PCH/ROC ARTICLE
Raun Melmed
Medical Director
Southwest Autism Research and Resource Center
Clinicians addressing the needs of children and adults with Autistic Disorders (AD) are challenged by
the myriad and subtle variability inherent to the disorders along with the veritable explosion of
information published relating to presentation, treatment and research. The plight of families in this
context is enormous. Not only do parents have the formidable challenge of raising a child with a severe
developmental disability but at the same time they are faced with confusing and often contradictory
professional advice on how best to treat their children.
A helpful approach to treatment involves integrating the child’s functional developmental capacity,
environmental influences, and constitutional make-up, into the family’s culture. This can be referred to
as a medical home environment where emphasis is placed on the role family’s play as partners in
caring for their children. Follow-up visits are an opportunity for team discussions with treatment
planning that respects the family’s input and culture.
A medical home requires looking at the child from a holistic perspective, and recognizing the centrality
of families and constructing a comfortable medical environment. Finding a qualified, compassionate
and responsive physician is a priority for any family seeking medical services for their child with autism.
Treatment of children with AD is a complex task with multi-modal interventions needed.
Comprehensive intervention, including parental counseling, behavior modification, special education,
sensory integration training, speech therapy, social skill training, along with biologically based
interventions can have significantly positive impact.
Children with AD have the same health care needs as those without disabilities and benefit from the
same health promotion and disease prevention activities. Children with AD do react differently however
especially when non-verbal. This is a consequence of unusual sensitivities to pain, the inherent
difficulty with history taking in children with disabilities, and the challenging of determining whether
presenting problems are a consequence of the core features of autism or whether they are as a result of
an underlying physical disorder. Here are some examples.
Common Symptoms in Autism
Self injurious behaviors
Self stimulatory behaviors
Sleep initiation challenges
Night-time wakening
Toe walking
Agitation
Loss of skills
Toilet training problems
Rectal digging
Behavior regression
Head banging
Skin rashes
Poor attention
Are possible signs of
Ear infections
Esophageal ulcerations
Dental abscess
Acid reflux
Constipation
Incorrect eye glasses
Seizures
Chronic diarrhea/constipation
Protozoal infections
Puberty, seizures
Upper respiratory infection
Food sensitivity
Constipation
The assessment of any behavioral or medical problem is facilitated by evidence directly obtained from
parent as well as other caregivers, therapists, attendants and teachers. This includes information regarding
duration, severity, frequency of symptoms, along with the degree of functional impairment.
Medical problems can impact the child with AD. Seizures can be difficult to identify in the presence of a
child's atypical, repetitive, and/or ritualistic behaviors. Seizures are present in approximately 20% to 35% of
children with AD and have 2 peaks of onset, the first during early childhood and the second during
adolescence. Subclinical signs of seizures can be subtle and accurate history taking and observation is
needed.
The high incidence of gastrointestinal (GI) symptomatology in children with AD has been reported. At
SARRC, studies have shown that 25% of the children had chronic diarrhea, and a further 25% had chronic
constipation. Carbohydrate intolerance secondary to disaccharidase deficiency has been seen in 55% of
children with AD with combined deficiency of disaccharidase enzymes seen in 15%. Symptoms which result
from these conditions need assessment by an astute physician.
Daytime irritability, inattention, or lethargy may be due to inadequate sleep. Between 50% and 80% of
children with AD have abnormal sleep patterns. The value of strict sleep hygiene habits cannot be
underestimated - sometimes more aggressive treatment might be warranted.
All team members – including the family - should understand the indications, side effects, and limitations of
any therapeutic approach. The individual with AD should be involved in the treatment process as much as
possible, despite any developmental limitations. For example, every effort should be made to help the child
understand the reason and purpose for taking medication and the possible side effects. The child with AD
becomes a partner in the treatment process.
Development is a transactional process. A wide variety of environmental interactive experiences can
produce physical changes and visa versa. For these forces to be harnessed, families’ treatment choices for
their children need to be understood and respected. That way, the healing capacity of health care providers
can be enhanced. An open-minded and integrated approach to caring along with an awareness of the
complex medical problems that children with AD face will benefit everyone.