Clinic Notes: Wakefield Redux

No one knows why Autism is epidemic. In my clinic 75 to 80% of the children I see each week have an autism diagnosis. From the studies we have published, the literature we have reviewed, and the histories we have taken of our patients I believe autism will be like cancer and have multiple causes. Like cancer, we have good treatment protocols for autism without knowing the cause, but it would be nice to know the cause--just one simple cause. It was reported to day that Andrew Wakefield, who published a study in a British medical journal linking autism to the MMR vaccine altered the medical histories of his patients. This was not a case of careless research, but an "elaborate fraud" as quoted by the British medical journal. Since Wakefield's article vaccination rates have gone down and predictably cases of measles and other diseases have gone up. Wakefield has lost his medical license, no one can reproduce his results, his co-authors have removed their names from the article, and the journal Lancet retracted the article. But all this will do little to dissuade Wakefield's supporters. Usually, autism is diagnosed between the second and third year of life. And the only thing that happened that year according to the parent's recollections was the vaccinations. It is very hard for parents to let go of that.

Clinic Notes: Technology for Treating Autism

Many parents who bring their children with autism to my clinic ask what they can do at home to help progress their child. Of course, we have then run the ABA programs for compliance that we run in the clinic and other ABA programs for skill building. But many parents want more. After looking at all of the autism products online they ask about their usefulness. We advise many parents to buy lap top computers if their child is high functioning and we point out software that is useful and that we use in our clinic. But they always want more. And the more has arrived in the Apple iPad. As I have mentioned in previous blogs children with autism are fascinated with the iPad. If you type "autism apps" in the search box in the iTunes store you will find a number of useful apps with more coming each day. If readers would like help in choosing apps for their child please let me know.

Clinic Notes: Children with Autism and the iPad

Apple's iPad is causing a lot of excitement in the autism community. Many parents of the children with autism who I see in my clinic have asked me if they should buy one for their child. So I thought I would blog about what I have seen in the app testing we are doing. First of all, I read an online article about a mother who won an iPad in a raffle and handed it to her child with autism. When she came back a few minutes later he had turned it on and was navigating through the different functions without having ever seen one or being instructed in how to use it. I thought this seemed farfetched so I handed my iPad to a child with autism who comes to our clinic. He looked it over and then proceeded to turn it on and navigate through the different functions without having seen it being used or given any instructions. So it is true--many children with autism have an intuitive feel for the iPad. I have even heard a rumor that Steve Jobs invented the iPad for children with autism, which he denies. In next weeks blog I will review some apps and tell readers the best way to use the iPad with a child with autism.

Autism Apps for the iPhone, Ipod Touch, and the iPad

Just about everyone who keeps up with what is going on in the autism world knows by now that children with autism are fascinated with computer technology. Apple's iPad seems to almost hypnotize them. I have handed my iPad to a child with autism and they learn to use it on their own in a few minutes. The iPad seems to work even better than the touch screen computers that we use in our clinic and I didn't think that was possible. The iTunes store has apps that are especially suited to the child with autism and we have been testing them in our clinic. Prolog2go is a communication app that turns the $400 dollar iPad into an $8000 dollar assisted communication device. We are putting our Discrete Trial Training apps (DT) in the store now. Our DTT apps have been tested in our clinic with children with autism and work very well. Go to http://itunes.apple.com/us/app/autism-colors/id406336763?mt=8#ls=1 and check them out.

Autism and the Christmas Holidays

Every December I repost my blog on Autism and the Christmas

The Christmas holidays can be a difficult time for parents of children with autism or other neuropsychological disorders. Of course, any holiday can be somewhat difficult for any child with all of the changes in their routine, especially when they get tired. But Christmas, with all the lights, the music, the relatives, and the crowded malls, is an especially difficult holiday, because children with autism or other neuropsychological disorders are often hypersensitive to visual, auditory, and tactile stimuli.
Children with autism are visual learners, and a month before Christmas you should take pictures of what is going to happen--the lights on the tree, the gifts, the music, the relatives that touch and hug. These pictures should be shown repeatedly each day to your child with autism or other neuropsychological disorders. While he/she is looking at the pictures, tell the child a little story about what's going to happen at Christmas, how to behave, and what your child can do if the stimulation is too much. Include your child in the pictures if possible. A picture of your child going to his or her room to escape the noise and confusion when he/she gets overloaded seems to help, too.
There are no sure-fire techniques to use with a child that will ensure a "Martha Stewart Christmas." But many families who have children with autism or some other neuropsychological disorder have used the visual learning procedure above and the ten tips that follow to have a better Christmas.
1. Try to keep your child in his or her usual routine as much as possible.
2. Sensory over stimulation—the lights, the sounds, the smells, and the relatives touching your child--are the main culprits during the holidays. Eliminating or minimizing these culprits are your best bet.
3. Some families who have children with autism or other neuropsychological disorders wait until Christmas Eve to put up their tree and decorate.
4. Some families let their children with autism or other neuropsychological disorders do all of the decorating. Children with autism or other neuropsychological disorders may line up or stack decorations rather than decorate in the traditional way, but so what.
5. Rather than try to do the Christmas shopping with children with autism or other neuropsychological disorders in a crowded, noisy mall, many families shop by catalog or online and let the child point to or circle the toys he/she wants. Websites, such as www.stars4kidz, offer a variety of toys for children with autism or other neuropsychological disorders. Just type "autism toys" in your search engine.
6. Tactile toys are often a better choice for children with autism or other neuropsychological disorders. Toys that make sounds or involve too much stimulation or are too complex may not cause an aversive reaction in the child. Try ordering some of these autism friendly toys and then let your child select the ones to play with, as they are unwrapped.
7. Talk to relatives before they come over about the best way to behave with children with autism or other neuropsychological disorders.
8. Generally, kids with autism or other neuropsychological disorders do better in the morning than in the late afternoon or evening when they are tired. It may be better to schedule Christmas events at these times.
9. The parents of children with autism or other neuropsychological disorders need to relax themselves. Often the child with autism picks up on the parents’ stress and that is enough to ruin Christmas.
10. And last but not least, realize that you are probably not going to have perfect food, perfect decorations, and perfect gifts. Christmas with children with autism or other neuropsychological disorders may not be traditional, but it can still have real meaning. I wish you and your child the happiest of holidays. Visit us at http://www.childrenstreatmentcenter4autism.com if you have questions about your child.

Clinic Notes: Handwriting and Autism

Many children with autism have fine motor problems and are receiving services from Occupational Therapists (OT's). Buttoning, tying shoes, coloring, puzzles, and stacking blocks can all be issues. A recent study (Schafer Report, November 24, 2010) found that handwriting problems persist into the adolescent years. I think this reinforces what I have been telling parents for years. Do not discontinue OT even if the Ot tells you that your child with autism has met all of the goals unless handwriting is easy for the child. Letters should not only be well formed but completed in a timely manner. I have seen children with autism make bad grades simply because they cannot write fast enough to finish assignments and tests.

Clinic Notes: Desensitizing a Child with Autism to Swallow Pills

About half of the children who come to The Children's Treatment Center are on medication. Many children with autism have issues with swallowing pills so parents have to hide the pills in food or find the medication in liquid form if available. Usually, this is only a short term fix. I use a desensitization procedure similar to a procedure covered in a recent Lovaas Institute Newsletter which works well. Begin by having the child swallow all of the liquid in a spoon in one swallow. Start with just a small amount of liquid and gradually increase the amount until the chills can easily swallow the entire spoon full. Do this with a variety of different liquids. Next add a small amount of juice powder to the liquid and gradually increase the amount by decreasing the amount of liquid. Follow this with a spoon of the child's favorite juice as a reinforcer. Small ice chips can then be placed on the spoon for the child to swallow and gradually increased in size. The transition can then be easily made to small pills.

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.