Clinic Notes: Dopamine 101

Tourette’s is caused by an excess of the neural transmitter, dopamine. Parkinson’s disease is caused by a depletion of dopamine producing neurons in an area of the brain called the substantia nigra. Dopamine agonist such as L-dopa can temporally alleviate the paralyzing effects of Parkinson’s just as dopamine antagonists, like haloperidol, temporally relieve the Touretter of his tics.
In the 1980s, synthetic heroin contaminated with MPTP appeared on the streets. Several addicts who injected this contaminated heroin became “frozen” and were admitted to psychiatric hospitals with a diagnosis of catatonic schizophrenia.
On closer examination, animal studies indicated that MPTP metabolized to a neurotoxin that destroyed dopamine neurons in the substantia nigra just like Parkinson’s. These frozen addicts were nearly mute, and somewhat like patients with locked-in syndrome.
See Case History # 9 in Little Bubba's Not Ready for Nashville Yet at http://www.aba4autism.com

Clinic Notes: Transiet hemiplegia and Alternating Hemiplegia of Childhood

Transient hemiplegia (one-sided paralysis) can be caused by low blood sugar in childhood diabetes and other organic conditions, such as transient ischemic attacks (TIA’s), and also some types of migraines. Like adults, children can have strokes with permanent paralysis. Sometimes the term transient hemiplegia refers to a rare condition known as Alternating Hemiplegia of Childhood. In this disorder, one side is paralyzed one day, and the other side is paralyzed on other days, which seems to defy basic neuroanatomy. The only minimally effective treatment reported for Alternating Hemiplegia of Childhood is a calcium channel blocker called Flunarizine. The FDA has not approved this drug, and since so few cases of Alternating Hemiplegia of Childhood exist, they are not likely to do so. Only 250 children worldwide are affected by this disorder so there’s a real shortage of patients for studies into the causes. Years ago, I saw a young child in my clinic with a diagnosis of Alternating Hemiplegia. I didn’t think it likely that such a rare disorder would pop up in my clinic and was suspicious of the diagnosis from the beginning. After several months it turned out to be a case exactly like Jamie’s. See http://www.rarediseases.org and The 2000 June-August issue of the online publication of Perspectives: A Mental Health Magazine at http://mentalhelp.net/perspectives/ for a brief account of this case.
Go to www.aba4autism.com for a complete case history in Little Bubba's Not Ready for Nashville.

Clinic notes: "The Longest Running Horror Movie."

David M. didn't have an appointment. I found him standing in my doorway one afternoon, his body trembling, a look of desperation on his face. After a few moments of silence, he sat down in the chair I pointed to across from my desk and began his history with a twenty-year flashback.
His father's car was parked beside a cemetery on a lonely country road. Of course, it was a dark and stormy night and a scream from the back seat "pierced the darkness."
"I know this sounds like the beginning to a second-rate horror movie," David conceded in a nervous voice. "But that's exactly what my life's been- -a second-rate horror movie."
For the rest of this case history go to http://www.aba4autism.com

Clinic Notes: Biting in Children

Recently my daughter called to tell me that my 14 month-old granddaughter had just bitten another child. Children age 13-24 months are bitten most often in day care centers and usually the biting is most likely to occur at the beginning of the school year. The arms and face of the child are the areas most frequently bitten, but only one bite in fifty actually breaks the skin. Occasionally, children get kicked out of day care for biting other children and staff.
More serious biting of others or one’s self is often seen in children with neuropsychological disorders like autism, Fragile X Syndrome, and mental retardation. In rare neuropsychological disorders, like Lesch-Nyham syndrome, children compulsively bite their lips, fingers and arms, and bite others as well. A variety of extreme measures, including teeth extraction have been used to try to control biting in this disorder. Physical restraints are te only effective remedy, and many Lesch-Nyham patients will ask to be placed in restraints when they feel a biting episode coming on.
See Case History # 6 in Little Bubba's Not Ready for Nashville Yet at http://www.aba4autism.com

Clinic Notes: Autism and Down Syndrome

I once had a set of twins coming to my clinic. One twin was developing normally, and the other twin had Down Syndrome and then developed Autism at the age of four four. Recent studies find that 7 to 10 percent of children with Down Syndrome also have Autism.
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.
Why some children with Down Syndrome develop autism and other do not is not known.
See Case History # 15 in Little Bubba's Not Ready for Nashville Yet at http://www.aba4autism.com

Clinic Notes: Aggressive Behavior in Children

Aggressive behavior is common in the kids we see in our clinic who present with various neuropsychological disorders. Nonverbal kids learn to use aggression as a way to communicate. Neurological damage to the cortex of the brain, caused by trauma or drugs taken by the mother while she is pregnant, can cause cortical disinhibition in the child and further increase the level of aggression. Children with neuropsychological disorders, as well as those without, also learn violent, abusive behavior from adult role models, video games, and the media.
Twenty-five percent of men imprisoned for violent crimes had a history of cruelty toward animals in their childhood. A comparison sample of men convicted for nonviolent crimes had no history of cruelty toward animals. Aggressive women prisoners show a similar history. Cruelty toward animals is also associated with child abuse. Apparently, the abused child takes out his frustration on family pets.
Since aggression is, at least partially, a learned response ABA programs can reduce and usually eliminate aggression. Occasionally, certain psychoactive drugs must be used along with the ABA programs.
See case Histories # 6, 16, and 20 in Little Bubba's Not Ready for Nashville Yet at http://www.aba4autism.com

Clinic Notes: Alternating Hemiplegia of Childhood

Transient hemiplegia (one-sided paralysis) can be caused by low blood sugar in childhood diabetes and other organic conditions, such as transient ischemic attacks (TIA’s), and also some types of migraines. Like adults, children can have strokes with permanent paralysis. Sometimes the term transient hemiplegia refers to a rare condition known as Alternating Hemiplegia of Childhood. In this disorder, one side is paralyzed one day, and the other side is paralyzed on other days, which seems to defy basic neuroanatomy. The only minimally effective treatment reported for Alternating Hemiplegia of Childhood is a calcium channel blocker called Flunarizine. The FDA has not approved this drug, and since so few cases of Alternating Hemiplegia of Childhood exist; they are not likely to do so. Only 250 children worldwide are affected by this disorder so there’s a real shortage of patients for studies into the causes. Years ago, I saw a young child in my clinic with a diagnosis of Alternating Hemiplegia. I didn’t think it likely that such a rare disorder would pop up in my clinic and was suspicious of the diagnosis from the beginning. After several months it turned out to be a case of the parents reinforcing the child whenever he was "paralyzed". The child could not remember which arm was "paralyzed" and often alternated his "paralysis" from day to day. See http://www.rarediseases.org and The 2000 June-August issue of the online publication of Perspectives: A Mental Health Magazine at http://mentalhelp.net/perspectives/ for a brief account of this case. This case is also available on my website http://www.ABA4Autism.com

Clinic Notes: Autism and Faces

Children with autism do not show interest and are not proficient in recognizing people’s faces. If they do look at a person’s face, they concentrate only on one part, such as the eyes or the mouth. In a paper presented to the Society for Research in Child Development, Geraldine Dawson showed groups of three-and four-year-old children with autism, mental retardation, or normal children, pictures of their mother and a stranger and pictures of their favorite toy and a strange toy. The brain wave recordings registered to pictures of mom and the favorite toy in the children with mental retardation and the normal children. The brain waves of the children with autism responded to the picture of the favorite toy, but there was no difference in the response to their mom’s face and the face of a stranger.
Excerpted from Little Bubba's Not Ready for Nashville Yet: Case Histories of Children with Autism or Other Neuropsychological Disorders. Available at http://www.ABA4Autism.com

Clinic Notes: ADHD

Parenting characteristics are a better predictor of ADHD than genetics. Smoking by the mother while she is pregnant has also been associated with ADHD. For the child who does not calm down Ritalin or Adderal is okay for the short term, but special parenting skills for handling the child with ADHD need to be acquired at some point. Even then ADHD may be a problem through the teen years and into adulthood. And normal tasks such as driving a car may be a problem for ADHD kids when they get older. Teens with a history of ADHD are four times more likely to have a wreck. As far as I know, insurance companies have not picked up on this because medical records are confidential, at least to a certain extent. Obviously, if insurance companies knew a teenager they were about to insure had ADHD their rates would go up.

Clinic Notes: Refrigerator Mothers

After American psychiatrist Leo Kanner published the first paper on autism in 1943, psychoanalyst Bruno Bettelheim wrote extensively about so-called “refrigerator mothers,” who were emotionally cold and rejecting. According to Bettelheim these mothers caused a psychosis in their children which was similar to schizophrenia. (Very few autistic children actually develop adult schizophrenia.) Unfortunately, mothers at the time not only had to deal with an autistic child, they also had to deal with their guilt. In the 1960s, following the publication of Bernard Rimland’s Infantile Autism many psychologists, psychiatrists, and of course neurologists, thought biological factors caused autism. I had dinner with Bettelheim in the early 1970s and I tried to discuss with him the role of biological factors in autism. He refused to accept the possibility and told me in no uncertain terms to go read his books. There I would find all of the answers to my questions. At the time he was still saying, for a fee, that moms caused autism. I experienced Bettelheim as a grouchy, depressed old man, and I’ve often wondered if he knew he was wrong and felt badly about all of the guilt he’d caused mothers. (I’d like to think there’s a certain amount of justice in the world.) Excerpted from Little Bubba's Not Ready for Nashville Yet" Available at http://www.ABA4Autism.com

Clinic Notes: Stem Cell Transplants for Batten Disease

StemCells, Inc. will soon begin clinical trials to evaluate their line of stem cells in the treatment of Batten disease, a rare fatal disorder in children. Children with Batten disease have seizures, loss of motor skills, vision, cognitive function, and speech. This is the first trial of stem cells as a potential therapy in children.
I hope the clinical trials are successful and I wonder if stem cell technology will ever have application with other neurodevelopment disorders in children such as autism.

Clinic Notes: Preventing Autism

I'm just like any other parent or grandparent. I worry about autism. When I see my grand babies staring at lights or fans I immediately re-direct them. I have been relieved to note that they were not rigid when picked up and they never banged their heads against the side of the crib. One had a slight language delay and the pediatrician suggested a possibility of autism, which scared my daughter, but fortunately, turned out to be a false alarm.
There are other early signs of autism, such as being a younger sibling of a child with autism. The concordance rate for identical twins is 60%, fraternal twins 4.5%, and non-twin siblings 4.5%.
What should a caregivers do if their child shows early signs of autism? Can autism be prevented with early intervention? Next week on my web site www.aba4autims.com I will post a discussion of some recent research.

Clinic Notes: ADHD?

Many parents already have an ADHD diagnosis for their child before they bring them to my clinic. I always separate the parents from their child and then observe the child in our playroom while the child is alone with my assistant and me. If the child appears ADHD, we do not say anything. We let the child run around the playroom as much as he or she wants. Often the child will calm down after a few minutes and play appropriately with the toys and then we will praise the child. Occasionally, we ask the child questions and praise the child if he or she answers the question the first time, but we ignore the child for not answering. Once the child has learned to pay attention to us and played calmly for twenty minutes or so, I ask the parents to come into the playroom. If the child becomes ADHD when the parents come in to the room, and do not settle down, I know the ADHD has been conditioned by the parents’ attention. In other words, the parents ignore the child whenever he or she is not being ADHD, and give the child attention whenever ADHD behaviors occur. This attention is reinforcing for the child and the ADHD behavior increases in its frequency. In cases like this I give the parents an ABA program for staying on task and decreasing other ADHD behaviors. The parents have to learn to reverse their behavior at home and give attention in the form of praise for non-ADHD behaviors and ignore ADHD behaviors. This is hard for the parents to do even with my weekly monitoring and guidance, but when they are successful this simple change in the parent’s behavior can decrease ADHD behavior without having to resort to medications.
Excerpted from Case History # 7. "The Night Life Ain’t No Good Life" Available at: http://www.ABA4Autism.com

Clinic Notes: Autism in the News

Check out the "Autism in the News" link on my website. Ten Things The Student with Autism Wishes You Knew

Ellen Notbohm, author of the book called, Ten Things Every Child With Autism Wished You Knew, has recently expanded her audience to teachers and has written an article, Ten Things The Student With Autism Wishes You Knew.

As a clinician I found this interesting and I think caregivers will too.

Clinic Notes: Selective Mutes

Children who are selective mutes have acquired speech, but never use speech. They point and gesture to get what they want; sometimes tantruming if their needs are not met promptly until caregivers begin to anticipate their needs. When I moved to Tennessee the first case I had in my clinic was a 6 year old girl with a dual diagnosis of autism and mental retardation who had not spoken in years.
In order to change this behavior I instructed everyone to not anticipate the child's needs or respond to pointing and grunting. Now everyone must wait until the child made a sound that approximated a word to get what she wanted. Once this was accomplished, everyone had to wait longer until the approximation more closely resembled a word. After several weeks speech was re-established in this child. Several months later I received a call from the caregivers saying the child was talking too much now and could they bring her back to my clinic.

Clinic Notes: Self-Injurious Behavior

Nothing is more frightening to parents of a child with autism or some other neuropsychological disorder than to see their child engage in self-injurious behaviors such as head banging, biting, or hitting themselves. Self-injurious behavior can occur in children with autism or mental retardation, as well as in children with numerous other neuropsychological disorders, and is the most common reason for institutionalization. Some children injure themselves for attention or to control the people in their environment. (See ABA program number 5 on my ABA4Autism website) With other children, the social environment doesn’t seem to matter. According to Frank Symons, 80 percent of self-injurious behavior is to 5 percent of the body--the hands and face. (The same areas often involved in acupuncture pain reduction.) The hands and face are innervated by areas of the brain, which lie adjacent to each other. Apparently, some autistic children injure themselves to release endorphins (naturally occurring brain opiates). Naltrexone, a drug which blocks opiate receptors, reduces head banging and hand biting in about a third of the kids with self-injurious behavior. Improved eye contact, socialization, and a reduction in self-stimulatory behavior also occurs in some kids with autism if they are receiving Naltrexone, leading to the hypothesis that autism is caused by an excess of endorphins. (North Carolina State Professor James Kalat suggests that in some ways autistic kids act like opium addicts going through withdrawal and then taking more opium.) Excerpted from "Little Bubba's Not Ready for Nashville Yet" available at http://www.ABA44Autism.com

Clinic Notes: ABA4Autism on eBay

This weekend we placed my ABA eBook and Case History eBook for sale on eBay. Both eBooks can be downloaded or we will mail them to you on CD-ROM. We will add individual ABA programs, individual Case Histories, and my online ABA course to eBay if caregivers find eBay a useful outlet. Just type ABA and Autism in eBay's search feature to find us. Of course, all of our ABA materials are still available at http://www.ABA4Autism.com.

Clinic Notes: Autism in Pakistan

A few weeks ago I received an email from Saadia Haseeb, who is the editor of Motherhood, Pakistan's first parenting magazine. She asked me if I would write an article on autism for her magazine. I found the magazine's web site and was amazed. There were articles concerning adopting homeless children who's parents were killed in the recent earthquake and other serious topics, as well as articles and columns on "lighter" topics like health and beauty. With all of the tragedy that Pakistan has endured this magazine wanted an article on autism. I finished the article and sent it in today and the editor was grateful. I'm left wondering how autism in Pakistan ranks with other diasters there?

Clinic Notes: Discussion Board

As promised, I have added a discussion board to my website. Visit http://www.aba4autism.com and read the posts and add your input or ask questions. I have posted several topics for discusion. Students in my ABA class will be posting weekly as a part of their practicum experience and the ABA therapist who work for me will also be posting.

Clinic Notes: The First ABA Program for a Child with Autism

I get many emails, letters, and phone calls from parents who want to start ABA. They give me a "shopping list" of behavioral problems in their child--usually starting with serious problems like self-injurious or aggressive behavior and continuing with sensory problems, compliance problems and communication problems. While all these behavior problems need to be addressed they leave out the behavior problem that needs to be dealt with first in many children with autism. Eye contact, both on command and spontaneous. It has been my experience that ABA is going nowhere if eye contact is not established. This is the first ABA program in my eBook and the one we always take up first in children who do not make eye contact.