Clinic Notes: Prognosis for a Child with Autism

Every parent wants to know what the future holds for his or her child. And this is especially true for a child with a disability such as autism. What is the prognosis for a child with autism? Well years ago I remember reading articles asking what happens to children with autism when they become adults? Back then children with autism just seemed to disappear--absorbed into society in one-way or another. The stats were 1 in 2500, later 1 in 500. But now with 1 in 150 children with an autism diagnosis how will the picture look like when these kids are grown?
Last week one parent told me that a speech-language pathologist told her that her child had severe autism and would never amount to anything. This seemed to me a very cruel thing to say to a mother, but setting that aside how accurate was this prediction? I remember reading that 50% of children with autism also had mental retardation and 10% were savant. But I wonder about the accuracy of this statement because I know a lot of children with autism have performance deficits. In other words, they know the correct answer to a question, but choose to not give the correct answer for one reason or another. If 50% of children behave as if they have mental retardation what programs will be available for them after they leave the school system? (Group homes and sheltered workshops now have long waiting lists.) I have not seen this problem addressed by any candidate running for any office. Maybe children with autism will just be absorbed into society when they grow up like they were in the past. But I doubt it.

Clinic Notes: Does the Autism Apple Fall Far from the Tree?

When I have a new child come into the clinic, and I am taking a history, I ask the parents if anyone else in the family has an autism diagnosis. The answer is almost always no. But often, after weeks of therapy, one or both parents, after having learned more about autism, often state that they wonder if they have autism. (And sometimes after getting to know the parents I wonder too.) Parents of children with autism analyze their past development and either interpret or misinterpret some of their behavior as autistic. This seems to be especially true of certain high tech professions.
Much the same thing is true of other maladies such as bipolar disorder, depression, and alcoholism. But these disorders usually show up in adults and not children. So instead of parents seeing themselves as perhaps having the same autistic behaviors as their children, children, especially grown children, see (blame) their bipolar, depressive, alcoholic behaviors in their parents.

Clinic Notes: Autism and Fever

A recent study in the journal Pediatrics reports that high fever decreases the symptoms of autism. Many parents have already observed this relationship, but this is the first study that documents the effect. Clinicians have also documented this effect. In 1980, a viral epidemic causing high fever hit Bellevue Psychiatric Hospital in New York. All of the staff there noticed an improvement in the autistic children they worked with. Sadly, after a few days, the fever dissipated and all of the children became autistic again." The improvement can be very dramatic, sometimes like a metamorphosis in which the child with autism or some other neuropsychological disorder becomes almost normal when they are running a high fever. I present such a case history, titled the "The Sometimes Son" in my case history eBook, Little Bubba's Not Ready for Nashville Yet. (http://www.aba4autism.com)

Clinic Notes: Early Signs of Autism

Pediatricians are recommending that children be screened for autism at 18 months and again at 2 years of age. There is no question that early intervention helps and this is certainly a step in the right direction. Usually, parents are the first to notice that something is wrong, but are sometimes hesitant to take action for one reason or another. Without question this early screening will result in more false positives but that can't be helped. I have a link on my website, www.aba4autism, for parents who are interested in reading about the early signs of autism

Clinic Notes: The Autism-Vaccine Debate: Stat 101. Correlation and Causality

Autism takes two forms: Infantile, which is present form infancy, and regressive where the child develops normally and then between 2 and 3 years of age begins to loose language and appropriate social behavior. Often self-stim and sensory problems also put in an appearance at this time. Of course, concerned parents look for a cause and the only thing that they note that was different was the MMR vaccine that there child received before autism began to develop. Further inquiry by the parents finds that the vaccine contained mercury, which is known to be toxic to the brain.
Congressional hearings have been held, research supporting and refuting the mercury-autism link has been presented and mercury has been removed from vaccines, but the debate goes on.
Stat 101. Much of the retrospective research on health issues relies on a statistical test know as correlation. A correlation will tell you if two variables are statistically related. So height and weight are correlated, intelligence and grades are correlated, and cigarette smoking and cancer are correlated. Since vaccinations are mandatory for the most part in the US and everyone receives the MMR vaccine it is hard to come up with an accurate. In parts of Europe where vaccinations are not mandatory the rates of autism are the same in vaccinated and non-vaccinated groups of children. What most people don't understand is that a correlation will tell you if two variables are related, but it will tell you nothing about causality. Just because autism follows the MMR vaccination does not mean that the vaccination caused the autism. Maybe mercury does play a role in autism. Increasingly there is more mercury in our environment as well as other neurotoxins. But a correlation cannot make a statement about causality.

Clinic Notes: Is There An Autism Epidemic?

According to a recent Associated Press article by Mike Stobbe, The 'Autism Epidemic' Largely Fueled By Special Ed Funding, Shift In Diagnosing (www.signonsandiego.com/news/health/20071102-1304-autismepidemic.html).
It is true that as the number of cases of children diagnosed with autism increases the number of children diagnosed with mental retardation and learning disabilities are decreasing. And in my practice I see this everyday. But I also see many, many more kids that have autism and there is no question about the diagnosis. The number of children with autism is increasing at an exponential rate in my little corner of the world.

Clinic Notes: New Autism Screening Recommendations

This week the American Academy of Pediatrics recommended that all children be screened for autism at 18 months of age and again at 24 months. No doubt early interventions by Speech-Language Pathologists, Psychologists, ABA Therapists, and other professionals will better lives for children with autism. At least that's the theory. But I'm worried about logistics. I already have a full clinic schedule and waiting lists of children that I can't get to or refer anyplace. If we are serious about treating all the children diagnosed then we are going to have to mobilize more financial and manpower resources then we have now.

Clinic Notes: Video Clip Diagnosis of Autism

Today's Schafer Report (October 16, 2007) has an article on a free new web site that features video clips of toddlers displaying autistic behavior such as stimming, echolalia, fascinated by a spinning cup, and other early signs of autism. The creators of the tape caution that these behaviors can be seen in normally developing children, but alert parents to the fact that an early evaluation might be advisable. As the article points out parents are often the first to recognize that something is not right. Unfortunately, parents, especially first time parents, wait too long. If you have concerns about your child or are just interested in the video clips go to http://www.autismspeaks.org

Clinic Notes: Predicting Autism

We just completed a study, which found among other things, that the mother having an infection while pregnant was a statistically significant predictor of autism in male children. Now a new published study finds that there is a link between schizophrenia, autism, and flu in the mother. Previous studies have found that flu in mothers during pregnancy
http://www.physorg.com/news110641743.html
increases the risk of schizophrenia 3-7 times. Schizophrenia and autism are thought to have a genetic component triggered by some pre or postnatal factor. As many as 21% of the cases of schizophrenia may be related to flu in the mother. It is not the virus itself that causes schizophrenia but the body's immune system reacting to the infection. The immune system's response to an infection at the cellular level releases proteins called cytokines. Theoretically, the fetus is affected by a cytokine called interleukin-6. If a pregnant mouse is injected with interleukin-6 her off spring display schizophrenia or autistic like behavior.

Clinic Notes: Anorexia and Autism

Kids with autism are often finicky eaters, rejecting foods on both taste and/or texture. The consensus is that this is just another one of those sensory issues which plague kids with autism. But now an interesting hypothesis carries the finicky eating problem one step further. Prof Treasure suggests that anorexia and autism share the same genetics. According to her, twenty percent of patients with an anorexia diagnosis could also be on the autism spectrum. Furthermore, anorexia might be the female form of Asperger's. It is true that perseveration occurs in autism and anorexia, as well as communication and social problems. But this hypothesis seems long on speculation and short on data.
http://tinyurl.com/2bcvka

Clinic Notes: Bipolar Disorder in Children and ABA?

According to a recent news report Bipolar Disorder is being diagnosed more frequently in children. Recently, a pediatrician referred a two-year old girl to my clinic whose psychiatrist had diagnosed with Bipolar Disorder and prescribed Depkote, and lithium, which are commonly used to treat Bipolar Disorder in adults. These are powerful medications, not approved for children, and this two-year old girl ended up in the hospital because of the drug's side effects. I evaluated this child and took a detailed history from the parents. I saw nothing but a spoiled child who ignored her parents when she didn't get what she wanted and then got very upset and threw tantrums if that did not work. After several weeks of ABA, teaching the parents some much-needed parenting skills, this child was okay. I was curious if the psychiatrist who diagnosed this child with Bipolar Disorder had children of his own.

Clinic Notes: Girls with Autism and ABA

Boys are three to four times more likely to be diagnosed with autism than girls. Last week I saw 35 children in my clinic with an autism diagnosis. Only 7 were girls. Not only is autism diagnosed less frequently in girls, it seems to me that the autism in not as severe. (Of course there are exceptions and I do occasionally see girls with moderate to severe autism.) Most of the girls I see with autism do okay with their academic subjects. They have problems handling concepts, and are very literal in their reading. Idioms and other peculiarities of language cause them problems, but for the most part academics is not their biggest problem. Girls with autism tend to have more problems socially than any other area. But then the same could be said of normally developing girls as well.

Clinic Notes: The Science Behind ABA

Applied Behavior Analysis (ABA) is the most popular and effective therapy for autism. However, ABA also has it critics who say it is too rigid and creates kids who are robotic. (I have been working in ABA for nearly 40 years and have yet to see ABA produce a robotic child.) A second criticism states that the research behind ABA is modest. Well, I think these critics do not know the history of learning theory and the countless experiments with experimental animals and humans that can be traced back to Thorndike's trial and error experiments with cats in 1898. B.F. Skinner's Functional Analysis of Behavior, which is the backbone of ABA, examined human behavior using behavior principles tested on years of animal experiments. Even today, countless scientific journals publish peer-reviewed studies examining ABA with various clinical populations. Based on decades of research, ABA is recommended as the treatment of choice in treating autism by CDC and other health agencies. How much science do the critics want?

Clinic Notes: ABA and Time Out

Time out means time out from positive reinforcement. If there is no positive reinforcement in the child's environment then time out will not work. Recently, a child with autism in Iowa school was left in time out for 3 hours. Of course, the parents were outraged and called a lawyer. But before the case came to trial the family moved and the school system continues to use its time out rooms in the same way. http://www.kcci.com/education/13826532/detail.html.
There has always been controversy about time out and the Iowa school is not the first to get into trouble over improper use of time out. Parents are always telling me that they have tried time out with their child but it does not work. Time out is a very good procedure when done right and ineffective when done wrong. The standard time out procedure below is the procedure I have been using for 30 + years and it works. It will not work for a child with autism that is removed from an environment that has no reinforcers. For example, an environment where there is too much stimulation or too many demands being placed on the child. Being placed in time out would be reinforcing. And time out should never be used by itself, but always combined with a reinforcement procedure for the appropriate behavior.
Time out 101:
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.
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.
In the beginning of this procedure it's 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. (Record the frequency and length of time outs and you will see the child's progress.)
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. Tell your child that he/she will have to go again if your directions are not followed immediately. Do not be timid with your voice or body language. (Go to www.AbA4Autism.com for ABA programs using time out and reinforcement that eliminate inappropriate behavior and establish appropriate behavior.)

Clinic Notes: Public Awareness of Autism and ABA

According to a recent Schafer Report the mayor of Albuquerque has called for a Town Hall meeting on Developmental Disabilities. One of the panels at the meeting will be devoted to autism. I think this is a great idea. And If I were the mayor I would require all city employees to attend. Policemen, firemen, teachers, anyone who might come in contact with a child or adult with autism should be there. And perhaps a special workshop should be offered as a follow up. I am in the process of trying to organize a day camp for children with autism. Games and other activities would be available, all run by qualified staff. While the children with autism were involved in recreation I would talk to teachers, parents, and other interested adults about ABA and autism and Speech-Language Pathologists, Occupational Therapists, and others ould do their part. And hopefully the community to come together to help fight the epidemic.

Clinic Notes: Diagnosis and Denial--Denial and Diagnosis the Chicken and Egg of Autism

Everyone will agree that early diagnosis of autism and intense ABA, along with other therapies, is effective. Sometimes it is possible to diagnosis autism as early as 18 month and start intervention. But only half of all autism cases are diagnosed before kindergarten most of these the second and third year when language delays and other symptoms of autism become apparent. Parents can be in denial before and after a diagnosis. Last week a mother brought her three-year old child in to my clinic. She had thought something was wrong since the child was two but dad kept saying the child was just hard headed. Mom took a trip with her friends and left the three year old with dad. When she returned home dad told her to make an appointment because something was wrong. In this case the child was able to get a diagnosis and treatment at an early but often we do not see children for the first time until they are six or seven. The parents knew something was wrong but were in denial. And the parents did not seek services until the school system insisted. And it is not always denial in the parents that prevents a child diagnosed with autism from getting services. More often costs, both in time and money are to blame.

Clinic Notes: An ABA Army to Combat Autism

A friend of mine has just returned from Iraq. I was asking him about how the war was going and he told me that the press is not giving enough credit to our military forces. They are well-trained professionals, doing an excellent job, under extremely difficult conditions. This got me thinking about my "war" with autism. Everyday I am asked to travel here and there--sometimes to foreign countries--to set up ABA programs for children with autism. If I can't go then I'm asked to recommend someone. Professional, well-qualified ABA therapists are in short supply. Parents around the country, and the world, cannot find ABA services, and if they do fined someone they are either not qualified or too expensive. I'm retiring from my university appointment, staying on to teach an ABA course and direct ABA students in internships, but most of my time now will be devoted to my practice. What we need is some kind of national program to train ABA therapists--an army of ABA therapist to go out and fight the autism war. Of course we will also need OT's, SLP's, and pediatric neurologists in the army too. If we don't do this we will loose the autism war and there will be a large fraction of a generation incapacitated by autism. Autism research needs to be better supported too, but until we find some answers the ABA army will have to fight the battle.

Clinic Notes: The "Autos" in Autism

In 1943, American psychiatrist Leo Kanner published the first paper on autism. The word “autism” comes from the Greek word “autos” or “self” and was first used by Eugen Bleuler, a Swiss psychiatrist, in 1912. Bleuler described “autistic thinking” as not involving outside reality, but only the individual's inner thoughts or feelings. He thought schizophrenics were locked into this way of thinking. Kanner used the term autism to describe the extreme social disinterest he observed in eleven young children, and thought the disorder was congenital. The stereotype of the child with autism being aloof locked in his or her own little world is still with us. However, I think that I have seen a change in this stereotype during my 37 years of clinical experience. Many of the kids who come to my clinic now with an autism diagnosis are very social or at least interested in being very social. Unfortunately, their verbal communication holds them back so they do not do well socially. Social stories and modeling social interactions can help, but unfortunately many kids do not solve their communication problems earlier enough to develop socially.

Clinic Notes: Jobs for People with Autism

Parents who bring their children diagnosed with autism to my clinic want to to know what the future holds. Of course, they ask about the immediate future, but they also ask about vocations and employment for adults with autism, even if their children are only two-years old at the time. I cannot predict the future, but I was glad to read about a new job placement service for people on the autism spectrum. Natural Learning Concepts which offers books and other materials has a job placement resource at http://www.nlconcepts.com
/autism-jobs.htm. Pro autism employers can post jobs and employees looking for jobs can "network." No word yet on the number of successful job placements.

Clinic Notes: The "Brat Syndrome" and Autism

When I was first starting out in ABA 30 + years ago I recall reading an article titled "The Brat Syndrome." The thesis of the article was that noncompliant behavior and tantrums or "brat behavior" in a child does not by itself constitute any psychiatric disorder or neuropsychological disorder. At the time ADHD was being over diagnosed and often children would receive an ADHD diagnosis just because they were noncompliant and had frequent tantrums (brat like). Now I see the same thing happening with autism. Noncompliant children are coming to my clinic with an autism diagnosis, usually conferred by a Special Ed teacher rather than a psychologist, pediatric neurologist, or psychiatrist. Many of my colleagues and associates do not like me to tell a parent that their child has the "Brat Syndrome." And I certainly do not tell a lot of parents that even when it is true. But a lot of parents are relieved when they hear that their child has the "Brat Syndrome" rather than autism.