Clinical UM Guideline

 

Subject: Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
Guideline #: CG-BEH-15 Publish Date:    06/28/2018
Status: New Last Review Date:    03/22/2018

Description

This document addresses activity therapy (for example, music, dance, art or play therapies) when used to treat Autism Spectrum Disorders (ASDs) and Rett syndrome. ASDs, as defined in the fifth edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5), include disorders previously referred to as:

Note: For information on other services that may be provided for Autism Spectrum Disorders, see:

Clinical Indications

Not Medically Necessary:

Activity therapy, including but not limited to music, dance, art or play therapies, is considered not medically necessary for the treatment of Autism Spectrum Disorders and Rett syndrome.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

 HCPCS

 

G0176

Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient’s disabling mental health problems, per session (45 minutes or more)

 

 

ICD-10 Diagnosis

 

F84.0

Autistic disorder

F84.2

Rett’s syndrome

F84.3

Other childhood disintegrative disorder

F84.5

Asperger’s syndrome

F84.8

Other pervasive developmental disorders

F84.9

Pervasive developmental disorder, unspecified

Discussion/General Information

In May 2013, the American Psychiatric Association (APA) released the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This edition of the DSM includes several significant changes over the previous edition, including combining several previously separate diagnoses under the single diagnosis of “autism spectrum disorder.” This diagnosis includes the following disorders, previously referred to as: atypical autism, Asperger’s disorder, childhood autism, childhood disintegrative disorder, early infantile autism, high-functioning autism, Kanner’s autism, and pervasive developmental disorder not otherwise specified. All of these conditions are now considered under one diagnosis, ASD. It should be noted that Rett is not included in the new DSM-5 ASD diagnostic group.

The DSM-5 describes the essential diagnostic features of autism spectrum disorder as both a persistent impairment in reciprocal social communication and restricted and repetitive pattern of behavior, interest or activities. These attributes are present from early childhood and limit or impair everyday functioning. Parents may note symptoms as early as infancy, and the typical age of onset is before 3 years of age. Symptoms may include problems with using and understanding language; difficulty relating to or reciprocating with people, objects, and events; lack of mutual gaze or inability to attend events conjointly; unusual play with toys and other objects; difficulty with changes in routine or familiar surroundings, and repetitive body movements or behavior patterns. Children with childhood disintegrative disorder are an exception to this description, in that they exhibit normal development for approximately 2 years followed by a marked regression in multiple areas of function.

Individuals with ASD vary widely in abilities, intelligence, and behaviors. Some children do not speak at all, others speak in limited phrases or conversations, and some have relatively normal language development. Repetitive play skills, resistance to change in routine and inability to share experiences with others, and limited social and motor skills are generally evident. Unusual responses to sensory information, such as loud noises and lights, are also common. Children unaffected by ASDs can exhibit unusual behaviors occasionally or seem shy around others sometimes without having ASD. What sets children with ASD apart is the consistency of their unusual behaviors. Symptoms of the disorder have to be present in all settings, not just at home or at school, and over considerable periods of time. With ASD, there is a lack of social interaction, impairment in nonverbal behaviors, and a failure to develop normal peer relations. A child with an ASD tends to ignore facial expressions and may not look at others; other children may fail to respect interpersonal boundaries and come too close and stare fixedly at another person. Individuals with ASDs may require additional assessments to differentiate between ASDs and other conditions that may co-occur, such as limited intellect.

The exact causes of autism are unknown, although genetic factors are strongly implicated. A study released by the Center for Disease Control and Prevention (2014) indicates that the incidence of ASD was as high as 1 in 68.

Rett syndrome is a disorder of the nervous system that leads to regression in development, especially in the areas of expressive language and hand use. In most cases, it is caused by a genetic mutation. It occurs almost exclusively in girls and may be misdiagnosed as autism or cerebral palsy.

Seventy-five percent of Rett syndrome cases have been linked to a specific genetic mutation on the X chromosome. This gene contains instructions for creating methyl-CpG-binding protein 2 (MeCP2), which regulates the manufacture of various other proteins. Mutations in the MeCP2 gene cause these other proteins to be produced incorrectly, which damage the maturing brain. Studies link mutations in this gene. Most cases of the mutation arise spontaneously without any traceable cause. However, there also seem to be some clusters within families and certain geographic regions, for example Norway, Sweden, and Northern Italy.

A child affected with Rett syndrome normally follows a standard developmental path for the first 5 months of life. After that time development in communication skills and motor movement in the hands seems to stagnate or regress. After a short period, stereotyped hand movements, gait disturbances, and slowing of the rate of head growth become apparent. Other problems may also be associated with Rett syndrome including seizures, disorganized breathing patterns while awake and apraxia/dyspraxia (the inability to program the body to perform motor movements). Apraxia/dyspraxia is a key symptom of Rett syndrome and it results in significant functional impairment, interfering with body movement, including eye gaze and speech.

There are a large variety of potential treatments for ASDs and Rett syndrome, including activity-based therapies such as music, dance, art and exercise therapies. Impairments associated with ASDs and Rett syndrome are often severe, and treatments include attention to comorbid medical and behavioral conditions. Activity therapy uses physical or creative approaches to address therapeutic goals such as improvement in behavioral, social, motor, communicative, and/or cognitive functioning. The medical service is administered to address these therapeutic goals rather than for recreational purposes. Activity therapies should be individualized. They are generally conducted by professionals trained in the specific discipline such as Master’s level art or music therapists.

Floortime® is a type of activity therapy that involves caregivers or parents getting ‘down on the floor’ and playing with children. Floortime, part of the Developmental, Individual-differences, and Relationship (DIR) model, is based on the premise that, when caregivers/parents follow the child’s lead and engage in activities that interest the child, emotional relationships between adults and children will improve. These improved relationships will then facilitate the child’s ability to achieve developmental milestones. Parents/caregivers usually receive training and ongoing support or coaching from certified professionals.

In addition to Floortime, there are other parent-mediated interventions such as the Relationship Development Intervention (RDI®). The RDI program involves training parents or caregivers to improve children’s ability to engage in reciprocal relationships. During RDI sessions, parents guide children in various activities such as playing games or listening to music, sometimes in the presence of an RDI coach. The ultimate purpose of the activities is to improve the child’s ability to bond and communicate with other people.

The use of various activity therapies have been investigated for the treatment of ASDs. Several randomized controlled trials (RCTs) have been published, including evaluating karate (Bahrami, 2016), theater (Corbett, 2016), music (Bieleninik, 2017),   dance/movement (Hildebrandt, 2016; Koehne, 2016; Srinivasan, 2015) or Floortime (Casenhiser 2011; Lal 2013; Pajareya 2011; Solomon 2014) interventions. The studies did not consistently find that the interventions provided clinically important benefits. No RCTs have evaluated RDI.

One of most recent and larger RCTs on activity therapy was published in 2017 by Bieleninik and colleagues. The trial, which was multicenter and assessor-blinded, randomized 364 children with ASD to high-intensity music therapy (n=90), low-intensity music therapy (n=92) or no music therapy (n=182). The music interventions lasted for 5 months and all study participants received enhanced standard care. The investigators did not find an additional effect of music therapy beyond that of enhanced standard care. Compared with baseline, at the end of the 5-month treatment period, there were not statistically significant differences among groups in the primary outcome, the social affect score of the Autism Diagnostic Observation Schedule (ADOS). Findings on the primary outcome were similar at the 12-month follow-up. Moreover, 17 of 20 secondary outcomes did not differ significantly among groups.

As identified above, several RCTs have evaluated Floortime. All of them compared DIR/FLoortime plus usual care to usual care alone. Recommended hours per week for parents to engage in Floortime with children was 14 to over 20 hours per week (Casenhiser 2011; Pajareya 2011; Solomon 2014). The fourth RCT (Lal, 2013) evaluated a brief intervention consisting of a total of 20 half-hour sessions. Sample sizes ranged from 126 to 128 participants. Studies used a variety of outcome measures and generally found a positive effect of Floortime. However, a common limitation of the RCTs was that they did not include a sham or alternative intervention of the same duration or intensity as DIR/Floortime, and thus did not control for the potential impact of additional parental support and/or additional time spent interacting with the child. 

The literature on some activity therapies has been summarized in systematic reviews. In 2017, the Agency for Healthcare Research and Quality (AHRQ) published a comparative effectiveness review on interventions targeting sensory challenges in children with ASDs (Weitlauf). Music therapy was one of the interventions addressed in the review. The authors identified four RCTs and one non-randomized comparative trial evaluating music-based interventions. The studies included a total of 115 children and the duration of treatment ranged from 6 to 20 weeks. Interventions were heterogeneous in that they evaluated different interventions of varying durations and reported on different outcomes. All but one study reported outcomes in the immediate post-intervention period and the other study reported 2 month follow-up data. The authors noted that all studies were small and short-term and stated that no conclusions could be drawn from the literature on the efficacy of music therapy for children with ASDs. 

In 2016, Bremer and colleagues published the results of a systematic review of the literature addressing exercise interventions for children with ASDs.  A total of  13 studies met their selection criteria; namely, controlled or uncontrolled studies evaluating a physical exercise intervention in individuals aged 0 to 16 years who were diagnosed with ASD and reporting at least one behavioral or cognitive outcome. Of these studies, four addressed hippotherapy, which is not addressed in this document. The remaining nine studies involved a variety of activities including martial arts, jogging, water exercise, and yoga. The largest of these studies included 15 subjects and the smallest involved 4 (mean 7.63). The authors reported that exercise interventions consisting of jogging, horseback riding, martial arts, swimming, and dance or yoga may result in improvements to numerous behavioral outcomes including stereotypic behaviors, social-emotional functioning, cognition and attention. However, they concluded that future research with well-controlled designs, standardized assessments, larger sample sizes and longitudinal follow-up is necessary. A 2017 systematic review of exercise-based interventions (Dillon, 2017) identified 23 controlled or uncontrolled studies. When the quality of studies was evaluated with the Adapted Physical Activity Taxonomy (APAT), the authors found that 13 had weak methods and 17 had weak results sections. Only 1 study met APAT’s minimal overall quality level. However, this study, which evaluated a water exercise program, had a small sample size (n=16) and used a crossover design which evaluated only the immediate post-intervention impact of the intervention.

There are few well-conducted controlled studies evaluating activity therapy for individuals with ASDs, and no controlled studies in individuals with Rett syndrome were identified. The available studies had heterogeneous interventions, durations and outcome measures, and had mixed findings. Most had methodologic limitations such as a control intervention that was not the same duration or intensity as the intervention under evaluation. In conclusion, there is insufficient evidence addressing the effectiveness, safety, relevance, and/or reliability of activity interventions in improving the pathological manifestations of ASDs or Rett syndrome.

Definitions

Activity therapy: Activities, such as music, art, dance, play and theater, which are used for therapeutic rather than recreational or diversional purposes. 

Asperger’s syndrome: A developmental disorder that affects the parts of the brain that control social interaction and communications.

Autism Spectrum Disorders: A collection of associated developmental disorders that affect the parts of the brain that control social interaction and verbal and non-verbal communication.

Childhood disintegrative disorder: A developmental disorder characterized by marked regression in multiple areas of functioning following a period of at least 2 years of apparently normal development.

Rett syndrome: A developmental disorder that affects the parts of the brain that control social interaction, communications, and motor function.

References

Peer Reviewed Publications:

  1. Bahrami F, Movahedi A, Marandi SM, Sorensen C. The effect of karate techniques training on communication deficit of children with autism spectrum disorders. J Autism Dev Disord. 2016; 46(3):978-986.
  2. Bieleninik L, Geretsegger M, Mossler K, et al. Effects of improvisational music therapy vs enhanced standard care on symptom severity among children with autism spectrum disorder: The TIME-A randomized clinical trial. JAMA. 2017; 318(8): 525-535.
  3. Bremer E, Crozier M, Lloyd M. A systematic review of the behavioural outcomes following exercise interventions for children and youth with autism spectrum disorder. Autism. 2016; 20(8):899-915.
  4. Casenhiser DM, Shanker SG, Stieben J. Learning through interaction in children with autism: preliminary data from asocial-communication-based intervention. Autism. 2013 Mar;17(2):220-241.
  5. Corbett BA, Key AP, Qualls L, et al. Improvement in social competence using a randomized trial of a theatre intervention for children with autism spectrum disorder. J Autism Dev Disord. 2016; 46(2):658-672.
  6. Dillon SR, Adams D, Goudy L, et al. Evaluating exercise as evidence-based practice for individuals with autism spectrum disorder. Front Public Health 2017; 4 (Article 290): 1-8. Available at: https://www.frontiersin.org/articles/10.3389/fpubh.2016.00290/full. Accessed on December 29, 2017.
  7. Hildebrandt MK, Koch SC, Fuchs T. "We dance and find each other"1: effects of dance/movement therapy on negative symptoms in autism spectrum disorder. Behav Sci (Basel). 2016 Nov 10;6(4). pii: E24.
  8. Koehne S, Behrends A, Fairhurst MT, Dziobek I. Fostering social cognition through an imitation- and synchronization-based dance/movement intervention in adults with autism spectrum disorder: a controlled proof-of-concept study. Psychother Psychosom. 2016; 85(1):27-35.
  9. Lal R, Chhabria R. Early intervention of autism: a case for Floor Time approach. Recent Advances in Autism Spectrum Disorders. 2013. Available online: https://www.intechopen.com/books/recent-advances-in-autism-spectrum-disorders-volume-i/early-intervention-of-autism-a-case-for-floor-time-approach. Accessed on January 8, 2018.
  10. Pajareya K, Nopmaneejumruslers K. A pilot randomized controlled trial of DIR/Floortime™ parent training intervention for pre-school children with autistic spectrum disorders. Autism. 2011 Sep;15(5):563-577.
  11. Solomon R, Van Egeren LA, Mahoney G, Quon Huber MS, Zimmerman P. PLAY Project Home Consultation intervention program for young children with autism spectrum disorders: a randomized controlled trial. J Dev Behav Pediatr. 2014;35(8):475-485.
  12. Srinivasan SM, Park IK, Neelly LB, Bhat AN. A comparison of the effects of rhythm and robotic interventions on repetitive behaviors and affective states of children with Autism Spectrum Disorder (ASD). Res Autism Spectr Disord, 2015; 18:51-63.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. DSM-5. Washington, DC. May 2013.
  2. Centers for Disease Control and Prevention. Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years — Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2010. Morbidity and Mortality Weekly Report (MMWR). 2014; 3(SS02):1-21.
  3. Weitlauf AS, Sathe NA, McPheeters ML, Warren Z. Interventions Targeting Sensory Challenges in Children With Autism Spectrum Disorder—An Update. Comparative Effectiveness Review No. 186. (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2015-00003-I.) AHRQ Publication No. 17-EHC004-EF. Rockville, MD: Agency for Healthcare Research and Quality; May 2017. Available at: https://www.effectivehealthcare.ahrq.gov/topics/asd-interventions/research-2017.  Accessed on January 8, 2017.
Websites for Additional Information
  1. Centers for Disease Control and Prevention. Autism Spectrum Disorder (ASD). Available at: https://www.cdc.gov/ncbddd/autism/index.html. Accessed on December 27, 2017.
  2. International Rett Syndrome Association. Available at: http://www.rettsyndrome.org. Accessed on January 8, 2017.
  3. National Library of Medicine. Medical Encyclopedia, Autism spectrum disorder Information Page. Available at: https://www.ninds.nih.gov/Disorders/All-Disorders/Autism-Spectrum-Disorder-Information-Page. Accessed on December 27, 2017.
  4. National Library of Medicine. Medical Encyclopedia, Rett Syndrome. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/001536.htm. Accessed on December 27, 2017.
  5. Interdisciplinary Council on Development and Learning (ICDL). Available at http://www.icdl.com/home. Accessed on January 11, 2018.
Index

Activity therapy
Music therapy
Art therapy
Movement therapy
Floortime

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status

Date

Action

Reviewed

03/22/2018

Medical Policy & Technology Assessment Committee (MPTAC) review.

New

02/23/2018

Behavioral Health Subcommitee review. Initial document development. Moved content of BEH.00004 Activity Therapy for Autism Spectrum Disorders and Rett Syndrome to new clinical utilization management guideline document with the same title.