Clinic Notes: What Causes Autism?

Everyone has a theory but know one knows what causes autism according to a recent article (No Easy Answers In Autism
Theories abound, but no known cause or cure for baffling disorder By Lisa Schencker, for the Californian
http://www.bakersfield.com/102/story/104427.html)
Well that's obvious and as the article points out there is no cure and a lot of "businesses" will prey on the ignorance of parents desperately looking for help. Genetics are one of the culprits but something in the environment is also responsible. The data on vaccines being the culprit is equivocal. I think we can rule out social and psychological causes. So that leaves the environment. Well what could be wrong with today's environment? How about the air, the ground, the food, the water, etc. And it is going to be hard to track down the causes or causes. Like everyone else I have a theory. I use to enjoy hunting quail. "Birds" as they are called in the south. Dogs would point the birds, we'd walk in and flush them, and when they flew we would shoot. Quail are delicious, all white meat. But the quail in the south are gone. There are many theories why--almost as many as there are about the causes of autism. I think it has to do with agriculture--fertilizer, pesticides etc. Larger animals survive but the smaller animals are always affected first by poisons. In parts of the south, like Texas, where there is only pasture or open land and no agriculture the quail are still around. Something is killing the quail and something is causing autism. I wouldn't be surprised to see that it was the same culprit.

Clinic Notes: Loosing Children with Autism

One of the first drills we run in my clinic after we have children compliant is the come here drill, so that children with autism and other neurodevelopmental disorders will come when they are called. Obvious safety issues are involved with this drill and most kids do learn to come when called. But every year I have a child or two with autism or some other neurodevelopmental disorder get lost. Some get out of the house at night while their parents are asleep. Others bolt when a parent is carrying on groceries and thinks their child is right behind them. That's what happened most recently. Mom was carrying in groceries from the car and thought her four year old was right behind her. But when she sat the groceries down and turned around she was not there. Mom ran out of the house and noticed a few small footprints leading to a 100-corn field. She called and called but the child was non-verbal. Night was falling and mom frantically called family and numbers to search the cornfield. Two hours later she was found sitting on the ground paying shucking corn. Fortunately, it was a warm night and this story had a happy ending. The parents purchased a GPS tracking bracelet the next day. According to a recent Schafer Report (http://tinyurl.com/2bczkp) parents can now purchase sneakers with a GPS chip. A monthly subscription costing $19.95 is also required. A small price to pay considering that sometimes there is not always a happy ending for children with autism or some other neurodevelopmental who get lost.

Clinic Notes: ABA, Autism, and a College Education

According to a recent article in the Schafer Report (3/7/07) an increasing number of children with autism want to go to college. (By Shaya Tayefe Mohajer for The Associated Press, Huntington, WV. http://tinyurl.com/3y49da). We have children with ADHD, Bi-Polar Disorder, Depression, and a host of neurological disorders attending college now so I don't why students with a diagnosis should be left out. And I'm sure that I already have students with Asperger's or high functioning autism in my classes now. My question as a college professor is what accommodations do we make for students diagnosed with autism. My question as a clinician is how do we make these accommodations. For students with a diagnosis of ADHD we have to give them all of the time they want on tests and let then take their test alone in a quite room. What accommodations will we have to make for children with autism who have sensory issues? And will we have to adapt out teaching methods--perhaps using ABA to teach college classes? This could be interesting especially if the federal government gets involved.

Clinic Notes: ABA and Criminal Intent

In recent Schafer Report (3/2/07) an article stated that early diagnosis of autism, when the brain has more neuroplasticity, is critical for effective treatment and yet very difficult. Part of the problem is getting parents, pediatricians, and other caregivers to recognize the early signs of autism and part of the problem is finding effective ABA, speech, and OT that is affordable and accessible. In the state where I practice the "Tennessee Early Intervention System" will pay for service up to age three. So if we can screen and identify kids by age two we have a year to work with them. After age 3 the school system is responsible for services and this is when the system often breaks down. Some school systems are very good about paying for services. Other schools systems depend on their special education programs to treat autism. Of course, most special education teachers are not trained in ABA so the school system usually sends the teachers to a few wrkshops. This does not solve the problem. It keeps the children with autism in special education and builds the census and funding. But the children with autism usually do not get the level of professional services that they are entitled to. The school systems know this and I think withholding services for these kids is criminal. There is no other word for it.

Clinical Notes: Autism in the News

There's no doubt about it. Autism is in the news and everyone has questions whether they are directly affected by autism or not. I was waiting to see a doctor at Vanderbilt several days ago. My wife started a conversation with a woman beside her and eventually the small talk got around to what I did. When my wife said that I was a psychologist who worked with children with autism a hush fell on the room. Everyone in the room looked at me and I couldn't hide behind my magazine. Then the questions started. First, from parents and grandparents, and teachers who had been directly affected by autism, and then by the curious who had read some article in the popular press. There were specific questions about specific children and then more general questions: Is one out of every 150 children affected? Do vaccines cause it? How can it be cured? I answered all of the questions as best I could and everyone was very appreciative. And then I was called back to the doctor's ofice. I was thinking about the questions I wanted to ask the doctor about my own health when he walked in. After a brief introduction the first question out of the doctor's mouth was, "what happens to children with autism when they grow up?" Autism is in the news.

Clinic Notes: Special Education and Autism Stats

According to some reports we are in the midst of an autism epidemic with one out of every 150 children diagnosed. At the same time the number of children diagnosed with learning disabilities or mental retardation is declining. Now we hear that for the first time in history the number of children in Special Education declined by 2.4%. (http://tinyurl.com/yuh59z) Furthermore, the number of children age 3-5 entering public education with speech/language impairments dropped 5%.
So what's happening? Are the speech/language impaired kids, which make up half of the kids with disabilities, now being diagnosed with autism and going into private autism schools where they can get more ABA? I'm confused

Clinic Notes: Thomas the Train, Bob the Builder, and ABA

There is some literature that suggests that children do not make eye contact because they perceive eye contact with another person as threatening. In fact some studies fine that if children with eye contact do look at faces they only see the mouth and nose. Interestingly, the face on Thomas the train and the construction equipment on Bob the Builder attract many children with autism. A recent study in Great Britain (http://news.bbc.co.uk/1/hi/health/6241733.stm) used vehicles with human faces to try and teach children with autism to overcome their fear of looking at faces. In my clinic I have been using Thomas the Train and Bob the Builder videos to teach children with autism how to label emotions with some success and plan a controlled study in the near future.

Clinic Notes: ABA and the Neurosciences

Most ABA therapists have little background in the neurosciences. Unfortunately, this often results in a "one size fits all" approach to ABA. In our clinic some children with neurological impairment resulting in low muscle tone get fatigued very quickly doing Discrete Trial Training (DTT). With these children we slow down, have longer intervals between trials and give frequent breaks. I've seen ABA therapist push these kids to the point that they break down and profit little from ABA. Other kids with ADHD types of behavior may need shorter intervals between trials and less frequent breaks to keep them on tasks. In my few view, at least one course in basic neuroscience.

Clinic Notes: The Autism Genome Project

What is being hailed as the largest genome scan ever has come up with two genetic abnormalities in families with at least two member diagnosed with autism. The gene neurexin 1 located on chromosome 2, which is know to be associated with the neurotransmitter glutamate, is one suspect as is several locations on chromosome 11. As many as 30 other genes are also suspects in the disorder and are under investigation. Research in genetics is an important part of the puzzle and these are interesting findings. But I am still puzzled. When you read genetic studies somewhere in the write up autism is referred to as a highly inheritable disorder. However, the concordance rate for identical twins is only 60% and drops to 4-8% for fraternal twins and non-siblings. Without doubt something else is involved in the etiology of autism.
(See Nikhil Swaminathan. http://tinyurl.com/ynr6ey)

Clinic Notes: Autism Myths

The sign hanging in front of my clinic building says, "The Children's' Treatment Center." And in small letters under the name, "For Autism or other Childhood Developmental Disorders." I am located in an old historic part of town where buildings build in the late 1800's have been restored; surrounded by lawyers, CPA's, and upscale retail stores. I am always asked the question by people aroung me, "What is autism?" That is a difficult question to answer and difficult for people to understand. The movie "Rain man" is the only exposure most people have had to autism until recently when autism has been in the popular media.
Part of the problem in answering this question for the general public is the lack of consensus for those of us who work in the field. Simple questions such as "Is autism increasing in children," cannot be answered to everyone's satisfaction. We are not even close to answering the question, "What causes autism."
There are so many controversies that "experts" at the 2006 annual meeting of the American Association for the Advancement of Science tried to separate "fact" from myth. Unfortunately, the experts could only argue about the interpretation of the limited amount of data, often contradictory, that we do have.
(See Ped Med: Autism Myths Abound
By Lidia Wasowicz for UPI.)

Clinic Notes: The New Autism Numbers

In a recent study, CDC reports that 1 in every 150 school age children are affected by autism. When I started practicing 35 years ago the numbers were more like 1 in 10,000. The lower rates are reported in the South and the higher rates in North Eastern cities. Whether this difference is real or because more services are available and a diagnosis is more likely in the North Eastern cities than the South is not known. The authors of the study say that the rise in autism rates could be related to better surveillance procedures now than in the past. Personally, I don't think 1 child out of every 150 has any chronic disease, Including autism. (Diaper rash could be the exception.)
(See Morbidity and Mortality Weekly Report Source reference: MMWR 2007, 56;SS-1;1-28.)

Clinic Notes: ABA, Music, and Autism

I see many children with autism in my clinic who are music savants. They have perfect pitch and can play a song on the keyboard after hearing it one time. The percentage of child with autism that have special music abilities is not know, but it is estimated that 10% of children with autism are savants.
In addition, many children with autism like music and we use it as a reinforcer in ABA programs. (Some kids with autism find music, and sounds in general aversive and cover their ears.) Neuroscientists tell us that infants are born with music preferences and even seem to enjoy music while still in the womb.
Some years back I had a 3 year-old girl come to my clinic with a diagnosis of autism. When I was taking her history her mother said she was not verbal, but she could sing. I then asked if she could follow directions. The mother said yes as long as she sang them. I then watched mother sing a direction and her daughter sang back her reply.
Tere is no music center in the brain. Pitch, loudness, and dimensions of music are in circuits of nerve cells, which are spread around in different parts of the brain. Why some children with autism have savant abilities is not even close to being understood.

Clinic Notes: ABA and the Rising Number of Children Diagnosed with Autism

In the January 31, 2007 Schafer Report (http://www.SARnet.org/), two separate articles dealt with the rising number of children diagnosed with autism. In California, 3385 new were added last year. The second article discussed the difficulty in determining whether or not the increase was real, and if it was, what was causing the increase.
Without doubt, I think there is an increase in the diagnosis and miss-diagnosis of autism. I see that almost everyday in referrals made to my clinic. But I also think there is something else going on. Autism does have a genetic link, but I'm not sure more people carrying the autism gene or genes are breeding and having more children with autism. I have no data to support that belief, but that is my belief. I think our attention needs to be directed towards the environment.
At any rate, it is getting very difficult for those of us in ABA to offer intense ABA for a child when we have so many children diagnosed with autism on our waiting list. Do I schedule one child for 10 hours of ABA a week? Or do I see ten children for one hour?

Clinic Notes: Risperdal, ABA, and Autism

A recent government study by the HHS' Agency for Healthcare Research and Quality found problems associated with off-label uses of Atypical Antipsychotic medications. Atypical Antipsychotic medications were developed to treat schizophrenia and bipolar disorders, but are now being prescribed for the elderly with dementia as well as children with autism. One atypical antipsychotic medication, Risperdal is approved for treatment of agitation and irritability in children ages 5-16 diagnosed with autism. Prescribing medications to children should be a last resort, only undertaken after all other therapies have been tried. But I can tell you that in many children with autism Risperdal is a necessary drug

Clinic Notes: Asperger's, ABA, and Crime

I see a number of children diagnosed with Asperger's Syndrome in my clinic. When they first present academic performance is the problem parents complain about the most followed by social problems. Children with Asperger's generally do well in math, spelling, and have trouble in science and social studies where they have to summarize information. Discrete Trial Training (DTT) and other ABA procedure are usually effective in managing the academic problems that Asperger's children have. The social problems associated with Asperger's are more difficult. We use a lot of social stories to teach social skills and how to behave in various situations and this works fairly well. But there is always a social situation that we did not anticipate that causes problems, especially for the adolescent. I wasn't surprised to see the news report this week where, allegedly, a teen with Asperger's stabbed a fellow student to death. The Asperger's defense has been used successfully in murder cases as well as other criminal charges, but I take no comfort in that. Seeing that no child with Asperger's commits a crime is a serious responsibility for ABA therapists.

Clinic Notes: ABA and Eye Contact Revisited

In a post last week I mentioned a study that found that children with autism perceived faces as threatening and that was the reason they did not make eye contact. The first ABA program in my ABA eBook is on eye contact. And I know from many years of clinical experience that a child with autism is not going to advance until they are making eye contact on command and are also making spontaneous eye contact.
A project in Great Britain is using cartoons of human faces on vehicles such as trains and cars to teach children with autism to make eye contact and understand human emotions. I have ordered their DVD and will evaluate this approach. In a future blog I will post the results

Clinic Notes: Mysteries and Autism

The best account that I have ever read of what it is it is like to have autism is a novel titled, The Curious Incident of the Dog in the Nighttime by Mark Haddon. A recent issue of the Schafer Report (Friday, January 12, 2007) describes a ten-year old child with autism who writes mysteries, which include people he knows in as various characters such as villain (the principal).
The mystery story has a long history in neurology. As I mention in the preface in my case history eBook, Little Bubba's Not Ready for Nashville, Yet, the most famous detective in fiction, Sherlock Holmes, was based on one of Sir Arthur Conan Doyle’s medical school professors at the Royal Infirmary in Edinburgh where he was a student in the late 1800s. Apparently, like Holmes, neurologist Joseph Bell mystified Doyle and his fellow students with his gift for clinical diagnosis. As I do research into the causes of autism and work with children with autism in my clinic and try to unravel the mystery of autism I often wonder what Holmes would do.

Clinic Notes: Eye Contact and Autism

A recent study at the University of Wisconsin suggests that children with autism do not make eye contact because they see faces as threatening. http://www.sciencedaily.com/releases/2005/03/050309151153.htm
Perhaps children with autism do see faces as threatening. I won't argue that. And I am familiar with the controversy about whether or not we should require that children with autism make eye contact. Many of the children with autism who come to my clinic, especially the young children, do not make eye contact on command or spontaneous eye contact. Of course, this results in social impairment, but it also results in impairment in observation learning or modeling and numerous developmental delays. The first ABA program in my eBook is on establishing eye contact. And the ABA program for eye contact is not first by accident. Thirty-five years of clinical experience has taught me that if eye contact is not established, the child with autism is not going to advance.

Clinic Notes: Ballet and Autism

A recent Schafer Autism Report had a story on a dance instructor in New York who was teaching a ballet class for girls with autism. Many children with autism have body orientation problems. For example, they will sit in front of the TV and not understand that other people cannot see the TV because of them. Or they will look at pictures in a book and think everyone in the room can see the pictures even though they are on no position to do so. One child with autism who comes to my clinic won an award at school. The principal asked her to come to the stage and stand beside him so he could present the award. Obligingly, she went to the stage and stood beside him, but facing away from the audience. Of course, everyone laughed and she got embarrassed. She thought she was doing what she was asked to do.
Spatial concepts and body orientation are difficult for a child with autism and I hope ballet helps the girls in the class. My qestion is since autism is four to five times more common in males why only a class for girls. I'm curious who decided the class would only be for girls. The teacher or parents of male children with autism

http://tinyurl.com/ylmc75

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.