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Original research article, “i just want to stay out there all day”: a case study of two special educators and five autistic children learning outside at school.

• 1 Department of Education and Wellness, Elon University, Elon, NC, United States
• 2 Department of Psychology, University of Cambridge, Cambridge, United Kingdom

School is often stressful for autistic students. Similarly, special educators are susceptible to burnout because of the unique demands of their jobs. There is ample evidence that spending time outside, particularly in nature, has many positive effects on mental, emotional, and physical wellbeing. In this case study of two special educators and five autistic students in a social skills group at an elementary school in the southeastern United States, we sought to identify the effects of moving the class outside several times per week. Findings indicated that while there were challenges, the autistic children experienced numerous affordances that supported development toward achieving Individualized Education Plan goals. Moreover, there were also notable positive effects for the special educators. We found that even with little prior experience, learning outside is possible and beneficial to everyone involved.

Introduction

The first time Jacob, an autistic 1 elementary student with selective mutism, ventured into an outdoor environment at his rural school, he spoke to his friend while they were in the midst of an activity. His special education teachers were shocked. They told us they had never heard him verbalize anything due to selective mutism, an anxiety disorder that inhibits individuals from speaking in certain social situations despite an ability to speak in more familiar or comfortable settings ( American Psychiatric Association, 2013 ). As the year progressed and Jacob went outside more often with his social skills class, he spoke spontaneously with greater frequency, sometimes asking questions and interacting with his peers. Toward the end of the year, Jacob approached a brick wall near the outdoor learning environment that the class was using that day. He noticed a spider spinning a web on the wall. “Look at this!” he called to his friends. Several other children in the group gathered around, and they discussed what the spider was doing and why it was there. Jacob was an active participant in the conversation, engaged and curious.

Since Jacob was a participant in our case study, we were able to observe the ways that he and his autistic peers interacted with their teachers, with each other, and with the environment. Autism is a neurodevelopmental condition that consists of several typical behaviors or traits. These include repetitive, stereotyped behaviors and difficulties or impairments with social interaction and communication ( World Health Organization, 1992 ; American Psychiatric Association, 2013 ). As it is a spectrum, the needs, abilities, and outcomes of autistic individuals varies greatly. There is limited research on how nature might affect autistic children, especially at school, but there are many anecdotal accounts, which is what inspired our investigation. Higashida (2007) , an autistic Japanese teenager who communicates through a letterboard and computer, shared that nature has the ability to alter his emotions: “Just by looking at nature, I feel as if I’m being swallowed up into it … Nature calms me down when I’m furious and laughs with me when I’m happy” (p. 124). Gordon (2013) wrote about a non-speaking autistic four-year-old child spelling his name for the first time ever while outside using sticks as props. The teacher in Gordon’s article believes that spending time outdoors every day helps children with additional needs accomplish tasks previously believed to be beyond their capabilities. Brewer (2016) highlighted two schools in England that offered opportunities for students with additional education needs to spend time outdoors. According to a teacher at one of the schools, being outside is calming and stress-relieving, especially for autistic students. James (2018) , a British forest school leader, felt so strongly regarding the benefits he saw from taking autistic people into nature that he authored Forest School and Autism: A Practical Guide to encourage others to follow suit. James wrote that there is a lack of research available supporting the use of outdoor spaces with autistic people despite the wealth of anecdotal accounts, including those he details in his book.

Evidence continues to mount that spending time in nature is good for everyone (e.g., Chawla, 2015 ; Williams, 2017 ). While there are numerous studies that demonstrate benefits for typically developing children and adults (e.g., Wells and Evans, 2003 ; Fjørtoft, 2004 ; Swarbrick et al., 2004 ; Morita et al., 2007 ; Berman et al., 2008 ; Abraham et al., 2010 ; Berman et al., 2012 ; Kuo et al., 2018a ), there is limited research on the effects of nature for those with autism. Moreover, using outdoor environments as an accommodation to support autistic students at school is understudied. Therefore, in this case study of two special educators and five autistic students in a social skills group, we addressed the following research questions: What are the challenges and affordances of outdoor learning for autistic children? What are the special educators’ perspectives on outdoor learning with autistic children?

Literature Review

There is growing interest in the use of outdoor environments to benefit children. For instance, the North American Association for Environmental Education (2017) reported that there were 250 nature-based preschools and kindergartens in the United States, a notable increase. Learning outside can serve various educational purposes. The Institute for Outdoor Learning (n.d.) emphasizes “discovery, experimentation, learning about and connecting to the natural world, and engaging in environmental and adventure activities,” which can happen through multi-day trips, residential experiences, and adventure sports. Relatedly, nature-based learning (NBL) is “an educational approach that uses the natural environment as the context for learning” ( Chawla, 2018 , p. xxvii). Forest School (FS) is one example of NBL. The Forest School Association, 2011 , a professional body in the United Kingdom, provides six principles to guide and support FS practitioners. For example, FS takes place in an immersive wooded or natural environment, and learning is child-led. Recent research suggests that FS may facilitate feelings of affinity or ownership over natural spaces, thus encouraging pro-environmental behaviors ( Harris, 2021 ). NBL can, in practice, look many different ways. Access to an immersive wooded or natural environment is not necessary, however. Outdoor learning can occur in urban areas where children explore sidewalks, subways, stores, and parks (e.g., Whitlock, 2020 ).

The effects of engaging with nature are diverse. There are benefits to mental health, including lower stress levels ( Wells and Evans, 2003 ; Morita et al., 2007 ), improved social and emotional wellbeing ( Abraham et al., 2010 ; Berman et al., 2012 ), and feelings of belonging and sense of self ( Swarbrick et al., 2004 ; Cummings and Nash, 2015 ). Interpersonal skills seem to be positively impacted ( Dillon et al., 2005 ), including increased expressions of sympathy toward others and the environment ( Barthel et al., 2018 ). Even nearby nature has notable implications for cognition, intelligence, and development in both educational and residential contexts. Wells (2000) found that, in a study of low-income families with children aged 7–12 years old, moving from a “low naturalness” area to a “high naturalness” area had significant effects for child cognitive function. Similarly, Wells and Evans (2003) , using a four-item naturalness scale, reported that nearby nature may be a buffer for stressful life events for children with a mean age of 9.2 years in rural residential contexts. In a study of adults in Australia, Astell-Burt and Feng (2019) reported that higher amounts of tree canopy (30%) as well as total green space were associated with lower psychological distress and better general health. Bijnens et al. (2020) found that residential green space could have positive impacts on intelligence for children ranging in age from 7 to 15 years old in urban settings.

The benefits of nature for educational purposes have also been documented. Dadvand et al. (2015) , in their study of over 2,500 7 to 10-year-olds in Barcelona, suggested the possibility of improvements in cognitive development associated with surrounding greenness, particularly greenness of schools. Kuo et al., 2018b studied grass and tree cover in a sample of over 318 public schools in Chicago in relation to achievement on state-level assessments. Tree cover was related to academic achievement, particularly for math, while grass cover was not related. Thus, the presence of green spaces in and around schools seems to offer benefits to children. Additionally, Kuo et al., 2018a concluded that classroom engagement from 9 to 10-year-old children increased following lessons that took place in nature, suggesting the potential for what the authors refer to as “refueling in flight” for student focus. This reinforces Kuo et al.'s (2019) sentiment that “it is time to take nature seriously as a resource for learning and development” (p. 6). Considering the existing research, could the same be true for engaging autistic students with nature?

The accommodations and supports each autistic individual requires, if any, are highly variable. A large number of interventions exist to address supposed impairments in autistic populations; these include commonly known interventions such as Applied Behavior Analysis ( Baer et al., 1968 ), TEACHH (Treatment and Education of Autistic and Communications - Handicapped Children; Mesibov et al., 2005 ), and intensive interaction ( Nind and Hewett, 1988 ). The type of intervention or support that an autistic school-age child will receive is dependent on the specifications of that individual's Individualized Education Plan (IEP); the IEP, when used correctly, serves as a roadmap of interventions and supports to attain specific, measurable goals ( Blackwell and Rossetti, 2014 ). Difficulties with social interactions, for example, may prompt the use of an intervention like a social skills group. Group social skills training involves the teaching and practice of social skills among peers. This is the context of our case study. The worthwhileness of such an intervention for targeting the social skills of autistic children remains unclear, with some evidence of effectiveness ( Hotton and Coles, 2016 ) and other authors concluding that the intervention has little impact ( Bellini et al., 2007 ); despite this, the teaching and practicing of social skills in a group setting remains a common practice in special education ( DeRosier et al., 2011 ).

School experiences can be difficult for autistic children, leading to increased mental health issues and additional support needs. Due to the differences or difficulties in social communication common in autistic people, interactions with peers can be complex and challenging, causing stress and anxiety. Autistic children are also more likely to be bullied at school because of their behavioral differences ( Rowley et al., 2012 ). In fact, autistic children and teenagers are more likely to experience bullying and victimization than typically developing peers and peers with intellectual disability. Additionally, autistic children may experience gaps in academic achievement as well due to social impairments and other difficulties not related to intellect or ability ( Estes et al., 2011 ). It is not surprising, then, that mental health issues are more prevalent among the autistic population than the general population, with some researchers reporting estimates of 20% of the autistic population experience co-occurring anxiety disorders ( Lai et al., 2019 ). Confounded with the usual difficulties of childhood and adolescence, school can be a tumultuous time for autistic students.

One potential avenue of support for autistic individuals that is underutilized and understudied is the use of outdoor environments. While there is extensive research showing that time spent in nature offers benefits for wellbeing, particularly mental health, and even cognition and intelligence in typically developing populations or those with attention deficit hyperactivity disorder (ADHD), there is far less research on what nature might offer autistic people, especially children. According to Blakesley et al. (2013) , gardening projects, summer camps, field visits, and animal therapy have shown to have positive effects for autistic children; however, more research on the potential of outdoor learning for autistic children at school is needed.

The research that does exist is promising. Bradley and Male (2017) interviewed four autistic children, ages 6–8 years old, who participated in FS as well as their parents. Despite the small sample size, several benefits were identified from the interviews; these included friends/friendship development, challenges and risk taking, learning outcomes, and experiencing success. Zachor et al. (2016) utilized quantitative methods to study the impact of an outdoor adventure program on the autistic symptomatology of 51 autistic children between the ages of 3–7 years, with findings indicating a reduction of symptomatology after participation in the outdoor group when compared to a control group. Additionally, Li et al. (2019) interviewed caregivers of autistic children in China, who ranged in age from 4 to 17 years old, and “identified multiple sensory-motor, emotional, and social benefits of nature for children with autism” (p. 78). The findings from these three studies demonstrate that learning outdoors may need to be considered an accommodation and intervention for autistic children. Further evidence, especially in a school context, would bolster the research base and potentially lead to nature-based accommodations for autistic children.

Theoretical Framework

This study is framed by the theory of stress recovery put forward by Ulrich et al. (1991) . Stress recovery theory (SRT) suggests that following a bout of stress, individuals who are exposed to natural settings are able to reduce that stress more quickly than those who were not exposed to natural settings, demonstrated even at a parasympathetic level. The authors noted that the idea of stress recovery occurring in natural settings is not a new one; it has been documented throughout history, including in evolutionary theories. Stress reduction has also been observed in a study using nature sounds rather than visual natural scenes ( Alvarsson et al., 2010 ). Decades of research show that natural settings contribute to decreased stress and associated mental health issues ( Wells and Evans, 2003 ; Morita et al., 2007 ; Abraham et al., 2010 ; Berman et al., 2012 ).

SRT has also been applied in a sample of 18 11-year-olds, some of whom were considered to have “bad” behavior. Roe and Aspinall (2011) measured mood and reflection on personal development before and after a typical indoor lesson and a FS session. The authors reported that greater positive behavioral change occurred after time in the forest environment, suggesting that the restorative potential of nature may have been at play. Additionally, SRT underpinned work conducted by Shao et al. (2020) in which 26 elementary-aged children performed first an electronic gardening task followed by a real-life horticultural activity. Various physiological measurements (e.g., heart rate variability and skin conductance) indicated that the children experienced positive impacts from the real-life horticultural activity, including a decrease in sympathetic nervous activity. Thus, SRT has been applied to work with a range of ages, including younger children.

As previously noted, autistic individuals have a more difficult school experience. Additionally, the levels of mental health issues among the autistic population is much higher than that of typically developing peers ( Lai et al., 2019 ). It is likely that those challenging and sometimes traumatic school experiences are among several factors contributing to increased mental health issues among school-age autistic children. Due to its significant and continued impact upon wellbeing and various outcomes, the school experience and associated mental health issues should be of focus for teachers, caregivers, counselors, interventionists, and other practitioners who engage with this population. Stress recovery offered by educational activities occurring in nature could be beneficial, then, by mitigating the stressful experiences of attending school or interacting socially with others.

Research Methods

As a case study, this is a preliminary investigation of a phenomenon over which we had little control ( Yin, 2017 ). According to Miles et al. (2019) , a case is “a phenomenon of some sort occurring in a bounded context” (p. 44). Thus, our case is a social skills group consisting of two special educators and five autistic students who used both indoor and outdoor environments at an elementary school in the southeastern United States. Furthermore, this is an exploratory case study given that it was not intended to test a particular hypothesis ( Yin, 2017 ). As noted by Hancock and Algozzine (2011) , exploratory case studies serve as a prelude for more expansive investigations that might seek to confirm a hypothesis or work with a concept in a more in-depth manner. Given the small sample size, our findings are not generalizable.

The case study was carried out at a public K-5 elementary school with approximately 600 students, an estimated 47% of whom are eligible for free or reduced price lunch. The school, which we will call Belington Elementary (pseudonym), has a special education department consisting of two teachers, both of whom participated in this study. They provide both push-in and pull-out support for students with IEPs, and they also co-facilitated a 30-min social skills group with five autistic students every day.

The purpose of this social skills group was to offer guidance and practice for communicating and interacting with peers through a variety of lessons. Sometimes the teachers provided direct instruction regarding specific concepts. For example, the teachers might read a book in which one of the characters demonstrates emotion regulation, or they might facilitate a matching activity that required students to align particular situations, as stated by the teacher, to the coordinating emotions that the individual in the fictional situation was likely feeling. Sometimes the teachers prompted the students to engage with each other through games and free play. For example, the teachers invited the students to build well-known international monuments using materials found outside in small groups, which required cooperation and collaboration. Social skills interventions are commonly used for autistic children, particularly those in mainstream environments, as they teach the social interaction behaviors that would be considered “typical” in society. The behaviors may include maintaining eye contact, reducing atypical speech patterns, and expressing interest in what other conversation partners are saying ( White et al., 2010 ). Social skills training programs have been reported to be effective in targeting perceived “deficits” or differences in social interaction (e.g., Kamps et al., 1992 ; Webb et al., 2004 ; Cappadocia and Weiss, 2011 ).

There were four outdoor environments generally used by the teachers for this case study (see Figure 1 ). First was a small pavilion situated very close to the school building. Next to the pavilion was a small garden, but it was overgrown and not actively used by anyone at the school. The second area was referred to as “the outdoor classroom” and was located in a more open area next to the school. The outdoor classroom consisted of several picnic tables under a large covering. Both the pavilion and the outdoor classroom were located just outside the door from the special education classroom, which both teachers shared. The third area was the playground, blacktop, and field located at the back of the school. Finally, there was a nature trail that led to a small clearing in a wooded area. There were wooden benches that formed a circle in the clearing. Accessing the nature trail required a slightly longer walk out of the building, across the parking lot, and over a small patch of grass. For the purposes of our research, we considered the pavilion, outdoor classroom, and playground/blacktop/field areas to be sites for outdoor learning; activities that took place in the nature trail and clearing in the wooded area were considered NBL due to the more immersive setting.

FIGURE 1 . Belington elementary campus. A = Indoor Classroom, B = Outdoor Classroom, C = Pavilion, D = Playground and Blacktop Area, E = Nature Trail, F = Forest Classroom

Participants

Participants included two special educators and five autistic students. The teachers, Mrs. Barrett and Ms. Smith (pseudonyms), were both in the early stages of their careers in special education. While Ms. Smith graduated from university two years prior, Mrs. Barrett worked for over 10 years in several other education and childcare contexts before seeking a special education qualification. Both teachers had minimal experience taking autistic children outside the classroom and no formal training or experience with outdoor learning. The social skills group was composed of five students from 2nd, 3rd, and 4th grades. All of them identified as male and white, had autism diagnoses, and spoke English as their first language. Basic descriptive information regarding the participants can be found in Table 1 .

TABLE 1 . Participant information.

Data Collection

A total of 31 visits were carried out, with 26 observations taking place outside and 5 taking place indoors. One visit was completed at the end of January while 7–8 visits were completed per month from February to May. Visits were typically on Mondays and Wednesdays, though seven of the visits were on other days of the week due to events at the elementary school, which meant the class was unable to meet, or to observe the children indoors. The 30-minute social skills classes met in the afternoon each day during the last lesson block of the day. At the start of the study, the teachers agreed among themselves that they would take the children outside on Mondays and Wednesdays. This plan sometimes changed due to weather or a change in lesson plans. Thus, the decision regarding which days to go outside was predetermined, but the teachers had the autonomy to make adjustments day-to-day. We did not observe the students during other subjects.

Field notes were handwritten when at the school and later typed on a shared document. We elaborated on the field notes on the shared document, which resulted in longer narratives. We also tracked the frequency of certain behaviors exhibited by three of the students (Curtis, Jacob, and Tracy; pseudonyms) in our field notes. The target behaviors were related to the IEP goals for each student; the purpose of focusing on IEP goals was to observe if an outdoor environment facilitated any progress or development in regards to those particular goals. Behavior frequency was noted throughout the entire class period, with tally marks indicating the presence of the target behavior. Further details denoting the content of the behaviors were recorded as well. For example, if Curtis asked a question, we would write down what he asked. The decision to track behaviors for only three of the five students was made due to the other two children’s IEP goals. That is, their goals were generally conversation-related but difficult to track using frequencies. Thus, we focused on tracking behaviors of three students with goals that could be more easily quantified.

Finally, we conducted semi-structured interviews with both teachers at the beginning, middle, and end of the data collection period. Interviews lasted 30–45 min and were carried out in person at the school. The first two interviews were with each teacher separately (i.e., two interviews for each) and the final interview was with both teachers together in an effort to provide a space for reflection and discussion between them. In the first interview, questions focused on their previous experiences working with children (both indoors and outdoors), their own relationship with nature, their feelings about incorporating outdoor learning, and their initial impressions or observations of their first few sessions outdoors. The second interview included questions regarding outdoor lesson planning inspiration, how the teachers felt the group was managing with outdoor lessons, how they themselves were impacted by taking their lessons outside, any difficulties they encountered, and how they were beginning to use outdoor learning with their other groups throughout the day. The final interview focused on reflections from both teachers regarding the challenges they faced throughout the experience and what they felt they did to be successful in outdoor environments. All interviews were audio recorded and transcribed.

Data Analysis

We followed Miles et al.'s (2019) guidance regarding qualitative data analysis. To start, we conducted two phases of coding on the interviews and field notes. Coding served to categorize like pieces of data. The first cycle of coding utilized several of the many types of coding, including descriptive, in vivo , and emotions coding. The purpose of the first cycle of coding was to summarize two of the available data sources. The second cycle of coding served to identify patterns in those codes. Codes were then grouped together into categories or themes.

Next, we completed a round of jottings. Jottings documented our thinking as we analyzed the data. These brief notes were written directly into the interview and field note documents to ensure continuity between the data that prompted the thought and the thought itself. Following the use of jottings, analytic memoing then served to “synthesize (descriptive summaries of data) into higher level analytic meanings” ( Miles et al., 2019 , p. 97). Beyond just noting thoughts about the data, analytic memos extend and connect various data with theory and researcher perception.

To formalize and organize our thoughts and findings, we produced assertions and propositions based on all sources of data. According to Miles et al. (2019) , assertions are declarative statements while propositions are conditional statements that serve to predict. These statements allowed us to look at the findings comprehensively and better determine the entire picture of what occurred throughout the study, based upon the available data. To summarize and conclude the process, we carried out a within-case analysis to describe what occurred within the single case of focus in our study.

Limitations

Case studies, particularly those that are exploratory and utilizing within-case analysis, are not generalizable as they focus in depth on one particular case to better understand some aspect of that case. More time observing the participants and conducting the study over a longer period of time would have given us a more robust set of data. Finally, the special educators in this case study were not experts in outdoor learning and had very limited experience taking students outside. Therefore, the challenges and affordances we found may be unique to this context.

When Mrs. Barrett and Ms. Smith agreed to participate in this case study, we had to rely on their willingness, creativity, and resilience to regularly use outdoor environments with their social skills group. Our first research question pertained to the effects of being outside on autistic students, but the second research question about special educators’ perceptions of outdoor learning was perhaps more significant. Mrs. Barrett and Ms. Smith decided what days they would go outside, where on the school campus they might go, what concepts and topics to integrate into their lessons, whether they were adequately meeting IEP goals, and how to respond to autistic students’ needs during transitions and disruptions to their routines. They were the conduits for the entire case study. If for any reason they were not comfortable using outdoor environments, we would not have been able to observe their students.

Neither of the special educators had significant prior experience or training with NBL. During our first interview, Ms. Smith said that she had not used the outdoor environments at her school very often, “just taking them out a few times last year.” She continued, “I would take them out to the outdoor classroom... sometimes on a nice sunny day” but confessed she did not have “a lot of experience incorporating, like, outdoor instruction or environmental education.” When we asked what inspired her to use the outdoor environments a few times, she said,

I thought that was really cool, and I kind of wanted to explore them too, um, just 'cause I knew we had a trail. I knew we had the outdoor classroom there for a reason, and I enjoyed it outside, especially like when the weather was nicer, and I figured it was a fun break for my students, too.

Even without much prior experience or training, both Ms. Smith and Mrs. Barrett found going outside to be appealing enough to participate in this study, and their comfort levels increased the more they used the outdoor environments. Mrs. Barrett noted during her second interview, “We were kind of hesitant before (about) going outside,” but then quickly followed with, “Now that we (are more) experienced... it's just like, calmer. It's peaceful. I just want to stay out there all day.” Both special educators found that outdoor environments offered more than just a fun break for students.

Before we began observing the social skills group, Ms. Smith and Mrs. Barrett shared with us the general IEP goals for their five autistic students. In an email, they highlighted the specific skills they would be working on during the study:

• Engaging in appropriate conversation with others (listening to others, asking relevant questions, using a “social filter”)

• Using “appropriate verbalizations” to express feelings and needs rather than shutting down or using aggressive/physical behaviors

• Identifying others’ perspectives and feelings

• Identifying the problem in a social situation and creating a solution to meet both party’s needs (problem-solving skills)

• Completing non-preferred tasks

• Asking for a break when frustrated

• Demonstrating verbal control in different social situations

They also stressed that there was not a set curriculum that they were required to follow, which allowed them the flexibility of creating their own lessons in ways that would meet their students’ needs and IEP goals. In fact, they were used to developing their own curriculum. “Last year we didn’t have any type of curriculum (provided),” they wrote in the email, “so we pulled from a lot of online resources.” From the beginning, Mrs. Barrett and Ms. Smith were both cautiously optimistic about regularly using outdoor environments with their autistic students. Their lack of experience and training was not insurmountable. Rather, they displayed a growth mindset throughout the study. This was especially apparent in the lessons they developed.

The first outdoor lesson we observed took place in the blacktop area just outside of their classroom (location D on Figure 1 ). The main objective was to support students’ identification of emotion states, so Ms. Smith wrote “happy,” “sad,” “angry,” and “afraid” on four distinct spaces on the blacktop in chalk. The students were then tasked with drawing pictures or writing words with chalk that they associated with the emotion words. The spaces for drawing were approximately five feet away from each other; the children worked in pairs, rotating to the various spaces as the lesson progressed. Throughout the lesson, students were observed laughing and smiling. Some children found nearby rocks on the ground and threw them toward the field while they were taking breaks from drawing. At the end of the activity, everyone sat on the ground in a circle to summarize what they learned. The students were largely engaged in the activity, though some noted that sitting on the hard ground hurt their hand or that the cracks in the asphalt got in the way of their drawing. Despite the colder weather on this day, the only comments about feeling cold came from adults present.

During the second outdoor lesson we observed, the children were noticeably different in their expressions of emotion and interactions with one another compared to their behavior at the start of the class indoors. When observation began at the start of class, before the group had moved outside, the children were being kept on the carpet because the teachers felt they were not following instructions to be quiet and still. Once outside, the activity, which involved running to various parts of the playground to select an emotion word that described the scenario being read aloud (e.g., happy, sad, angry), prompted smiles, laughter, happy screaming, and talking among the students. This was true for Jacob as well, which caused Ms. Smith to comment that she’d never before seen Jacob speak to peers unprompted during an activity.

Several days later, they took a book about emotion regulation outside to the picnic tables to read as a group. While Ms. Smith read aloud, many of the students moved their bodies, tapping on the tables and alternating between standing and sitting. At one point during the lesson, Jacob was moving around rocks and items he found on the ground. Ms. Smith asked a question specifically addressed to him in what appeared to be an attempt to re-engage him in the story. During the following outdoor lesson, the group reviewed the book. Then, to enhance their understanding of the book, Mrs. Barrett and Ms. Smith showed the students a container of bubbles, pulled out the plastic wand, and blew a few into the air. The bubbles were meant to indicate feelings of anger that eventually build up until they pop. The students provided answers to the question, “What makes you angry?” and then were to chase a bubble and “pop” it. Jacob and Tracy in particular seemed to enjoy the opportunity to run after and pop bubbles, as they laughed and smiled throughout this portion of the activity. Mark seemed eager to help Ms. Smith with blowing the bubbles.

During the next outdoor lesson, the concept was advanced further through the use of a liter bottle of soda. The lesson began with a discussion of what they learned about being angry or frustrated from the bubble popping activity. During this review, Tracy and Jacob were moving around, displaying stimming behaviors, and standing up. The teachers shook the bottle to indicate the process of getting angry. The bottle was then opened, and some of its contents spilled out, much to the delight of the children. This prompted a conversation about what strategies could have been used to prevent the spill. The students suggested taking a break while shaking the bottle to allow the fizzing to calm down, which they demonstrated with another bottle of soda. They waited a few minutes after shaking the bottle, and the students discussed whether this was a long enough break to prevent another explosion. During this portion of the lesson, Tracy was corrected by the teachers for not paying attention. This was then related to strategies that they could use to defuse anger. These strategies were demonstrated through the use of skits; the students were put into two groups and tasked with acting out a situation where someone was upset and had to employ a strategy to diffuse their anger. The children largely participated in the skits, though Tracy commented that he was cold and spent some time zipping and unzipping his jacket. Additionally, Jacob was not taking part in this activity, as he was slightly away from the group, touching one of the gazebo’s columns. This was not acknowledged by the teacher.

Continuing with the theme of emotion regulation, another activity on a particularly warm and sunny day included four hula hoops with colors coordinating to the Zones of Regulation, an emotional control system created by Leah Kuypers. The four colors help to categorize different emotions, with blue indicating low alertness, green indicating calm states, yellow indicating elevated emotions, and red indicating extremely elevated emotions. One of the teachers read a scenario, and the children responded by moving to the hula hoop that corresponded to the regulation zone they felt was represented by the scenario. For instance, one scenario was, “Tommy was walking to his table in the cafeteria when he dropped his tray of food. All of his food went on the ground. What zone do you think Tommy was in when this happened?” At first, all of the children moved together, seeming to make the same decisions. Eventually, students broke off and made their own choices about what zone matched best. Throughout the activity, Alex appeared to be dancing as he participated. When students did choose a hula hoop that no one else went to, the teachers asked them to justify their choice, prompting a discussion. For instance, toward the end of the activity, Jacob broke off from the group and went to a different hoop than his peers. The teachers then asked him to explain why he made that choice.

After several months of incorporating outdoor environments into their instruction, the teachers planned a series of lessons to develop teamwork skills. During an indoor class lesson, the students began to work on a small group project. The groups were tasked with building well-known structures out of Legos (e.g., Statue of Liberty, Sphinx, Great Wall of China). The next day, the class took their Lego projects outside to work at the outdoor classroom under the pavilion. Several classes later, the teachers told the students that they would be repeating the same process of building famous structures in small groups; this time, though, the students would be utilizing whatever natural materials they could find outside. Over the course of several outdoor lessons, the students, in their groups, brainstormed what types of materials they would need, where they could get those materials outside, and how they would build the structures. One day was spent on the nature trail collecting materials in a bucket to take back inside. Then, several lessons, both indoor and outdoor, were spent creating their structures. The outdoor lessons to prepare for making a famous structure out of natural materials were interspersed with indoor lessons teaching, reviewing, and discussing what teamwork looks like. That is, concepts were taught inside that were then immediately incorporated into outdoor activities, creating an indoor-outdoor transfer of skills and knowledge.

The aforementioned are only a small sample of the lessons planned and executed by Ms. Smith and Mrs. Barrett for their social skills group with autistic students. Table 2 presents details about all of the lessons that were observed during the study.

TABLE 2 . Descriptions of lessons.

Our analysis of the data revealed the challenges experienced by the special educators and their students, the adaptations the teachers made in response to the challenges, and the affordances for everyone in the case study.

Not surprisingly, taking autistic children into new learning environments has its challenges. To begin, there were several reasons why the teachers, who taught at a school with several well-developed outdoor spaces, had never utilized these locations before. The main barrier was timing; the teachers had only 30 min with their social skills group and were hesitant to use some of that limited time to travel to and from the outdoor environments. Once the teachers tried taking their group out, they realized that “it didn’t take as long to get out there as I thought it would.” Importantly, they used that transition time effectively, as we explain below, incorporating it into their lesson so that travel time was not “wasted” time.

Once the group started going outside more regularly, the teachers found that an additional barrier was the weather; more specifically, a lack of appropriate clothing and footwear for adverse weather conditions sometimes stopped the class from going outside. On one day, the teachers changed the plans to go outside “because it was raining and cold, and we didn't want anybody getting sick.” Another day, the class decided to stay inside because one of the students had new shoes on and didn’t want to get them muddy on the nature trail.

Over the course of the study, the teachers also came to realize that not all of the outdoor spaces available to them were equal. That is, the class had several options, including a pavilion close to the school that had a view of the front parking lot, where buses and parents would line up at the end of the school day; the playground, blacktop, and field behind the school that had a view of a road; and the nature trail and outdoor classroom that was secluded from any views of the road or the school. Ms. Smith quickly found that “they’re able to focus more when we're in areas further away from the road.” Both teachers agreed that the students were less “distracted” when they were in the nature trail and forest classroom, leading them to prefer taking the students there.

It seems that this preference was shared by the students as well; during one lesson, Ms. Smith told the students they would be going to the pavilion, and several students groaned and expressed that they felt that space was boring because “it’s just land.” When outside at the pavilion or on the field that had views of the road, there were several instances of children becoming noticeably “distracted” when large trucks passed by, often commenting on what they saw. Additionally, several of the children experienced anxiety related to knowing what time it was and having sufficient time to prepare for going home. Thus, when the class was at the outdoor pavilion and the students could see parents and buses arriving for pickup, this anxiety increased and became disruptive to the lesson.

Despite the clear barriers that existed, the teachers persisted in incorporating outdoor learning into their social skills class. This persistence necessitated a willingness by the teachers to adapt accordingly.

Adaptations

On a larger scale, both teachers underwent a transition in their approach to teaching this particular social skills group. As mentioned previously, neither teacher had experience taking children, particularly autistic children, outside for educational purposes. Throughout the study, both became more confident and comfortable with taking autistic children, and children with other additional needs, into outdoor environments. They became so comfortable, in fact, that they began taking children from their other groups, including reading and math support groups, outside. This was not an expectation of the study; rather, the teachers noticed the effects on themselves and their students and were compelled to try it on their own.

In a more literal sense, the importance of transitions to the success of the group’s outdoor lessons was quickly apparent. An initial apprehension existed with both teachers regarding the amount of time that would be spent walking to the outdoor environments in use for that lesson. Because of this, the teachers often opted for closer locations when going outside, such as the playground, grass field behind the school, or pavilion that was right next to the building; the students often complained when they were told this was their destination for the day, however. Additionally, there were downsides to these more easily accessible outdoor environments such as proximity to roads and parking lots and the presence of other classes. This challenged the teachers to find a way to access a more secluded outdoor location and deliver a meaningful lesson within the 30-minute time frame of the class session.

To do this, Ms. Smith found that transition time could be effectively harnessed so that the five-minute walk to the more secluded outdoor environment on the nature trail became a feasible option for the class. During several sessions, Ms. Smith used the time spent walking back into the building to have individual “check-outs” with the students. Describing her thought process for doing this, Ms. Smith said, “That’s why I was like, let’s just do individual check-outs as we walk back instead, where I just talk to them one-on-one, because they’re not listening to each other as a group … I just checked in with a couple as we walked to ask them, ‘Hey, do you think you met your goal today, and how did you do that?’ I talked to at least three or four of them.” On trips from the building out to the nature trail, the teachers sometimes explained rules, procedures, and expectations for the day, told the class what the planned activity was, or asked individual students what emotion regulation zone they felt they were in at that time. On other days, transition time was used to play “I Spy” to encourage students to pay attention to their surroundings. With their newfound realization of the impact that effective transitions can have, both teachers felt that “trying to plan for those transitions” during lesson planning was particularly crucial to increasing the chances for success.

While we offered the teachers support with brainstorming ideas and developing lesson plans, they did not ask for this help and were insistent on using their own ideas. To start, the teachers often opted to take the lessons they would use indoors and simply move them to an outdoor environment. For instance, they did this several times with read-aloud books and post-reading discussions. Early in the study, Ms. Smith mentioned that she was “very comfortable taking indoor activities outside. But I don’t necessarily feel like I’m great at using what’s outside for the lesson.” After observing this, we found that lessons could be categorized in four ways: indoor lessons delivered inside, indoor lessons that are simply moved into an outdoor setting, indoor lessons that are adapted to utilize some element of the outdoor setting, and lessons designed for use only outdoors.

An added difficulty was the topic that this particular group needed to cover: social skills. Ms. Smith found this more difficult as “social skills was something like, I don't know if I was, if I would say I was necessarily, like, really taught how to teach necessarily.” In an effort to utilize the outdoors for social skills lessons more effectively, the teachers found that it was easiest to search for one of those elements -- outdoor learning or social skills -- and then adapt the idea they’ve found to include the other element. Thus, they avoided the frustration of trying to find ideas for “social skills lessons outdoors,” which may not readily exist online.

To source ideas for their outdoor lessons, the teachers utilized online searches and platforms like Pinterest as well as asking their colleagues for input, and they had success with these methods. Lesson planning required a learning curve, though, as Ms. Smith noted that she had to realize that “it’s okay to, like, go back to something that's worked because it's familiar and it's good … good for them, too. Because I think some, at the beginning, I was just feeling pressured to like come up with something new every time, too.” Additionally, the teachers had to remember that going outside meant they were able to utilize an entirely new set of materials. Ms. Smith found that her “normal frame of mind is worksheets. Videos … maybe a game inside. But now, it's like I need to think about a different space, different materials and what not.” With this, Ms. Smith demonstrated how she adapted her approach to lesson planning during the study.

Adaptations were evident throughout the five months of the study. For instance, the teachers learned that their class responded best when new concepts were introduced indoors and follow-up activities were conducted outside, rather than trying to teach new concepts in the outdoor environment. The teachers believed that this was the case because “when you’re outside, you don’t want to just be sitting and listening. They’re ready to move and be active.” Allowing for movement and physical activity -- taking advantage of having more space outdoors -- was another key to success for the class as the teachers focused on “trying to incorporate more movement, so we've done a lot of games.” Additionally, understanding that lessons don’t have to be complicated to be impactful meant that outdoor lessons felt more approachable for the teachers. Ms. Smith stated that “coming up with your own ideas is a little bit easier now. Like, just thinking of the spaces that we have and … just it's easier to think about. I was like, ‘Well, we can take a walk outside,’ like even just something as simple as taking a walk outside to see all the different places.”

The teachers also expressed that flexibility, both in carrying out lesson plans and in expectations, was key when taking their autistic students outside. For instance, on one day that was intended to be an indoor lesson, the class took a vote to decide where they would prefer to work; four of the students voted to work outside, so the class moved locations and simply took the indoor lesson into the outdoor classroom. This happened quite frequently, as Ms. Smith noted that the class was spending more time outside than what was required from the study because “the kids have been asking to.” During another lesson, Mrs. Barrett realized that she had forgotten one of the key materials, a small whiteboard, inside. She adapted the lesson to account for this, having the children act out the scenarios she was going to draw instead, resulting in a successful lesson.

While the class certainly discussed and adhered to rules and procedures for being outside in order to keep all of the students as safe as possible, the expectations that students were held to evolved as the class spent more time outside. Certain behaviors were discouraged in any setting, such as interrupting teachers or classmates by speaking out of turn. Others, however, were allowed in the outdoor space as the teachers noticed that they adapted their own attitudes toward what constituted acceptable behavior while outdoors. Mrs. Barrett admitted that, when taking the class outside, she was “more flexible with [them]... I don’t expect them to sit still.” She also shared that while she still expected students to listen to her as she teaches, those specific listening behaviors that she is looking out for are also different outside, noting that “I can tell. I can say, ‘Okay. So who … ’ And they say it right back. I know they're listening.” Additionally, observations of the class and teachers indoors showed that sitting still and showing body language that was indicative of focus on the teacher were expectations; children who deviated from these expectations were given reminders of “proper” behavior. When outdoors, however, bodily movement became more accepted, with Mrs. Bartlett sharing, “One chose to sit on the boardwalk and the other three sat on the bench. Well, one started off on the bench and he went off, under the bench. Like, okay. Whatever. As long as you're listening, I'm good.”

Despite the adaptations that the teachers made toward more accepting and flexible behavioral expectations when outside, styles of instruction that would align more closely with NBL or FS, the lessons remained fairly “traditional” in that they were teacher-centered and lesson-centered. Each lesson focused on a particular skill that was addressed; these skills aligned with expectations of what a social skills group should cover and included, during the time of the study, constructs such as emotion regulation, teamwork, problem solving, and conversational turn-taking. A further shift toward an embrace of NBL or FS would result in lessons being more child-centered, child-led, and inquiry-based. These adaptations were not observed during the study.

Affordances

During our observations, we tracked the frequency of certain behaviors exhibited by three of the students, Jacob, Tracy, and Curtis; the target behaviors were selected based upon the students’ IEP goals. Jacob’s goal involved “being able to communicate basic wants and needs and … asking and answering questions.” Tracy’s IEP goal was to utilize self-regulation skills to identify and remove himself from situations that made him over-stimulated, and Curtis’ goal was to ask questions to elicit more information, rather than staying silent, which can then lead to frustration. We wanted to see if being outside might help these students meet the goals in their IEPs.

In tracking Curtis’ goal, we found that his question asking increased more indoors compared to outdoors. Those indoor questions, however, pertained to going outside. For instance, during one session, Curtis asked about a specific material that was being brought outside and if he could help carry it. In another, he asked if he could wear his sunglasses outside. While outdoors, Curtis noticed a helicopter leaf on the ground. After he asked what it was, Ms. Smith helped him to pick it up and throw it in the air to watch how it floated to the ground. The number of times Curtis asked questions certainly increased overall, and it appeared that his interest or enjoyment in going outside prompted those questions.

During the study, Tracy did not utilize any self-regulation techniques. We did not observe him reach a point of being over-stimulated during any of the outdoor or indoor sessions that we observed. This suggests that, despite some fears from the teachers, the outdoor environments did not overwhelm or worsen any feelings for Tracy. To the contrary, we noticed that Tracy enjoyed being outside and looked forward to learning in the outdoor environments. In fact, several situations occurred while outdoors that reasonably could have led to conflict or feeling overwhelmed but did not. For instance, during the lesson where the class read a book about diffusing anger, one of his peers seemed to become annoyed with Tracy’s movements (stomping on the ground) and yelled, “Stop!” In response, Tracy stopped what he was doing and further conflict was avoided. In several other instances, Tracy was directed to pay attention or stop a certain behavior; in each case, Tracy effectively followed the teacher or peer’s directions and re-engaged with the activity. This was in contrast to the indoor lessons, where his behavior was observed to be more chaotic and unsettled. During one indoor lesson, Tracy interrupted the lesson by whispering, “Tornado!” unprompted. He then pretended to play the drums on his legs and moved his body and mouth throughout the rest of instruction. In another indoor lesson that required the students to sit on the carpet and watch a video, Tracy repeatedly spoke aloud during the video.

Perhaps most strikingly, Jacob’s goal of increasing his utterances as well as his responses to questions was clearly and certainly addressed while outside. Jacob spoke and responded to prompts more frequently while outside compared to inside; it also seemed that teachers and peers prompted Jacob to speak more frequently while outside as well. Reflecting on this, Ms. Smith said, “[Jacob] speaks up more. He speaks up more to his classmates, I would say, outside. Like, I think, ‘cause … he feels like there’s more space between him and the teacher … but he does initiate more conversation to his peers outside than he does inside.” Mrs. Barrett attributed this to the outdoor environment, noting, “[Ms. Smith] told me that he talked, had a conversation with another student in front of her, and he asked a question, point blank, to her … Very unusual. That’s where we see him, like, even after school, when they're outside playing, that's when we see him really interacting, is outside. That's when he … That’s his forte, I guess.” This was evident from the first outdoor lesson, when Ms. Smith noted that Jacob was speaking to his peers as she’d never observed before, through to one of the last sessions that we observed when Jacob and his peers found a spider on its web. When asked if he preferred the classroom or being outdoors, Jacob replied, “Outdoors.”

Separate from the frequency tracking of specific IEP goals, the group also experienced additional affordances from spending time outside. Ms. Smith observed “a higher energy level outside, just in more of an eagerness to participate because it's almost like it’s a surprise, what we're gonna, like, what are we gonna do now? And the kids really do look forward to it every time they come in.” The unpredictability of the use of outdoor environments excited and interested the students.

Both teachers repeatedly mentioned that all of their students were more focused while outside and exhibited clearer signs of listening during activities. Additionally, several students who were more prone to shouting out or interrupting other speakers inside were noticeably calmer and shouted out far less while outside. This was particularly true for Mark; according to Ms. Smith, “(Mark) doesn't call out as much outside. He listens more. I don't know why, but he does. I don't know if it's the environment or he knows we're doing something new so he has to pay attention more.” One of Mark’s daily behavioral goals was to reduce instances of blurting out in class; thus, these observations were particularly significant to the teachers.

Finally, the students seemed to benefit from the fresh air, the ability to more freely move around, and the ability to fidget or move when necessary while still listening without disrupting their peers’ learning. Additionally, while instances of the students struggling with behavior outside were very infrequent, Mrs. Barrett did note that the class “did have one incident out there where (a student) shut down, but after the … incident, like, he refused to move. So, we just calmly had everyone come back in because it was at the end. I let him sit there … He got up. Because usually before in the classroom, he would throw chairs, desks, things.” Thus, students potentially had more space to safely work through the process of regulating their emotions when outside. Most importantly, perhaps, in assuaging any fears that teachers may have about taking their autistic students into a new environment is Ms. Smith’s view that “no one’s (behavior has) gotten worse outside.”

The students were not the only participants who experienced clear positive effects from spending time outside. Both teachers repeatedly noted ways that they benefited from the experience as well. The teachers felt that the outdoor environments required them to be more creative in lesson planning. While this may have been challenging at times, they also noted that it made them “more thoughtful about the space we use and how we use it.” Additionally, the teachers seemed to harness the feelings of being challenged by their mission to use the outdoor environments in a productive way, sharing that while it was sometimes intimidating, they found the experience exciting as well. The other main impact that the teachers experienced was increasing feelings of peacefulness and calm while taking the students outside. Ms. Smith said that she doesn’t “feel quite as drained after being outside. I think it’s more refreshing because it's a break from the usual.

Nature can serve as an accommodation to support autistic students in meeting IEP goals, particularly due to the positive impact time outside has on stress reduction ( Ulrich et al., 1991 ). Our observations suggest that the outdoor environments did not hinder progress in meeting IEP goals and, in some cases, may have facilitated opportunities to work toward those goals due to lower stress levels.

Jacob, for instance, did not speak unprompted in the social skills class for the first half of the year when the class was inside, likely due to selective mutism. Selective mutism is reported as being connected to stressful life experiences, including those occurring at school ( Muris and Ollendick, 2015 ), though some autistic individuals with selective mutism are reported as not speaking due to a lack of interest in the social context rather than shyness or anxiety ( Steffenburg et al., 2018 ). It is possible that this was a factor for Jacob as well. During the first trip outside and in many subsequent sessions, Jacob participated verbally. There could be a number of reasons that Jacob felt more able to speak while outside; these include having physical distance from the teachers, feeling more relaxed and enjoying class more, or the different style of activities used in some instances outside (e.g., incorporating more physical movement). Additionally, the stress reduction that occurs in nature might have allowed Jacob to feel comfortable enough to speak. Whatever the reason, it was evident from tracking Jacob’s utterances, both prompted and unprompted, that being outside led to an increase in utterances, moving him closer to that specific IEP goal.

In the case of Tracy, the outdoor environments did not cause him to feel overstimulated to the point of having difficulty regulating his feelings or behavior. While we are not able to conclude whether this was from being in an outdoor space or if another alternative education space that was indoors would have had a similar effect on him, it is possible that the stress reduction from being outdoors minimized feelings of overstimulation. Regardless, the impact of the outdoor environments on Tracy was not a negative one. Both Jacob and Tracy’s suspected experiences of lower stress levels outdoors are supported by prior research (e.g., Wells and Evans, 2003 ; Chawla, 2015 ).

Finally, the outdoors seemed to provide a topic of conversation for Curtis, as he asked several questions regarding the details of his class going outside. In the case of all three students, being outside did not hinder their progress toward addressing their IEP goals; rather, our data suggest that outdoor environments moved them closer to reaching those goals. Given the well documented negative effects that poorly designed indoor classrooms can have on autistic children ( McAllister and Maguire, 2012 ), accessing an educational space that does not have those same detrimental impacts could have additional beneficial effects and should be considered as a relatively accessible support or accommodation. Despite the aforementioned benefits, it is important to avoid romanticizing the positive impacts of time outdoors for autistic children. It is unreasonable to expect that all people, including all autistic children, will enjoy being outdoors all of the time or respond positively; in some cases, time in or near nature may increase anxiety ( Larson et al., 2018 ).

While this began as a study focused on how outdoor environments might affect autistic students, the picture that emerged following five months of data collection placed the teachers’ experiences front and center as well. The two special educators demonstrated a growth mindset; they began the study with no outdoor learning experience, confronted the barriers that they came across throughout the process, and appreciated the benefits that outdoor learning offered to themselves and their students. This growth mindset was likely supported by the impacts to teachers that we did not expect. There are many legitimate reasons why teachers may be hesitant to take their students outside; these include time constraints, safety concerns, lack of confidence, or rigidity in developing lessons to adhere to standards ( Rickinson et al., 2004 ; Dyment, 2005 ). Several of these barriers were factors for the teachers in the study, particularly the lack of confidence and feelings of having insufficient time. Despite the presence of these challenges, Ms. Smith and Mrs. Barrett persisted and continued to take their students outside. Thus began what seemed to be a feedback loop: the more the teachers took their students outside, the more the students looked forward and expected to go outside. Furthermore, as the teachers gained more experience taking their social skills group outside, their confidence increased to the point that, unprompted, they began taking their other classes outside as well.

Additionally, teachers are undoubtedly under a tremendous amount of stress, which can lead to burnout and negative impacts to wellbeing ( Richards et al., 2018 ). While we initially expected Ulrich et al.'s (1991) SRT to be a factor influencing how autistic students responded in the outdoor environment due to reported stressful school experiences, it is possible that the teachers equally benefited from stress reduction while outside, evidenced by continued mention of feelings of calm, enjoying the peace of the outdoors, and feeling less drained. It would seem that in the midst of a chaotic school day, spending time outside offered a reprieve for the teachers that outweighed the difficulties of identifying and planning lessons to execute outside. Feelings of lowered stress and increased relaxation are among the most commonly noted positive effects of exposure to nature for adults ( Maller et al., 2006 ; Morita et al., 2007 ; Cole and Hall, 2010 ).

In particular, Mrs. Barrett seemed to undergo a stark transformation. When approached about the research, we received a more reluctant acceptance from Mrs. Barrett; it seemed that Ms. Smith naturally took the lead, likely due to a higher comfort level with the topic or more motivation to tackle the opportunity. Whatever the reason, it is due to this initial hesitance that Mrs. Barrett’s experience taking her students outside is more striking. When interviewing her at the end of the study, she reported having opted to take her other special education classes outdoors as well, citing the positive feelings that she got from the experience as a driving factor. She made at least three references to feeling peaceful and calm while outdoors in her second interview. Mrs. Barrett also seemed to evolve in her expectations of her students while outside, mentioning that as long as she knew her students were listening, she did not mind them moving around or choosing to stand or lay down while she taught outside. This contrasted with her teaching style inside, which was far more structured and emphasized traditional listening cues such as sitting upright, being quiet, and maintaining eye contact.

Future Research

Despite our initial focus on the development of the students, the teachers in our study, Ms. Smith and Mrs. Barrett, became crucially important to the overall case. The evolution and impacts that they experienced suggest that future research should explore the wellbeing effects for teachers who take their students outside as well as the implications this may have for job satisfaction, teacher retention, and reducing burnout.

In our observations of a social skills class consisting of five autistic students and their two special education teachers who incorporated outdoor learning into their day for five months, we saw a range of affordances available to teachers and students alike and ample evidence of their enjoying these affordances. Harnessing such benefits in an educational context requires teachers who are willing and capable of supporting students in engaging with the outdoors. Ms. Smith and Mrs. Barrett, neither of whom had any previous experience or training with taking autistic children outside to learn, were able to adapt their existing knowledge and skills to support their students in learning in the new environment. Additionally, there was no evidence of students experiencing negative outcomes or feeling worse while outside. Coupled with the progress that students such as Jacob showed during the outdoor lessons, this suggests that nature should be considered as an option to meet the needs of autistic children during the school day. This case study serves to demonstrate that, even for teachers with no prior experience taking children into nature, outdoor learning is possible and beneficial to everyone involved.

Data Availability Statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.

Ethics Statement

The studies involving human participants were reviewed and approved by Elon University Institutional Review Board. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.

Author Contributions

SF and SM contributed to conception, design, and recruitment for the study. SF collected data. Both SF and SM contributed to analysis. SF wrote the first draft of the manuscript, and both SF and SM revised and approved the manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

The authors would like to thank Jessica Wery and Maddie Craft for their assistance on this study.

1 Following Kenny et al.’s (2016) study of preferred terminology in the autism community, we are using identity-first language throughout.

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Keywords: outdoor learning, nature-based learning, special education, case study, autism

Citation: Friedman S and Morrison SA (2021) “I just want to stay out there all day”: A Case Study of Two Special Educators and Five Autistic Children Learning Outside at School. Front. Educ. 6:668991. doi: 10.3389/feduc.2021.668991

Received: 17 February 2021; Accepted: 30 April 2021; Published: 20 May 2021.

Reviewed by:

Copyright © 2021 Friedman and Morrison. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Samantha Friedman, [email protected]

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Diagnosing Adult Autism: Case Study

Lukenotes, spring 2017.

Sister Monica received a message from her superior, asking her to meet later in the day about something that was very important.

Immediately, Sr. Monica began to feel anxious. She had a good relationship with Sr. Mary. She found her compassionate, but she could tell by the tone of her voice that the meeting was serious.

Sr. Monica finished up her paperwork at the parish and headed to her house where she could retreat to her room.

She thought about having a drink before the meeting to calm her nerves, but knew that this was not a good idea. However bad it was, things would be worse if Sr. Mary smelled alcohol on her breath.

Once home, she politely said hello to the other sisters before heading upstairs. Sr. Monica had learned it was far easier to say something polite quickly rather than not say anything at all. As a child, not responding had earned a good deal of teasing. In her room, she lay down and tried to relax, though unsuccessfully.

The Meeting

Later that afternoon, Sr. Monica nervously walked into the meeting with Sr. Mary, who jumped right into the issues. A number of people had reported concerns about Sr. Monica. The pastor, Father John, complained about her chronically tardy paperwork. He reported that when he raised the issue, sometimes angrily, she simply stared at him blankly.

The sisters she lived with said she rarely spent time with them, refusing invitations to dinner, movies, and even skipping out on meetings, household duties and communal prayer. They had expressed concern that they sometimes smelled alcohol on her, as well. Sr. Mary asked Sr. Monica directly what was happening and if she was all right.

Sr. Monica shared that the past several months had been very hard. She had no friends in community, felt awkward and was overwhelmed by tasks at work. She was trying her best to get things done and fit in, but no matter what she did, something never felt quite right and people either ignored her or became frustrated. This had happened most of her life. She had been hopeful things would be different when she took on this new ministry and living situation. As a way of coping with the anxiety, she had started drinking daily.

Finding an Answer

Sr. Mary contacted the community’s health administrator, who referred them to Saint Luke Institute.

Sr. Monica came to Saint Luke for a one-week evaluation. During one of the interviews with a therapist, she talked about her background. She did not speak until she was two years old. Even after that, it was difficult for her to communicate with others. She was relentlessly teased throughout elementary school for being so quiet, for having a hard time reading aloud and for a habit she had of rocking back and forth when she was upset.

During high school, a school psychologist suggested she had ADHD and dyslexia.

Raised in a devout Catholic family, she felt called to a religious vocation and she had come to love the sense of community and dedication she gained from religious life.

After interviews, neuropsychological testing and medical and psychiatric consultations, the evaluation team at Saint Luke diagnosed Sr. Monica with autism spectrum disorder, generalized anxiety disorder, persistent depressive disorder, and alcohol use disorder. This was the first time anyone had suggested autism.

Given the complexity of issues, the team recommended residential treatment. While at Saint Luke’s Talitha-Life program for women, Sr. Monica learned more about ASD. She was relieved to feel that it was not that she was stupid or lazy, but that her brain simply worked differently.

In individual and group therapy, she learned how to better communicate and interact with other people. She learned to identify healthy ways of coping with stress and anxiety and, working with her therapists, identified sources of support to help her continue to stay healthy after residential treatment.

Saint Luke’s continuing care team assisted both Sr. Monica and her community with her transition back to ministry, with a re-entry workshop, support team and follow-up care. This provided Sr. Monica and the community leadership great relief.

Disclosing her Diagnosis

After discussing the issue with her therapists and support team, Sr. Monica decided to disclose her diagnosis to her community. Several members approached her to offer words of support. While there are still moments of challenge and frustration, Sr. Monica has come to see her experience as one of learning and perseverance.

She began teaching and assisting sisters at their retirement home, a better fit for her than the heavy administrative position she had at the parish. When Sr. Monica looks back, she regrets the years of not knowing. Still, she is grateful for the opportunity now to understand herself better and, with the right support, to continue living out and sharing her vocation in a meaningful way.

Tasha Dorsey, Psy.D., is a therapist for the residential program at Saint Luke Institute.

To ensure confidentiality, names, identifying data and other details have been altered.

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Pharmacotherapy in autism spectrum disorders, including promising older drugs warranting trials

Jessica hellings.

Department of Psychiatry, University of Missouri-Kansas City, Lee's Summit, MO 64063, United States. [email protected]

Corresponding author: Jessica Hellings, MB.BCh., MMed, Professor, Department of Psychiatry, University of Missouri-Kansas City, 300 SE Second St, Lee's Summit, MO 64063, United States. [email protected]

Available pharmacotherapies for autism spectrum disorders (ASD) are reviewed based on clinical and research experience, highlighting some older drugs with emerging evidence. Several medications show efficacy in ASD, though controlled studies in ASD are largely lacking. Only risperidone and aripiprazole have Federal Drug Administration approval in the United States. Methylphenidate (MPH) studies showed lower efficacy and tolerability for attention deficit hyperactivity disorder (ADHD) than in the typically developing (TD) population; atomoxetine demonstrated lower efficacy but comparable tolerability to TD outcomes. Guanfacine improved hyperactivity in ASD comparably to TD. Dex-troamphetamine promises greater efficacy than MPH in ASD. ADHD medications reduce impulsive aggression in youth, and may also be key for this in adults. Controlled trials of the selective serotonin reuptake inhibitors citalopram and fluoxetine demonstrated poor tolerability and lack of efficacy for repetitive behaviors. Trials of antiseizure medications in ASD remain inconclusive, however clinical trials may be warranted in severely disabled individuals showing bizarre behaviors. No identified drugs treat ASD core symptoms; oxytocin lacked efficacy. Amitriptyline and loxapine however, show promise. Loxapine at 5-10 mg daily resembled an atypical antipsychotic in positron emission tomography studies, but may be weight-sparing. Amitriptyline at approximately 1 mg/ kg/day used cautiously, shows efficacy for sleep, anxiety, impulsivity and ADHD, repetitive behaviors, and enuresis. Both drugs have promising neurotrophic properties.

Core Tip: Most prescribing in autism spectrum disorders (ASD) is off-label; only risperidone and aripiprazole are Federal Drug Administration-approved in ASD, for irritability. Atypical antipsychotics are associated with metabolic side effects. Loxapine at 5-10 mg/day resembled an atypical antipsychotic in positron emission tomography studies; preliminary studies and clinical experience in ASD suggest efficacy and a promising metabolic profile. Controlled attention deficit hyperactivity disorder (ADHD) medication trials in ASD youth include methylphenidate, atomoxetine and guanfacine. The author recommends dextroamphetamine as an important treatment option for ADHD in ASD. Amitriptyline often improves impulsive aggression, self-injury, sleep, anxiety and enuresis. This article recommends additional older drug trials in ASD: Detroamphetamine, amitriptyline, loxapine, and lamotrigine for likely seizures.

INTRODUCTION

Autism spectrum disorder (ASD) is diagnosed using criteria of significant deficits in social communication and interaction, together with at least two types of restricted and repetitive interests and behaviors (RRBs)[ 1 ]. ASD develops prenatally and during early childhood. There is no longer an age cut-off for diagnosis, though it is often evident by age 1-3 years. The prevalence of ASD has risen globally since 2000. Two separate United States studies using the 2016 National Survey of Children’s Health reported ASD prevalence of 1 in 40 children[ 2 , 3 ]. After decades there is still no definitive medication treatment for the core features of autism likely due to the heterogeneity of ASD, including various genetic causes. Recent studies with negative findings for core symptoms include oxytocin, bumetanide and selective serotonin reuptake inhibitors (SSRIs) fluoxetine and citalopram for RRBs[ 4 ]. A meta-analysis confirmed there are still no treatments with efficacy for RRBs[ 5 ].

In addition to core ASD disabilities, the majority of these individuals have other serious challenges affecting them. Approximately 30%-50% also have intellectual disability (ID)[ 6 ]. Those more severely affected for example by birth injuries may have hydrocephalus and cerebral palsy, along with varying degrees of motor paralysis. Although there is a tendency worldwide to diagnose ASD in high-functioning, milder cases, an estimated quarter of individuals with ASD have less than 20 words of expressive language and are thus minimally verbal[ 7 ]. Approximately 20%-40% of those with ASD also have epilepsy, with greater rates in the more severely affected[ 8 ], which includes minimally verbal individuals.

In addition, psychiatric illness occurs several times more commonly in those with ASD than in the general population[ 9 , 10 ]. Common presenting problems include hyperactivity, impulsive aggression, property destruction and self-injury, which are not Diagnostic and Statistical Manual-fifth edition-Text Revised (DSM-5-TR) diagnoses. A study of 1380 youth with ASD found that over two thirds (68%) manifested aggression towards a caregiver, and almost half (49%) showed aggression towards non-caregivers[ 11 ]. Psychiatrist training in the field of developmental disabilities is seriously lacking in most universities worldwide, and has marginally improved in the United States in the past 5 years[ 12 , 13 ]. Individuals with ASD and their caregivers have great difficulty identifying a provider in their geographical area who will treat them. The field still suffers from a serious lack of clinical trials to guide treatment of psychiatric comorbidity. Those providers who treat such patients must rely on the few ASD clinical trials published, experience gained by different medication trials, and extrapolation from studies in typically developing (TD) individuals.

An analysis of 33565 children with ASD, found that 35% received 2 or more psychotropic medications, while 15% received 3 or more[ 14 ]. Polypharmacy especially with antipsychotics is even greater in adults, when many non-psychiatric medications are also prescribed apart from psychotropic medications[ 15 ]. The lack of evidence base results inevitably in exposure of these individuals to repeated medication trials, an unnecessary burden of side effects, and attrition from care[ 16 ]. Individuals with ASD often have one or more comorbid DSM-5-TR diagnoses. Working DSM-5-TR diagnoses are important guides for selecting classes of medications. Diagnostic symptoms of DSM-5-TR diagnoses may be more difficult to recognize in those more severely affected, including the minimally verbal. The Diagnostic Manual of Intellectual Disabilities-2 (DM-ID2)[ 17 ] is a useful crosswalk for applying DSM-5 criteria to individuals with intellectual and developmental disorders and/or ASD. Clearly the verbal criteria for diagnoses are not used in the minimally verbal.

Only risperidone and aripiprazole are Federal Drug Administration (FDA)-approved in the United States for individuals with ASD and irritability. The few other drugs prospectively studied in randomized controlled trials (RCTs) in ASD include methylphenidate (MPH), atomoxetine (ATX), guanfacine, the SSRIs fluoxetine and citalopram, and valproic acid[ 18 ]. Metformin, arbaclofen, lovastatin, trifinetide, 5-hydroxytryptamine7 (5-HT7) agonist ligands, flavonoids, and the dietary supplement sulfurophane amongst others, are still being studied[ 4 ]. More RCTs are urgently needed for individuals with ASD/ID. While studies continue to test possible treatments for the core symptoms of ASD, even experts frequently run out of options for the many comorbidities, after many medication trials including clozapine have failed. It may also turn out that no one drug will target and treat the core symptoms in ASD, given the vast heterogeneity of genetic and other causes.

Behavior analysis and psychosocial treatments play a key role in any overall management plan, since problems due to environmental factors or maladaptive learning will not respond to medication treatments. This article highlights several available older medications, with decades of community use in the general population, that show promise in ASD. Emerging evidence about them includes preliminary observed efficacy, neurotrophic effects and apparent tolerability in low dose.

ATTENTION DEFICIT HYPERACTIVITY DISORDER: EXISTING STUDIES AND EMERGING EVIDENCE ON OTHER OLD MEDICATIONS

Symptoms of attention deficit hyperactivity disorder (ADHD) include inattention, distractibility, hyperactivity and impulsivity. ADHD in ASD is often associated with dangerous behaviors including impulsive aggression and self-injury[ 19 ]. Prior to DSM-5, ADHD was not recognized as a separate diagnosis for individuals with ASD. Since it does not manifest in all individuals with ASD but does so in a large proportion, notably 28%-68%[ 20 ] it is now included as a separate diagnosis. ADHD is increasingly identified and treated in adults with ASD; a recent study found high rates of ADHD in 63 tertiary-referred adults with ASD screened for psychiatric comorbidity, notably 68% for lifetime prevalence of ADHD[ 9 ]. Additionally, ADHD is less likely to improve after adolescence in youth with ASD than in the general population with ADHD. In the community, inattentive-type ADHD is the most common subtype found in ASD/ID, however it is often untreated.

The hyperactive-impulsive subtype of ADHD has poorer outcomes in individuals with ASD, related to the more disruptive nature of hyperactivity as well as a greater likelihood of impulsive aggression, self-injury and property destruction[ 19 ]. Affect dysregulation, the inability to properly regulate and modulate emotions, was not included in DSM-5 as a diagnostic feature of ADHD, but is emphasized in DM-ID2 as an important feature in individuals with developmental disabilities including ASD. The authors of the DSM-5 ADHD criteria later published an article emphasizing affect dysregulation as an important part of ADHD[ 21 ]. ADHD-associated mood fluctuations present an important source of impairment especially in those with developmental disabilities and ADHD. Especially in adults with ASD, the ADHD diagnosis may be overlooked, resulting in a bipolar or borderline personality disorder misdiagnosis.

ADHD medications are important for improving learning, speech and language, and executive functions including inhibitory self- control. These medications improve affect dysregulation in ASD, which often manifests as impulsive aggression when the person is frustrated. Response inhibition of affective fluctuations such as laughing or crying is impaired in ADHD, related to executive function deficits. A meta-analysis of executive function in ASD found that broad executive function deficits remain stable and do not improve across development in such individuals[ 22 ]. Obsessive compulsive disorder (OCD) is very commonly associated as well in ASD, and could complicate treatment of ADHD with stimulants since the latter may increase anxiety in a dose-related manner[ 23 ]. On the other hand, non-stimulant ADHD medications may help reduce OCD and repetitive behaviors in ASD, although studies are still needed. Medications for ADHD can be divided into stimulant and non-stimulant drug categories.

When to try stimulants in ASD?

Stimulants are more likely to show efficacy and tolerability in higher-functioning individuals with ASD who have predominantly ADHD symptoms in contrast to cases with OCD symptoms, prominent repetitive behaviors or self-injury. In the latter group, non-stimulant medications may be a more tolerable choice. Young children with ASD often begin their first ADHD medication trials when their disruptive behavior interferes with education of themselves and others in the classroom. As with TD young children with ADHD, the first drug tried is usually the stimulant MPH, in divided doses three times a day, up to 1 mg/kg/day or less; individual responses vary.

Dextroamphetamine (DEX) immediate release (ir) merits study in ASD, according to the author’s decades-long experience. DEX has double the potency and duration of action as MPH, notably 4 to 6 h. A meta-analysis comparing efficacy of stimulants in 23 controlled studies for ADHD found a modest advantage of amphetamines over MPH for treating ADHD in pediatric patients[ 24 ]. Divided doses given morning, lunch time, and a half-dose at 4 pm if needed, totaling approximately 0.5 mg/kg/day or less give good coverage, better than MPH. Overall, DEX ir produces less lunch-time appetite suppression, less anxiety and irritability than long-acting stimulants according to author experience. Despite the current low level of evidence for DEX in ASD, clinical trials are warranted, and patient trials in the office may be beneficial.

However, MPH is the only stimulant studied so far in ASD, with findings of lower tolerability and lower efficacy than in TD youth. Large studies include a multisite study by the group Research Units on Pediatric Psychopharmacology (RUPP)[ 25 ], and a Cochrane database systematic review[ 26 ]. The RUPP study of 72 children with ASD, aged 5 to 13 years, found all low doses studied were superior to placebo for hyperactivity and impulsivity. Subjects were pre-selected for ability to tolerate a test dose of MPH for a week. Total doses, each given for a week, were 0.125 mg/kg, 0.25 mg/kg, and 0.5 mg/kg and were deliberately low in order to minimize side effects. However only 49% were responders, a rate much lower than the 75% response rate in TD children. Even the greatest effect size of 0.54 was significantly lower than that for ADHD response in TD children. Side effect rates were approximately double those found in TD children, and 18% exited the study early due to intolerable side effects. These included irritability, decreased appetite, and insomnia. Parent-rated lethargy, social withdrawal, and inappropriate speech increased significantly. There are also two small RCT studies and one multisite study of MPH for ADHD in ASD. Two small RCT studies of MPH for aggression in ASD found benefit over placebo on the Aberrant Behavior Checklist-Irritability (ABC-I) subscale[ 27 - 29 ]. Intolerable side effects were common in the latter study also, including mood changes, agitation and abnormal movements.

The Cochrane systematic review[ 26 ] of MPH in children and adolescents with ASD included 4 crossover studies, totaling 113 children ages 5 to 13 years; most (83%) were boys. There was a significant benefit on teacher-rated inattention but insufficient data to perform an impulsivity-outcome meta-analysis. Treatment duration for each dose of MPH was 1 wk. High-dose MPH significantly improved hyperactivity as rated by teachers in 4 studies, 73 subjects, ( P < 0.001) low quality evidence, and parents in 2 studies, 71 subjects ( P = 0.02), low quality evidence. Ratings were on the hyperactivity subscale of the ABC. MPH clinical usefulness is also limited by its short half-life of 2-4 h.

Of the long-acting stimulants in ASD, only one small study has been published. This small study of 24 children, mean age 8.8 years, found significant benefit of MPH-extended release in ASD[ 30 ]. However this was not a representative ASD sample, since the participants’ mean IQ was 85.0 (SD = 16.8). MPH-ER may be useful and more tolerable for example in high-functioning individuals with ASD. Comparative studies of long-acting stimulants are lacking in ASD, including for irritability[ 31 ]. Long-acting stimulants were designed to take effect and wear off gradually, and to reduce side effects and rebound effects in the general population with ADHD. However, clinical observations suggest that in ASD, long-acting stimulants may have even greater side effects than immediate-release preparations, including worsened anxiety, appetite suppression, self-injury, lip-licking, nail-picking, trichotillomania, and compulsive behaviors, in a dose-dependent manner. The more severe the ASD, the more of a problem such side effects present, although studies are needed. Therefore, non-stimulant ADHD medications may be preferable in these individuals.

When to try non-stimulant ADHD medications in ASD?

As stated, non-stimulant ADHD medications are preferable to stimulants for individuals who have more severe ASD, and those who also have prominent OCD, RRBs and self-injury. These include ATX, alpha agonists and tricyclic antidepressants (TCAs). Clinical experience in ASD suggests that these medications can be added to low-dose stimulants that are partially helpful if the person is unable to tolerate stimulant dose increases due to side effects. Several clinical trials in TD individuals have found efficacy and tolerability of ATX in combination with stimulants, although such combinations are not FDA-approved[ 32 ]. A recent review compared responses between MPH, ATX and guanfacine in 9 controlled studies of 430 children with ASD[ 33 ]. MPH and ATX were superior to placebo for ADHD. Poorer response was found in more cognitively disabled individuals.

Atomoxetine (ATX)

ATX is a noradrenergic reuptake inhibitor shown to produce improvements in inhibitory control as part of executive functions. Importantly, acute ATX administration increased behavioral inhibition as measured by a stop-signal task in adult ADHD not accompanied by ASD[ 34 ] as well as in normal adults without either ADHD or ASD[ 35 ]. Author experience confirms that ATX may be a good choice for impulsive aggression in ASD including in adults and minimally verbal individuals, and for poor focus and disorganization in higher-functioning individuals. A randomized, multisite 10-wk double-blind placebo-controlled trial of ATX, with or without parent training, was performed for ADHD in 128 children aged 5 to 14 years with ASD. ATX showed greatest efficacy together with parent- training, but also the drug alone was superior to placebo[ 36 ]. Overall, tolerability was good, to a maximum dose of 1.8 mg/kg/day; mean dose was 1.4 mg/kg/day. Dosing was divided into twice-daily doses, to reduce side effects. The most common side effects were nausea, decreased appetite, early morning wakening and fatigue. Suicidal ideation and QTc changes were not found, in contrast to findings in children without ASD[ 37 ]. In addition, another acute RCT study of 97 youths with ASD treated with ATX, including open long-term follow-up, showed moderately improved ADHD symptoms and side effects similar to those found in studies of ATX in youth with ADHD but no ASD[ 38 , 39 ].

ATX trials are warranted in ADHD in adults with ASD, especially for impulsive aggression, based on author experience. The strategy is to “start low and go slow” while response is observed for, using divided doses of twice a day to improve tolerability and coverage. A recent retrospective study disputes the need for extra caution however and found similar responses to ADHD treatments in adults with ADHD and ASD to those found in a comparison group with ADHD but no ASD[ 40 ]. The therapeutic window may be narrower in minimally verbal and lower-functioning individuals with more severe degrees of ASD, according to clinical experience. Should behavioral worsening occur after an ATX dose increase, the beneficial response is usually recaptured by dose reduction.

Amitriptyline

Amitriptyline in low doses may be especially useful if used with caution, in comparison with other available non-stimulant medications, despite a lack of comparative studies. TCAs including amitriptyline are second only to stimulants in ADHD efficacy, although most evidence for their use in ADHD is from studies of the second generation TCA desipramine in youth without ASD. An advantage over stimulants according to this author’s experience is that amitriptyline may benefit ADHD, anxiety, OCD, gastrointestinal pain, headaches, enuresis and insomnia[ 15 ]. Though currently there is a low level of published evidence, prospective studies are warranted, in the author’s opinion. A retrospective chart review on amitriptyline[ 41 ] published by the author’s group examined 50 tertiary-referred children and adolescents with ASD, ADHD and high rates of aggression and self-injury, who received low dose AMI (mean dose 1.3 ± 0.6 mg/kg/day) with mean trough blood level of 114.1 ± 50.5 ng/mL. Response occurred clinically in 60% of patients at the final visit, and in 82% of patients for at least 50% of follow-up visits. Importantly, 30% had failed ATX, and 40% had failed 3 or more other ADHD medication trials. Amtriptyline was used in combination with stimulants, most often low dose DEX ir, and also low dose risperidone or aripiprazole. In the low doses used amitriptyline did not cause complaints of constipation or urinary retention. Side effects included QTc increase on routine electrocardiogram, which did not halt treatment except in 3 cases with QTc > 440, behavioral activation and worsening of aggression. Prospective, randomized controlled studies of amitriptyline in ASD are warranted.

While a 2014 Cochrane review[ 42 ] of TCAs in TD youth showed no serious adverse events associated with taking TCAs, mild increases in pulse rates and diastolic blood pressure occurred. Of note is that the overdose risk with TCAs is lower in individuals with ASD since most individuals including adults with ASD do not self-administer their medications. TCAs should not be prescribed for use in chaotic households or those with a risk of overdose by a family member.

Alpha agonists

The class of alpha-agonist drugs is FDA-approved for ADHD in TD children but not in ASD. Since these drugs may benefit tics and Tourette disorder, they are usually a first-line treatment choice in such individuals. This drug class includes guanfacine, clonidine, long-acting guanfacine (Intuniv TM) and long-acting clonidine XR (Kapvay TM). An 8-wk multisite study of extended-release guanfacine in 62 children with ASD and ADHD, mean age 8.5 years, found a significant improvement in comparison with placebo. Modal guanfacine ER dose was 3 mg/day (range 1-4 mg/day)[ 43 ]. The most common side effects were fatigue, drowsiness and decreased appetite. For subjects on guanfacine, blood pressure dropped in the initial 4 wk, but returned almost to baseline by week 8. Pulse rate also dropped but remained lower than baseline at week 8. A small study of clonidine[ 44 ] examined response of 8 male children with autistic disorder in a double-blind, placebo-controlled crossover design for ADHD symptoms. While parent-rated Conner’s questionnaire ADHD ratings improved significantly during clonidine treatment, teacher ratings were not significantly improved except for oppositional behavior. Side effects included drowsiness and decreased activity. Due to their short half-lives, the immediate-release preparations of clonidine and guanfacine should be dosed 3 times a day. Dosing is built up gradually while monitoring for dizziness, hypotension and bradycardia. Other side effects include weight gain, sedation and irritability.

Although alpha agonists improve attention, studies in otherwise TD youth with ADHD have shown their combination use with a stimulant medication produces greater attentional improvement than does either alone. Combination treatments of alpha agonists and stimulants are FDA-approved for ADHD in the non-ASD population, but not in ASD. Clinical experience suggests however that alpha agonists may be less helpful for ADHD symptoms in adults with ASD.

Thus in the author’s opinion, DEX, ATX and amitriptyline may be useful additions to treatment options for ADHD comorbid with ASD, including in adults.

EXISTING ANTIPSYCHOTIC STUDIES, AND EMERGING EVIDENCE FOR OTHER ANTIPSYCHOTICS

Antipsychotics are used to treat psychosis as well as irritability in ASD, and are classified into two classes: Atypical/novel antipsychotics and typical/classical antipsychotics. ASD core symptoms including odd, stereotyped talk on unusual restricted topics of interest are still often misdiagnosed as schizophrenia symptoms in everyday practice. Psychosis can also be confused with bizarre behavior related to subclinical seizures, in which case antiseizure medications may help. Psychotic disorders can be comorbid with ASD, including schizophrenia, delusional disorder, unspecified psychosis, or as a component of a major mood disorder such as bipolar disorder, major depressive disorder or schizoaffective disorder[ 45 ].

Typical antipsychotics

Typical antipsychotics block dopamine D2 receptors to alleviate psychosis or mania, but produce motor side effects including acute dystonias, extrapyramidal side effects (EPS), tardive dyskinesia and more rarely, neuroleptic malignant syndrome which can be fatal. Haloperidol was studied in early trials by Campbell and colleagues, in young children, but found to produce tardive withdrawal movements[ 46 , 47 ] and further studies were halted. According to clinical experience, typical antipsychotics often have a lag time to onset of response in individuals with ASD, and increasing the dose early in treatment especially of high potency antipsychotics like haloperidol may result in extremely severe EPS and dysphagia after a while, especially more severely disabled individuals, with resulting joint contractures[ 16 ]. Low potency typical antipsychotics including chlorpromazine produce hypotension, slowing, cognitive dulling and weight gain in those with developmental disabilities as well as in the general population. Thioridazine produced QTc prolongation and is no longer marketed.

The medium-potency, typical antipsychotic loxapine blocks serotonin as well as dopamine, and in low doses resembles an atypical antipsychotic in positron emission tomography (PET) studies, but with less or no weight gain[ 48 - 50 ] which will be discussed in more detail below. Atypical antipsychotics were designed to overcome these motor side effects of typical antipsychotics by a different mechanism of action, notably by blocking serotonin as well as dopamine receptors, amongst others. However an unanticipated side effect of the atypical antipsychotics turned out to be weight gain, Type II diabetes and multiple other medical side effects[ 51 ], which are more severe in those with developmental disabilities. Atypical antipsychotics also produce possible motor side effects including neuroleptic malignant syndrome and tardive dyskinesia in the general population but also in ASD.

Atypical antipsychotics

Only two antipsychotics are FDA-approved in ASD, for children ages 6 years and older with irritability, notably risperidone and aripiprazole. The RUPP multisite 8-wk risperidone RCT study of 101 children and adolescents, mean age 8.8 years, found significant efficacy of risperidone vs placebo for irritability on the Clinical Global Impressions-Improvement subscale[ 52 ], and the ABC-I subscale[ 29 ] at a mean dose of 1.8 mg/day. Effect size was 1.2. Side effects included significant weight gain, appetite increase in 73%, fatigue in 59%, and drowsiness in 49%, as well as prolactin elevation. The greatest benefits reported by parents were for self-injury and aggression. Another larger multisite RCT study of risperidone and parent training in 124 children and adolescents ages 4 through 13 found that parent training could lessen the dose of risperidone needed[ 53 ]. Risperidone doses were a mean of 2.26 mg/day or 0.071 mg/ kg in the risperidone-only group, vs 1.98 mg/day or 0.066 mg/kg ( P = 0.04, two-sided test) in the combination group of risperidone plus parent training.

Weight gain associated with risperidone treatment was marked, especially in some individuals in a double-blind crossover study performed by the author’s group, of risperidone vs placebo for challenging behaviors in participants aged 6 to 65 with ID and ASD[ 54 ]. In a subset of 19 subjects over approximately a year, weight gain was as follows: Children ( n = 5) ages 8 to 12 years gained 8.2 kg on average, adolescents ( n = 6) aged 13 to 16 years gained 8.4 kg on average, and adults gained 5.4 kg on average[ 55 ]. Prolactin elevation is greater with risperidone than with other atypical antipsychotics. Breast development, galactorrhea and amenorrhea should be monitored[ 56 ]. It is important to monitor for weight gain and metabolic syndrome abnormalities, notably hypertension, glucose elevation, midline obesity, and triglyceride elevations. These are important predisposing factors for diabetes, stroke, myocardial infarction, and cognitive dysfunction and brain abnormalities[ 55 ]. In the author’s experience, keeping risperidone doses low at or below 2 mg/day total, and splitting dosing to three times a day can help minimize weight gain. Importantly, clinical experience suggests that risperidone may be the most effective antipsychotic for self-injurious behavior.

A multisite RCT of aripiprazole in 218 children and adolescents with ASD, aged 6-17 years, mean age 9.3 years, found significant improvement in irritability in the aripiprazole vs the placebo group. Doses were 5, 10 or 15 mg/day in this 8-wk, parallel groups study. However, there was no protection against long-term relapse, the author agrees with this finding based on clinical practice, meaning that the efficacy may decrease over time, and increasing the dose may not recapture the initial good response. Side effects included sedation, the most common side effect leading to discontinuation, and significant weight gain[ 57 ]. Mean weight increases at week 8 were 0.3 kg for placebo, 1.3 kg for 5 mg/day, 1.3 kg for 10 mg/day and 1.5 kg for 15 mg/day groups, all P < 0.05 vs placebo. Importantly, aripiprazole in a low dose of 1 mg/day normalizes prolactin for example in an individual responding to risperidone who has elevated prolactin producing gynecomastia[ 58 ]. One small open pilot study compared olanzapine with haloperidol in children with autistic disorder[ 59 ] and one studied ziprasidone vs placebo[ 60 ] in ASD. Metformin for weight gain treatment with atypical antipsychotics was studied in a 16-wk, 4-center multisite RCT of 60 children. Metformin was associated with reductions in future weight gain, notably body mass index (BMI) z-scores decreased significantly more from baseline to week 16 than in the placebo group ( P = 0.003). However metformin did not alter lipid abnormalities, and gastrointestinal side effects identified included abdominal discomfort, abdominal pains and diarrhea[ 61 ] (in contrast to loxapine substitution discussed below).

Loxapine resembles an atypical antipsychotic at 5-10 mg/day

Loxapine shows promise clinically in adolescents and adults with ASD according to preliminary studies, and RCTs are warranted. This antipsychotic is a dibenzoxazepine tricyclic structure classified in the medium potency group of the typical antipsychotic class. Loxapine was designed in the 1980s to resemble clozapine but without the clozapine molecular component causing agranulocytosis. Loxapine has a history of extensive use in schizophrenia, usually at 40 to 80 mg/day (maximum dose of 200 mg/day) and may lack the marked weight gain and metabolic side effects of clozapine and other atypical antipsychotics[ 62 ]. A case report of a 10 year old female with autistic disorder who responded to loxapine 15 mg/day described its efficacy for treatment-resistant aggression and self-injurious behavior[ 63 ]. In low doses of 5 to 10 mg/day, loxapine resembles an atypical antipsychotic on PET brain studies, but lacks the weight gain and metabolic side effects[ 64 , 65 ]. A prospective 12-wk open trial of loxapine for irritability and aggression in 16 adolescents and adults with ASD[ 48 ], demonstrated that loxapine in low doses of 5 to 10 mg per day significantly improved irritability ratings on the ABC-I, with large pre- to post- treatment effect sizes on 4 subscales, d = 1.0-1.1. Fourteen of 16 subjects completed the study, all of whom had Clinical Global Impressions-Improvement scale ratings of Very Much Improved or Much Improved at week 12. Larger clinical trials are warranted.

A retrospective loxapine chart review, also by the author’s group, of 15 outpatient adolescents and adults with ASD and irritability, illustrates the strategy of adding loxapine 5-10 mg/day, followed by extremely gradual taper of offending antipsychotics, which reversed weight gain, metabolic syndrome and insulin resistance including diabetes[ 49 ]. All those in the series had gained weight and manifested at least one other metabolic abnormality since starting on the baseline antipsychotic. Fourteen of the subjects were being treated with atypical antipsychotics and one received chlorpromazine, prior to addition of loxapine 5 to 10 mg daily, followed by behavioral improvement and then taper of the offending antipsychotic. Final loxapine dose in 12 subjects was 5 mg/day, and 10 mg/day in 2 subjects. At the time of chart review, all but one subject (93%) were Very Much Improved or Much Improved on CGI-I. Mean weight loss after an average of 17 mo (range 7 to 26 mo) on loxapine was -5.7 kg, with BMI reduction averaging -1.9. Mean reduction in triglycerides was -33.7 mg/dL ( P = 0.03). Two subjects were tapered off metformin by their endocrinologists, and one person’s insulin for Type II diabetes was discontinued. Weight loss did not differ in those already receiving metformin at the time of loxapine add-on ( n = 4) though the numbers are small and the reader is therefore cautioned.

In a long-term outcomes chart review study, of 34 children, adolescents and adults with ASD, mean age 23.4 years (range 8 to 32 years), long-term low-dose loxapine at a mean dose of 8.9 mg/day (range 5 to 30 mg) was associated with lower rates of tardive dyskinesia and EPS than expected for a typical antipsychotic, mean treatment duration was 4.2 years[ 50 ]. Stahl[ 62 ] describes the addition of low doses of a classical antipsychotic to an atypical antipsychotic to “lead in” or “top up” the effect. Using loxapine add-on at 5-10 mg/day, the author has been able to minimize risperidone dose increases above 1.5-2 mg a day total of risperidone and this strategy appears weight-sparing.

Dysphagia and bowel obstruction associated with antipsychotics

A clinical word of caution is important regarding minimally verbal and neurologically impaired individuals treated with antipsychotics. Dysphagia is a common but often overlooked side effect of antipsychotics, predisposing to aspiration pneumonia and initiation of parenteral feeding after surgical insertion of gastrostomy tubes, which may then be life-long if the antipsychotic medications are not changed. Aspiration pneumonia is more common in those with severe developmental disabilities and minimally verbal individuals and those with cerebral palsy or quadriplegia treated with even moderate doses of antipsychotics, especially if the individual also receives concomitant cytochrome P450 2D6 (CYP2D6)-inhibiting SSRIs[ 66 ].

Substitution of the antipsychotic with other medications if needed, and gradual dose taper may allow swallowing improvement and normal eating reinstatement provided a repeat video swallow study is normal. A large study in non-psychiatric inpatients without ASD receiving antipsychotics mostly for delirium control found a significant association with aspiration pneumonia in comparison with a non-antipsychotic-exposed group[ 67 ]. The association magnitude was similar for typical and atypical antipsychotics. Also repeated ED and medical visits are commonly needed for ostomy revisions and infections. In clinical practice the problem is often magnified in individuals with spasticity by high dose anticholinergics such as baclofen or tizanidine. SSRIs that inhibit CYP2D6 may increase the effective dose of antispychotics and other medications such that small-appearing doses actually are effectively much larger. In addition, such prescribing practices often lead to severe constipation, paralytic ileus, bowel obstruction and resection in individuals with severe disabilities. The author avoids using loxapine in individuals with severe disabilities and uses low dose risperidone in divided doses instead, due to the elevated dysphagia and EPS risks.

SSRI STUDIES IN ASD; AND WHAT DRUGS MAY HELP RRBs?

Ssri studies have not demonstrated efficacy for rrbs.

While SSRIs may initially appear to help anxiety, depression and compulsive behaviors they may later worsen problems significantly and produce behavioral activation, especially in higher doses, in a dose-related manner. A 12-wk RCT study of 149 youth aged 5 to 17 years with ASD treated with citalopram, dosed up to 20 mg daily (mean dose 16 mg/day) for RRBs in ASD, was negative[ 68 ]. Overall there was no change in repetitive behavior but also significant side effects occurred. These included impulsiveness, increased energy level, hyperactivity, decreased concentration, increased RRBs, insomnia, diarrhea and skin dryness and itching.

A 14-wk RCT study of 158 youth aged 5 to 17 years with ASD, treated with fluoxetine found no differences from placebo for RRBs as rated on the Child Yale-Brown Obsessive Compulsive Scale-Pervasive Developmental Disorders version[ 69 ]. Another fluoxetine RCT was also negative; Australian investigators randomized 146 youth aged 7.5 to 18 years with ASD to fluoxetine (20 mg/day if < 40 kg or 30 mg/day if ≥ 40 kg) or placebo. Any differences favoring fluoxetine were statistically nonsignificant after variables of gender, verbal abilities and baseline differences were controlled for. There was also no significant trend toward improvement on secondary outcome measures of RRBs, irritability, anxiety or global change[ 70 ]. An older, smaller RCT study of 39 youths aged 5-16 years found that a mean dose of 9.9 mg/day of fluoxetine was superior to placebo[ 71 ], however this has not been replicated. Some individual case studies and a case series suggested fluoxetine response however[ 72 ].

SSRIs are the most commonly prescribed drugs in ASD[ 4 ], although their use is not backed by study evidence. In the author’s experience they may be helpful in high-functioning individuals with ASD for anxiety or depression. The Cochrane collaboration literature review of SSRIs in autism found no overall benefit in ASD, weighing positive and negative studies against each other[ 73 ]. In the author’s experience, non-stimulant ADHD medications rather than SSRIs can help OCD and repetitive behaviors, including ATX and amitriptyline, this is anecdotal evidence but could be worth a try in the clinic. Many times the patient is presenting on an antipsychotic already. RRBs may relate also to ADHD symptoms, notably impulsivity, as part of a common cognitive impairment of executive function (“putting the breaks on”) i.e. non-specific response inhibition[ 74 ]. These investigators found significant associations between repetitive speech and impulsive speech, between stereotyped behavior and overactivity, and between restricted preferences and impulsivity. This study further justifies the argument for studying non-stimulant ADHD medications for RRBs.

The TCA clomipramine reduced RRBs in one small study

Two TCAs typically targeting OCD, repetitive behaviors and hyperactivity, notably clomipramine and desipramine were compared with placebo in one double-blind study[ 75 ]. The investigators compared clomipramine to placebo in 12 subjects with autism using a crossover design, together with 12 different subjects completing a parallel trial of clomipramine vs desipramine. Clomipramine was superior to placebo and desipramine in reducing ratings on stereotypies, compulsive ritualized behaviors ( P < 0.05) and anger, while desipramine was no different from placebo except in reducing hyperactivity. However in the author’s experience substitution of amitriptyline for clomipramine in patients who present on clomipramine has produced greater global clinical improvements. This was an empirical observation made by the author’s team in the 1990s that appears valid still today[ 41 ].

In a small cross-over study, 5 of 18 children (28%) treated with low dose fluvoxamine responded[ 76 ]. Fluvoxamine was found to benefit RRBs, maladaptive behavior, aggression and language in a small 12-wk RCT of 30 adults with autistic disorder[ 77 ]. Treatment studies of SSRIs or other classes of agents for depression and for suicidal behavior in ASD are lacking. For anxiety disorders in general in ASD, some smaller studies suggest the efficacy of citalopram, and some were positive for buspirone. One buspirone study in ASD found worsening of aggression and self-injury[ 78 ].

Maintenance benzodiazepines are avoided as a general principle in individuals with developmental disabilities, except for insomnia and as pre-sedation for blood tests and other procedures including dental work. Downsides include disinhibition effects, cognitive slowing and impairment, clumsiness, falls and injuries associated with benzodiazepine treatment.

HOW TO APPROACH ANTI-SEIZURE MEDICATIONS?

The therapeutic behavioral effects of anti-seizure medications in ASD for use other than seizures are inconclusive, according to available evidence. An RCT by the author’s team of valproic acid for aggressive behavior in youth with ASD was negative, although some subjects appeared to benefit from it, likely related to the heterogeneity within ASD[ 79 ]. Another study found valproic acid to be beneficial for RRBs in ASD, however this finding has not been replicated. Worsening of behavior occurred in 4 of 13 cases[ 80 ]. Divalproex was effective for controlling irritability associated with fluoxetine treatment in ASD[ 81 ].

Clinical experience suggests a trial of anti-seizure medication such as valproic acid or lamotrigine (LTG) may be beneficial especially if seizures are known or suspected, and the presentation of behavior problems is bizarre or atypical. This pertains especially to minimally verbal individuals with severe ASD, who have very high rates of seizures, and those with a known history of traumatic brain injury.

For mood disorders

Apart from ADHD, bipolar disorder is another, much less common cause of impulsive aggression in ASD. A 25% lifetime prevalence for bipolar disorder vs 68% for ADHD was found in a tertiary-referred population of high-functioning adults with ASD[ 9 ]. Minimally verbal individuals may also present with bipolar-like illness however studies of this portion of the ASD spectrum are still needed. Although lithium may be helpful, anti-seizure medications are a first line of treatment for bipolar disorder in individuals with developmental disabilities.

Divalproex and carbamazepine

Mood-stabilizing anti-seizure medications including divalproex and carbamazepine are the first-line treatments for mania, mixed or rapid cycling bipolar disorder in the general population[ 82 ] as well as in individuals with developmental disabilities. Valproate/divalproex is FDA-approved for bipolar mania but not for acute bipolar depression in the general population. Divalproex can also be effective for acute mixed bipolar disorder[ 83 ]. Side effects include weight gain, polycystic ovarian syndrome, low blood platelets, alopecia, elevated liver enzymes and less often pancreatitis. In addition, divalproex can cause ASD if taken in early pregnancy[ 84 ]. Weight gain, hepatic enzymes and blood cell counts require monitoring.

Both divalproex and carbamazepine are available in extended-release formulations. Carbamazepine is weight-neutral but side effects may include nausea, vomiting, dizziness, drowsiness, dry mouth, constipation and unsteadiness. A rare but extremely serious potential side effect of carbamazepine is Stevens-Johnson syndrome, which may start as an influenza-like illness but progress to a blistering skin rash, skin peeling and death.

Lamotrigine (LTG)

LTG is the mood-stabilizing anti-seizure medication of choice for bipolar depression treatment as well as prophylaxis[ 85 ]. Apart from the vigilance needed for a serious skin rash again associated with Stevens-Johnson syndrome, and the need to start LTG slowly to try and prevent this, the longer-term profile of LTG is favorable in comparison with other anti-seizure medications. Another important use for consideration in psychiatry, according to author experience, is for suspected seizures including spells of eye-blinking, mouth movements or disorientation episodes accompanied by bizarre behavior presentations in ASD, as mentioned above.

Evidence for LTG is weaker for acute bipolar depression and rapid cycling bipolar disorder in the general population. LTG must be started extremely slowly by adding a low dose every 1 to 2 wk, and even more gradually if the individual is receiving divalproex (adding 25 mg every 2 wk), to avoid a potentially life-threatening skin rash that begins on the upper chest region. Skin rash signs include skin peeling, blistering, hives, itching and painful sores in the mouth or around the eyes. Other LTG side effects include blurred or double vision, poor motor coordination, headache, drowsiness, and difficulty thinking or speaking.

Gabapentin is an add-on anti-seizure medication often prescribed off-label in psychiatry for various indications despite negative RCTs including for bipolar disorder. Rather than acting on gamma-amino butyric acid, gabapentin likely acts on calcium channels in the brain and spinal cord, and has few drug interactions since it is renally excreted. Gabapentin add-on to valproic acid and low dose antipsychotic was helpful in an open study by the author, in adults with developmental disabilities[ 86 ]. Gabapentin in divided doses 3 times a day, totaling 900 to 1800 mg a day were effective as add-on to valproic acid and low dose antipsychotic, and also in a subset replaced lithium and thus eliminated lithium side effects. Gabapentin side effects included dizziness and clumsiness; to prevent these it was started at 100 mg daily and increased slowly by only 100-200 mg per week, although prospective RCT studies are needed.

While lithium is still used in ASD, the side effects are often worse in those with developmental disabilities, and include polydipsia and polyuria (excessive thirst, drinking and enuresis) and tremor. Acute toxicity is a medical emergency requiring dialysis and intensive care units treatment, and is a greater risk in individuals with disabilities. Vomiting, diarrhea, failure to drink fluids for any reason, and certain medications including the angiotensin-converting enzyme inhibitor losartan predispose to toxicity[ 86 ].

Insomnia is very common in ASD and should not be interpreted as mania-related illness unless accompanied by other observable mania features. Another pitfall is that loud, rapid speech and outgoing personality may not be due to bipolar disorder but an enduring personality trait with a life-long history.

Anti-seizure medication-related behavioral side effects

Importantly, several anti-seizure medications while benefitting seizures may produce adverse behavioral effects. The latter may not have been considered by the neurologist if the seizures are adequately controlled. Therefore identification of such side effects by the psychiatrist is essential. Barbiturate-based anti-seizure medications including phenobarbital and phenytoin, and ben-zodiazepine-based medications, as well as vigabitrin often worsen behavior. Such medications may lead to an ADHD-like picture of affect dysregulation, hyperactivity, restlessness, impulsive aggression and self-injury[ 87 ]. Carbamazepine, oxcarbazepine, levetiracetam and topiramate may also worsen hyperactivity, mood or psychotic symptoms or other behavior problems. LTG and divalproex may be less likely to have behavioral side effects in adults with ASD according to clinical experience.

Studies included followed a broad and thorough literature review of pharmacotherapy in ASD, in order to provide a clear overview of the topic as well as the author’s expert opinion. For a summary of key points for pharmacotherapy in ASD (Table ​ (Table1). 1 ). Limitations of this opinion review include that aside from evidence-based guidelines, prescribing practices may be extremely variable, not only by country and region, but also by individual practitioners who may find other medications useful in ASD. The author has however attempted to provide a personal but balanced view overall. Regarding future drug treatments for core ASD symptoms it may not be possible for one drug to target and treat all of the many subtypes of ASD, given the many genetic and other causes. Of note is that while certain drugs such as ATX may not be available in all countries, amitriptyline is approved in many countries and is available in generic forms.

Key points for pharmacotherapy in autism spectrum disorders

Selective serotonin reuptake inhibitors may reduce anxiety or depression in high-functioning individuals but are unlikely to alleviate repe-titive/compulsive behaviors in autism spectrum disorders, and often cause activation and behavioral worsening. ASD: Autism spectrum disorders; ADHD: Attention deficit hyperactivity disorder.

CLINICAL PEARLS GLEANED OVER MANY DECADES OF RESEARCH AND PRACTICE TREATING ALL AGES WITH DEVELOPMENTAL DISABILITIES

Environmental and emotional causes are more likely to respond to behavioral consultation: this can be key also in treatment resistance.

It is important to emphasize that environmental and emotional causes of behavior problems will be more likely to respond to behavioral consultation and psychosocial interventions. Of late, there has been greater recognition of environmental contributors to psychiatric illness in the field in general. Abuse of all types is also more likely in vulnerable individuals such as those with developmental disabilities. Taking a detailed longitudinal history is essential, regarding likely environmental stressors such as family deaths or job losses, moves and staff changes leading to frustration and severe “protest” behavior problems including aggression, before making psychiatric diagnoses and trying medication treatments. Protest behaviors and use of aggression as communication are more likely especially if the individual has demonstrated consistently good functioning over one or more periods of time in their past. A developmental and childhood psychiatric history is also essential to understanding of presenting problems. Irritability can result from many non-psychiatric causes, including medical illness, lack of sleep, general frustration or unhappiness with a living situation. Treating just dimensional behavior problems, such as irritability or hyperactivity with single medications may be feasible for milder cases. As in other branches of medicine, if the diagnosis is wrong then the treatment will unlikely help.

Closer examination for ADHD and trying ADHD treatments pays off, including in females and adults with severe disabilities

This applies to ADHD wrongly diagnosed as bipolar disorder, since antipsychotics and mood stabilizers do not adequately treat ADHD-related impulsivity. This was a personal lesson the author learned early on in practice after specializing in treating this population. Females diagnosed with depression and recurrent suicidality may also respond to ADHD treatments, allowing for cautious taper off of antidepressants. Parents and caregivers often describe a person with ADHD person as “anxious” since they rarely sit still, and “moody” due to lack of affect regulation associated with easy crying or laughing spells.

DEX, ATX and amitriptyline are useful for ADHD comorbid with ASD

Impulsive aggression such as cussing, hitting, kicking, biting, pinching and running off may respond to one or more ADHD treatments if the ADHD history and diagnosis are elicited. Many adults already received treatment for ADHD as children but once transitioning services happens the ADHD diagnosis is overlooked. Although only studies in TD individuals are available as discussed above, a combination of low dose stimulant together with a non-stimulant ADHD medication such as ATX, amitriptyline or guanfacine may be needed. Low dose risperidone may also be used in combination with the ADHD treatments, although again only one study in the TD participants is available regarding this[ 88 ].

Two ADHD medications may be needed (stimulant and non-stimulant) possibly also together with low dose antipsychotic such as risperidone in moderate-to -severe cases with aggression. In the author’s experience, ATX is frequently clinically useful for ADHD with impulsive aggression, including in more severely disabled individuals. The tolerable doses may be lower than in higher functioning individuals, although improvements may be regained if the dose is decreased again after behavioral worsening following a dose increase occurs. More studies are warranted. Amitriptyline in low doses can be extremely helpful for cases with insomnia, headaches, gastrointestinal issues, ADHD, impulsive aggression and OCD, used with caution and watching for drug interactions. Studies are warranted of amitriptyline for RRBs in ASD according to author experience.

Are RRBs part of the ADHD spectrum, and could they respond to ADHD treatments?

The study by Burbridge and coworkers[ 74 ] leading to the concept of RRBs as related to ADHD, in other words a type of motor impulsivity, may be key to guiding future studies for RRB etiology and treatments. One study found ATX was somewhat effective for RRBs in youth with ASD, which is promising[ 39 ]. No known treatment currently exists for core ASD features, likely due to the heterogeneity and many different genetic causes. Metformin, arbaclofen, lovastatin, trifinetide, 5-HT7 agonist ligands, flavonoids, cannabidiol, cannabis and the dietary supplement sulfurophane amongst others, are still being studied[ 4 ].

Risperidone remains useful in youth with severe irritability and may be helpful for self-injury; dose at ≤ 2 mg/day in divided doses

Dosing risperidone at or below 2 mg/day given in divided doses may mitigate weight gain and metabolic side effects, though individuals vary in this regard. Another author observation is that risperidone may be the most effective medication for self-injurious behaviors including self-biting, head- banging, self-hitting and others. Weight gain and metabolic side effects require monitoring.

Loxapine at 5-10 mg/day resembles an atypical antipsychotic but likely with emerging safety evidence of a more favorable metabolic profile

Loxapine is one of the main antipsychotics now used in practice by the author and several colleagues in other regions, for adolescents and adults with ASD, related to an empirical finding made over 2 decades ago and then the preliminary published studies discussed above. Addition of 5-10 mg/day of loxapine often produces significant clinical improvement in irritability and aggression, which if needed then allows very gradual taper of other antipsychotics which have caused excessive weight gain or produced too little response. While a common practice may be to follow schizophrenia guidelines and convert a treatment-resistant person to a depo antipsychotic, hoping for improved aggression control, adding loxapine, in the author’s experience produces superior results overall. However loxapine is likely not suitable for more severely disabled individuals due to its potent dopamine blocking action that may cause dysphagia in them; low dose risperidone may be preferable in this setting. Olanzapine is another cause of dysphagia in those with more severe disabilities, according to clinical experience.

Gabapentin may be a useful add-on to divalproex and low dose antipsychotic if lithium is not a good choice for the individual patient

Published preliminary evidence on gabapentin add-on to valproate and low dose antipsychotic in ASD may be useful when lithium is not tolerated due to side effects, or if lithium toxicity has already occurred once or more. Studies are needed.

SSRIs may be helpful in higher-functioning ASD for anxiety or depression, but not for RRBs

SSRIs remain the most widely prescribed drug class in ASD in the United States overall. Recent negative studies of citalopram and fluoxetine for RRBs in youth with ASD are helpful in this clarification. In many cases, high dose SSRIs worsen OCD and agitation, while gradual SSRI taper may lead to clinical improvements. Also, in cases involving SSRIs increasing the effective antipsychotic dose due to CYP2D6 inhibition, swallowing impairment and bowel motility problems may be reversed by gradual SSRI taper and medication revisions.

Existing studies in ASD are useful guides for clinical practice, but many more are still needed. Most prescribing in individuals with developmental disabilities is of clinical necessity off-label. Some older psychotropic medications with emerging evidence may extend and improve possible successful treatment options for clinicians serving individuals of all ages with ASD and severe behavior problems. Until controlled studies of these drugs become available, cautious clinical use starting with low doses and minding drug interactions may be justified. Another important focus should be alerts regarding possible ADHD with impulsive aggression, especially in females and in adults with ASD. The older medications worth trying include, but are clearly not limited to, DEX, ATX and amitriptyline for individuals with ADHD associated with impulsive aggression.

For irritability and psychotic comorbidity in adolescents and adults with ASD, preliminary published evidence and clinical experience point to loxapine in doses of 5-10 mg/day having atypical antipsychotic properties but likely with lower metabolic risk associated. For likely seizure activity associated with bizarre behaviors that is unable to be worked up via electroencephalogram due to lack of cooperation, LTG may be considered, especially in those with severe disabilities since they have higher rates of seizures. No medications have been identified and replicated so far to treat the core symptoms of autism, including RRBs. Drugs without demonstrated benefit for core symptoms include risperidone, oxytocin, bumetanide, buspirone, citalopram, fluoxetine, fluvoxamine and N-acetyl cysteine. While SSRIs are the most commonly prescribed drugs in ASD and may help individual patients, recent RCT studies did not show significant efficacy for RRBs in ASD, but rather a significant side effect burden including behavioral activation. Clinical trials of the older drugs discussed are warranted. All medications should be used in conjunction with other multimodal therapies including behavioral consultation, and selected for the individual patient.

ACKNOWLEDGEMENTS

Thanks to Jakob Waterborg, PhD, for assistance with the table.

Conflict-of-interest statement: The author has been an investigator for Janssen Pharmaceuticals, Abbott Laboratories, Forest Laboratories, Supernus, Young Living Essential Oils, NIMH and NICHD. NICHD previously funded a risperidone program project grant with the author as principal investigator of the drug study project. The author currently has internal funding from University of Missouri-Kansas City to study amitriptyline in ASD.

Provenance and peer review: Invited article; Externally peer reviewed.

Peer-review model: Single blind

Peer-review started: December 28, 2022

First decision: February 21, 2023

Article in press: April 18, 2023

Specialty type: Psychiatry

Country/Territory of origin: United States

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P-Reviewer: Hosak L, Czech Republic; Nwabo Kamdje AH, Cameroon S-Editor: Fan JR L-Editor: A P-Editor: Chen YX