Clinic Notes: Biomed and Autism

Many parents tell me that raising a child with autism is just more than they can do. Keeping up with all of the ABA programs they are supposed to run in the home, speech therapy, OT, meds, it's just too much. Well, as a clinician I have to agree. Keeping clinical progress notes is often just too much for me too. There's a new app for the iPad called Biomed, which tracks patient care. A patient profile is created--name, birth date, diadnosis, etc. Next a treatment history is entered and quantified if possible. Once all of the information is entered updates are added. Biomed then summarizes everything and you can review all of the information that you have entered on a topic--say ABA-with a tap. We have started using this app at the Children's Treatment Center and we will report in a future blog how it goes.

Clinic Notes: Bad Autism "News"

Last night, after working all day with children with autism in my clinic, I was scanning the autism news, looking for something to blog about. I found the usual scientific studies on genetics, brain function, therapies -- all of great interest, and countless stories about all of the good things that were being done to help children with autism. But what really caught my attention was what a bad day it had been for some children with autism. A substitute teacher was accused of biting a child with autism, a babysitter poured scalding water on a child with autism because of a toileting accident, a student was charged for bullying a child with autism, and a school in Scotland built a cage for a child with autism to "play" in at recess. Maybe tomorrow will be a better day.

Clinic Notes: Autism and Robots

Children with autism have problems understanding where to look. They often do not make eye contact and often do not look where others are looking. ABA programs for establishing eye contact are usually the first thing we do in the clinic and these programs work well. But getting a child to look where others are looking can be more difficult. A recent study by psychologist Andrew Meltzoff and his associates at the University of Washington let 18 month-old infants play with toys. Then a screen hiding a robot was removed. Half of the children observed an adult talking to the robot and play a game with it while half sat the adult not pay attention to the robot. Then the adult left the room, the robot beeped, and turned its head toward a toy. The children in the group that had seen the adult interact with the robot were four times more likely to look at the toy the robot was looking at. The children in this study were normally developing, but perhaps in the studies that are developing "robot therapies" for children with autism observing a little human-robot interaction could be important.

Clinic Notes: Autism and Lying

It is widely accepted that children with autism do not have insight into the thoughts and feelings of other people. But in a recent study it was found that children with autism are just as likely as control children to tell a white lie in order to not hurt other people's feelings. In the study children were told they were going to get a wonderful gift. They were then given a bar of soap. When the researcher asked if they like the gift they said yes and did not say they were disappointed.

Clinic Notes: Illegal Immigrants and Autism

I have noticed an increase in the number of Hispanic children in my clinic lately. I don't know if their parents are documented or illegal immigrants or not. And I don't care. They do work at jobs that provide no health insurance so they all pay cash. Usually, just one parent is present. After the evaluation, regardless of he outcome, they want a letter addressed to "whom it may concern" describing the diagnosis and the need for the absent to join them. As I understand it autism and other childhood developmental disorders is classified a as a "exceptional and extremely unusual hardship" and could be a factor in avoiding deportation. On the other hand, I also hear of Hispanic parents who are afraid to seek treatment for their children who they suspect have autism because they fear deportation. I really don't know how to advise these parents.

Clinic Notes: Seriously now, Girls with Autism and ADHD

Often when women complain about symptoms, which could indicate heart diseases, the physician does not take them as seriously as they would a male. Fewer test are run and fewer medications are prescribed. Now a recent study finds the same is true when girls in Sweden seek help with symptoms indicating ADHD or autism. The parents of were concerned about the behavior of the girls early in life, but had not been given a diagnosis. When they were older and re-examined because their symptoms persisted nearly half were diagnosed with autism or ADHD. Socioeconomic status was ruled out as a factor.

Clinic Notes: Yawning and Autism

Most of us yawn during the day. The exact reason is not known, but boredom or a lack of sleep, are likely causes. Some studies have found that a yawn causes a sudden intake of oxygen, increases heart rate, and ventilates the lungs resulting in increased alertness. While the data on why we yawn is not clear it is clear that yawning is contagious. When one person yawns others around him or her are more likely to yawn. But there is one exception. Children with autism do not yawn contagiously. This makes sense to me and other clinicians who work daily with children with autism. Usually, imitation is not common in children with autism, especially those who are low functioning. The fact that children with autism do not yawn when others yawn tells me that yawning contagiously is a learned response.

Clinic Notes: Eye Tracking and Autism

Clinically, I think a lack of eye contact or infrequent and un-sustained eye contact is a good indicator of autism in young children. Scientists at the University of California, San Diego School of Medicine tracked eye movements in toddlers and found that those with autism spent significantly more time looking at geometric patterns than social pictures. The children who spent more than 69% of their time looking at the geometric patterns could be diagnosed with autism. Some of these infants were as young as 14 months. This could turn out to be a useful diagnostic tool.

Clinic Notes: Special Education and Autism

Unfortunately, many children with autism are in a Special Education classroom along with children with other diagnoses. Many Special Ed teachers tell me that they don't have time or don't know what to do with the children with autism. This problem can be even more difficult when you have children with autism who are at different places on the spectrum and teachers who are not trained in Applied Behavior Analysis (ABA) for managing behavior and ABA procedures such as Discrete Trial Training (DTT) for teaching skills. In our clinic everyone is well trained in these procedures and this is out primary focus with many of our children. But with some of our children who have trouble focusing there is a variety of software available from companies like Super Duper Inc. for children with autism. Children with autism function best in their visual modality and the animation in the software holds their attention. So Special Ed teachers need to find several computers, old computers will do fine, add a touch screen and some software, (neither are expensive) and they can quickly be in the business of educating children with autism.

Clinic Notes: Too Much Noise in the Brains of Children with Autism

Anyone who is around a child with autism for very long will notice problems in focusing on the relevant aspects of the environment. A recent study by Jeffrey Hutsler, assistant professor of psychology at the University of Nevada, Reno provides some answers to why this is so. He examined postmortem tissue samples and found that children with autism have a 20% higher density of synaptic connections in the outer layer of the brain's cortex. The outer layer of the cortex is the last to develop and the connections are formed as the child interacts with the environment. Apparently, the excessive synaptic connections create "noise" making it more difficult for the proper connections to occur. Early interventions with the behavior therapies can help form the appropriate connections between neurons and thereby improve behavior.

Clinic Notes: Plastics, Testosterone, and Autism

A recent study has found that the chemical BPA, found in plastics, including some baby bottles, and cash register receipts raises testosterone levels in men. This is interesting because Simon Baron Cohen of Cambridge University found that high testosterone levels in the amniotic fluid of the womb was related to later autistic behaviors in children. Furthermore, autism is 4-5 times more common in males than females suggesting that high levels of testosterone over masculinities the male brain. Of course, our exposure to plastics has increased over the last several decades so this could be an important etiological variable in the increased number of children with autism.

Clinic Notes: Environmental Causes of Autism

As I mentioned in an earlier blog, I used to enjoy quail hunting. Flushing a covey that your dogs have pointed and having fried quail for breakfast was a real treat in the South where I live. But those days are gone. In Texas, where I'm from there are still quail, but the difference seems to be that in Texas there is ranch land and in the area of the South where I live it's farmland. Farmland means chemicals-pesticides-herbicides-fertilizer-etc. There are studies that show the closer you live to an agricultural field the higher the incidence of autism. I think there is a good chance that whatever killed the quail is also getting into our children either pre or post-natal. Humans are larger than quail so the unknown chemical culprits are not in high enough concentration to be fatal, but in high enough concentration to mess with the wiring of the brain. I was glad to see that more research into the environmental causes of autism was suggested to the Interagency Autism Coordinating Committee (IACC). Autism has a genetic component, but the concordance rate is low and other etiological factors have to be investigated. There is already some evidence to suggest that ADHD is related to environmental chemicals so the hypothesis seems reasonable.

Clinic Notes: Is the Autism Epidemic for Real? Redux

The argument regarding the autism epidemic goes on. One side saying we are in the midst of an autism epidemic with 1 in 110 children being born ending up with an autism diagnosis. The other side saying changes in the diagnostic criteria for autism which resulted in a drop in the number of children diagnosed with mental retardation and learning disabilities explains the increase. A recent study by Peter Bearman at Columbia University in New York sheds some light on the controversy. He and his colleagues identified three variables, which account for much of the increase in the number of cases of autism. Diagnostic changes, parents being more aware of autism, and older parents. However, when they quantified these 3 variables to see what percentage of the increase they accounted for they found that these 3 variables only accounted for half of the increase in the number of autism cases. So it sounds like both sides are right--half right anyway.

Clinic Notes: Autism and SSRI's

A class of drugs called selective serotonin reuptake inhibitors (SSRI's) are commonly used to treat autism in children as young as two. SSRI's are better known as antidepressants by their trade names--Prozac, Zoloft, Celexia, etc. Serotonin is a neural transmitter in the brain involved in a variety of functions and some studies have implicated low serotonin levels in the brains of children with autism. Serotonin is measured peripherally in the blood or urine and no one has proved that peripheral measures of serotonin correspond to serotonin levels in the brain. A recent study concludes that there is not clear evidence that the SSRI's help children with autism. And I believe that when you look at the group statistics that is true. In our clinic many of the children with autism are prescribed SSRI's at some point. In some children I see no improvement. But in others, usually the younger children with poor muscle tone I see significant improvement so I think a trial is warranted.

Clinic Notes: Autism and Lupron

Autism is 4-5 times more common in males than females. This observation led Simon Baron-Cohen to suggest that autism is caused by an extreme “male brain” which is in turn is caused by exposure to high levels of testosterone in utero. Research has shown that both males and females exposed to high levels of testosterone in the womb develop behaviors characteristic of autism. In my opinion, this is the best theory of autism that we have to date. In thinking about studies to test this theory I thought of a study that would test this theory, but was potentially harmful and could not be done. Then, this week to my surprise I read that if was being done--sort of anyway. Lupron is cancer drug, which blocks the body from making testosterone. Taking advantage of desperate parents, a group of doctors in South Florida are giving the drug to children with autism. But this is not a test of the extreme male brain theory. This is an attempt to remove mercury from the body, which is "believed" by some to be the cause of autism. There's no evidence that the Lupron removes mercury or that mercury is excessive in children with autism. Futhermore, there are significant health risk in giving Lupron treatments, which cost around $5000 a month, to children.

Clinic Notes: Autism and Feeding Problems

A recent large-scale study published online in Pediatrics reports that children with autism are "slow feeders" at 6 months and at 15 months are finicky eaters compared to normally developing children. However, these feeding problems do not appear to affect growth or energy levels. The authors suggest that feeding problems may be early diagnostic signs of autism so clinicians should ask about feeding problems. I think this is a good idea, but maybe the finicky eating has nothing to do with food. In my clinic I often note that children with autism are finicky eaters at all ages. But I think this could be because children with autism are just as likely to reject food on the basis of texture as taste and I also know that children with autism do not like change and characteristically follow rigid routines. I've seen cases where a rigid diet would be followed for years and I don't think it had anything to do with food, but simply routine. I know of one adult with autism who had eaten the same exact lunch, a peanut butter and jelly sandwich, for 20 years and on the few occasions when some other food was given to him he had tantrums. He would eat the other foods that were offered to him just not at lunch.

Clinic Notes: Munchausen Syndrome by Proxy and Autism

On my website and in my clinic I recommend that parents of children with autism seek help from multiple professionals such as Speech Language Pathologists, Occupational Therapists, sometimes Physical Therapists, and Pediatric Neurologists in addition to the psychological services that I provide. And many parents follow my advice. Now I hear that some mothers of children with autism, so far none who come to my clinic, have been accused of Munchausen Syndrome by Proxy (MSBP). In MSBP mothers seek excessive medical care, sometimes for a disease they have caused or fabricated, and the multiple treatments may threaten or actually harm the child. Mothers accused of MSBP often have their children taken away from them by the court and now there is at least one case in court where a mother of a child with autism is being accused of MSBP and is in danger of having her child taken away from her. I guess no good deed goes unpunished.

Clinic Notes: Making Sense of Autism Research

As a clinician, who also does research into the etiology (causes) of autism, I am often overwhelmed by the explosion of research findings. Which findings are useful in diagnosis? Which findings are useful in revising treatment options? Which findings are useful in designing future studies? It is simply too much--too much data in too many places with no organization. I was thrilled to read about the National Institute of Health's (NIH) new autism database. The National Database for Autism Research (NDAR) that will have research findings in one place that can be accessed by clinicians and researchers. As I read further though I was less thrilled. The database will only contain data from NIH sponsored research and will not be operational until 2012. Oh well, one small step . . .

Clinic Notes: Asperger's and God

In last week's blog I discussed a teenager with Asperger's who had murdered a classmate after years of rejection by his peers. Now a big switch to a study that examined how Asperger's folks see purpose in their lives. People without Asperger's who believe in God saw His purpose behind many events in their lives. Similiarly, in terms of thinking, a group of atheists stated that things just happen there is no Devine intervention. This study supports the idea that children and adults on the Spectrum lack a "theory of mind" an ability to see or hypothesize what others are thinking.

Clinic Notes: Asperger's and Murder

Children with Asperger's have problems socially. Often they are isolated and friendless and cannot understand why. Theoretically, children with Asperger's lack a theory of mind. In other words they cannot hypothesize what others are thinking and therefore cannot adjust their behavior in social situations. Recently, a child with Asperger's who had been rejected all of his life commited murder. Children with Asperger's have obsessions and this child committed murder because of his obsession with Stephen Ling novels--one of which said that the 19th would be a day of doom. So on the 19th he took a kitchen knife to school and stabbed another student to death in the restroom. The jury did not buy his insanity defense. I see a number of Asperger's children in my clinic each week and have yet to see any that are violent. Interestingly, in the new DSM revision, which is the bible of psychiatry and psychology, Asperger's will be deleted and children with Asperger's will be diagnosed with high functioning Autism. In my next blog I will discuss Asperger's and belief in God.