Identification, Evaluation, and Management of Children With Autism Spectrum Disorder

Susan L. Hyman; Susan E. Levy; Scott M. Myers; COUNCIL ON CHILDREN WITH DISABILITIES, SECTION ON DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS

doi:10.1542/peds.2019-3447

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TABLE 1

DSM-5 Criteria for Autism Spectrum Disorder

Domains	Criteria: Deficits	Examples
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history; must have all 3 symptoms in this domain	1. Social-emotional reciprocity	Abnormal social approach and failure of normal back-and-forth conversation; reduced sharing of interests, emotions, or affect; failure to initiate or respond to social interactions
	2. Nonverbal communicative behaviors used for social interaction	Poorly integrated verbal and nonverbal communication; abnormalities in eye contact and body language or deficits in understanding and use of gestures; total lack of facial expressions and nonverbal communication
	3. Developing, maintaining, and understanding relationships	Difficulties adjusting behavior to suit various social contexts; difficulties in sharing imaginative play or in making friends; absence of interest in peers
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least 2 of the following, currently or by history; must have 2 of the 4 symptoms	1. Stereotyped or repetitive motor movements, use of objects, or speech	Simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases
	2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior	Extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day
	3. Highly restricted, fixated interests that are abnormal in intensity or focus	Strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest
	4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment	Apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement

Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities or may be masked by learned strategies in later life). Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and ASD frequently co-occur; to make comorbid diagnoses of ASD and intellectual disability, social communication should be below that expected for the general developmental level. Specify whether: with or without accompanying intellectual impairment, language impairment or associated with a known medical or genetic condition or environmental factor. Add code 293.89 if catatonia is also present. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (copyright 2013). American Psychiatric Association. All Rights Reserved.

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TABLE 2

ASD Symptoms by Level of Severity

Severity Level	Social Affective	Restricted and Repetitive Behaviors
Level 1. “Requiring support”	Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions, and clear examples of atypical or unsuccessful response to social overtures of others. May appear to have decreased interest in social interactions.	Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence.
Level 2. “Requiring substantial support”	Marked deficits in verbal and nonverbal social communication skills. Social impairments apparent even with supports in place. Limited initiation of social interactions and reduced or abnormal responses to social overtures from others.	Inflexibility of behavior, difficulty coping with change, or other restricted and repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts.
		Distress and/or difficulty changing focus or action.
Level 3. “Requiring very substantial support”	Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning, very limited initiation of social interactions, and minimal response to social overtures from others.	Inflexibility of behavior, extreme difficulty coping with change, or other restricted and repetitive behaviors markedly interfere with functioning in all spheres. Great distress at or difficulty with changing focus or action.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (copyright 2013). American Psychiatric Association. All Rights Reserved.

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TABLE 3

DSM-5 Social (Pragmatic) Communication Disorder (DSM-5 315.39)

A. Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following:

1. Deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is appropriate for the social context.

2. Impairment of the ability to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on the playground, talking differently to a child than to an adult, and avoiding use of overly formal language.

3. Difficulties following rules for conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction.

4. Difficulties understanding what is not explicitly stated (eg, making inferences) and nonliteral or ambiguous meanings of language (eg, idioms, humor, metaphors, multiple meanings that depend on the context for interpretation).

B. The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination.

C. The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities).

D. The symptoms are not attributable to another medical or neurologic condition or to low abilities in the domains or word structure and grammar and are not better explained by ASD, intellectual disability (intellectual developmental disorder), global developmental delay, or another mental disorder.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (copyright 2013). American Psychiatric Association. All Rights Reserved.

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TABLE 4

Red Flags: Early Symptoms of ASD

	Symptom
By 12 months	• Does not respond to name
By 14 months	• Does not point at objects to show interest
By 18 months	• Does not pretend play
General	• Avoids eye contact and may want to be alone • Has trouble understanding other people's feelings or talking about their own feelings • Has delayed speech and language skills • Repeats words or phrases over and over (echolalia) • Gives unrelated answers to questions • Gets upset by minor changes • Has obsessive interests • Makes repetitive movements like flapping hands, rocking, or spinning in circles • Has unusual reactions to the way things sound, smell, taste, look, or feel

Information from this table is adapted from http://www.cdc.gov/ncbddd/autism/signs.html.

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TABLE 5

Resources and Guidance for Developmental Screening

• AAP Bright Futures: Guidelines for the Health Supervision of Infants, Children, and Adolescents

• AAP early childhood screening

• AAP clinical report: “Promoting Optimal Development: Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening”⁴⁹

• Additional guidance for developmental and behavioral screening can be found in “Birth to 5: Watch Me Thrive!” which contains helpful information for the primary care provider about how to present the results of developmental screening (available at: https://www.acf.hhs.gov/sites/default/files/ecd/pcp_screening_guide_march2014.pdf).

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TABLE 6

Commonly Used ASD Screening Tests

Autism Screening Tests	Description	Age Range	Average No. Items	Administration Time	Forms Available EHR compatible	Psychometric Properties	Scoring Method	Cultural Considerations	Source	Key References
M-CHAT-R/F	Parent-completed questionnaire designed to identify children at risk for autism from the general population; follow-up clinician-administered questions and repeat questionnaire required for specificity	16–30 mo	20	5–10 min	Yes	Standardization sample included 16 071 children screened; 115 had positive screen results, 348 needed evaluation, 221 were evaluated, and 105 diagnosed with an ASD; validated by using the ADI-R, ADOS-G, CARS, and DSM-IV-TR; sensitivity: 0.91; specificity: 0.95 for low-risk 18- and 24-mo-old children with follow-up questionnaire and interview; 45% of children with a score ≥3 on the initial screen and ≥2 on follow-up had ASD; 95% had clinically significant developmental delay	Risk categorization for questionnaire (pass/need interview/ fail); after interview (pass/fail)	Available in multiple languages; see test information for details	http://mchatscreen.com/	Ref 51
SCQ	Parent-completed questionnaire; designed to identify children at risk for ASD from the general population; based on items in the ADI-R	4+ y	40	5–10 min	No	Validated by using the ADI-R and DSM-IV on 200 subjects (160 with pervasive developmental disorder, 40 without pervasive developmental disorder); for use in children with mental age of at least 2 y and chronologic age 4+ y; available in 2 forms: lifetime and current. overall test: sensitivity: 0.85 (moderate), specificity: 0.75 (moderate); sensitivity can be improved with lowering cutoff for children younger than 5 y and 5–7 y, specificity poor for younger children	Risk categorization (pass/fail)	Available in multiple languages; see test information for details.	Western Psychological Corporation: www.wpspublish.com	Refs 77 and 572
STAT	Clinician-directed, interactive, and observation measure; requires training of clinician for standardized administration; not for population screening	24–35 mo; <24 mo (exploratory)	12	20–30 min	No	Validated by comparison with ADOS-G results in 52 children 24–35 mo (26 with autism, 26 with developmental delay); sensitivity: 0.83, specificity: 0.86, PPV: 0.77, NPV: 0.90, for <24 mo: sensitivity: 0.95, specificity: 0.73, PPV: 0.56, NPV: 0.97; screening properties improved for children >14 mo	12 activities to observe early social-communicative behavior; risk categorization (high risk/low risk)	English	http://stat.vueinnovations.com/	Refs 573 and 574
Promising autism screening tests
The Infant/Toddler Checklist (Communication and Symbolic Behavior Scales Developmental Profile)	Parent questionnaire: screens for language delay	6–24 mo	24	15 min	No	PPV DD: 0.43 (6–8 mo); PPV DD: 0.79 (21–24 mo)	Identifies language delays (alone/with ASD); risk for ASD; risk status for social, speech, symbolic composites, and total score	Available in multiple languages; see test information for details	Paul H. Brookes Publishing Co Inc: 800-638-3775 or www.brookespublishing.com	Ref 59
Early Screening for Autism and Communication Disorders	Parent questionnaire: research edition, 47 items	12–36 mo	47	10–15 min	No	Sensitivity: 0.85–0.91; specificity: 0.82–0.84; PPV: 0.55–0.81; NPV: 0.88–0.98	Investigation ongoing of subset (24 items)	English	https://firstwordsproject.com/screen-my-child/	Not in peer-reviewed literature
First-Year Inventory	Parent questionnaire; promising in high-risk population to identify risk in 12-mo-old infants	12 mo	63	10 min	No	Sensitivity, specificity, PPV not reported	Scores at risk; promising in high-risk (infant sibling) cohort (Rowberry et al⁵⁷⁵)	English	https://www.med.unc.edu/ahs/pearls/research/first-year-inventory-fyi-development/	Ref 575
Parent’s Observations of Social Interactions	Parent questionnaire used to assess autism risk; ASD screening included on 18-, 24-, and 30-mo The Survey of Well-Being of Young Children: forms	16–35 mo	7	∼5 min	Available through patient tools, epic, and CHADIS; available for free download as pdfs from www.theswyc.org	Sensitivity: 83%–93%, average 88.5%; specificity: 42%–75%, average 56.9%	3 of 7 symptoms in at-risk range	Available in multiple languages; see test information for details	Free download from www.theswyc.org	Publications and User’s Manual available at www.theswyc.org; Refs 576 and 577
Rapid Interactive Screening Test for Autism in Toddlers 13	Clinician observation: administered by trained examiner	12–36 mo	9 interactive items	20–30 min	No	Cutoff >15; sensitivity: 1; specificity: 0.84; PPV: 0.88; NPV: 0.94; needs further study in larger samples	9 interactive activities; total score summed, cutoff score of 15 (for that sample)	English	https://umassmed.edu/AutismRITA-T/about-the-test/	Ref 578

The AAP does not approve/endorse any specific tool for screening purposes. This table is not exhaustive, and other tests may be available. ADOS-G, Autism Diagnostic Observation Schedule – Generic; CARS, Childhood Autism Rating Scale; CHADIS, Comprehensive Health and Decision Information System; EHR, electronic health record; ICD-10, International Classification of Diseases, 10th revision; IMFAR, International Meeting for Autism Research; NPV, negative predictive value; PPV, positive predictive value.

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TABLE 7

Potential Benefits of Establishing a Genetic Etiologic Diagnosis

• Improving accuracy of counseling provided to patients and families:

o Prognosis or expected clinical course

o Recurrence risk for the family and the individual affected

• Providing condition-specific family support, such as:

o Improving psychosocial outcomes for patients and their families (eg, knowledge and sense of empowerment, parental quality of life)

• Preventing morbidity and treating medical conditions associated with the genotype, such as:

o Conditions or anomalies likely to be present at diagnosis

o Conditions that may develop later

• Refining treatment options, including:

o Avoiding therapeutic interventions that may be based on unfounded etiologic theories

o Avoiding ineffective or potentially harmful treatments

o Providing access to emerging etiology-specific treatments

• Facilitating acquisition of needed services and access to research treatment protocols

• Avoiding additional diagnostic tests, which may be unnecessary, expensive, and/or uncomfortable

Adapted from Sun F, Oristaglio J, Levy SE, et al. Genetic Testing for Developmental Disabilities, Intellectual Disability, and Autism Spectrum Disorder. Rockville, MD: Agency for Healthcare Research and Quality (US); 2015; Amiet C, Couchon E, Carr K, Carayol J, Cohen D. Are there cultural differences in parental interest in early diagnosis and genetic risk assessment for autism spectrum disorder? Front Pediatr. 2014;2:32; Srivastava S, Cohen JS, Vernon H, et al. Clinical whole exome sequencing in child neurology practice. Ann Neurol. 2014;76(4):473–483; Iglesias A, Anyane-Yeboa K, Wynn J, et al. The usefulness of whole-exome sequencing in routine clinical practice. Genet Med. 2014;16(12):922–931; Lingen M, Albers L, Borchers M, et al. Obtaining a genetic diagnosis in a child with disability: impact on parental quality of life. Clin Genet. 2016;89(2):258–266; Riggs ER, Wain KE, Riethmaier D, et al. Chromosomal microarray impacts clinical management. Clin Genet. 2014;85(2):147–153; and ACMG Board of Directors. Clinical utility of genetic and genomic services: a position statement of the American College of Medical Genetics and Genomics. Genet Med. 2015;17(6):505–507.

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TABLE 8

Genetic Etiologic Investigations in Patients With ASD

Step	Genetic Etiologic Investigations
1	Consider referral for pediatric genetics evaluation
2	Comprehensive history (including 3-generation family history with emphasis on individuals with ASD and other developmental, behavioral and/or psychiatric, and neurologic diagnoses)
	Physical examination (including dysmorphology, growth parameters [including head circumference], and skin examination)
	• If syndrome diagnosis or metabolic disorder is suspected, go back to step 1 (genetics and/or metabolism referral) and/or order the appropriate targeted testing
	• Otherwise, proceed to step 3
3	Laboratory studies
	• Discuss and offer CMA analysis
	• Discuss and offer fragile X analysis; if family history is suggestive of sex-linked intellectual disabilities, refer to genetics for additional testing
	• If patient is a girl, consider evaluation for Rett syndrome, MECP2 testing
	• If these studies do not reveal the etiology, proceed to step 4
4	Consider referral to genetics, workup might include WES

Adapted from Schaefer GB, Mendelsohn NJ; Professional Practice and Guidelines Committee. Clinical genetics evaluation in identifying the etiology of autism spectrum disorders: 2013 guideline revisions. Genet Med. 2013;15(5):399–407; Srivastava S, Love-Nichols JA, Dies KA, et al; NDD Exome Scoping Review Work Group. Meta-analysis and multidisciplinary consensus statement: exome sequencing is a first-tier clinical diagnostic test for individuals with neurodevelopmental disorders [published online ahead of print June 11, 2019]. Genet Med. and Shevell M, Ashwal S, Donley D, et al; Quality Standards Subcommittee of the American Academy of Neurology; Practice Committee of the Child Neurology Society. Practice parameter: evaluation of the child with global developmental delay: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2003;60(3):367–380.

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TABLE 9

Characteristics of Effective Interventions

Features of Practice	Common Characteristics of Empirically Supported Interventions
Assessment and goals	Systematically assess skills
	Include input of family (shared decision-making)
	Select individualized measurable goals and instructional procedures on the basis of objective assessment of each child
	Use assessment-based, empirically supported instructional methods to build, generalize, and maintain skills and reduce problem behaviors
Instructional methods	Address core symptoms in social communication and restricted and repetitive behaviors as well as skill deficits
	Provide a student/teacher ratio low enough to address the child’s individualized goals
	Interventions should be by providers who are properly trained and should maintain fidelity with the treatment approach selected
	Ensure that multiple providers work collaboratively
Services and supports	Individualize services and support
	Make use of the child’s interests and preferences in determining reinforcement systems
	Incorporate preferred activities to increase engagement in activities
Environment	Provide a structured learning environment that helps children anticipate transition between activities, including a predictable routine and visual activity schedules
	Organize workspaces to minimize distraction and promote task completion
	Limit access to things that may distract a student
	The environment should promote opportunities for the student to initiate communication and interact with peers
Behavioral management	Implement a functional behavioral analysis to identify the reasons why challenging behaviors occur and develop a behavior improvement plan based on this assessment (IDEA-mandated approach)
	Teach children more appropriate responses using the behavior improvement plan
Progress	Systematically measure and document the individual child’s progress
	Adjust instructional strategies as necessary to enable acquisition of target skills
Family support	Involve and educate families so they can use the behavioral strategies at home and in the community
Transition planning	Plan for transitions in school settings and to adulthood (eg, from home-based early intervention to preschool services, preschool to elementary school, elementary school to middle school, middle school to high school, high school to work or postsecondary education, and home to community living)

Adapted from Smith T, Iadarola S. Evidence base update for autism spectrum disorder. J Clin Child Adolesc Psychol. 2015;44(6):897–922; Myers SA, Pipinos II, Johanning JM, Stergiou N. Gait variability of patients with intermittent claudication is similar before and after the onset of claudication pain. Clin Biomech (Bristol, Avon). 2011;26(7):729–734; and Myers SM. Management of autism spectrum disorders in primary care. Pediatr Ann. 2009;38(1):42–49.

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TABLE 10

Considerations Surrounding Medication Use

No current medication corrects core social and communication symptoms of ASD

Accurate diagnosis of coexisting psychiatric conditions guide therapy

Medication is used to help manage

• Coexisting behavioral health disorders (eg, ADHD, mood disorders, or anxiety disorders)

• Associated problem behaviors or symptoms causing significant impairment and distress

o Examples include the following: aggression, self-injurious behavior, sleep disturbance, mood lability, anxiety, hyperactivity, impulsivity, inattention

Medication should only be considered after

• Careful accounting of when the behavior started and what seems to exacerbate it

• A functional behavioral assessment should guide development of a treatment plan in the school setting

o Consider whether the behavior serves as communication of distress or refusal

• Consider referral to a behavior therapist outside of school to assess the reasons for the behavior, provide the family with strategies, and collaborate in care

• Careful history and physical to look for medical factors that may cause or exacerbate challenging behaviors (eg, gastroesophageal reflux and acute sources of pain, such as otitis media, dental injury, fracture, and others)^{34,380,391,485,579}

Consider medication after treatable medical conditions and behavioral factors assessed and intervention does not address the symptoms of concern

Include the family and patient in shared decision making that considers their goals and values⁵⁴³

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TABLE 11

Psychotropic Medication Options for Common Target Symptoms

Target Symptoms	Medication Class (Examples)	Comments
Hyperactivity Impulsivity Inattention Distractibility	Psychostimulants (methylphenidate, dexmethylphenidate, mixed amphetamine salts, lisdexamfetamine, dextroamphetamine)^{466,580–587}	With other coexisting symptoms, medication may not appear as effective
	SNRIs (atomoxetine)^588–590	May be more sensitive to adverse effects
	α-2 adrenergic agonists (clonidine, guanfacine)^591–594	Steps:
	Atypical (second generation) antipsychotics (aripiprazole, risperidone)^595–598	• Behavioral approaches implemented
		• Problems persist, trial of medication management
		• Start with a low-dose stimulant (eg, methylphenidate or mixed dextroamphetamine salts) and increase as needed and tolerated
		May be most effective in children without comorbid intellectual disability
		Targets symptoms of impulsivity and hyperactivity
		• If there are adverse effects or if not effective:
		Consider atomoxetine, especially if also with social anxiety
		Consider α-2 agonists (eg, short- or long-acting guanfacine, clonidine)
		Other medications (less evidence): atypical antipsychotic medications may decrease hyperactivity; their primary use is for irritability and aggression
		Adverse effects:
		Psychostimulants: appetite suppression and insomnia; also irritability, depressive symptoms, and social withdrawal; it does not appear to worsen repetitive behavior or oppositional behavior
		Guanfacine, clonidine: drowsiness, fatigue and irritability; may also include appetite suppression, nausea, sleep disturbance, and decreased blood pressure and heart rate; rebound if not weaned
Irritability and severe disruptive behavior	Atypical (second generation) antipsychotics (aripiprazole, risperidone)^595–608	Medication most effective if combined with behavioral strategies addressing identified environmental causes for the behavior and developing more appropriate responses for the child
• Vocal and motoric outbursts of anger, frustration, and distress		DB/PCs strong support for 2 second-generation atypical antipsychotic medications (risperidone and aripiprazole) for reducing irritability, stereotyped or repetitive movements, self-injury, and hyperactivity
• Acts of aggression, self-injury, property destruction		• Risperidone and aripiprazole are currently the only medications with FDA-approved labeling specific to irritability in ASD
• Behaviors referred to by caregivers as “agitation,” “tantrums,” “meltdowns,” or “rages”		Adverse effects and monitoring:
		• Common adverse effects include wt gain and dyslipidemia
		• Monitoring: periodic assessment for extrapyramidal symptoms; measurement of wt, height, and BMI; and laboratory monitoring of glucose and lipid levels
		• Metformin might be a useful treatment to help control wt gain.⁶⁰⁹
		Other agents in this class, such as olanzapine and quetiapine, may have utility on the basis of their adverse effect profiles but do not have current FDA package insert indication for use in children with ASD
	α-2 adrenergic agonists (clonidine, guanfacine)^591,610	Small studies documenting beneficial effects on irritability; need larger trials; may have better adverse effect profiles than atypical antipsychotics
	SSRIs (fluvoxamine, citalopram)^611,612	Few studies focused on irritability and/or aggression; some reporting improvement in irritability; insufficient evidence to advise practice
	Anticonvulsant mood stabilizers (valproic acid and divalproex sodium)^613–618	Small studies suggestive of improvement in irritability; need larger studies; a limited number of placebo-controlled studies either do not support or are inconclusive regarding anticonvulsant medication as a treatment of irritability in patients with ASD
	Serotonin-norepinephrine reuptake inhibitor (venlafaxine)⁶¹⁹	Effect size of improvement associated with venlafaxine was small, and irritability was not the primary outcome measured
Repetitive behavior	Atypical (second generation) antipsychotics (aripiprazole, risperidone)^{595–598,620}	Multiple DB/PCs documenting improvement in repetitive behavior; short-term treatment
• Stereotyped motor mannerisms		Common adverse effects include increased appetite, fatigue, drowsiness, dizziness, and drooling
• Compulsions		More effective for targets of tantrums, aggression, and SIB
• Behavioral rigidity, insistence on sameness	Anticonvulsants (valproic acid and divalproex sodium)^613,621,622	Modest improvement has been reported with divalproex sodium treatment
		May have improvement with topiramate as a second agent with risperidone
		Most antiseizure drugs have potential for sedation, cognitive adverse events
	SSRI (fluoxetine, fluvoxamine)^{480,509,611,612,623–627}	Studies to date have not revealed effectiveness of SSRI medications for repetitive behaviors related to ASD, although they may diminish anxiety
		SSRIs may be effective for reducing symptoms of OCD and of anxiety when included in a comprehensive approach to treatment
		Need comprehensive behavioral approaches to minimize repetitive behaviors
Anxiety, depression	SSRIs^469,628	Anxiety relief has been reported in trials of citalopram and buspirone, with fluvoxamine revealing some effect in female patients with ASD; documented utility in children and youth without ASD
	α-adrenergic (clonidine, guanfacine)	Hyperactivation is an adverse effect of SSRIs in children and youth with ASD that may result in stopping the medication
		The anxiety disorders most amenable to treatment are generalized anxiety disorder, separation anxiety disorder, and social phobias
	Atypical (second generation) antipsychotics^469,620	If a mood dysregulation disorder is identified, treatment with a mood stabilizer and/or a second-generation antipsychotic is recommended, although an SSRI may be used to treat comorbid anxiety, OCD, or depression; behavioral activation with hypomanic or manic switches has been reported
		First-line treatment is a program of cognitive behavioral therapy to reduce symptoms^472–475
		Few studies have examined the specific effects for these symptoms; clinicians may consider use of these agents; although SSRIs, SNRIs, and/or buspirone may be effective for the treatment of anxiety in children with ASD, they have not been rigorously evaluated for this purpose^{507,626,627,629,630}
		Medications to consider include sertraline, fluoxetine, citalopram, or escitalopram for symptoms of anxiety and α-2 agonists (eg, guanfacine and clonidine and β-blockers such as propranolol), which may be useful for anxiety-related physiologic symptoms and behavioral dysregulation, and a short-acting benzodiazepine, such as lorazepam, could be considered for event related anxiety

DB/PC, double-blind placebo-controlled trial; FDA, US Food and Drug Administration; SIB, self-injurious behavior; SNRI, selective norepinephrine reuptake inhibitor. Adapted from Riddle MA. Pediatric Psychopharmacology for Primary Care. 1st ed. Elk Grove Village, IL: American Academy of Pediatrics; 2016.

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TABLE 12

Common Presentations of Self-Injurious Behavior and the Medical Conditions to Consider If New Onset

Type of Self-Injury	Potential Associated Conditions	Potential Associated Injury
Head banging	Headache, toothache, sinus infection, ear infection	Detached retina, abrasions, contusions
Head hitting or slapping	Headache, toothache, sinus infection, ear infection	Fracture of bones in hand, detached retina, abrasions, contusions
Eye poking	Vision loss, eye pain	Eye abrasion
Gum or tooth digging or banging	Dental pain, gingivitis	Gum injury, tooth autoextraction, tooth fracture
Scratching and skin picking	Allergy, eczema, drug reaction, skin infection or infestation (eg, fleas, scabies)	Infection, scarring
Finger and toenail biting or picking	Pain	Infection, nail removal, ingrown nails, paronychia
Kicking or stomping	Restless leg syndrome, leg pain	Bruises, fractures
Rumination	Gastroesophageal reflux, eosinophilic esophagitis	Esophageal ulceration and bleeding, dental damage, nutritional compromise, precancerous lesions of esophagus