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)

Clinic Notes: Designing Non-Autistic Babies

Scientists in the UK already have approval to screen embryos for genetic disorders that would shorten life expectancy before implantation. Now ethicists are upset because these scientist want to only use female embryos for implantation in families with a high risk for autism. Since the incidence of autism is four to five times more likely in males than females this would cut the risk considerably. The ethicist argue that such screening procedures will create a society were only perfect children are tolerated. Well I don't know about that. But I do know there will still be plenty of children with autism around, both male and female. http://tinyurl.com/fwgcm

Clinic Notes: What Horses Tell Us About Autism

I grew up in Texas, and in high school my life was horses and rodeo. I’m certainly not an expert on horse behavior by any means, but the first time I came in contact with a child with autism, I thought that some of their behavior looked horse-like--unbroken horse-like. For example, many unbroken horses, and many children with autism, will become uneasy if you try to approach them head on. You have to approach them from behind or at a forty-five degree angle. Horses and kids with autism also seem to know by your body language and touch whom they can ride/manage them and who they can take advantage of. I wrote Monty Roberts, a well known, practicing horse whisperer. He told me several clinicians had already recognized the similarities between autism and horse misbehavior and were applying his horse training techniques in their work with kids with autism. (See montyroberts.com)
Go to www.ABA4Autism.com for a longer article on horses and autism ad to learn how horse whisperer might help you manage your child with autism.

Clinic Notes: What does a Diagnosis of Autism Mean?

The first thing parents who bring their children to my clinic want to know is does my child have autism. If the child is older and already diagnosed with autism parents will often ask if their child still has autism. A recent study found that most children diagnosed with autism when they were two also were still diagnosed with autism at age nine. On the other hand, children diagnosed with pervasive developmental disorder not otherwise specified (PDD-NOS) when they were young had their diagnosis changed to autism when they were older. (Autism Diagnosis Remains Through Early Childhood So much for recovery? SOURCE: Archives of General Psychiatry, June 2006.)
I see some health care professionals diagnose a child with PDD simply because they do not to alarm parents by using the "a" word. I don't worry too much about diagnosis because with ABA you simply treat the problem behaviors, which vary from child to child with a diagnosis of autism or PDD. I also tell parents who have children with a high functioning autism or PDD diagnosis that they are probably better off not telling the school system the child's diagnosis. Teachers are will always notice more behavior problems in a child with a diagnosis.

Clinic Notes: Early Biological Markers of Autism and ABA

Autism is usually diagnosed between the second and third year of life. Everyone agrees that the earlier autism can be diagnosed and treatment started the better. Now if the research at Yale University School of medicine holds up it may be possible to diagnose autism at birth. The found that children with autism were three times more likely to have trophoblast inclusions which reflect abnormal folding of microscopic layers in the placenta and are caused by altered cell growth. It was already known that trophoblast inclusions were more common in cases of chromosome abnormalities and genetic diseases. Citation: Biological Psychiatry, Published online (June 26, 2006).
It may very well be in the future that we start ABA and other therapies at an earlier age if this biological marker is a reliable indicator of autism.

Clinic Notes: Cruelty Toward Animals

In The Dragons of Eden, Carl Sagan presented the thesis that the cortex evolved to repress and control our lower reptilian brain, making civilized human behavior possible. I don’t know it this is true, but I do know that damage to the cortex that causes disinhibition is a significant clinical problem in children I see in my clinic, especially when aggression toward pets, care givers, and other kids is involved.
Aggressive behavior is common in kids 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.
See "Just Another Serial Killer Thriller" at http://www.aba4autism.com for the rest of this case history

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