Clinic Notes: Tourette’s Syndrome

Tourette's is easy to spot in public. The motor and verbal tics are obvious. Haloperidol is an effective but unpopular treatment for Tourette’s. In animal models of Tourette’s, nicotine potentiates the effects of haloperidol. In other words, a smaller dose of haloperidol can be effectively given. I don’t know of any studies that have used nicotine to potentiate haloperidal in humans with Tourette’s. Patients with schizophrenia are deficient in nicotinic cholinergic neural transmission. Many smoke to make up for their nicotine deficiency.
See "Tourette Turtle" at www.ABA4Autism.com

Clinic Notes: Having An Autistic Sibling

Many parents who bring their children to my clinic ask what effect will a child with autism have on a normal sibling. The studies that have been done on the effects of having a sibling with a neuropsychological disorder such as autism are conflicting. Some studies and anecdotal reports show an adverse effect on the sibling without the neuropsychological disorder while others do not. Girls seem to be more adversely affected than boys. Psychological problems in the parents such as depression and a host of other factors must be also considered when examining this issue. (Howling, P. “Living with Impairment: the Effects on Children of having an Autistic Sibling.” See http://mugsy.org/howlin.htm.)
See Case Number 12 "Twinship" at www.ABA4Autism.com

Clinic Notes: Preventing Autism

Autism in not usually diagnosed until the second or third year of life. A recent article suggests that autism and behaviors that correlate with the later development of autism may be identified as early as 6-8 months. Furthermore, there are studies, which suggest that intensive ABA may prevent autism if begun at an earlier enough age. One study reported that a one-year-old child at high risk for developing autism was completely after three years of ABA therapy. This doesn't surprise me. I have always thought that ABA "rewired" or appropriately wired the brains of young children.
(Preventing Autism Now: A Possible Next Step For Behavior Analysis, Philip W. Drash, Autism Early Intervention Center)

Clinic Notes: Denial in Parents of Children with Autism

I don't know the exact percentage of parents with children diagnosed with autism that are in denial. In my clinic I would estimate it is much less than half. When I first tell parents the time and money they will need to invest in ABA, Speech, OT, and other services many never blink and want to know what else they can do to help their children. But with others, one or both parents tell me their child is not really that bad off and ABA, speech, and OT services are not needed. Sometimes these parents wake up and come back, but most do not. They continue their lives without providing any services for their child except what the school has to offer. In a rural area I often get to watch these children languish in special ed while I wonder what might have been.

Clinic Notes: Discrete Trial Training

I have posted below the general procedure for discrete trial training from my web site. This is a very useful procedure for teaching children with autism or other neuropsychological disorders. In future posts I will have specific programs. If you are having problems teaching a child let me know and I will help.

10. Applied Behavioral Analysis (ABA) Program for Teaching
Children Shapes, Colors, Numbers, and Letters

Some children with neuropsychological disorders fail to learn different shapes, colors, numbers, or letters because of compliance problems, while other children with neuropsychological disorders do not learn because of sensory and/or neurological processing problems associated with certain disorders. If a reward is given to the child for a correct response, performance often dramatically improves in noncompliant children. On the other hand, the rate of improvement in children with actual sensory/neurological problems is much, much slower. In the beginning the best thing to do when we are trying to teach a child to learn the differences between stimuli, such as two colors or two shapes, is to run intensive drills using bite size rewards for all children, which we then fade out. The rate by which the child improves tells us if we are dealing with a noncompliant child or a true sensory processing problem. See Case History Number 1 in Little Bubba’s Not Ready For Nashville Yet for an example. (Available at http://wwwABA4autism.com).
Discrete Trial Training
Teaching discriminations between stimuli is easier if only two stimuli are used in the beginning. For example, take two objects, which are different colors. Start with the easiest discriminations first. The difference between blue and red should be easier to learn than the difference between red and orange.
Behavioral Assessment
Use objects which are identical but have different colors, such as pieces of cloth or pieces of construction paper. (It is better not to use different colored toys which the child would want to play with.) Ask the child to point to or hand you one color and record the number of correct responses and incorrect responses on the attached form. Do this for several days without comment or reward in order to obtain a baseline. (If you run blocks of ten trials, then it is easy to calculate the percentage of correct responses.) Only wait 3-5 seconds for a response and 3-5 seconds between trials. Be sure to switch the different colored objects from side to side so the child will not learn a position habit. (In other words, a child can learn right or left side rather than the color and still be correct.)
Behavioral Intervention
After you have a baseline, reward the child immediately for each time he/she correctly picks the right color with a bite size treat. (A Tupperware bowl full of bite size goodies is what we use as tangible reinforcers for most kids in our clinic. The child only gets to pick one bite size piece.) If the child gets it wrong say, “no,” and ask the child again. After the child receives a “no” response twice in a row, prompt the child with the correct answer (give no reward). Point to the correct color; move it closer--anything that will make the discrimination between the two colors easier for the child. Then fade the prompt on later trials by gradually moving the correct colored object back so it is in line with the colored object. Continue to wait 3-5 seconds for a response and 3-5 seconds between trials. And be sure to switch the objects from side to side so the child will not learn a position habit.
Once the child is picking the correct color, ask the child to point to or hand you the other color. When the child can discriminate between the two colors, move to another color. Again, make it easy for the child. Red and green would be easier than red and yellow. Children with neuropsychological disorders may not generalize from one set of colors to another so be prepared to spend a long time in discrete trial training. If you get no improvement after a large number of trials, try black and white discrimination because the child may be color blind.
Maintenance and Generalization
Deliver social reinforcement in the form of praise, hugs, pats on the back, etc. as often as you can once the child learns the difference between stimuli. Edible reinforcers, such as candy or other treats, may be faded out once a significant change from baseline is achieved. Only give the tangible reinforcer every other time, then every third time, etc. until it is no longer required to maintain appropriate behavior. Of course, social reinforcement should be given as often as possible.
If you are not getting anywhere after several weeks, contact a psychologist versed in ABA in your area, if at all possible. (Go to http://www.aabt.org/ to locate ABA therapists.) One possibility for the ABA program not working is satiation. In other words, your child is getting tired of whatever reinforcer you are using.
(See http://www.polyxo.com/discretetrial/ for a good overview of discrete trial training.)

Clinic Notes: Asperger's Syndrome and Bi-polar Disorder

There's is a lot in the literature about bi-polar disorder being co-morbid with the Autistic Spectrum Disorders, especially Asperger's Syndrome. Children with Asperger's Syndrome perseverate and also have social problems. One common perseveration in children with Asperger's is being right. Often I have been running ABA drills in my clinic with a child with Asperger's and noticed that if the child gives the wrong answer and I tell the child that they have made an error they will often insist that they have given the correct answer. When I try and explain why the answer is wrong the intensity of arguing often increases, sometimes to the point that it resembles manic behavior. Once the child calms down they seem often to become "hyper-calm" almost moody and depressed. I have also had two-year old children come to my clinic with a diagnosis of bi-polar disorder, and often heavily medicated. In our assessment we find that the child does display "manic" like bhavior, but the "manic" like behavior always follows the child being given a direction that the child did not want to follow. If the child is made to mind then they also become moody and depressed. These children do well on ABA programs for compliance.

Clinic Notes: Why the Causes of Autism Are so Illusive

Recently, a pediatrician who had just had a child diagnosed with autism, emailed me. "The neurologist told me that autism is a brain disorder," she wrote. "And the gastroenterologist told me that autism is a gut disease, and the immunologist says that it is an immune disorder. Please tell me what autism is and how to treat it."
Of course, I told her about ABA, speech, OT, and the meds pediatric neurologist prescribe, but I could not answer her question completely. I don't think her question will be answered until we get a better classification system of autism spectrum then we have now. If you saw the kids in my clinic who are diagnosed with autism you would see so much variation in symptoms that you would wonder if they all had the same disorder. Some self-stim others don't, some are verbal others are not, some are compliant others are not, some have sensory issues others don't, some are remote ohers are very loving, some have digestive problems others don't, some have immune problems others don't, and so on. If all these children all have the same disorder, then why the wide variation in symptoms? I think autism will turn out to be a disease like cancer. There are many different types of autism with different causes and different treatments.

Clinic Notes: Social Stories for Children with Autism or Other Neuropsychological Disorders

What is a Social Story?
Social stories are short descriptions of how a child should behave in a wide variety of situations. Children with autism and Asperger's, as well as children with other disorders, have problems socially because of an inability to understand the point of view of others and their expectations. Everyday activities such as how to behave during circle time, what to say if someone compliments you, or how to handle bullying can be addressed by using social stories.
How to Use Social Stories.
Social stories are useful in teaching a child how to behave in situations when the therapist cannot be there to prompt and reinforce appropriate behavior. For example, if a child becomes aggressive at day care when another child takes a toy away then a social story about sharing or how to behave when a child takes a toy away can be very useful. A social story describing what the child should do to obtain a positive outcome, personalizing as much as possible the story for the child, is written. After reading the story to the child several times the child can be asked, "What do you do when Billy takes a toy you are playing with and starts playing with it himself?" If the child cannot remember the story or the answered then he/she can be cued. The correct answer may vary for different children in different settings. Telling the teacher might be appropriate in one situation; playing with another toy may be appropriate in another. At any rate the story is repeated until the child has memorized the correct answer. If the therapist finds out that child did engage in the appropriate behavior described in the social story then reinforcement in the form of praise and tangible reinforcement can be given at a later time.
How to Write a Social Story.
Social stories should be written from the point of view of the child and provide information on how to behave, what other expect, and the positive consequences of appropriate behavior. Social stories should be short and the child may have to memorize the correct way to behave and then replay the social story in his or her head when in the actual situation.

Clinic Notes: When Time Out Does Not Work for Children with Autism

In my last blog I discussed how to do time out properly. As I mentioned time out is a often used and misused procedure. But even when used properly time out can have limited success with children with autism. Time out means time out from positive reinforcement. So if a child with autism is engaging in a reinforcing activity such as playing with a toy, watching a video, etc, and you send the child to time out for some inappropriate behavior such as not following directions then time out will in all probability be effective. On the other hand, if you are running discrete trial training and trying to teach a child with autism letters of the alphabet, which is hard for the child, then sending the child to time out for an inappropriate behavior such as not paying attention will not be effective. The drills are not reinforcing so time out will not work. In this situation we usually run the body parts drill. In this drill we take the child’s wrist and use the child’s hand to point to different body parts. Fade the physical prompts as the child begins to do the drill on his or her own. In other words, use less and less force to move the child’s hand as the child becomes compliant. (This is the same behavioral principal a rider would use to get a horse that balks to cross a ditch or go up a hill. The rider would pull the reins to the right or left and make the horse go around in a circle several times. If the horse did not comply then the rider would have the horse go around in circles several more time and try again.

Clinic Notes: Time out and Autism

Time out is an often used and misused procedure. If done properly, time out is a very effective, humane procedure. Find a place in your house where a time out chair, preferably a chair with arms and not a bench, can be left. The chair should face a blank wall and not be close to a window, shelves, glass, electrical outlets, or storage cabinets containing chemicals. Hallways and alcoves often work. Do not use bathrooms or closets. The time out chair should be close to the play area so the child can be placed in time out quickly. Think safety, especially for small children. (If the child is very young, then the baby bed will do, and no, the child will not develop an aversion to the baby bed and have sleep problems. An alternative time out procedure for a young toddler is to sit him/her down on the floor with his/her back to you and hold them there for thirty seconds. Do not talk to the child except to tell him or her at the beginning and end of time out why he or she is in time out.) For young toddlers you can just count to thirty in your head. For older children, use an egg timer and teach the child that he or she cannot get out of time out until the egg timer goes off. The child has to stay in time out for three minutes plus one minute of good behavior. In other words, the child has to be quiet and cannot be arguing, complaining, or tantruming for one full minute before he or she can get out of time out. Do not be surprised if the child comes up with a whole bag of new inappropriate behaviors in order to get out of time out. Kids have been known to gag, vomit, and one of my own kids even hit herself in the face several times. Do not respond and thereby reinforce these new inappropriate behaviors or they will increase in their frequency. Only good behavior gets the child out of time out. (Initially, some kids have to be held in time out. Gradually, decrease the restraint you have on the child and make sure he/she is sitting there quietly for one minute before he/she gets out. If the child is too large to safely hold in time out, then use a response cost procedure instead. In response cost something the child values is taken away temporarily. Examples include watching TV, going outside, videos, the opportunity to play games with caregivers, favorite foods or beverages, a favorite toy, etc.) In the beginning of this procedure, it is not unusual for a child to be in time out for fifteen to twenty minutes before he/she quiets down, and to go to time out as often as twenty times a day. After a few days the child learns the requirements of the time out procedure and he/she gets out in the minimum four minutes. The number of times the child goes to time out each day also drops dramatically. When the child gets out of time out, remind your child of why he or she had to go to time out in a firm tone. Do not be timid with your voice or body language. (Excerpted from my ABA eBook available at www.aba4autism) In my next blog I will discuss why time out does not always work with children with autism

Clinic Notes: Autism and Hearing

Parents and professionals expect auditory processing problems when they see a child with autism cover his or her ears with their hands. Other children with autism act as if they are deaf. Many children with autism, who have partially recovered, report sensory distortions. The sound of a vacuum cleaner or hair dryer may be so loud that it frightens the child with autism. A single voice may be so soft that it is not heard, while several voices, as in a classroom, may be deafening. Temple Grandin’s governess used to punish her when she was a child by popping a paper bag. In my clinic we often run an ABA program to desensitize a child to aversive sounds. Desensitization also works well for the child with autism or other neuropsychological disorders who are distracted by sounds when they are trying to concentrate. Go to my website aba4autism.com for a desensitization program for your child.

Clinic Notes: Autism in Malaysia

Last week I noticed that an order on my website for one of my ABA eBooks was from a woman in Malaysia. I receive orders from all over the world, but I think this was the first one that I have from Malaysia. I recall wondering at the time what services were available for children with autism in Malaysia. I'm still not sure what all the services are like, but a recent report indicates that there was some abuse by parents of the so-called "naughty" children. The National Autism Society of Malaysia (Nasom) has set up 13 Nasom centers nationwide to provide early behavioral management for children with autism. In addition, Nasom plans to train 2000 preschool and primary school teachers on how to teach children with autism. Perhaps things aren't so bad for children with autism in Malaysia.
http://tinyurl.com/mk

Technorati

I am indexing my blog in Technorati

Technorati Profile

Clinic Notes: Sex Differences and Autism

Autism is 4 to 5 times more prevalent in boys than girls and often more severe. In a recent study at the University of Washington, researchers found that different genes may be involved in autism in males and females. Furthermore, different genes may cause early onset autism and regressive autism. (http://www.emaxhealth.com/37/6827.html).

Clinic Notes: Down Syndrome and Autism

Last year I had a child come to my clinic with Down Syndrome who had recently developed autism. Recent studies find that 7 to 10 percent of children with Down Syndrome also have autism. I think that it is more appropriate to say that they exhibit some autistic behavior. In 1959 the genetic basis of Down Syndrome was found to be trisomy 21 in 95 percent of the cases and the extra chromosome is usually maternal in origin. People with Down Syndrome are depicted in ancient art; so apparently the disorder has been around for a long time. In 1866 Dr. John Langdon Down wrote about the facial similarities of many of his patients with mental retardation using a racial description (Mongol), which unfortunately stayed around for nearly a century. Once the genetic basis of the disorder was known ,the terminology changed and now the correct terminology is to refer to them as persons with trisomy 21 or a person with Down Syndrome. See http://www.nas.com/downsyn/trumble.html for a detailed discussion of Down Syndrome.
Women older than forty or mothers who already have a child with Down Syndrome are more likely to give birth to babies with Down Syndrome, and routinely undergo amniocentesis at sixteen weeks. Taking into account surgical and spontaneous abortions the incidence of Down’s is approximately one in every eight hundred births. Younger mothers who do not undergo amniocentesis deliver the majority of Down’s babies because they don’t get tested. A new test, which combines blood tests and an ultrasound, is 90 percent accurate in the first trimester and can be done four to six weeks earlier than the standard Triple Test. (We understand more about genetics now than we did in John Donne’s day. But it seems like fate still plays a role.)
Children with Down’s have a variety of physical characteristics. Most of these children do not reach adult height. The head is usually smaller (microcephaly) and the nose may be flattened. The tongue protrudes and the eyes slant upward. Many children with Down’s have a rounded fold of skin (epicanthal fold) in the inner corner of the eye. The hands and fingers are broad and have a single crease in the palm. Medical problems may include congenital heart defects, gastrointestinal problems, hypotonia, and acute lymphocytic leukemia. The average mental age is eight years.
Some newborns with Down Syndrome have visual and hearing deficits. Cataracts occur in 3 percent of the cases and glaucoma is more likely also. Hearing should be tested on a yearly basis according to some experts. Hypotonia not only affects mobility it also affects feeding. The protruding tongue means feeding will take longer and dysphagia (difficulty in swallowing) and choking episodes are common. The usual developmental milestones are globally delayed.
Ten percent of kids with Down Syndrome have seizure disorders which are usually tonic clonic. In older patients with Down Syndrome, seizures associated with Alzheimer’s often develop.
Children with Down Syndrome usually do well with ABA. When autistic behavior develops with Down Syndrome the ABA is more difficult.
Go to http://www.aba4autism.com and read case number 15 for additional information on Down Syndrome.

Clinic Notes: The Curious Incident of the Dog in the Nighttime Redux

Last year I read the novel, The Curious Incident of the Dog in the Nighttime by Mark Haddon. The protagonist in the novel is a boy with autism and is one of the best descriptions of the disorder that I have read. In a recent Schaffer Report reporter Jim Maniaci (http://www.gallupindependent.com/
2006/july/071206deaddog.html)
describes another "curious incident" in which a New Mexico woman returned home to find her autistic grandson's dog shot. She put the dog's body in a box by the road and her child frequently visited the temporary grave a number of times. The deputy investigating the case returned several days later and advised the grandmother she would have to bury the dog or call animal control because of the flies

Clinic Notes: Prenatal Exposure to Recreational Drugs

Prenatal exposure to recreational drugs causes a host of physical and neuropsychological problems in children. Some disorders, such as Fetal Alcohol Syndrome, are stereotypical while exposure to other drugs cause problem behaviors, which are more diverse. Investigative techniques used to study the precise neurological mechanisms involved in prenatal exposure to various drugs are too invasive to use with children as subjects so it is necessary to turn to animal models. The research is limited here, but we do know that prenatal exposure to alcohol produces abnormal spines on the dendrites of the neuron and reduces neural plasticity. In other words, it is more difficult for the neural circuits underlying various neurological functions to form when alcohol has been ingested.

Clinic Notes: Paying for ABA

Recently, I was in a meeting with the Commissioner Of Mental Health in Tennessee. After the meeting the psychologist who works for the Commissioner told me that TennCare, the states program for the uninsured, was now paying for ABA. Unfortunately, the reimbursement rate was only $27.00 per hour. Normally, ABA costs from $30,000 to $80,000 depending on the number of hours per week. Alberta Province in Canada pays up to $60,000 per year for ABA. At the Tenncare rate I would make $28,000 per year if I saw a child for 20 hours a week. When school systems and insurance companies agree to pay for ABA, which does not always happen, the pay rate is 2-3 time what Tenncare pays. I wonder who is doing ABA for $27 an hour? Probably not anyone qualified. It's unlikely that many kids on Tenncare are getting ABA. I guess if you want ABA for your child with autism and you cannot pay or get anyone else to pay do what many Canadians from other provinces are doing. Move to Aberta.
http://www.cbc.ca/canada/calgary/story/2006/07/10/
autism-therapy.html

Clinic Notes: Where is the Best Placement for a High Functioning Child with Autism?

One question I always get in my clinic from parents of high functioning children with autism is what program is best. Of course, the school system usually wants to put them in special ed classes or a separate autism program in the larger school systems. But then you run into a modeling problem. Children with or without developmental delays are going to imitate their peers. So if you have a class of children with autism who is the high functioning child going to imitate?
I have a mother of a high functioning child coming to my clinic now. She and her husband are traveling all over the country looking for the best autism program. I'd mainstream this child, while at the same time providing the ABA services the child needs. I've done this many time and it works well.

Clinic Notes: Wild Child

In graduate school I’d read The Wild Boy of Aveyron, an account of a ten to twelve year old who was captured in 1799 by French peasants in the forest where he had been living. The child acted like a wild animal running around on all fours, eating off the ground, smelling everything. There have been other published cases of abandoned kids, found living in the wild, like Amala and Kamala, the so-called “Wolf Children” found in India in the 1920s and “Wild Peter” discovered in Germany in 1724. Bruno Bettelheim argues that these wild or feral children were really abandoned autistic children. Since they couldn’t speak, it was assumed by the people who found them that these kids were raised in the wild by animals. There is some doubt about authenticity of these cases. None of them responded to "therapy" and their behavior was similar to more recent, confirmed cases of isolation and deprivation: infants and young children who have been kept in captivity, locked up in small rooms, closets, or attics, isolated from the outside world, and oten abused. I often wondered if these accounts of feral children led Bettelheim to propose his refrigerator theory of autism back in the forties. I had dinner with him in the seventies and asked him directly. But he was a grouchy depressed man and waved his hand at me and would not answer.
(See "Wild Child" at www.aba4autism.com)