Clinic Notes: Preventing Autism Redux

In a previous post I described several studies, which found that intensive ABA in young children at risk for autism seemed to work. Of course, identifying children at risk for autism while they are young is a major hurdle. Some kind of early screening system, perhaps involving pediatricians and early well-baby exams, would have to be established. But there is a second hurdle and that is accepting the idea that intensive ABA changes the mis-wiring in the brain. Most everyone now accepts the idea that autism is a neurological disorder. But not everyone accepts the idea that ABA is rewiring faulty brain circuits.

Clinic Notes: Autism and the Christmas Holidays

I am reposting this for the holidays:
I have had many parents of children with autism or other neuropsychological disorders tell me that the Christmas holidays are an especially difficult time for them. Of course, any holiday can be difficult for any child with the changes in routine. But Christmas is usually the most difficult holiday for parents of children with autism or other neuropsychological disorders.
There are no sure-fire techniques to use with your child that will insure a "Martha Stewart Christmas." Families who have children with autism or other neuropsychological disorders have used the following 10 tips to make their Christmas better. And this year I'm adding a new suggestion to the list.
Several years ago Leigh Grannon and I did a study using pictures to increase social interactions in a child with autism. Children with autism are visual learners, and I have suggested to parents that they take pictures of what is going to happen at Christmas--the tree, the gifts, the relatives--and starting several weeks before Christmas show these pictures repeatedly to the child with autism. Tell a little story to the child while he/she is looking at the picture about how to behave, what's going to happen, and what the child can do if it is too much. Include your child in the pictures if possible. A picture of the child going to his room to escape the noise and confusion when he/she gets overloaded seems to help, too.
1. Try to keep your child in his or her usual routine as much as possible.
2. Sensory over stimulation—the lights, the sounds, the smells, the relatives touching your child--are the main culprits during the holidays. Eliminating or minimizing these culprits are your best bet.
3. Some families who have children with autism or other neuropsychological disorders wait until Christmas Eve to put up their tree and decorate.
4. Some families let their children with autism or other neuropsychological disorders do all of the decorating. Children with autism or other neuropsychological disorders may line up or stack decorations rather than decorate in the traditional way, but so what.
5. Rather than try to do the Christmas shopping with children with autism or other neuropsychological disorders in a crowded, noisy mall, many families shop by catalog or online and let the child point to or circle the toys he/she wants. Websites, such as www.stars4kidz, offer a variety of toys for children with autism or other neuropsychological disorders. Just type "autism toys" in your search engine.
6. Tactile toys are often a better choice for children with autism or other neuropsychological disorders. Toys that make sounds or involve too much stimulation or are too complex may not cause an aversive reaction in the child. As mentioned above there are web sites that sell toys designed for children with autism or other neuropsychological disorders. Try ordering some of these toys and then let your child select the ones to play with as they are unwrapped.
7. Talk to relatives before they come over about the best way to behave with children with autism or other neuropsychological disorders. Have them read my article, “What Horses Tell Us About Autism,” which is available for free on the second page of my website.
8. Generally, kids with autism or other neuropsychological disorders do better in the morning than in the late afternoon or evening when they are tired. It may be better to schedule Christmas events at these times.
9. The parents of children with autism or other neuropsychological disorders need to relax themselves. Often the child with autism picks up on the parents’ stress and that is enough to ruin Christmas.
10. And last but not least, realize that you are probably not going to have a perfect food, perfect decorations, and perfect gifts. Christmas with children with autism or other neuropsychological disorders may not be traditional, but it can still have real meaning. (Sometimes I wonder if children with autism or other neuropsychological disorders know that Christmas has become too commercial.)
I wish you and your child the happiest of holidays.
Gary Brown, Ph.D
Psychologist/HSP

Clinic Notes: Autism as a Neurological Disorder vs. Autistic Behavior

Presently we are analyzing data from over 2500 surveys from mothers of children diagnosed with autism and mothers of normally developing children. The survey, which can be found at http://www.ABA4Autism.com, has a variety of pre and post-natal questions. In the biographical portion of the survey we ask mothers to give us their child's diagnosis. We thought we would get several different diagnostic labels such as autism, PDD-NOS, or Asperger's. Instead we have so many diagnostic labels that we are not sure how to proceed. We have many comorbid diagnoses such as Down's syndrome and autism, Fragile X syndrome and autism, Autism Spectrum Disorder, with and without comorbid disorders, and countless more. Physicians or psychologist made all of these diagnoses. There are many problems in diagnosing autism and I certainly don't have the answer for all of the problems. But I think much of the confusion is caused by professionals who talk of atism as a neurological disorder and professionals, sometime the same professionals, who talk about autistic behaviors such as self-stim, OCD, sensory issues, etc. These "autistic behaviors" can be seen in a wide variety of neurological disorders. Before we can do definitive research in autism we need to be clear on what we are talking about when we make a diagnosis.

Clinic Notes: The Combating Autism Act

According to a recent note in the Schafer Report funding for investigating the role of environmental factors as a possible cause of autism has been removed in the House by Energy and Commerce Chair Joe Barton. The Senate has already voted 100 to 0 to fund special centers that would focus on the role of environmental factors as possible cause of autism. I don't know how this will all turn out in this lame duck congress. Last summer the Senate voted to exclude money that would look into vaccines containing thimerosal as a possible cause of autism. So both houses are trying to play to special interest and hogtie science. But science doesn't work that way. I have no idea whether thimerosal or environmental factors are involved in autism. We are now analyzing data from over 2500 surveys from mothers of children with autism and normally developing children and we will look at what we damn well want to. And the rest of the scientific community should do the same. Many in Congress have already demonstrated that they are cntrolled by special interest and are not concerned with finding a cure for autism. Science should find away to do the research without government funding.Schafer Autism Report Nov. 20, 2006

Clinic Notes: Mercury and Autism

In 1971, Iraq was given 90,000 metric tons of wheat seed by the United States. The seed was supposed to be planted by the Iraqis and had been treated with the fungicide methylmercury. Unfortunately, the Iraqis ground the seed and baked it into bread. Six thousand people were hospitalized with mercury poisoning and 450 died. Pregnant women gave birth to children with mental retardation, seizures, and other birth defects. The number of children, if any, who developed autism, is unknown. Without question mercury causes brain damage in children and adults. And like other poisons size matters. The same dose can be 100 times more harmful in a child than an adult. Mercury is now a part of our environment. Common products such as tuna fish, as well as other fish, and many vaccines other than the MMR vaccine contain mercury. Mercury is also a byproduct of industry. The question is how much mercury can the body tolerate without damage. We have some guidance, such as eating fish no more than 2-3 times per week. But supposed you eat fish 2-3 times per week and also live in an area contaminated with mercury because of industrial pollution? The EPA estimates that 1 woman in 5 during their childbearing years have mercury levels in their blood that exceed EPA safety guidelines. Perhaps we should be worrying more about mercury levels in the environment and not just confine our worries to vaccines.

For more information read the article by Lidia Wasowicz http://tinyurl.com/y4k46t

Clinic Notes: Blaming Moms Blaming Dads for Autism

In the 1940's, after Leo Kanner had described autism in children, psychoanalyst Bruno Bettelheim wrote extensively about the causal relationship between emotionally distant mothers (refrigerator mothers) and their autistic children. Of course, you can imagine the guilt this caused moms. Now maybe it's dad's turn. A recent study by epidemiologist Avi Reichenberg of the Mt. Sinai School of Medicine found that dads older than forty were six times more likely to have children diagnosed with autism than younger dads. Theoretically, the DNA in the older sperm has decayed.

(See James Ottar Grundvig for The Epoch Times at
http://www.theepochtimes.com/news/6-11-13/48039.html)

Clinic Notes: The CDC's Proposed Autism Study

The Center for Disease Control and Prevention (CDC) announced a large-scale study that will look for pre and postnatal causes of autism. The $7.8 million dollar study will be conducted in 5 or 6 states and is the largest federally autism study to date. The press release said that the study would include as many as 2700 hundred children. Their sample includes both children with autism and normally developing children. For $7.8 million dollars I would expect a larger sample. We are now analyzing data on more than 2000 children with autism and normally developing children and even if we include our faculty salaries we are well under a $150,00 and we are not working on the study full time. I hope the autism community gets what they are paying for.
http://www.edweek.org/ew/articles/2006/11/08/11health-1.h26.html

Clinic Notes: Mirror Neurons and ABA

If I am shopping with my wife and I see her pick up a man's shirt and smile and look at me I not only observe her behavior I know her intentions. Furthermore, we could monitor my wife's brain activity and see which neurons were involved in her behavior. The interesting thing here is that if we also monitored my brain activity as I observed my wife's behavior the same neurons would be firing in my brain. These so-called mirror neurons in my brain are thought to be templates for specific behaviors. One hypothesis suggests that mirror neurons do not function in children with autism and cause social problems. If this is true then how might we use ABA to improve mirror neuron functioning in children with autism? I would suggest a first step would be to teach children with autism to model behavior in a normally developing peer. Once the child with autism is modeling the behavior we would then ask the child with autism questions about the peer's behavior and itentions. No doubt we would have to use verbal prompts to establish the correct intention to the modeled behavior. Hopefully, with repetition we could set up circuits of functioning mirror neurons in the child with autism. In my clinic I am exploring this and we will see what happens.

Clinic Notes: ABA and other Neuropsychological Disorders

Approximately half of the children who come to my clinic now are diagnosed with one of the Autism Spectrum Disorders, such as Rhett’s Disorder, Pervasive Developmental Disorder Not Otherwise Specified, Asperger's or just plain Autism. And that is not surprising. Autism is in the news now reportedly increasing at epidemic rates. The rest of the children who come to my clinic have some other neuropsychological disorder,sometimes a rare disorders such as Aarskog Syndrome or Alternating Hemiplegia of Childhood (see http://www.rarediseases.org/search/rdblist.html). More commonly, a child comes in who has obvious neurological problems, but no diagnosis can be made. No matter what the diagnosis or lack of, most of these children have compliance problems when they first come in and parents and other caregivers do not know which behaviors are related to the syndromes and which behaviors are simply noncompliant behaviors. In order to deal with the behaviors related to the syndromes, it is usually necessary to first manage the behaviors having to do with compliance. The first ABA programs we run in our clinic almost always have to do with compliance issues, such as making eye contact, following directions consistently, and eliminating behaviors that interfere with compliance, such as tantrums, aggressive behavior, or self-injurious behavior. Then ABA programs dealing with specific problems, such as attention deficits, etc., are implemented. Having your child compliant and under verbal control is also important so other therapists can work effectively with your child.
Additional information and ABA programs for the behavioral problems and an online ABA course for caregivers can be found at http://www.aba4autism.com/.

Clinic Notes: California Reports 2nd Highest Number of New Autism Cases In 37 Years

The California Department of Developmental Services (DDS) reported 841 new cases of autism during the 3rd quarter. Most of the increase was due to older children entering the system as opposed to younger children in the past. Various explanations for this difference are offered in the article. My question is where have these older children been? Why did they all show up during the third quarter? I am seeing more case of autism in my clinic, but I am also seeing more cases of misdiagnosis. Children diagnosed with autism that would have received a different, or no diagnosis, in the past. I still think the question regarding an autism epidemic has not been answered,

The California DDS numbers are here:
http://www.sarnet.org/lib/QrtData-AllCategoryChange.xls

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