As a mother of a moderately affected autistic child and family physician to a number of autistic children, I have found that autistic persons are as varied as fingerprints, and each child needs an individualized, multidisciplinary approach. Autism is a wide-spectrum, pervasive developmental disorder of uncertain etiology. Family physicians are likely to encounter these children in their practices and should know basic diagnostic criteria to recognize autism during well-child evaluations. Higher functioning autistic children with Asperger's syndrome have often been misdiagnosed with psychiatric disorders, or not diagnosed at all, resulting in inappropriate interventions or no intervention. The article in this issue of American Family Physician by Prater and Zylstra1 contains practical, comprehensive, and useful information, and will help increase awareness so that children with autism will be diagnosed at an earlier age when intensive educational and behavioral interventions have the greatest impact.
Autism research is in its infancy, and partly because of parental advocacy and lobbying, the federal government has significantly increased research funding. The cause of autism appears to be multifactorial in its biology. Although a possible association between the measles, mumps, and rubella (MMR) vaccine and autism received widespread media attention, epidemiologic studies and related evidence do not support this hypothesis.2–6 Thimerosal, a mercury preservative, is being phased out of vaccines because of its potential toxicity in vulnerable children and concern from parents and clinicians. Although most of the current evidence favors the safety of the MMR vaccine, especially with the removal of thimerosal, continued research is needed in this area before parents will feel that this issue has been resolved completely.
Children meeting the diagnostic criteria of autism should be referred to school and state programs for evaluation, and parents should be encouraged to contact local and national organizations for autism to receive support and information. The child should be evaluated by a developmental pediatrician or child psychologist experienced in treating autistic children. Early intensive behavioral, multidisciplinary intervention is essential. From the highly structured Lovaas method,7 to the more child-centered approaches of Green-span8 and the Son-Rise method,9 the choice of program often will depend on what resources are available in the community, the desired level of involvement of the parents, and the characteristics of the child.
The Lovaas method7 involves a highly structured, classical behavior approach using reinforcements for desired behaviors and extinction for those behaviors that are considered undesirable. The child conforms to a preset program. The Greenspan8 and Son-Rise9 approaches respond to the needs and strengths of the child without highly structured, predetermined exercises. Play or “floor time” is maximized to engage the child in developmental tasks that are uniquely stimulating for that particular child. Intellectual and emotional growth are encouraged and emphasized. The Son-Rise method9 is unique in that it is parent- rather than therapist-directed, involving volunteer therapists and having less dependence on local resources. Many intensive therapy programs are based on these major approaches or a modification of them. As Prater and Zylstra1 point out, it is essential with all interventions that objective data collection and outcome monitoring be done to assess for effectiveness. This is especially important given the lack of research and the plethora of alternative theories and treatments that have benefitted some children with autism.
Parents are often overwhelmed with grief, and the family physician's support and recommendations for counseling are important. When families ask about alternative treatments, physicians can be open-minded and supportive, be willing to learn from parents, and as research in this area increases, share what evidence is available for these interventions. For interventions that appear benign, encourage parents to keep data and monitor outcomes, and share information with you. As a mother, I recommend that you listen attentively, treat the child with love and curiosity, be open-hearted and open-minded, and become comfortable with the triumphs as well as the tears that autism can bring to a family.