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Cited by 60Autism Spectrum Disorder ResearchChild Nutrition and Feeding IssuesBehavioral and Psychological Studies

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Clinical practice guidelines for autism spectrum disorders

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Subramanyam, AlkaA, Mukherjee, Abir, Dave, Malay, Chavda, Kersi·2019·Indian Journal of Psychiatry
DOI 10.4103/psychiatry.indianjpsychiatry_542_18PMC PMC6345133
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Abstract

INTRODUCTION These guidelines have been framed after an amalgamation of expert guidelines across the globe, and existing practices in India, as outlined by experts in the field. Due to the lack of systematic research in the field of autism in India, the evidence of the said practices is not documented, which becomes a limitation of these guidelines. The good part is that India has an indigenous tool for assessment, which has been recommended by the Government of India, which we have attached as an Appendix 1. Autism has till date always been viewed as an illness from the medical model, and hunt for a “cure” has been the norm. With the increase in awareness and available therapies, the focus shifted to disability and inclusion. However, as more autistic individuals express themselves and their needs, the focus now has shifted from the medical model to the social model of neurodiversity, thereby implying that autism is actually a variant of normal human development and human diversity. The next decade will probably see how best the two paradigms can be aligned to destigmatize and integrate autistic individuals into society at large. Keeping the above in mind, the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) shifted from grouping the disorders as separate diagnoses under the umbrella of pervasive developmental disorders (PDDs) to conceptualizing them as all members of the broader category of known as autism spectrum disorder (ASD). The number of core domain deficits was reduced to two (social communication and repetitive behavior). ASD would now be diagnosed when a patient demonstrated at least three symptoms in the domain of social communication and at least two symptoms of restricted interests/repetitive behaviors; including an added behavior of hyper-or hypo-reactivity to sensory input or unusual interests in sensory aspects of the environment [Table 1].Table 1: Diagnostic and statistical manual of mental disorders -IV-TR versus diagnostic and statistical manual of mental disorders - 5MAJOR CHANGES TO THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS-5, AUTISM DIAGNOSTIC CRITERIA Category name changed from PDDs to ASDs The inclusion of sensory differences in criteria Recommendation to identify “specifiers” to better understand the individual needs of each child with ASD (cognitive and language ability, level of supports needed, co-occurring medical and mental health conditions, catatonia) The inclusion of co-occurring mental health disorders (e.g., attention-deficit/hyperactivity disorder). The International Classification of Diseases-10th version (ICD-10), still used the term PDD. What is interesting is that the proposed changes in ICD-11 have not only changed the nosology to ASD but have also included intellectual development and functional language, which is closer to the clinical picture, and also is in keeping with the concept of neurodiversity. At a glance, when we compare these classificatory systems, below are the changes we can see [Table 2].Table 2: Change in the classification of autismThus with the above inclusions, the numbers are bound to increase. The latest statistics state that the prevalence of ASD, is now estimated at 1 in 68, more in males, (Centre for Disease Control National Center on Birth Defects and Developmental Disabilities, USA, 2014), which is alarming rise from 1:500 less than a decade ago. The possible reason for this is increase in the number of copy number variation and gene variations. Multiple genes seem to be involved. These genes are responsible for synaptic plasticity, synaptic scaffolding proteins, receptors, cell adhesion molecules or proteins that are involved in chromatin remodeling, transcription, protein synthesis or degradation, or actin cytoskeleton dynamics. For example, Genes for neuroligins, SHANKs, CNTNAP2, FMR1 to name a few. On analysis of neuronal growth and pathways cortico-striato-thalamo-cortical circuits (for repetitive behaviors), ventral tegmental area connectivity to nucleus accumbens (for social interaction), and amydala to ventral hippocampal connectivity (for social interactions) are areas of active interest and study. The validity of the same, and the translation into structural diagnostic neuro-imaging is yet to be established, and hence limits the use of the same. Similarly, functional neuropathology reveals excessive synapses due to a slow pruning process. However, diagnostic modalities to ascertain the same are yet awaited. PROCESS OF ASSESSMENT Autism being a complex disorder, the assessment should as far as possible be done by multidisciplinary team who besides the psychiatrist should include a psychologist, a special educator, an occupational therapist, and an audiologist and speech therapist [Figure 1]. In the western world, educational psychologists in school settings double up for the assessment of cognition and curricular level too. Furthermore, it is good to keep the child's pediatrician i

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Figure 1 Approach to assessment of autism
Figure 1 Approach to assessment of autismCC BY-NC-SA · PubMed Central
Figure 2 A target symptom approach to pharmacotherapy of autism spectrum disorder. SSRI: Selective serotonin reuptake inhibitors, NT: Not tolerated
Figure 2 A target symptom approach to pharmacotherapy of autism spectrum disorder. SSRI: Selective serotonin reuptake inhibitors, NT: Not toleratedCC BY-NC-SA · PubMed Central
Figure 3 Management of distress, anxiety and agitation in autism spectrum disorder. Patients with autism spectrum disorder may require much lower or much larger doses than commonly prescribed thus individual titration of dose is a must
Figure 3 Management of distress, anxiety and agitation in autism spectrum disorder. Patients with autism spectrum disorder may require much lower or much larger doses than commonly prescribed thus individual titration of dose is a mustCC BY-NC-SA · PubMed Central
Figure 4 Management of mood disorders in autism spectrum disorder
Figure 4 Management of mood disorders in autism spectrum disorderCC BY-NC-SA · PubMed Central
Figure 5 Management of feeding disorders in children with autism spectrum disorder
Figure 5 Management of feeding disorders in children with autism spectrum disorderCC BY-NC-SA · PubMed Central

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Research works printed but not linked: 3

  1. Lai, 2014, Autism, Lancet, 896
  2. Stigler, 2014, Psychopharmacologic management of serious behavioral disturbance in ASD, Child Adolesc Psychiatr Clin N Am, 73
  3. Volkmar, 2014, Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder, J Am Acad Child Adolesc Psychiatry, 237

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Metadata

Authors
Subramanyam, A., Mukherjee, A., Dave, M., & Chavda, K.
Affiliations
  • Topiwala National Medical College & BYL Nair Charitable Hospital (IN)
  • P. D. Hinduja Hospital and Medical Research Centre (IN)
ORCID
Dave, Malay
Venue
Indian Journal of Psychiatry
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2019
Volume
61
Issue
8
Pages
254
ISSN
0019-5545 (ISSN-L)
DOI
10.4103/psychiatry.indianjpsychiatry_542_18
PMC
PMC6345133
OpenAlex
W2910508166
Cited by
59
References
31
Citations by year
2026: 4 · 2025: 10 · 2024: 10 · 2023: 6 · 2022: 16 · 2021: 6 · 2020: 4 · 2019: 3
FWCI
4.22
Type
journal article
Language
en
Open access
Licence
cc-by-nc-sa
Locations
  • Indian Journal of Psychiatry (publishedVersion, cc-by-nc-sa)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by-nc-sa)
  • PubMed Central (publishedVersion, cc-by-nc-sa)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
Topics
  • Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
  • Health Sciences › Medicine › Psychiatry and Mental health › Child Nutrition and Feeding Issues
  • Social Sciences › Psychology › Developmental and Educational Psychology › Behavioral and Psychological Studies
Keywords
autism spectrum disorder, autism diagnosis, DSM-5 diagnostic criteria, ICD-11, medical model of autism, autism treatment, inclusive education, pervasive developmental disorders, sensory hypersensitivity, restricted and repetitive behaviors, social communication deficits, co-occurring mental health disorders

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