Over the past half-century, two treatment approaches have dominated autism therapy. One is behavioral therapy (for instance, applied behavior analysis), while the other is traditional medical intervention relying largely on medications such as Prozac, Risperdal, Haldol, Tegretol, and Ritalin. Numerous studies support the effectiveness of both approaches.
During this time, other approaches have emerged; however, these approaches have received relatively little attention from researchers in the autism field. They include biomedical interventions (for instance, fecal transplants, methyl B12, and detoxification), nutrition-related health programs, sensory interventions, and communication/speech/language therapies. These treatments are increasingly popular as a result of positive results demonstrated by a modest amount of research as well as benefits seen by parents, teachers, and therapists.
Is reliance on a single treatment discipline misguided?
Most behavioral and traditional medical approaches to autism treatment, as well as many alternative treatments, use standardized methods to alleviate symptoms commonly associated with autism. These symptoms include but are not limited to hyperactivity, anxiety, depression, challenging behaviors, and eating and sleeping problems.
Each intervention is highly effective for many children, but less effective (or even ineffective or harmful) for others. This begs the question: Given the heterogeneity of the autism spectrum, which intervention can best treat each symptom?
Today, parents are often urged by professionals to rely on only one treatment approach, or at most two, to help their children. The most typical approaches include behavioral therapy and medications.
Furthermore, clinicians and researchers in the fields of behavioral therapy and traditional medicine frequently raise doubts about the efficacy of other disciplines. Often, this stems from concerns about possible adverse effects, a supposed lack of research on the effectiveness of the approaches, or even hearsay about how the treatments are administered.
However, the assumption that only one or two disciplines will always offer the best results across the entire autism spectrum is scientifically unsubstantiated and causes many children with autism to miss out on potentially life-changing interventions. What we need, instead, is a systematic way to determine which approaches will work for each individual child.
Multidisciplinary treatment: what is the best approach?
In comparison to a single treatment approach, a multidisciplinary treatment approach involves identifying symptoms and behaviors of concern and then selecting interventions from various disciplines that are known to effectively treat them.
There are at least two types of multidisciplinary treatment approaches. In one type, treatments presumed to be most effective for each symptom and behavior are included in the treatment plan. For example, this may involve hiring a behaviorist to treat aggression, assigning a sensory therapist to neutralize sensory sensitivities, and having a pediatrician or specialist treat activity level, anxiety, and sleep disorders. These recommendations will likely result in improvements, but they may not be optimal for each individual.
The second type of approach is an evidence-based multidisciplinary approach. This involves assessing symptoms and behaviors of concern with respect to each available treatment discipline. Such an assessment can often provide sufficient information to determine rather precisely how best to treat each symptom and behavior.
This approach may require more time and even incur additional costs, but it is systematic and thorough. The goal for every treatment plan should be to optimize improvement and not to settle for anything less.
The evidence-based multidisciplinary approach begins with identifying symptoms and behaviors of concern. This can be done via clinical interviews, direct observations, and/or parent-based questionnaires and checklists, such as the Autism Research Institute’s Autism Treatment Evaluation Checklist (ATEC). Next, these symptoms and behaviors are evaluated in greater depth. Many valid questionnaires are available for assessing anxiety, challenging behaviors, GI function, sensory sensitivities and insensitivities, sleep problems, and more. The evaluation can also include laboratory testing and/or a functional behavioral assessment.
Once information regarding the symptoms and behaviors is gathered, other factors can be considered before assigning specific interventions. The possibility of adverse effects may not be acceptable in many cases, especially for those who are medically fragile or emotionally sensitive. For example, specific medications may not be advisable given that they may exacerbate further constipation in children with gastrointestinal issues. In addition, strict behavioral therapy may not be acceptable to parents with emotionally sensitive children.
Urgency may also be an important factor when deciding which treatments are appropriate. For instance, medication may be the correct choice for an individual with autism who exhibits severe self-injury, even if the recommended medication has potentially serious side effects.
The availability of an intervention (e.g., wait list, distance to the closest referral) should also be a consideration, as well as its affordability (e.g., insurance coverage).
The order of the treatments should also be taken into account. Some interventions may or even should be given simultaneously, whereas others need to be administered in a specific order. For example, a child who is a picky eater should be treated for oral sensitivity prior to starting a nutrition program. Another child who experiences headaches should be treated medically before starting an intense behavior program.
Clinicians and researchers: a powerful multidisciplinary team
If clinicians use valid and reliable measures to assess their patients, they can then partner with researchers to evaluate the effectiveness of various interventions in applied real-world settings. Outcome measures should always be assessed objectively to determine whether or not each treatment is, in fact, helpful. Researchers may also want to include direct observation procedures conducted in laboratory or in natural situations.
A relatively large database could be generated from such a coordinated study, involving numerous clinical and research sites. This would allow researchers to formulate statistical algorithms (formulas) to objectively determine an optimal plan for each individual. Specific characteristics of the individual could also be integrated in such algorithms, including age, sex, and other variables found to be relevant in predicting optimal treatment success.
Using such an approach, we could effectively address the wide range of symptoms and behaviors seen across the autism spectrum. As a result, we could minimize trial-and-error and maximize the opportunity for each individual to reach his or her true potential. Thus, I encourage those in the autism treatment community to reconsider their opinions about the value of a multidisciplinary approach—an approach that I strongly believe will help us to better address the needs of the diverse population we serve.
Stephen M. Edelson, Ph.D.
Executive Director, Autism Research Institute
The editorial appeared in Autism Research Review International, Vol. 33, No. 3, 2019