"What are the best treatments for children on the autism spectrum (those that are high functioning)?"
The core traits of Asperger’s (AS) and High-Functioning Autism (HFA) can't be cured. But, many kids on the autism spectrum grow into happy, well-adjusted grown-ups. Most of these young people will benefit from early specialized interventions that focus on behavior management and social skills training. Certain medications and supplements can also help with associated symptoms (e.g., anxiety, sleep problems, etc.). Your physician can help identify resources in your area that may work for your “special needs” son or daughter.
AS and HFA treatment options include the following:
1. Applied behavior analysis: Applied behavior analysis (ABA) is the applied research field of the science of behavior analysis and supports a wide range of treatment strategies. ABA is widely recognized as a safe and effective treatment for kids on the autism spectrum. It has been endorsed by a number of state and federal agencies, including the U.S. Surgeon General and the New York State Department of Health. ABA principles and techniques can promote basic skills (e.g., looking, listening, imitating), as well as complex skills (e.g., reading, conversing, understanding another person’s perspective).
2. Aripiprazole (Abilify): This drug may be effective for treating irritability related to AS and HFA. Side effects may include weight gain and an increase in blood sugar levels.
3. Avoidance diets: Some moms and dads have turned to gluten-free and/or casein-free diets to treat autism spectrum disorders. Many parents assert that these diets work, but anyone attempting such a diet needs guidance from a registered dietitian to ensure the youngster's nutritional requirements are met.
4. Cognitive behavioral therapy: This general term encompasses many techniques aimed at curbing problem behaviors (e.g., interrupting, obsessions, meltdowns, angry outbursts), as well as developing certain social skills (e.g., recognizing feelings, coping with anxiety). Cognitive behavioral therapy usually focuses on training the youngster to recognize a troublesome situation (e.g., a new place or an event with lots of social demands), and then select a specific learned strategy to cope with that situation.
5. Communication and social skills training: Kids with AS and HFA may be able to learn the unwritten rules of socialization and communication when taught in an explicit and rote fashion (much like the way students learn foreign languages). These young people may also learn how to speak in a more natural rhythm, as well as how to interpret communication techniques (e.g., gestures, eye contact, tone of voice, humor, sarcasm).
6. Computer-assisted therapy: Many remediation techniques have not taken into account that children on the spectrum suffer from difficulties in learning social rules by example. Computer-assisted therapy has been proposed to teach not simply using examples, but to teach the rule along with it. Learning starts from the basic concepts of knowledge and intention and proceeds to more complex communicative actions (e.g., explaining, agreeing, pretending).
7. Dietary supplements: Numerous dietary supplements have been tried in children on the autism spectrum. Those that may have some evidence to support their use include: Carnosine, Omega-3 fatty acids, Vitamin B-6, Magnesium, and Vitamin C (usually in combination with other vitamins).
8. Floortime: The Floortime/DIR approach is a developmental intervention to autism spectrum disorders. Its core principle is to understand the youngster's sensory differences, follow the youngster's lead, and use these to encourage the child to climb up the developmental ladder. This approach is based on the idea that the core deficits in autism spectrum disorders are individual differences in (a) difficulties in communication and relation to others, (b) motor planning problems, (c) the inability to connect ones desire to intentional action and communication, and (d) the sensory system.
9. Guanfacine (Intuniv): This medication may be helpful for the problems of hyperactivity and inattention in kids with AS and HFA. Side effects may include drowsiness, irritability, headache, constipation and bedwetting.
10. Melatonin: Sleep problems are common in kids with AS and HFA, and melatonin supplements may help regulate your youngster's sleep-wake cycle. The recommended dose is 3 mg, 30 minutes before bedtime. Possible side effects include excessive sleepiness, dizziness and headache.
11. Naltrexone (Revia): This medication may help reduce some of the repetitive behaviors associated with AS and HFA. However, the use of low-dose naltrexone — in doses as low as two to four mg a day — has been gaining favor recently. But, there's no good evidence that such low doses have any effect on AS and HFA.
12. Olanzapine (Zyprexa): Olanzapine is sometimes prescribed to reduce repetitive behaviors. Possible side effects include increased appetite, drowsiness, weight gain, and increased blood sugar and cholesterol levels.
13. Pivotal response therapy: Pivotal response therapy (PRT) is a naturalistic intervention derived from ABA principles. Instead of individual behaviors, this approach targets pivotal areas of a youngster's development (e.g., motivation, responsivity to multiple cues, self-management, social initiations). The youngster determines activities and objects that will be used in a PRT exchange. Intended attempts at the target behavior are rewarded with a “natural reinforcer” (e.g., if a youngster attempts a request for a stuffed animal, he receives the animal, not a piece of candy or other unrelated reinforcer).
14. Relationship based, developmental models: Relationship based models give importance to the relationships that help AS and HFA kids reach and master early developmental milestones. These are often missed or not mastered in young people on the autism spectrum. Examples of these early milestones are (a) engagement and interest in the world, (b) intimacy with a parent or other caretaker, and (c) intentionality of action.
15. Relationship Development Intervention: Relationship development intervention is a family-based treatment program for kids on the spectrum. This program is based on the belief that the development of dynamic intelligence (i.e., the ability to think flexibly, take different perspectives, cope with change, and process information simultaneously) is key to improving the quality of life for AS and HFA kids.
16. Risperidone (Risperdal): This medication may be prescribed for agitation and irritability. It may cause trouble sleeping, a runny nose and an increased appetite. This drug has also been associated with an increase in cholesterol and blood sugar levels.
17. SCERTS: The SCERTS model is an educational model for working with kids on the autism spectrum. It was designed to help parents, teachers and therapists work cooperatively together to maximize progress in supporting the youngster. The acronym refers to the focus on: (1) SC - social communication (the development of functional communication and emotional expression); (2) ER - emotional regulation (the development of well-regulated emotions and ability to cope with stress); and (3) TS - transactional support (the implementation of supports to help parents, teachers and therapists respond to the child's needs, adapt the environment, and provide tools to enhance learning).
18. Selective serotonin reuptake inhibitors (SSRIs): Drugs such as fluvoxamine (Luvox) may be used to treat depression or to help control repetitive behaviors. Possible side effects include restlessness and agitation.
19. Sensory integration: The term Sensory integration means the ability to use all of ones senses to accomplish a task. Unusual responses to sensory stimuli are common in kids on the spectrum. This treatment includes prism lenses, physical exercise, auditory integration training, and sensory stimulation such as "deep pressure," which is firm touch-pressure applied either manually or via a hug machine or a pressure garment. Occupational therapists sometimes prescribe sensory treatments for AS and HFA kids.
20. Social stories: Social stories is devised as a tool to help kids on the autism spectrum better understand the nuances of interpersonal communication so that they can interact in an effective and appropriate manner. Although the prescribed format was meant for high functioning children with basic communication skills, the format was adapted substantially to suit children with poor communication skills and low level functioning. Social stories are being used in targeted ways to prepare AS and HFA children for social interaction and assist with coping skills.
21. TEACCH: Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH) emphasizes structure by using organized physical environments, predictably sequenced activities, visual schedules and visually structured activities, and structured work/activity systems where each youngster can practice various tasks. Moms and dads are taught to implement the treatment at home. One study found that kids treated with a TEACCH-based home program improved significantly more than a control group.
22. The P.L.A.Y. Project: The P.L.A.Y. Project is a community-based, national autism training and early intervention program. The program is designed to train moms and dads to implement intensive, developmental interventions for younger kids (2 to 6 years) with autism spectrum disorders. The program is operating in nearly 100 agencies worldwide, including 25 U.S. states and in 5 countries outside of the U.S. The P.L.A.Y. Project received a $1.85 million grant from the National Institute of Mental Health to conduct a 3-year controlled, clinical study of the P.L.A.Y. Project model. The study compares the outcomes of 60 kids who participate in The P.L.A.Y. Project with the outcomes of 60 kids who receive standard community interventions, making it the largest study of its kind. Before and after the 12-month intervention, each youngster is assessed with a battery of tests to measure developmental level, speech and language, sensory-motor profile, and social skills.
Additional suggestions:
You'll need to make important decisions about your youngster's education and treatment. So, find a team of educators and therapists who can help evaluate the options in your area and explain the federal regulations regarding kids with disabilities.
Lean on family and friends when you can. Ask someone who understands your youngster's needs to babysit sometimes so that you can get an occasional break. You may also find a support group for moms and dads of AS/HFA kids helpful. Ask your youngster's physician if he or she knows of any groups in your area.
Most kids with AS and HFA have no visible sign of disability, so you may need to alert teachers, coaches, relatives and other grown-ups to your youngster's special needs. Otherwise, a well-meaning adult may spend time lecturing your youngster on "looking at me while I'm talking" (something that can be very difficult for the youngster to do).
The tendency to fixate on a particular narrow topic is one of the hallmarks of AS and HFA, and it can be annoying to those who must listen to incessant talk about the favorite topic every day. But, a consuming interest can also connect a youngster to schoolwork and social activities. In some cases, kids with AS and HFA can even turn their childhood fascination into a career or profession.
There are numerous books and websites dedicated to autism spectrum disorders. Do some research so that you better understand your youngster's challenges and the range of services in your school district and state.
The signs and symptoms of AS and HFA vary for each youngster, and these kids have a hard time explaining their behaviors and challenges. But, with time and patience, you'll learn which situations and environments may cause problems for your youngster and which coping strategies work. Keeping a diary and looking for patterns may help.
Maintain a consistent schedule whenever possible. If you have to introduce change, do so gradually.
More resources for parents of children and teens with High-Functioning Autism and Asperger's:
“My granddaughter (7yrs old) was just diagnosed with autism and level 1.5. What does that mean and what's the differences between that and aspergers?”
To answer this question, let’s first look at the new criteria for Autism as described in the DSM 5:
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history):
Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history:
Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).
Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).
C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).
D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and Autism spectrum disorder frequently co-occur; to make comorbid diagnoses of Autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.
The DSM 5 specifies the severity levels of Autism as follows:
Level 1: Requiring Support—
Social Communication: With supports in place, deficits in social communication cause noticeable impairments. Has difficulties initiating social interactions, and demonstrates clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions.
Restricted Interests and Repetitive Behaviors: Rituals and repetitive behaviors (RRB’s) cause significant interference with functioning in one or more contexts. Resists attempts by others to interrupt RRB’s or to be redirected from fixated interest.
Level 2: Requiring Substantial Support—
Social Communication: Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with social supports in place; limited initiation of social interactions and reduced or abnormal response to social overtures from others.
Restricted Interests and Repetitive Behaviors: RRB’s and/or preoccupations or fixated interests appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress or frustration is apparent when RRB’s are interrupted; difficult to redirect from fixated interest.
Level 3: Requiring Very Substantial Support—
Social Communication: Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning; very limited initiation of social interactions and minimal response to social overtures from others.
Restricted Interests and Repetitive Behaviors: Preoccupations, fixated rituals and/or repetitive behaviors markedly interfere with functioning in all spheres. Marked distress when rituals or routines are interrupted; very difficult to redirect from fixated interest or returns to it quickly.
So as you can see, Level 1 would be considered high-functioning Autism. Disability will be common among children with Level 3 Autism and non-existent in Level 1 (where children currently diagnosed with Aspergers will be reclassified).
The new method for diagnosing Autism replaces the five prior diagnoses: Asperger Syndrome, Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS), Childhood Disintegrative Disorder, and Autistic Disorder. If a child has a pre-existing diagnosis of any of these disorders, he or she is automatically considered to have an Autism diagnosis.
Children who are being newly diagnosed (or re-evaluated) and do not fit into the new criteria for Autism may receive a new diagnosis called Social Communication Disorder. This appears to be an extremely mild version of Autism (the child does not have sensory issues or repetitive behaviors) and is similar in many ways to the old PDD-NOS.
The DSM-5 defines Autism as a single “spectrum disorder,” with a set of criteria describing symptoms in the areas of social communication, behavior, flexibility, and sensory sensitivity. If a child has symptoms in these areas, he or she will probably be diagnosed as “on the spectrum.” When a physician diagnoses a youngster with Autism, it's important to know the severity of the disorder. If the physician does give his/her opinion on the severity, it’s with the disclaimer that it’s only an opinion, not a medical diagnosis. Whether the opinion is that it's severe, or that it's mild, it has no bearing on the actual diagnosis. A youngster with Autism deemed as mild is just as autistic as one believed to be severe. The medical diagnosis for both is exactly the same.
Autistic kids have issues with social interactions, behavioral issues, restricted interests, self-stimulatory activities and sensory issues. So severity in each of these categories needs to be determined to assess severity as a whole. While the severity of Autism is not a diagnosis, physicians who specialize in Autism can tell where a youngster is in relation to the other kids they have treated. The same youngster will get different opinions of severity from different people. Since determining a “Level” is subjective and not a technical diagnosis, there is no right or wrong answer.
The three Autism “levels” raise many questions, for example:
Depression and anxiety are very common traits among children on the Autism Spectrum, and this can cause major challenges in typical settings. If a child is bright, verbal and academically capable – but moody and anxious, and therefore in need of significant support in order to function at school – where does he or she fit in?
Some children on the Autism Spectrum do fine at home, but need help in the classroom. Others do well in the classroom, but not at home (where there’s less structure). So, in which social settings do children at various levels require “support?”
Some autistic children have received adequate therapy to appear “close to normal” when interacting with adults – but have significant problems when playing/interacting with their friends. Others get along well with peers, but not adults (especially authority figures). What type of support do they need?
The severity of Autism changes not only day to day, but also situation to situation. For example, autistic kids may exhibit significant social deficits when trying to play with their peers on the playground -- but in the classroom, they may blend in perfectly with their peers. Autism severity is simply a place to start. It’s something to use to help the youngster make progress by getting more services and to help describe the youngster to therapists, teachers, etc. It’s just a snapshot, not something that reflects the future or the youngster in all situations.
Resources for parents of children and teens on the autism spectrum:
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.
Best comment: Thank you for the great explanations to the new DSM-5. I shared this on my FB page -- your blogs (and your book) are so helpful to me as the mom of a 15-year old Aspie. After reading this, I actually kind of like the new classification. My son wasn't "officially" diagnosed with high-functioning autism until he was 14, because prior to that he had been just diagnosed as ADD, bipolar, and OCD, although they did diagnose correctly the sensory processing disorder when he was 7 (with "borderline Aspergers" at that time as well). He began ABA therapy for the first time just 8 months ago, and started at a non-public school (specifically for kids with autism) five months ago. Between those two major changes in his life, we have seen remarkable improvements in his daily functioning. So it seems to me that it is possible to transition from one level to another due to outside influences, don't you think? Thank you again for such a great post!
