While an insistence on the same type of food or having rigid adherence to a narrow range of feeding behaviors could be consistent with the core features of ASD, food selectivity in some children with ASD may be causally related to a common associated condition known as sensory processing disorder. Although not considered a core symptom, this condition, defined as unusual or unexpected responses to environmental and sensory stimuli that adversely affect life activities, has been strongly associated with ASD (Kern et al. 2006). Children with tactile defensiveness, who have a negative response to being touched or hugged may be particularly prone to food sensitivity (Smith et al. 2005). Clinicians should also be alert to the possibility of one of the gastrointestinal disorders discussed earlier, such as GERD, constipation or food allergy as an underlying cause of food selectivity. Any of these gastrointestinal conditions may make the experience of eating less pleasurable and result in a child becoming more food selective .

Despite the issue of food selectivity, it is unclear if children with ASD as a group have higher rates of nutritional deficiencies compared with typically developing peers. Some studies have found significantly lower intakes of certain macro and micronutrients (Herndon et al. 2009; Schreck et al. 2004b), while others have not (Levy et al. 2007). Significant illnesses related to nutritional deficiencies, such as scurvy from vitamin C deficiency and vision loss related to hypovitaminosis A and vitamin B12 deficiency, have been reported among children with ASD and food selectivity (Bruins et al. 2011; Duggan et al. 2007; Pineles et al. 2010; Tang et al. 2011). Food selectivity in children with ASD may also place them at risk for becoming underweight and overweight (Curtin et al. 2010; Hebebrand et al. 1997). Thus, although the risks of nutritional problems among children with ASD as a group are uncertain, it is clear that those with food selectivity are at increased risk.

Children with food selectivity, especially those with abnormalities in growth parameters (underweight, overweight, or significant changes in growth rate), those with symptoms of dysphagia (difficulty in swallowing) or a history of aspiration pneumonia, and those with symptoms of food allergy should be evaluated by an interdisciplinary team. A registered dietician can assess nutrient intake, the risk for nutritional deficiencies and make recommendations about nutritional support with regards to caloric intake and vitamin and mineral supplementation. An allergist may recommend appropriate allergy testing (skin testing, measurement of allergen-specific IgE levels) in those children in which food allergy is suspected. A feeding therapist (generally within the discipline of occupational or speech therapy) can help to identify the underlying cause of food selectivity with specialized studies of swallowing function and evaluation of sensory processing difficulties. Based on the underlying cause a treatment plan can be developed. In the case of sensory processing difficulties, the feeding therapist may work with caregivers to identify alternative foods or food preparation strategies that slowly increase the tolerability of a wider variety of foods that meet the child’s nutritional needs. Gradual desensitization can also be helpful. Behavioral therapists can use behavioral modification techniques to motivate the child to accept new foods, and an occupational therapist may be able to modify the feeding environment to reduce excess stimuli that may be increasing mealtime stress (Cermak et al. 2010).

ASD and seizures/epilepsy are complex, heterogeneous conditions; therefore, the management of children with both conditions may be challenging . Both can result from conditions such as tuberous sclerosis, or they can by themselves be diagnosed (e.g., idiopathic autism and absence epilepsy). Much of the research done in the past attempted to include patient groups that seemed at the time to be homogeneous but are now recognized as including patients with autism and genetic syndromes associated with epilepsy (e.g., Angelman and Rett syndromes), making conclusions difficult .

Seizures are defined as events resulting from paroxysmal, excessive electrical discharges in the brain that cause a variety of clinical manifestations. Epilepsy is a term used when an individual has recurrent seizures .

Individuals with ASD have, compared with the general population, an increased incidence of electroencephalographic abnormalities without clinical manifestations of seizures. These include paroxysmal bursts of spike, spike/wave, polyspike, polyspike/wave, and localized spikes in central, temporal, and parietal regions, similar to those seen in the benign focal epilepsies of childhood. The significance of electroencephalographic abnormalities in individuals without clinical seizures are not well understood but may be viewed as evidence of central nervous system dysfunction (Spence and Schneider 2009).

Individuals with ASD have a higher incidence of seizures/epilepsy than the general population. Although rates vary widely depending on inclusion criteria for patients, epilepsy is found in 6–46 % of individuals with ASD compared with a lifetime risk for epilepsy in the general population of 3 % (Spence and Schneider 2009) . Individuals with ASD who also have cerebral palsy or intellectual disability are on the high end of this range, while individuals with ASD without these conditions have a much lower prevalence of epilepsy (2–8 %) (Tuchman and Rapin 2002). Individuals with ASD also have a higher percentage of electroencephalographic abnormalities without clinical seizures , although the significance of this is unclear (Tuchman and Rapin 2002) .

There are two age peaks for epilepsy in children with ASD, early childhood and adolescence. As many individuals with ASD and seizures have long-term, possibly life-long epilepsy, prevalence increases as the age of the population being studied increases (Tuchman and Rapin 2002). Many seizure types have been described in individuals with ASD (Spence and Schneider 2009) although some authors feel that complex partial seizures are the most common (Hara 2007). The regression in language and social interaction observed in approximately one-third of children with ASD (Levisohn 2007) appears to occur at the same frequency whether or not that child has epilepsy, but a regression in verbal abilities may signal a more severe clinical course in terms of cognitive and behavioral outcomes (Shinnar et al. 2001b).

Not surprisingly, individuals with ASD and epilepsy often have a diminished quality of life compared with individuals with only one of these conditions (Shinnar et al. 2001). Individuals with ASD and epilepsy score lower on social maturity scales and are more likely to be prescribed psychotropic medications than individuals without seizures (Hara 2007). Individuals with both conditions are also more likely to have intellectual disability than individuals with ASD alone (Tuchman and Cuccaro 2011). Lastly, it is unclear whether individuals with ASD and seizures begin with a more severe underlying brain disorder than those with ASD alone or whether the presence of epilepsy leads to a further decline in function .

Is it a seizure? The first question in any child with a seizure-like event is whether the noted event is a true epileptic seizure . This distinction is especially important in a child with ASD who may have stereotypies such as hand-flapping, other repetitive motor behaviors, or behavioral events such as rage or aggression. These and symptoms such as daydreaming, syncope, and night terrors may be misinterpreted as seizures. Some studies suggest that non-epileptic events are misdiagnosed as seizures 30 % of the time; such misdiagnoses may expose individuals to unnecessary procedures or medications (Perrig and Jallon 2008) .

To address the question of whether or not the event of concern is a seizure, a comprehensive history of the event(s) that might have been a seizure(s) needs to be elucidated. Is this event(s) predictable and stereotypical? Does it occur with anxiety or anger? If so, the event(s) are unlikely to be caused by seizure activity. It may be difficult to be certain at the initial evaluation whether the event was a seizure or not, it is often wise to have the parents monitor for subsequent similar events, videotape them, and keep an event journal. It may sometimes be useful to perform a long-term electroencephalogram (EEG) with video monitoring in order to catch the event at the same time as the EEG tracing. An event not accompanied by epileptiform EEG abnormalities is not likely to respond to antiepileptic medications. If the events being questioned are staring spells, the parents should be asked to touch and speak to the child during the episode; if the staring stops with this attention, a seizure is unlikely. Parents should also be asked to look for interruptions in activity (e.g., drinking a glass of water, walking across a room). If such interruptions are noted, the staring spells are more likely to be seizures. Environmental triggers should be noted carefully. Many children with seizures are more likely to have them if they are tired or ill, and on awakening from sleep. If there is uncertainty, it is best to acknowledge that and to continue to work with the parents until there is some clear understanding of whether an event is epileptic or not (Beach and Reading 2005). In a situation where it is not clear whether the child is having seizures or not, it is unlikely that getting an EEG will resolve the problem. As noted above, large proportion of children with ASD have abnormal EEGs (Spence and Schneider 2009). Conversely, a child with definite seizures may have a normal EEG. The child should instead be followed closely clinically. Sometimes the question of seizures comes from the school or therapists. If so, they need to be engaged in tracking events as well. Follow-up visits to discuss the journal of events or to view videos of the events should be scheduled before the family leaves the office to ensure that the possibility of seizures continues to be addressed. If the issue remains uncertain, a referral to a pediatric neurologist may be helpful in reaching a conclusion concerning the nature of the event (Deacon et al. 2003) .

What kind of seizure is it? Once the event has been determined to be a seizure, understanding the type of seizure will guide evaluation and choice of medication. Caregivers should be asked to identify, if they can, where in the body an event that may be a seizure started; for instance, eyes beating to the left before jerking begins. A brief description of seizure types follows; a more extensive review of seizure classification has been previously published (Tuxhorn and Kotagal 2008).

Focal onset seizures (also called localized or partial seizures) start in one part of the body. Examples of focal onset seizures include: a seizure that starts with hand jerking, tingling on one side of the body, or a sense of fear. Focal onset seizures occur in children of all ages and may be difficult to diagnose and treat. Because these seizures may be associated with focal brain pathology (e.g., stroke or tumor), neuroimaging is almost always indicated. Seizures with focal onset before generalization are classified as focal seizures with secondary generalization, and for purposes of evaluation and treatment should be treated as focal seizures.

Generalized seizures begin with widespread manifestations, caused by widespread electrical dysfunction of the entire cortex. Some types of generalized seizures include :

Seizures may be either a symptom of an underlying disease (e.g., meningitis, tuberous sclerosis) or a disease diagnosis as in idiopathic generalized epilepsy. It is important to rule out any underlying cause for the seizures and to garner as much information as possible since this will often be helpful in treatment choice. Most children with an ASD and seizures should be referred to pediatric neurology at least to initiate management. The medical home and the specialist should clarify who will be assuming ongoing care, which will depend on the comfort level of the pediatrician.

Extended release preparations may have fewer side effects than immediate release preparations as blood levels stay more constant. However, extended release preparations may be more expensive as they are often newer and are not considered first line medications by insurance companies. A letter of medical necessity delineating why the extended release preparation is necessary may be helpful.

The form of medication, whether it is liquid, sprinkle capsules, tablets, or capsules must be considered as many children with ASD may refuse to take medications in a certain form (Williams et al. 2000). The active ingredient and additional substances in the tablet or capsule need to be considered if the child is on a special diet. In an individual who has a difficult time with blood draws, medications requiring regular blood monitoring should be avoided when possible .

The effects of antiepileptic medications on appetite should also be considered. Topiramate, which may decrease appetite, might not be the best first choice for children who are very picky eaters. Valproic acid may lead to weight gain.

Children who have difficulty sleeping should not, as the first choice, be put on medications which may keep them awake. For instance, topiramate causes wakefulness in some individuals whereas other medications for seizures may be helpful for sleep induction .

Some of the antiepileptic medications are more helpful in children with generalized epilepsy (levetiracetam, lamotrigine, valproic acid) whereas others are used in those with partial epilepsy (oxcarbazepine; Azar and Abou-Khalil 2008). Many of the newer medications are more expensive than older medications but do not require blood level monitoring so they may be cheaper and easier in the long run. The newer medications are also less likely to have significant side effects and/or drug interactions. All of the medications used for seizures may cause sleepiness, difficulty with retaining information, irritability, and other changes. Most of these will diminish after the first few days of use but may be severe enough to necessitate a trial with a different medication. Medication should be started at the lowest recommended dosage and titrated up with incremental changes to enhance effectiveness and tolerability. Increases in dose can usually be done every few days or weekly. An exception is lamotrigine which requires a longer interval (2 weeks) between dose increases. Written and understandable instructions on how to titrate the dose should be given to the family. As there is no perfect medication, families should be encouraged to stay with one medication for at least a few weeks before coming to a decision about the medication .