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Integrative Guidelines for Pediatric Practice: Autism Spectrum Disorders (ASDs)

Updated: Sep 21, 2021

Integrative medicine approaches to pediatric care emphasize prevention and anticipatory guidance to support safety and the role of family dynamics in child wellness (Kligler & Lee, 2013). The increased prevalence of children living with chronic conditions as well as the desire to reduce pediatric prescription medication are major factors currently driving increased interest in complementary and alternative treatments for this population (McClafferty et al., 2017). Alternative approaches are often chosen to treat a specific condition such as head or chest cold, musculoskeletal conditions, anxiety or stress, and attention-deficit/hyperactivity disorder (McClafferty et al., 2017). The role of the pediatrician as the primary contact and gatekeeper of services includes early identification and coordination of services for families of autistic children by promoting functional independence and quality of life through education and support of families (Myers & Johnson, 2007).


Education


Intensive education approaches are the foundation of ASD management. Assessment-based curricula such as Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH), Strategies for Teaching based on Autism Research (STAR), and Teach Town vary in strategy but share common principles and components. A high degree of structure, ongoing measurement and documentation of progress, a low student-to-teacher ratio with small group instruction and sufficient 1:1 time, parent training as needed, intentional generalization, and a dosage of 25 hours per week for 12 months per year are suggested for effective engagement. Applied behavior analysis (ABA), Speech and language therapy, Occupational therapy (OT) are specific practices that are frequently integrated into educational programs to reduce interfering behaviors, teach social communication skills, and support participation in meaningful activities (Myers & Johnson, 2007).


Sleep


Autistic children need basic health care but may also require attention to unique needs related to their underlying neurodiversity (Myers & Johnson, 2007). 50-80% of children experience sleep difficulties (Klein & Kemper, 2016). Identifiable causes such as gastroesophageal reflux and sleep apnea should be ruled out as a part of an initial assessment. Sleep interventions for children with ASD should begin with parent education in the use of behavioral approaches as a first-line approach. Melatonin may be effective for improving sleep onset. Antihistamines, benzodiazepines, trazodone, and newer nonbenzodiazepine hypnotic agents, such as zolpidem and zaleplon may be prescribed in extreme cases of insomnia. (Myers & Johnson, 2007).


Nutrition


A gluten-free, casein-free diet (gfcf-d) is used by up to 38% of the ASD population with comorbid gastrointestinal and behavioral symptoms (Dosman et al.,2013). Gluten is a protein in wheat, rye, triticale, and barley. Casein is a protein in mammalian milk products (e.g., milk, cheese, yogurt, butter, processed foods). The exclusion of these foods from the diet is supported by a controversial leaky gut hypothesis. Dosman et al. (2013) suggest ruling out celiac disease and failure to thrive prior to a trial of gfcf-d. If the baseline diet has limited foods, a gradual implementation over 12 weeks suggested with dietitian guidance to ensure nutritional adequacy and an OT or SLP with specialization in feeding (Dosman, 2013).


Neurofeedback


Increases in children’s sustained attention, communication, social participation, and cognitive flexibility were documented in four small RCTs (Klein &Kemper, 2016). Transcranial Magnetic Stimulation modulates evoked and induced gamma oscillations in the cerebral cortex influencing neurological processing (Casanova, 2020). Outcomes include improved executive functioning and stimulus-bound behaviors such as sensory processing (Casanova, 2020). Friedrich et al. (2015) found that neurofeedback training paired with gamification of social interactions improved electrophysiology in mirror neurons, emotional responsiveness, and behavior. However, the cost of treatment is unreasonable for many families if it is not covered by insurance.


References


Casanova, M. F., Sokhadze, E. M., Casanova, E. L., & Li, X. (2020). Transcranial Magnetic Stimulation in Autism Spectrum Disorders: Neuropathological Underpinnings and Clinical Correlations. Seminars in Pediatric Neurology, 35.https://doi/10.1016/j.spen.2020.100832


Dosman, C., Adams, D., Wudel, B., Vogels, L., Turner, J., & Vohra, S. (2013). Complementary, holistic, and integrative medicine: autism spectrum disorder and gluten- and casein-free diet. Pediatrics in Review, 34(10),e36-41.https://doi.org/10.1542/pir.34-10-e36


Friedrich, E., Sivanathan, A., Lim, T., Suttie, N., Louchart, S., Pillen, S., & Pineda, J. (2015). An Effective Neurofeedback Intervention to Improve Social Interactions in Children with Autism Spectrum Disorder. Journal of Autism & Developmental Disorders, 45(12), 4084–4100. https://doi.org/10.1007/s10803-015-2523-5


Klein, N., & Kemper, K. J. (2016). Integrative Approaches to Caring for Children with Autism. Current Problems in Pediatric & Adolescent Health Care, 46(6), 195–201. https://doi.org/10.1016/j.cppeds.2015.12.004


Kligler, B. & Lee, R. (2013). Integrative Medicine: Principles for Practice. New York: McGraw Hill.


McClafferty, H., Vohra, S., Bailey, M., Brown, M., Esparham, A., Gerstbacher, D., . . . Yeh, A. M. (2017). Pediatric Integrative Medicine. Pediatrics, 140(3).


Myers, S. M., & Johnson, C. P. (2007). Management of Children With Autism Spectrum Disorders. Pediatrics, 120(5), 1162-1182.


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