Clinical Correlate: Autism
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Figure 1: Art therapy and music therapy are both effective with Autism Spectrum Disorder (ASD).
Definition
Autism Spectrum Disorder (ASD) is a developmental disorder of the nervous system that interferes with a child's ability to communicate and interact with other people. This may be accompanied by restricted repetitive behaviors, and limited interests and activities. These behavioral issues impair the child's social and occupational development.
ASD is defined by the American Psychiatric Association's Diagnosis and Statistical Manual of Mental Disorders (DSM-5) as a single disorder[1]. It includes several disorders that were once thought to be distinct, including: Autism, Asperger's Syndrome, childhood disintegrative disorder, and pervasive developmental disorder.
By defining a spectrum of ASD, healthcare professionals can take into account a wide range of symptoms and severity of manifestations in individual clients. While the term "Asperger's Syndrome" is no longer included in the Diagnostic and Statistical Manual, it is still used by some professionals to denote the less severe end of Autism Spectrum Disorder[2].
Etiology³
While for the majority of individuals with ASD, the causes of the disorder are unknown, in up to 25% of cases a genetic cause can be identified[4].
Recent work has led to the identification of several autism susceptibility genes. It has been determined that de novo(newly occurred) mutations and the inheritance of an abnormal number of copies of one or more sections of DNA contributes to the development of ASD[5].
Increased environmental stress (from air pollution, and exposure to pesticides[6] and heavy metals) also seems to play a role. It is possible that environmental factors interact with genetic factor as some gene variants in ASD confer increased vulnerability to environmental exposures[7].
Signs and Symptoms
ASD is usually diagnosed at an early age. However, while some children may show signs of ASD in early infancy, others will develop normally for the first three to six months and then become acutely withdrawn or aggressive. They may even loose communication skills they have already developed.
In general, teenagers with ASD demonstrate severe behavioral problems. But, as some teenagers grow, they can become more engaged with other people, demonstrate fewer behavioral disturbances, and eventually lead nearly normal lives. Others, however, continue to have difficulty with language and/or social skills throughout their whole lives.
There is a significant variability between ASD symptoms. The National Institutes of Health include[8]:
Communication
Does not respond to his/her name by 12 months of ageCannot explain what he/she wantsDoesn't follow directionsSeems to hear sometimes, but not other timesDoesn't point or wave "bye-bye"Used to say a few words or babble, but now does not
Social Behavior
Doesn't smile when smiled atHas poor eye contactSeems to prefer to play aloneGets things for him/herself onlyIs very independent for his/her ageSeems to be in his/her "own world"Seems to tune people outIs not interested in other childrenDoesn't point out interesting objects by 14 months of ageDoesn't like to play "peek-a-boo"Doesn't try to attract his/her parent's attention
Stereotyped Behavior
Gets "stuck" doing the same things over and over and can't move on to other thingsShows unusual attachments to toys, objects, or routines (for example, always holding a string or having to put on socks before pants)Spends a lot of time lining things up or putting things in a certain orderRepeats words or phrases
Other Behavior
Doesn't play "make believe" or pretend by 18 months of ageHas odd movement patternsDoesn't know how to play with toysDoes things "early" compared to other childrenWalks on his/her toesDoesn't like to climb on things, such as stairsDoesn't imitate silly facesSeems to stare at nothing or wander around with no purposeThrows intense or violent tantrumsIs overly active, uncooperative, or resistantSeems overly sensitive to noiseDoesn't like to be swung or bounced on his/her parent's knee, etc.
Differential Analysis
The differential diagnosis of ASD includes:
Anxiety Disorders
The term "anxiety disorders" encompasses a large group of disorders that include generalized anxiety disorder, panic disorder, and various phobias. Anxiety disorders, and specifically generalized anxiety disorder, are the most common causes of mental, emotional, and behavioral problems during childhood and adolescence.
Anxiety disorders may get confused with ASD due to the similarity in symptoms. For example, the obsessions and compulsions of Obsessive-Compulsive Disorder may look similar to repetitive and stereotyped behaviors in children with ASD.
Adolescents who have Asperger's Syndrome or high-functioning autism are also often misdiagnosed with anxiety disorders.
Lead Poisoning
Lead poisoning may cause a number of symptoms similar to the ones exhibited by children with ASD, such as: Cognitive deficit, learning disability, behavioral delays, neurological immaturity, and attention deficit.
However, lead poisoning can be distinguished as it does not affect children's ability to have relationships with others; children remain communicative with parents and siblings.
Holistic Protocols
Exercise Program
Participation in group physical activities is highly recommended for individuals with ASD. In addition to helping with development of motor skills and physical fitness, these activities promote social skills and may reduce behavioral abnormalities.
Various activities, including snowshoeing and walking[9], swimming[10], and aerobics[11], were successfully used.
In addition, physical exercises can help to counteract obesity, which is an extremely widespread problem among kids with ASD[12].
Holistic Nutrition
Children with ASD often have idiosyncratic food preferences and eating habits that are difficult to regulate. They may be looking for the very specific dry or wet forms, colors, shapes, and even brand packaging. Studies have demonstrated that this may cause vitamin C, iron, vitamin D, niacin, riboflavin, vitamin B6, calcium, and zinc deficiencies, as well as excessive calcium intake (due to milk consumption)[13].
It is essential to try to diversify the diet of children with ASD. As there is a high possibility they will refuse new foods, use a stepwise approach. First, simply look at the new food product together. Next, suggest smelling and/or touching it together. Finally, ask to taste the food. It can also help if you mix the new food(s) with a familiar and preferred food for the first taste.
Gluten-free and Casein-free Diet
Many parents of children with ASD report that behavior improves with a diet free of the proteins gluten and casein. Behavioral improvements were also reported in a number of case reports and small-scale studies[14].
Gluten is found primarily in wheat, barley and rye; casein is present in dairy products. Thus, a number of food products need to be eliminated, including: Milk, butter, cheese, cottage cheese, ice cream, yogurt, and barley/rye/wheat flours.
As the eliminated products are good sources of calcium, vitamins A, B, and D, it is recommended to add calcium-fortified orange juice or multivitamin supplements into the daily diet.
Chicken, fish, meat, fruits, vegetables, potatoes, and rice that do not contain gluten or casein can safely be included in a diet as well.
Almond, rice, and soy milk are good substitutes for dairy products, while coconut and olive oils can be used instead of butter for cooking.
Also, buckwheat, lentil, millet, quinoa, sweet potato, and yucca flower are great substitutes for barley, rye, and wheat.
Supplements
Omega-3 Fatty Acids
Omega-3 fatty acid supplementation may be considered; they are critical for the development, structure, and function of brain cells.
The two omega-3 acids of particular interest are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Based on data from other disorders, they may improve mood, attention, and activity level, and mediate some other autism symptoms. According to one of the studies, daily supplementation of one and a half grams of omega-3 fatty acids (0.8 gram of EPA and 0.7 gram of DHA) significantly reduced hyperactivity and repetitive behavior[15]. Behavioral improvements were also indicated in other reports[16].
Vitamin B6 and Magnesium
High-dose supplementation with vitamin B6 and magnesium is often recommended with ASD. Studies provide mixed evidence of the efficacy of this therapy. In one study, children responded to B6 (600 to 1,125 milligrams per day) and magnesium lactate (400 to 500 milligrams per day) supplementation with increased alertness and reduced outbursts, negativism, self-mutilation, and stereotyped behavior.
However, improvements disappeared during the withdrawal[17]. Significant improvements followed by the return of conditions after the supplementation came to the end were also reported in another study[18].
However, no improvements were observed in a 10-week long study (600 milligrams of B6 and 200 milligrams of magnesium oxide per day)[19].
If B6 and magnesium supplementation is used, keep daily doses of B6 well below one gram and daily doses of magnesium less than 200 to 300 grams. Use of higher doses poses risk of neuropathy from B6 or diarrhea from magnesium.
Emerging evidence from epidemiological studies supports the notion that maternal folate status early in pregnancy may reduce the risk of autism spectrum disorders in children[3].
Aromatherapy
Aromatherapy is believed to be an effective intervention for children with ASD. Diffusing essential oils at home will stimulate children's senses and encourage children's brains to build connections across different modes of input.
It is an easy way to add a new sensory layer to any activity that a child is engaged in.
Aromatherapy massage with lavender Lavandula angustifolia (Mill.) essential oil can improve sleep quality, which is often problematic for children with ASD. In addition, according to the case reports, both aromatherapy massage and essential oil diffused in air can increase attention and improve behavior of children with ASD[20][21].
Massage Therapy
Children with ASD can greatly benefit from massage therapy. Its primary benefit is that it promotes relaxation, which can further help combat fatigue and anxiety, improve sleep pattern, and support creative ability and the thinking process.
After massage therapy, autistic children were reported to exhibit less hyperactivity, stereotypical and off-task behavior, and reduced sleep problems[22].
Massage delivered by parents was reported to be particularly effective and, in addition to behavioral improvements, helped to increase child-to-parent bonding and reduce parenting stress[23].
Biofeedback
Biofeedback was successfully used to manage the behavior of children with ASD. According to one study, significant improvement in all behavioral categories— socialization, vocalization, anxiety, schoolwork, tantrums, and sleep—were observed for children who received training[24]. Another study also reported improved focus and decreased anxiety[25].
Biofeedback utilizes electronic instrumentation to provide the client with real-time feedback of brainwave activity. The client is trained to increase the production of the brainwave patterns that reduce or eliminate the ASD symptoms.
Expressive Therapies
Expressive therapies—such as music, art, and drama therapies—promote children's development and learning. They are particularly effective for children with ASD since these activities provide unique sensory input and stimulation to the mind and body.
Studies have demonstrated that music therapy can help children with ASD develop social skills and communicative skills, strengthen parent-child relationships, and decrease undesirable behavior[26].
While less studied, drama and art therapies were also reported to improve social skills and reduce problematic behaviors[27].
References
[1] American Psychiatric Association. (2013). DSM-5 Autism Spectrum Disorder Fact Sheet American Psychiatric Publishing. Retrieved from http://www.dsm5.org/Documents/Autism%20Spectrum%20Disorder%20Fact%20Sheet.pdf
[2] Autism Society. (n.d.). Asperger's Syndrome. AutismSociety.org. Retrieved from http://www.autism-society.org/what-is/aspergers-syndrome/
[3] Etiology is the cause(s) for a disease or condition.
[4] Huguet, G., Ey, E., & Bourgeron, T. (2013). The Genetic Landscapes of Autism Spectrum Disorders. Annual Review Of Genomics And Human Genetics, 14(1):191-213. doi:10.1146/annurev-genom-091212-153431
[5] Abrahams, B., & Geschwind, D. (2008). Advances in autism genetics: on the threshold of a new neurobiology.Nat Rev Genet., 9(5):341-355. doi:10.1038/nrg2346
[6] Shelton, J., Hertz-Picciotto, I., & Pessah, I. (2012). Tipping the Balance of Autism Risk: Potential Mechanisms Linking Pesticides and Autism. Environ Health Perspect., 120(7):944-951. doi:10.1289/ehp.1104553
[7] Herbert, M. (2010). Contributions of the environment and environmentally vulnerable physiology to autism spectrum disorders. Current Opinion In Neurology, 23(2):103-110. doi:10.1097/wco.0b013e328336a01f Goines, P., & Ashwood, P. (2013). Cytokine dysregulation in autism spectrum disorders (ASD): Possible role of the environment. Neurotoxicology And Teratology, 36:67-81. doi:10.1016/j.ntt.2012.07.006
[8] National Institute of Child Health and Human Development. (2014). What are the symptoms of autism spectrum disorder (ASD)? NICHD.NIH.gov. Retrieved from https://www.nichd.nih.gov/health/topics/autism/conditioninfo/Pages/symptoms.aspx
[9] Todd, T., & Reid, G. (2006). Increasing Physical Activity in Individuals With Autism. Focus On Autism And Other Developmental Disabilities, 21(3):167-176. doi:10.1177/10883576060210030501
[10] Pan, C. (2010). Effects of water exercise swimming program on aquatic skills and social behaviors in children with autism spectrum disorders. Autism, 14(1):9-28. doi:10.1177/1362361309339496
[11] Oriel, K., George, C., Peckus, R., & Semon, A. (2011). The Effects of Aerobic Exercise on Academic Engagement in Young Children With Autism Spectrum Disorder. Pediatric Physical Therapy, 23(2):187-193. doi:10.1097/pep.0b013e318218f149
[12] Curtin, C., Anderson, S., Must, A., & Bandini, L. (2010). The prevalence of obesity in children with autism: a secondary data analysis using nationally representative data from the National Survey of Children's Health. BMC Pediatrics, 10(1):11. doi:10.1186/1471-2431-10-11
[13] Cornish, E. (1998). A balanced approach towards healthy eating in autism. Journal Of Human Nutrition And Dietetics, 11(6):501-509. doi:10.1046/j.1365-277x.1998.00132.x; Zimmer, M., Hart, L., Manning-Courtney, P., Murray, D., Bing, N., & Summer, S. (2011). Food Variety as a Predictor of Nutritional Status Among Children with Autism. J Autism Dev Disord, 42(4):549-556. doi:10.1007/s10803-011-1268-z
[14] Whiteley, P., Rodgers, J., Savery, D., & Shattock, P. (1999). A Gluten-Free Diet as an Intervention for Autism and Associated Spectrum Disorders: Preliminary Findings. Autism, 3(1):45-65. doi:10.1177/1362361399003001005; Hsu, C., Lin, D., Chen, C., Wang, C., & Wong, A. (2009). Gluten and casein-free diet in autism. Chang Gung Med J., 32(4):459-464; Pennesi, C., & Klein, L. (2012). Effectiveness of the gluten-free, casein-free diet for children diagnosed with autism spectrum disorder: Based on parental report. Nutritional Neuroscience, 15(2):85-91. doi:10.1179/1476830512y.0000000003
[15] Amminger, G., Berger, G., Schäfer, M., Klier, C., Friedrich, M., & Feucht, M. (2007). Omega-3 Fatty Acids Supplementation in Children with Autism: A Double-blind Randomized, Placebo-controlled Pilot Study. Biological Psychiatry, 61(4):551-553. doi:10.1016/j.biopsych.2006.05.007
[16] Meiri, G., Bichovsky, Y., & Belmaker, R. (2009). Omega 3 Fatty Acid Treatment in Autism. Journal Of Child And Adolescent Psychopharmacology, 19(4):449-451. doi:10.1089/cap.2008.0123 ; Ooi, Y., Weng, S., Jang, L., Low, L., Seah, J., & Teo, S., et al. (2015). Omega-3 fatty acids in the management of autism spectrum disorders: findings from an open-label pilot study in Singapore. European Journal Of Clinical Nutrition. European Journal of Clinical Nutrition, 69:969-971. doi:10.1038/ejcn.2015.28
[17] Lelord, G., Muh, J., Barthelemy, C., Martineau, J., Garreau, B., & Callaway, E. (1981). Effects of pyridoxine and magnesium on autistic symptoms - initial observations. J Autism Dev Disord., 11(2):219-230. doi:10.1007/bf01531686
[18] Mousain-Bosc, M., Roche, M., Polge, A., Pradal-Prat, D., Rapin, J., & Bali, J. (2006). Improvement of neurobehavioral disorders in children supplemented with magnesium-vitamin B6. II. Pervasive developmental disorder-autism. Magnes Res., 19(1):53-62.
[19] Findling, R., Maxwell, K., Scotese-Wojtila, L., Yamashita, T., & Wiznitzer, M. (1997). High-Dose Pyridoxine and Magnesium Administration in Children with Autistic Disorder: An Absence of Salutary Effects in a Double-Blind, Placebo-Controlled Study. Journal Of Autism And Developmental Disorders, 27(4): 467-478.
[20] Solomons, S. (2005). Using aromatherapy massage to increase shared attention behaviours in children with autistic spectrum disorders and severe learning difficulties. British Journal Of Special Education, 32(3): 127-137. doi:10.1111/j.0952-3383.2005.00385.x
[21] Kumari, A., Mansingh, S., & Perepa, P. (2006). Effects of aromatherapy on the development of communication skills in children with autism. Presentation, Unravelling autism: causes, diagnostics and intervention conference, New Delhi, India.
[22] Escalona, A., Field, T., Singer-Strunck, R., Cullen, C., & Hartshorn, K. (2001). Brief Report: Improvements in the Behavior of Children with Autism Following Massage Therapy. Journal Of Autism And Developmental Disorders, 31(5):513-516; Piravej, K., Tangtrongchitr, P., Chandarasiri, P., Paothong, L., & Sukprasong, S. (2009). Effects of Thai Traditional Massage on Autistic Children's Behavior. The Journal Of Alternative And Complementary Medicine, 15(12):1355-1361. doi:10.1089/acm.2009.0258; Silva, L., Schalock, M., Ayres, R., Bunse, C., & Budden, S. (2009). Qigong Massage Treatment for Sensory and Self-Regulation Problems in Young Children With Autism: A Randomized Controlled Trial. American Journal Of Occupational Therapy, 63(4):423-432. doi:10.5014/ajot.63.4.423
[23] Silva, L., Schalock, M., Gabrielsen, K., Budden, S., Buenrostro, M., & Horton, G. (2015). Early Intervention with a Parent-Delivered Massage Protocol Directed at Tactile Abnormalities Decreases Severity of Autism and Improves Child-to-Parent Interactions: A Replication Study. Autism Research And Treatment, 1-16. doi:10.1155/2015/904585
[24] Jarusiewicz, B. (2002). Efficacy of Neurofeedback for Children in the Autistic Spectrum: A Pilot Study. Journal Of Neurotherapy, 6(4):39-49. doi:10.1300/j184v06n04_05
[25] Scolnick, B. (2005). Effects of electroencephalogram biofeedback with Asperger's syndrome. International Journal Of Rehabilitation Research, 28(2):159-163. doi:10.1097/00004356-200506000-00010
[26] Geretsegger, M., Elefant, C., Mössler, K., & Gold, C. (2014). Music therapy for people with autism spectrum disorder. Cochrane Database Of Systematic Reviews. doi:10.1002/14651858.cd004381.pub3 ; Thompson, G., McFerran, K., & Gold, C. (2013). Family-centred music therapy to promote social engagement in young children with severe autism spectrum disorder: a randomized controlled study. Child: Care, Health And Development, 40(6):840-852. doi:10.1111/cch.12121 ; James, R., Sigafoos, J., Green, V., Lancioni, G., O'Reilly, M., & Lang, R., et al. (2014). Music Therapy for Individuals with Autism Spectrum Disorder: a Systematic Review. Rev J Autism Dev Disord., 2(1):39-54. doi:10.1007/s40489-014-0035-4
[27] D'Amico, M., Lalonde, C., & Snow, S. (2015). Evaluating the efficacy of drama therapy in teaching social skills to children with Autism Spectrum Disorders. Drama Therapy Review, 1(1):21-39. doi:10.1386/dtr.1.1.21_1; Schweizer, C., Knorth, E., & Spreen, M. (2014). Art therapy with children with Autism Spectrum Disorders: A review of clinical case descriptions on 'what works'. The Arts In Psychotherapy, 41(5):577-593. doi:10.1016/j.aip.2014.10.009
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