Management of Autism Spectrum Disorder in Children and Adolescents

Key Messages

1. Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterised

by impairments in communication, behaviour and social functioning which begin in
childhood.
2. Early diagnosis and prompt intervention of children with ASD is crucial for the best
outcome.
3. Modified Checklist for Autism in Toddlers (M-CHAT) may be used as a screening tool
for ASD among children of 18 months and repeat at 24 months if the child passes
the earlier M-CHAT.
• It may be used to screen children up until the age of 30 months if the child
misses the earlier screening.
• Regardless of the screening result, children suspected of ASD at any age by the
family or other care providers should be referred for evaluation.
4. Diagnosis of ASD should be made clinically, based on comprehensive history and
observation.
5. Audiological assessment should be performed in children with or suspected of ASD.
6. Children with ASD should be managed by a multidisciplinary team.
7. Parents or carers should actively participate in any intervention offered to children
with ASD.
8. Children with ASD should receive:
• Applied behaviour analysis
• Speech, language and communication interventions
• Occupational therapy
9. Parental training should be offered to parents of children with ASD.
10. Traditional and Complementary Medicine could not be recommended to children
with ASD because of insufficient evidence and potential harmful effects.

This Quick Reference provides key messages and a summary of the main
recommendations in the Clinical Practice Guidelines (CPG) on the Management of
Autism Spectrum Disorder in Children and Adolescents.

Details of the evidence supporting these recommendations can be found in the above
CPG, available on the following websites:
• Ministry of Health Malaysia: www.moh.gov.my
• Academy of Medicine Malaysia: www.acadmed.org.my
• Malaysian Psychiatric Association: www.psychiatry-malaysia.org

Clinical Practice Guidelines Secretariat

Malaysian Health Technology Assessment Section (MaHTAS)
Medical Development Division
Ministry of Health Malaysia
Level 4, Block E1, Precinct 1, 62590, Putrajaya
Tel: 603-8883 1246, E-mail: [email protected]

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Management of Autism Spectrum Disorder in Children and Adolescents

Risk Factors

Screening for ASD should be emphasised in children with the following high risk factors:-
• Increased parental age
• Maternal age >40 years old
• Paternal age >50 years old
• First born of mother aged >35 years old and father aged >40 years old

Main Features of ASD

A. Persistent deficits in social communication and social interaction across multiple

contexts.

B. Restricted, repetitive patterns of behaviour, interests, or activities.

C. 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).

D. Symptoms cause clinically significant impairment in social, occupational, or other

important areas of current functioning.

E. These disturbances are not better explained by intellectual disability (intellectual

developmental disorder) or global developmental delay.

Comorbidities

• Children with ASD can experience a wide range of difficulties with emotional,
attentional, activity, thought, behavioural and medical problems.

• Diagnosis of comorbid disorders is of major importance as it may cause significant

clinical impairment in children with ASD.

• The comorbidities are:

a) Intellectual disabilities

b) Attention deficit hyperactivity disorder (ADHD)

c) Sleep disorders

d) Epilepsy

e) Gastrointestinal problems such as feeding problems and constipation

f) Motor incoordination such as poor handwriting

g) Other psychiatric disorderssuch as anxiety and depressive disorder

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 Management of Autism Spectrum Disorder in Children and Adolescents

Audiological Evaluation

• Audiological evaluation is an important component of initial assessment to rule out

hearing impairment.

• The electrophysiological test is preferably used to evaluate hearing impairment in

children with ASD as compared to behavioural test.

Treatment

i. Applied Behaviour Analysis (ABA)

Lovaas therapy and early intensive behavioural intervention variants improve among
others, social communication skills, language and daily living skills, cognitive performance,
language skills and adaptive behavioural skill.

ii. Speech, Language and Communication Interventions

Interventions Types Benefits

Naturalistic Responsive Education and Improves social communication
approach Prelinguistic Milieu Teaching & language learning
(RPMT)

Reciprocal Imitation Training (RIT) Improves elicited & spontaneous

imitation of objects & gestures
(<5 years old) with a greater play
repertoire

Augmentative Picture Exchange Communication Improves communication skills

and Alternative System (PECS) & requesting skills
Communication
(AAC)

Speech Generating Device (SGD) SGD with enhanced milieu

teaching & signing improves
requesting skills

Video modelling Video self-modelling Improves social communication

skills, functional skills & behavioural
functioning

Video modelling with other as Improves play skills, independent

model living & social-communicative
skills

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Management of Autism Spectrum Disorder in Children and Adolescents

iii. Occupational Therapy

Interventions Benefits
Sensory integration therapy Improves in sensory processing, motor skills, social
functioning & autistic mannerisms but further study
required to support current findings
Social skills and self-help skills Improves overall social competence & friendship quality

Joint attention Improves joint attention & joint engagement

Perceptual motor training Increases attention span

iv. Other Interventions

Interventions Benefits
Social Stories Improves social skills & reduces inappropriate
behaviours
Developmental, Individual- Improves developmental skills & reduces autistic
difference, Relationship-based symptoms
(DIR) FloortimeTM
Music therapy Improves joint attention skills & longer eye contact
Parent education and support Improves parent-child interaction, parent synchrony,
child’s language comprehension & functional verbal
utterances

v. Pharmacotherapy

• Children with ASD may be offered:

o atypical antipsychotics as a short-term treatment for irritability
o methylphenidate and atomoxetine for hyperactivity
o melatonin for sleep difficulties

Social Welfare Service

Children with ASD should be referred to the Department of Social Welfare at their respective
local districts. This will enable the child to be registered for social welfare benefits.

Transition from Adolescent to Adult Services

• Transition for adolescents with ASD should be discussed and planned early by all
who are involved in their management.

• Care for children and adolescents with ASD should be continued to adult health
services. There is a need for establishment of this service to support adolescents
when they enter adulthood.

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 Management of Autism Spectrum Disorder in Children and Adolescents

Modified Checklist for Autism in Toddlers (M-CHAT)

Answer ALL questions. Circle the appropriate answer.
Jawab SEMUA soalan. Bulatkan jawapan yang sesuai.

1 Adakah anak anda seronok apabila ditimang, dibuai atau dihenjut atas kaki / Ya / Yes Tidak / No
paha dan sebagainya?
Does your child enjoy being swung, bounced on your knee, etc?

2 Adakah anak anda menunjukkan minat terhadap kanak-kanak Ya / Yes Tidak / No

lain? (contohnya bergaul, bermain, berkawan)
Does your child take an interest in other children?

3 Adakah anak anda suka memanjat, contohnya tangga, kerusi, meja dan Ya / Yes Tidak / No
lain-lain?
Does your child like climbing on things, such as up stairs?
4 Adakah anak anda seronok bermain “cak-cak” atau main sorok-sorok? Ya / Yes Tidak / No
Does your child enjoy playing peek-a-boo or hide and seek?
5 Adakah anak anda pernah bermain-main olok-olok / berlakon, contohnya Ya / Yes Tidak / No
menelefon, bermain anak patung atau bermain masak-masak dan
sebagainya?
Does your child ever pretend for example to talk on the phone or take care
of dolls or pretend other things?
6 Adakah anak anda pernah menunjuk menggunakan jari telunjuk untuk Ya / Yes Tidak / No
meminta sesuatu?
Does your child ever use his / her index finger to point, to ask for
something?
7 Adakah anak anda pernah menunjuk / menggunakan jari telunjuk Ya / Yes Tidak / No
terhadap sesuatu yang menarik minatnya?
Does your child ever use his / her index finger to point, to indicate
interest in something?

8 Bolehkah anak anda bermain dengan alat permainan yang kecil dengan Ya / Yes Tidak / No
betul, selain dari memasukkannya ke dalam mulut, membelek-belek atau
menjatuhkan permainan itu? (contohnya kiub, kereta kecil, dan lain-lain)
Can your child play properly with small toys without just mouthing, fiddling
or dropping them?
9 Pernahkah anak anda membawa objek / benda dan menunjukannya Ya / Yes Tidak / No
kepada anda?
Does your child ever bring objects over to you (parent) to show
you something?

10 Adakah anak anda bertentang mata dengan anda lebih daripada dua Ya / Yes Tidak / No
saat?
Does your child look you in the eye for more than a second or two?
11 Pernahkah anak anda kelihatan seperti tersangat sensitif / terganggu Ya / Yes Tidak / No
terhadap bunyi bising (contohnya: menutup telinga)?
Does your child ever seem oversensitive to noise? (e.g. plugging ears)
12 Adakah anak anda senyum bila melihat anda atau membalas senyuman Ya / Yes Tidak / No
anda?
Does your child smile in response to your face or your smile?

13 Adakah anak anda meniru perlakuan anda (contohnya meniru Ya / Yes Tidak / No
mimik muka anda dan sebagainya)?
Does your child imitate you? (e.g. if you make a face will your
child imitate it?)

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Management of Autism Spectrum Disorder in Children and Adolescents

14 Adakah anak anda bertindak balas apabila namanya Ya / Yes Tidak / No

dipanggil?
Does your child respond to his / her name when you call?

15 Sekiranya anda menunjuk pada alat permainan yang jauh dari Ya / Yes Tidak / No
anda, adakah anak anda akan melihat kepada alat permainan
tersebut?
If you point at a toy across the room, does your child look at it?

16 Bolehkah anak anda berjalan? Ya / Yes Tidak / No

Does your child walk?
17 Adakah anak anda akan melihat pada benda yang sedang anda Ya / Yes Tidak / No
lihat?
Does your child look at things you are looking at?
18 Adakah anak anda membuat pergerakan jari yang ganjil / pelik dekat Ya / Yes Tidak / No
mukanya?
Does your child make unusual finger movements near his / her face?
19 Adakah anak anda cuba menarik perhatian anda terhadap aktiviti yang Ya / Yes Tidak / No
dilakukannya?
Does your child try to attract your attention to his / her own activity?
20 Pernahkah anda terfikir bahawa anak anda ada masalah pendengaran? Ya / Yes Tidak / No
Have you ever wondered if your child is deaf?
21 Adakah anak anda dapat memahami percakapan orang? Ya / Yes Tidak / No
Does your child understand what people say?
22 Adakah anak anda kadang-kala kelihatan temenung atau merayau / Ya / Yes Tidak / No
berjalan tanpa tujuan?
Does your child sometimes stare at nothing or wander with no purpose?
23 Adakah anak anda memandang ke muka anda untuk melihat reaksi / Ya / Yes Tidak / No
tindakabalas anda apabila ia menghadapi sesuatu yang baru atau luar
biasa?
Does your child look at your face to check your reaction when faced with
something unfamiliar?

1. No / Tidak 6. No / Tidak 11. Yes / Ya v 16. No / Tidak 21. No / Tidak

2. No / Tidak 7. No / Tidak 12. No / Tidak 17. No / Tidak 22. No / Tidak

3. No / Tidak 8. No / Tidak 13. No / Tidak 18. No / Tidak 23. No / Tidak

4. No / Tidak 9. No / Tidak 14. No / Tidak 19. No / Tidak 24. No / Tidak

5. No / Tidak 10. No / Tidak 15. No / Tidak 11. Yes / Ya v 25. No / Tidak

Scoring:
▪ The bold items are critical; i.e. 2, 7, 9, 13, 14, 15
▪ A chid requires referral (i.e. fail M-CHAT) for further evaluation if he / she fulfills
the following:
• 2 or more of critical items
• 3 or more of any items
Not all children who fail the checklist will meet criteria for a diagnosis on the autism
spectrum disorder. However, children who fail the checklist should be evaluated in more
depth by the relevant specialist.

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 Management of Autism Spectrum Disorder in Children and Adolescents

Algorithm on Management of Children with Autism Spectrum Disorder

Growth and developmental

assessment for children Referral from Referral from
under six years of age at school / community / parent Practitioners / Therapists
Maternal & Child Health
Clinic

M-CHAT screening
(at 18 and 24 months)*
• to be completed by parents
• assisted if necessary

Scoring** Fail
Refer Pg 6

Verification by Medical
Practitioner
Follow-up

Diagnosis confirmed by
Family Medicine Specialist /
Paediatrician / Psychiatrist

Multidisciplinary Assessment
and Management***

Speech- Psychological
Occupational Social Pharmacotherapy
language / behavioural Education
therapy welfare for comorbidities
therapy therapy

Early intervention programme (EIP) is strongly advocated

* M-CHAT may be used to screen children up until 30 months

of age if the child misses the earlier screening
**Regardless of the screening result, children suspected of
ASD by the family or other care provider should be referred
for evaluation
***Multidisciplinary Assessment and Management Team
may include:
• Family Medicine Specialist
• Paediatrician
• Psychiatrist
• Clinical Psychologist
• Occupational Therapist
• Speech-Language Therapist
• Audiologist
• Medical Social Worker