Evidence-based treatments for autism spectrum disorders

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that involves persistent deficits in communication and social interaction, as well as the presence of restricted and repetitive patterns of behavior, specific interests, and sensory abnormalities.

Individuals with ASD are very different from one another, and therefore, the nature and intensity of the support and treatment will vary for each person, always adapting to their individual characteristics and stage of life. Furthermore, a coordinated, multidisciplinary approach involving the family is recommended. In this regard, a family-centered approach is advised, which aims to empower families based on their specific characteristics and strengths.

The design of the intervention plan should include evidence-based practices , since evidence-based treatments have undergone a rigorous and scientific process that demonstrates that they are useful and effective strategies.

Several of the recommendations that we will give below are valid for childhood, adolescence and adulthood in people with ASD.

Designing the intervention plan for people with ASD

Some key elements for the effective design of the intervention are:

Recommended treatments for people with ASD

• Adapt the characteristics of the environment : anticipation, visual aids (visual tools, agendas, schedules), stimulus control, sensory protection, clear and stable routines and a structured and organized environment, with stimuli that help to convey security and control.
• Offer strategies to the people surrounding the affected person:

1. Design an error-free learning plan. Offer support that guarantees success in the task, gradually withdrawing this support. This fosters motivation and minimizes disruptive behaviors related to low frustration tolerance.
2. Provide positive reinforcement for attempts and efforts, not just achievements.
3. Avoid criticism and punishment.
4. Replace "no" with constructive messages, providing suitable alternatives to modify behavior.
5. Include aspects that promote the generalization of learning to the natural context.

• Develop skills : create strategies for training in communication skills, social interaction, flexibility in the face of change, and emotional regulation skills.  
• Pay attention to the person's comorbidity: focus on managing difficulties in emotional and behavioral regulation, anxiety symptoms, mood, sleep problems, and eating disorders.
• Base the intervention on a functional assessment of behavior: conduct a comprehensive assessment that determines the function and objective of the behavior.
• Providing support during the transition to adulthood: Support is key during this transition to adulthood, given all the changes that occur (in roles, responsibilities, and even in the services available to the individual). But this support is also important during other transitions that may occur in childhood (such as the transition from primary to secondary school).
• Intervening in daily living skills: these should be adapted to the person's developmental stage and the individual's own capabilities.
• Support and assistance during working life and old age.

Some of the most recommended evidence-based practices in recent reviews are (Hume et al., 2020; Fuentes et al., 2020):

Early intervention therapies

Early intervention programs are designed to facilitate social communication between children and their parents. They are key to promoting the child's development and are based on joint attention, imitation, and play.

Some examples of programs that have shown evidence are:

• Jasper model.
• Individual Relationship Development Model (DIR).
• PACT ( Pediatric Autism Communication Therapy ).
• The Hanen Program .

On the other hand, naturalistic interventions have also proven highly useful. These interventions use techniques and strategies embedded in everyday activities or routines to naturally promote the development of skills. One example of a naturalistic intervention model is the Denver Model of Early Intervention.

Along the same lines of naturalistic intervention is Incidental teaching reinforces a child's attempts when they perform behaviors that approximate the desired behavior. This type of intervention can be used beyond early childhood.

Behavior-based interventions

Applied behavior analysis (ABA) is a set of behavior modification principles and techniques based on learning theories. It focuses on the antecedent-behavior-consequence (ABC) model and the use of positive reinforcement.

Some specific techniques are:

• Antecedent-based interventions: These interventions seek to modify antecedents (stimulus or situation that elicits or produces a response) to promote an increase in desired behaviors and reduce maladaptive behaviors.
• Extinction: Extinction involves withdrawing attention from behaviors we consider inappropriate. When we don't pay attention to a behavior, the reinforcement is removed, and the behavior tends to decrease until it disappears.
• Modeling: providing an example of the expected behavior to facilitate the learning of a desired behavior. This can be done through video modeling.
• Positive reinforcement: This is recognition, a reward, or a pleasant activity that increases motivation. It increases the likelihood that a behavior will be repeated.
• Discrete trial training: This technique breaks down skills into small components. The therapist trains these skills one by one, using tangible reinforcement for approximations to the target behavior.
• Delay time: intervention used to gradually fade the use of supports, using a short delay between the initial instruction and another instruction or use of support.
• Differential reinforcement of alternatives: This involves ceasing to reinforce the behavior that one wants to eliminate and reinforcing a functionally equivalent alternative behavior. It can also involve reinforcing behaviors that are incompatible with the problematic behavior.

A recommended model for reducing behavioral problems and improving people's quality of life is positive behavioral support . This approach begins with a functional assessment of behavior and involves skills training and adaptation to the person's context.

Augmentative and Alternative Communication (AAC) systems

AAC systems are communication systems other than spoken language that aim to augment and compensate for difficulties in communication and language.

One of the most widely used AAC systems is the Pictures Exchange Communication System (PECS ) , an augmentative and alternative communication system that uses picture exchange. It involves working with the individual and teaching them to use pictures to make requests, comments, or ask questions.

Social skills training

Social skills are trained, such as recognizing and expressing emotions, theory of mind, solving social problems, reciprocal conversation, stress management, decision making, perspective taking, group play, etc.

In the area of social skills , social narratives are often useful; these are interventions that describe social situations to highlight what is happening in the situation and what is expected of the subject in that situation.

Cognitive-behavioral strategies

They combine behavioral model techniques with strategies that involve more cognitive aspects.

TEACCH System

It is a system for the treatment and education of students with autism and communication difficulties. It is based on adapting the environment to the individual's characteristics and involves close collaboration between family members and professionals. It combines the use of visual supports and clear structure with other techniques, flexibly combined according to the individual's needs: cognitive-behavioral techniques, AAC, etc.

SCERTS Model ( Social Communication Emotional Regulation Transactional Support )

It is a comprehensive educational approach whose objectives are social communication and emotional regulation. It is implemented through transactional aids (interpersonal and learning support) in a natural environment.

Pharmacological treatment

There are no medications that can treat the main symptoms of ASD, but there are medications that help control some related symptoms. For example, medication can reduce attention problems, mood swings, seizures, or impulsivity.

Complementary treatments in ASD

In addition to these specific practices, there are other complementary treatments:

• Music-mediated intervention: interventions that incorporate songs, melodic intonations, and rhythms to promote the learning of skills or behaviors.
• Peer-mediated intervention: intervention in which the peer group directly promotes social interactions with individuals with ASD, or another objective, and an adult provides support when needed.
• Sensory integration: interventions that help develop the ability to integrate sensory information (auditory, tactile, olfactory, visual), coming from one's own body or the environment.
• Technology-mediated intervention: an intervention in which technology is the central tool and has been specifically designed to promote training in a behavior or skill.
• Occupational therapy: trains skills that help a person live as independently as possible. These are usually daily living skills, such as eating, dressing, personal hygiene, and interacting with others.

On the other hand, there are families and users who mention other intervention strategies, although these have not yet been shown to have scientific evidence :

• Dietary approaches

Nutritional treatments are based on dietary changes, such as eliminating certain foods and using specific supplements, with the aim of reducing difficulties associated with ASD. However, most of these treatments lack the necessary scientific basis to make a general recommendation. It is advisable to speak with your doctor before making any such changes.

• Complementary and alternative treatments

Complementary and alternative therapies are practices that are generally outside the usual recommendations of a primary care physician. Some examples include chelation (a treatment that aims to remove heavy metals from the body) or the use of certain biological substances, such as secretin. These treatments lack sufficient scientific evidence, and it is recommended to consult with a primary care physician before starting them.