This document provides information on autism spectrum disorder (ASD), including criteria for diagnosis, differential diagnosis, treatment options, and guidelines for specific medications. ASD is characterized by deficits in social communication and interaction, and restricted, repetitive behaviors. It can be diagnosed when criteria A and B are met. Common treatments include behavioral therapies, social skills training, and pharmacotherapy depending on specific symptoms. Medications may be used to target irritability, restricted interests, sleep issues, anxiety/depression, or attention problems. Close monitoring is needed with any medication used to treat ASD.

1. Autism Spectrum
Disorder
Maudsley Prescribing Guidelines
Ahmed M. Ibrahim

2. Contents
• Introduction
• Criteria
• Differential Diagnosis
• Treatment

3. Autism spectrum disorder (ASD) is a complex condition characterised by core
deficits in three areas of development:
1. Language
2. Social interaction
3. Behaviour (stereotypies and/or restricted and unusual patterns of interests).
Autism Spectrum includes:
• ICD-10: Autism, Asperger’s syndrome and pervasive developmental disorders not
otherwise specified (PDD-NOS)
• DSM‐V no longer includes these sub‐groups but defines ASD in one single category

4. Clinical Picture
- M>F (4:1)
- Females with the disorder are more likely to have more severe mental
retardation.
- Onset before age of 3 years.

5. Criteria of ASD
A)Persistent deficits in social communication and social interaction
Deficits in social-emotional
reciprocity
- Failure of normal back-
and-forth conversation
- Reduced sharing of
interests, emotions, or
affect
Deficits in developing,
maintaining, and
understanding relationships
- Difficulties in sharing
imaginative play or in
making friends
- Absence of interest in
peers.
Deficits in nonverbal
communicative behaviors used
for social interaction
- Abnormalities in eye
contact and body
language or deficits in
understanding and use of
gestures
- A total lack of facial
expressions and nonverbal
communication.

6. Criteria of ASD
B)Restricted, repetitive patterns of behavior, interests, or activities
Stereotyped or repetitive
motor movements, use of
objects, or speech
- Simple motor
stereotypies
- Lining up toys
- Flipping objects
- Echolalia
- Idiosyncratic phrases
Insistence on sameness,
inflexible adherence to
routines
- Extreme distress at
small changes
- Difficulties with
transitions
- Rigid thinking
patterns
- Greeting rituals
Restricted interests that
are abnormal in intensity
or focus
- Strong attachment to
or preoccupation
with unusual objects
- Excessively
circumscribed
- Perseverative interest
Hyper- or hyporeactivity
to sensory input
- Apparent indifference to
pain/temperature
- Adverse response to
specific sounds or
textures
- Excessive smelling or
touching of objects
- Visual fascination with
lights or movement

7. Videos
Hand Flapping Walking on toes

8. Head Banging Repetitive movements

9. Differential Diagnosis
▪Not before age of 5 years
▪+ve family history of Schizophrenia
▪Presence of hallucinations, delusions, thought disorders
Schizophrenia
with childhood
onset
▪A diagnosis of attention-deficit/hyperactivity disorder (ADHD) should be considered when
attentional difficulties or hyperactivity exceeds that typically seen in individuals of
comparable mental age
▪Abnormalities of attention (overly focused or easily distracted) are common in individuals
with autism spectrum disorder, as is hyperactivity.
ADHD
In selective mutism
early development is not typically disturbed.
The affected child usually exhibits appropriate communication skills in certain contexts and
settings.
Even in settings where the child is mute, social reciprocity is not impaired, nor are restricted
or repetitive patterns of behavior present.
Selective mutism

10. • Disruption of social interaction may be
observed during the regressive phase of Rett
syndrome (typically between 1-4 years of
age); thus, a substantial proportion of
affected young girls may have a
presentation that meets diagnostic criteria
for autism spectrum disorder.
• However, after this period, most individuals
with Rett syndrome improve their social
communication skills, and autistic features
are no longer a major area of concern.
• Consequently, autism spectrum disorder
should be considered only when all
diagnostic criteria are met.
Rett
syndrome

11. • Child is normal for several years before losing both receptive and expressive language.
• Most have a few seizures and generalized EEG abnormalities at onset that do not persist.
• A profound language comprehension disorder then follows, characterized by deviant
speech pattern and speech impairment.
Acquired
aphasia with
convulsion
• Infants have a history of relatively normal babbling that tapers off gradually and may stop
from 6 months to 1 year of age.
• Children respond only to loud sounds.
• Auditory or auditory-evoked potentials indicate significant hearing loss.
• Children usually relate to their parents, seek their affection, and enjoy being held as
infants.
Congenital
deafness or
severe hearing
impairment

12. Treatment: Pharmacotherapy + Psychological interventions
A) Social and communication impairment
• Currently, no drug has been consistently shown to improve the core social and
communication impairments in ASD.
• Risperidone may have a secondary effect through improvement in irritability.
• Given the limited number of RCTs, the findings on the effectiveness of oxytocin in
ASD should still be considered as unproven.
• Sulforaphane, insulin growth factor 1 (IGF‐1), glutamatergic agents, Acetylcysteine
await further work to prove their efficacy in modifying ASD core symptoms.

13. B) Restricted repetitive behaviours and interests
• Behavioural therapies should be used as first line.
• Pharmacotherapy: if severe behavior with significant impact on functioning and/or
pose risks to others or self
• were thought to be effective and have therefore become perhaps the most widely prescribed
medications to treat RRBIs in pediatric ASD populations
• The available literature reports inconsistent benefit from SSRIs and there remains
uncertainty about the optimal dose regime.
SSRIs
1- Second‐generation antipsychotics: Research with respect to risperidone indicates that it is
effective in reducing repetitive behaviors in children who have high levels of irritability or
aggression
2- Anticonvulsants
3- Oxytocin.
Others

14. Treatment of Comorbid conditions
1- Inattention, overactivity and impulsiveness in ASD (symptoms of ADHD)
Methylphenidate
• A large double‐blind placebo‐controlled trial of methylphenidate in children with intellectual disability and
ADHD showed that optimal dosing with methylphenidate was effective in some.
• Adverse effects are more commonly reported than in children with ADHD alone.
Amphetamines
• There are no published data on the efficacy of amphetamines in children with ASD
Atomoxetine
• it may be useful in children with ASD but large‐scale RCTs are awaited
Others
Risperidone, alpha2‐agonists, SSRIs, venlafaxine, benzodiazepines, mood stabilisers.

15. 2-Irritability (aggression, self‐injurious behaviour, severe disruptive behaviours)
• Behavioural and environment approaches should be first‐line treatments, more
severe and dangerous behaviours usually necessitate pharmacotherapy.
• Duration of recommended treatment is difficult to derive from published evidence
but treatment appears to be beneficial for up to 6–12 months.
• Second‐generation antipsychotics (SGAs) are the first‐line pharmacological
treatment: Risperidone and aripiprazole (Both have been approved by the FDA to
treat irritability associated with ASD.)

16. Others
• The effectiveness of other SGAs such as olanzapine, quetiapine, ziprasidone and
clozapine has not been tested in adequately powered RCTs.
• Whilst controlled studies support the use of mood stabilisers such as lithium, and
sodium valproate as being effective in the treatment of persistent aggression in the
paediatric population, available data suggest that mood stabilisers and
anticonvulsants may not be as effective as SGAs for the treatment of irritability in
ASD.
• Limited data support the combination of risperidone and topiramate being better
than risperidone alone.
• Using benzodiazepines to manage irritability and aggression in ASD is not
recommended. However, it may be necessary to manage acute aggression with a
benzodiazepine.

17. 3-Sleep disturbance
1- Melatonin has been shown in 17 studies to be beneficial in children with ASD
2- Risperidone may benefit sleep difficulties in those with extreme irritability
3- In the anxious or depressed child, antidepressants may be beneficial.
4- Insomnia due to Hyperarousal may benefit from clonidine or clonazepam.
4-Anxiety and depression
1-SSRIs (sertraline, fluvoxamine, citalopram), despite being widely used to treat anxiety
and depression in typically developing young people and those with ASDhave yet to
show specific efficacy in ASD.
2-Some data on buspirone.
3-propranolol showing positive cognitive effects in ASD

18. Risperidone
■■ Risperidone can be administered once daily or twice daily.
■■ Patients experiencing somnolence may benefit from taking the whole daily dose at bedtime.
■■ There is insufficient evidence from controlled trials to indicate how long treatment should continue.
*Risperidone usually causes hyperprolactinaemia which may not be symptomatic but which may have
longer‐term effects. Close monitoring is advised.

19. Fluoxetine
• When using fluoxetine to treat repetitive behaviours in ASD patients,
doses much lower than those used to treat depression are normally
required. It is advisable to use a liquid preparation and begin at the
lowest possible dose, monitoring for adverse effects.

20. Aripiprazole
• The usual recommended clinical dose of aripiprazole for maintenance is between 5
and 15 mg daily (starting with 2 mg/day)

21. Non-pharmacological
Psychosocial interventions
Consider a specific social-communication intervention for the core features of autism in
children and young people that includes play-based strategies with parents, carers and
teachers to increase joint attention, engagement and reciprocal communication in the
child or young person. Strategies should:
• be adjusted to the child or young person's developmental level
• aim to increase the parents', carers', teachers' or peers' understanding of, and sensitivity
and responsiveness to, the child or young person's patterns of communication and
interaction
• include techniques of therapist modelling and video-interaction feedback
• include techniques to expand the child or young person's communication, interactive
play and social routines. The intervention should be delivered by a trained professional.
For pre-school children consider parent, carer or teacher mediation. For school-aged
children consider peer mediation.

22. Thank You