August 2009  << Back  

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Autism spectrum disorders: Navigating in uncharted waters

Sanjay Gupta, MD

Clinical Professor, Department of Psychiatry, SUNY Upstate Medical University, Syracuse, NY, USA

Clinical Professor, Department of Psychiatry, SUNY at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, USA

Associate Director of Geriatric Psychiatry, BryLin Hospital, Buffalo, NY, USA

Daniel A. Rossignol, MD, FAAFP

International Child Development Resource Center, Melbourne, FL, USA

Even in the 21st century, the cause(s) of autism spectrum disorders (ASD) remain(s) elusive, and few treatments are supported by double-blind studies. In this special issue of Annals of Clinical Psychiatry, we highlight studies that address new research exploring possible causes of ASD and potential new treatments.

The hallmarks of ASD are profound impairments in socialization, delayed and unusual communication, and repetitive behaviors with restricted interests. Diagnosis can be made as early as 18 months, although the medical community’s lack of awareness often delays diagnosis. Often we still hear, “He is a boy, and boys talk late.” It is critical to identify ASD early to expedite treatment and provide the best chance of improvement. Many clinicians are not experienced or knowledgeable enough to make a proper diagnosis, which is unfortunate because early intervention in ASD can make a significant difference in outcome.

Risperidone is the only medication approved by the FDA to treat aggression in children with ASD, and recent research has shown that citalopram, which is used off label, does not reduce repetitive behaviors in ASD.1 Because of potential delays in ASD diagnosis and the scarcity of proven treatments, some parents turn to unconventional and/or off-label approaches, ranging from high doses of vitamins and special diets to chelation. They learn about these treatments from other parents of autistic children, the Internet, and books and make choices based on their comfort level, the severity of their child’s dysfunction, the risk of side effects with conventional treatments, or their confidence in the treating clinician.

Clinicians need to recognize that off-label treatments commonly are used for children with ASD and to maintain an open mind. Viewing issues from a parent’s perspective—such as that time is running out for their child while waiting for newer treatments supported by double-blind, placebo-controlled studies—might help clinicians gain a fresh understanding of what parents are feeling. In addition, because treating physicians might not be aware of these unconventional treatments, they often do not ask if a child is receiving them. This is a particular concern for clinicians who treat behavioral manifestations and comorbid psychiatric disorders with psychotropic medications that could interact with these unconventional treatments.

In this the first of 2 special editions of Annals focused on autism, we wish to increase clinicians’ awareness of ASD. Karen Pierce, PhD, and colleagues discuss the importance of early diagnosis and the need to identify biological markers of ASD. They argue for viewing ASD as a puzzle with multiple causes.

In some studies, autoimmune pathology has been linked to ASD, as Vijendra K. Singh, PhD, discusses in his article. This observation led him to identify autoimmune autistic disorder, a subset of autism.

Doreen Granpeesheh, PhD, BCBA, and colleagues review Applied Behavior Analysis therapy, the only treatment established and replicated by double-blind studies and the mainstay of behavioral treatment.

Relationship Development Intervention (RDI), described by Steven E. Gutstein, PhD, takes a common-sense approach to addressing behavioral manifestations of these disorders. RDI empowers and teaches parents how to facilitate their child’s mental development through guided interaction in daily activities.

Behavioral interventions based on evidence-based research need to be publicized and more widely available to autism patients and their families. It is our hope that this issue of Annals brings a fresh perspective to this perplexing disorder.


A staff-written summary of a presentation by Marlene P. Freeman, MD (Annals of Clinical Psychiatry, May 2009, p. 68) paraphrased her as saying “atypical antipsychotics may pose a lower risk of fetal malformations compared with lithium or anticonvulsants.” Dr. Freeman did not make this statement and states that available data are insufficient to support this comparison. She wishes to clarify what the scientific evidence supports when treating bipolar disorder in pregnant patients:

“Because relapse rates for bipolar women who discontinue medication during pregnancy are high, it is recommended that patients consider the serious risks of untreated bipolar disorder as well as medication exposure. Valproate appears to be the mood stabilizer associated with the greatest teratogenic potential. Among the anticonvulsants, lamotrigine appears to have the most favorable reproductive safety profile, and lithium appears to have a much lower risk of teratogenicity than was thought years ago, with a very low absolute risk of malformations with first-trimester exposure. More data are needed to inform the use of atypical antipsychotics across pregnancy and breastfeeding.”


  1. King BH, Hollander E, Sikich L, et al. Lack of efficacy of citalopram in children with autism spectrum disorders and high levels of repetitive behavior. Arch Gen Psychiatry. 2009;66:583–590.

CORRESPONDENCE: Sanjay Gupta, MD 515 Main Street Olean, NY 14760 USA. E-MAIL: