Effective autism care requires attention to comorbidities, research indicates

Caring for youths with autism spectrum disorder can be overwhelming for some primary care physicians because of the multiple comorbid conditions that often accompany ASD, said Boston pediatrician James M. Perrin, MD. Such conditions commonly include constipation, insomnia and symptoms of attention-deficit/hyperactivity disorder.

But treating these associated health issues often helps children with ASD feel better and can improve their behavior and performance in school, said Dr. Perrin, a professor of pediatrics at Harvard Medical School in Boston and president-elect of the American Academy of Pediatrics. He also is editor of a special supplement on ASD that was published online Nov. 1 in Pediatrics.

The supplement, which features 18 articles, recommends behavioral therapy for treating insomnia, encourages looking for ADHD symptoms in children with autism and highlights the prevalence of supplement use among this population.

“Our hope is that this issue will help inform the health [professionals] and parents about the needs of children with autism and the evolving knowledge, practices and guidelines that can ultimately improve the quality of health care that children and their families receive,” said the editor’s note in the supplement.

Childhood autism diagnoses continue to rise in the United States. A study of 8-year-olds showed that one in 88 has some form of ASD. In 2006, the rate was one in 110, said the study, published in the March 30 issue of the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.

Common among this population is use of complementary and alternative medicine, or CAM, to ease symptoms of comorbid conditions, such as gastrointestinal problems, said a study of 3,413 youths age 2 to 18 with ASD that was in the Pediatrics supplement. CAM includes adhering to a gluten-free diet, avoiding processed sugars or receiving acupuncture.

To prevent negative interactions between CAM and prescribed drugs, physicians regularly should talk to families about whether a child is being treated with CAM, Dr. Perrin said.

Improving behavior issues

Some patients use alternative health practices to help control behavior problems, medical experts say. Those problems often are symptoms of ADHD that will improve with proper medical treatment, said a study of 3,066 youths ages 2 to 17 that was in the special supplement.

Researchers found that more than a third of children with autism and related conditions have some ADHD symptoms. Those symptoms are related to impairment in the person’s adaptive functioning and a poorer health-related quality of life.

The study encourages physicians to evaluate youths with autism for the presence of ADHD symptoms. If such symptoms are present, they should be treated, said lead study author Darryn M. Sikora, PhD.

“It’s not a good standard of care to assume that problems [in patients with ASD] are simply because of autism,” said Sikora, a pediatric psychologist at the Providence Child Center in Portland, Ore. “It’s important to look at other [potential health issues] and be mindful of the impact those problems could have.”

Addressing symptoms of ADHD “will make a positive difference” in the health of patients with autism and related conditions, she added.

So will treating insomnia in youths with ASD, according to two studies in the special supplement. Between 50% and 80% of children with ASD have trouble falling asleep or staying asleep, data show.

Insomnia is associated with an increase in problem behavior and emotional issues, including anxiety and emotional reactivity, said a study in the supplement of 1,193 youths 4 to 10 who have ASD and live in the U.S. and Canada.

A separate report in the same Pediatrics issue recommends that physicians screen all children with ASD for insomnia. For youths identified as having the condition, doctors should talk to parents about behavioral approaches to improve the problem, such as keeping a regular sleep schedule and offering positive reinforcement when the child displays appropriate sleep behaviors.

“Although medications and supplements are often used to treat insomnia experienced by children and adolescents with ASD, the evidence base for pharmacologic treatment is limited,” the report said.

Regardless of the treatment type, doctors should follow up with patients between two weeks and one month after starting therapy for sleep problems, said the review of 20 insomnia-related studies published between January 1995 and June 2010.

“We need to empower primary care physicians to know that they already have the skill set to work with children who have autism,” Sikora said. Doctors “can address these co-occurring behaviors head-on. It will make a positive difference.”