Kaplan + Sadock's Synopsis of Psychiatry, 11e

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31.5 Autism Spectrum Disorder

bedtime and throughout the night, such that there is a removal of reinforcement and attention for being awake, leading to a gradual extinction of the “staying awake” behavior. Several studies using massage therapy before bedtime in children with autism spectrum disorder between the ages of 2 years and 13 years provided an improvement in falling asleep and a sense of relaxation. Educational interventions for children with autism spectrum disorder 1. Treatment andEducation ofAutistic and Communication- related Handicapped children (TEACCH). Originally developed at the University of North Carolina at Chapel Hill in the 1970s, TEACCH involves structured teaching based on the notion that children with autism spectrum disorder have difficulty with perception, and so this teaching method incor- porates many visual supports and a picture schedule to aid in teaching academic subjects as well as socially appropriate responses. The physical environment is arranged to support visual learning, and the day is structured to promote auton- omy and social relatedness. 2. Broad-based approaches. These educational plans include a blend of teaching strategies that use behavioral analysis and also focus on language remediation. Behavioral reinforce- ment is provided for socially acceptable behaviors while academic subjects are being taught. TEACCH may also be incorporated into a broader special educational program for autism spectrum disorder. 3. Computer-basedapproaches andvirtual reality. Computer- based approaches and virtual reality teaching are centered on using computer-based programs, games, and interactive programs to teach language acquisition and reading skills. This provides the child with a sense of mastery and delivers a behaviorally based instruction in a modality that is appealing for the child. The Let’s Face It! program is a computerized game that helps to teach children with autism spectrum dis- order to recognize faces. It consists of seven interactive com- puter games that target changes in facial expression, attention to the eye region of the face, holistic face recognition, and identifying emotional expression. A randomized controlled trial of use of this program with children with autism spec- trum disorder provided evidence that after 20 hours of face training with Let’s Face It!, compared to the control group, the trained children demonstrated improvement in their abil- ity to focus on the eye region of a face and improved their analytic and holistic face-processing skills. Several stud- ies using virtual reality environments to teach children with autism spectrum disorder social skills and interaction have provided evidence of their value. In one study, a virtual café for children with autism spectrum disorder allowed the chil- dren to practice ordering and paying for drinks and food by navigation with the use of a computer mouse. Psychopharmacological Interventions Psychopharmacological interventions in autism spectrum dis- order are mainly directed at ameliorating impairing associated behavioral symptoms rather than core features of autism spec- trum disorder. Target symptoms include irritability, broadly

acquisition, and for parents, may be administered at a lower intensity such as weekly; however, once parents are trained, the interventions occur throughout the day with the child. Another example of a parent training approach is the Hanen More Than Words Program. Social Skills Approaches 1. Social Skills Training. Typically provided by therapeutic leaders to children of various ages in a group setting with peers; children are given guided practice in initiating social conversation, greetings, initiating games, and joint attention. Emotion identification and regulation are often included in practice with recognizing and learning how to label emotions in given social situations, learning to attribute appropriate emotional reactions in others, and social problem-solving techniques. The goals are that with practice in the group setting, the child will be able to use the techniques in less-structured settings and internalize strategies to interact posi- Behaviors and Associated Symptoms 1. Behavioral Therapy. Applied behavioral analysis has been found to be somewhat effective in reducing some repetitive behaviors in children and adolescents with autism spectrum disorder. Early intervention is recommended for repetitive behaviors that are self-injurious; behavioral interventions may need to be combined with pharmacologic treatments to adequately manage the symptoms. 2. Cognitive-Behavioral Therapy. There is a significant evi- dence base from RCTs for the efficacy of CBT for symptoms of anxiety, depression, and obsessive-compulsive disorders in children. There are fewer controlled trials of this treatment in children with autism spectrum disorder, although there are at least two published studies in which CBT was used to treat repetitive behavior in individuals with autism spectrum disorder. Interventions for comorbid symptoms in autism spectrum disorder 1. Neurofeedback. This modality has been administered in an attempt to influence symptoms of attention-deficit/hyperac- tivity disorder (ADHD), anxiety, and increased social inter- action by providing computer games or other games in which the desired behavior is reinforced, while the child wears elec- trodes that monitor electrical activity in the brain. The aim is to influence brainwave activity to prolong or produce electri- cal activity present during the desired behaviors. This modal- ity is still under investigation in the treatment of symptoms in autism spectrum disorder. 2. Management of insomnia in autism spectrum disorder. Insomnia is a prevalent concern among children and ado- lescents with autism spectrum disorder, and both behavioral and pharmacologic interventions may be administered to improve this condition. The most common behavioral inter- vention for insomnia in autism spectrum disorder is based on changing the parents behavior first toward the child at tively with peers. Behavioral Interventions (BIs) and Cognitive-Behavioral Therapy (CBT) for Repetitive