Showing posts with label ABA. Show all posts
Showing posts with label ABA. Show all posts

Friday, 26 January 2018

Ambitious about Autism? All roads lead to Las Vegas

There are many odd things in the world of autism. One is ABA (Applied Behavioral Analysis), the gold standard therapy in North America, where it is seen as evidence-based.  In the rest of the world there is very little ABA and that same “evidence” is not seen as conclusive.
Raymond in Las Vegas with his “assistant” Charlie

In the US, Federal Government funded very early intensive intervention is available to anyone under three years old with an autism diagnosis. The “evidence” shows that such very early intervention can change the outcome.  But why stop at three years old? What is magical about 36 months of age? After this age some people continue to get intensive intervention and some do not; it all depends where you live and who wants to pay.
If the evidence is so strong that very early intervention is so effective, why do rich European countries leave it to far older than 36 months to even diagnose autism?
Much does not add up in the world of autism.
Personally, I am a fan of ABA as a teaching method, but only when done in a fun way, which is how our US-trained Behavioral Consultants practised it. Lots of high fives, “good jobs”, smiling faces, tickling, dancing and generally a good time; no tears and no stress.
I cannot see why you would stop your intensive intervention so soon after starting it and I really doubt you make a life-changing difference very often, by 36 months of age.
One of our Behavioral Consultants came from the New England Center for Children and I recall asking her, “so when do you stop with your therapy?” She told me that they have people in their 60s still in therapy and they might go on a trip with their assistant to Las Vegas (yes, just like in Rain Man).   
There are many special schools in the US using techniques like ABA. Because of the high ratio of staff to pupils, these schools are very expensive and somebody has to pick up the bill.
In Europe there are very few ABA schools, one of the first is called Tree House and was established in London.  It was set up by a charity called Ambitious about Autism.  This school is very expensive and the idea is that the municipal authority where you live is supposed to pay the fee for you. This would come out of their budget for special needs kids, so the more money they spend on such private schools the less money there is left over for the kids with less demanding parents, who do not advocate for their kids.
Anyway, I recently came across the fact that Ambitious about Autism has gone a step further and now runs Ambitious College for people up to the age of 25.
This made me wonder if you go to the ABA school from 4 to 18 years old and then go to the ABA college until you are 25, when does it end? Perhaps with a trip to Las Vegas? 

ABA as a treatment or a teaching method
While I see ABA as a (highly effective, in the right hands) teaching method, the ABA specialists put if forward as a proven treatment, meaning you should get better. 

Ambitious or Realistic?
When treating a three year old with autism I think you have to be ambitious, optimistic and hopeful.
At some point I think you need to be realistic.
Day care and activities for young adults with severe autism is a great idea. Including them in activities with non-autistic people would be even better.
With people living longer there are many activities for retired older people, which are entirely suitable for adults with (non-violent) severe autism, or indeed with Down Syndrome.  Why can’t the 25 year old with severe autism play table tennis with the 70 year old retired teacher and go to the same keep fit class?  Last year Monty, aged 14 with ASD, was in Shanghai and when he saw a large group of older Chinese people doing their group exercises in a public park; he joined in. Everybody enjoyed it. 
I am not sure creating a “College” for people with severe autism is helpful. Helping people with autism go to a regular college, by giving them an assistant, is a good idea.
If it really is day care, why not call it day care?
If it is about preparing for life in the real world, what was happening at the ABA school from 4 to 18 years old?

Sunday, 20 September 2015

A New School Year – Still keeping up

Before I return to the science-heavy posts, this is another post to encourage people not just to read about autism, but to treat it.  No pseudoscience or great expense is required.

After close to three years of using biology, rather than just behavioral therapy, where have we got to?

Acquiring new skills is effortless for clever typical kids; we have also got one of those.  For kids with classic autism, even the most basic skills need to be taught and taught again, until eventually, they might sink in.  I do not think this has anything to do with permanent MR/ID (mental retardation/intellectual disability), although I can see why it often gets diagnosed as such; it turns out to be treatable.

In the race to keep up with the typical kids, or at least keep them in sight, we started with ABA and about 1,800 hours a year of 1:1 time with an assistant.  After a few years the typical kids had pulled far ahead.

At age 9, I started to correct the underlying dysfunctions, first with Bumetanide, using very recent findings in the scientific literature.  This coincided with the decision to change his (neurotypical) peer group at school to those 2-3 years his junior.  Time was reset.

We still had the 1,800 hours a year of 1:1 time with an assistant, half at school and half at home.

At age 12, the original peer group is now far out of sight, but after three years we are still keeping up academically with the new “friends at school”.

Monty, now aged 12 with ASD, is in the same small mainstream international school he has attended for eight years.  Three years ago I held him back two years, since he was becoming completely “un-includable”.  So we went Year 1, Year 2, Year 3 then back to Year 2, then Year 3, Year 4 and now Year 5. 

Since most readers are American, where school starts one year later, to convert UK school year to US grade, just subtract one.  UK Year 5 = US 4th grade.  In the US you finish in 12th Grade whereas in the UK system you finish in Year 13, both typically in your 18th year. (so in the US system, he went K, 1st, 2nd, then 1st, 2nd 3rd and now 4th)

Many kids with autism are now “included” in mainstream education, but in reality some are just having a private 1:1 lesson with their assistant at the back of the class. This is not a good idea; for the last three years Monty has been able to follow the teacher.  If you cannot follow the teacher, you really should not be in that class.

We have a new class teacher, an American, he has been teaching for 15 years, but has never had a special needs kid before; that in itself tells you something.  Now he has Monty, aged 12 with “treated” classic autism, something he probably will never see again.

After a couple of weeks, his conclusion is “he can read nicely and do the exercises”.  This makes it sound rather a non-event.  A few short years ago, his school teachers were rather stunned that his 1:1 assistant got him to read very simple words.  Now he can read aloud from “chapter books” to the rest of the class.   

When they had a spelling test (words like graduate, icicles, sausages) he got 18/20 and one of the new girls in class told her mother how clever Monty is.  When told he has “special needs” and an assistant, she replied “special needs … no special needs”.  That was nice, but Monty does still have plenty of special needs, but for three years he has been able to move forward academically at a similar rate to his classmates, albeit that they are all 2 years his junior.  That progression is quite extraordinary, if you know about outcomes in classic autism. 

Having been using ABA for five years prior to starting with the biology/pharmacology, and seen steady but slow progress and so falling ever further behind his peers, I never expected to be here in 2015 with Monty being able to subtract 7,794 from 9,621, or add up 8,756 + 4,326 + 7,832, interpret data from graphs and use x,y coordinates.  Until five years ago he did not even attend numeracy/math classes at school, because we had to focus on basic speech, basic reading and things like standing in line and changing shoes.

I have no idea how far he can go. I was expecting by now to again have to repeat a school year, but it has not been necessary.

Behavioral problems (SIB, anxiety, aggression etc.) were generally rooted in biology and have been more than 90% treatable.

With neither behavioral, nor pharmacological intervention, it would not now be a pretty sight.

It is sad that almost nobody treats Classic Autism pharmacologically; there are so many unnecessary, unhappy, consequences, lives sometimes lost to what can be a treatable condition.

It also appears likely that by treating the dysfunctions in Classic Autism, you may avoid the possible later progression to epilepsy/seizures and all the problems that may cause (even SUDEP, drowning etc).  This was something we had been warned might develop, but now looks much less likely.  For some people, seizures are a bigger issue than their autism. Some data, for those interested:-

This is among the largest studies to date of children with ASD and co-occurring epilepsy. Our sample includes 5,815 participants with ASD, 289 of whom had co-morbid epilepsy. Using statistical modeling in this well-powered sample of patients we have made several important observations about a contemporary group of individuals with ASD and epilepsy. We identified several correlates of epilepsy in children with ASD including older age, lower cognitive and adaptive functioning, poorer language skills, a history of developmental regression, and more severe ASD symptoms. Through multivariate logistic regression we found that only age and cognitive ability were independent predictors of epilepsy.

The average prevalence of epilepsy among children aged 2 to 17 years in our population-based sample, the NSCH, was 12.5%. This estimate is comparable to a recent report of a 15.5% rate of epilepsy in another population-based sample of children with ASD. While the prevalence was 10% or lower in children under 13 years of age, by adolescence it reached 26.2%. Therefore, the best estimate of the cumulative prevalence of epilepsy in ASD through 17 years of age is 26%. Our study replicates findings from prior studies that have followed children with ASD into adolescence/early adulthood and reported epilepsy prevalence rates from 22% to 38%

Note that Classic Autism accounts for about 30% of ASD; it is not hard to guess where you would find most of the 26% with ASD who later develop epilepsy.  

Odd epileptiform activity (seen on an EEG), falling short of epilepsy, is common in young children with autism and I think might be considered as pre-epilepsy.  Just as someone who has prediabetes has the chance to do something about it, before it progresses to type II diabetes, unusual EEG activity should prompt consideration of a treatable excitatory/inhibitory imbalance. 


At least I have treated the only autism case I am responsible for. I encourage others to do the same; it is never too late, even in adulthood.  We have one reader, Roger, who got his core biological autism dysfunction diagnosed and treated in adulthood.

If you prefer to wait for 100% FDA-guaranteed solutions, you will wait forever.  

Thursday, 22 January 2015

ABA Strikes Again

This blog is mainly about clever pills and potions that may improve some people’s autism, but I do like to remind people of the power of behavioral interventions.

Monty, aged 11 with ASD, has had three behavioral consultants since we began his home ABA program when he was aged about four.  Since there are no ABA consultants in our part of the world, we have to fly them in.  We have our local therapists/assistants, who then work with some support from the foreign consultant.  The net result is a mixture of approaches, which admittedly becomes more “ABA” when the consultant comes to visit.  We now have a vast collection of ABA books, manuals and training materials.

Last week our excellent American-Greek behavioral consultant came for a two day visit and so it was a good opportunity to look at progress.

Monty went to the airport to wait for her and then we went home for some discussions and Monty showed off his piano playing.  Later everyone went out to a pizza restaurant; all went well and Monty quietly devoured his full-sized margarita pizza.

The next day the consultant went to school with Monty and his assistant, to see how things are handled there.  The last time she came, she pointed out that there was little interaction with the other kids.  Now things are much better in that area.  In class, she noted than he can now sit attentively and follow much of what the class teacher is saying/doing.

Then back home to see Monty’s afternoon home program with his other assistant.

Another school visit the next day and the visit was over.  Now we wait to find the suggested items to work on at home, as we work our way through one of the ABA bibles, which in our case is:-

We have lots of other material, but we still often use this book.

Academically and socially we have moved on a fair way since the last visit.  Back home our consultant runs more intensive clinic-based ABA programs and she was wondering out loud how come we are making all this progress.

“Our other kids have six times as much intervention”; I am not sure exactly how the six figure was picked, but I do get her point.

Near the end of the visit she did ask “are you giving him any drugs?”

The answer was “yes, but not any ones you will have heard of”.  I did then give a brief explanation of my "extra-curricular" activities.

I have learnt it is best not to mix messages with different audiences.  ABA people are great, but do tend to think nothing else can help.  Equally, people convinced that the problem is candida or vaccines, have also already made up their minds.

It is, of course, not a good idea to compare one child with ASD’s performance against another, but everybody still does it.

It looks like the kind of people our consultant works with now and encountered at a leading center in the US, where she trained until 10 years ago, are generally more affected by autism than Monty.  Most of the people I read about today with “autism” (mainly from the US) are clearly much less affected than Monty.  This does rather suggest that what passes for “autism” there has really changed a lot in 10 years.  Now that Asperger’s has ceased to exist in the US, under their latest DSM, this process will continue yet further.


My conclusion is that ABA works great and so does the Polypill.

Hopefully, next time we go to the airport to meet our ABA consultant, or even drop by her in Athens, we will again have moved forward nicely.

For now everyone is happy.

Saturday, 5 April 2014

True Self

I could have given this post and the above graphic a fancy name like "Psycho-neurobiological model of autism", but True Self seems more appropriate.

If you have ever read a book on autism by a psychologist, it is worlds away from the books by the scientific boffins.  In reality, the psychologists have a simpler job, since they do not have to prove their theories with biological data.

One interesting observation from psychology is the concept that the human body has two parallel control mechanisms, the nervous system and the hormone system.  The nervous system mediates immediate changes, while the hormonal system sets the background changes.

When it comes to fear and stress, there are measurable hormonal changes.  Using willpower or even singing, you can make your self feel better and make a measurable change in the hormone levels.  We saw this earlier with the example of singing lowering the stress hormone cortisol, as measured in saliva.

This NIKE (Just do it!) effect means that you can directly influence your own hormones.  By inference, if you have a hormone imbalance, as seems to be the case on some types of autism, you have some powers to modulate it yourself.  You could think of it as willpower, or mind over matter. 

I suggest that even instincts may fall into this category.  Just as soldiers are taught to react instinctively, without pausing for thought, it should be possible to teach young children to develop their instincts.  The apparent lack of gross motor skills in kids with ASD can often be overcome with practice and repetition (the foundations of ABA);  in effect you are teaching the child what is instinctive in other kids.  If you through a ball at a younger kid with autism, he does not react and will let it hit him.  He does not know what to do and he lacks the instinct to either get out of the way, or to catch it.

As part of a good ABA programme a lot of time is spent practicing both gross motor skills (ball play, jumping, dancing etc) and fine motor skills.  Then you have these skills, without the need to consciously think about them.

People do ask why ABA seems to work so well for some children, is it the child? is it the therapist? it is just the sheer amount of it that matters?  They tend not to wonder what the ABA is actually doing inside the child's head.

It is relevant to this blog, which is all about the biology of the brain.  We have a pretty good idea of some of things that are dysfunctional in autism and how some emerging drug interventions work.  But at the same time, there is this behavioral intervention that seems able to overcome some of these biological deficits.

The NIKE effect (Just do it) and the AVIS effect (We try harder) are extremely potent.  In reality, they are very much part of the body's nervous control system.  In some cases this training is so powerful that instead of being derailed by interference from ion channels and oxidative stress, all that matters is completing the task.

Some typical people's headaches are also caused by ion channel dysfunction; when it happens they might call in sick.  Another type of person is more driven, the fact they have some other obligations is more important than their headache, so they just press on.

The Faucet/Tap/Valve

A conventional faucet/tap might look like this old one on the left.

A so-called "in line valve" has a pipe on both ends and as you turn it, you gradually reduce the flow to zero

If you make a technical drawing involving a valve, there are various special symbols, but they generally look like this.  Sometimes if the valve is closed it would be solid black.

Why does drug intention in autism sometimes stop working ?

We have seen in this blog that several apparently different, but interconnected, conditions seem to mediate autism, at least in some people:-
  • Oxidative stress
  • Neuroinflammation
  • Channelopathies
  • Hormonal dysfunction
  • Immune system "over-activation"

So if you now look again at the True Self graphic

Oxidative stress, if present, will manifest itself as stereotypy and in the graphic it will close the valve a little blocking the true self.  In hard science, the oxidative stress will also reduce the level of the thyroid hormone T3 in the brain.  We saw this in research from Harvard that showed that the oxidative stress reduces the level of the enzyme D2 that converts the pro-hormone T4 into T3.  So both the blue valve and the green valve close.

In similar fashion both neuro-inflammation and channelopathies affect both the nervous system and the hormonal system. 

This might explain the fact that sleeping patterns, appetite, emotions, empathy, self-confidence are all sometimes impaired in autism.  To some extent, these impairments seem to be reversible.

In the only real case of autism that I have to contend with, the most important factor seems to be, the sometimes over-activated, immune system.  I am presuming it is just affecting the nervous system.  In this case, the blue valve to the left can shut completely; the Observable Self is then a totally different person to the True Self.  It also means that even though the other valves upstream may be wide open, it is all to no avail.

So when my autism drugs "stopped working" it was because further down stream there was an insurmountable problem.  Even NIKE and Avis had little effect.   

In the children for whom none of these drugs show any effect, I suspect either the immune system is involved, or in their type of autism, there are other additional factors at play.

A Note on ABA

ABA (Applied Behavioral Analysis) is not the subject of this blog, but it would be more than worthy.  When well implemented, ABA is a powerful resource and not only for small children.  The general public perception of ABA rather misses the point, it is actually more a philosophy applicable life-long.

We once had an excellent young ABA consultant trained at the New England Centre for Children, in Massachusetts.  I was surprised to hear from her about the support still being given to older adults; the adult and their buddy (ABA assistant) would even go on short trips, like to Las Vegas.

We are now using ABA to develop conversational skills.  An example is giving Monty, aged 10 with ASD, the task in break time at school, to go and initiate five conversations with the potential reward of his favourite candy.  This might sound very staged, but he goes around the school looking for kids to talk to, some of whom he has never spoken to before, initiates the conversation, looks over his shoulder to check his assistant has noticed, plays a bit and then finds someone else to talk to.  He did not take the easy option and just find the nearest five kids and say "Hi, how are you".  I was surprised how well this worked.

Later you can fade the reinforcer, so that he works for praise and not candy.  You can also gradually increase the target of five conversations.  You can then also extend the requirement to have more stages to and fro, in the conversation.  It may sound very odd to do this, but the end result will be learning to make social conversation, which would be natural in other kids.  

What people do not realize is just how much ABA is needed and that it is not just like having a music lesson, it is more like a religion.  If everyone who interacts with the child consistently applies the principles, much can be achieved.  If ABA is just a lesson the child goes to and then comes home, it is not a surprise that very much less is achieved.

If you talk to the parent of a child who has persevered with ABA for years, you will see just how committed they became.  If you prefer sport as an analogy, it is just like a would-be professional tennis player, who practices every day from the early hours.  It is an obsession, but if you want to compete at a high level, you just have to do it.

Where we live there is no ABA school, but there is a Novak Djokovic tennis academy, in fact they came to visit Monty's school last week.  I think Novak would definitely understand the NIKE and Avis effects, he probably would not think ABA was odd at all.


Friday, 17 January 2014

Increasing Good Behaviors and Reducing Bad Behaviors in Autism

This blog is all about clever chemicals that can make life better for people with autism, but for several years I have also been learning all about behavioral therapy to achieve the same goal.  So I thought I should look for any lessons that I might apply from my earlier endeavours.  

Two of the best books in my ABA collection, based on feedback from all of our Assistants/Therapists/Friends are the oldest, and indeed the lightest.  They are more than 30 years old, as you might imagine from the front cover, which is a big turn off for many parents.

They are great books, that tell you what you actually want to know: how to get rid of horrible behaviours and how to encourage nice ones.
Dr Foxx is still going strong and won the 2013 Award for Distinguished Professional Contributions to Applied Research from the American Psychological Association. Foxx is a professor of psychology at Pennsylvania State Harrisburg and an adjunct professor of pediatrics at the Pennsylvania State University College of Medicine.

The thing I always found odd was why Dr. Foxx wrote two separate books, surely it is all the same subject matter.  He had his reasons.
Here is my parallel with my quest to develop a smart combination of safe drugs to help in autism. 

So far, most of what I have been doing is focused on decreasing the bad behaviors, so the blue part of the pill; the remaining work is find to ways to promote the good behaviors, the yellow part of the pill.

This might actually be more relevant that you realize.  While it is clear that bad behaviors in autism vary widely in both type and extent, desirable good behaviors should have much more in common.  We know that many individual drugs on the "blue side" are effective only in a minority of people, but perhaps there will be much more commonality on the "yellow side".  I expect this to be the case.
So my Polypill is taking colour, as well as shape.

Another good piece of news is that I found a precedent for orphan drug designation in classic autism.  It appears that in 1998 the FDA awarded orphan drug status to Naltrexone to treat childhood autism with SIB.  In the US, orphan drug status is only possible for rare diseases affecting less than 200,000 people.  There are other cases of orphan drugs in autism, but they are for rare genetic variants. Currently the FDA website for orphan drugs does not list Autism for Naltrexone.
Also, an interesting Australian drug NNZ-2566,  mentioned in a previous post, has recently been given orphan drug status in the US, this time based on Fragile X designation.  The drug is an analogue of IGF-1 and looks interesting to me.

If you want to see what orphan drug designation in the EU means, here is what Novartis received for its new Fragile X treatment, Mavoglurant.
Orphan drug status reduces the cost of approving a drug.  But how rare is classic autism, these days?


Thursday, 5 September 2013

Promoting Speech in a 7 year old Non-verbal Child with Autism

I was recently asked if I would be happy to talk to the parents of a 7 year old non-verbal child with autism.  I agreed to share what I have learned so far from both behavioural interventions and more recently from drug therapy.  I decided that a dedicated post could also be very useful.

When Monty, now aged 10, was diagnosed with autism aged three and a half, he embarked on a home-based ABA programme, soon complemented by the use of PECS (Picture Exchange Communication System).  PECS is great, and when correctly implemented, clearly can work wonders.  Sadly, most people take shortcuts and just laminate a few pictures, stick them on the fridge and say they are “doing PECS”.

Click below to see short training videos:-
Once a non-verbal child has a communication system, be it PECS or sign language, then he/she can open up to the world.  Often speech then follows, but not always.

Monty learned to talk using ABA, PECS and special computer software.

With what I have since learned about the possibility of safe and effective drug therapy, I would do things slightly differently.  I would keep all the ABA and PECS and just add Bumetanide, NAC and Atorvastatin.  I can never know if Monty would have then spoken earlier, but I am pretty sure that would have been the effect.

Science based, not “Biomedical”, not Complimentary Medicine and not DAN!

Just in case you are wondering, my findings are based on reading the scientific literature on autism and its comorbidities.  I decide what research looks sound and what looks dubious; I draw my own conclusions.  “Biomedical” is a word that has been hijacked to apply to therapies that we would like to work, but usually lack a thorough grounding in science.  DAN seems to stand for trying everything, “Biomedical” and more.  Nonetheless, within the hundreds of DAN therapies are at least one or two that do stand up to scientific investigation.  

By applying a very blinkered view to the existing research, the Medical Establishment’s general view continues to be that autism is pretty much untreatable.  Having accepted this view myself for several years, I have learned that this view is fundamentally flawed; you just have to objectively follow the science and do a little research yourself.

7 years old and non-verbal

The longer a child remains non-verbal, the more challenging it becomes.  After a long period of time a child will just not see the point of changing.  It may cease to be a biological problem and become just a behavioural problem.

My combination of Bumetanide, NAC and Atorvastatin is as close as you can ever get with drugs to being risk free.  This has been a prerequisite of mine.  If after 7 years my child was non-verbal, I would probably be willing to take additional risks, but still nothing without clearly understood boundaries.

For the last few years we have had a little box in our kitchen drug cabinet marked “emergency asthma drug, one a half tablets”.  We have never had to actually use this drug.  The drug is Prednisone and it is for use when an acute asthma attack does not respond to the Ventolin “rescue” inhaler.  Prednisone is a corticosteroid, widely available, cheap and saves lives; but long term use can have major side effects. 

Prednisone lowers the body's immune system.  The science suggests that the overactive/damaged immune system in autism is a factor behind the autistic behaviours in children with ASD.  It would seem logical that temporarily lowering the immune system might trigger behavioral change in autsim, such as regaining lost speech or initiating it.  The most serious doctor I could find who is knowledgeable about this subject is Dr Michael Chez, of the Pediatric Neurology and Autism Neurodevelopmental Program, Sutter Neuroscience Institute in Sacramento California.
He wrote a paper I have already referred to in this blog called:-
Immune Therapy in Autism: Historical Experience and Future Directions with Immunomodulatory Therapy
In that paper he talks of his knowledge of the effects of prednisone on children with autism and he mentions the dosage used.

. Treatment was usually prescribed with daily prednisone doses of 2 mg/kg/day for 3 to 6 months. Limitations to therapy were usually Cushingoid side effects. As in other chronic conditions requiring steroids, pulse dosing was tried with steroids in the form of prednisone or prednisolone at 5 to 10 mg/kg twice per week.  

Long-term success with no dependence or minimal Cushingoid effects has been noted in several hundred patients treated in this manner (Chez, unpublished data, personal communication).

In all, 17 of 32 patients showed response to prednisone after 2 to 4 months of  treatment (53%). Improvements were seen on EEG and  in language skills of the patients. Other steroid treatment series of regressed language in autistic spectrum patients diagnosed with LKS variant showed improved language with pulse-dose steroids.

Going to California is not an option for most people, but if I had a 7 year old non-verbal child with autism and ABA/PECS did not help initiate speech, then I would certainly read up on what he is suggesting.  I would still focus the time and effort on ABA/PECS and just hope that the drugs provide a little extra push.


Saturday, 18 May 2013

Finished switching ears off!

I had another surprise a couple of days ago; I was standing with Monty outside the entrance to a very noisy ice-cream bar.  There were babies crying, a lady begging rather aggressively and an orderly queue to enter the shop.  Finally, the noise abated and I heard Monty say:-

“Finished switching ears off!”

Is there more to this than the emergence of spontaneous and appropriate speech?

Selective Hearing, Elective hearing and (S)elective mutism

I once did a course called Noise Control as part of my Engineering degree.  I recall that at the start of the course, the Professor confessed his desire to be able to turn his hearing on and off; clearly there were some noises he would prefer not to hear.

If you have children you will have discovered “selective hearing”; whenever you want them to come for a meal, they just do not seem to hear you.  If you offer ice cream though, they will hear the first time you call.

There is also the relatively common case of selective mutism, in people with anxiety disorders, they lose the ability to speak in stressful situations.

I think that many non-verbal autistic children probably have elective mutism; they just decide not to speak, or perhaps there is a barrier inside them that they just cannot get over.

Many people with autistic children initially go through a phase of thinking their child is deaf.  I know a child who lost his hearing and then a couple of years later regained it.  I met him just after his hearing was restored and I was convinced he had autism; he had all the characteristics.

Maybe some autistic children have elective deafness and/or elective mutism and perhaps a little pharmacological intervention could actually help them overcome this barrier?

For Monty, thankfully, these problems are in the past.  For him ABA and PECS did the job.

Wednesday, 8 May 2013

Neurogenesis & Neuroplasticity

Today we have two new N- words and we finally get to the bottom of what autism is and what it is not.   There is nothing revolutionary here, it can all be found in the research and indeed most of it can be found in just one book, but then who would read my blog?
We will start with the bad news and finish with the good news.

Neurogenesis sounds like a good thing; it is the birth of neurons in the brain.  This is substantially completed in the pre-natal period, but it can continue in certain parts of the brain throughout life.  After a head injury, or trauma, neurogenesis can take place.

In the case of autism the potential benefit exists, but seems likely to be minimal.
Many studies have already established the pattern of deformities in the autistic brain.  One researcher in particular, Eric Courchesne, seems to have chosen to make this his life’s work.  He has carried out repeated studies over many years focused on examination of brain growth, and overgrowth, in autism using post-mortem brains and later MRI (magnetic resonance imaging).
His findings are unequivocal, and in line with those of his peers.  In his autistic subjects, the brain grows much faster in the first couple of years than typical subjects and then the process slows right down and in later life the autistic brain starts to shrink.  His and other studies show that in later life the brain does seem to try to compensate for its defective development; this is seen as ineffective (but how can anyone possibly know?).

He finds a wide pattern of abnormalities, including the expected presence of a reduced number of Purkinje cells.  He goes on to argue that his evidence shows that this damage was done in the pre-natal period, so he will not be popular with the vaccine damage theorists.

“Thus, given the resulting tight bond between the olivary neurons and the Purkinje cells after this time, loss or damage to the cerebellar Purkinje cells results in an obligatory retrograde loss of olivary neurons. Since, in the autistic brain, the number of the olivary neurons is preserved, it is likely that whatever event resulted in the reduction of the Purkinje cells in these cases has to have occurred before this tight bond has been  established, and thus before 28–30 weeks gestation.”
“In addition, microscopic observations of enlarged cells in some brain regions in autistic children and small pale cells that are reduced in number in these same areas in adults strongly indicate changes with age. Clinically and pathologically, this process does not appear to a degenerative one and may reflect the brain’s attempt to compensate for its atypical circuitry over time.”

“This early cessation of growth results in a 2–4 year old autistic brain size that is not different from a normal adolescent or adult in the majority of cases. Thus, at the age of typical clinical diagnosis of the disorder (i.e. 3–4 years), the period of pathological growth and arrest has likely already passed, leaving clinicians and researchers with an outcome, rather than process, of pathology for study and treatment intervention.”

Here are three of Eric’s studies, which include graphs showing autistic brain development vs. the control group at various ages throughout life.

If neurogenesis was the bad news then neuroplasticity is certainly the good news. I think that Eric needs to read up on this subject and perk himself up.  It seems even a deformed brain can do some pretty clever stuff.

Neuroplasticity, also known as brain plasticity, refers to changes in neural pathways and synapses which are due to changes in behavior, environment and neural processes, as well as changes resulting from bodily injury.  Neuroplasticity has replaced the formerly-held position that the brain is a physiologically static organ, and explores how - and in which ways - the brain changes throughout life.
In the field of neuroplasticity we have some pioneering work from  Michael Merzenich is a neuroscientist. He has made some of "the most ambitious claims for the field - that brain exercises may be as useful as drugs to treat diseases as severe as schizophrenia - that plasticity exists from cradle to the grave, and that radical improvements in cognitive functioning - how we learn, think, perceive, and remember are possible even in the elderly."  Merzenich’s work was affected by a crucial discovery made by Hubel and Wiesel in their work with kittens. The experiment involved sewing one eye shut and recording the cortical brain maps. Hubel and Wiesel saw that the portion of the kitten’s brain associated with the shut eye was not idle, as expected. Instead, it processed visual information from the open eye. It was"… as though the brain didn’t want to waste any ‘cortical real estate’ and had found a way to rewire itself.
Merzenich created a plasticity-based computer aided learning programme called FastForWord, which  offers seven brain exercises to help with the language and learning deficits of dyslexia.

ABA and neuroplasticity.  Then of course, I started thinking about Monty’s  6 years of ABA and endless hours on his computer based learning programmes.  This of course is the link between neuroscience and ABA - the fuzzy science of neuroplasticity; otherwise known as making the most of what you’ve got. 
We have established that autistic behaviours are likely caused by stress and inflammation in the cerebellum, and in particular in the region of the Purkinje Cell Layer (PCL).

We have seen that in classic autism this stress and inflammation is associated with physical brain growth abnormalities that occurred in the pre-natal and early post natal period.  The oxidative stress and inflammation is ongoing throughout adulthood.
We have seen that stress and inflammation in the cerebellum can be caused by entirely different causes, that take effect later in life, such as Tuberous Sclerosis Complex (TSC).  There is another truly horrible one called Childhood Disintegrative Disorder (CDD).

With the availability of noninvasive MRI scans, it would be interesting and highly possible to ascertain the level of brain deformity in milder cases of autism and Asperger’s syndrome. 
Given that by the time autistic behaviors are exhibited, the damage to the brain  has already run its course, our main ally would seem to be neuroplasticity and of course to halt the ongoing oxidative stress and inflammation.

In addition, we need to consider countering the apparent ion-channel disfunction, and maybe give the damaged hippocampus a lesson or two about hormone production.




Sunday, 10 March 2013

See you in Hell then.

Does religion have something to do with treating autism?  It should not have, but actually it does.
Depending on where you live in the world, you may come across a lot of religious intolerance.  In Iraq, Muslim Sunnis don’t seem to care for Muslim Shias, in the Indian subcontinent Hindus for Muslims, in Northern Ireland some Protestants for Catholics, the list goes on.  To an outsider, the differences between the competing teachings may seem marginal, but to an insider it can even be a reason to go to war.  It has often been the case that some of those going to these extremes, do not even really understand the competing teachings of their own religion.
What you might ask does this have to do with Autism and the subject of my blog?
If you have a child with autism, or you work full-time as a carer or therapist, you will likely have experienced emotional stresses that would destabilize all but the calmest of souls.  If you are new to the subject of autism you will probably skip over this part, if not, it will surely resonate deeply.
As will become apparent in forthcoming posts, this syndrome is very relevant when sifting through the research papers.  Acronyms are very popular in the literature of Applied Behavioural Analysis, neuroscience and psychiatry. Being a mixture of engineer/strategy consultant/PR consultant and aspiring entrepreneur I often struggle with spelling, let alone remembering what all the acronyms mean.  In this case, I will make an exception.  I will term it Autistic Stress Syndrome (ASS) and define it as when a sufferer loses all, or part of, their rational objectivity and becomes obsessive, close minded and  perhaps judgemental themselves.  A professional suffering from the syndrome will be lovingly termed “a smart ass”.  There are of course very many well intentioned smart asses and indeed some of the most useful people you can know will be smart asses.
This blog is all about science.  To be a good scientist you have to rational and objective.  To be a great scientist you also need to challenge accepted wisdom, realize that you do not (yet) know everything and sometimes you might just have got it wrong.
In the field of managing/teaching children with autism there are several schools of thought, some of which overlap.  Here is a short list:-
1.    Applied Behavioural Analysis (ABA) / Lovaas / Verbal Behaviour (VB)
2.    Floor time / Greenspan
3.    Hannen
4.    Occupational Therapy (OT)
5.    Picture Exchange Communication System (PECS)
6.    Speech  & language Therapy (SLT)
7.    Structure, Positive, Empathy, Low arousal, Links (SPELL)
8.    TEACCH
It is striking is that in many cases a professional specialized in one of these areas will not even want to discuss there being any merit whatsoever in the others.  As with religion, if you advocate a mix and match approach, rather than accept a one size fits all approach you will be consigned to purgatory or even hell.
When it comes to the field of Complementary and Alternative Medicine (CAM) the religious fervour grows even stronger and science goes completely out of the window.
 From my own biased experience of behavioural intereventions, here is what matters:-
·         Earliest possible start of intervention
·         Consistency 24/7 among care givers / therapists
·        Superhuman effort to provide near constant, stimulating, one-to-one contact during waking   hours for as a many years as it takes
I looked into all methods and found that the choice of ABA/ VB was a no brainer.  VB is just an approach within ABA that prioritizes speech.  PECS is a communication system for non-verbal kids, that is based on the principals of ABA.   Before the child is verbal, Hannen and Floor time are very useful approaches to encourage interaction. SPELL and TEACCH have lots of good methods highlighting the need to have structure, employ visual cues etc.  If the speech therapist (SLT) can teach you and your non-verbal child PECS that would be great.  Motor skills and play skills are a key part of an ABA/VB programme; they are also part of Occupational Therapy.  The OT therapist is probably using ABA without even knowing it.