Tuesday, July 9, 2019

Pseudoscience in Autism Treatment

Complementary and Alternative Medicine (CAM) 

Controversial therapies and interventions continue to be a significant part of the history of children and youth with autism, perhaps more so than any other childhood disorder. Unfortunately, families are often exposed to unsubstantiated, pseudoscientific theories, and related clinical practices and therapies that are ineffective and compete with validated treatments, or that have the potential to result in physical, emotional, or financial harm. Many treatments are recommended to families based on anecdotal reports that make exaggerated claims, often appearing on the internet or in the popular media that do not qualify as scientific research. Given that autism has no known cure, parents and advocates will understandably pursue interventions and treatments that offer the possibility of helping the child with autism, particularly if they are perceived as unlikely to have any adverse effects and are generally accepted or popularized.

CAM Therapies

Complementary and alternative medicine (CAM), also called integrative medicine, is an approach widely used by families caring for individuals with autism. 
CAM is defined as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.” Current research estimates that
between 30 and 95 percent of children with autism spectrum disorder (ASD) have tried complementary or alternative medicine therapies, and up to 10% may be using a potentially dangerous treatment. The most commonly used CAM treatments for ASD fall into the categories of "biological" and “non-biological.” Examples of biological therapies include immunoregulatory interventions (e.g., dietary restriction of food allergens or administration of immunoglobulin or antiviral agents); detoxification therapies (e.g., chelation); stem-cell therapy; hyperbaric oxygen therapy (HBOT); gastrointestinal treatments (e.g., digestive enzymes, antifungal agents, probiotics, and gluten/casein-free diet); cannabidiol (CBD), and dietary supplement regimens (e.g., vitamin A, vitamin C, vitamin B6 and magnesium, folinic acid, vitamin B12, dimethylglycine and trimethylglycine, carnosine, omega-3 fatty acids, inositol, and various minerals). Non-biological interventions include treatments such as auditory integration training; sensory integration therapy; neurofeedback; pet therapy; massage therapy; aromatherapy; behavioral optometry; craniosacral manipulation; acupuncture; chiropractic treatment, and facilitated communication. These CAM therapies are generally described as pseudoscience and typically involve claims of scientifically supported evidence, which is in fact, lacking or misinterpreted.
At present, the empirical and treatment literature does not support and recommend the use of either biological or non-biological CAM treatments for children with ASD. Overall, there is sparse evidence on the usefulness of CAM treatments with autism. Although some CAM practices appear to have emerging evidence to support their use in traditional medical practice (i.e., melatonin), there are no CAM interventions with sufficient evidence to suggest they are effective. The most extensively evaluated biological CAM treatment for autism, the hormone secretin, has been thoroughly evaluated and shown to be ineffective with respect to core symptoms of ASD, including self-stimulatory behaviors, impaired communication, restrictive and repetitive behaviors, and gastrointestinal problems.  Additionally, research does not support the use of biological detoxification therapies such as chelation for ASD. According to the U. S. Food and Drug Administration, there are serious safety issues associated with chelation products. Similarly, the FDA has announced that hyperbaric oxygen treatment (HBOT) is not an approved or effective treatment for autism.

Unfortunately, pseudoscience is commonly practiced with ASD. Professionals in clinical and school contexts play an important role in helping parents and caregivers to differentiate empirically validated treatment approaches from treatments that are unproven and potentially ineffective and/or harmful. The major risk of CAM treatments is not only the potential for harm (e.g., chelation products), but the time and resources devoted to ineffective therapies at the expense of evidence-based interventions that have demonstrated effectiveness. The time, effort, and financial resources spent on pseudo and ineffective treatments can create an additional burden on families. 

All treatment selections should be evidence-based and include peer-reviewed studies with well-defined populations, randomized, large samples, control for confounding factors, and the use of validated outcome measures. There are few peer-reviewed, well-controlled, independent studies about CAM therapies, both for autism and many other health conditions. The paucity of validated, evidence-based data limits the ability to make fully informed decisions about the appropriateness of these treatments, particularly when considering that some CAM therapies are initiated without the guidance of a medical professional. 

More methodologically sound research needs to be completed on CAM treatments, and this information disseminated to families by well-informed professionals, so that parents can make educated judgments in selecting interventions. Parents and professionals should exercise caution when considering interventions and treatments that (a) are based on overly simplified scientific theories; (b) make claims of recovery and/or cure; (c) use case reports or anecdotal data rather than scientific studies; (d) lack peer-reviewed references or deny the need for controlled research studies; or (e) are advertised to have no potential or reported adverse effects. 
Adapted from Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London and Philadelphia: Jessica Kingsley Publishers.
                                              Key References and Further Reading
American Academy of Pediatrics, Section on Complementary and Integrative Medicine and Council on Children with Disabilities, Policy Statement (2012). Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics, 1186-1189. doi: 10.1542/peds.2012-0876. 
Autism Science Foundation. Beware of Non-Evidence-Based Treatments. Available from https://autismsciencefoundation.org/what-is-autism/beware-of-non-evidence-based-treatments/
Brondino, N., Fusar-Poli, L., Rocchetti, M., Provenzani, U., Barale, F., & Politi, P. (2015). Complementary and Alternative Therapies for Autism Spectrum Disorder. Evidence-Based Complementary and Alternative Medicine. Article ID 258589, 31 pages http://dx.doi.org/10.1155/2015/258589
Christon, L. M., Mackintosh, V. H., & Myers, B. J. (2010). Use of complementary and alternative medicine (CAM) treatments by parents of children with autism spectrum disorders. Research in Autism Spectrum Disorders, 4, 249–259.
Green, G., & Perry, L. (1999). Science, Pseudoscience and Antiscience. Science in Autism Treatment, 1(1), 5-6.
Granpeesheh, D., Tarbox, J., Dixon, D. R., Wilke, A. E., Allen, M. S., & Bradstreet, J. J. (2010). Randomized trial of hyperbaric oxygen therapy for children with autism. Research in Autism Spectrum Disorders, 4, 268-275.
Hopf, K. P., Madren, E., & Santianni, K. A. (2016). Use and Perceived Effectiveness of Complementary and Alternative Medicine to Treat and Manage the Symptoms of Autism in Children: A Survey of Parents in a Community Population. Journal of alternative and complementary medicine (New York, N.Y.)22(1), 25–32. doi:10.1089/acm.2015.0163
Huffman, L. C., Sutcliffe, T. K., Tanner, I. S. D., & Feldman, H. M. (2011). Management of symptoms in children with autism spectrum disorders: A comprehensive review of pharmacologic and complementary-alternative medicine treatments. Journal of Developmental and Behavioral Pediatrics, 32, 56-68. 
Hyman, S. L., Stewart, P. A., Foley, J., Cain, U., Peck, R., Morris, D. D…Smith, T. (2016). The gluten-free/casein-free diet: A double-blind challenge trial in children with autism. Journal of Autism and Developmental Disorders, 46, 205-220. doi.10.1007/s10803-015-2564-9
Lange, K.W., Hauser, J., & Reissmann, A. (2015). Gluten-free and casein-free diets in the therapy of autism. Current Opinion in Clinical Nutrition & Metabolic Care, 18, 572-575.
Lang, R., O’Reilly, M., Healy, O., Rispoli, M., Lydon, H., Streusand, W…Giesbers, S. (2012). Sensory integration therapy for autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders, 6, 1004-1018. doi:10.1016/j.rasd.2012.01.006
Levy, S. Complementary and Alternative Medicine Among Children Recently Diagnosed with Autistic Spectrum Disorder; Journal of Developmental and Behavioral Pediatrics, December 2003; vol 24: pp 418-423. News release, Health Behavior News Service.
Levy, S. E., & Hyman, S. L. (2008). “Complementary and Alternative Medicine Treatments for Children with Autism Spectrum Disorders.” Child and Adolescent Psychiatric Clinics of North America17(4), 803–ix. http://doi.org/10.1016/j.chc.2008.06.004
Lindly, O.J., Thorburn, S., Heisler, K. et al. (2018).  Parents’ Use of Complementary Health Approaches for Young Children with Autism Spectrum Disorder. Journal of  Autism and Developmental Disorders, 48: 1803-1818. https://doi.org/10.1007/s10803-017-3432-6
Mulloy, A., Lang, R., O’Reilly, M., Sigafoos, J., Lancioni, G., & Rispoli, M. (2010). Gluten-free and casein-free diets in the treatment of autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders, 4, 328-339.
Nath, D. (2017). Complementary and Alternative Medicine in the School-Age Child With Autism. Journal of Pediatric Health Care, vol. 31, no. 3, pp. 393–397.

National Autism Center (2015). Findings and conclusions: National standards project, phase 2. Randolph, MA: Author. Available from: http://www.nationalautismcenter.org/national-standards-project/phase-2/
National Professional Development Center on Autism Spectrum Disorders. (2015). Evidence-Based Practices. Available from: http://autismpdc.fpg.unc.edu/evidence-based-practices
National Research Council (2001). Educating children with autism. Committee on Educational Interventions for Children with Autism. C. Lord & J. P. McGee (Eds). Division of Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.
Odom, S. L., & Wong, C. (Summer, 2015). Connecting the dots: Supporting students with autism spectrum disorder. American Educator, 12-19.
Rubenstein, E., Schieve, L., Bradley, C., DiGuiseppi, C., Moody, E., Thomas, K., & Daniels, J. (2018). The prevalence of gluten free diet use among preschool children with autism spectrum disorder. Autism research: official journal of the International Society for Autism Research11(1), 185–193. doi:10.1002/aur.1896
Salgado, C. A., & Castellanos, D. (2018). Autism Spectrum Disorder and Cannabidiol: Have We Seen This Movie Before? Global pediatric health5, 2333794X18815412. doi:10.1177/2333794X18815412
Sathe Nila, Andrews Jeffrey C, McPheeters Melissa L, Warren Zachary E. Nutritional and dietary interventions for autism spectrum disorder: A systematic review. Pediatrics. 2017;139(6)
Umbarger, G. T. (2007). State of the Evidence Regarding Complementary and Alternative Medical Treatments for Autism Spectrum Disorders. Education and Training in Developmental Disabilities, 42, 437– 447
U.S. Food and Drug Administration (2014). Beware of False or misleading claims for treating autism. Available from www.fda.gov/forconsumers/consumerupdates/ucm394757.htm
Warren, Z., Veenstra-VanderWeele, J., Stone, W., Bruzek, J. L., Nahmias, A. S., Foss-Feig, J. H…McPheeters, M. (2011). Therapies for children with autism spectrum disorders. Comparative Effectiveness Review, Number 26. AHRQ Publication No. 11-EHC029-EF. Rockville, MD: Agency for Healthcare Research and Quality. 
Wong, C., Odom, S. L., Hume, K. A., Cox, C. W., Fettig, A., Kurcharczyk…Schultz, T. R. (2015). Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. Journal of Autism and Developmental Disorders, 45, 1951-66. doi: 10.1007/s10803-014-2351-z
Lee A. Wilkinson, PhD, is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. He is also editor of a text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

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