A. Treatment of core symptoms of autism spectrum disorders. Primary care providers are expected to help families make decisions about the management of a child with autism spectrum disorders (ASD). Because the spectrum is wide and includes a range of ability and disability, there is no one management strategy that works for all affected children. There is a growing body of research that supports the use of specific educational interventions as the foundation of therapy for ASD. However, individual children with ASD have variable responses to therapy, and there is regional variation in quality and quantity of available services. As a result, many families utilize a wide variety of therapies, both proven and unproven, in an attempt to treat both the core features of autism (deficits in verbal and nonverbal communication, impairment in social interactions, and restricted interests or repetitive behaviors) and the many associated difficulties commonly seen in children with ASD, such as deficits in sensory processing, sleep disturbance, gastrointestinal complaints, seizures, and anxiety or depression. (See Chapter 26 on Autism Spectrum Disorders and Chapter 24 on Asperger Syndrome in this volume for more information.) Pediatric providers should have a general familiarity with the strengths and limitations of both widely accepted and unconventional treatments for ASD and be able to steer parents toward evidence-based therapies available in the community whenever possible. (See as well Chapter 27 on Complementary and Alternative Medicine in Autism Spectrum Disorders in this volume.)

B. Medical and psychiatric comorbidities. The primary care provider should be alert to common medical comorbidities in ASD and for signs of medical symptoms that may be obscured by, or difficult to assess because of, the symptoms of ASD. For example, changes in behaviors of children with ASD (such as self-injury or aggression) may be attributed to worsening symptoms of ASD, causing an underlying medical disorder unrelated to ASD (such as gastroesophageal reflux or a dental abscess) to be missed. Challenges of history taking and detailed physical examination in the nonverbal or noncompliant child with ASD may compound this problem. Psychopharmacologic management, although not demonstrated to improve the core deficits in autism, can be helpful in managing some associated symptoms.

A. Applied behavioral analysis (ABA). ABA is a systematic and structured approach to instruction based on the science of behavior and learning which utilizes observation, data collection, and positive reinforcement to teach communication, academic, and social skills and to reduce problem behaviors. ABA can be used in both structured and naturalistic settings by skilled therapists, and programs such as Pivotal Response Training and Verbal Behavior Therapy also are grounded in the theories of ABA. Instruction based on ABA is widely used in preschool- and school-aged children, but the cost of one-on-one instruction of the intensity recommended in most studies can be prohibitively expensive. Coverage of the cost of these services through medical insurance and educational systems varies both by state and locally, but there are growing efforts by advocacy groups to mandate coverage of ABA and other therapies through medical insurance. ABA is the best studied of the educational approaches for ASD.

B. Structured teaching. The Treatment and Education of Autistic and related Communication-handicapped Children (TEACCH) program is the most prominent example of structured teaching for children with ASD. This method “structures” the physical environment and teaching techniques using visual supports and a predictable routine. The use of visual schedules fosters a predictable sequence of daily activities and structures activities. The emphasis of this method is on improving skills and modifying the environment to adapt to the learning preferences and needs of children with ASD.