HOW TO TREAT AUTISM SPECTRUM DISORDER (ASD) 2025

HOW TO TREAT AUTISM SPECTRUM DISORDER (ASD) 2025

GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF COMMON MENTAL DISORDERS

(Enacted under Decision No. 2058/QĐ-BYT dated May 14, 2020, by the Minister of Health)

Article 29

AUTISM SPECTRUM DISORDER (ASD)

CHIEF EDITOR

Associate Professor, PhD Nguyễn Trường Sơn

CO-EDITOR

Associate Professor, PhD Lương Ngọc Khuê

PhD Nguyễn Doãn Phương

CONTRIBUTING AUTHORS

PhD Trần Thị Hà An

MSc Trịnh Thị Vân Anh

PhD Vũ Thy Cầm

MSc Trần Mạnh Cường

PhD Nguyễn Văn Dũng

PhD Vương Ánh Dương

PhD Lê Thị Thu Hà

MSc Trần Thị Thu Hà

MSc Phạm Công Huân

MSc Đoàn Thị Huệ

Specialist Doctor II Nguyễn Thị Minh Hương

MSc Vũ Thị Lan

1. Nguyễn Phương Linh

Specialist Doctor II Nguyễn Thị Phương Loan

MSc Bùi Văn Lợi

MSc Nguyễn Thị Phương Mai

PhD Trần Nguyễn Ngọc

MSc Bùi Nguyễn Hồng Bảo Ngọc

MSc Trương Lê Vân Ngọc

MSc Bùi Văn San

PhD Dương Minh Tâm

MSc Phạm Xuân Thắng

MSc Lê Thị Phương Thảo

MSc Lê Công Thiện

MSc Vương Đình Thủy

Associate Professor, PhD Nguyễn Văn Tuấn

Specialist Doctor II Ngô Văn Tuất

MSc Đặng Thanh Tùng

MSc Vũ Sơn Tùng

MSc Cao Thị Ánh Tuyết

MSc Nguyễn Thị Ái Vân

Specialist Doctor II Hồ Thu Yến

MSc Nguyễn Hoàng Yến

CONTRIBUTORS TO EVALUATION AND FEEDBACK

Associate Professor, PhD Nguyễn Thanh Bình

PhD Vũ Thy Cầm

PhD Nguyễn Hữu Chiến

Specialist Doctor II Võ Thành Đông

PhD Lê Thị Thu Hà

Specialist Doctor II Đỗ Huy Hùng

PhD Nguyễn Mạnh Hùng

MSc Nguyễn Trọng Khoa

Specialist Doctor II Ngô Hùng Lâm

Associate Professor, PhD Phạm Văn Mạnh

Specialist Doctor II Trần Ngọc Nhân

PhD Dương Minh Tâm

MSc Đặng Duy Thanh

PhD Vương Văn Tịnh

Specialist Doctor II Lâm Tứ Trung

PhD Lại Đức Trường

PhD Cao Văn Tuân

Associate Professor, PhD Nguyễn Văn Tuấn

SECRETARIAT TEAM

MSc Đặng Thanh Tùng

MSc Trương Lê Vân Ngọc

BA Đỗ Thị Thư

Article 29

AUTISM SPECTRUM DISORDER (ASD)

I. DEFINITION  

Autism is a spectrum of neurodevelopmental disorders ranging from mild to severe, with onset before age 3 and a lifelong course. It manifests across three core domains:  

– Social interaction.  

– Communication.  

– Restricted, repetitive behaviors and interests.  

ASD often co-occurs with conditions like attention-deficit/hyperactivity disorder (ADHD) and intellectual developmental disorder.

II. ETIOLOGY  

The exact cause of ASD is unclear, but multiple factors are implicated:  

1. Genetics:  

   – Recent research identifies genetics as a primary factor in most cases, with multiple abnormal genes interacting (notably on chromosomes 2, 4, 7, 15, 19).  

   – Concordance rates: 70-90% in identical twins, 0% in fraternal twins; 3-5% sibling recurrence.  

   – Approximately 1% of ASD cases involve Fragile X syndrome.  

   – More common in males (linked to X chromosome), especially in autism and Asperger’s syndrome.  

2. Environmental Factors:  

   – Maternal conditions pre-/during pregnancy: rubella, influenza, measles, thyroid disorders, metabolic diseases (e.g., diabetes), use of drugs like valproic acid, antipsychotics, NSAIDs.  

   – Excessive stress, folic acid overuse, alcohol, ultrasound exposure during pregnancy may increase risk.  

3. Neurological Factors:  

   – Grand mal epilepsy, tuberous sclerosis, prenatal brain damage.  

   – Structural brain changes (cerebellum, hippocampus, prefrontal cortex, temporal lobes); autistic brains are larger/heavier due to excess white matter.  

   – Abnormal connectivity between midbrain, cerebellum, and cortex leads to sensory over-/under-sensitivity and atypical behaviors.  

   – Neurochemical imbalances involving dopamine, catecholamines, and serotonin.

III. DIAGNOSIS  

1. Definitive Diagnosis (ICD-10)  

1.1. Clinical Features  

1. Impaired Social Interaction (Core Deficit):  

   – Early signs: indifference, reduced eye contact, poor response to name, lack of gestures (e.g., pointing, reaching, nodding/shaking head), using others’ hands to get needs met.  

   – Reduced joint attention: doesn’t follow pointing, no reciprocal smiling, doesn’t share interests.  

   – Solitary play, no peer interaction, lacks sharing or emotional reciprocity.  

1. Abnormal Language/Communication:  

   – Delayed speech; some lose initial words.  

   – Atypical speech: meaningless sounds, self-talk, echolalia (repeating ads/songs), rote counting/letter recitation, parroting.  

   – Passive language: speech only for essentials (e.g., food, play), no questioning.  

   – Some speak but can’t narrate, converse, or comment; unusual tone (high-pitched, monotone, fast, garbled), literal interpretation (misses figurative meaning).  

   – Lack of imaginative or age-appropriate social pretend play.  

1. Abnormal Behaviors:  

   – Stereotyped movements: toe-walking, spinning, hand-gazing, finger-flicking, hand-flapping, head-tilting, mouthing hands.  

   – Rigid routines: fixed paths, specific seating/lying spots, precise object placement, inflexible daily habits.  

   – Narrow interests: fixation on videos/TV/ads, holding items (e.g., sticks, bottles), playing with limited objects (e.g., cars, balls), spinning wheels, watching moving objects.  

   – Excessive focus on object details.  

1. Associated Features:  

   – Impulsivity/aggression: grabbing, throwing, tantrums, head-banging, biting/hitting.  

   – Hyperactivity: constant running, mischief, ignoring danger.  

   – Intellectual impairment in many cases: poor recognition, rote number/letter skills, learning difficulties.  

   – Excessive fears, selective eating (e.g., no chewing, limited food preferences).  

1.2. Diagnostic Criteria  

1. At least 6 symptoms from (1), (2), and (3), including ≥2 from (1) and ≥1 each from (2) and (3):  
2. Qualitative Social Impairment: ≥2 of:  
3. a) Marked deficits in nonverbal behaviors (eye contact, facial expression, posture, gestures).  
4. b) Failure to develop age-appropriate peer relationships.  
5. c) Lack of spontaneous sharing of enjoyment/interests/achievements.  
6. d) Lack of social/emotional reciprocity.  
7. Qualitative Communication Impairment: ≥1 of:  
8. a) Delayed/absent spoken language development.  
9. b) Inadequate initiation/sustaining of conversation (if language present).  
10. c) Stereotyped, repetitive, or idiosyncratic language.  
11. d) Lack of age-appropriate imaginative play.  
12. Restricted, Repetitive Behaviors/Interests: ≥1 of:  
13. a) Intense preoccupation with narrow, abnormal interests.  
14. b) Rigid adherence to nonfunctional routines/rituals.  
15. c) Stereotyped, repetitive motor mannerisms.  
16. d) Persistent focus on parts of objects.  
17. Delayed/abnormal development in ≥1 domain before age 3.  
18. Not better explained by Rett syndrome or childhood disintegrative disorder.  
19. Ancillary Testing  

– Routine Tests: Complete blood count, biochemistry, urinalysis, ECG, abdominal ultrasound, chest X-ray.  

– Autism-Specific Assessments: ADOS-G, CARS, M-CHAT (screening).  

– Comorbidity Assessments: Intelligence (WISC, Raven, Denver), ADHD (Vanderbilt), behavior (CBCL), depression (RADS).  

– Specialized Tests: Metabolic/genetic screening (e.g., Fragile X), EEG, CT/MRI brain, hearing tests (to rule out auditory issues).  

3. Differential Diagnosis  

– Intellectual Developmental Disorder: 40% of autistic children have moderate/severe intellectual impairment; unlike autism, they relate to others at their mental age, use available language for communication, and show uniform rather than selective deficits.  

– Early-Onset Schizophrenia: Rare under age 5, involves hallucinations, less seizure risk, more stable IQ than autism.  

– Mixed Receptive-Expressive Language Disorder: Language-specific deficits without social/behavioral features.  

– Congenital Deafness/Severe Hearing Loss: Auditory impairment mimics communication delays.

IV. TREATMENT  

1. Treatment Principles  

– No single approach fits all; combines multiple methods.  

– Aims: Enhance social skills, create supportive environments.  

– Relies on cognitive-behavioral therapy with visual aids.  

– Multidisciplinary team: doctors, psychologists, educators, speech therapists, rehabilitation specialists.  

– Early intervention (ideally ages 2-4), individualized, continuous, and long-term.  

– Active family involvement, supported by healthcare, education, and psychology sectors.

2. Treatment Framework  

Early Interventions for Young Children:  

1. Applied Behavior Analysis (ABA): 40 hours/week for 2 years; uses antecedent-behavior-consequence model to teach activities, language, and peer interaction.  
2. TEACCH (Treatment and Education of Autistic and Communication-Handicapped Children): Individualized assessment/education plans, social/vocational skill training, parental/school guidance.  
3. Picture Exchange Communication System (PECS): Uses pictures/symbols for schedules, requests, choices, and task steps.  
4. Speech Therapy: Teaches gestures, speech, social expression/communication.  
5. Occupational Therapy: Fine/gross motor skills, play-based activities.  
6. Sensory Integration Therapy: Music, lights, massage, hydrotherapy to stimulate senses.  
7. Self-Care Skills Training: Promotes independence in daily living.  
8. Social Stories: Uses visuals/text to teach social interaction and situational responses.  

For Older Children (Based on Severity/IQ):  

1. Inclusive education.  
2. Specialized classes in mainstream schools.  
3. Centers for children with disabilities.  

Pharmacotherapy:  

– ASD is lifelong; medications target co-occurring symptoms:  

  – Agitation, Aggression, Self-Injury, Stereotypies, Anxiety, OCD-Like Behaviors: Risperidone, Olanzapine, Quetiapine.  

  – Hyperactivity, Irritability, Depression, OCD, Anxiety: Methylphenidate, Clonidine, SSRIs, anxiolytics.  

  – Epilepsy/Behavioral-Emotional Symptoms: Anticonvulsants (alone or combined):  

    – Valproate (30-50 mg/kg/day), Carbamazepine (15-20 mg/kg/day), Phenobarbital (3-6 mg/kg/day), Oxcarbazepine (30-46 mg/kg/day), Gabapentin (25-50 mg/kg/day), Lamotrigine (5-15 mg/kg/day), Levetiracetam (40-100 mg/kg/day).  

  – Neuroprotection: Piracetam, ginkgo biloba, vinpocetine, choline alfoscerate, nicergoline.  

  – Supportive: Liver function aids, cognitive enhancers, nutrition (vitamins B, minerals, digestible diet, IV nutrition if needed).

V. PROGNOSIS AND COMPLICATIONS  

– Delayed schooling, poor integration, limited communication, learning difficulties. Severe cases need special education; mild cases may integrate.  

– Some mildly affected individuals with communication skills may live independently as adults, often alone.  

– ~50% of classic autism cases remain nonverbal or minimally verbal into adulthood, heavily reliant on family or long-term intervention centers.  

– Good prognosis with early intervention, high IQ, communication ability, and fewer atypical behaviors.  

– Symptoms may evolve with age; some develop self-injury, agitation, anxiety, or depression.

VI. PREVENTION  

– Pregnant women (especially first trimester): Full vaccinations (influenza, measles, rubella), avoid medication overuse.  

– Maintain balanced work/rest/nutrition, positive mood, avoid stress.  

– Provide nurturing, attentive child care.  

– Early detection/intervention minimizes complications and sequelae.

REFERENCES

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