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Friday 11 December 2015

Treatable ID and Some Autism







Vancouver is one of the most attractive cities I have visited.  It is home to BC Children’s Hospital and Dr Sylvia Stöckler-Ipsiroglu and Dr Clara van Karnebeek. Together they have produced a remarkably thorough website called Treatable-ID, which sets out information on 82 treatable forms of Intellectual Disability (ID), formerly known as Mental Retardation (MR).
  
This excellent resource was recently brought to my attention by a reader of this blog from Down Under, another place well worth visiting.  Thanks, Alexandria.



ID/MR and Autism

ID/MR is defined as having an IQ less than 70; this means the cognitively weakest 2.2% of the population.

Classic Autism, Autistic Disorder or what we might now also call Strict Definition Autism affects about 0.3% of the population.  It is likely that about half of this group would score <70 in an IQ test.  I do not suggest they take one.

It is clear that an overlap might exist between the causes of MR/ID and the cause of some Strict Definition Autism.

In earlier posts I have referred to improving cognitive function in autism using Bumetanide.  We even saw that it should also improve cognitive function in Down Syndrome.

I suggested that Diamox/ Acetazolamide, another diuretic, could also have a similar effect (via the AE3 cotransporter).  One reader of this blog, Agnieszka, has been sharing her use of Acetazolamide, in the comments on the previous post.

People with RASopathies often have autism and MR/ID.  There are potential RAS therapies, one of which is a cheap statin drug.

We saw how dendritic spine morphology could be modulated and how that could affect cognitive function.  PAK inhibitors can, in theory, achieve this.

So I am already sold on the idea of some cognitive dysfunction being treatable, but I thought I was in a minority of a few dozen. Apparently not.

A friend recently highlighted my suggested autism therapies to a leading Spanish Neurologist, who clearly thinks I am just dreaming.  What would he make of Sylvia and Clara, the BC Duo?  Too much medicinal marijuana, perhaps? 

Science is all about remaining open-minded.  This should also be true for Medicine, but very often it is not. Combine this with the reality that kids with ID/MR/autism are bottom of the list of most people's priorities and you will see why things do not change, unless YOU make the changes, for your n=1 at home. 




81 inborn errors of metabolism related to Intellectual Disability and amenable to therapy

The BC Duo have collated the data on 81 treatable forms of ID/MR.

Not surprisingly some of these 81 also lead to “autism”, so they must also be treatable.  Roger, one this blog’s followers, has at least one of these 81.

So I suggest that anyone interested in a type of autism with some degree of cognitive impairment takes a good look at their site.













These are the 81 inborn errors:-







Not to confuse Sylvia and Clara with the other dynamic duo, your kids may know, from DC, rather than BC.

With so many treatable forms of MR/ID/Autism out there, is it not a little strange that thorough metabolic testing and Whole Exome Sequencing (WES) are not standard procedures after diagnosis?

By the way, WES is only as good as its interpretation.  Even world leading centres can be very weak in this respect. Insist on receiving the extended report and check all the possibly dysfunctional genes yourself.  It is not so hard.







Monday 7 December 2015

One of Thousands Autism




Some occasional visitors of this blog ask why if one drug helps their case of autism, another can be ineffective.

Perhaps it would be much more helpful right at the start to diagnose people with “one of thousands autism”, then people might better understand their situation,  and plan their way forward.

Autism is not a biological diagnosis, it is just an observational diagnosis.

Some readers have suggested “sorry, we don’t know” would be the honest diagnosis.



Several hundred autism genes and still counting

Some of these 740 genes linked to autism are shown here:-



There are existing mouse models covering 192 individual genes that can cause “autism”.

There are 18 known individual chemicals that can induce ‘autism” in mice



You may wonder how come there is a thimerosal-induced mouse model, but it exists.



There are dozens of rescue models, where scientists can make a mouse have “autism” and then reverse it.




Autism as an Adaptive Response

Any combination of what will likely become at least a thousand genetic and environmental factors can lead to what gets termed “autism”.  Autism is just the result of the brain’s adaptive response to those factors.

Certainly there are common pathways and downstream nexuses, where unrelated dysfunctions converge.

So in the end there will be a manageable number of clusters where most people’s autism can be located.

The thousand autisms will not require a thousand different therapies.

Sooner or later it will be necessary to stop calling it autism and start diagnosing each person’s biological dysfunction.  Only then can you treat it properly.

The efforts of the late Lorna Wing (autism as a “spectrum disorder”, ASD) and Barons Cohen (autism is not a disorder, it’s a friendly “autistic spectrum condition”, ASC) have certainly served to dramatically widen the number of people diagnosed, and even now wanting to be diagnosed, but have made actually treating it, very much harder.

We should start with what Knut Wittkowski, from the previous post, called Strict Definition Autism.  Apply what doctors call triage, start with those where you can make the biggest impact;  minimize cognitive dysfunction (mental retardation), self-injury, aggression and epilepsy.

   
Your one in thousands Autism

If you took a representative sample of 2015 diagnosed children with “autism”, who would it contain?

The following is based on what appears in previous posts and is not supposed to be definitive.


·        The largest category is probably misdiagnosed autism 

This would include people who are naturally late at developing speech, some people better diagnosed as ADHD, some people with Mental Retardation / Intellectual Disability, people who were deaf during key developmental periods and even people brought up in a cold, stimulus free environment like a 1980/90s orphanage in Romania.  Recall Leo Kanner's refrigerator mother ideas.

Quasi-autistic patterns following severe early global privation. English and Romanian Adoptees (ERA)Study Team.



·        Metabolic disorders that are likely not caused by a single gene

The big one here is mitochondrial disease, often triggered by some environmental event, like oxidative stress or an inflammatory response.  This includes the group that had a viral infection and then regress into autism, usually before the age of five.

There are other metabolic disorders like, cerebral folate deficiency, that are substantially reversible.


·        Then comes the large number of single gene dysfunctions that lead to symptoms that often include autistic behaviors

These vary from reversible to treatable.  Some well-known and not so well known, examples are:-

·        Smith–Lemli–Opitz syndrome (also SLOS, or 7-dehydrocholesterol reductase deficiency) which is in effect low cholesterol

·        Biotinidase deficiency

·        X-linked creatine deficiency

·        Pitt Hopkins

·        Rett Syndrome

·        Fragile X

All the above can be identified by genetic testing, but often are not.

·        Then comes “Dysmaturational Syndrome” which is Tourette’s Syndrome with autism “recovery” by 6 years old


This group accounted for about 5% of diagnoses in a large Italian study.   They do maintain their tics, but the autism features just fade away.


Now we are heading to what the “experts” call “Idiopathic autism”, which is the “we really don’t know”, catch-all category.

This group I will split into hypo/hyperactive pro-growth signaling pathways, based on the clever recent suggestion of Subramanian et al, from Johns Hopkins, we saw in an earlier post.









·        Hyperactive pro-growth signaling pathways

This group includes the textbook classic autism, with accelerated (brain) growth.  They can be identified by some of the following:-

·        Noticeably big head (and brain), maybe just at birth and maybe even Chiari 1 brain hernia (caused by no space for the growing brain)

·        High birth weight and muscular tone as a one year year old

·        Subsequent large drop down the percentiles on growth charts.


·        Hypoactive pro-growth signaling pathways

This group is smaller than the Hyperactive pro-growth category, but is sufficiently large to make most autism clinical trial pretty useless.

In many ways this hypo group are the entire opposite the hyper group, and what is good for them, may well be the opposite of what is good for the others.

This group will have small brains and I presume will have low birth weight. 

This does not mean they will be small as adults.

The hypo/hyper active growth refers to what is happening as the fetus develops and in the first year or two after birth. 



Implications for Clinical Trials and Therapies

It really is not good enough to carry out clinical trials on people, based solely on a DSM behavioral diagnosis of autism.  They are almost doomed to fail and indeed they almost always have failed.

Identify sub-types of autism, based on biological markers and then make trials on one sub-type vs another sub-type.  Then we might actually learn much more.

Some interventions that work in one sub-group should actually aggravate the autism of other sub-groups.  This should be entirely expected.

Autism researchers need to wake up, read other people's research and properly plan their trials based on the entirety of what we already know.  It is not rocket science; that is actually far more complex.  Planning trips to Mars is far more complex than what most autism researchers get up to. 

If you are going to compare therapies with other autism Mums/Moms and Dads, first check that your sub-type of autism is vaguely similar to their sub-type.  Otherwise you may be wasting your time/money and possibly doing more harm than good.




Conclusion

After receiving a diagnosis of autism, ASD or PDD-NOS, I suggest you ask the specialist to be more specific and help find you a biological diagnosis, rather than the observational/behavioral one.

If they cannot give you, at least pointers towards, a biological diagnosis, perhaps they should not be diagnosing  autism? Or just admit “I do not read the autism literature and so I know little more than you; but I get well paid as an autism expert, regardless”.








Wednesday 2 December 2015

“Autism treatments proposed by clinical studies and human genetics are complementary” & the NSAID Ponstan as a Novel Autism Therapy





Today’s post was not my idea at all, it was the author of one of the papers who has drawn my attention to the subject.

Genetic studies are complicated and are not the sort of thing I would have chosen to read, let alone write about, before starting this blog. 



The optimal time to initiate pharmacological 
intervention in Autism?


However, much of the complex subject matter has now already been covered, step by step, in earlier posts. Regular readers should not feel put off.

It is perhaps easier to think about ion channel dysfunctions, or channelopathies.  Some of the key genetic dysfunctions produce these channelopathies.  There are many posts in this blog about channelopathies, partly because many therapies already exist to treat them.

Then we have the complex signaling pathways which are often the subject of cancer research, but we have seen that certain ones like RAS and PTEN are key to conditions like some autism and some MR/ID.

So it is not a big leap therefore to consider the findings of a statistical reassessment of the existing genome-wide association studies (GWAS).  As is often the case in medical science, it is the acronyms/abbreviations, like GWAS, that make it look more complex than it really is.

If you only ever read one paper about the genetics of autism, I suggest you make it this one.

Fortunately, the conclusion from the genetic study really fits nicely with the clinical studies reviewed on this blog and even my own first-hand experience of investigating and treating my n=1 case of autism.


Knut, the Biometrician

It was Knut who left a brief comment on this blog and, after a little digging, I was very surprised how much a statistician/biometrician could figure out about autism, from re-analyzing the existing genome-wide association studies (GWAS).

I think the Simons Foundation could save themselves a decade or two by giving him a call.



The Research

For those wanting the science-lite version, there is a short article reviewing the research in lay terms:-


Biostatistics provides clues to understanding autism: an interview with Dr Knut M. Wittkowski



“Hence, modulation of ion channels in children at the age of about 12 months, when the first symptoms of autism can be detected, may prevent progression to the more severe end of the spectrum.” .



The actual research paper is here:-

You may find it heavy going and I have highlighted some key parts.


A novel computational biostatistics approach implies impaired dephosphorylationof growth factor receptors as associated with severity of autism

  
“Despite evidence for a likely involvement of de novo and environmental or epigenetic risk factors, including maternal antibodies or stress during pregnancy  and paternal age, we contend that coding variations contribute substantially to the heritability of ASD and can be successfully detected and assembled into connected pathways with GWAS—if the experimental design, the primary outcome, the statistical methods used, and the decision rules applied were better targeted toward the particulars of non-randomized studies of common diseases.”


The data comes from the Autism Genome Project (AGP), and there are two sets of data AGPI and AGPPII.

The third data set is for Childhood Absence Epilepsy (CAE)

What I would call Classic Autism, others call severe autism or autistic disorder; Knut calls it Strict Definition Autism (SDA).  HFA is high functioning autism, much of which is Asperger’s Syndrome.



“Study design We aimed at risk factors specific to strict definition autism (SDA) by comparing case subpopulations meeting the definition of SDA and milder cases with ASD (excluding SDA), for which we here use the term ‘highfunctioning autism’ (HFA). To reduce variance, we included only subjects of European ancestry genotyped on the more frequently used platform in either stage. In AGP II, we also excluded female cases because of confounding between chip platform and disease severity. The total number of subjects included (m: male/f: female) was 547/98 (SDA) and 358/68 (HFA) in AGP I and 375 (SDA) and 201 (HFA) in AGP II.

Overall, the results (see Supplementary Figure 1 for a Manhattan plot) are highly consistent with previously proposed aspects of the etiology of ASD. The clusters of genes implicated in both of the independent stages (Figure 2a/b) consistently overlap with our published CAE results (Figure 2c), confirming the involvement of ion channels (top right) and signaling downstream of RAS (bottom left), with two noticeable additional gene clusters in ASD. Both stages implicate several genes involved in deactivation of growth factor (GF) receptors (Figure 2a/b, top left) as ASD-specific risk factors and chloride (Cl − ) signaling, either through Ca2+ activated Cl− channels









Click to enlarge the figure 




A new term is PTPR (protein tyrosine phosphatases receptor), just to confuse us it is also called RPTP.

Receptor Protein Tyrosine Phosphatases in Nervous System Development

 

For example, the receptor protein tyrosine phosphatases gamma (PTPRG) and zeta (PTPRZ) are expressed primarily in the nervous system and mediate cell adhesion and signaling events during development.

In an earlier post I highlighted the numerous dysfunctions in growth factors (GF) in autism.  Knut is highlighting here the effect of PTPR on growth factors.  Later it is suggested that this cascade of GF dysfunctions could be halted, pharmacologically if it was identified very early.  But, as Courchesne from UC San Diego noted, by the time people have been identified as having autism, around three years old, the accelerated brain growth has already run its course.

You would need to intervene around one year old.



Broad evidence for involvement of PTPRs One of the most striking observations is the involvement of at least five PTPRs in ASD (Figure 2, 10 o’clock position). PTPRs (Table 1e) regulate GF signaling through reversible protein tyrosine dephosphorylation.72 PTPRT (90th/20th, 8.57) was implicated in ASD by a deletion73 (Table S2 AU018704) and a somatic mutation










It was my post pondering the reasons for the positive effect of potassium supplementation that drew Knut’s attention to this blog.  Now we move on to Knut’s ideas on potassium and chloride channels.



K+ and Cl− ion channels as drug targets

Aside from PTPRs (Figure 2, 10 o’clock) as a risk factor for protracted GF signaling, our results suggest a second functional cluster of genes, involved in Cl− transport and signaling, as specific to ASD (Table 1f). In AGP I, the CaCCs ANO4 and ANO7 scored 1st and 70th, respectively. In AGP II, the lysosome membrane H+ /Cl- exchange transporter CLCN7 scored 21st, followed by CAMK2A, which regulates ion channels, including anoctamins82 (55th), and LRRC7 (densin-180), which regulates CAMK2A83 (Figure 2a/b, 2 o’clock). The role of the anoctamins in pathophysiology is not well understood, except that CaCC activity in some neurons is predicted to be excitatory84 and to have a role in neuropathic pain or nerve regeneration. More recently, CaCCs have also been suggested as involved in ‘neurite (re)growth’. Finally, we compared the HFA and SDA cases as separate groups against all parental controls in the larger AGP I population. Overall, the level of significance is lower and the enrichment is less pronounced, especially for the SDA cases (Supplementary Figure 9), as expected when cases and some controls are related. For the HFA cases (Figure 4, and Supplementary Figure 8), however, a second anoctamin, ANO2, located on the other arm of chromosome 12, competes with ANO4 (Figure 1, left), for the most significant gene among the result. Hence, drugs targeting anoctamins might have broader benefits for the treatment of ASD than in preventing progression to more severe forms of autism. ANO2 and ANO6 are associated with panic disorder and major depressive disorder, respectively. ANO3, ANO4, ANO8 and ANO10, but not ANO1, are also expressed in neuronal tissue.86 As ‘druggable channels’, anoctamins ‘may be ideal pharmacological targets to control physiological function or to correct defects in diseases’.  Few drugs, however, target individual anoctamins or even exclusively CaCCs. Cl− channel blockers such as fenamates, for instance, may decrease neuronal excitability primarily by activating Ca2+-dependent outward rectifying K+ channels.



Here is a follow-up paper with consideration of the possible next steps.





Gene gene environment behavior development interaction at the core of autism:

Here, we combine a recent wide-locus approach with novel decision strategies fine-tuned to GWAS. With these methodological advances, mechanistically related clusters of genes and novel treatment options, including prevention of more severe forms of ASD, can now be suggested from studies of a few hundred narrowly defined cases only.
(Nonsyndromic) autism starts with largely unknown prenatal events (: age, : virus/stress ...)
• Mutations in growth factor regulators (PTPRs) lead to neuronal overgrowth (brain sizes).
• Mutations in K+/Cl− channels cause Ca2+ mediated over excitation of neurons (“intense world”).
• Stressful environments (urbanization) contribute to epistatic interaction (increasing prevalence).
• This GGE interaction causes “migraine-like” experiences during the “stranger anxiety” period where children learn verbal/social skills, leading to behavioral maladaptation (“tune-out”).
The lack of verbal/social stimuli causes “patches of disorganization” (Stoner 2014, NEJM) as a form of developmental maladaptation when underutilized brain areas are permanently “pruned”. The PTPRs point to a short window of opportunity (WoO) for pharmacological intervention:
• Treatment has to begin as early as possible, while neurons are still growing (12 months of age. Broad support for the proposed unifying etiology and the 2nd year of life as the WoO:
• Regression (“loss of language”) seen in some children >12 mos of age.
• “Patches of disorganization” in >2 yr old brains.
• Romanian orphans developed “quasi-autism” when placed into foster care at >24 mos of age. 
• Hearing impairment leading to intellectual disability when diagnosed >24 mos of age.

 A rational drug target: treating either of two epistatic risk factors suffices:
• Blocking growth factors (Gleevac, ...) is unacceptable in children merely at risk of ASD.
• Ion channel modulators have been used in small children for arthritis and seizures.








Here is a response to Knut’s first paper from a professor at the UCLA medical school who suggests the combination of the specific NSAID and bumetanide. 
The professor would better understand the mechanism of action of bumetanide in autism if he read Ben Ari’s research more thoroughly, or even this blog.
  
  
The article by Wittkowski et al.1 reports results of human genetic studies that suggest that a nonsteroidal anti-inflammatory drug (NSAID) given for a few months from the time of the first symptoms might help some children who are at risk of developing more severe forms of atrial septal defect.
While the authors mention the recent article by Lemonnier et al.,2 which reported that a clinical study of the diuretic Bumetanide was partially effective in children with milder forms of autism, they seem to have overlooked that these two treatments may well be complementary, leading to sequential interventions, each targeting specific risks related to well-defined stages in the development of brain and social interactions.
Since abnormal brain development in autistic disorder goes through different stages from infancy to childhood, targeting different developmental stages with different treatment interventions may well be necessary to foster continued normalization of brain growth.
Bumetanide is known to block inward chloride transporters, yet the relation of this mechanism to the etiology of autism is unknown. Wittkowski et al. identified mutations in calcium-activated (outward) chloride channels as associated with autistic disorder, suggesting loss-of-function mutations in anoctamins as one of the risk factors for autism. This provides a testable hypothesis for the mechanism by which Bumetanide alleviates symptoms of autism. For example, mouse models could test whether Bumetanide ameliorates a stress-induced phenotype caused by a knockout/down in ANO2 and/or ANO4.
A second cluster of genes identified receptor protein tyrosine phosphatases, which downregulate growth factors. These findings support the notion that successful treatment should start as early as possible,3 while neuronal development still takes place.
The rationale for combining these two treatments rests on the fact that Bumetanide is contraindicated in infancy because it is known to interfere with neuronal development when used long term. In contrast, the NSAID proposed in the second study has been given for decades to children with juvenile idiopathic arthritis from 6 months of age on, with no adverse effects on brain development. It is known to modulate chloride channels (see above) as well as potassium channels.4
In conclusion, I wish to extend their hypothesis based on the synergy of the two treatment approaches: (1) early treatment with NSAID can reduce early maladaptive behaviors that cause abnormal pruning of neurons in the cortical areas; (2) these children could subsequently benefit from Bumetanide, which would compensate for the primary ion channel defect, but could not reverse the secondary effect of abnormal pruning.
This hypothesis allows for a novel two-way interaction between behavior and molecular events. Traditionally, one assumes that molecular events determine behavior. The new hypothesis, based on human genetics, also allows for symptoms (such as the absence of social interactions, delayed speech onset and language development) during certain sensitive periods to change molecular events (pruning of neurons in areas required for normal development).



Therapeutic implications from the genetic analysis

Some of the therapies that Knut is proposing, based on the genetic analysis, have already been reviewed in this blog.  Some have not.  A few therapeutic ideas in this blog actually target genes Knut has identified, but not highlighted a therapy.

I will just review the drugs and genes that the above study highlights.


Benzodiazepines

Low dose clonazepam fits in this category.  We have the work of Professor Catterall to support its use.  At higher doses, benzodiazepines have different effects but use is associated with various troubling side effects.


Bumetanide

Bumetanide is at the core of my suggested therapy for classic autism or what Knut calls SDA (strict definition autism).  We have Ben-Ari to thank for this



Fenamates (ANO 2/4/7 & KCNMA1)

Here Knut is trying to target the ion channels expressed by the genes ANO 2/4/7 & KCNMA1. 

·        ANO 2/4/7 are calcium activated chloride channels. (CACCs)


·        KCNMA1 is a calcium activated potassium channel.  KCNMA1 encodes the ion channel KCa1.1, otherwise known as BK (big potassium).  This was the subject of post that I never got round to publishing.
  
Fenamates are an important group of clinically used non-steroidal anti-inflammatory drugs (NSAIDs), but they have other effects beyond being anti-inflammatory.  They act as CaCC inhibitors and also stimulate BKCa channel activity.
  

Fenamates stimulate BKCachannel osteoblast-like MG-63 cells activity in the human.


 The fenamates can stimulate BKCa channel activity in a manner that seems to be independent of the action of these drugs on the prostaglandin pathway”


Molecular and functional significance of Ca2+-activated Cl− channels in pulmonary arterial smooth muscle



Of this “first generation” of CaCC inhibitors, NFA (a fenamate called niflumic acid)  is the most potent blocker of these channels and the compound most frequently used to investigate the physiological role of CaCCs”



Choice of Fenamate
There are several fenamate-type NSAIDs, but one is a very well used generic drug, Mefenamic acid known as Ponstan, Ponalar, Ponstyl, Ponstel and other generic names.  It is even available as a syrup for children.
 It is not available in all countries.



Gabapentin


Gabapentin is used primarily to treat seizures and neuropathic pain. It is also commonly prescribed for many off-label uses, such as treatment of anxiety disorders, insomnia, and bipolar disorder.

Some people with autism are prescribed Gabapentin.  Some people suffer side effects and others do not.

If you have a dysfunction of voltage operated calcium channels, Gabapentin should help.



Memantine

This is all about modifying NMDA receptors.  Memantine is but one method.




Minocycline

Minocycline is an antibiotic with several little known extra properties.  In autism, we looked at its ability to reduce microglial activation and so improve autism.  A clinical trial showed that it did not help autism.

Minocycline also affects MMP-9.  MMP-9 is an enzyme found to be associated with numerous pathological processes, including cancer, immunologic and cardiovascular diseases.

High MMP-9 activity levels in fragile X syndrome are lowered by minocycline.


 “ The results of this study suggest that, in humans, activity levels of MMP-9 are lowered by minocycline and that, in some cases, changes in MMP-9 activity are positively associated with improvement based on clinical measures.


So if you are treating a case of Fragile-X, or partial "Fragile-X-like" autism, better take note.



Rapamycin

Rapamycin and mTOR was the subject of the following post:

mTOR – Indirect inhibition, the Holy Grail for Life Extension and Perhaps Some Autism



Both too much and too little mTOR can occur in autism.




Conclusion

My conclusion is probably different to yours.

For me, it seems that all the pieces really are fitting together and so this blog on the cause and treatment of classic autism will eventually cover the current scientific knowledge, in its entirety.  No complex areas are off limits, because in the end they are not as complex as they seem, when you lift the veil of jargon and acronyms.

From the all-important therapeutic perspective, new insights from today’s post are:-

·        Those with a dysfunction of voltage operated calcium channels might want to give Gabapentin (Neurontin) a try.

·        The fenamate-type NSAID mefenamic acid,  widely known as Ponstan, really should be tested, either at home, or in a clinical trial.

This statistical analysis is based on “all autism”, so any one person would be highly unlikely to have all the mentioned dysfunctions.  These are the most common genetic dysfunctions and many can both hypo and hyper, as in the case of NMDA dysfunctions and indeed mTOR. 

In Knut’s chart, I would add a green line pointing to RAS and PTEN with the word Atorvastatin.  Baclofen would point to the growth factors.  Verapamil would point in multiple places.

The motto of University of Tübingen, where Knut originally comes from, is Attempto !  The Latin for "I dare".

This might be a useful motto for readers of this blog, and also a good tittle for a book on treating autism.