Autism Spectrum Disorder

Abstract

Introduction: Autism Spectrum Disorder (ASD) mentions that children with ASD show delay in developing oneself to understand situation and emotions of someone else or show hindrance in understanding one’s feelings and thoughts. The individuals with ASD develop anxiety due to various reasons one of which may be due to their impairment regarding social communication which leads them develop fear to interact socially out of negative evaluation. This leads the ASD individuals to avoid social situations and express anxiety and aggressiveness towards being placed in such situation in turn limiting their opportunity for practising social skills.

Aim: The aim of the study is to identify the effectiveness of cognitive behavioural therapy (CBT) and medication in the treatment of physically aggressive behaviour among children and teenagers suffering from autism spectrum disorder (ASD).

Methods: The secondary research design is to be used and the PICO framework is to be followed in developing the research question. The electronic database to be used in framing the search are CINHAL, EBSCO, Google scholar, Cochrane library and others. The keywords to be used in the study are “children and teenagers with ASD”, “aggressiveness in ASD”, “Cognitive Behaviour Therapy (CBT)”, “medicine treatment for aggression in ASD” and others. The inclusion criteria to be followed in the study are articles published on and after 2011, has primary data, written in English language, includes detailed information, contains information related to children and teenagers with ASD and academic in nature. The exclusion criteria to be followed in the study are articles containing information regarding adult with ASD, not written in English, only abstract available, published before 2011, secondary data and non-academic in nature.

Results: CBT helped the children and teenagers with ASD have shorter aggressive outburst, better management of anger and emotional changes that are all responsible in making them physically aggressive. The risperidone is found to be effective medication for managing aggression in children and teenagers with ASD. The impact of other medication that is aripiprazole on its effectiveness in controlling aggression among children and teenagers with ASD I found to be positive. The nicotine transdermal are effective option after the anti-psychotic in managing aggression in children and teenagers with ASD.

Conclusion: CBT was positively effective for children and teenagers with ASD in helping them cope clinical anxiety which often makes them to be aggressive. Moreover, pharmacological intervention accompanied by the therapy is found to be more effective in easy management of aggressive behaviour in AD children and teenagers.

Introduction

Autism Spectrum Disorder (ASD) is a complicated neuro-developmental disorder which creates persistent challenges in social interaction, non-verbal communication and speech development among individuals along with persistent or repetitive behaviour. The impact of the spectrum and its severity is found to be different in each individual (Lord et al., 2018). ASD is mainly diagnosed in the childhood as most of the symptoms regarding the spectrum is obviously presented within 2-3 years of age. There are various therapies and medication used in controlling ASD among children and children and teenagers so that they can be provided empowerment to cope the health issue. In this study, the effectiveness of the use of cognitive behaviour therapy (CBT) and medication in controlling hindered and aggressive behaviour of the ASD affected children and teenagers is to be discussed.

Background of the study

In many children and teenagers, clinically elevated symptoms of autism spectrum disorder (ASD) is experienced which is a characteristic related with disruptive functioning of various domains of the health spectrum. It is seen that a high proportion of the children and teenagers with ASD express meeting the criteria for concurrent psychological disorder such as anxiety and depressive disorder along with clinically elevated psychiatric symptoms such as dysphoric symptoms, aggressiveness and anxiousness (Campisi et al., 2018). The individuals with ASD develop anxiety due to various reasons one of which may be due to their impairment regarding social communication which leads them develop fear to interact socially out of negative evaluation. This leads the ASD individuals to avoid social situations and express anxiety and aggressiveness towards being placed in such situation in turn limiting their opportunity for practising social skills (Wiggins et al., 2019). In contrast, social impairment of the children and teenagers with ASD may evoke over protection from the parents which may impact to strengthen the behaviour of attachment of the patient. However, it later leads to create anxiety and aggressiveness in the ASD individual when they are separated from their figures of attachment for involving in higher educational purpose and others out of feeling of fear and lck of support (Hirota et al., 2020).

The presence of phobia regarding certain situation developed over the course of life may lead the children and teenagers with ASD express high anxiety out of over responsiveness toward the threat and fear regarding the situation (Sullivan et al., 2019). In contrast, the obsessive-compulsive disorder characterised by intrusive and unwanted thinking and feeling along with compulsive behaviour is a comorbid condition found in children and teenagers with ASD. This is mentioned to be presented as a way to overcome anxious situation created by specific phobia (Hirota et al., 2020). In regard to treatment of the children and teenagers with ASD, there is considerable work found to relate with addressing the overall needs of treatment of children and teenagers with ASD with varying clinical representation (Hirota et al., 2020). This is evident from the study of Cuomo et al., (2017) where it is mentioned that educational therapies are to be used as notion of treatment for ensuring effective learning behaviour management in ASD children and teenagers. Moreover, the study by Wilson and Landa (2019) mentioned that communication therapies are to be used as treatment for children and teenagers with ASD in helping them overcome speech impairment and hindrance with social communication.

In addition, the study by Chlebowski et al. (2018) informed that family therapies are to be used to make the children and teenagers with ASD develop effective relationship with the family members. This is because children and teenagers and children with ASD due to impairment of social understanding are unable to effectively form relation with the family. However, there are limited studies present that shows treatment for aggressive behaviour in children and teenagers with ASD. Thus, the current study determining effectiveness of cognitive behavioural therapy (CBT) and medication in the treatment of physically aggressive behaviour among children and teenagers suffering from autism spectrum disorder is essential to be performed. This is because it would help to derive information about the specific treatment could be used in managing the aggressiveness shown by the ASD children and teenagers which often makes them to be highly unaccepted in the society and the family.

Rationale of the study

Autism Spectrum Disorder (ASD) is prevalent both globally and in the UK. This is evident from the review of (BMA, 2020) which mentioned that in global context the prevalence of the disease is 1.04% of the population and in UK, there are nearly 700,000 autistic people present. Moreover, 1 in 100 children and young people in the UK have diagnosis of ASD which is 1.6% of the population (BMA, 2020). The core features of ASD seen among the diagnosed individuals are hindrance with social interaction, high variation in abilities, repetitive behaviour and others. The presence of anxiety and aggressive behaviour is not core features of individuals with ASD but still 40% of children and teenagers with ASD are seen to have clinically elevated level of anxiety and aggression (BMA, 2020).

The clinical anxiety and aggressive behaviour among the children and teenagers with ASD is an issue because it is found to be linked with high functional impairment in them. For instance, the study by Postorino et al. (2017), mentioned that high aggressive behaviour and anxiety creates increased impairment for the children and teenagers with ASD to access social responsiveness and makes them to remain isolated. This is because people in the society fear the children and teenagers with ASD having aggressive behaviour would unintentionally harm them, in turn, they avoid the children and teenagers to retain own safety. The aggressive behaviour among children and teenagers is an issue because it could create positive impact on further functional impairment. This is people trying to assist the children and teenagers with ASD to overcome the impairment show lack of zeal and fear due to their aggression in assisting them (Saqr et al., 2018). Moreover, it is possible that aggression of the children and teenagers with ASD could led them to show increased severity of the core symptoms of the spectrum (Postorino et al., 2017).

The development of aggressive behaviour among the children and teenagers with ASD ha currently become an issue because even though parents are trying to stay calm and limiting what are expressed towards the young people, still no effective change in them are seen. The persistent aggression among the children and teenagers with ASD is creating parents to keep their children in closed places which is creating little exposure of them to lead a normal life in the society (Sullivan et al., 2019). Therefore, the current study is important to be performed so that effectiveness of CBT and medication on managing aggressive behaviour among AD children and teenagers can be determined. This is because it would create better social interaction and relationship ability among the ASD children and teenagers and would help them to live without isolation in the society.

Aim

The aim of the study is to identify the effectiveness of cognitive behavioural therapy (CBT) and medication in the treatment of physically aggressive behaviour among children and teenagers suffering from autism spectrum disorder (ASD).

Introduction

In this chapter, various scholar sources related to specific topic of the research is to be explored. This is to derive effective information in framing the work in suitable manner so that existing knowledge regarding the topic is effectively known.

Concept of Cognitive Behaviour Therapy (CBT)

The Cognitive Behaviour Therapy (CBT) is referred to a nature of psychotherapy which is used as treatment approach for range of emotional and mental health issues including depression and anxious thoughts. It helps in changing hindered or unhealthy ways of feeling, thinking and behaviour among individual to provide them enhanced positive change in life that improve their quality of life. The CBT aim to make individual realise the way their thinking is affecting their mood which in turn influencing their behaviour to be aggressive or depressed.

The CBT teaches individuals to think in a less negative way regarding their life (Lopresti, 2017). There are mainly six phases in the CBT which are examination of phycological condition of the patient, reconceptualization, acquisition of skills, consolidation of skills and application training, generalisation and post-treatment assessment and follow-up (Cooper et al., 2017). In CBT, various interventions are used in delivering the therapy such as self-instructions, relaxation or biofeedback, creation of adaptive coping strategies, goal setting and changing beliefs regarding pain and fear (Steel et al., 2017). There is emerging evidence which mentions that CBT is aimed at lowering symptoms of anxiety, depression, aggression and obsessive-compulsive disorder among the adults with ASD as intellectual disability. The research though focussed on adult, but it can be determined that CBT is equally effective for the autistic children and teenagers and young people (Benevides et al., 2020).

Factors influencing use of CBT

In the study by Maddox et al. (2019), it is mentioned that cognitive behaviour therapy (CBT) is able to improve depression and anxiety leading to aggression in autistic people, but only few autistic individuals are seen to have received the treatment. In the study, factors which influenced the physicians to used CBT as treatment for ASD individuals are explored. It is mentioned on survey of 100 clinicians that factors like development of stronger intentions among ASD individuals, favourable attitude development, high normative pressure and creation of increased self-efficacy is responsible for its use. Thus, the findings inform that effectively deigned and tailored strategies increases the attitude of the clinicians in adopting CBT use for autistic individuals.

The therapist factors that influence CBT use includes their extent of experience or skills in use of the therapy to be delivered to patients. This is because hindered experience or lack of skill leads to create complication and barrier in effective delivery of the therapy (Cooper et al., 2017). In contrast, the study by Newman et al. (2020) mentions that presence of vague and non-specific idea of therapeutic goals among the clinicians leads them fail to deliver CBT effectively. The level of therapeutic relationship present between the clinicians and patients also influences the success or failure of use of CBT for overcoming negative emotional state.

Model of Cognitive therapy

The ABC model develop by Albert Ellis (1957) provide effective insight regarding the process to be followed in delivering cognitive behaviour therapy. The steps are activating event, belief and consequences. In the activating event, the recording of the objective situation which is the key events that is leading individuals to develop high emotional response or develop negative dysfunctional attitude and thinking is to be identified.

In the belief state, the client or patient is to be asked to inform the negative thoughts which are occurring to them which is leading them to be anxious and aggressive (Schenk et al., 2020). In the consequence stage, the link between the negative thoughts mentioned in the belief state is linked with situations that are causing the individual to develop distressed feeling. According to the model, the activating event is not the one that causes individuals develop negative emotion, but it is the individual who interprets the events in unrealistic way and thus develops an irrational belief system which causes them the consequence of negative cognitive behaviour (Joy, 2018).

Theory of Cognitive therapy

The Beck’s Cognitive theory mentions that negative emotional state is raised due to three mechanism which are cognitive triad, negative self-schemas and error in logical thinking. The cognitive triad are referred to 3 types of negative thinking linked with hindered emotional state which are negative thoughts regarding own actions, future and the current world (Beck, 2020). It is evident ass individual with ASD show negative thinking regarding their actions and to be judged in the current and future society for their hindered interaction ability.

The negative self-schemas are mainly acquired due to traumatic situation such as loss of parent, rejection by parent and bullying at school (Beck, 2020). The children and teenagers with ASD are found to be closely attached to their parents and therefore loss of their parents could cause them to develop negative self-schemas. Moreover, the teenager with ASD are prone to get bullied in school and social environment which may act as negative self-schemas in making them aggressive to avoid getting abused in turn showcasing hindered behaviour (Beck, 2020).

The cognitive distortions are mainly oriented from negative self-schemas where the individuals los their logical ability to think (Beck, 2020). In children and teenagers with ASD, the already lack effective emotional and cognitive ability and along with negative self-schemas disrupts their minimum amount of cognitive ability present to be used for thinking, in turn, making them show negative psychological behaviour (Beck, 2020). The theory mentions that the CBT is to be delivered by considering these facts.

Concept of Autism Spectrum Disorder

The Autism Spectrum Disorder (ASD) is a neurodegenerative disorder which leads individuals affected by the spectrum represent symptoms like hindered facial expression, impaired body posture, abnormal tone of voice, deficit in comprehension of language and speech, delay in learning, hindered social communication and others (Spain et al., 2017). It is usually detected in a person by the age of 3 years and last throughout their entire life.

In people with autism, aggressive and anxious behaviour through not frequently seen but is expressed by many at some point of time. They express anxiety often in stressful situation which creates their behaviour to be aggressive at times. There are no clinical diagnosis present to detect the disease and the DSM-V is used for psychological diagnosis of the spectrum to determine its level of influence on the individual mind to be impaired (Gaigg et al., 2020). The presence of ASD in individuals leads them to develop learning disability due to their hindered social skills and communication ability (Masi et al., 2017).

Factors influencing behaviour in Autism Spectrum Disorder (ASD)

The exposure of the children and teenagers with ASD in supportive family and parental guidance is seen to create positive behaviour among them. This is because they feel being loved and supported along with develop conformation regarding their safety and well-being out of trust towards the family and parents (Lord et al., 2018). However, the presence of non-supportive family or restricted care by the parents towards the children and teenagers with ASD makes them feel agitated and threatened out of fear of lack of safety and support in leading their life (Zachor and Ben-Itzchak, 2017).

In contrast, the bullying of the children and teenagers with ASD also makes them to become aggressive. This is because bullying makes them to feel threatened and they develop aggression for self-survival and protection (Hwang et al., 2018). The other factor which influences behaviour of the children and teenagers with Autism is their support from the society. This is because often inappropriate bully and threatening from the society leads the children and teenagers with ASD become aggressive and perform self-harm or intend to suicide to overcome the situation. It is evident from a large study in the UK where is found that 66% of children and teenagers with ASD has attempted suicide compare to 17% of non-autistic individuals (Hirvikoski et al., 2016).

Model of Disability

The social model of disability creates a view of the world from the perspectives of the disabled people. The model refers that disability in caused by the problem and barriers developed by the society and not only due to the impaired condition of the disabled people (Levitt, 2017). This is evident in case of teenager with ASD because they are seen to have impairment in social communication, language development and others. However, there are barriers in the society towards the acceptance of ASD as a health issue as wide stigma is prevalent due to cultural customs and lack of education as well as awareness regarding the disease. It has led many normal people in the society create barriers towards allowing learning and participation in social activity by the children and teenagers with AD, in turn, making them unable to explore their true abilities and be regarded a disabled people (Woods, 2017).

In contrast, the medical model of disability informed that physical condition are responsible in causing disability among individuals (Smith and Bundon, 2018). In this respect, the presence of fragile X syndrome along with other genetic mutation in the body is considered top be responsible in causing ASD among people. In addition, low birth weight, metabolic imbalances, exposure to environmental toxins are other physical features responsible in causing ASD among children and teenagers and make them show aggressive behaviour (Sandin et al., 2017).

Theory of Autism Spectrum Disorder

The Mindblindness theory for Autism Spectrum Disorder (ASD) mentions that children with ASD show delay in developing oneself to understand situation and emotions of someone else or show hindrance in understanding one’s feelings and thoughts. In normal individual, when they show theory of mind it is seen that such individuals are able to make effective sense of other’s people condition and can predict the actions to be performed by others (Van Tiel et al., 2020). However, in the ASD children due to delayed development of theory of mind, they are seen to remain confused and unpredictable to understand other’ actions. This often leads them to be frightened and feel insecurity which contributes towards their hindered psychological expression (Kung, 2020).

The Intense World hypothesis mentions that people with ASD are seen to show increased brain activity due to which they may face hardship in specifically paying attention to certain activities or things. They are intended to experience the world to be more intense or overwhelming compared to other neurotypical people. The idea would indicate that the core feature of ASD that are sensory sensitivity and social challenges with emotions may be rooted in their overactive responses of the brain (Rahimian et al., 2019).

Impact of use of CBT and medication for managing aggression in Autism Spectrum Disorder

The cognitive behaviour therapy (CBT) is used for children with having mild autism since the 1960s to control their aggressive behaviour and depression. The impact of the CBT on child with autism is to trigger their individual behaviour so that the individual is able to understand the moments that are contributing their hindered emotional state. In order words, it effects the children with autism confront the situations that are responsible for their anxiety and to make them understand the situations are to be controlled to ensure having better mental state (White et al., 2018). However, it is informed by Singh et al. (2018) that Applied Behaviour Analysis (ABA) is the most-effective psychological intervention for people with autism. This is because it helps to not only improve problematic behaviours and social living skill of the autistic individuals but also contributes to enhance their playing, communication and self-care skills which are not covered through CBT.

In the study by Nanjapp et al. (2020), it is mentioned that serotonin medication has an enhanced impact on reducing aggression in individuals with Autism. This is because high serotonin impact on the pre-frontal cortex region of the brain to develop better control of the emotional response to anger which are developed within the amygdala in the brain. However, the study by Yıldırım et al. (2018) mentions that haloperidol is the medication that belongs to butyrophenone group acts in autistic individuals to help them overcome aggression. In addition, the study by D’Alò et al. (2020) mentioned that use of atypical anti-psychotic medication is effective for treating the irritability in autism that is responsible in making them aggressive.

Challenge in providing CBT and medication for managing aggression in Autism Spectrum Disorder

One of the challenges determined to be faced with CBT use for children with ASD is if they have adequate skills needed for succeeding through the therapy. However, the study developed in 2012 mentioned that people with ASD do have the ability to succeed in CBT. This is evident as evaluation of social and cognitive skills of children with ASD in the study revealed that they have ability to think, feel and behave in altering their thoughts but the only area in which they faced difficulty is inability to recognise emotions (Lickel et al., 2012). The other challenge with providing CBT to the autistic children is hindered linguistic ability and abstract thinking ability of the people to understand the approaches in the therapy. The CBT is found to be unstructured and due to which it may create challenge for the children with ASD to positively involve in the therapy. This is because the ASD children may show withdrawal to be confronted to their emotions which they themselves are unable to understand at times (Im, 2021).

The challenges with medication as treatment and managing aggressiveness in people with ASD is that they may show withdrawal in having the medication due to lack of understanding regarding its need for them. This is because people with ASD show mid blindness which negatively affects their ability for reasoning in taking actions (Ajram et al., 2017). Further, the side-effects of the medication create challenge in using them for managing aggressiveness in ASD individuals. This is because the side-effects of medications such as confusion, sweating, vomiting, fatigue and others may influence the individual with ASD to get further agitated in avoiding complying with the carer in taking the medication (Lacivita et al., 2017).

Gaps in Literature

The existing literature informs the detailed concept regarding CBT and aggressiveness along with behaviour in ASD. However, the literature lacks effective discussion regarding the practical impact of CBT in managing aggressiveness among children and teenagers with ASD. Moreover, it lacked focus to mention which medications are appropriate for treatment of aggression in children and teenagers with ASD. The literature also lacked focus on why the medication for aggression works effectively to resolve hindered emotions in children and teenagers with ASD. Thus, to focus on better development of further knowledge regarding the identified gaps, the current study is been developed.

Methodology

The comprehensive, descriptive and broad gathering of existing data for critiquing and summarising in the study from existing journals and articles is the process followed in secondary research. The main purpose of secondary research is to gather existing data that covers the overall problem in the study but may not specifically address all the identified issues in the study (Latkovikj and Popovska, 2019). The advantage of secondary research is that it is cost-effective compared to primary studies. This is because in secondary research the researchers do not require to separately design practical data collection approach and require only use of theoretical analysis process to gather data and present in the study (Iyer et al., 2020).

The benefit of secondary research is that it is time-saving because it does not require much time to find related articles from credible source through use of electronic search (Vetter and Mascha, 2017). The other advantage of secondary research is that it helps in creating enhanced credibility of perspective in the study. This is because in this process existing data are backed by potential explanation to prove its credibility in the study (Iyer et al., 2020). However, the limitation of the secondary research is that the validity and reliability of the data may be compromised during presentation due to the influence of personal belief of the researcher (Latkovikj and Popovska, 2019). In order to avoid this limitation, the researcher requires to reanalyse the gathered data by an unbiased researcher to evaluate its validity and reliability for presentation in the study.

The research question is required to be structured effectively so that it helps to guide the exact information to be collected in the study (Saaiq and Ashraf, 2017). The PICO framework is an effective tool that indicates the key parts to be focused in framing an effective research question. The PICO framework stands for population, intervention, comparison and outcome. The population is mainly the people who are focused in the study which in this research is children and teenagers with Autism Spectrum Disorder (ASD). The intervention is mainly the methods and techniques implemented in the study for creating positive change for the determined population in the study (Kang et al., 2019). The intervention in this research is cognitive behaviour therapy (CBT) and medication. In this research, there is no scope of making any comparison with exiting techniques. The outcome is mainly the results that are presented in the study. In this research, the outcome is resolving aggressiveness of the children and teenagers with ASD. Thus, the research question is: How effective is Cognitive Behavioural Therapy (CBT) and medication in the treatment of physically aggressive behaviour among children and teenagers suffering from Autism Spectrum Disorder?

In this study, to gather evidence the electronic search strategy is to be used. The benefit of using it is that electronic search reduces the hindrance of increased time expenditure and requirement of enhanced effort as it allows use of keywords to make potential data available for the study. Moreover, margin of error faced in physically collecting data is also reduced in physical search (Spry and Mierzwinski‐Urban, 2018). The platforms to be used for making electronic search are EBSCO, Google scholar, Cochrane library and others as these sites contain wide number of medical journals from various geographic location and authors.

The keywords to be used in the study are “children and teenagers with ASD”, “aggressiveness in ASD”, “Cognitive Behaviour Therapy (CBT)”, “medicine treatment for aggression in ASD” and others. The inclusion criteria to be followed in the study are articles published on and after 2011, has primary data, written in English language, includes detailed information, contains information related to children and teenagers with ASD and academic in nature. The exclusion criteria to be followed in the study are articles containing information regarding adult with ASD, not written in English, only abstract available, published before 2011, secondary data and non-academic in nature.

The articles published with content regarding children and teenagers who are autistic individuals is to be include and those related to adults are to be excluded because the key participant focused in the study are children and teenagers. Therefore, to avoid error in presentation of the result, the following inclusion criteria is to be followed. The articles published on and after 2011 is to be included in the study because it would help to include scientifically updated data backed by potential experimental evidence to be included in the study.

The studies published before 2011 is excluded so that error can be avoided that may be raised due to backdated use of information which are non-validated by new studies. The studies published in English is to be used because the research is set in UK where the key language understood and spoken is English and the researchers belonging from UK has only knowledge regarding the specific language. The primary articles are to be used as primary articles contain first-hand data to be explored. The secondary articles are not to be used because it contains data that may have already been influenced by other researchers during presentation and inclusion of such information would lead to create error in the study.

The thematic analysis is the data analysis process to be used in the study. The key purpose of it is to create enhanced focus in framing enriched description of data within the themes for meaningful data interpretation (Valley and Stallones, 2018). The advantage of using thematic analysis is that it makes the researchers to feel freedom for analysing the existing studies in gathering potential data. Moreover, it allows to present large amount of data in a confined and structured way (Kiger and Varpio, 2020). In total 4 theme is to be created in presenting the collected data from the articles.

The ethical consideration in the study is to be followed by the researchers by presenting specific data with reference to the name of the real author. Moreover, the content is to be paraphrased to avoid plagiarism. Moreover, to maintain confidentiality no personal information if available in existing study regarding participants are avoided to be shared. However, if the personal data of the participants found are mentioned to be morally presented in the study, them they may be included in the current study. In addition, personal beliefs and influences are to be avoided in presenting the data by remaining neutral during evaluation of the studies.

Causes of aggressiveness among children and teenagers with Autism Spectrum Disorder (ASD)

The cause and impact of aggressive behaviour among children and teenagers who have ASD are important to be understood so that the key source of the problem can be identified. The study by Sullivan et al. (2019), expressed the key aim to gain insight regarding aggressive behaviour of the children with autism to understand what factors are responsible for instigating hindered behaviour in them. For this purpose, the researcher executed latent profile analysis of 2857 individuals with ASD who were between 6-18 year of age. The exclusion criteria followed in the study was avoiding people who have known condition such as low birth weight, Fragile X-syndrome and others considered to cause autism and involving people with first degree relative with ASD.

The results revealed that social understanding, intelligent quotient and higher anxiety are co-related with causing aggression among individuals. It is reported that higher anxiety is related with increased aggression among the individuals with ASD. Moreover, it is identified that environmental condition impact people with ASD to become aggressive such as classroom removal, hindered care support from the parents and stressful living environment. The strength of the study is that clinically meaningful sub-groups are able to be included in the study for examining the condition effective for the participants. However, the limitation of the study is that it avoids generalisation of the results in the broader field of ASD as the participants selected are specifically from families who has single child with autism which paused to understand how interaction of two autistic child could have influenced aggression. In contrast, the study by Lundwall et al. (2017) focused on the neurological problem in children and teenagers with ASD responsible for them being aggressive in nature. This is because the researcher has found that brain structure and its organisation is related with causing aggressive attitude of ASD people. In this context, the researchers included 45 male children with ASD along with data of 150 children with ASD those are all part of the collaborative longitudinal study performed at the University of Utah and Brigham Young University. The examination of the neuroimage data of the participants who were with ASD versus the control group who were normal revealed that reduced brainstem volumes are related with high odds of people with ASD in expressing increased rate of aggression. The strength of the study is that it developed the results by investigating potential differences in sex, exploration of different stages of development and age and by including image modalities to reach the decision mentioned in the results that indicate effective analysis from all extent. However, the limitation of the study is that it did not thoroughly explained the neural mechanism that leads short brainstem responsible for high aggression in people with ASD.

In comparison, the study by Ambler et al. (2015) considered that anxiety and aggression in children and teenagers with ASD are inter-related. In this purpose, the study aimed to determine relation of anxiety and aggression in children and teenagers with ASD who are attending mainstream education. The researcher selected 104 high school children and teenagers and among them 52 students had ASD and without intellectual disorder while rest 52 students were recruited as control group who were normal without ASD.

The results reveal that teachers mentioned student with ASD expressed higher anxiety along with reactive anger compared to their normal peer and were at increased risk of being suspended from school who attended mainstream education. It was identified that social aggression is an important moderator relationship between physical aggression and autism for ASD students. However, it was seen that children with ASD who expressed high anger control were less aggressive. The strength of the study is that there were high number of volunteers who were mainly children at school and not the caregivers or parents. This helped to execute the study by fulfilling its focus which was understanding the feeling and attitude of the children and teenagers with ASD directly that is contributing them to be aggressive. However, the limitation of the study is that it did not inform the reason that led ASD children to face social anxiety that is related to them being aggressive.

Effectiveness of Cognitive Behaviour Therapy (CBT) on aggression among children and teenagers with Autism Spectrum Disorder (ASD)

The Cognitive Behaviour Therapy (CBT) is found to be effective behaviour therapy used for controlling anxiety and aggression among individuals. In this relation, the study by Wood et al. (2015) explored the effectiveness of CBT as intervention in coping anxiety leading to aggression among the children with ASD. For this purpose, 33 children and teenagers with ASD from the age of 11-15 years are randomly included in the study who were provided 16 sessions of cognitive behaviour therapy or an equal waiting period. The CBT was used for them to emphasise its exposure on challenging irrational attitudes of aggression as well as beliefs and to provide behavioural support to the caregivers.

The results revealed that the group who were provided CBT outperformed the group who were waitlisted on evaluation of the anxiety levels through Paediatric Anxiety Rating Scale (PARS). It was also seen that 79% of the individuals who were provided CBT expressed greater improvement on the Clinical Global Impression-Improvement scale with only 28.6% from the waitlist group. This indicated that CBT was positively effective for children and teenagers with ASD in helping them cope clinical anxiety which often makes them to be aggressive. It is evident from the individuals with ASD’s better impression in the society after receiving CBT. The strength of the study is that it developed a control group which helped in comparing the result of the impact of CBT as intervention on ASD individual’s behaviour and attitude in effective manner. However, the limitation of the study is that it included a small sample size and lacked analysis of the objective measures that are expressed beyond the measure of the diagnostic interview regarding effectiveness of CBT.

The study by Scarpa and Reyes (2011) aimed to also understand the effectiveness of CBT on children with high functioning ASD in enhancing their emotional regulation. For this purpose, the researchers executed a pilot study in which exploration of the impact of developmentally modified CBT for young individuals with ASD in teaching them strategies of regulation of emotions for anger and anxiety is done. The study randomly assigned 11 individuals with ASD in the study who were provided CBT as therapy.

The results on analysis of post and pre-treatment revealed that children on availing CBT expressed less liability of care on parents, shorter emotional outbursts, better coping of anger and aggressive emotions and others. The strength of the article is that it included pilot study due to which enhanced validity of the results could be achieved as they expressed upon evaluation through expert knowledge from other researchers in the specific discipline, in turn, avoiding falsified work to be included. However, the limitation in the study is that it included a smaller sample size and avoided to mention group differences due to more sophisticated and effective evaluated results are not achieved.

The study by Weiss et al. (2018) similarly mentioned that mental health problems are common in people with ASD which lead them to face hindered emotional regulation and makes them face issues such as anger, aggression, anxiety and others. The CBT is considered to be an efficacious intervention for improving behavioural problem in ASD individuals and therefore, the key aim is to examine the impact of CBT as a transdiagnostic approach in emotional well-being of individuals. For this purpose, total of 68 children of 11-14 years are selected and their parents are included in the study. The children are randomly allocated to a waitlist group (n=33) or the intervention group (n=35). A 10-week follow-up program was arranged where the children are provided CBT in managing their emotions and behaviour.

The results revealed that the children who were under CBT action expressed significant improvement regarding emotional regulation such as anxiety and anger along with they expressed enhanced aspect of psychopathology that is improved adaptive behaviour with less showcasing of aggression and better emotional internalisation symptoms. The strength of the study is that a control group is maintained due to which the results from the experimental group can be compared with them to determine the extent of change in the variable that is the key basis of the study. However, the limitation faced is that the study gathered results on the basis of parent-reported information and not direct observation. Thus, it created possibility that the positive experience of the patients in participating in the process may have influenced them to provide positive experiences for the children which may be dubious. Moreover, a response bias may have been faced as the therapists were only allowed to rate the emotional effect of the child after CBT process and not the child themselves.

Effectiveness of medication treatment on aggression among children and teenagers with Autism Spectrum Disorder (ASD)

In the study by Nuntamool et al. (2018), it is mentioned that the aggression is found to be often present in higher amount among the teenagers and children with ASD compared to normal individuals. For this purpose, the study evaluated the relationship of pharmacogenic factors as well as clinical outcomes in autistic children and teenagers who are administered risperidone for long-term. The researchers included 82 autistic individuals as subjects in the study who are also diagnosed with DSM-IV and they were provided risperidone for nearly one year.

The results revealed that nearly 89.02% expressed stable aggressive behaviour, 71.95% expressed stable overactivity, 70.8% expressed stable repetitive behaviour and 81.71% expressed stable clinical symptoms at the end of the medication term. However, only 4.48% of the participants expressed deteriorated Pharmacogenomics and clinical outcome (CGI-I) score. The dose difference of risperidone expressed no significant change in clinical outcome for the subjects. However, the requirement of risperidone dose, level of 9-OH risperidone and prolactin is found to be significantly higher in the non-stable group compared to the stable group.

The associated rise in body weight and increased appetite are the common side-effects faced by autistic subjects of having risperidone for one year (Nuntamool et al., 2018). The strength of the study is that impact of use of risperidone along with side-effects of the medication is mentioned in detailed. This would lead the study to be used as effective evidence for clinical practice to decide if the medication is to be provided to autistic children and teenagers in managing their aggressive behaviour. However, the limitation of the study is that small number of participants are included mainly in the group for non-stable symptom that limited to make effective comparison of many subjects in the present study. The other limitation is that naturalistic organisation of the study led some factors to remain uncontrolled such as food intake and compliance in care due to which the exact side-effects of the medication may have been alerted with the act (Nuntamool et al., 2018).

The study by Aman et al. (2015) mentioned that risperidone has been found to be effective for management of severe irritability and aggression in people with ASD when used for 6-8 months but no long-term impact of the medication is determined. Thus, the study aimed to determine the impact of risperidone on managing aggression and irritability of the children and teenager with ASD when provided for a follow-up period of 1-2 year. For this purpose, 84 children and teenagers are included in the study and were assessed on an average for 21.4 months after they enter into 8-week administration of risperidone. During the follow-up, the risperidone was related with excessive appetite, weight gain but not with adverse effect of neurological condition.

The clinical results revealed that administration of risperidone caused considerable enhancement in the maladaptive behaviour of the autistic individuals when compared with their baseline data. The social skills of the autistic children were found to be improved with use of risperidone as determined from the Vineland Adaptive Behaviour Scale (VABS). The strength of the study was that it used appropriate tools to present evidential data that valid the positive use of risperidone on people with ASD and not based the conclusion on observational results by the researchers. However, the limitation of the study is that no control group was present due to which the results of the experimental group could not be compared to reflect its true impact. The other limitations were lack of control on the subjects for developmental impact and limited rating of instruments for examining care domains regarding ASD (Aman et al., 2015).

In contrast, the study by Ichikawa et al. (2017) mentioned that children and teenagers with ASD express different nature of irritability such as aggression, self-injurious behaviour and tantrums. Thus, the study aimed to evaluate the impact and safety of use of aripiprazole for the treatment of different nature of irritability present in children and teenagers with ASD. For this purpose, 92 patients are randomly chosen in the placebo (n-45) and aripiprazole (n=47) group. The determination of the impact of aripiprazole on aggression which is part of irritability in autistic individuals along with other emotions is done by using Aberrant Behaviour Checklist Japanese Version irritability subscale score (ABC-J scale).

The follow-up results for the experimental group at the end of week 8 revealed reduced mean score from the baseline data on use of ABC-J scale. There as significant decrease in irritability and aggression score seen to be initiated from week 3 to week 8 on use of aripiprazole for children and teenagers with ASD. The group which received aripiprazole expressed statistically significant score when calculated through mean clinical-rated CGI-scale compared to the placebo group.

In relation to safety outcomes for the use of aripiprazole in case of ASD individuals, the study mentioned that 39 people in the experimental group and 33 people in the placebo group expressed at least one adverse side-effect of the medication. However, the side-effects were mainly between mild to moderate and no deaths due to the adverse event of aripiprazole use is reported in the study. The strength of the study is that it allows wider data in the form of evidence to be used in practical field to determine if aripiprazole is to be used for ASD children and teenagers in resolving their aggression or irritability. However, the limitation of the study is that it determines the impact of the medication for short-term and therefore, the long-term efficacy of the use of medication could not be identified (Ichikawa et al., 2017).

In comparison, the study by Stutzman and Dopheide (2015) focussed on determining the impact of acetylcysteine in controlling aggression and irritability in a hospitalised teenager with ASD. For this purpose, the case study of the patient is explained with detailed observation to inform the effect of acetylcysteine on the individual in controlling his hindered behaviour. The patient in the study included is mentioned to be a 17-year-old male who is Hispanic and with ASD. He is hospitalised in the inpatient psychiatric ward due to increased violent behaviour and impulsive emotional expression. In the first few weeks, the individual is provided diphenhydramine and lorazepam through intramuscular injection, but the patient still expressed aggression and impulsive behaviour. In further care, the patient is provided 20% diphenhydramine orally initially at a dose of 600 mg twice in a single day in addition to the quetiapine therapy. In 6 weeks, it was seen that a drastic reduction in the aggression and impulsive behaviour occurred in the patient making him show less tantrums, irritability and aggression.

The use of acetylcysteine is continued but the quetiapine dose was lowered from 700mg to 400 mg per day. It was found that acetylcysteine is effectively tolerated with less observed report of adversity in the patient. It was seen that acetylcysteine did not created any sedating impact of the patients unlike the clonidine or guanfacine. The strength of the study is that it allowed effective comparison of other medication with acetylcysteine to determine if it is effective to create enhanced reduction of aggression in children and teenagers with ASD. However, the limitation of the study is that an objective scale was not present to document the gradual changes in the behaviour of the patient during his tenure at the hospital. Moreover, the impact of acetylcysteine on a single patient is described in the study and thus the information cannot be generalised to be used in practical field.

In contrast, the study by Loebel et al. (2016) aimed to determine the short-term efficiency and safety of lurasidone for treatment of aggression, irritability, agitation and others in children and teenagers with ASD. For this purpose, the researcher included 150 participants in the study who were randomly selected for 6 weeks to receive double-blind treatment of which 149 received the drug who were either in lurasidone group or placebo. The 6-weeks complication rates revealed 92% for the lurasidone group having 60mg of medication for each day, 88% for the lurasidone group having 20 mg of medication per day and 76% for the individuals in the placebo group. The efficiency of impact of the medication is executed by Clinical Global Impressions, Improvement (CGI-I) scale and the Aberrant Behaviour Checklist Irritability subscale (ABC-I).

The results revealed that least square mean improvement for patient from baseline data to week 6 in the ABC-I was not statistically any different for use of lurasidone 20mg/day and 60 mg/day. The discontinuation rate due to adverse effect of lurasidone was 4.1% who received 20mg/day lurasidone, 3.9% who received 60mg/day lurasidone and 8.2% who were in the placebo group. The adverse event with use of lurasidone reported were somnolence and vomiting. However, only modest level of change in weight and metabolic condition is seen with use of lurasidone. It was concluded that there was no impact of lurasidone in short-term to resolve aggression and irritability in teenagers and children with ASD. The limitation in the study is lack of presence of an effective control group for comparison of the impact of the medication

In the study of Van Schalkwyk et al. (2015), it is mentioned that nicotine acetylcholinergic neurotransmitters plays an effective role in pathophysiology of ASD to lower aggression-related behaviour among individuals. Thus, the study aimed to determine the effective of transdermal nicotine as medication for treating agitation or aggression in individual with ASD. For this purpose, the researcher included the detailed case report of JC who was teenager admitted to the inpatient unit of the hospital due to self-directed physical aggression such as biting, banging head on the wall and continuously reopening closed wounds. The behaviour of the individual was found to be escalating instead of enhanced medication regime that included use of clonidine 0.15 mg/twice a day, chlorpromazine 75 mg/day and divalproex sodium 1500mg/night and constant therapeutic intervention. After the failure of the provided care, the patient with the consent of his parents was provided 21mg nicotine patch based on his aggression and agitation. The nicotine patch dose was determined by examining the body mass of the patient.

After the initiation of the transdermal nicotine protocol, it is seen that the patient’s agitation and aggressive behaviour on many accounts was able to be controlled. The patch was used for 4 weeks and discontinued before the release of the patient from the hospital to which the individual with ASD expressed effective response and mentioned no need of the patch on release from the hospital. The strength of the study is that it can be used in evidence-based practice by nurses to control aggressiveness in individuals with ASD as it has detailed account of the process to be gradually followed to complete the car. However, the limitation of the study is that the result cannot be generalised as it is based on a single teenager. Therefore, its impact on a large number of individuals of similar nature is not known to allow generalisation of the facts to be used as evidence in care.

Discussion

The key outcome explored in this study is effectiveness of cognitive behaviour therapy (CBT) as pharmacotherapy and use of medication in controlling and managing physical aggression in children and teenagers with Autism Spectrum Disorder (ASD). In order to understand the evidence regarding it, initially the cause of aggression among individuals with ASD is explored. This is to determine why the emotional issue is raised among individuals with ASD for which such wide discussion of effectiveness of intervention is required. The study by Sullivan et al. (2019) mentioned that social anxiety and environmental condition like carelessness of parents, removal from classroom and stressful situation is responsible for raising aggression in children and teenagers with ASD. This is evident as stressful environment leads autistic children and teenagers to be vulnerable which makes them use aggression to defend themselves to cope with the situation. Moreover, removal from classroom and unavailability of parent’s care makes the autistic teenagers and children to be anxious and agitated regarding their safety in turn making them be aggressive to protect own self.

The fact by Sullivan et al. (2019) is supported by the study of Ambler et al. (2015) who also mentioned anxiety to have greater link in creating aggressive behaviour of the autistic children and teenagers. However, compared to the two studies of Ambler et al. (2015) and Sullivan et al. (2019), the study by Lundwall et al. (2017) focussed to mention from the neurological aspect the key reason of aggression among individuals with ASD. It revealed that shorter brainstem volumes are responsible in causing increased agitation and aggression among teenagers and children with ASD. However, there was lack of presence of other studies which mentioned similar context as most of the other studies like Bosco et al. (2019) and Dadalko and Travers (2018) related brainstem volume to be reason of learning difficulty and additional symptoms in ASD but not revealed if it influenced emotional behaviour of autistic individuals.

The study by Wood et al. (2015) focussed on the impact of managing the cause of aggression in autistic individuals that is anxiety through CBT unlike the other two studies of Scarpa and Reyes (2011) and Weiss et al. (2018) where they focused on impact of CBT in managing aggression as itself in autistic teenagers and children. In all these studies, it was seen that CBT was effective in controlling aggressive behaviour of autistic individuals as well as the factors causing them. It is evident as the study by Wood et al. (2015) mentioned with use of CBT, anxiety which results autistic individuals to be aggressive at times was effectively controlled and they were seen to show better and impressive behaviour. In addition, the study by Scarpa and Reyes (2011) mentioned that CBT helped the children and teenagers with ASD have shorter aggressive outburst, better management of anger and emotional changes that are all responsible in making them physically aggressive. Moreover, the fact is supported by Weiss et al. (2018) where they also mentioned CBT impacted the autistic children and teenager to control anxiety and anger that are responsible in making them aggressive. In all the studies, the CBT tried to make the autistic children understand how they can control their moods and emotion to avoid being aggressive which in interfering with them to make effective social connections.

Apart from the cognitive therapeutic options for managing aggression in ASD, few discussions of medication intervention are also focused as they are seemed to take less time to resolve the condition or act to enhance the effect of the therapy. In this respect, the studies by Nuntamool et al. (2018) and Aman et al. (2015) mentioned risperidone to be effective medication for managing aggression in children and teenagers with ASD. The first study focused on 1-year use of the medication and the second study focused on 2-year use of the medication. In both the cases, positive impact of the medication is seen but the side-effects informed in the patients are weight gain and increased appetite. In contrast to them, the study by Ichikawa et al. (2017) focussed to understand the impact of other medication that is aripiprazole on its effectiveness in controlling aggression among children and teenagers with ASD. It was revealed that the medication also worked in similar way like the risperidone and resolved increased aggression of individuals with ASD in making them to act soberly.

The further studies explored other impact of other anti-psychotic drugs or medicine on managing aggressive behaviour in children and teenagers with ASD. In the study by Stutzman and Dopheide (2015) it was mentioned that acetylcysteine compared to clonidine or guanfacine creates less sedation of ASD individuals to help them cope with aggression. It is also effective when used with quetiapine under managed dose on ASD individuals. However, the study by Loebel et al. (2016) identified that lurasidone which also an anti-psychotic medication did not create any improvement in aggressive behaviour of children and individuals with ASD. Thus, the use of the specific medication is to be avoided for management of aggression in ASD. In contrast, the study by Van Schalkwyk et al. (2015) determined if nicotine transdermal are effective option after the anti-psychotic in managing aggression in children and teenagers with ASD. It was revealed that it does acted as effective intervention in managing aggression and did not made the patient show any withdrawal symptom on stopping the intervention. It ensures it can effective alternative after anti-psychotic medicine in managing aggression in children and teenagers with ASD.

Conclusion

The topic discussed regarding the effectiveness of Cognitive Behavioural Therapy (CBT) and medication in managing aggressive behaviour initially highlighted that physical aggression in ASD children and teenagers are common issue and therefore discussion regarding the topic is essential. The initial background of the topic mentioned that Autism Spectrum Disorder (ASD) is a disruptive functional disorder that impairs the individual affected by the disorder to express ineffective ability to socially communicate and interact with people. This difference leads the ASD children and teenagers to be considered as vulnerable people by normal individuals and reject them from being socially included. It causes the ASD to gradually develop fear to socially interact and when they are placed in such satiation, it is seen that the ASD people express aggressiveness to avoid being in the situation.

The background led to understand that ASD individual uses aggressiveness as the way of protection from social abuse out of fear of being considered inappropriately and vulnerable by others in the society. However, no studies are widely found that could explore the most specific reason for the aggressiveness in ASD children and teenagers along with the nature of impact CBT and medication therapy could act in controlling the situation. Thus, the current study is been mentioned to be developed to resolve the aggressiveness issues being faced by ASD individual which also makes them to considered vulnerable in the society which they are not.

The rationale of the study mentioned that ASD is currently present in wide numbers among children and teenagers in the UK as well as globally and it is increasing at an exponential rate to make it one of the prevailing functional and learning disorders in future. The increase in the rates of ASD also indicates that more children and teenagers affected by the disorder would show increased aggressive behaviour as a result of social impact regarding the disorder which would compromise their social life and interaction with others. The behaviour in them if not control would also make them isolated and excluded from interaction with others in the society. Therefore, effective understanding of the therapeutic and pharmacological treatment regarding reduction of affection in ASD children and teenager is needed to help them develop better future life.

The studies explored in the research mentioned that Cognitive Behavioural Therapy (CBT) is one such therapeutic interaction in controlling aggressive behaviour in ASD children and teenagers which is also one of the key focused variables of the research. The CBT is mentioned to be psychotherapy that uses range of methods in alerting the hindered emotional and cognitive state of the individuals. The CBT assist people to change their negative thinking by making them understand the source of the negative thinking and the way it is to be changed to avoid its impact on their lives. The studies mentioned that CBT in children and teenagers with ASD assist them to alter and avoid aggressive behaviour by making them aware of the determinants leading to such behaviour and way the factors are to be avoided. This is evident as CBT makes the ASD children and teenagers understand the way anxiety, lack of social support from parents during separation from them and others affects their mental and emotional state to make them show aggressive behaviour. The CBT also educates them regarding the way to control the negative emotion to avoid being aggressive in the social condition.

The studies also mention that apart from CBT, the pharmacological intervention in ASD children and teenagers provide faster and better results in controlling their emotion of being aggressive in behaviour. This is evident a medication like risperidone is mentioned to lower aggressive behaviour in children with ASD by making them develop clam emotional state. The pharmacological intervention such as aripiprazole is found work similarity like risperidone to helps ASD teenagers avoid showing aggressive behaviour. The medication such as acetylcysteine compared to clonidine or guanfacine are found to create lower aggressive behaviour by creating less sedative effect on the AD children and teenagers in controlling their behaviour. Moreover, nicotine transdermal is found to alterative to anti-psychotic medication in making AD children and teenagers avoid developing aggressive behaviour. The medication when provided in link with the CBT therapy were mentioned to provide greater impact in enhanced control of aggressive behaviour among ASD children and teenagers.

Recommendations

Recruit trained therapist in delivering CBT

In delivering Cognitive Behaviour Therapy (CBT) to the ASD children and teenagers in controlling their aggressive behaviour, trained therapist with effective knolwdege of working with ASD individuals is to be recruited. This is because ASD children often show lower cognitive and learning ability compared to people with other mental disorder due to which the therapy required to be customised accordingly. It is required so that the children with ASD feel supported and work along with the therapist in effective manner to institutionalise change in their emotion and thinking to avoid being aggressive. Moreover, the trained therapist is required in delivering CBT so that the specific techniques to be used in customising the CBT therapy as per ASD children need are appropriately judged. This is to be achieved by ensuring ASD children and teenager with aggressive behaviour wishing to access CBT are referred to CBT therapist who already have past experience in treating similar individuals.

Determining proper medicine dose

The dose of medicine to be provided to the ASD children and teenagers in controlling their aggressive behaviour is to be appropriately determined through analysis of their health condition. This is because intake of increased doe of certain medication may make the ASD develop increased sedation that may resolve their aggressive behaviour but create side-effect such as fatigue, lack of energy and others which interferes with their ability to perform everyday talk with efficiency. The side-effect and withdrawal symptoms of the medicine used (if any) in patients with ASD for managing aggressive behaviour are to be followed-up by the service providers and according make arrangement resolve the raised issues.

Awareness regarding CBT use

An effective awareness regarding importance and need of use of CBT is to be created among the ASD children and teenagers along with their parents. The awareness is to specify the way CBT can resolve aggressive attitude in the ASD individual and create enhanced social ability among them to make them live a better life. This is because such action would make people understand the benefit of the therapy and access them in resolving aggression. This is to be established by creating awareness campaign in offline and online mode to be reached specifically to the ASD people and their parents.

Strength and Limitations of the Study

The strength of the study is that the data are reliable and valid this is because they are accessed from published studies where the results presented are mentioned to be real and valid. Moreover, the currently gathered data is seen to specifically answer all the raised questions in the study and effectively helped to meet the objectives of the study due to which it can be considered as reliable and valid. The limitation of the study is that no primary information through direct communication with participants was able to be included in the study. This is because of the current COVID-19 situation where direct interview with the individuals in unable to be performed due to medical reason and restriction created by the authorities. The other limitation is lack of adequate availability of research papers regarding the mentioned topic due to which effective information in enriched manner could not be identified that would have led to create better critically analysed results to be presented. The time contain in another limitation been faced due to which adequate data could not be explored and follow-up study cannot be performed. The other limitation is lack of finances because lack of money leads to avoid access of many paid articles relevant to the topic which could have helped in gathering more diverse data for enriched execution of the study.

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