Jun 30

Conceptual Treatment Goals

Seeing the forest from the trees is sometimes a difficult task when everybody else is excitedly looking at the leaves.  Many therapists love to focus on the detail and so I am going to step back and look at the forest.  When you work with broad concepts you can develop new insightful approaches rather than fine tune existing approaches.  As de Bono would argue it allows us to break out from the slow linear treatment improvements we are currently engaged in.

When you see the forest clearly you can ask yourself the critical question – How would my current treatment strategy differ if I were to address the big conceptual issues?

I have broken the big picture into three standpoints: (1) neurological, (2) functional and (3) treatment goals.

1. A neurological perspective

The core issue with Autism Spectrum Disorder is that specialist regions of the brain are under or over connected to each other.

2. The triad of cognitive functional impairment:

1.   A stronger reliance on visual processing of information over verbal processing.

2.   Emotional processing  deficits arising from limbic system deficits

3.   Reduced capacity to abstract information.

 

3. Core treatment goals

Leading from the neurological perspective the treatment goals are to enhance brain plasticity in order to develop normal neuronal pathways and to restore brain specialisation.

Opportunities

With the exception of detoxification approaches almost all of our treatments for ASD are traditional cognitive behavioural techniques. Techniques that work well with neuro-typical brains where brain plasticity is not a major issue.  More effective treatments need to target restoring normal brain connectivity by increasing brain plasticity more directly.

With this in mind perhaps intensive ABA style learning should be coupled with approaches that increase brain plasticity such as pharmaceutics that enhance learning or vigorous exercise programs.  With this paradigm in mind the therapeutic approaches used with individuals who have suffered a stroke (cerebrovascular accidents) could be applied to ASD.  These techniques include brain stimulation such as deep repetitive transcranial magnetic stimulation.

The detailed focus on specific skill acquisition yields short-term results but perhaps they could achieve greater long-term gains if the skill acquisition was constructed around core treatment goals.  A pure behaviourist model seems to inadequately address the neurological goals.

Permanent link to this article: http://www.autismedge.com/archives/conceptual-treatment-goals/

Jun 22

Averaged abilities

I was fortunate enough to chat to Dr Murray Dyck about his paper “Are abilities abnormally interdependent in children with Autism?”  In summary the paper states that as neuro-typical kids grow up they start developing differentiated skills.  That is their sporting skills may not relate to how good they are in the classroom.  Dyck demonstrated that this is generally not the case for ASD kids.  If they are uncoordinated on the soccer pitch then they are probably not doing so well in the classroom.  Dyck felt that this supported the theory that the ASD brain has connection problems.  The over-connectivity from one specialised area to another specialist area essentially creates an unspecialised brain.

This raises some interesting issues for treatment if the over-wired brain is the core issue.  The key treatment question is how to strengthen normal pathways and decrease over-wired pathways.  Leading from this the treatment goals treatment goals are to enhance brain plasticity in order to develop normal neuronal pathways and to restore brain specialisation.

I would propose that vigorous and prolonged physical exercise may increase brain plasticity and assists in developing motor skill brain specialisation.  In a review of 18 studies, Dr Lang found that physical exercise decreased ASD symptoms.

With a plasticity and specialisation framework treatment goals should include both cognitive and physical components.

 

References

Dyck, M. J., Piek, J. P., Hay, D., Smith, L., & Hallmayer, J. (2006). Are abilities abnormally interdependent in children with autism? J Clin Child Adolesc Psychol, 35(1), 20-33. doi: 10.1207/s15374424jccp3501_3

Lang, R., Koegel, L. K., Ashbaugh, K., Regester, A., Ence, W., & Smith, W. Physical exercise and individuals with autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders, 4(4), 565-576. doi: 10.1016/j.rasd.2010.01.006

Permanent link to this article: http://www.autismedge.com/archives/averaged-abilities/

Jun 06

Autism revisited

In a previous life when I worked with senior managers to develop key performance indicators (KPI) for their business I was always stunned at how quickly they lurched for the easiest thing to measure, even though this may not accurately reflect the core of the business.  Cashin and Barker (2009) are two researchers who have basically come to the same conclusion about how people see Autism.  They argue that the current paradigm essentially grew out of the need to objectively measure observed behaviour.  This in itself is not a bad thing but it coloured the conceptualisation of what autism is.  Cashin and Barker argue that the traditional conceptualisation has been built on three elements.  Firstly, impaired verbal and non-verbal communication.  Secondly, social skills are deficient due to an inability to form a theory of mind.  Finally, behavioural inflexibility or an inability to cope with change.

The researchers argue that these are all true but is it the best way to conceptualise autism?  Instead they propose autism is best thought of in terms of the underlying issue; autism is a neurological variant in brain growth and so the triad of issues are best expressed as cognitive variants.  These variants are:

  1. A stronger reliance on visual processing of information over verbal processing.
  2. Inability to abstract information.  Put simply the ability to generalise from one case to the next is severely limited.
  3. An impaired theory of mind or an inability to regulate communication and social contact.

Chasin and Barker argue this conceptualisation will assist in developing better treatment strategies.  If we quickly return to the case of the KPI’s, it would not be uncommon for a manager to measure call centre service in terms of number of called taken by an operator.  The predictable outcome is that the operator offers less help, moves the caller on quicker and closes problem cases early to improve measures.  All bad for business.  So it is with autism measures.  By targeting the right element in the treatment the long term outcomes are addressed.

My only issue with this article is a theoretical one.

I would argue that theory of mind deficit is essentially  a result of a reduced capacity for the abstraction of social cues combined with incomplete limbic system processing.

I would therefore propose a variant on the Cashin and Barker model and suggest the triad of cognitive impairment is best viewed as:

  1. A stronger reliance on visual processing of information over verbal processing.
  2. Emotional processing  deficits arising from limbic system deficits
  3. Reduced capacity to abstract information.

When emotional processing and information abstraction is combined this goes a long way towards explaining theory of mind issues and incorporates poor emotional regulation.  If conceptualised in this form it can open up new approaches to tackle the issues more creatively.

 

Reference
Barker, P., Sci, D. A., & Cashin, A. (2009). The triad of impairment in autism revisited. Journal of Child and Adolescent Psychiatric Nursing, 22(4), 189. doi:10.1111/j.1744-6171.2009.00198.x

Permanent link to this article: http://www.autismedge.com/archives/autism-revisited/

May 26

Training teachers about Asperger’s

If you place your Asperger’s child in a neurotypical class you would assume that the teacher has been taught how to work with the inevitable issues associated with Asperger’s. Research indicates that this is not the case.

“Mainstream teachers receive little education… in relation to implementation of behavioural programs in relation or the features of autism or Asperger’s”  Sharon Hinton (2008)

Hinton and her co-researchers asked the obvious question:

If we train teachers will it make any difference to the kids’ behaviour?

The researchers trained a group of 58 teachers (77% female) in a six hour Asperger’s awareness and intervention program. Half of the group attended the training and the other half just monitored behavioural issues while they waited to attend the training. The results indicated trained teachers noticed behavioural problems dropped by roughly a quarter and children’s behaviours stayed the same for untrained teachers. The key message is that you can expect a significant and sizeable reduction in your Asperger’s child’s behavioural problems if your teacher has been properly trained.

So why not ask your child’s teacher:

Have you trained in behavioural management of Asperger’s syndrome?

Reference:
Sheffield, J., Sofronoff, K., & Hinton, S. (2008). Training teachers to manage students with asperger’s syndrome in an inclusive classroom setting. Australian Educational and Developmental Psychologist, the, 25(2), 34-48.

Permanent link to this article: http://www.autismedge.com/archives/training-teachers-about-asperger%e2%80%99s/

May 05

A mother’s diet remedy and alcohol case study

A case study is where one or a handful of people are intensely investigated and the facts of the case are reported.  Case study research is both good and bad.  It is good because it (1) delves deep into the complexity of one individual and (2) it can be an example of something that occurs more widely in the population.  The downside is that can (1) be unrepresentative or misleading and (2) makes it difficult to draw conclusions about the implication for other people.

A recent Spanish case study published in 2011 by Juan Garcia and others is an example of what is both good and bad about case study research in ASD.  Garcia documented the case of a mother of an ASD child who (1) consumed 1200mg of horsetail (Equisetum arvense), a herbal remedy that aids in weight loss one year prior to conception and (2) consumed 20g-40g of ethanol or 2-3 standard drinks per day for the first 9 days after conception and then 1 standard drink per day for a further 2 weeks and then stopped consumption during pregnancy.

The combination of the herbal remedy and the alcohol resulted in a measurable vitamin B deficiency.  In addition, the consumption of alcohol during the early developmental stage resulted is known to have impacts on the embryos neuronal development.  To fix the vitamin B deficiency the mother was supplied with vitamin B supplements 9 weeks into the pregnancy.  If vitamin B deficiency was a contributor to ASD then this intervention proved inadequate.

Based on this information it would be relatively easy to conclude that the alcohol and the diet pills resulted in the birth of an ASD child.  The news media may jump to this conclusion and quickly report “a new link found to ASD”.  The results however are much more inconclusive.  If the case of vitamin B deficiency and alcohol was a clear determinate then why wouldn’t the children of alcoholics automatically have ASD?  It turns out that these children have foetal alcohol syndrome and although some features overlap this condition lacks the critical ASD features.

The bottom line

In summary this article is a clear warning that potential parents should get a full assessment before embarking on a pregnancy.  They need to eliminate alcohol and ensure vitamin B levels are correct before pregnancy starts.

 

References

http://www.jmedicalcasereports.com/content/5/1/129

Permanent link to this article: http://www.autismedge.com/archives/a-mother%e2%80%99s-diet-remedy-and-alcohol-case-study/

Apr 29

What’s that?

Approximately 50% of ASD children do not develop functional speech. Picture exchange systems have been developed that are effective in aiding communication. Using this approach the child learns to associate a particular request with a specific picture. For example, pointing at or handing over an image of a cup will indicate that the child requires a drink. A current drawback to picture systems is that they lack the ability to instigate direct questions. Questioning is a critical way for the child to socially engage others and to learn.

There is a typical acquisition pattern of questioning development that is found in neuro-typical children. This sequence is from (1) what, (2) where, (3) who, (4) why and (5) when. Researchers conducted a small study of three ASD children who successfully learnt to appropriately verbalise “What’s that?” when presented with toys hidden in a cloth bag.
The researchers used an image of a child pointing inquisitively on a card to act as the question. Using repetitive training with supportive verbal prompting (What’s that?) the children quickly mastered the use of the picture prompt. They were then able to transition from the picture to verbal prompting with the child eventually discontinuing the use of the picture for the questioning task.

The bottom line

If your ASD child is using a picture exchange system then work with the therapist to include questioning pictures.

Reference
Cheryl Ostryn, & Pamela S Wolfe. (2011). Teaching children with autism to ask “what’s that?” using a picture communication with vocal results. Infants and Young Children, 24(2), 174-192. doi:10.1097/IYC.0b013e31820d95ff

Permanent link to this article: http://www.autismedge.com/archives/whats-that/

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