Treatment of ASD

The manifestation and severity of symptoms of ASD differ widely, and treatments include a range of behavioral, psychosocial, educational, medical, and complementary approaches^7–10 that vary by a child’s age and developmental status. The goals of treatment for ASD typically focus on improving core deficits in communication, social interactions, or restricted behaviors, as changing these fundamental deficits may help children develop greater functional skills and independence.¹¹ Treatment frequently is complicated by symptoms or comorbidities that may warrant targeted intervention. There is no cure for ASD and no global consensus on which intervention is most effective.^{12, 13} Individual goals for treatment vary for different children and may include combinations of behavioral therapies, educational therapies, medical and related therapies, approaches targeting sensory issues, and allied health therapies; parents may also pursue complementary and alternative medicine therapies.

Scope of Review

This review updates findings reported in the 2011 Agency for Healthcare Research and Quality (AHRQ) review Therapies for Children with ASD¹⁴ with a focus on studies of interventions targeting sensory challenges. We defined interventions targeting sensory challenges in line with the DSM-5 definition and definitions used in other reviews of sensory-focused interventions.^{2, 3} DSM-5 classifies sensory challenges as a manifestation of the core symptom of restricted and repetitive patterns of behavior, interests, or activities. The DSM describes sensory challenges as “hyper- or hyporeactivity to sensory input, manifested through extreme responses to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects, and sometimes apparent indifference to pain, heat, or cold.”¹ Interventions targeting sensory challenges are typically described as designed to provide controlled sensory experiences in order to encourage the modulation and integration of information from the environment, thus promoting adaptive responses to sensory inputs.

Though the field lacks broad consensus on a definition of sensory-focused approaches, interventions typically use sensory modalities to target behaviors that may be associated with sensory-related impairments.^{3, 15} We do not include studies of other approaches (e.g., educational interventions) that may address a sensory-related outcome in the current review. A companion review updating findings related to medical interventions is available on the AHRQ Effective Health Care Web site.

Key Questions

We developed Key Questions (KQs) in consultation with Key Informants and the Task Order Officer. KQs were posted for review to the AHRQ Effective Health Care Web site.

KQs were as follows:

KQ1.

Among children ages 2–12 with ASD, what is the comparative effectiveness (benefits and harms) of interventions targeting sensory challenges?

1. What are the effects on core symptoms (e.g., deficits in social communication and interaction; restricted, repetitive patterns of behavior, interests, or activities including hyper- or hypo- reactivity to sensory input or unusual interest in sensory aspects of the environment) in the short term (<6 months)?
2. What are the effects on commonly associated symptoms (e.g., motor, medical, mood/anxiety, irritability, and hyperactivity) in the short term (<6 months)?
3. What are the longer term effects (≥6 months) on core symptoms (e.g., social deficits, communication deficits, and repetitive behaviors)?
4. What are the longer term effects (≥6 months) on commonly associated symptoms (e.g., motor, medical, mood/anxiety, irritability, and hyperactivity)?

KQ2.

Among children ages 2–12 with ASD, what are the modifiers of outcome for different interventions targeting sensory challenges?

1. Is the effectiveness of the therapies reviewed affected by the frequency, duration, intensity, or dose of the intervention?
2. Is the effectiveness of the therapies reviewed affected by co-interventions or prior treatment, or the training and/or experience of the individual providing the therapy?
3. What characteristics (e.g., age, symptom severity), if any, of the child modify the effectiveness of the therapies reviewed?
4. What characteristics, if any, of the family modify the effectiveness of the therapies reviewed?

KQ3.

What is the time to effect of interventions targeting sensory challenges?

KQ4.

What is the evidence that effects measured at the end of the treatment phase predict long-term functional outcomes of interventions targeting sensory challenges?

KQ5.

Is the effectiveness of interventions targeting sensory challenges maintained across environments or contexts (e.g., people, places, materials)?

KQ6.

What evidence supports specific components of treatment with interventions targeting sensory challenges as driving outcomes, either within a single treatment or across treatments?

Categorization of Interventions

Interventions targeting sensory challenges may be broadly categorized by their core focus (e.g., environmental modification/adaptation, compensatory strategies, sensory processing, auditory integration). However, frequently these categories of sensory-related approaches include overlapping targets and intervention strategies, as well as unique and differing aspects of the same constructs. As such it is extremely challenging to identify definitively the category into which many offered interventions should be placed. With input from our clinical experts, we categorized approaches based on the core strategies used in each intervention. In some cases this approach grouped together interventions that may have used specific, manualized techniques with others that used only a subset of those techniques (e.g., Ayres-based sensory integration and sensory integration models that may have used some Ayres strategies). We note that no alternative approaches (e.g., considering Ayres-based approaches and other sensory integration approaches as separate categories) would have substantially changed our overall findings in terms of strength of evidence.

Based on the literature meeting criteria for this review, we categorized interventions as:

• Sensory integration-based (interventions using combinations of sensory and kinetic components such as materials with different textures, touch/massage, swinging and trampoline exercises, and balance and muscle resistance exercises to ameliorate sensory challenges)
• Environmental enrichment-based (interventions incorporating targeted exposure to sensory stimuli to promote tolerance of stimuli in other contexts)
• Auditory integration-based (interventions incorporating auditory components such as filtered sound to ameliorate sensory processing challenges via theorized re-training of aural pathways)
• Music therapy-based (interventions incorporating playing or singing music, or movement to music, to improve challenging behaviors and sensory difficulties)
• Touch/Massage-based (interventions incorporating touch-based approaches by a therapist or caregiver)
• Other (included interventions [tactile-based tasks, weighted blankets] not cleanly fitting into one of the broader categories).

We recognize that other approaches to categorizing interventions targeting sensory challenges could be used.