Psychiatrists plan to revise clinical guidelines for the treatment of autism spectrum disorder

The Russian Society of Psychiatrists plans to revise clinical guidelines for the treatment of autism spectrum disorder (ASD). But the published project caused sharp criticism from representatives of the professional community and parents of children with ASD. They point out that the authors of the new version criticize modern methods for behavior correction and at the same time recommend the use of the outdated drug haloperidol. At the same time, critics of the project praise the current version of the clinical guidelines. The Psychiatric Society promises to “examine” the criticisms.

Clinical guidelines (clinrecs) are a document like a “road map”, according to which the doctor should carry out diagnosis and treatment. Failure to comply with accepted clinical recommendations is considered to be the provision of medical services of inadequate quality. They are reviewed at least once every three years and no more than once every six months. In the case of mental disorders, draft clinical recommendations should be published on the websites of the Russian Society of Psychiatrists (RSP) and the Ministry of Health for discussion by the professional community. After collecting feedback, projects undergo additional review by experts appointed by the Ministry of Health, after which they are sent for consideration to the ministry.

The current clinical guidelines on the topic “Autism Spectrum Disorder” were approved in 2020 and are subject to updating, said ROP President Professor Nikolai Neznanov. The draft revised cleanrecs were published at the end of February; Until the end of March, the ministry was collecting feedback on it. To date, they have not been published, but many experts have publicly criticized the document. Some of them published their reviews on social networks.

One of the main complaints against the project is permission to use the drug haloperidol to correct aggressive behavior in children with ASD from two years of age. Child psychiatrist, postgraduate student at the National Medical Research Center for PN named after. V. M. Bekhterev Stepan Krasnoshchekov explains that drugs for behavior correction are conventionally divided into old (haloperidol includes) and new generations. Their effectiveness is similar, says the doctor, but there are important differences: “Any modern studies show that atypical second-generation antipsychotics are better tolerated by both children and adults in terms of side effects.”

The current clinical recommendations indicate risperidone and aripiprazole as the drugs of choice – according to Mr. Krasnoshchekov, these are “modern drugs that are used all over the world.” He considers adding outdated haloperidol to them a serious mistake: “If the recommendations state that several options are possible, then, of course, the choice will be up to the attending physician. And of course, the choice will be in favor of what is more familiar – and haloperidol is more familiar, because it is old. In addition, the issue is price: haloperidol costs 5 rubles, and risperidone costs 10 rubles. per tablet. The difference is small, but probably noticeable for the budget.”

Certified behavior analyst Alexandra Gucheva is extremely surprised by the appearance of haloperidol in “children’s” clinical trials. She believes that in domestic psychiatry in the last decade there has been “a certain upsurge,” so it is very strange “to prescribe a first-generation antipsychotic to children who need development, which is not the first-line drug of choice for ASD anywhere in the world.”

However, leading researcher at the Department of Forensic Psychiatry and Social Problems of Children and Adolescents at the National Medical Research Center for Psychiatry and Narcology named after. V.P. Serbsky Ministry of Health of Russia Lev Perezhogin claims that haloperidol is one of the few antipsychotic drugs approved for use in early childhood. “The effectiveness and safety of the use of most modern antipsychotics in children, unfortunately, has not been studied. Therefore, I think that haloperidol was included in the project precisely for reasons of proven effectiveness and safety in children,” Mr. Perezhogin told Kommersant.

Another complaint from experts is that the Cleanrecs project contains criticism of modern methods of behavior correction. In particular, the popular ABA therapy (applied behavior analysis, the gradual introduction of necessary missing skills into a child’s life and their consolidation through encouragement) and alternative communication PECS (Picture Exchange Communication System, a system of communication through picture cards). According to the authors of the new clinical guidelines, ABA therapy can sometimes be useful, but “in some cases” it is “not only useless, but also harmful”; they call the PECS system ineffective.

Alexandra Gucheva says that ABA therapy is pedagogical and psychological methods based on the laws of behavior. According to her, ABA helps correct the problematic behavior of children with ASD and teach them the necessary skills. In addition, ABA therapy methods solve problems associated with natural needs, such as sleep, eating and the formation of toilet skills. “About AVA in the cleanrek project it is written, of course, “on the knee.” The authors’ statements are not supported by any reference to studies proving the ineffectiveness or danger of therapy. And while this is so, such statements are nothing more than conjectures of the authors,” she believes.

Clinical psychologist, specialist in alternative communication PECS, director of the ANO “My Planet” for working with children with ASD Olga Popova reminds: according to statistics, 30% of children with ASD are speechless. And if the child does not have verbal communication, then, says the psychologist, he needs to be given, for example, an alternative PECS system: “The child gives you a card with a picture of an apple – and you give him an apple. Immediately, from the first days of training, the child begins to understand the “asked-received” relationship. And it becomes much calmer. As a result of such training, children’s unwanted behavior disappears quite quickly, after just a few lessons.” Olga Popova claims that many clinical studies have confirmed the high effectiveness of PECS for working with nonverbal children; According to her, there are Russian scientific publications about this.

In a conversation with Kommersant, the psychologist emphasized that parents of children with ASD and specialists in this field are “grateful to the Ministry of Health of the Russian Federation for the current clinical recommendations” adopted in 2020. According to Ms. Popova, this was a precedent for real interdepartmental interaction, thanks to which doctors began to recommend methods of psychological and pedagogical correction that have evidence of effectiveness. “The new project actually resets all this and returns us to pills and injections,” Ms. Popova worries. “But, as you know, there is no pill for autism. Autism is a communication disorder.”

Development Director of the Anton Is Near Charitable Foundation (systematically supports people with autism) Evgenia Petelchuk also believes that the new cleanrek project throws Russia back several decades: “We do not see in the document a strategy for the treatment of concomitant diseases and the described working tools for habilitation, instead This is why we see criticism there of instruments with proven effectiveness.” Therefore, Ms. Petelchuk emphasizes the importance of the participation of the professional community in the development of clinical recommendations: “The opportunity for discussion and mutual attention will help create a person-oriented system using current scientific, social, and pedagogical practices. Now in reviews on the website of the Ministry of Health, doctors share research and practice, parents share their experience of child development and educational routes, and autistic people share their own experience of diagnosis and therapy. Experts from the Ministry of Health can take these voices into account. Let’s hope they are heard.”

Responding to criticism, ROP President Nikolai Neznanov said that the methods used in the new clinical guidelines “have been verified and adapted to work in our country.” “Of course, a number of methods, only translated, but not tested in our country, cannot find a place in clinical recommendations,” he believes. “The methods developed by the Russian Society of Psychiatrists are not outdated in any way and are based on current international classifications; they are confirmed by references to scientific sources indicated in the list of references.” Mr. Neznanov added that the working group “will also study the experience of using and the effectiveness of a number of methods of psychological and pedagogical correction for ASD – and will consider the possibility of their inclusion in clinical recommendations in accordance with the requirements for the inclusion of new methods.”

Natalya Kostarnova, Kirill Klyuchnikov