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    Musicoterapia No Autismo

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    Andressa Nasato

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    Licensed to Andressa - andressanasato@hotmail.com “Complementary and Alternative Medicine Treatments for Children with Autism Spectrum Disorders” ‘Susan E. Levy, MD. and Susan L. Hyman, M.D. SYNOPSIS Complementary and alternative medical treatments are commonly used for children with autism spectrum disorders. This review discusses the evidence supporting the most frequently used treatments, including eategories of mind-body medicine, energy ‘medicine, biologically based, manipulative and body-based practices, withthe latter two the most commonly selected by families. tis important for clinical providers to understand the evidence for efficacy (or lack thereof) and potential side effects. Some CAM. practices have evidence to reject their use, such as secretin, others have emerging evidence to support their use, like melatonin, Most treatments, however, have not been adequately studied and do not have evidence fo support their use. Keywords: autism, autism spectrum, complementary and altemative treatments, evidence based Autism spectrum disorders (ASD) are common disorders (affecting | in 150 children) * and are typically first recognized in early childhood. ASDs are characterized by core deficits in socialization, communication and behavior * with a wide range of severity of symptoms, Disorders include autism, Asperge’s Disorder, Childhood Disintegrative Disorder, Rett syndrome and Pervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS). For the purpose of this paper, we will include autism, Asperger's Disorder and PDD-NOS as the ASDs for discussion, as Childhood Disintegrative Disorder and Ret's Disorder have different caraetersties, outcome and treatment, Function and outcome is affected not only by core deficits but by Frequently associated comorbid behaviors", suchas iitbility, sensory abnormalities, hyperactivity, ffetve disorders and ohes. Outcome is farther affected by the presence or absence of language and by overall cognitive ability While existing seientifie data suggests the etiology is largely genetic withthe plausibility of environmental factors, the specific causes are often not known, In addition, the symptoms are behaviorally defined, heterogencous and change with acquisition of. ‘developmental skills, For these reasons families of children with autism and related disorders may turn to therapies that are not based inthe realm of conventional medical or psychological practic. In this review we will discuss the common use of complementary and altemative medicine (CAM) by families of children with autism spectrum disorders (ASD), investigate the reasons families seek CAM, review the commonly used CAM therapies for ASD, and describe the issues faced by conventional practitioners whose patients are interested in CAM use. The combination of conventional practice and complementary techniques which have some supportive evidence is often called “Integrative Medicine.” ‘Som interventions originally considered CAM are embraced into conventional practice as evidence supports their use. Treatments for Children with ASD Research has shown thatthe mos effective treatment i @ combination of specialized and supportive educational programming, communication training (such as specch/language therapy), social skills support and behavioral intervention “Other treatments suel as occupational therapy and physical therapy may promote progress as they address possible comorbid difficulties of motor coordination and sensory deficits. Progress may be slow, in part duc tothe pervasive nature ofthe core deficits and comorbid features Prevalence of CAM Use for Symptoms of Autism in Children Licensed to Andressa - andressanasato@hotmail.com The use of CAM is increasing for both adults and children, The National Center for Complementary and Alternative Medicine (NCCAM) reports that over % of American adults use CAM for treatment of disease orto maintain health (htp:inccam.nih govinews/camsurvey_fS1 hn), The use of CAM in children mirrors the treatment choices oftheir parents. Its estimated that 2-50% of children in the United States are given CAM therapies This i likely tobe an underestimate Children with chronic illness, such as cancer, asthma, rheumatoid arthritis, and neurodevelopmental disorders suchas autism, are treated with CAM therapies at even higher ates. Up to 50 to 75% of children with autism may be treated with CAM."™!"), CAM use may be even more likely in chikiren with comorbid intellectual disability. Levy etal reported that almost 1/3 of young children referred for evaluation of ASD were being treated with dietary therapies by their parents even before confirmation of diagnosis, ‘A wide range of CAM therapies are used in children, NCCAM groups CAM therapies into four domains, including mind-body ‘medicine, biologically based practices, manipulative and body-based practices and energy medicine. The most commonly used CAM treatments for ASD fall into the categories of biologically based practice and manipulative and body-based practices. Approximately half of families of children with ASD will use a biologically based therapy, 30% a mind body therapy, and 25% a ‘manipulation or body based method ®. The range of reported response about usage is dependent upon the population queried and hhow the question is asked. Hanson ” reported that 41% of respondents endorsed benefit with dietary and nutritional treatments, hile Wong and Smith found that 75% of respondents thought ther treatments were helpful, Who Uses CAM Therapies and Why Conventional medicine has been directed at the goals of diagnosis, treatment, and when possible, cure, of disease states. CAM practices add promotion of health and involvement ofthe patient in process of healing that must ultimately adress the underlying cause of illness as interpreted by the practitioner. CAM is often perceived as “natural”, without the side effets of conventional medical treatments The reasons why Families use ‘CAM have been studied in other chronic disorders of chilthood, Adverse effects from conventional medication was the only significant predictor for CAM use in children with inflammatory bowel disease. Similarly, for children with asthma, CAM use was predicted by older age, worse control of symptoms, more medications, more medical visits and more side effects ™. A survey in ltaly identified fear of side effets as the most common reason for parents to choose a CAM therapy for routine illness. Satisfaction was reported in 81% and successfil symptom resolution attributed tothe CAM therapy "Adults who use CAM believe that a combined approach of CAM and conventional therapy is more likey to be successful than either one alone, that nutritional suppor is an important part of health maintenance, and prefer nt to ake prescription medications“, Among families of children with ASD surveyed by Hanson etal, over 75% of families chose therapies based on their perception of safety, absence of side effects or prior experience with side effects, Despite the common use of CAM, 23 of families report that they base their therapeutic choices on the recommendation of their health care provider or scientfi support. Approximately $0% of families repor that they desire more control over the therapies elected, choose CAM because oa hope for a cure, or because of recommendations by friends or families of other children with ASD. Only 39% elect CAM because they prefer “natura” therapies and 25% report choices based on medi, CAM therapies are pursued to treat core symptoms of ASD, as well as to increase attention, to enhance relaxation, fo decrease gastrointestinal symptoms, regulate sleep, and to promote general health, in that order Patients who seek out CAM providers may be secking the longer visits typically offered in CAM settings and perceive thatthe CCAM provider pays more attention tothe symptoms of concer to the family. Parents who use CAM for thet children tend to use CCAM for their own health and be better educated, It isnot dissatisfaction with conventional care that leads families to employ CCAM. The most commonly reported reasons are concer regarding side effects, a desire to include multiple approaches to address symptoms, and personal beliefs about health. With changes in society such as self determination in health care, greater accessibility, Licensed to Andressa - andressanasato@hotmail.com to information on the intemet and a decline in the fit in science and technology people seck more control over their own mecal decision making CAM Therapies All treatments should be based on principles of evidence-based medicine (EBM), integrating clinical expertise, patient (or family) values, and the best evidence for efficacy ®'*". The selection of some treatments may reflect a bia, affected by the caregivers clinical experience, education or skills, and the fail 1 unique concems and expectations. Studies of efficacy of treatment should be judged by standards of scientific research, guiding study design and the hierarchy of types of study. The hierarchy of strength of evidence includes randomized, controlled clinical trials, which are atthe peak, followed by cohort studies, ease control studies and then case report, The most robust evidence would include metaanalyses, which thoroughly examine a number of valid studies on a topic. Meta-analysis combines results using accepted statistical methodology as if they were from one lange study ora systemic review which focuses on clinical question and includes an extensive literature search to identify all studies with sound ‘methodology. Unfortunately, even some commonly used medical treatments have not met these standards. For the purposes ofthis paper, we reviewed the existing literature and repor the strength ofthe evidence as Grade A (randomized controlled trials, reviews andor meta-analyses), Grade B (other evidence such as isolated well-designed controlled and uncontrolled studies), or Grade C (case reports or theories), This grading refers tothe strength of the evidence; evidence that supports or refutes the use ofthe intervention Mind-Body Medicine Yoga - Grade C Decreasing anxiety through nonpharmacologie techniques has great ction to both families and clinicians. Yoga isa mind-body approach that enjoys popular practice fr inreasing the sense of well being and control with the potential to decrease anxiety. A trial of yoga for symptoms of ADHD was underpowered to demonstrate effect, but suggested some benefit in children on medication *, Relaxation therapy decreased symptoms of anxiety in inpatients with anxiety on a child psychiatry service "and in children with mental retardation. No studies have yet been published related to symptoms of autism and response to yoga techniques. Music Therapy - Grade B Use of musi to reinforce communication is froquently applied in the context of educational interventions, The use of music in discrete therapeutic format to enhance social skill and communication development in children with autism has been examined in sonal rials withthe potential for postive effects on spoken and gestural communication“, No effect on overall chor was reported. Clinical practice often pairs music with othe interventions with subjective benefit ®. Further study ofthe neurobiology of music processing in people with autism may provide additional rationale for msc therapy a a discrete treatment or apart of other educational interventions," Biologically Based Practices Dietary supplements BelMg++- Grade B Vitamin supplements to improve symptoms of mental health disorders have been in use for over SO years with 'B6 and Magnesium a popular treatment for autism over the past 20 years. This treatment hasbeen the subject of reviews hy several authors "7, Due tothe small numberof studies, methodological deficits, small sample sizes meta-analysis could not be done Licensed to Andressa - andressanasato@hotmail.com and the evidence was not adequate to support use of this supplement. ‘The most recent Cochrane Review” identified thee studies completed between 1993 and 2002 which compared outcomes to citer placebo or non-treated group. A toa of 28 subjects were weated in thes rials. Fidling and colleagues ® studied 12 participants sing a randomized, double blind placeho-conrlled Wal following a2 weck pre-andomization placebo lead ia period, No effects of teatment were scen in th 10 subjets who completed the study. More recently Kuriyama * and colleagues reported improvement in 1Q and social quotient scores in 8 children treated with B6 and Mg Despite the Fact that these studies sme titra for Cochrane review, they all suffered fom significant methodological weaknesses, including inadequate description of diagnosis and seletion eriteria and outcome measures. One addtional study with similar methodological issues has been published since this review, deseribing an open sty of 33 children with ASD who were reported to improve in symptoms after Mg-16 weatmeat DMG Grade B Dimethyl glycine (DMG) and a related compound, trimethyl glycine (TMG), are commonly used nutritional supplements. An olde case series suggested improvement in language and attention in a group of children with intellectual Aisabilty treated with DMG. Two small, double blind studies of DMG have not demonstrated postive effets on symptoms of autism compared to placebo Melatonin Grade B Some nutritional supplements have known pharmacologic properties. Melatonin isa hormone produced by the pineal gland that regulates sleep. Clinical studies have demonstrated abnormal in melatonin produetion or release in individuals with ASD. Clinical benefit in sleep onset and maintenance has been demonstrated in at least one large case seies at ‘ses from 0.75 mg to 6 mg prior to bedtime °. This would be predicted by the large effect size in small randomized tials. Few side effets were reported, Of 107 children with autism, many of whom were also being treated with psychotropic medications, treated with melatonin by Andersen etal’ side effects of early morning sleepiness or enuresis were reported in three cases. No effect on seizures was noted. Vitamin © Grade 8 Vitamin C is not commonly used as an isolated treatment but is frequently added to vitamin mixtures used by children with ASD. Dolske and colleagues ® reported postive results of decreased stereotyped behavior ina 30 week double- blind placebo controlled tril in 18 children with ASD. To date this study has not been replicated. Other reports have implicated Vitamin Cin its role with oxidative stress, ‘Amino Acids ~ Grade C; Carnosine - Grade B Amino acids are both precursors to neurotransmitters and act as neurotransmitters themselves . As such, i isnot surprising that some complementary approaches attempt to manipulate neurochemical actions by embers was hutritional supplementation. The abnormalities in peripheral serotonin levels in people with autism and their family ‘one ofthe first biologic findings in autism. Supplemental tryptophan migh increase brain production of serotonin because the uptake across the blood brain barriers sensitive to concentration in the bloodstream, However no trials have examined clinical effet of tryptophan supplementation on symptoms of autism, In adults with autism, tryptophan depletion exacerbated symptoms ©. There are no peer reviewed studies to date examining the effects of supplementation with other amino aeids such as taurine, lysine, or GAB in children with autism although they are often part of a CAM nutritional supplementation strategy. Taurine is 2 semi-essential sulphur containing amino acid derived from methionine and eystne. I has antioxidant properties and has been associated with improved visual learning in rodents. L-Camosine is a dipeptide that was demonstrated in one double blind placebo controled tral in 31 children with autism to improve expressive and receptive vocabulary and subjective improvement on the liam Autism Rating Seale over an 8 week tral at $00 mg/day "Lysine is an amino acid exogenously obtained from meat and milk products, With methionine it ean be endogenously made into carnitine "®, Carnitine is involved in intaceliular transport of long chain faty acids and therefore is important in energy generation. Although caine has documented usefulness ins Aeficiency states and inthe presence of certain medications such as valproic acid, it has never been evaluated asa treatment for ‘motor or behavioral symptoms of autism, There is one ease series of children with autism with elevated alanine and low cart suggesting that some children with autism may have mitochondrial disease Licensed to Andressa - andressanasato@hotmail.com (Omega 3faty acids - Grade 8 Polyunsaturated fatty acids, in particular Omega 3 fatty acids, are crucial for brain development and cannot be manufactured in the body. Dietary consumption occurs through ingestion of fish or fish oils, Oral supplementation with essential fatty acids has become popular for children with developmental differences including autism and ADHD“. Studies have examined differences in plasma levels of children with autism which are deereased compared to typical volunteers” without clinical correlations. Recently, Amminger and colleagues * reported improvement in behavior following a randomized double-blind placebo-controlled 6 week pilot tril of oral supplementation in 13 children with ASD with severe behavior difficulties, No side effets were noted beyond gastrointestinal symptoms. Folate and Oxidative stress ~ Grade © I has been hypothesized that exposure to toxic agents or endogenous abnormalities that lead to ‘oxidative stress may cause neuronal insult and lead to the regression seen in up to 1/3 of children with autism ‘!, Neuroanatomic Aiterences in white and gray mater, cerebellar pathology (eg, Purkinje cell loss) and other evidence of cellular disruption * as \well as Funetional abnormalities * led to the search for potential environmental causes of atypical brain development, Abnormal levels of antioxidants, transferrin, lipid peroxidases, methionine and other biochemical intermediates have been reported in children with autism ®, without clinical coreation. James and colleagues “have deseribed abnormal metabolic profiles in 20 children with autism compared to 33 controls, consistent with a presumed impaired methylation capacity. Laboratory findings normalized following atrial of folinic acid, betaine and methyleabalamin. However, no clinical outcome data was reported, James and colleagues “also reported decreased measured indicators of methylation capacity in a larger population (80 with autism and 73 controls) also without clinical correlaton.. At present there are no randomized, controlled treatment trials reported in the ssientifc literature, These hypotheses requite further study Diet -Gluteree! Caseir-tee diet (GFICF)- Grade B In addition to supplen tation with vitamins o other nutritional supplements 10 auddress hypothetical deficiencies orto provide pharmacologic effect, modification of dietary intake has been a popular intervention {or behavioral modification in children with ASD. It has been suggested thatthe elimination of the proeins gluten (found in barley, ‘wheat, and rye) and casein (ound in milk products) which ether «damaged (“Ieaky”) intestinal ining by acting as false opiate neuropeptides will improve behavior of children with ASD. The significance of rors of inecased levels of metabolites of casein and gate inthe rine of people with autism remains unclear suse or aggravate symptoms of ASD after absorption across & Urinary peptides are not used in conventional practice to prescribe or monitor dietary estcton. Aneedoal reports and case series of dctaryretrition leading to subjective improvement in the symptoms of autism have resulted ina report of «small single blind trial that suggested some improvement * and a double blind trial that didnot identify objetive improvement in language oF behavior although some parents reported subjective differences. It isnot yet clear whether some ofthe perceived improvements are due to elimination of lactose in children who ae lactose intolerant or other changes related tothe alter jon in protein source and food composition. Families who desire to try the gluten/easein fre diet must be counseled that adequate calcium and vitamin D intake must be maintained with supplements or supplemented foods. Attention to protein intake is als important since many young children obtain much oftheir protein through dairy products. Vegetable based beverages including rice, potato, and almond “milk” do not contribute to protein sufficieney as soy based products do. Consultation witha registered dietitian should be recommended. Common dietary approaches to symptoms of inattention in children with ADHD are also often considered for children with ASD \with hyperkinesis, Double blind, placebo controlled methods have consistently demonstrated no relationship of sugar to attention or elated behaviors "2. Although not specific for symptoms of ASD, there may be subgroups of children who do have a behavioral response to elimination of chemicals used as food colors" 6 medications - Grade © Dietary treatments are not the only gastrointestinal treatments that are pursued. Gastrointestinal symptoms of gastroesophageal reflux, constipation, diarrhea, feeding refusal and others are frequently eported in clinical settings * although there is not yet documentation ofinereased population based prevalence of gastrointestinal abnormalities *. Given the frequent report of symptoms, digestive enzymes are used by some families", No evidence based studies are available to evaluate efficacy Licensed to Andressa - andressanasato@hotmail.com Probiotics are also usd to improve the microbial environment inthe intestine" Soottin- Grade A Secretn, a gastrointestinal hormone, has the distinction of being one ofthe most extensively studied pharmacotherapeutic agent for autism. It came to light as @ potential treatment after a lay television show highlighted a report of case series by Horvath * describing improvement in symptoms of autism after administration during endoscopy o examine pancreatic secretions. More than a dozen well designed, well-executed studies have been published, filing to demonstrate efficacy of secretin for symptoms of autism. A recent Cochrane review reported [4 randomized controlled tials, wih a total of 618 children, Nine studies used crossover ieatment design. The authors concluded that there is no evidence that single or multiple dose intravenous seeretin is effective for treatment of ASD! Hyperbaric Oxygen Therapy (HBOT) - Grade C Hyperbaric Oxygen Therapy (HBOT) is used in conventional practice to treat earbon ‘monoxide poisoning, to enhance wound healing and for pressure equalization ater diving injures »!, HBOT provides pressurized ‘oxygen at pressures greater than or equal to 2 atm. HBOT is generally considered to have few side effets other than a potential for exacerbation of ear pain or seizures, but lite data is available, Because of attributed properties of increasing blood flow andor oxygen tothe brain and decreasing inflammation, i has been evaluated therapeutically in disorders ofthe central nervous system, including cerebral palsy, dementia, and traumatic brain injury, Randomized controled trials of HBOT in children with cerebral palsy at 100%% 02 at 1.75 atm compared 1 a control condition of room ur at 1.3 atm reported no diference in motor and behavioral symptoms ‘There is increasing popular interest in using HBOT for symptoms of autism because of hypotheses regarding inflammation ofthe {gut or brain, brain hypoperfusion, and aberrant oxidative stress response which proponents of HBOT suggest might be improved by upregulation ofthe metabotie pathways by HBOT “In an open clinical tral, 18 children with autism were given 40 sessions of HBOT at | 3atm and 24% 02 (n~6) oF LS atm and 100% 02 (n-12) ina non random fashion, ‘7. Metabolic marker for oxidative stress, C reactive protein to eval inflammation and parental report of behavior on the Aberrant Behavior Checklist, Responsiveness Seale, and ATEC were recorded before treatment then after each 10 sessions. Each child received 40 sessions. “Many children were already on antioxidant therapy, which is noted by the authors when they report no difference in markers of oxidative stress. CRP decreased in the subgroup with the highest values. Parents reported subjective improvements in several areas. The subjective data and potential confounds make this study difficult to interpret. There are no randomized controlled trials of HBOT for symptoms of ASD to support the clinical use ofthis modality CChlaton - Grade © Reports of increased prevalence rates of autism, likey du to multiple factors, has resulted in a search for potential environmental causes. Questions ofthe reli jonship to vaccine administration came about in part because symptoms of autism are identified during late infancy and toddlerhood, and a temporal relationship with immunizations is noted in some cases, '. A paper published in 2001 ® developed a hypothesis relating symptoms of mercury intoxication to symptoms of autism, Meta- analysis completed by Ng and colleagues of 2 studies concluded that there was not enough evidence to show that aie mercury level was lower in autistic children than typical. A numberof epidemiologic studies have failed to confim a link between use of thimerosal as a vaccine preservative and elevated autism prevalence 2456147978110... Despite the lack of scientific evidence of link between the exposure to ethyl mercury in thimerosal (the mercury containing preservative used in vaccines that has been largely eliminated inthe US since 2001), chemical chelation process of administering either DMPS (2,3-dimercaptopropane--sulfonate) or DMSA (2,3-dimercaptosuecinic acid) to bind heavy eatments are a popula intervention. Chelation isthe metals such as mercury and feclitate elimination from the body. There are no controled studies that examine the safety or efficacy of prescription or nonprescription chelation regimens for children with autism. More importantly, there have been deaths reported from inappropriate use of a chelator, EDTA, from hypocalcemia ". Proponents ofthis therapy suggest that mercury is poorly climinated by children with autison and that it interferes with immune function and other biochemical systems. Immune Therapies Grade © There is increasing evidence that prenatal immune response may affect fetal brain development. The ata regarding immune funetion in children with autism, however, varies among reported populations", yonouei eta? Licensed to Andressa - andressanasato@hotmail.com fou that dctary restriction did not alter immune Fangs a cildeen wih or without gaswontestnal symptoms, Thc case series ‘epor trials of children who were infused with intravenous immunoglobuln-G to treat purported immune deficits and symptoms of autism. One open tril repoted improvement in subjective data but subsequent tials with specific outcome measures and beter subject characterization did not corroborate this finding Other treatments for immune function have been proposed, but remain Without support inthe peer reviewed literature In the absence of conventional symptoms of immune disorders, work up and treatment of immune status is not currently recommended in children with autism ”. Antibiotics Grade © Reports of frequent respiratory or gastrointestinal infections during the early years of development of children th autism have suggested these exposures may be etiologic agents by promoting gut dysbiosis or as confirmation of immune dysfunction. Niehus and Lord 7 reported a cohort of young children with ASD who had s history of more frequent episodes of olits media, but no more illness related fevers or use of anibities compared to typically developing peers. Reports of frequency of gastrointestinal infection o colonization are inconsistent, and suffer from methodologic difficulties suchas small sample size, lack of clinical correlation to laboratory findings’ and lack of a control group *”. Sandler and colleagues ” reported short term behavioral improvement in 11 children treated with oral vancomycin, No further data or studies are available, and even the investigators suggested vancomycin should not be a routine clinical treatment ‘Antiungal Agents - Grade G Treatment with anti-fungal agents i based upon an earlier report of presumed candidal overgrowth in 2 boys with autistic behavior who demonstrated what was interpreted as yeast metabolites in urine organic acids "and reports suggesting yeast overgrowth duc to antibiotic use or sugar ingestion". Yeast overgrowth is conjectured to be secondary to intestinal dysbisis or to some other immune factors unique to autism, No controled trials have tested this intervention to date despite the popularity of probiotic use and medications such as nystatin (Mycostatin) and luconazole (Diflucan) for treatment of yeast overgrowth. Manipulative and Body-Based Practices Chiropractic - Grade C The peer reviewed literature doesnot include reports that specifically addres either chiropractic manipulation or eraniosaeral massage for symptoms of autism. Chiropractic eae is a common approach used by many families for general health issues. The Potential for harm is low, however it has been associated with injury from spinal manipulation and missed medical diagnoses '"" Craniosacral Massage - Grade C Phy therapists and others for specific therapeutic purposes. Despite claims that practitioners can alter and sense cerebrospinal uid ical manipulation ofthe skull and cervical spine has been used by chiropractors, osteopathic physi 1s, occupational (CSF) flow or the Cranial Rhythm Impulse, no movement of boney sutures of alteration of pressure could be demonstrated in a Taboratory model. or in humans ” It is possible that perceived therapeutic response might be secondary to another aspect of the therapy such as touch. No studies are reported that examine this modality for use in autism. Massageltherapeutic touch therapies - Grade C Sensory differences are frequently described by parents, but donot figure prominently in the DSM IV eitria for diagnosis of autism, Therapeutic approaches inthis category include massage and Aroma ‘Therapy ‘Auditory integration - Grade B The goal of Auditory integration training (AIT) is to ameliorate auditory processing deficits and improve concenteation , Many Licensed to Andressa - andressanasato@hotmail.com parents also report improved behaviors, Different methods of ALT include listening through headphones to electronically modified music, voice or sounds in an effort to improve function. Recent systematic reviews "included 6 randomized controlled trials, hich al showed significant methodologi ‘weaknesses, prohibiting meta-analysis. The authors ofthe Cochrane review agreed With the recommendations ofthe American Academy of Pediaties, that AIT shouldbe considered an experimental treatment until evidence base trials support its use 9” Energy Medicine Transcranial Magnetic Stimulation - no grade ‘Transcranial magnetic stimulation (TMS) involves placement ofan electromagnetic coil onthe scalp with the production of low level electrical curens in cortex secondary to rapid magnetic pulses". This research tool is curently being used to examine the potential overconnectivity of cortical neuron in autism "and to examine neurologie Function in other disorders such as ADHD Treatment ral are underway for depression, pain syndromes, and motor function in other disease states. This technology is unrelated tothe use of commercially obtained magnets applied topically as a typeof community based energy medicine, There are no reports of therapeutic use of transcranial magnetic stimulation or other magnet therapy for symptoms of autism to date When Your Patient Elects CAM ‘Traditionally trained clinicians know that many families they treat also elect to use CAM for their children with ASD. Although there i a beginning literature about the reasons people choose CAM, the altitudes and response of trait nal practitioners to the requests for information or prescription of CAM is less well studied". While over half of families indiate that they would like to ask their doctors about CAM, many reasons ate given for not disclosing CAM use, These include perceived lack of knowledge about CAM therapies on the part ofthe physician, the physician not asking, not seeing the necessity of reporting se of other therapies, and concem regarding disapproval by the physician" Although families often report that they use CAM because of fear of side effects, there is limited data regarding side effects of CCAM practices themselves. Side effects may range from direct systemic or topical toxicity, to allergic reaction, to presence of contaminants, to interactions with presribed medications", Given the popularity of CAM, the interaction of CAM with prescription medi ton requires further study. CAM use may be underreported and the dosage and type of exposure is often unknown, Only if here i an open dialogue about CAM, will the CAM practices used be reported tothe health care provider and potential side effets and interactions can be adequately studied and monitored. The healthcare provider needs to discuss the importance of continuing pharmacotogi or other therapeutic interventions white CAM therapy i being used. ‘tritional supplements are not regulated as drugs but as foods, so there is lite oversight regarding quality control. Variability in response may be duc to family o social factors or due to variable delivery of active compound, Summary ‘As health care providers are increasingly looking toward the evidence for conventional medical practices, we should also be examining the evidence for CAM practices that patients may be using. We should encourage families to share all interventions that they are pursuing, whether or not prescribed or endorsed, by conventional practice. This is important for health monitoring of side effets and forthe potential for drug interactions. Some CAM practices have evidence to reject their use, suchas secretin, Some CCAM practices have emerging evidence to support ther ue in traitional medical practice, like melatonin. Most treatments, however, have not been adequately studied and do not have evidence to support their use. Although not direct effets of CAM practices, undesired side-effects may relate tothe delay or discontinuation of otherwise effective treatment. Licensed to Andressa - andressanasato@hotmail.com ‘Acknowledgments Dr. Hyman was supported in part by NIMH POLHD3S466 and National Center for Research Resources (NCRR) NIH. ULIRRO24160 Footnotes Publisher’ Disclaimer: This is a PDF fl ofan uneced manuscript tha has been accepted for pubcaton, As serie to ur customers we ae providing ths ety version ofthe manusarip. The manvsarip wil undergo copyediting, ypesetng and review ofthe resulting peat elo itis published ins al stable fom, Please note hat during he profuction process errorsmayte discovered wich col fect the content, nal egal disaimers hat aply tthe ural pertain, Article information Chi Adlese Psychiat CN Am, Author manusept valle n PMC 2008 Oat. Published in fiat formas: (hil Adlese Psychiatr Cin N Am, 2008 Oct: 17 802- ei 10.2018 2008.08.008 Meio: PMC2507105 ‘NAMSIO:NNSTI068 ai: 18775571, ‘Susan E. Loy, MO and Susan L Hyman, M.0 E> “Cina Profesor of Peiarics, University of Pennsylvania Schoo of Medicine, The Chile's Hospital of Philadelphia "associate Professor of Pediatrics, University of Rochester School of Medicine, Glsano Chin's Hospital at Song “lSoresponding author “caesponding author for proof ané reprints: Susan E. Ley, M.D. University of PensyWvania School of Medicine The Children’s Hospital of Philadephia 3405 Civic Canter Boulevard Philadephia, PA (215) 590-7528 FAX 215 58-6804 ewys@emalchop.edu coauthor adres: Susan L Hyman, MLO. University of Rochester School of Macicine Golisano Chile's Hospital at Strong Box 671 601 Eimwood Avenue Rochester NY 14642 (595275 2966 FAX (585)275 3966 susan_hymandlurme.ocheser.edu Copyright notice Publisher's Disclaimer ‘The publishes inal edited version of this article is avaliable at Child doles Paya Cin N Am ‘See oer atiles in PMC that cite the published article References 1. American Academy of Pediatrics. 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