Autism spectrum disorder (ASD) is a lifelong neurodevelopmental condition characterized by communication and social impairment, sensory challenges and repetitive behaviors. ASD can be diagnosed during toddlerhood. Often the first signs are delayed speech, nonresponse to the speech of others, and avoidance of family and social interactions (e.g., cuddling, play). Children living with ASD often present themselves as withdrawn and fail to keep eye contact or respond to others, are unusually reactive towards pain and sensory stimuli, and engage in odd behaviors (e.g., rocking or hand flapping). ASD ranges from mildly impairing (e.g., children who do well academically but struggle to make friends) to severely so (e.g., intellectually disabled with a failure to develop speech).
According to the Centers for Disease Control and Prevention’s 2022 report, ASD affects 1 in 36 Connecticut children, less than the national prevalence of 1 in 50. Risk factors include having a family member with ASD, certain genetic conditions such as Fragile X, birth complications, or being born to older parents. ASD is most frequently comorbid with ADHD, anxiety disorder, learning disabilities, and epilepsy. Children living with ASD frequently struggle with aggressive behavior, restricted palate, and insomnia.
Early diagnosis of ASD is crucial for providing timely intervention to improve long-term functioning. Treatment includes psychosocial interventions such as Applied Behavioral Analysis. No medication directly treats ASD, but medication can be helpful for some children who struggle with related aggressive behavior, hyperactivity, anxiety, or insomnia.
In Connecticut, state law mandates that health insurance policies cover the diagnosis and treatment of ASD in youth. Private insurance in Connecticut is more likely to cover mental health treatment than any other US state, according to the 2024 state of mental health report. CT ranks 10th among U.S. states in percentage of youth granted an Individualized Education Plan (IEP) for Emotional Disturbance. Finding appropriate care for youth with ASD in Connecticut can be challenging but is necessary to optimize long-term outcomes.
Guidelines for Diagnosis
History:
For patients diagnosed with ASD, it is important to obtain a history of developmental delays, functioning in different areas as well as comorbid psychiatric issues:
Important Elements of History:
| Early Development | Delays in developmental milestones are often the first indicator for later diagnosis of ASD, especially delays in speech and language development. |
| Functioning | |
| 1. School | – FSIQ (full scale intelligence quotient) – learning challenges – educational achievement – social functioning – communication difficulties – play (cooperative vs. parallel, imaginative and storytelling vs. sorting, scripting) – may help identify comorbid ADHD/anxiety |
| 2. Home | – insomnia/sleep difficulties – diet (narrow food preferences, sensory issues) – other sensory issues: noise/sounds, clothing textures, lights – toileting (constipation is commonly noted; incontinence and enuresis may be additional concerns) – behavioral problems – structure and routines – screen usage |
Common Comorbid Diagnoses to Consider:
Guidelines for Screening and Assessment
Presenting Symptoms
Management of children living with ASD focuses primarily on emotional and behavioral issues such as irritability and aggression among others.
| Symptom | Description | Management | |
| 1 | Irritability and Aggression | A key reason for seeking help. Symptoms range from irritability, low frustration tolerance, crying episodes, aggression toward others, and property destruction. | Assess contributory factors by eliciting history as noted above. Contributing causes include physical symptoms (pain, constipation), sensory factors, family functioning issues, speech difficulties to various psychiatric comorbidities such as anxiety or ADHD. Consider Applied Behavioral Analysis (ABA), School based supports, Occupational Therapy (OT) & Social-relational supports. Consider medications |
| 2 | Hyperactivity and Inattention | Common and often treated with medications. Includes difficulty focusing, impulsiveness, and inability to sit still. | History was obtained from school and parents. Consider screening for ADHD School-based support plans Consider medications |
| 3 | Self-Injurious Behaviors | Seen in about 11% of children living with ASD. Presents with head banging, hitting, biting, or scratching themselves, ranging from mild to severe. Even mild behaviors can cause injury. | Applied Behavioral Analysis (ABA) is the most evidence-based treatment |
| 4 | Insomnia | Prevalent among children living with ASD, typically involving difficulty falling asleep. May be worsened by excessive screen time. | Behavioral strategies first i.e., removal of electronics, consistent bedtime routines Cognitive Behavioral Therapy, Insomnia (CBT-I) Melatonin can be helpful |
| 5 | Repetitive Behaviors | Includes repetitive motor movements (e.g., rocking, hand flapping), sensory-related behaviors (e.g., rubbing), or repeating sounds/phrases | If in the context of anxiety, treat the underlying issue May be adaptive, soothing, difficult to interrupt Limited data for medications (SSRIs, antipsychotics) |
| 6 | Inappropriate Sexualized Behaviors | May occur due to a lack of understanding of social rules or boundaries. Could also indicate abuse. | Rule out sexual abuse or exposure to content via media Education about appropriate sexual behaviors and boundaries Behavioral therapy or ABA |
| 7 | Pica | The consumption of non-food items, sometimes linked to iron deficiency but also occurring in children living with ASD without nutritional deficiencies. | Correct nutritional deficiency, if present ABA |
| 8 | Bruxism | teeth grinding, especially during sleep May be related to sensory processing issues, sleep apnea and anxiety. | Behavioral interventions (CBT) Dental referral |
| 9 | Anxiety and Depression | This can occur in children living with ASD and may require behavioral or medical treatment. | Consider medications |
Mental Status Examination – Autism-Specific Observations
| Domain | What To Observe |
| Appearance & Behavior | – engagement in back-and-forth play or conversation – efforts to seek or share attention with others – sensory sensitivities (e.g., hyperreactivity to sound or touch) – self-injurious behaviors (e.g., head banging, scratching, hitting self) |
| Movements | – presence of repetitive or stereotyped movements (e.g., hand flapping, rocking) – gait abnormalities such as toe walking |
| Eye Contact | -quality and frequency of eye contact – determine whether reduced eye contact is due to social communication difficulty (common in autism) or other factors like anxiety or mood |
| Speech & Language | – delays in speech development – atypical language use (e.g., echolalia, scripting) – pragmatic language deficits (e.g., difficulty with conversational turn-taking, understanding non-verbal cues) |
| Affect | – appropriateness of emotional expression – flat, blunted, or incongruent to affect |
| Thought Process | – rigid or inflexible thinking patterns – concrete thinking style (e.g., difficulty with abstract or hypothetical questions) |
Labs/Medical Work Up
| Baseline Labs/Tests | Ongoing tests/Monitoring |
| Waist circumference and Body Mass Index (height and weight) and vital signs | BMI and waist circumference monthly for six months then quarterly when medication dose is stable |
| Fasting Plasma Glucose or HbA1c (antipsychotics) | FPG or HbA1c repeat three to four months after initiating medication then as clinically indicated and at least annually |
| Fasting lipid profile within 30 days of initiation of medication if not done within last year | Fasting lipid panel three to four months after initiating a new antipsychotic and at least annually if lipid levels are in normal range; repeat every six months if LDL is > 130 mg/dL |
| Extrapyramidal Symptoms (EPS) evaluation (exam for rigidity, tremor, akathisia) | EPS evaluation weekly after medication initiation & dose increases, continue two weeks after last increase |
| Tardive Dyskinesia assessment (AIMS) | TD assessment (AIMS) every three months and as clinically indicated |
| ECG at baseline or as soon as scheduling allows, and patient is able to cooperate | ECG as clinically indicated |
| Magnesium for iloperidone and ziprasidone if at risk for electrolyte disturbance | Serum potassium and magnesium periodically for iloperidone and ziprasidone if at risk for electrolyte disturbance |
| Complete Blood Count | CBC as clinically indicated, Absolute Neutrophil Count (ANC) per product labeling for clozapine |
| Complete Metabolic Panel | CMP includes renal and liver function annually |
| Thyroid Stimulating Hormone | TSH as clinically indicated |
ASD Screening and Rating Scales
Screening tools for autism are helpful in the initial evaluation.
Call Your ACCESS Mental Health for Youth Hub Team for assistance:
Hartford Hospital Hub: 1-855-561-7135
Wheeler Clinic Hub: 1-855-631-9835
Yale Child Study Center Hub: 1-844-751-8955
Connecticut Crisis Services
Medication Guidelines
Medication Management
Medications may be used to target problematic symptoms that occur in individuals with autism spectrum disorder. Co-occurring conditions are often the cause of such symptoms. A thorough evaluation should determine the cause as well as precipitating and mediating factors. Pharmacological intervention may be considered if environmental, behavioral and therapeutic interventions are not effective. The best medication management approach for this population is to begin with low doses and increase slowly and gradually as needed and tolerated.
Inattention, Hyperactivity, and Impulsivity
These symptoms often indicate a comorbidity with attention deficit hyperactivity disorder (ADHD). ADHD commonly co-occurs with autism, with a prevalence of 30%-60%. Management with a stimulant such as Methylphenidate or mixed Amphetamine salts may be considered first. Non-stimulant options that have shown efficacy include Atomoxetine, Guanfacine and Clonidine.
Refer to the ADHD toolkit for details
Anxiety and Depression
Selective Serotonin Reuptake Inhibitors (SSRIs) should be considered as a first line medication option for symptoms that are suggestive of an Anxiety or Depressive Disorder. Sertraline, Fluoxetine and Escitalopram are FDA-approved to treat both conditions.
Refer to the Depression Toolkit or Anxiety Toolkit for details
Aggression, Irritability, and Self-injurious Behavior
Management of these symptoms should include treatment of comorbid ADHD, depression, or anxiety if these conditions are determined to be the primary cause. Otherwise, consider initiation of an antipsychotic. Risperidone (Risperdal) and Aripiprazole (Abilify) have been shown to be effective in treating aggression and tantrums in children living with ASD.
Prior to starting treatment with an antipsychotic, and every three to six months thereafter, obtain the following baseline labs and measurements: height, weight, body mass index, blood pressure, fasting glucose, fasting lipid panel.
Risperidone
Aripiprazole
Psychosis
Some children living with ASD may struggle with thoughts that are not based in reality. Symptoms that impact level of functioning may be treated with an antipsychotic such as Risperdal.
Refer to the dosing guideline for autism-related irritability above.
Inappropriate Sexualized Behavior
Some individuals living with ASD may display these socially unacceptable behaviors due to limited social understanding. Treatment with antidepressants (SSRIs; Mirtazapine) or antipsychotics have been utilized to decrease libido.
Refer to the Depression toolkit for details.
Insomnia
Difficulty initiating and maintaining sleep is a frequent occurrence in individuals living with ASD. Melatonin has been shown in controlled studies to be effective in improving sleep for some children living with ASD.
Melatonin
Clonidine(if melatonin ineffective)
Repetitive Behaviors
Antipsychotics such as Risperdal and Abilify have been minimally effective in reducing these symptoms. There has been little to no effect with the use of antidepressants to treat these behaviors in children living with ASD.
Non-pharmacological Treatment
1. Speech and Language Therapy (SLT)
Purpose: Enhances communication skills including verbal speech, nonverbal communication (gestures, pictures, AAC), and pragmatic/social language.
Recommended For: Children with delays in expressive and/or receptive language, or difficulties with conversational turn-taking and understanding social cues.
Key Points:
CT Access:
2. Occupational Therapy (OT)
Purpose: Improves skills for daily functioning, sensory integration, fine motor coordination, and self-regulation.
Recommended For: Children with sensory processing difficulties, trouble with self-care skills, handwriting, or play skills.
Key Points:
CT Access:
3. Physical Therapy (PT)
Purpose: Enhances gross motor skills such as balance, coordination, and strength.
Recommended for: Children with hypotonia, gait abnormalities, or difficulties with physical activity participation.
Key Points:
4. Applied Behavior Analysis (ABA)
Purpose: A structured behavioral intervention that works to reinforce desired behavior in a child and reduce undesired behaviors.
Recommended for: Children with significant behavioral difficulties or skill deficits; most effective when started early and delivered intensively.
Key Points:
CT Access:
5. Social-Relational Support
Purpose: Helps children learn how to interact with peers and better understands social situations.
Recommended for: Children with difficulties in peer relationships or understanding social norms, particularly those with average to above-average cognitive functioning.
Key Points:
Developmental, Individual Differences, Relationship-Based (DIR/Floortime): This approach emphasizes following the child’s natural interests to foster emotional connection and communication. Therapists and caregivers engage in play-based interactions that are tailored to the child’s developmental level and individual sensory and motor profiles.
Relationship Development Intervention (RDI): RDI focuses on building the child’s capacity for social connection and flexible thinking. Through guided experiences, it aims to increase motivation and competence in shared activities, fostering deeper social engagement and emotional understanding.
Social Stories: These are short, personalized narratives that help individuals with autism understand and navigate specific social situations. They describe events, expectations, and appropriate responses in a simple, structured format.
Social Skills Groups: These group-based interventions provide a supportive, structured setting for children with autism to learn and practice age-appropriate social skills such as conversation, turn-taking, emotion recognition, and problem-solving with peers.
6. Therapy for Comorbidities (e.g. Anxiety, OCD, Depression)
Purpose: Offers a safe space to express emotions and experiences; builds self-esteem and emotional understanding.
Recommended for: Children with sufficient cognitive and verbal abilities who benefit from emotional processing and relationship-building.
Key Points:
7. School-Based Supports
Purpose: School-based supports aim to provide individualized, evidence-based interventions within the educational setting to help children with autism spectrum disorder (ASD) access learning, regulate behavior, and participate meaningfully in the school environment. These services are mandated under federal and state education law when a child’s disability impacts their ability to make educational progress.
A. Functional Behavioral Assessment (FBA) and Behavior Intervention Plans (BIPs)
An FBA is a structured process conducted by school psychologists or behavioral specialists to identify the reasons behind a child’s challenging behaviors in the classroom. Using direct observation, data collection, and team input, the FBA helps determine the function of the behavior and informs the development of a Behavior Intervention Plan (BIP).
B. Individualized Education Plan (IEP)
An IEP is a legally binding document that outlines the special education services and supports a child living with ASD requires to succeed in school.
C. Social and Communication-Based Interventions
Many school districts also provide structured interventions aimed at improving communication and social functioning in children living with ASD. These are most effective when integrated into the IEP and adapted to the child’s developmental level.
8. Additional Considerations
ACCESS Mental Health for Youth Clinical Conversations Trainings
Family Resources
Provider Resources