**6. Clinical recommendations in ASD**

The following clinical recommendations can be done as a result of more than twenty years of personal clinical practice in Child Neurology dealing with ASD children, among other neuropediatric situations. For instance, our Child Neurology Unit (http://www.ufrgs.br/ neuropediatria) usually makes more than 16,000 neuropediatric evaluations per year.

From the clinical point of view, it is important to remember the ongoing changes in DSM criteria for ASD diagnosis. To date, we still deal with five different diagnosis of autism, according with DSM-IV criteria. Even after modifications due the new DSM-V classification, ASD children will remain as a heterogeneous group, making difficult the exact clinical diagnosis.

It is important to remember that ASD diagnosis can be catastrophic to parents. As a result, an incorrect diagnosis would be even worse. That is the reason to be careful in terms of making ASD diagnosis as well as to make a double check if diagnosis is really correct.

After finishing a list of the prominent symptoms, the next step is to decide if they are intense enough to deserve treatment, which is not easy. Some symptoms seem to be more unpleasant to parents than the ASD child. At this point, there is no guideline to follow, and the previous clinical experience is extremely helpful.

Usually the non-medical treatment is started earlier than the use of medications. It is important to remember the relevance of evidence-based CAM, since there are a great number of proposed non-medical treatments.

In general, medications are used in addition to non-medical treatments. The best medica‐ tion approach would be monotherapy, but it is not always possible in the real clinical world. Another critical problem in terms of psychopharmacotherapy is the paucity of well-conducted RCT, as pointed before in this chapter, especially in the table 2. To date, there are only two FDA-approved antipsychotic medications for ASD in children: risperi‐ done and aripiprazole.

Risperidone was approved by FDA in 2006. The usual dose varies from 1 to 3mg/day. In our practice, 3mg/day of risperidone seems to be the cutoff dose in terms of seizure susceptibility. We have identified patients who experienced seizures with doses higher than 3mg/day. Aripiprazole was FDA-approved in 2009 and the daily dose is up to 15mg.

Because of ASD patients are almost twenty times more prone to have epilepsy when compared with normally developing children, and because of many of the drugs used in autism can decrease the seizure threshold in susceptible children, it is important to assure that there is a previous normal EEG before prescribing psychopharmacotherapy.
