Management of Children With Autism Spectrum Disorders

Every so often, I find a research article that makes me want to celebrate. On the other hand, I also periodically find articles that make me want to slam my head against a wall in response to their sheer stupidity.


And, although it's rarer, I do occasionally find an article that makes me want to do both. For obvious reasons, it's almost inevitably different sections of the same article that do each. I haven't had the experience of having both reactions to the same sentence... or the same paragraph, for that matter.

I bring this up because that last is the sort of reaction that I had to this article (also findable here), which was published two years ago in the absurdly prestegious journal Pediatrics.

Entitled "Management of Children With Autism Spectrum Disorders", the article is basically a comprehensive introduction to autism, intended for general practitioners so that they can familiarize themselves with the field for whenever they get an autistic patient.

It's a nice idea -- and the journal it got published in is probably the one which pediatricians are most likely to read. Unfortunately, a good bit of the information contained within is biased or just plain wrong.

Now, to be fair, the article is two years old and a lot of the studies refuting points in it were published in the last two years (thanks, Michelle!). Some of it, however, was just plain wrong, even with what we knew then... and to say that the clinical philosophy statement is questionable is a major understatement.

To quote:

The primary goals of treatment are to minimize the core features and associated deficits, maximize functional independence and quality of life, and alleviate family distress. (pp. 1162-1163)

The first clause of this, "to minimize the core features and associated deficts" comes in direct conflict with the remainder for the simple reason that autism isn't just a set of deficits. "Minimizing the core features" of autism includes those srengths as well as weaknesses -- it's trying to turn an autistic person (to the degree possible) into a non-autistic person. This is pretty thoroughly appalling... but almost to be expected.


The article also drags up the whole theory of mind myth, the joint attention thing, the myth of the "need" for intensive behavioral intervention... the list goes on and on. In general, it drags up a crapload of invented, so-called "knowledge" and passes it off as truth.

Hell, it even manages to miss the fact that autistic children learn and develop in ways completely out of line with neurotypical developmental timetables and skill hierarchies.


The worst section of the paper, however, is the section on applied behavior analysis. The errors start with what ABA is... and just keep piling up from there. If you believe the article, ABA is:

... the process of applying interventions that are based on the principles of learning derived from experimental psychology research to systematically change behavior and to demonstrate that the interventions used are responsible for the observable improvement in behavior (p. 1164).

... umm, no.

Cooper, Heron, & Heward's (2007) textbook, Applied Behavior Analysis (2nd Edition) is pretty much considered (for the time being, anyway) the definitive reference on ABA. Its definition is:

Applied behavior analysis is the science in which tactics derived from the priniciples of behavior are applied systematically to improve socially significant behavior and experimentation is used to identify the variables responsible for behavior change (p. 20).

In other words, Myers et al. are wrong on two major points:

• ABA is a science. The process of using tactics derived from that science is technically referred to as clinical practice based on ABA. While this may seem like quibbling, it's actually a fairly important distinction. Like any science, ABA offers predictions -- "what will happen if I do this?" -- theories, and very little else... although there are certainly interventions derived from it and experimental tests of those interventions (with the tests falling under the "ABA" category, but the manuals arguably not).
• Practice based on ABA does not use "the principles of learning derived from experimental psychology research". ABA-based methods use the principles of behavior derived from EAB and ABA research. While some of these can be described as (or can act as) principles of learning, EAB and ABA research is only a subset of experimental psychology research... and much of the non-behavioral research has been devoted to learning. Simply put, Myers et al.'s definition suffers from both deficiency and contamination.

I could go on to critique the other various errors in this section... but won't. Frankly, the fact that the article couldn't even get the definition of ABA right about sums up the accuracy of the article's ABA section... and makes me wonder how the heck it got published in Pediatrics of all places!

While I'm not overly familiar with the developmental treatment models, there are a number of issues with the article's section of them as well... although, to be fair, some of these may be flaws in the actual models themselves. The DIR model, for instance, "targets the core impairment in social reciprocity" (p. 1165) despite the fact that while such a deficit does exist, it certainly doesn't lie with autistic children!

The section on speech and language therapy is comparatively good (which shouldn't be confused with an unqualified "good"), but the recommendations the article makes regarding social skills instruction are, frankly, abominable from an etical standpoint (not to mention that it drags up certain fallacies regarding joint attention yet again).

I'm not even going to get into the section on comparative efficacy. Let's just say that it's at least better than the section on ABA... which means that it at least got the definition of its subject matter right.

The section on sleep disturbance, however, was just plain scary. Benzodiazepines? Zolpidem? Trazodone?!? By contrast, the reccommendation of zaleplon was almost understandable.

Its section on psychopharmacology wasn't much better.

There was also one line which made me blink and react in a manner fully consistent with typical usage of the acronym WTF. Specifically: "However, if a child with an ASD presents with symptoms such as chronic or recurrent abdominal pain, vomiting, diarrhea, or constipation, it is reasonable to evaluate the gastrointestinal tract."

This needed to be said?

After all of that, however, the article had some truly outstanding points. Its coverage of complementary and alternative medicine (AKA "woo") is excellent (barring, perhaps, its coverage of facilitated communication, which I can't comment too much on). One line that comes to mind as particularly noteworthy is:

Some treatments, such as intravenous chelation, may be particularly dangerous and should be discouraged. One child with autism died as a result of chelation with edate disodium... despite the facts that a causal association between mercury and ASDs has not been demonstrated, there is no scientific evidence that chelation is an effective treatment for ASDs, and the effectiveness of chelation therapy to improve nervous system symptoms of chronic mercury toxicity has not been established. (p. 1174, chemical formula of edate disodium omitted)

Another worthy line:

Educational programs should be individualized to address the specific impairments and needed supports while capitalizing on the child's assets rather than being based on a particular diagnostic label. (p. 1167)

In short, I have highly mixed feelings about this article... but at least reading through the contents of the reference section will keep me busy for a while.