyond the study period.  It is possible that ongoing treatments would be necessary to maintain the improvements observed, but this study was not designed to examine that possibility.  These findings suggest that additional hyperbaric treatments beyond 40 total sessions may lead to additional improvements; however, further studies are needed to formally validate these observations.  Finally, this study was not designed to determine if higher hyperbaric treatment parameters (higher atmospheric pressure and oxygen levels, which can only be provided in a clinic setting) would lead to better or more long-lasting results.  Additional studies are needed to investigate that possibility.

It is interesting to note that Yildiz and colleagues (2008) stated that neither the Undersea Hyperbaric Medical Society nor the European Committee for Hyperbaric Medicine "approves" autism as an indication for hyperbaric oxygen therapy.  The authors concluded that there is insufficient evidence to support the use of hyperbaric oxygen therapy in the treatment of children with autism.

It has been claimed that weighted blankets are beneficial for patients with autism since they "calm" the nervous system so afflicted individuals can relax and sleep.  It is believed that weighted blanket leads to releases of melatonin, which plays a role in the body and brain’s sensory processing.  Melantonin has been used for autistic children with sleep disorders despite insufficient evidence of its effectiveness in this population.  Moreover, there is a lack of evidence regarding the clinical benefits of weighted blankets for individuals with autism or other pervasive developmental disorders.

Stephenson and Carter (2009) noted that therapists who use sensory integration therapy may recommend that children wear weighted vests as an intervention strategy that they claim may assist in remediating problems such as inattentiveness, hyperactivity, stereotypic behaviors and clumsiness.  These investigators reviewed 7 studies on weighted vests.  The authors concluded that while there is only a limited body of research and a number of methodological weaknesses, on balance, indications are that weighted vests are ineffective.  There may be an arguable case for continued research on this intervention but weighted vests can not be recommended for clinical application at this point.

Floor time therapy is a series of 20- to 30-min periods during which parents interact and play with their autistic child on the floor.  The aim of the interaction is to promote social and communicative abilities.  A British Medical Journal Clinical Evidence systematic assessment on autism (Parr, 2006) concluded that the effectiveness of floor time therapy for autism is unknown.

Ichim and colleagues (2007) stated that ASDs are a group of neurodevelopmental conditions whose incidence is reaching epidemic proportions, afflicting approximately 1 in 166 children.  Autistic disorder, or autism is the most common form of ASD.  Although several neurophysiological alterations have been associated with autism, immune abnormalities and neural hypo-perfusion appear to be broadly consistent.  These appear to be causative since correlation of altered inflammatory responses, and hypo-perfusion with symptomatology was reported.  Mesenchymal stem cells (MSC) are in late phases of clinical development for treatment of graft versus host disease and Crohn's Disease, 2 conditions of immune dysregulation.  Cord blood CD34+ cells are known to be potent angiogenic stimulators, having demonstrated positive effects in not only peripheral ischemia, but also in models of cerebral ischemia.  Additionally, anecdotal clinical cases have reported responses in autistic children receiving cord blood CD34+ cells.  These researchers proposed the combined use of MSC and cord blood CD34+cells may be useful in the treatment of autism.

Thompson and colleagues (2010) summarized data from a review of neurofeedback (NFB) training with 150 patients with Asperger's syndrome (AS) and 9 patients with ASD seen over a 15-year period in a clinical setting.  The main objective was to examine if NFB (also known as EEG biofeedback) made a significant difference in patients diagnosed with AS.  A further aim of the current report was to provide practitioners with a detailed description of the method used to address some of the key symptoms of AS in order to encourage further research and clinical work to refine the use of NFB plus biofeedback in the treatment of AS.  All charts were included for review where there was a diagnosis of AS or ASD and pre- and post-training testing results were available for one or more of the standardized tests used.  Patients received 40 to 60 sessions of NFB, which was combined with training in meta-cognitive strategies and, for most older adolescent and adult patients, with biofeedback of respiration, electrodermal response, and, more recently, heart rate variability.  For the majority of patients, feedback was contingent on decreasing slow wave activity (usually 3 to 7 Hz), decreasing beta spindling if it was present (usually between 23 and 35 Hz), and increasing fast wave activity termed sensorimotor rhythm (SMR) (12 to 15 or 13 to 15 Hz depending on assessment findings).  The most common initial montage was referential placement at the vertex (CZ) for children and at FCz (midway between FZ and CZ) for adults, referenced to the right ear.  Meta-cognitive strategies relevant to social understanding, spatial reasoning, reading comprehension, and math were taught when the feedback indicated that the patient was relaxed, calm, and focused.  Significant improvements were found on measures of attention (T.O.V.A. and IVA), core symptoms (Australian Scale for Asperger's Syndrome, Conners' Global Index, SNAP version of the DSM-IV criteria for ADHD, and the ADD-Q), achievement (Wide Range Achievement Test), and intelligence (Wechsler Intelligence Scales). The average gain for the Full Scale IQ score was 9 points.  A decrease in relevant EEG ratios was also observed.  The ratios measured were (4 to 8 Hz)(2)/(13 to 21 Hz)(2), (4 to 8 Hz)/(16 to 20 Hz), and (3 to 7 Hz)/(12 to 15 Hz).  The positive outcomes of decreased symptoms of Asperger's and attention deficit hyperactivity disorder (including a decrease in difficulties with attention, anxiety, aprosodias, and social functioning) plus improved academic and intellectual functioning, provided preliminary support for the use of NFB as a helpful component of effective intervention in people with AS.

Massage involves manipulation of tissues (as by rubbing or kneading) with the hand or an instrument for therapeutic purposes. Lee et al (2011) examined the effectiveness of massage as a treatment option for autism.  These investigators searched the following electronic databases using the time of their inception through March 2010: MEDLINE, AMED, CINAHL, EMBASE, PsycINFO, Health Technology Assessment, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Psychology and Behavioral Sciences Collection, 6 Korean medical databases (KSI, DBpia, KISTEP, RISS, KoreaMed, and National Digital Library), China Academic Journal (through China National Knowledge Infrastructure), and 3 Japanese medical databases (Journal@rchive, Science Links Japan, and Japan Science & Technology link).  The search phrase used was "(massage or touch or acupressure) and (autistic or autism or Asperger's syndrome or pervasive developmental disorder)".  The references in all located articles were also searched.  No language restrictions were imposed.  Prospective controlled clinical studies of any type of massage therapy for autistic patients were included.  Trials in which massage was part of a complex intervention were also included.  Case studies, case series, qualitative studies, uncontrolled trials, studies that failed to provide detailed results, and trials that compared one type of massage with another were excluded.  All articles were read by 2 independent reviewers, who extracted data from the articles according to predefined criteria.  Risk of bias was assessed using the Cochrane classification.  Of 132 articles, only 6 studies met inclusion criteria.  One RCT found that massage plus conventional language therapy was superior to conventional language therapy alone for symptom severity (p < 0.05) and communication attitude (p < 0.01).  Two RCTs reported a significant benefit of massage for sensory profile (p < 0.01), adaptive behavior (p < 0.05), and language and social abilities (p < 0.01) as compared with a special education program.  The fourth RCT showed beneficial effects of massage for social communication (p < 0.05).  Two non-RCTs suggested that massage therapy is effective.  However, all of the included trials have high risk of bias.  The main limitations of the included studies were small sample sizes, predefined primary outcome measures, inadequate control for non-specific effects, and a lack of power calculations or adequate follow-up.  The authors concluded that limited evidence exists for the effectiveness of massage therapy as a symptomatic treatment of autism.  Because the risk of bias was high, firm conclusions can not be drawn.  They stated that future, more rigorous RCTs are warranted.

The Agency for Healthcare Research and Quality's report on comparative effectiveness of therapies for children with ASDs (AHRQ, 2011) has the following conclusions:

• Early intensive behavioral and developmental interventions such as the UCLA/Lovaas Model improve cognitive, language, and adaptive outcomes in certain subgroups of children (Low confidence scale).
• The evidence is insufficient to understand the effectiveness, benefits, or adverse events from any other behavioral interventions.
• Secretin does not improve language, cognition, behavior, communication, autism symptom severity, or socialization (High confidence scale).
• The evidence is insufficient to understand the effectiveness, benefits, or adverse events from any educational intervention.
• The evidence is insufficient to understand the effectiveness, benefits, or adverse events from any allied health or complementary and alternative medicine intervention.

In a Cochrane review, Sinha et al (2011) examined the effectiveness of AIT or other methods of sound therapy in individuals with ASDs.  For this update, these investigators searched the following databases in September 2010: CENTRAL (2010, Issue 2), MEDLINE (1950 to September week 2, 2010), EMBASE (1980 to Week 38, 2010), CINAHL (1937 to current), PsycINFO (1887 to current), ERIC (1966 to current), LILACS (September 2010) and the reference lists of published papers.  One new study was found for inclusion.  Randomized controlled trials involving adults or children with ASDs were reviewed.  Treatment was AIT or other sound therapies involving listening to music modified by filtering and modulation.  Control groups could involve no treatment, a waiting list, usual therapy or a placebo equivalent.  The outcomes were changes in core and associated features of ASDs, auditory processing, quality of life and adverse events.  Two independent review authors performed data extraction.  All outcome data in the included papers were continuous.  They calculated point estimates and standard errors from t-test scores and post-intervention means.  Meta-analysis was inappropriate for the available data.  These researchers identified 6 RCTs of AIT and 1 of Tomatis therapy, involving a total of 182 individuals aged 3 to 39 years.  Two were cross-over trials; 5 trials had fewer than 20 participants.  Allocation concealment was inadequate for all studies.  Twenty different outcome measures were used and only 2 outcomes were used by 3 or more studies.  Meta-analysis was not possible due to very high heterogeneity or the presentation of data in unusable forms.  Three studies (Bettison 1996; Zollweg 1997; Mudford 2000) did not demonstrate any benefit of AIT over control conditions.  Three studies (Veale 1993; Rimland 1995; Edelson 1999) reported improvements at 3 months for the AIT group based on the Aberrant Behaviour Checklist, but they used a total score rather than subgroup scores, which is of questionable validity, and Veale's results did not reach statistical significance.  Rimland (1995) also reported improvements at 3 months in the AIT group for the Aberrant Behaviour Checklist subgroup scores.  The study addressing Tomatis therapy (Corbett 2008) described an improvement in language with no difference between treatment and control conditions and did not report on the behavioral outcomes that were used in the AIT trials.  The authors concluded that there is no evidence that AIT or other sound therapies are effective as treatments for ASDs.  As synthesis of existing data has been limited by the disparate outcome measures used between studies, there is insufficient evidence to prove that this treatment is ineffective.  However, of the 7 studies including 182 participants that have been reported to date, only 2 (with an author in common), involving a total of 35 participants, reported statistically significant improvements in the AIT group and for only 2 outcome measures (Aberrant Behaviour Checklist and Fisher's Auditory Problems Checklist).  As such, there is no evidence to support the use of AIT at this time.

1. the study was a primary investigation/report published in an English peer-reviewed journal;
2. the study involved patients less than or equal to 18 years; and
3. patients are diagnosed with autism, Asperger's Syndrome, Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS), or ASD. 

Review of the literature revealed a total of 5 articles consisting of 3 case reports, 1 cohort study and 1 randomized comparison trial.  The literature is lacking on documenting chiropractic care of children with ASD.  These researchers stated that at the heart of the core symptoms of ASD (i.e., impaired social interactions, deficits in communication and repetitive or restricted behavioral patterns) is abnormal sensory processing.  Preliminary studies indicated that chiropractic adjustment may attenuate sensorimotor integration based on somatosensory evoked potentials studies.  The authors concluded that they encourage further research for definitive studies on chiropractic's effectiveness for ASD.

In a Cochrane review, James et al (2011) examined the efficacy of omega-3 fatty acids for improving core features of ASD (e.g., social interaction, communication, and stereotypies) and associated symptoms.  These investigators searched the following databases on June 2, 2010: CENTRAL (2010, Issue 2), MEDLINE (1950 to May Week 3 2010), EMBASE (1980 to 2010 Week 21), PsycINFO (1806 to current), BIOSIS (1985 to current), CINAHL (1982 to current), Science Citation Index (1970 to current), Social Science Citation Index (1970 to current), metaRegister of Controlled Trials (November 20, 2008) and ClinicalTrials.gov (December 10, 2010).  Dissertation Abstracts International was searched on December 10, 2008, but was no longer available to the authors or editorial base in 2010.  All RCTs of omega-3 fatty acids supplementation compared to placebo in individuals with ASD were reviewed.  Three authors independently selected studies, assessed them for risk of bias and extracted relevant data.  They conducted meta-analysis of the included studies for 3 primary outcomes (social interaction, communication, and stereotypy) and 1 secondary outcome (hyper-activity).  These researchers included 2 trials with a total of 37 children diagnosed with ASD who were randomized into groups that received either omega-3 fatty acids supplementation or a placebo.  They excluded 6 trials because they were either non-RCTs, did not contain a control group, or the control group did not receive a placebo.  Overall, there was no evidence that omega-3 supplements had an effect on social interaction (mean difference (MD) 0.82, 95 % confidence interval [CI]: -2.84 to 4.48, I(2) = 0 %), communication (MD 0.62, 95 % CI: -0.89 to 2.14, I(2) = 0 %), stereotypy (MD 0.77, 95 % CI: -0.69 to 2.22, I(2) = 8 %), or hyper-activity (MD 3.46, 95 % CI: -0.79 to 7.70, I(2) = 0 %).  The authors concluded that to date there is no high quality evidence that omega-3 fatty acids supplementation is effective for improving core and associated symptoms of ASD.  Given the paucity of rigorous studies in this area, there is a need for large well-conducted RCTs that examine both high- and low-functioning individuals with ASD, and that have longer follow-up periods.

Wuang et al (2010) examined the effectiveness of a 20-week Simulated Developmental Horse-Riding Program (SDHRP) by using an innovative exercise equipment (Joba) on the motor proficiency and sensory integrative functions in 60 children with autism (age of 6 years, 5 months to 8 years, 9 months).  In the 1st phase of 20 weeks, 30 children received the SDHRP in addition to their regular occupational therapy while another 30 children received regular occupational therapy only.  The arrangement was reversed in the 2nd phase of another 20 weeks.  Children with autism in this study showed improved motor proficiency and sensory integrative functions after 20-week SDHRP (p < 0.01).  In addition, the therapeutic effect appeared to be sustained for at least 24 weeks (6 months).  This study utilized Joba, an exercise equipment that served as simulated horseback riding; not conventional horseback riding. 

1. before beginning a 3-to-6 month waiting period,
2. before starting the riding treatment,
3. after 3 months, and
4. 6 months of riding.

A total of 24 participants completed the waiting list period and began the riding program, and 20 participants completed the entire 6 months of riding.  Pre-treatment was compared to post-treatment with each child acting as his or her own control.  A reduction in the severity of autism symptoms occurred with the therapeutic riding treatment.  There was no change in CARS scores during the pre-treatment baseline period; however, there was a significant decrease after treatment at 3 months and 6 months of riding.  The Timberlawn Parent-Child Interaction Scale showed a significant improvement in Mood and Tone at 3 months and 6 months of riding and a marginal improvement in the reduction of Negative Regard at 6 months of riding.  The parent-rated quality of life measure showed improvement, including the pre-treatment waiting period.  All of the ratings in the Treatment Satisfaction Survey were between good and very good.  The authors concluded that these results suggested that children with ASD benefit from equine-assisted activities.  The findings of this small study need to be validated by well-designed studies.

An UpToDate review on “Autism spectrum disorder in children and adolescents: Overview of management” (Weissman and Bridgemohan, 2013a) does not mention the use of hippotherapy as a management tool.  Furthermore, an UpToDate review on “Autism spectrum disorders in children and adolescents: Complementary and alternative therapies” (Weissman and Bridgemohan, 2013b) states that “The use of therapeutic horseback riding (hippotherapy) for children with ASD is based upon the hypothesis that therapeutic horseback riding stimulates multiple domains of functioning (e.g., cognitive, social, gross motor).  In a nonrandomized study, 19 children with autism who participated in 12 weeks of therapeutic horseback riding (hippotherapy) demonstrated improvements in attention, distractibility, and social motivation compared with 15 wait-list controls.  Additional studies are necessary before this therapy can be recommended”.

1. improves the core features of autism (social interaction, communication and behavioral problems);
2. improves other non-core aspects of behavior or function such as self-injurious behavior;
3. improves the quality of life of adults or children and their carers;
4. has short- and long-term effects on outcome; and
5. causes harm. 

These investigators searched the following databases up until March 2013: CENTRAL, Ovid MEDLINE, Embase, CINAHL, PsycINFO, ERIC and Sociological Abstracts.  They also searched ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP).  This was supplemented by searching reference lists and contacting known experts in the field.  Randomized controlled trials of any dose of oral SSRI compared with placebo, in people with ASD were selected for analysis.  Two authors independently selected studies for inclusion, extracted data and appraised each study's risk of bias.  A total of 9 RCTs with 320 participants were included.  Four SSRIs were evaluated: fluoxetine (3 studies), fluvoxamine (2 studies), fenfluramine (2 studies) and citalopram (2 studies).  Five studies included only children and 4 studies included only adults.  Varying inclusion criteria were used with regard to diagnostic criteria and intelligence quotient of participants; 18 different outcome measures were reported.  Although more than 1 study reported data for Clinical Global Impression (CGI) and obsessive-compulsive behavior (OCB), different tool types or components of these outcomes were used in each study.  As such, data were unsuitable for meta-analysis, except for 1 outcome (proportion improvement).  One large, high-quality study in children showed no evidence of positive effect of citalopram; 3 small studies in adults showed positive outcomes for CGI and OCB; 1 study showed improvements in aggression, and another in anxiety.  The authors concluded that there is no evidence of effect of SSRIs in children and emerging evidence of harm.  There is limited evidence of the effectiveness of SSRIs in adults from small studies in which risk of bias is unclear.

Furthermore, an UpToDate review on “Autism spectrum disorder in children and adolescents: Pharmacologic interventions” (Weissman and Bridgemohan, 2014) lists SSRI as one of the potential treatments for repetitive behaviors, stereotypies, and rigidity in children with ASD.  The review also notes that “When used in children and adolescents with depression, SSRI have been associated with increased suicidal ideation.  Increased suicidal ideation has not been demonstrated in studies of SSRI in individuals with ASD.  However, most studies did not assess suicidal ideation and included too few subjects to detect rare adverse effects, such as suicidal ideation”.

In an open-label study, Erickson et al (2014) evaluated the safety, tolerability, and effectiveness of arbaclofen, a selective GABA-B agonist, in non-syndromic ASD.  This study enrolled 32 children and adolescents with either autistic disorder or PDD-not otherwise specified, and a score greater than or equal to 17 on the ABC-Irritability subscale.  Arbaclofen was generally well-tolerated.  The most common adverse events were agitation and irritability, which typically resolved without dose changes, and were often felt to represent spontaneous variation in underlying symptoms.  Improvements were observed on several outcome measures in this exploratory trial, including the ABC-Irritability (the primary end-point) and the Lethargy/Social Withdrawal subscales, the Social Responsiveness Scale, the CY-BOCS-PDD, and CGI scales.  The authors concluded that placebo-controlled study of arbaclofen is needed.

Latent Class Analysis

Kyriakopoulos et al (2015) stated that in children with ASD, high rates of idiosyncratic fears and anxiety reactions and thought disorder are thought to increase the risk of psychosis.  The critical next step is to identify whether combinations of these symptoms can be used to categorize individual patients into ASD subclasses, and to test their relevance to psychosis.  In this study, all patients with ASD (n = 84) admitted to a specialist national inpatient unit from 2003 to 2012 were rated for the presence or absence of impairment in affective regulation and anxiety (peculiar phobias, panic episodes, explosive reactions to anxiety), social deficits (social disinterest, avoidance or withdrawal and abnormal attachment) and thought disorder (disorganized or illogical thinking, bizarre fantasies, over-valued or delusional ideas).  Latent class analysis of individual symptoms was conducted to identify ASD classes.  External validation of these classes was performed using as a criterion the presence of hallucinations.  Latent class analysis identified 2 distinct classes.  Bizarre fears and anxiety reactions and thought disorder symptoms differentiated ASD patients into those with psychotic features (ASD-P: 51 %) and those without (ASD-NonP: 49 %).  Hallucinations were present in 26 % of the ASD-P class but only 2.4 % of the ASD-NonP.  Both the ASD-P and the ASD-NonP class benefited from inpatient treatment although inpatient stay was prolonged in the ASD-P class.  The authors concluded that the findings of this study provided the first empirically derived classification of ASD in relation to psychosis based on 3 underlying symptom dimensions, anxiety, social deficits and thought disorder.  They stated that these results can be further developed by testing the reproducibility and prognostic value of the identified classes.

Tests for Glutamatergic Candidate Genes

Chiocchetti and associates (2014) noted that ASD are neurodevelopmental disorders with early onset in childhood.  Most of the risk for ASD can be explained by genetic variants that act in interaction with biological environmental risk factors.  However, the architecture of the genetic components is still unclear.  Genetic studies and subsequent systems biological approaches described converging functional effects of identified genes towards pathways relevant for neuronal signaling.  Mouse models suggested an aberrant synaptic plasticity at the neuropathological level, which is believed to be conferred by dysregulation of long-term potentiation or depression of neuronal connections.  A central pathway regulating these mechanisms is glutamatergic signaling.  These researchers hypothesized that susceptibility genes for ASD are enriched for components of this pathway.  To further understand the impact of ASD risk genes on the glutamatergic pathway, these investigators performed a systematic review using the literature database "PubMed" and the "AutismKB" knowledgebase.  They provided an overview of the glutamatergic system in typical brain function and development, and summarized findings from linkage, association, copy number variants, and sequencing studies in ASD to provide a comprehensive picture of the glutamatergic landscape of ASD genetics.  Genetic variants associated with ASD were enriched in glutamatergic pathways, affecting receptor signaling, metabolism and transport.  Furthermore, in genetically modified mouse models for ASD, pharmacological compounds acting on ionotropic or metabotropic receptor activity were able to rescue ASD reminiscent phenotypes.  The authors concluded that glutamatergic genetic risk factors for ASD showed a complex pattern and further studies are needed to fully understand its mechanisms, before translation of findings into clinical applications and individualized treatment approaches will be possible.

Electro-Convulsive Therapy

DeJong et al (2014) performed a systematic review to examine the effectiveness of a range of treatments for autistic catatonia.  The review identified 22 relevant papers, reporting a total of 28 cases including both adult and pediatric patients.  Treatments included electro-convulsive therapy (ECT), medication, behavioral and sensory interventions.  Quality assessment found the standard of the existing literature to be generally poor, with particular limitations in treatment description and outcome measurement.  The authors concluded that there was some limited evidence to support the use of ECT, high dose lorazepam and behavioral interventions for people with autistic catatonia; however, there is a need for controlled, high-quality trials.  They also noted that reporting of side effects and adverse events should also be improved, in order to better evaluate the safety of these treatments.

Oxytocin Therapy

Tachibana et al (2013) stated that oxytocin (OT) has been a candidate for the treatment of ASD, and the impact of intra-nasally delivered OT on ASD has been investigated.  However, most previous studies were conducted by single-dose administration to adults; and, therefore, the long-term effect of nasal OT on ASD patients and its effect on children remain to be clarified.  These researchers conducted a singled-armed, open-label study in which OT was administered intra-nasally over the long term to 8 male youth with ASD (10 to 14 years of age; intelligence quotient [IQ] 20 to 101).  The OT administration was performed in a step-wise increased dosage manner every 2 months (8, 16, 24 IU/dose).  A placebo period (1 to 2 weeks) was inserted before each step.  The outcome measures were autism diagnostic observation schedule -- generic (ADOS-G), child behavior checklist (CBCL), and the aberrant behavior checklist (ABC).   In addition, side effects were monitored by measuring blood pressure and examining urine and blood samples.  Six of the 8 participants showed improved scores on the communication and social interaction domains of the ADOS-G.  However, regarding the T-scores of the CBCL and the scores of the ABC, these investigators could not find any statistically significant improvement, although several subcategories showed a mild tendency for improvement.  Care-givers of 5 of the 8 participants reported certain positive effects of the OT therapy, especially on the quality of reciprocal communication.  All participants showed excellent compliance and no side effects.  The authors concluded that although these findings on the effectiveness of long-term nasal OT therapy still remain controversial, to the best of these researchers’ knowledge, this was the first report documenting the safety of long-term nasal OT therapy for children with ASD.  They stated that even though these data were too preliminary to draw any definite conclusions about effectiveness, they do suggest this therapy to be safe, promising, and worthy of a large-scale, double-blind placebo-controlled study.

Anagnostou et al (2014) reviewed the literature for OT and ASD and reported on early dosing, safety and efficacy data of multi-dose OT on aspects of social cognition/function, as well as repetitive behaviors and co-occurring anxiety within ASD.  A total of 15 children and adolescents with verbal IQs greater than or equal to 70 were diagnosed with ASD using the ADOS and the ADI-R.  They participated in a modified maximum tolerated dose study of intra-nasal OT (Syntocinon).  Data were modeled using repeated measures regression analysis controlling for week, dose, age, and sex.  Among 4 doses tested, the highest dose evaluated, 0.4 IU/kg/dose, was found to be well-tolerated.  No serious or severe adverse events were reported and adverse events reported/observed were mild-to-moderate.  Over 12 weeks of treatment, several measures of social cognition/function, repetitive behaviors and anxiety showed sensitivity to change with some measures suggesting maintenance of effect 3 months past discontinuation of intra-nasal OT.  The authors concluded that the findings of this pilot study suggested that daily administration of intra-nasal OT at 0.4 IU/kg/dose in children and adolescents with ASD is safe and has therapeutic potential.  Moreover, they stated that larger studies are needed.

Preti et al (2014) noted that little is known about the effectiveness of pharmacological interventions on ASD.  These investigators performed a systematic review of RCTs of OT interventions in autism (from January 1990 to September 2013).  A search of computerized databases was supplemented by manual search in the bibliographies of key publications.  The methodological quality of the studies included in the review was evaluated independently by 2 researchers, according to a set of formal criteria.  Discrepancies in scoring were resolved through discussion.  The review yielded 7 RCTs, including 101 subjects with ASD (males = 95) and 8 males with Fragile X syndrome.  The main categories of target symptoms tested in the studies were repetitive behaviors, eye gaze, and emotion recognition.  The studies had a medium to high risk of bias.  Most studies had small samples (median = 15).  All the studies but 1 reported statistically significant between-group differences on at least 1 outcome variable.  Most findings were characterized by medium effect size.  Only 1 study had evidence that the improvement in emotion recognition was maintained after 6 weeks of treatment with intra-nasal OT.  Overall, OT was well-tolerated and side effects, when present, were generally rated as mild; however, restlessness, increased irritability, and increased energy occurred more often under OT.  The authors concluded that RCTs of OT interventions in autism yielded potentially promising findings in measures of emotion recognition and eye gaze, which were impaired early in the course of the ASD condition and might disrupt social skills learning in developing children.  They stated that there is a need for larger, more methodologically rigorous RCTs in this area.  They noted that future studies should be better powered to estimate outcomes with medium to low effect size, and should try to enroll female participants, who were rarely considered in previous studies; risk of bias should be minimized.  These researchers stated that human long-term administration studies are needed before clinical recommendations can be made.

1. the intra-nasally delivered OT may diffuse directly into the CNS where it directly engages OT receptors;
2. the intra-nasally delivered OT may trigger increased central release via an indirect peripheral mechanism; and
3. the indirect peripheral effects may directly lead to behavioral effects via some mechanism other than increased central release. 

Although intra-nasally delivered OT likely affects behavior, there are conflicting reports as to the exact nature of those behavioral changes: some studies suggested that OT effects are not always "pro-social" and others suggested effects on social behaviors are due to a more general anxiolytic effect.  In this critique, the authors drew from work in healthy human populations and the animal literature to review the mechanistic aspects of intra-nasal OT delivery, and discussed intra-nasal OT effects on social cognition and behavior.  They concluded that future work should control carefully for anxiolytic and gender effects, which could underlie inconsistencies in the existing literature.

Quintana et al (2015) stated that accumulating evidence demonstrated the important role of OT in the modulation of social cognition and behavior.  This has led many to suggest that the intra-nasal administration of OT may benefit psychiatric disorders characterized by social dysfunction, such as ASD and schizophrenia.  These investigators reviewed nasal anatomy and OT pathways to central and peripheral destinations, along with the impact of OT delivery to these destinations on social behavior and cognition.  The primary goal of this review is to describe how these identified pathways may contribute to mechanisms of OT action on social cognition and behavior (i.e., modulation of social information processing, anxiolytic effects, increases in approach-behaviors).  The authors proposed a 2-level model involving 3 pathways to account for responses observed in both social cognition and behavior after intra-nasal OT administration and suggested avenues for future research to advance this research field.

Furthermore, an UpToDate review on “Autism spectrum disorder in children and adolescents: Pharmacologic interventions” (Weissman and Bridgemohan, 2015) states that “Pharmacologic agents that demonstrated potential benefit for social deficits in individuals with autism spectrum disorder in small open-label studies include oxytocin, D-cycloserine, tetrahydrobiopterin, and cognition enhancers used in the treatment of Alzheimer disease (e.g., galantamine, memantine, and rivastigmine).  Additional controlled studies are necessary to confirm efficacy and safety before these therapies can be recommended”.

Tests for Olfactory Function

Tonacci and colleagues (2017) stated that olfactory function is a well-known early biomarker for neurodegeneration and neural functioning in the adult population, being supported by a number of brain structures that could be dysfunctioning in neurodegenerative processes. Evidence has suggested that atypical sensory and, particularly, olfactory processing is present in several neurodevelopmental conditions, including ASDs.  These investigators presented data obtained by a systematic literature review, conducted according to PRISMA guidelines, regarding the possible association between olfaction and ASDs, and analyzed them critically in order to evaluate the occurrence of olfactory impairment in ASDs, as well as the possible usefulness of olfactory evaluation in such conditions.  The results obtained in this analysis suggested a possible involvement of olfactory impairment in ASDs, underlining the importance of olfactory evaluation in the clinical assessment of ASDs.  The authors concluded that this assessment could be potentially included as a complementary evaluation in the diagnostic protocol of the condition.

Whole-Exome Sequencing

1. essential,
2. equivocal, and
3. complex (scores of 0 to 3, 4 to 5, and greater than or equal to 6). 

All probands underwent CMA, with WES performed for 95 proband-parent trios.  Main outcome measure was the overall molecular diagnostic yield for CMA and WES in a population-based ASD sample stratified in 3 phenotypic groups.  Of 258 probands, 24 (9.3 %, 95 % CI: 6.1 % to 13.5 %) received a molecular diagnosis from CMA and 8/95 (8.4 %, 95 % CI: 3.7 % to 15.9 %) from WES.  The yields were statistically different between the morphological groups.  Among the children who underwent both CMA and WES testing, the estimated proportion with an identifiable genetic etiology was 15.8 % (95 % CI: 9.1 % to 24.7 %; 15/95 children).  This included 2 children who received molecular diagnoses from both tests.  The combined yield was significantly higher in the complex group when compared with the essential group (pair-wise comparison, p = 0.002).  The authors concluded that among a heterogeneous sample of children with ASD, the molecular diagnostic yields of CMA and WES were comparable, and the combined molecular diagnostic yield was higher in children with more complex morphological phenotypes in comparison with the children in the essential category.  They stated that if replicated in additional populations, these findings may inform appropriate selection of molecular diagnostic testing for children affected by ASD.  The drawbacks of this study were:

1. a relatively small sample size as well as possible ascertainment bias related to the clinical differences that may have existed between families who consented and declined (less than 10 % declined to participate in the study after diagnosis in the developmental pediatric clinics),
2. only 63.5 % of the children had brain MRI, which may have skewed the final morphological classification in favor of the  essential group, and only 49.2 % (127/258) of the study sample underwent IQ testing,
3. only 36.8 % (95/258) of the children were included in the WES analysis, which could have led to an unmeasured confounding effect on the results,
4. WES does not provide equal coverage for all the coding sequence regions, and lacks sensitivity and specificity for the detection of structural variants, and
5. the resolution limits of CMA, the inability to detect the majority of larger indels (greater than20 base pairs) and smaller CNVs (less than 20 kilobases).

Screening in Young Children

1. American Academy of Family Physicians (2015) which states that the current evidence is insufficient to assess the balance of benefits and harms of screening for ASD in children for whom no concerns of ASD have been raised by their parents or clinical provider, and
2. the UK national Screening Committee (2015), which does not recommend systematic population screening, citing concerns about the stability of ASD diagnosis at a young age, lack of data on positive predictive value, and weakness of the evidence for the efficacy of treatment.

GABAergic Agents

Brondino et al (2016) stated that it has been hypothesized that autism may result from an imbalance between excitatory glutamatergic and inhibitory GABAergic pathways. Commonly used medications such as valproate, acamprosate, and arbaclofen may act on the GABAergic system and be a potential treatment for people with ASD.  These investigators evaluated the state-of-the-art of clinical trials of GABA modulators in autism.  The authors concluded that there is insufficient evidence to suggest the use of these drugs in autistic subjects, even if data are promising.  They stated that short-term use of all the reviewed medications appeared to be safe; however, future well-designed trials are needed to elucidate these preliminary findings.

Nutritional Therapy

Sausmikat and Smollich (2016) provided evidence-based data on nutritional interventions for children and adolescents with ASD, thus enabling practitioners to competently assess these diets. Applying defined inclusion and exclusion criteria, a systematic literature research in PubMed, Cinahl and the Cochrane Library was conducted.  Studies published earlier than 1999 were excluded.  Study quality was assessed by using the CONSORT, STROBE or PRISMA checklist, respectively.  A total of 12 RCTs and 2 non-controlled studies were included in the evaluation (n = 971).  There is no proven efficacy of the widely used gluten-free and casein-free diets (GFCF), and no respective predictive marker has been proven significant.  The authors concluded that based on available data, no evidence-based recommendations regarding nutritional interventions for children and adolescents with ASD can be made.  They stated that future studies need to clarify whether particular patients may yet benefit from certain diets.

Genetic Testing for DRD2, HTR2C, MTHFR, RELN, SLC25A12 and UGT2B15

Wang and associates (2014) noted that the reelin gene (RELN), which plays a crucial role in the migration and positioning of neurons during brain development, has been strongly posed as a candidate gene for ASD.  Genetic variants in RELN have been investigated as risk factors of ASD in numerous epidemiologic studies but with inconclusive results.  To clearly discern the effects of RELN variants on ASD, these researchers conducted a meta-analysis integrating case-control and transmission disequilibrium test (TDT) studies published through 2001 to 2013.  Odds ratios (ORs) with 95 % CIs were used to estimate the associations between 3 RELN variants (rs736707, rs362691, and GGC repeat variant) and ASD.  Overall, the summary ORs for rs736707, rs362691, and GGC repeat variant were 1.11 [95 % CI: 0.80 to 1.54], 0.69 (95 % CI: 0.56 to 0.86), and 1.09 (95 % CI: 0.97 to 1.23), respectively.  Besides, positive result was also obtained in subgroup of broadly-defined ASD for rs362691 (OR = 0.67, 95 % CI: 0.52 to 0.86).  The authors concluded that the findings of this meta-analysis revealed that the RELN rs362691, rather than rs736707 or GGC repeat variant, might contribute to ASD risk.

Liu and colleagues (2015) noted that the solute carrier family 25 (aspartate/glutamate carrier), member 12 gene (SLC25A12) has been suggested as a candidate gene for ASD given its role in mitochondrial function and adenosine triphosphate (ATP) synthesis.  Evidence is growing for the association between SLC25A12 variants (rs2056202 and rs2292813) and ASD risk, but the results are inconsistent.  To clarify the effect of these 2 variants on ASD, these researchers performed a meta-analysis integrating case-control and TDT studies.  The PubMed, Embase, Cochrane Library, Web of Science, Chinese BioMedical Literature, Wanfang, and Chinese National Knowledge Infrastructure databases were systematically searched to identify relevant studies published up to May 2014; ORs and 95 % CIs were calculated to assess the strength of association.  A total of 775 cases, 922 controls, and 1,289 families available from 8 studies concerning rs2056202, and 465 cases, 450 controls, and 1,516 families available from 7 studies concerning rs2292813 were finally included.  In the overall meta-analysis, the rs2056202 T allele and rs2292813 T allele were both significantly associated with a decreased risk of ASD (rs2056202: OR = 0.809, p = 0.001, 95 % CI: 0.713 to 0.917, I(2) = 0.0 %, and p (heterogeneity) = 0.526; rs2292813: OR = 0.752, p < 0.001, 95 % CI: 0.649 to 0.871, I(2) = 0.0 %, p (heterogeneity) = 0.486).  Besides, subjects with T-T haplotype of rs2056202-rs2292813 had a significantly reduced risk of ASD (OR = 0.672, p < 0.001, 95 % CI: 0.564 to 0.801, I(2) = 0.0 %, p (heterogeneity) = 0.631).  Sensitivity analysis, cumulative meta-analysis, and publication bias diagnostics confirmed the reliability and stability of these results.  The authors concluded that the findings of this meta-analysis suggested that rs2056202 and rs2292813 in SLC25A12 may contribute to ASD risk.

Aoki and Cortese (2016) stated that mitochondrial dysfunction has been reported to be involved in the pathophysiology of ASD.  Studies investigating the possible association between ASD and polymorphism in SLC25A12, which encodes the mitochondrial aspartate/glutamate carrier, have yielded inconsistent results.  These researchers conducted a systematic review and meta-analysis of such studies to elucidate if and which SLC25A12 single nucleotide polymorphisms (SNPs) are associated with ASD.  They searched PubMed, Ovid, Web of Science, and ERIC databases through September 20, 2014; ORs were aggregated using random effect models.  Sensitivity analyses were conducted based on study design (family-based or case-control); 15 out of 79 non-duplicate records were retained for qualitative synthesis.  These investigators pooled 10 datasets from 9 studies with 2,001 families, 735 individuals with ASD and 632 typically developing (TD) individuals for the meta-analysis of rs2292813, as well as 11 datasets from 10 studies with 2,016 families, 852 individuals with ASD and 1,058 TD individuals for the meta-analysis of rs2056202.  They found a statistically significant association between ASD and variant in rs2292813 (OR = 1.190, 95 % CI: 1.052 to 1.346, p = 0.006) as well as in rs2056202 (OR = 1.206, 95 % CI: 1.035 to 1.405, p = 0.016).  Sensitivity analyses including only studies with family-based design demonstrated significant association between ASD and polymorphism in rs2292813 (OR = 1.216, 95 % CI: 1.075 to 1.376, p = 0.002) and rs2056202 (OR = 1.267, 95 % CI: 1.041 to 1.542, p = 0.018).  In contrast, sensitivity analyses including case-control design studies only failed to find a significant association.  The authors concluded that further research on the role of SLC25A12 and ASD may pave the way for potential innovative therapeutic interventions.

Long and Goldblatt (2016) noted that a polymorphism is a variant within a gene that does not necessarily affect its function, unlike a pathogenic mutation.  Genetic testing for 2 common polymorphisms in the methylenetetrahydrofolate reductase gene (MTHFR), 677C>T and 1298A>C, is being accessed by general practitioners (GPs) and alternative medicine practitioners (based on in-house records from referrals), and promoted through some pharmacies in Western Australia (based on the authors' personal communication).  Due to the large, varied and often conflicting data reported on MTHFR, these polymorphisms have been weakly associated with multiple conditions, including autism, schizophrenia, cardiac disease, fetal neural tube defects, poor pregnancy outcomes and colorectal cancer.  These investigators explained the difficulty in translating inconclusive results -- and results of uncertain clinical relevance -- of genetic-association studies on common polymorphisms into clinical practice.  They explored why testing for polymorphisms needs to be re-considered in a diagnostic clinical setting.  The authors concluded that on the basis of the available scientific evidence, they proposed that there are very limited clinical indications for testing for the 677C>T and the 1298A>C polymorphisms in the MTHFR gene, and that testing is not indicated as a non-specific screening test in the asymptomatic general population.

1. they focused their search on economic evaluations of genetic tests for ASD, and
2. they searched for any economic evaluation (EE) of genetic tests. 

These researchers identified 185 EE of genetic tests for various diseases.  However, not a single EE of genetic tests has been found for ASD.  The outcomes used in the EE of the genetic tests were heterogeneous, and results were generally not comparable.  The authors concluded that there is no evidence for cost-effectiveness of any genetic diagnostic test for ASD, although such genetic tests are available commercially.  They stated that cost-effectiveness analyses for genetic diagnostic tests for ASD are needed; there is a clear lack in research for EE of genetic tests.

Furthermore, an UpToDate review on “Autism spectrum disorder: Diagnosis” (Augustyn, 2017) does not mention testing for the DRD2, HTR2C, MTHFR, RELN, SLC25A12 and UGT2B15 genes.

Emotion Recognition Training for the Treatment of Autism Spectrum Disorder

Berggren and colleagues (2018) evaluated the generalizability of findings from RCTs evaluating emotion recognition training (ERT) for children and adolescents with ASD.  These investigators presented a systematic review and narrative synthesis of the determinants of external validity in RCTs on ERT.  Generalizability of the findings across situations, populations, settings, treatment delivery, and intervention formats was considered.  These researchers identified 13 eligible studies.  Participants were predominantly boys with ASD in the normative IQ range (IQ over 70), with an age span from 4 to 18 years across studies.  Interventions and outcome measures were highly variable.  Several studies indicated that training may improve ER, but it is still largely unknown to what extent training effects are translated to daily social life.  The authors concluded that the generalizability of findings from currently available RCTs remains unclear.

Memantine for the Treatment of Autism Spectrum Disorder

In a prospective, 12-week, open-label, clinical  trial, Joshi and colleagues (2016) evaluated the tolerability and effectiveness of memantine for the treatment of core social and cognitive deficits in adults with high-functioning ASD.  Measures for assessment of therapeutic response included the Social Responsiveness Scale-Adult Research Version (SRS-A), disorder-specific Clinical Global Impression scales, Behavior Rating Inventory of Executive Functioning-Adult Self-Report, Diagnostic Analysis of Nonverbal Accuracy Scale, and Cambridge Neuropsychological Test Automated Battery.  A total of 18 adults (mean age of 28 ± 9.5 years) with high-functioning ASD (SRS-A raw score, 99 ± 17) were treated with memantine (mean dose of 19.7 ± 1.2 mg/day; range of 15 to 20 mg), and 17 (94 %) completed the trial.  Treatment with memantine was associated with significant reduction on informant-rated (SRS-A, -28 ± 25; p < 0.001) and clinician-rated (Clinical Global Impression-Improvement subscale ≤ 2, 83 %) measures of autism severity.  In addition, memantine treatment was associated with significant improvement in ADHD and anxiety symptom severity.  Significant improvement was noted in nonverbal communication on the Diagnostic Analysis of Nonverbal Accuracy Scale test and in executive function per self-report (Behavior Rating Inventory of Executive Functioning-Adult Self-Report Global Executive Composite, -6 ± 8.8; p < 0.015) and neuropsychological assessments (Cambridge Neuropsychological Test Automated Battery).  Memantine treatment was generally well-tolerated and was not associated with any serious adverse events (AEs).  The authors concluded that treatment with memantine appeared to be beneficial for the treatment of ASD and associated psychopathology and cognitive dysfunction in intellectually capable adults.  Moreover, they stated that future placebo-controlled trials are needed.

In a 12-week, randomized, placebo-controlled, study with a 48-week open-label extension, Aman and associates (2017) examined the safety, tolerability, and effectiveness of memantine (once-daily extended-release [ER]) in children with autism.  A total of 121 children aged  6 to 12 years with Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR)-defined autistic disorder were randomized (1:1) to placebo or memantine ER for 12 weeks; 104 children entered the subsequent extension trial.  Maximum memantine doses were determined by body weight and ranged from 3 to 15 mg/day.  There was 1 serious adverse event (SAE) (affective disorder, with memantine) in the 12-week study and 1 SAE (lobar pneumonia) in the 48-week extension; both were deemed unrelated to treatment.  Other AEs were considered mild or moderate and most were deemed not related to treatment.  No clinically significant changes occurred in clinical laboratory values, vital signs, or electrocardiogram (ECG).  There was no significant between-group difference on the primary effectiveness outcome of caregiver/parent ratings on the SRS, although an improvement over baseline at week 12 was observed in both groups.  A trend for improvement at the end of the 48-week extension was observed.  No improvements in the active group were observed on any of the secondary end-points, with 1 communication measure showing significant worsening with memantine compared with placebo (p = 0.02) after 12 weeks.  The authors concluded that this trial did not demonstrate clinical effectiveness of memantine ER in autism; however, the tolerability and safety data were reassuring.  They noted that these findings could inform future trial design in this population and may facilitate the investigation of memantine ER for other clinical applications.

Furthermore, the largest RCT study of memantine for ASD, conducted by Forrest Pharmaceuticals, had negative results.  Since this was a negative trial, the results have not been published but are posted on ClinicalTrials.gov.

FDA-approved Pharmacotherapy for Autism

As of 2017, there were two FDA-approved medications on the market for the treatment of irritability associated with autistic disorder, risperidone and aripiprazole.

In 2006, the U.S. Food and Drug Administration (FDA) approved Risperdal (risperidone) for the treatment of irritability associated with autistic disorder, including symptoms of aggression, deliberate self-injury, temper tantrums, and quickly changing moods, in children and adolescents aged 5 to 16 years. This was noted to be the first FDA-approved medication for use in children and adolescents with autism (BioSpace, 2006). The drug is marketed by Janssen, L.P, a subsidiary of Johnson & Johnson.

In a systematic review on novel and emerging treatments for ASD, Rossignol (2009) stated that risperidone was FDA-approved for the treatment of ASD.  The use of novel, unconventional, and off-label treatments for ASD is common, with up to 74 % of children with ASD using these treatments; however, treating physicians are often unaware of this usage.  The author performed a systematic review of electronic scientific databases to identify studies of novel and emerging treatments for ASD, including nutritional supplements, diets, medications, and non-biological treatments.  A grade of recommendation ("Grade") was then assigned to each treatment using a validated evidence-based guideline as outlined in this review: Grade A: Supported by at least 2 prospective randomized controlled trials (RCTs) or 1 systematic review; Grade B: Supported by at least 1 prospective RCT or 2 non-RCTs; Grade C: Supported by at least 1 non-RCT or 2 case series; and Grade D: Troublingly inconsistent or inconclusive studies or studies reporting no improvements.  Potential adverse effects for each treatment were also reviewed.  Grade A treatments for ASD include melatonin, acetylcholinesterase inhibitors, naltrexone, and music therapy.  Grade B treatments include carnitine, tetrahydrobiopterin, vitamin C, alpha-2 adrenergic agonists, hyperbaric oxygen treatment, immunomodulation and anti-inflammatory treatments, oxytocin, and vision therapy.  Grade C treatments for ASD include carnosine, multi-vitamin/mineral complex, piracetam, polyunsaturated fatty acids, vitamin B6/magnesium, elimination diets, chelation, cyproheptadine, famotidine, glutamate antagonists, acupuncture, AIT, massage, and neurofeedback.  The author concluded that the reviewed treatments for ASD are commonly used, and some are supported by prospective RCTs.  Promising treatments include melatonin, antioxidants, acetylcholinesterase inhibitors, naltrexone, and music therapy.  All of the reviewed treatments are currently considered off-label for ASD and some have adverse effects.  The author stated that further studies exploring these treatments are needed.

In 2009, Bristol-Myers Squibb Company announced the FDA approval of Abilify (aripiprazole) for the treatment of irritability associated with autistic disorder in pediatric patients ages 6 to 17 years, including symptoms of aggression towards others, deliberate self-injuriousness, temper tantrums, and quickly changing moods (BMS, 2009).

Approval was based on  two 8-week, randomized, double-blind, placebo-controlled ,Phase III trials in pediatric patients (6 to 17 years of age) who met the DSM-IV criteria for autistic disorder and demonstrated behaviors such as tantrums, aggression, self-injurious behavior, or a combination of these problems. Efficacy was evaluated using two assessment scales: the Aberrant Behavior Checklist (ABC) and the Clinical Global Impression-Improvement (CGI-I) scale. The primary outcome measure in both trials was the change from baseline to endpoint in the Irritability subscale of the ABC (ABC-I). The ABC-I subscale measured symptoms of irritability in autistic disorder. Results of the first 8-week trial, contained 98 children and adolescents with autistic disorder. The participants received daily doses of placebo or Abilify 2 to 15 mg/day. Abilify, starting at 2 mg/day with increases allowed up to 15 mg/day based on clinical response, significantly improved scores on the ABC-I subscale and on the CGI-I scale compared with placebo. The mean daily dose of Abilify at the end of 8week treatment was 8.6 mg/day (Otsuka, 2016).

The second 8-week trial contained 218 children and adolescents with autistic disorder.  Three fixed doses of Abilify (5 mg/day, 10 mg/day, or 15 mg/day) were compared to placebo. Abilify dosing started at 2 mg/day and was increased to 5 mg/day after one week. After a second week, it was increased to 10 mg/day for patients in the 10 and 15 mg dose arms, and after a third week, it was increased to 15 mg/day in the 15 mg/day treatment arm (Study 2 in Table 29). All three doses of Abilify significantly improved scores on the ABC-I subscale compared with placebo (Otsuka, 2016).

Abilify is available as oral tablets, orally-disintegrating tablets, and oral solution for treatment of irritability associated with autistic disorder. According to prescribing information (Otsuka, 2016), it is not known if Abilify is safe or effective in children under 6 years of age with irritability associated with autistic disorder.

Music Therapy

Crawford and colleagues (2017) stated that preliminary studies have indicated that music therapy may benefit children with ASD.  In an international, multi-center, 3-arm, single-masked RCT, including a National Institute for Health Research (NIHR)-funded center, these researchers examined the effects of improvisational music therapy (IMT) on social affect and responsiveness of children with ASD.  Randomization was via a remote service using permuted blocks, stratified by study site.  Subjects were children aged between 4 and 7 years with a confirmed diagnosis of ASD and a parent or guardian who provided written informed consent.  These investigators excluded children with serious sensory disorder and those who had received music therapy within the past 12 months.  All parents and children received enhanced standard care (ESC), which involved three 60-min sessions of advice and support in addition to treatment as usual.  In addition, they were randomized to either 1 (low-frequency) or 3 (high-frequency) sessions of IMT per week, or to ESC alone, over 5 months in a ratio of 1 : 1 : 2.  The primary outcome was measured using the social affect score derived from the ADOS at 5 months: higher scores indicated greater impairment; secondary outcomes included social affect at 12 months and parent-rated social responsiveness at 5 and 12 months (higher scores indicated greater impairment).  A total of 364 participants were randomized between 2011 and 2015.  A total of 182 children were allocated to IMT (90 to high-frequency sessions and 92 to low-frequency sessions), and 182 were allocated to ESC alone.  A total of 314 (86.3 %) of the total sample were followed-up at 5 months [165 (90.7 %) in the intervention group and 149 (81.9 %) in the control group].  Among those randomized to IMT, 171 (94.0 %) received it.  From baseline to 5 months, mean scores of ADOS social affect decreased from 14.1 to 13.3 in music therapy and from 13.5 to 12.4 in standard care [MD: music therapy versus standard care = 0.06, 95 % CI: -0.70 to 0.81], with no significant difference in improvement.  There were also no differences in the parent-rated social responsiveness score, which decreased from 96.0 to 89.2 in the music therapy group and from 96.1 to 93.3 in the standard care group over this period (MD: music therapy versus standard care = -3.32, 95 % CI: -7.56 to 0.91).  There were 7 admissions to hospital that were unrelated to the study interventions in the 2 IMT arms compared with 10 unrelated admissions in the ESC group.  The authors concluded that adding IMT to the treatment received by children with ASD did not improve social affect or parent-assessed social responsiveness.

In an assessor-blinded, randomized clinical trial, conducted in 9 countries, Bieleninik and associates (2017) examined the effects of IMT on generalized social communication skills of children with ASD.  Children aged 4 to 7 years with ASD were enrolled in this study; they were recruited from November 2011 to November 2015, with follow-up between January 2012 and November 2016.  These researchers compared ESC (n = 182) versus ESC plus IMT (n = 182), allocated in a 1:1 ratio; ESC consisted of usual care as locally available plus parent counseling to discuss parents' concerns and provide information about ASD.  In IMT, trained music therapists sang or played music with each child, attuned and adapted to the child's focus of attention, to help children develop affect sharing and joint attention.  The primary outcome was symptom severity over 5 months, based on the ADOS, social affect domain (range of 0 to 27; higher scores indicate greater severity; minimal clinically important difference, 1).  Pre-specified secondary outcomes included parent-rated social responsiveness.  All outcomes were also assessed at 2 and 12 months.  Among 364 participants randomized (mean age of 5.4 years; 83 % boys), 314 (86 %) completed the primary end-point and 290 (80 %) completed the last end-point.  Over 5 months, participants assigned to IMT received a median of 19 music therapy, 3 parent counseling, and 36 other therapy sessions, compared with 3 parent counseling and 45 other therapy sessions for those assigned to ESC.  From baseline to 5 months, mean ADOS social affect scores estimated by linear mixed-effects models decreased from 14.08 to 13.23 in the IMT group and from 13.49 to 12.58 in the ESC group (MD, 0.06; 95 % CI: -0.70 to 0.81; p = 0.88), with no significant difference in improvement.  Of 20 exploratory secondary outcomes, 17 showed no significant difference.  The authors concluded that among children with ASD, IMT, compared with ESC, resulted in no significant difference in symptom severity based on the ADOS social affect domain over 5 months.  They stated that these findings did not support the use of IMT for symptom reduction in children with ASD.

Ciliary Neurotrophic Factor (CNTF) as a Biomarker for ASD

Brondino and colleagues (2018) stated that ciliary neurotrophic factor (CNTF) is a neurotrophin that could signal neuronal suffering and at the same time acts as a neuroprotective agent.  These researchers evaluated CNTF serum levels in ASD.  They noted that considering the role of CNTF as a neuronal damage signal and the role of neuro-inflammation, excito-inhibitory imbalance and excito-toxicity in the pathogenesis of ASD, a possible alteration of CNTF in ASD could be hypothesized.  These investigators recruited 23 individuals with ASD and intellectual disability (ID), 20 ID subjects and 26 typical adults.  A complete medical and psychopathological characterization of the participants was performed; CNTF serum levels were measured with ELISA.  Serum levels of CNTF were significantly higher in the ASD+ID group compared to ID (p < 0.001) or typically developed subjects (p < 0.001).  The authors concluded that CNTF may be considered as a potential biomarker candidate for ASD in the context of severe ID.  They stated these findings support the hypothesis of neurotrophic imbalance in ASD.

GABA Receptor Polymorphisms Testing

Mahdavi and colleagues (2018) noted that previous studies have reported the association of GABA receptor subunits B3, A5, and G3 single-nucleotide polymorphisms (SNPs) in chromosome 15q11-q13 with ASDs.  However, the currently available results are inconsistent.  These investigators examined the association between ASD and the GABA receptor SNPs in chromosomal region 15q11-q13.  The association was calculated by the overall OR with a 95 % CI.  These researchers used sensitivity analyses and the assessment of publication bias in their meta-analysis.  A total of 8 independent case-control studies involving 1,408 cases and 2,846 healthy controls were analyzed, namely, 8 studies for GABRB3 SNPs as well as 4 studies for GABRA5 and GABRG3 polymorphisms.  The meta-analysis showed that GABRB3 polymorphisms in general were not significantly associated with autism (OR = 0.846; 95 % CI: 0.595 to 1.201, I2 = 79.1 %).  Further analysis indicated that no associations were found between GABRB3 SNPs and autism on rs2081648 (OR = 0.84; 95 % CI: 0.41 to 1.72, I2 = 89.2 %) and rs1426217 (OR = 1.13; 95 % CI: 0.64 to 2.0, I2 = 83 %).  An OR of 0.95; 95 % CI: 0.77 to 1.17 was reported; I2 = 0.0 %) for GABRA5 SNPs and an OR of 0.96; 95 % CI:  0.24 to 3.81 was obtained from GABRG3 SNPs; I2 = 97.8 %).  The authors concluded that the findings of this meta-analysis provided strong evidence that different SNPs of GABA receptor B3, A5, and G3 subunit genes located on chromosome 15q11-q13 are not associated with the development of autism spectrum diseases in different ethnic populations.

Serum Cytokine and Growth Factor Levels

Lochman and colleagues (2018) noted that the immune system may have a role in the pathogenesis of ASD, including typical and atypical autism.  These researchers examined if a cytokine and growth factor panel could be identified for the diagnosis and prognosis in children with ASD, including typical and atypical autism.  This trial enrolled 26 children with ASD (typical or atypical) and 11 of their siblings who did not have ASD.  A panel of 10 serum cytokines and growth factors were investigated using addressable laser bead assay (ALBIA) and enzyme-linked immunosorbent assay (ELISA) kits.  Results were correlated with scores using the CARS and ADOS for the children with ASD and compared with the findings from their siblings without ASD.  There were no statistically significant differences in serum cytokine and growth factor levels between children with ASD and their siblings.  The scores using CARS and ADOS were significantly greater in children with typical autism compared with children with atypical autism as part of the ASD spectrum.  Serum levels of cytokines and growth factors showed a positive correlation with CARS and ADOS scores but differed between children with typical and atypical autism and their siblings.  The authors concluded that the findings of this study showed that serum measurement of appropriately selected panels of cytokines and growth factors might have a role in the diagnosis of ASD.

Therapeutic Diets (e.g., Ketogenic Diet and Modified Atkins Diet)

El-Rashidy and colleagues (2017) stated that many diet regimens were studied for patients with ASD over the past several years.  Ketogenic diet is gaining attention due to its proven effect on neurological conditions like epilepsy in children.  In a case-control study, a total of 45 children aged 3 to 8 years diagnosed with ASD based on DSM-5 criteria were enrolled to compare ketogenic diet versus gluten free casein free diet for the treatment of ASD.  Patients were equally divided into 3 groups, first group received ketogenic diet as modified Atkins diet (MAD), second group received gluten free casein free (GFCF) diet, and the third group received balanced nutrition and served as a control group.  All patients were assessed in terms of neurological examination, anthropometric measures, as well as Childhood Autism Rating Scale (CARS), Autism Treatment Evaluation Test (ATEC) scales before and 6 months after starting diet.  Both diet groups showed significant improvement in ATEC and CARS scores in comparison to control group, yet ketogenic scored better results in cognition and sociability compared to GFCF diet group.  The authors concluded that depending on the parameters measured in this study, modified Atkins diet and gluten free casein free diet regimens may safely improve autistic manifestations and could be recommended for children with ASD.  Moreover, they noted that this study was a single-center trial with a small number of subjects (n = 45); more large-scale prospective studies are needed to confirm these findings.

Gogou and Kolios (2018) stated that a nutritional background has been recognized in the pathophysiology of autism and a series of nutritional interventions have been considered as complementary therapeutic options.  As available treatments and interventions are not effective in all individuals, new therapies could broaden management options for these patients.  These investigators provided current literature data regarding the effect of therapeutic diets on ASD.  A systematic review was conducted by 2 reviewers independently; prospective clinical and pre-clinical studies were considered.  Therapeutic diets that have been used in children with autism include ketogenic and gluten/casein-free diet.  These researchers were able to identify 8 studies conducted in animal models of autism demonstrating a beneficial effect on neurophysiological and clinical parameters.  Only 1 clinical study was found showing improvement in childhood autism rating scale after implementation of ketogenic diet.  With regard to gluten/casein-free diet, 4 clinical studies were totally found with 2 of them showing a favorable outcome in children with autism.  Furthermore, a combination of gluten-free and modified ketogenic diet in a study had a positive effect on social affect scores.  No serious adverse events (AEs) have been reported.  The authors concluded that despite encouraging laboratory data, there is controversy regarding the real clinical effect of therapeutic diets in patients with ASD.  They stated that more research is needed to provide sounder scientific evidence.

Transcranial Direct Current Stimulation

Kang and colleagues (2018) noted that ASD is a heterogeneous neurodevelopmental disorder that affects the developmental trajectory in several behavioral domains, including impairments of social communication, cognitive and language abilities.  Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique, and it was used for modulating the brain disorders.  In this study, these researchers enrolled 13 ASD children (11 males and 2 females; mean ± SD age of 6.5 ± 1.7 years) to examine the effects of tDCS on ASD.  Each patient received 10 treatments over the dorsolateral prefrontal cortex (DLPFC) once every 2 days.  Also, these investigators enrolled 13 ASD children (11 males and 2 females; mean ± SD age of 6.3 ± 1.7 years) waiting to receive therapy as controls.  A maximum entropy ratio (MER) method was adapted to measure the change of complexity of EEG series.  It was found that the MER value significantly increased after tDCS.  The authors concluded that the findings of this study suggested that tDCS may be helpful in the rehabilitation of children with ASD.  Moreover, they stated that further research is needed to examine the potential of brain stimulation treatments for ASD and to interpret the mechanisms of these treatments using neuroimaging techniques.

The authors stated that this study had several drawbacks.  First, resting-state EEG of ASD children can be influenced by many factors, including EOG and other movements.  Second, the stimulation region of DLPFC was not confirmed by neuroimaging but rather by using a slightly less accurate F3 placement of the standard international system.  furthermore, sham stimulation was not obtained in the experiment. 

Metabolomic analyses of blood samples (as a biomarker for ASD)

Metabolomics is the large-scale study of small molecules, commonly known as metabolites, within cells, biofluids, tissues or organisms. Collectively, these small molecules and their interactions within a biological system are known as the metabolome. 

NeuroPointDX, the neurological disorders division of Stemina Biomarker Discovery, announced that it has validated a first-generation autism diagnostic blood test panel in the Children’s Autism Metabolome Project (CAMP), its clinical study (Smith et al.; article in press).

Smith et al [article in press] stated Autism Spectrum Disorder (ASD) is behaviorally and biologically heterogeneous and likely represents a series of conditions arising from different underlying genetic, metabolic, and environmental factors. There are currently no reliable diagnostic biomarkers for ASD. Based on evidence that dysregulation of branch chain amino acids (BCAA) may contribute to the behavioral characteristics of ASD, the authors tested whether dysregulation of amino acids (AA) was a pervasive phenomenon in individuals with ASD. This is the first paper to report results from the Children’s Autism Metabolome Project (CAMP, ClinicalTrials.gov Identifier: NCT02548442), a large-scale effort to define autism biomarkers based on metabolomic analyses of blood samples from young children. Dysregulation of AA metabolism was identified by comparing plasma metabolites from 516 children with ASD with those from 164 age-matched typically-developing (TYP) children recruited into CAMP. ASD subjects were stratified into subpopulations based on shared metabolic phenotypes associated with BCAA dysregulation. The authors identified groups of AAs with positive correlations that were, as a group, negatively correlated with BCAA levels in ASD. Imbalances between these two groups of AAs identified three ASD associated Amino Acid Dysregulation Metabotypes (AADM). The combination of glutamine, glycine, and ornithine AADMs identified a dysregulation in AA/BCAA metabolism that is present in 16.7% of the CAMP ASD subjects and is detectable with a specificity of 96.3% and a PPV of 93.5%. The authors concluded that identification and utilization of metabotypes of ASD can lead to actionable metabolic tests that support early diagnosis and stratification for targeted therapeutic interventions.

West et al (2014) stated the diagnosis of autism spectrum disorder (ASD) at the earliest age possible is important for initiating optimally effective intervention. In the United States the average age of diagnosis is 4 years. Identifying metabolic biomarker signatures of ASD from blood samples offers an opportunity for development of diagnostic tests for detection of ASD at an early age. The objective of this study was to discover metabolic features present in plasma samples that can discriminate children with ASD from typically developing (TD) children. The ultimate goal is to identify and develop blood-based ASD biomarkers that can be validated in larger clinical trials and deployed to guide individualized therapy and treatment. Blood plasma was obtained from children aged 4 to 6, 52 with ASD and 30 age-matched TD children. Samples were analyzed using 5 mass spectrometry-based methods designed to orthogonally measure a broad range of metabolites. Univariate, multivariate and machine learning methods were used to develop models to rank the importance of features that could distinguish ASD from TD. A set of 179 statistically significant features resulting from univariate analysis were used for multivariate modeling. Subsets of these features properly classified the ASD and TD samples in the 61-sample training set with average accuracies of 84% and 86%, and with a maximum accuracy of 81% in an independent 21-sample validation set. The authors concluded that this analysis of blood plasma metabolites resulted in the discovery of biomarkers that may be valuable in the diagnosis of young children with ASD. The results will form the basis for additional discovery and validation research for 1) determining biomarkers to develop diagnostic tests to detect ASD earlier and improve patient outcomes, 2) gaining new insight into the biochemical mechanisms of various subtypes of ASD 3) identifying biomolecular targets for new modes of therapy, and 4) providing the basis for individualized treatment recommendations.

In June 1998, the National Institutes of Health Autism Coordinating Committee (NIH/ACC) invited representatives of 13 major medical and other professional academies and associations and six national autism parent research organizations to review research data on screening and diagnosis of autism spectrum disorders. Ten review papers and more than 4,000 publications were consulted in this effort. This paper highlights some promising areas for research identified in this process. One of the highest priorities is the search for the ultimate diagnostic indicator, a biological marker(s), for example, genetic, metabolic, immunologic, neurologic, that will distinguish autism unequivocally from other developmental disabilities. In the interim, research on infant screening and diagnosis might lower the threshold age for diagnosis to 8-12 months. The role of sensory-motor disorders in early diagnosis needs further research. Earlier and better diagnosis of co-occurring, potentially treatable disorders, including epileptic and epileptiform disorders, has implications both for diagnosis and treatment. Pharmacogenetic and pharmacogenomic research strategies could help diagnose subtypes and responders versus nonresponders to potential treatments. Better endpoints and outcome measures are needed, including improved procedures for cognitive and neuropsychological testing, more knowledge about verbal and nonverbal communication milestones, and less invasive and more sensitive neuroimaging measures. Critical questions remain regarding regression after apparently normal development, and about possible environmental precipitants. Finally, field trials of the reliability and validity of screening and diagnosis using the newly developed practice guidelines are needed.

The above policy is based on the following references: