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Autism Spectrum Disorders (ASD)

At Istituto di Neuroscienze del Prof. Stefano Pallanti psychological and physical health constitute a priority. Our care is tailored to each patient’s individual needs: we offer unique and individualized treatment programs, that go beyond the only use of drugs and psychotherapy. In fact, traditional treatments such as pharmacotherapy and behavioural therapy appear frequently inadequate, and for this reason we are studying other treatment options such as neuromodulation techniques (TMS and tDCS) for alleviating symptomatology in such kind of patients.

In line with our philosophy which support the necessity of a personalized medicine, great importance is given to the assessment process, which includes cutting-edge diagnostic testing and also the consideration of immune and microbioma profiles.

The diagnostic evaluations are  completed by teams of ASD experts in various disciplines who collaborate all together in order to elaborate a comprehensive and individual plan of care.

As experts in the Autism Spectrum Disorder (ASD) field, we provide our patients and their families with the most up-to-date diagnostic information and help them understand the patient’s strengths and needs. The treatment of ASD provided at INS follows a multimodal and multidisciplinary approach, which includes: 

behavioural intervention;

verbal and augmentative communication treatment;

cognition intervention;

neuromodulation techniques with different targets for specific clusters of symptoms;

social skills programs;

medical management;

family support services.

Driven by ongoing research, our clinical programs offer patients the most innovative therapies available. In line with our aim of a personalised psychiatry, the presence of one or more comorbid disorders can guide the selection of treatment options, but the interventions are combined on the basis of individual needs.

ASD and comorbid ADHD

According to DSM-5 it is now possible to diagnose ADHD in presence of an Autism Spectrum Disorder (ASD), in consideration of their frequent co-occurrence. As both conditions cause a negative impact on the daily life of people affected and their families, we elaborated a specific program which include training on social skills and communication as well coaching for improve planning and organizational capabilities. To improve social cognition, we developed a specific software to enhance emotion recognition that is used during neuromodulation (tDCS) on the specific targets for reducing ASD as well ADHD symptomatology.

Towards a personalized approach

ASD is a disorder that reduces the quality of life of individuals affected and determines a heavy social and financial burden for the families. At INS we use new treatments that can be integrated easily into the daily life of patients: among these there are telemental health service and the use of particular tools that allow patients to be treated directly at their home, under the supervision of the clinicians thanks to specific web platforms.

In this way medical appointments and health-care costs can thereby be reduced, and at the same time the acceptance of the treatment is increased.

Brain inflammation and Microbioma
We believe in the role of brain inflammation as a detrimental factor for ASD symptomatology and for the patient wellbeing. As not every individual with autism has brain inflammation, but a significant percentage do or are suspected of having this problem, specialists at INS always consider such possibility and promote therapies that have been demonstrated to be helpful.

Moreover, since accumulating evidence demonstrates that gastrointestinal symptoms are a common comorbidity in patients with ASD, and are also associated with a greater severity of ASD, we also promote the use of specific supplements, such as probiotics, that have shown to exert beneficial effects on gut microbiota.

Trascranial Magnetic Stimulation (TMS)

Mental and neurodevelopmental disorders are disorders of brain circuitries and the Neuromodulation techniques are privileged tools to act on brain circuitries. Transcranial Magnetic Stimulation is a method for non-invasive focal cortical stimulation where small intracranial electrical currents are generated by a rapidly fluctuated extracranial magnetic field. In the table, there are some TMS targets and observed positive effects.

rTMS protocol	Neural Targets	Observed symptom dimensions’ improvement
Low frequency	Dorsolateral prefrontal cortex  (Baruth, 2010; Casanova, 2012; Tasman, 2014)	Irritability / Repetitive behaviors  Error monitoring Target detection
	Inferior frontal gyrus (Fecteau, 2011)	Object Naming
	Supplementary motor area (Enticott, 2012)	Motor planning
	Primary motor cortex	Motor planning
High frequency	Medial prefrontal cortex (Enticott, 2012)	Social communication mentalizing
	Premotor area (Panerai, 2013)	Eye-hand coordination Speech production

TMS IN ASD AND PERSPECTIVES

•Considered the heterogeneity in the ASD phenotype, TMS will be a privileged tool to dissect the phenotype and assess targets

•In line with NIH priorities towards precision medicine,  studies that multimodally combine TMS with functional neuroimaging and behavioral measures should be implemented to identify treatment target based on the anatomy of each individual patient and determine the efficacy of this intervention

•Efficient TMS protocol such as TBS with the potential to induce longer-lasting clinical effects with very short treatment sessions should be implemented

•TMS protocols could be combined with other treatment strategies, such as medications, neurofeedback or behavioral challenges

Transcranial Direct currents Stimulation (tDCS)

Another kind of neuromodulation technique is the non-invasive transcranial direct currents stimulation, which uses weak electric currents (1 mA or 2 mA). The stimulation is applied on the skull and modulates activity of cortical neurons by influencing membrane excitability. During the stimulation the patient feels only a light itching, that gradually tends to fade away and to be present during the turn on and turn off of the stimulation device. ASD is currently considered as a disorder of abnormal neural connectivity that underlines the neurocognitive deficits (e.g. theory of mind) and the impairments in social communication. It has been shown that tDCS induces modifications in intra- and interhemispheric connectivity and it is an effective alternative to pharmacological treatment in ASD.

tDCS applied over the Dorsolateral prefrontal cortex (DLPFC) showed to determine an  improvement in autistic symptoms and syntax acquisition, whereas tDCS applied over the temporo-parietal junction (TPJ), considered the key region of the social brain, improves social cognition and social interaction. In children and adolescents, 1 mA anodal tDCS causes an increase in cortical excitability resulting in changes in behaviour and performance.

At INS, when it is necessary we train patients and family to apply tDCS by themselves after a sufficient instruction and with  regular supervision or remote control of application. In this way tDCS can be applied in a home-based setting, reducing costs of clinic visits and increasing benefits thanks to the cumulative effect.

Finally, tDCS treatment costs less than TMS, so it is a cost-effective tool.

ASD + PANDAS

There is a condition frequently associated with ASD called PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections). It is caused by an immune reaction triggered by a toxin produced from a Group A Beta-Hemolytic Streptococcal infection, exerting an impact on the Basal Ganglia area in the brain. When basal ganglia are damaged some disorders emerge, such as tic movements, obsessive-compulsive behaviour and choreic movements. Our research and clinical team carefully investigates signs of the disorder, and in the case provide the most effective treatment to short-circuit the autoimmune response.

Oxytocine and ASD

Oxytocin is a hormone involved in social bonding that demonstrated beneficial effects in the treatment for individuals affected by ASD. It is administered either as a sublingual tablet or nasal spray, and it showed to improve social interaction. Moreover, by acting to decrease nerve signaling from the amygdala (“the emotional brain”), it reduces the anxiety and apprehension promoting easier social communication. 

At INS we include the oxytocin therapy in the treatment program because of its numerous benefits:

reduction of the cortisol levels and of anxiety and fear,

improvement social interactions and increases bonding,

enhancement facial recognition cues.

No adverse effect have been seen.

Social cognition + trainer on social competence and emotion recognition

Since an altered processing of emotions negatively affect the ability for social interaction and communication in ASD, we developed a specific software to train the emotion recognition, in both adults and children faces. Patients are trained to recognize a number of facial expression during a session of neuromodulation, with the specific protocol to improve social cognition.

Music Therapy and Autism Home About music therapy Music Therapy and Autism

Music therapy is known to reduce anxiety and social isolation, alleviate frustration and it can support both verbal and non-verbal communication. There is evidence supporting an utility of music therapy in improving communication in ASD by stimulating language development through songs and turn taking and increasing tolerance at sound. Moreover, it offers a diversion from repetitive behaviour and promote the development of expressive abilities and creativity.

At INS we use a particular device having the shape of a pillow that allows to listen to the audio contents by simply leaning the head on it. This comfortable listening experience allows the clinician to guide the exploration of emotions and feelings and the sharing of emotional experience.