Alternative treatments in ASD Dr Teresa Carter Consultant community paediatrician

Alternative/complementary treatments Doctors’ responsibility Do no harm critical appraisal – check for bias, complicating factors, placebo effect Reason we need good studies Dealing with a moving target The dangers of anecdotal evidence Useful books - Bad Science – Ben Goldacre Defeating Autism: A Damaging Delusion Paperback by Michael Fitzpatrick 2

What’s the problem and what does it mean? ASD is not one condition Common genetic variants Rare genetic variants Genetic syndromes Metabolic conditions* Mitochondrial disorders* Learning potential/style Social Anxiety Use of Language How to communicate Routines/Restricted Sensory/Repetitive ASD Marc Woodbury-Smith, Stephen Scherer Progress in the genetics of autism spectrum disorder Dev Med Child Neurol. 2018 May;60(5):445-451.

Nutrition & supplements Iron deficiency – high rates in ASD, which persist beyond preschool years, not just in children with restricted diets B12 – no good studies, no evidence it is implicated and no need for supplements B6 & Mg – many studies but only two were well controlled, these showed no benefit Dosman CF et al (2007, Mar) Children with autism: effect of iron supplementation on sleep and ferritin Pediatr Neurol. 36(3):152- 8. Sidrak S, Yoong T, Woolfenden Iron deficiency in children with global developmental delay and autism spectrum disorder. J Paediatr Child Health 2014 May;50(5):356-61. 4

Nutrition & supplements Probiotics – no evidence of benefit or harm Omega 3 Fatty Acids – no evidence of benefit in 2017 review of evidence Gluten Casein free diet – 1 in 100 people have coeliac disease and up to 1 in 10 may have some gluten intolerance, so there will be overlap, casein intolerance affects children less than 2 years usually, 7% white population lactose intolerant Allergy elimination – same as for general population Oxytocin – studies are inconclusive Antioxidants - these may be of benefit in a sub group of children with metabolic disorders Sathe et al. Nutritional and Dietary Interventions for Autism Spectrum Disorder: A Systematic Review Pediatrics June 2017, VOLUME 139 / ISSUE 6 5

Alternative Treatments Chelation therapy – there is no evidence that chelation works, a trial in US was stopped early because of safety concerns, there have been deaths associated with the treatment Hyperbaric oxygen treatment - the 1st study suggested it worked, but it was poorly designed and it was biased. Later well designed studies show no effect Craniosacral Therapy – no evidence it works but it is not harmful Chiropractic manipulation – no evidence of benefit Acupuncture – recent review 2018 inconclusive 6

Alternative Treatments Cannabis THC (9-tetrahydrocannabinol) Stays in body several days Psychotropic Effects vary by person and dose Deceased anxiety, sedation Euphoria Heightened perception Increased sociability Sensation of time slowing Increased appetite Decreased pain Paranoia Anxiety Irritability Worsened short-term memory Poor attention Altered awareness of the passage of time Impaired judgment Decreased coordination and balance Distorted spatial perception Medical Marijuana: Review of the Science and Implications for Developmental-Behavioral Pediatric Practice SE Hadland, J R. Knight, SK. HarrisJ Dev Behav Pediatr 36:115–123, 2015 7

Alternative Treatments Cannabis - in medicine, cannabinoids useful for increased muscle tone and central pain. Used in US for drug resistant epilepsy in children. Also, used for nausea and appetite stimulation there in adults and children. Cannabidiol example of a non psychoactive compound. Increasing interest in this substance but it remains poorly understood Conflicting evidence in mice Stockings E, Zagic D, Campbell G, et al. Evidence for cannabis and cannabinoids for epilepsy: a systematic review of controlled and observational evidence. J Neurol Neurosurg Psychiatry. 2018 Mar 8

Why else? Conflicting evidence Endocannabinoid areas of the brain are involved in brain development Conflicting evidence

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