The Comprehensive Autism Care Demonstration: Solutions for Military Families (2025)
Chapter: 2 Autism: Prevalence, Diagnosis, and Interventions
2
Autism: Prevalence, Diagnosis, and Interventions
Autism is a complex, heterogenous neurodevelopmental condition that is characterized by challenges in social interactions, communication, and repetitive and restrictive behaviors that affect various aspects of functioning. It is one of several neurodevelopmental disorders (NDDs), which also include attention-deficit/hyperactivity disorder (ADHD), developmental delays and/or intellectual disabilities, learning disorders, fetal alcohol spectrum disorder, tic disorders, and a wide range of behavioral and mental health conditions such as depression and anxiety.
Autism presentation varies considerably from person to person, and symptoms may range from non-existent to profound, with varying degrees to which functioning is impaired. Historically, diagnoses of autism focused on discrete, severe manifestations. As understanding of autism has developed, the current spectrum approach (described in detail later in this chapter) has helped make legible the degree to which severity can vary from person to person, illuminate the heterogeneity of autism, and reveal the frequent co-occurrence of multiple conditions.
This evolution in understanding autism has led to more nuanced diagnostic criteria and ongoing efforts toward better-tailored interventions that address the complex, interwoven nature of autism and other NDDs and resulting behaviors. Improved understanding has also encouraged more comprehensive holistic support systems for affected individuals that are more focused on wellness rather than requiring or expecting a cure. This chapter reviews the prevalence of autism, its diagnosis, and interventions for autism. It reviews this background in the context of the task before the committee to evaluate the Comprehensive Autism Care Demonstration (ACD).
Autism can be accompanied by seizures and/or a range of mental health conditions including ADHD, anxiety, depression, and aggression. Additionally, other NDDs that affect cognitive processing, such as fragile X syndrome and fetal alcohol spectrum disorder, can manifest symptoms of autism,1 and research has shown that autism symptoms tend to be most severe for those with comorbid cognitive impairment (Amanat et al., 2024).
While often co-occurring, the rate of autism diagnosis is increasing more quickly than other NDDs, research shows. For example, a study of autism among over 4,600 children between 2000 and 2016 observed a twofold increase in prevalence of autism co-occurring with intellectual disability but a five-fold increase in the prevalence of autism without a co-occurring intellectual disability over the same period (Shenouda et al., 2023).
PREVALENCE OF AUTISM
The committee is charged with conducting an analysis on whether the incidence of autism is higher among the children of military families than in the general population (for the committee’s statement of task, see Chapter 1). The incidence of a condition is related to its prevalence. Prevalence is a measure of existing cases at a particular point in time (Kim, 2024; U.S. Department of Health and Human Services, n.d.). Incidence is a dynamic estimate of new cases that develop over a short period of time rather than an estimate of total cases recorded in a given population (CDC, 2022). Both prevalence and incidence are important metrics to track trends in the frequency of specific conditions.
Historically, autism and other NDDs were viewed as rare and isolated conditions. While the diagnostic criteria have evolved over time (making it difficult to precisely interpret trends), the best estimates in the late 1970s showed that autism prevalence was approximately 20 in 10,000 (Fombonne, 2003). By the 2000s, it had increased to 34 in 10,000 (Yeargin-Allsopp, Rice, & Mervis, 2003). The most recent estimate from the Centers for Disease Control and Prevention (CDC), based on data from 2022, is that autism affects 1 in every 31 children aged eight (Shaw et al., 2025), an increase from the previous CDC estimate of 1 in 36 children (CDC, 2023a,b).
The increase in rates of autism is multifactorial and may be related in part to changes in diagnosis criteria and increased medical and social attention that have elevated awareness and treatment of it. Diagnostic re-categorization and corresponding declines in the prevalence of intellectual disability are also factors contributing to the increase in autism prevalence (Coo et al., 2008; Polyak, Kubina, & Girirajan, 2015; Shattuck, 2006).
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1 For more information about fragile X syndrome, see https://www.cdc.gov/fragile-x-syndrome/about/index.html
While much is still unknown about the causal risk factors of autism, this increase in autism prevalence is often misunderstood. Some recent evidence suggests that both rare and common genetic variants contribute to autism. There are also many epidemiological and environmental factors associated with autism, including advanced parental age at conception; prenatal exposure to environmental toxins; maternal obesity, diabetes, or immune system disorders; extreme premature birth or low birthweight; and birth difficulty that results in periods of oxygen deprivation to a baby’s brain (U.S. Department of Health and Human Services, 2025). One common misconception is that there is a causal association between childhood vaccines and autism and that this association is the reason for the increase in autism prevalence. This question has been studied extensively in the peer-reviewed literature, and the committee is not aware of any credible evidence that suggests a causal association (Di Pietrantonj et al., 2020; Gabis et al., 2022; Hviid et al., 2019; Taylor, Swerdfeger, & Eslick, 2014).
The CDC began monitoring the prevalence of autism in Atlanta in 1996. In 2000, the CDC established the Autism and Developmental Disabilities Monitoring (ADDM) Network and began tracking autism prevalence in additional areas of the country. Currently, CDC tracks 16 sites in Arizona, Arkansas, California, Georgia, Indiana, Maryland, Minnesota, Missouri, New Jersey, Pennsylvania, Puerto Rico, Tennessee, Texas (two sites), Utah, and Wisconsin. It is important to note that these are specific sites within states. Researchers note that (a) site-level data are not meant to be representative of the states in which the sites are located and (b) findings are not necessarily generalizable nationally (Maenner et al., 2023). Within these sites, ADDM measures the prevalence as the proportion of eight-year-old children who meet CDC’s defined case definition: documentation of ever receiving (a) a written autism diagnosis by a qualified professional, (b) a special education classification of autism, or (c) an autism International Classification of Diseases code obtained from administrative or billing information (Maenner et al., 2021; Shaw, Maenner, & Bakian, 2021). Although autism is often diagnosed earlier, the age of eight years old was selected to ensure that later diagnoses are captured. In addition, children aged four years old are tracked to see if communities are getting better at detecting autism earlier. Every two years since 2000, CDC has published prevalence data updates in the Morbidity and Mortality Weekly Report, CDC’s journal highlighting public health investigations (CDC, 2023a,b). During the past two decades, autism prevalence estimates of children aged eight years have increased markedly per the ADDM Network, from 1 in 150 (0.67%) in 2000 to 1 in 36 (2.77%) in 2020 and to 1 in 31 (3.2%) in 2022 (CDC, 2023a,b; Shaw et al., 2025).
Although CDC cautions against making precise estimates based on these data, the data are useful for monitoring trends in the prevalence of
autism among the general population in the United States.2 The latest CDC report with the 2022 estimates, however, notes that the 2018 cohort of children had increased rates of early identification compared to previous cohorts, which also likely contributed to the increase in prevalence compared to 2020 data (Shaw et al., 2025).
A recent review of military diagnoses of autism during the COVID-19 pandemic, using data from the Military Health System Data Repository, identified that 3.5% or 1 in every 28 children were diagnosed with autism in the period 2019 to 2023—a rate slightly higher than CDC estimates for the general population described above (Yeh et al., 2025). The National Survey of Children’s Health (NSCH) is a data source that breaks out respondents by military status. The NSCH collects a range of information from parents/caregivers nationally on the health and well-being of children ages 0–17 years. One question asks respondents to indicate if their child age 3–17 years old has autism. For the 2021–2022 survey, the prevalence of the condition reached close to 4% among caregivers considered active duty, prior active duty, or in the Reserve or National Guard compared to 3.2% for caregivers who had never served in the military (Child and Adolescent Health Measurement Initiative, n.d.).
Universal access to health care in the military may be one of the reasons for a slightly higher rate of diagnosis and fewer disparities in diagnosis rates among different demographic groups (Chikezie-Darron, Sakai, & Tolson, 2025). At present, while some limited information is available, there is not enough information for a rigorous comparison of autism prevalence between military versus non-military communities (Maenner, 2024).
DIAGNOSIS
Autism is a result of altered brain development and neural reorganization and is associated with a number of genetic risk factors (Genovese & Butler, 2023). There are currently no biomarkers to reliably diagnose autism, so all diagnoses are based solely on assessments of behavior using observations or historical reports of behavior. While manifestations of autism vary greatly from person to person, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM–5), released in 2013, provides the standardized criteria currently used to diagnose autism spectrum disorder (APA, 2013). The DSM-5 criteria help ensure consistency and reliability in the diagnosis of autism and provide a common language and framework for professionals across different settings and regions to use for purposes of
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2 For more information on the prevalence estimates and comparison with other data sources, see https://www.cdc.gov/ncbddd/autism/data/index.html
clinical practice, research, and the provision of services. Related diagnoses such as Asperger’s syndrome and others are now considered part of the autism spectrum disorder diagnosis, which is a change from previous versions of the DSM (APA, 1980, 1994) and contributes to the heterogenous nature of the condition.
According to DSM-5, the diagnosis of autism spectrum disorder is based on two core domains:
- Persistent deficits in social communication and social interaction across multiple contexts, including deficits in social interaction, nonverbal communicative behaviors, and developing, maintaining, and understanding relationships.
- Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following: stereotyped or repetitive motor movements, use of objects, or speech; insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior; highly restricted, fixated interests that are abnormal in intensity or focus; and hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment.
In classifying autism as a spectrum disorder, the DSM-5 introduced three levels of autism severity: Level 1 (“requiring support”), Level 2 (“requiring substantial support”), and Level 3 (“requiring very substantial support”; APA, 2013). These levels have been challenging to adhere to as autism affects each individual and families differently and as such their support requirements vary and can change over time (Waizbard-Bartov & Miller, 2023; Waizbard-Bartov et al., 2023). See Table 2-1.
Although autism is often diagnosed after the age of three or four years, there are early signs of autism that are commonly present in children who ultimately receive an autism diagnosis. By 12 months of age, children who later receive an autism diagnosis often exhibit diminished social attention, poor eye contact, reduced reaction to speech, and reduced interest in interaction and play, as well as less smiling, expressiveness, and vocalization and babbling. Characteristically, they also commonly fail to point or to respond to being called by their name. Between 12 months and three years old, children who are later diagnosed with autism begin to exhibit many of the key characteristics of autism that are found in older children and adults. These include reduced attention to social stimuli (visual and verbal), limited eye contact, reduced social engagement, and increased isolation. Language delays and a paucity of joint attention are also among the most commonly reported parental concerns during this early period of development. Repetitive behaviors, including repeated play with an object such as the wheels of
TABLE 2-1 Levels of Autism Severity
| Level 1 Autism: Requiring Support | Level 2 Autism: Requiring Substantial Support | Level 3 Autism: Requiring Very Substantial Support |
|---|---|---|
|
|
|
SOURCE: Committee generated with information from Autism Speaks, n.d.b.
a toy car, or repetitive body movements, as well as delayed motor skills also tend to emerge during this period of childhood. Many children with autism also experience significant sensory issues (smell, taste, texture, sound, light) and have significant difficulty with transitions. Regression, or loss of skills or skill stagnation, is also commonplace during this period of development, occurring in approximately 10 to 50% of all children who later receive a diagnosis (Webb & Jones, 2009). Reports of regression usually involve loss of spoken language, but loss of socioemotional skills is also observed, either paired with language regression or in isolation.
Diagnostic Challenges
Diagnosing autism is an inherently difficult process due to the heterogeneity of the condition, the commonality of co-occurring conditions that can be challenging to parse out, and the fact that the behaviors associated with autism are dependent on a number of factors, such as cognitive function and age, that may be unrelated to autism (Hus & Segal, 2021). Language development, for example, is highly variable in young children and parental concerns with language development are equally common in children under four with and without autism (Kim & Lord, 2012). Co-morbidities can
both increase the heterogeneity of autism presentation and disguise autism symptoms, thus potentially contributing to delaying diagnosis or misdiagnosing altogether (Hus & Segal, 2021).
Early diagnosis and intervention for autism is an important factor in increasing the likelihood of achieving individual goals and functional independence later in life (Hus & Segal, 2021; Myers, Johnson, & American Academy of Pediatrics, 2007) and is associated with better prognoses (Swanson et al., 2013; Volkmar, 2014). Early diagnosis in young children (two to three years old) may require repeated screening and assessment, particularly in children with mild symptoms. Similarly, in young children who receive an autism diagnosis, a re-evaluation is recommended the following year (or sooner if there are questions about the validity of the initial diagnosis). While autism does not go away, specific needs, strengths, and difficulties do evolve over time, especially in young children (Huerta & Lord, 2012).
Evolution of the Autism Diagnosis
Early identification of autism began in the mid-20th century. In 1943, Dr. Leo Kanner published a seminal paper describing what would later be called “early infantile autism,” characterizing it by distinct social and communicative impairments in children (Kanner, 1943, 1944). Simultaneously, Dr. Hans Asperger conducted research on what he termed “autistic psychopathy,” focusing on children who exhibited similar social challenges but often had higher cognitive abilities and better verbal skills (Asperger, 1944).
The formal recognition of autism within the diagnostic criteria began with its inclusion in the DSM-III in 1980 (APA, 1980). This edition delineated autism as a distinct category, setting the stage for more standardized diagnosis and research. The DSM-IV (APA, 1994), published in 1994, further refined these criteria by introducing subtypes such as Asperger’s Syndrome, Pervasive Developmental Disorder–Not Otherwise Specified (PDD-NOS), and Autistic Disorder. This classification allowed for a more nuanced understanding of autism’s varying presentations.
A significant shift occurred with the release of the DSM-5 in 2013, which consolidated these subtypes into a single diagnosis of autism (APA, 2013). This change reflected a growing understanding that autism manifests across a spectrum of symptoms and severities rather than as distinct conditions.
Screening and Diagnostic Tools
Diagnosing autism is an inherently complex clinical process that requires a balance of various measures. Improved concordance and transparency of the diagnosis of autism requires a multifaceted approach that integrates
standardized criteria, objective assessment tools, and clinical judgment. In addition to using a DSM-5 framework, other objective measures have been developed to help clarify observations and information on patients’ behaviors. Screening tools help support the clinical diagnosis based on both reported and observed behaviors and help ensure a more consistent and reliable identification of autism. The American Academy of Pediatrics recommends screening using the most valid of current measures at 18 and 24 months of age (Hyman et al., 2020). The most studied and widely used universal screening tool for toddlers is the Modified Checklist for Autism in Toddlers (M-CHAT).3 It is recommended to also consider the following to assist with a diagnosis:
- Subjective Parent Reports: Parents’ observations and reports of their child’s behavior and developmental history are invaluable. They provide context and details that may not be evident in a clinical setting.
- Standardized Measures: There are many validated tools clinicians can use when screening for autism, some of which are free to use while others require licensing. These include, but are not limited to, the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2);4 the Parent’s Observation of Social Interactions (Loo, Yang, & Cheng, 2025); the Rapid Interactive Screening Test for Autism in Toddlers (RITA-T);5 the Autism Diagnostic Interview–Revised (ADI-R);6 the Screening Tool for Autism in Toddlers & Young Children (STAT);7 the Childhood Autism Rating Scale, Second Edition (CARS-2);8 the autism-PEDS;9 and the Gilliam Autism Rating Scale, Third Edition (GARS-3).10 These tools and others offer structured methods for evaluating behavior and development, adding objectivity to the diagnostic process. The tools’ psychometric properties vary, but many offer high sensitivity and specificity, helping healthcare professionals detect autism signs in young children. Some of these tools may require special training for administration.
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3 For more information on the M-CHAT, see https://www.mchatscreen.com/
4 For more information on the ADOS-2, see https://www.wpspublish.com/ados-2-autism-diagnostic-observation-schedule-second-edition
5 For more information on the RITA-T, see https://www.kennedykrieger.org/research/centers-labs-cores/rita-t-research
6 For more information on the ADI-R, see https://www.wpspublish.com/adi-r-autism-diagnostic-interviewrevised.html
7 For more information on the STAT, see https://stat.vueinnovations.com/
8 For more information on the CARS-2, see https://www.wpspublish.com/cars-2-childhood-autism-rating-scale-second-edition.html
9 For more information on the autism-PEDS, see https://vkc.vumc.org/vkc/triad/manual/autism-peds/
10 For more information on the GARS-3, see https://www.pearsonassessments.com/store/usassessments/en/Store/Professional-Assessments/Behavior/Gilliam-Autism-Rating-Scale-%7C-Third-Edition/p/100000802.html
- Clinical Observation: Directly observing the individual in different settings allows clinicians to assess behavior and interactions in real time. To date, there is no laboratory, radiology, genetic, or other measure to diagnose autism reliably, and much of the diagnosis is based on subjective interpretation of presenting and historical data.
In 2014, the ACD encouraged the use of standardized diagnostic tools, such as the ADOS-2 and the ADI-R. Subsequently, with changes to the operations manual in 2021, ACD now formally recognizes other validated assessment tools (STAT, GARS, and CARS) to assist with direct observations and comprehensive evaluation to diagnose autism. Since 2021, the ACD requires that in addition to using a TRICARE-approved assessment tool, diagnosing clinicians must also use a Defense Health Agency (DHA)–approved DSM-5 checklist (see Figure 2-1).11 While such checklists are valuable to help standardize the diagnosis process and to demonstrate that the full diagnostic criteria were considered, there is nothing unique about DHA-approved DSM-5 checklist—there are many readily available DSM-5 checklists for autism that are essentially the same. This requirement is an administrative burden for providers, especially those who care for individuals with autism across multiple payors. This is an extra bureaucratic requirement that may slow down care, especially if an unapproved checklist is inadvertently used, submitted, and rejected despite containing the same information.
Providers Qualified to Diagnose Autism
The evolution of diagnostic criteria has also influenced who is deemed qualified to diagnose autism. The expansion of standardized tools and clinical guidance has enabled a broader range of licensed providers to diagnose children with autism and manage their care and referrals. Over time, the ACD has expanded the list of qualified professionals who can conduct autism evaluations. This change aimed to help address ongoing feedback about long waiting lists for families to get an autism diagnosis; however, such waits still impact many medical systems (Bisgaier & Rhodes, 2011; Black, 2023; Turner, Ricketts, & Leslie, 2020). Currently, TRICARE-authorized pediatricians, pediatric family medicine physicians, pediatric or family nurse practitioners, or autism-diagnosing specialists (developmental pediatricians and child psychologists/psychiatrists, as well as other neurodevelopment or behavioral subspecialists) are authorized to diagnose autism for TRICARE beneficiaries (DHA, 2023a). TRICARE policies have adapted to align with updates in the DSM, ensuring that diagnostic practices remain current with the latest clinical guidelines.
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11 The 2025 TRICARE Provider Handbook for the East Region is available at https://www.humanamilitary.com/content/dam/sites/humana-military-com/provider/tricare-provider-handbook.pdf
Some more complex cases of autism may benefit from subspecialist care, such as behavioral-developmental pediatricians, child psychologists, and child psychiatrists. Their training in child development, psychological assessment, and mental health allows them to identify the complex behaviors associated with autism.
Training in NDD is essential for professionals involved in the diagnostic process. This training can occur during residency, fellowship, or as supplemental training for primary care providers. Similarly, an interdisciplinary team-based approach to diagnosing autism can enhance the diagnostic accuracy and comprehensiveness and provide a holistic view of the child’s abilities and challenges. Speech therapists, occupational therapists, special educators, and child behavior specialists are all equipped with specialized skill sets to help assist with the autism diagnosis. They can help differentiate between typical or atypical development in their particular field of expertise. When available, this interdisciplinary approach—and the comprehensive understanding of the child’s strengths and needs that it can yield—can facilitate the development of tailored intervention strategies (Gerdts et al., 2018).
INTERVENTIONS FOR AUTISM COVERED BY TRICARE
Interventions for autism span a variety of approaches, including behavioral, developmental, educational, social-relational, pharmacological, and psychological. Some interventions incorporate more than one of these categories. Applied behavior analysis services are perhaps the most widely used behavioral intervention for individuals with autism and are described in detail in Chapter 5.
This section briefly describes several commonly used interventions to support individuals with autism that are covered by TRICARE as a Basic benefit for eligible individuals.12 These include speech and language pathology services, occupational therapy, physical therapy, medication management, and psychotherapy (DHA, 2025).13 Some of these interventions are delivered by child behavioral specialists or developmental therapists who often work with young children with autism to develop communication, social, and daily living skills using a variety of approaches.
As this section notes, several of the interventions covered by TRICARE (and that are considered the standard of care for autism in other settings)
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12 For a list of services covered by TRICARE for beneficiaries with autism, see https://www.tricare.mil/CoveredServices/IsItCovered/AutismSpectrumDisorder
13 Medical interventions used to treat co-occurring conditions, such as sleep disorders, seizures, digestive conditions, and others, are also common.
have a relatively limited evidence base supporting their usefulness in addressing the needs of autistic individuals. While the committee agrees that the interventions discussed below should continue to be covered as TRICARE Basic benefits, it is also the committee’s view that the TRICARE hierarchy of reliable evidence standards for proven medical care is not equally applied to all interventions used for autism.
Speech and Language Pathology
Speech and language pathology interventions address communication deficits, one of the core symptoms of individuals with autism. Depending on autism severity, spoken language may be slow to develop, may not develop at all, or may be present but ineffective at communicating clearly enough for the individual to interact socially. Language delays or regression is also one of the first concerns parents of children with autism often have about their child’s development.
Speech and language pathology interventions typically follow one of three approaches: didactic, naturalistic, or developmental (often referred to as “pragmatic”). Didactic approaches are based on stimulus-response techniques, with reinforcement to encourage desired behaviors. Repetition and practice, directed by the interventionist, are core features of a didactic intervention (Paul, 2008). Naturalistic approaches are grounded in more natural social interactions and the intrinsic rewards that come in response to effective communication. Naturalistic approaches also encourage more proactive, rather than reactive, communication as part of the intervention. Developmental or pragmatic interventions focus on functional communication rather than speech specifically. This can include gestures or vocalization to communicate. These forms of communication can be the foundation for future speech development or help develop communication skills in children who ultimately never become verbal. Developmental interventions are generally child-directed and marked by positive reinforcement to behaviors that elicit any form of communication. For children who have severe speech deficits, augmentative and alternative communication (AAC) strategies may be introduced. These interventions teach children techniques to express ideas and intentions when speech is not present. Sign language, Picture Exchange Communication System (a system by which children use pictures to initiate communication), and computerized voice output communication devices are examples of AAC strategies to help children develop communication skills (Paul, 2008).
There is some evidence that speech and language pathology interventions can lead to improved language and communication among children with autism. A 2023 systematic review of early initiation of speech therapy concluded that early and consistent speech therapy interventions can lead to
improvements in language, communication, and social skills, although the efficacy of the interventions has a negative correlation with the stress level among the caretakers and teachers facilitating the treatment. The review also revealed that web-based speech therapy has shown positive outcomes and should also be considered (Osman et al., 2023).
Occupational Therapy
Occupational therapy targets cognitive, physical, social, and motor skills in individuals and is designed to help people participate in daily living activities. It can help improve well-being and health, and helps people build the skills they need to be more self-sufficient and achieve the goals that are most important to them, such as going to school or work, or engaging socially and with family (American Occupational Therapy Association, 2025). In individuals with autism, occupational therapy typically focuses on activities of daily living, such as independent dressing, eating, grooming, toileting, and fine motor-skills, such as writing.
An evidence review of occupational therapy interventions for individuals with autism found that successful interventions were individualized to the person receiving services. Successful interventions are informed by current skills and development; consider physiological factors (such as sensory processing), maladaptive behaviors, and environmental influences on those behaviors; identify pivotal behaviors that are the foundation of learning; and identify variables that promote or inhibit progress (Case-Smith & Arbesman, 2008).
Physical Therapy
Physical therapy for people with autism focuses on building strength, motor skills, posture, and balance. Interventions target muscle control to improve movement-based activities, such as playing with other children. While physical therapy is a common intervention for autism, the evidence of its effectiveness is limited (Downey & Rapport, 2012; Guivarch et al., 2021).
Evidence of physical exercise therapy is also limited; however, a recent systematic review and meta-analysis of physical exercise therapy for children with autism showed that interventions were associated with a significant benefit for motor function, overall severity of autism symptoms, social impairment, and repetitive behaviors. It also showed significant benefit in inhibitory control, emotion management, and planning, all of which are within the domain of executive functioning. There was no demonstrated benefit for cognitive flexibility or enhanced working memory (Wu et al., 2024).
Medication Management
While there is no pharmacological cure for autism, there are Food and Drug Administration-approved pharmacological interventions to treat certain behaviors of individuals with autism. For example, a physician may prescribe medications that can reduce self-injurious behaviors or aggression. This can allow providers and parents to focus on other behavioral interventions and skills development (Aman et al., 2009). The anti-psychotic drugs risperidone and aripripazole are approved for use in individuals with autism and are used to treat irritability. Other drugs, such as selective serotonin reuptake inhibitors, anti-depressants, anti-anxiety medication, stimulants, and anticonvulsants are also often used in to treat autism-related symptoms but are not specifically approved for treating autism.14
Psychotherapy
Individuals with autism commonly have co-occurring mental health disorders such as anxiety, depression, obsessive–compulsive disorder (OCD), ADHD, and other psychiatric symptoms that may benefit from psychotherapy. Psychotherapeutic interventions are often adapted to better serve individuals with autism. For example, the pacing of sessions is often modified to align with individual needs, given that many individuals with autism can have difficulty identifying and expressing their feelings (Cooper, Loades, & Russell, 2018).
While evidence is relatively scant regarding the effectiveness of psychotherapy for individuals with autism, a systematic review in 2022 showed that cognitive behavioral therapy in particular was associated with a moderate reduction in anxiety in children with autism. Social skills training interventions, another type of behavioral therapy, also showed a moderate reduction in anxiety and depressive symptoms in children (Wichers et al., 2023). A Cochrane Review of behavioral and cognitive behavioral therapy interventions for individuals with autism and OCD had mixed findings. Only one study met the inclusion criteria of the review and showed that cognitive behavioral therapy may show improved outcomes compared to anxiety management for OCD, depressive symptoms, anxiety symptoms, and quality of life; however, the level of certainty was low (Elliott et al., 2021).
COMPLEMENTARY AND ALTERNATIVE THERAPIES
In addition to traditional therapies, various non-medical and holistic treatments are often used to support individuals with autism; however, they
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14 For more information about medication treatment for autism, see https://www.nichd.nih.gov/health/topics/autism/conditioninfo/treatments/medication-treatment
are not covered by TRICARE or the ACD,15 and there is little evidence supporting their efficacy (Brondino et al., 2015; Guiot et al., 2022). These therapies aim to address sensory, emotional, and developmental needs in a more integrated way. Hippotherapy, or therapeutic horseback riding, is one such approach, utilizing the movement of horses to improve motor skills, balance, and sensory integration. Art therapy provides a creative outlet for self-expression, helping individuals with autism communicate and process emotions through visual arts. Auditory therapies, such as auditory integration training, aim to address sensory processing issues by exposing individuals to specific sound frequencies. Vision therapy, focused on improving visual processing and eye coordination, can also be beneficial. Other holistic approaches, such as music therapy and massage therapy, further promote emotional regulation, relaxation, and sensory integration. While these therapies may not replace medical interventions, some families gravitate toward these options, and they may play a role in improving the quality of life as well as supporting positive clinical outcomes of medically necessary interventions for individuals with autism.
CONCLUSION
Autism is a complex neurodevelopmental condition that is highly heterogeneous and often co-occurs with other neurodevelopmental, behavioral, and physical disorders. Autism can affect all aspects of a person’s life, from social interaction and communication to academic and occupational functioning. How it affects individuals, however, is highly variable; manifestations of autism occur on a broad spectrum, and hallmark symptoms range from non-existent to profound. The wide variability of autism manifestations necessitates an equally wide range of interventions to support autistic individuals. While there is evidence that autism prevalence has increased dramatically in recent decades, this may be partially due to increased knowledge about and acceptance of autism, as well as efforts to improve diagnostic criteria. Other factors that may contribute to the increased prevalence are not well understood.
Currently, the DSM-5 defines autism as a spectrum disorder with three levels of severity, characterized by challenges that fall under two core domains: (1) persistent deficits in social communication and social interaction and (2) restricted, repetitive patterns of behavior, interests, or activities (APA, 2023). While several screening and diagnostic tools and questionnaires are available to help clinicians diagnose autism, diagnosis remains a complex clinical process that requires a multifaceted approach
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15 For more information on alternative treatments, see https://tricare.mil/CoveredServices/IsItCovered/AlternativeTreatments
that integrates standardized criteria, objective assessment tools, and clinical judgment.
Interventions to help support people with autism are not one-size-fits-all and are as varied and individualized as the manifestations of the condition: they are designed to target individual needs and goals, and what works or is desirable for one individual or family may not be a good fit for another.
