A Roadmap for Successful Intervention in Autism

UH Rainbow neurologist co-author of paper in Lancet Neurology

Innovations in Pediatrics | Fall 2020

What are the best evidence-based approaches for supporting people with autism across the lifespan? A group of experts recently published a roadmap in the journal Lancet Neurology with important advice for fellow clinicians.

 Max Wiznitzer, MD

A crucial prerequisite, they say, is moving away from the debate whether autism is a disability or just a difference and instead embracing its dual nature.

“Autism is both a medical condition that gives rise to disability and an example of human variation that is characterized by neurological and cognitive differences. An approach that acknowledges the dual nature of autism—encompassing both disabilities (resulting from atypical neurobiology) and differences (a neurodivergent profile of strengths and weaknesses)—is key to supporting autistic people,” the article states. “The duality view creates a common ground for medical, psychological, social and environmental intervention and support for autistic people, with the aim of alleviating distress and improving adaptive functioning and quality of life.”¹

For pediatric neurologist Max Wiznitzer, MD, who treats patients with autism at UH Rainbow Babies & Children’s Hospital and who was a co-author of the new article, this shift will empower more patient-centric care. Dr. Wiznitzer is also Professor of Pediatrics and Neurology at Case Western Reserve University School of Medicine.

“We treat the person,” he says. “We don't treat the diagnosis. We treat the person with the diagnosis.”

In the Lancet Neurology article, Dr. Wiznitzer and his colleagues highlight the need for more rigorous research into the effectiveness of different autism interventions. However, they do point to some noteworthy approaches. Evidence suggests, they say, that comprehensive, naturalistic early intervention with active caregiver involvement can facilitate early social communication, adaptive functioning, and cognitive development, while targeted intervention can help to enhance social skills and aspects of cognition.

“Most evidence is available for specific models of naturalistic early intervention that actively involve caregivers, targeted interventions for the building of social skills, and specific treatments for co-occurring mental health challenges,” the article states.

“The intervention has to be appropriate for child's developmental level and needs,” Dr. Wiznitzer explains. “And it has to be implemented not in a sterile classroom type setting, but in a real-world setting where the individuals will learn how to utilize the skills.”

Augmentative and alternative communication interventions also show preliminary evidence of benefit in minimizing communication barriers for people with autism, the authors write.

With all interventions, the authors argue, the details matter. When the correct intervention is paired with the correct patient, the results can be dramatic, Dr. Wiznitzer says.

“In some cases when interventions are being done, you can actually see a rise in IQ points,” he says. “Some of the studies have shown that, which really means that the individuals have the potential, but it was not being tapped. Our goal then with an intervention is to tap the potential that exists within the individual for skills, whether they're social skills or cognitive skills. You have to find out which intervention is going to be most effective for the individual. It’s like choosing a medication. The first medicine may not always work, so you may have to try something different. What works for one individual may not work for another who has different clinical profile.”

In order to help achieve the best results for their patients with autism, Dr. Wiznitzer and his colleagues argue for creating more autism-friendly environments for people of all age groups – something which is currently lacking.

“Support should be dynamic across the lifespan, as adaptation issues differ in childhood (e.g., educational) versus adulthood (e.g., residential and occupational),” they write. “Transition to adulthood can be challenging and evidence-based support is insufficient at present. Moreover, obtaining services and support for autistic adults, with or without communication or intellectual disabilities, has been particularly difficult owing to the structure of healthcare service systems and insufficient funding, signaling a pressing need for systems-level improvement.”

If more autism-friendly change were to occur, Dr. Wiznitzer says, it could lead to measurable improvements in quality of life not only for people with autism, but also for those with other developmental disabilities.

“Autism is just one of many developmental disabilities,” he says. “So the issues, ideas and concepts we're discussing here for autism can be transferred to other individuals with other developmental disabilities -- the concept of the duality. the constant of involving families in the decision-making process. All of this we can think of as a template for people with other developmental disabilities to gain and improve.”

For more information about Dr. Wiznitzer or treatment for autism at UH Rainbow Babies & Children’s Hospital, please email Peds.Innovations@UHhospitals.org.

¹ Meng-Chuan Lai, Evdokia Anagnostou, Max Wiznitzer, Carrie Allison, Simon Baron-Cohen. Evidence-based support for autistic people across the lifespan: maximizing potential, minimizing barriers, and optimizing the person-environment fit. Lancet Neurol. 2020 May;19(5):434-451.  doi: 10.1016/S1474-4422(20)30034-X.  Epub 2020 Mar 3.