Wednesday, December 30, 2009

Overlap in Sensory, ADHD and Autism

I am doing tons of reading right now to prepare for a class on self-regulation I'm giving in April.

Current literature is looking at ways to separate out ADHD from Autism and to identify sensory characteristics of each. This is a technical post, but if you read lightly, you can find some interesting tidbits.

There is a technical term: nosology that refers to the hieracrchy of diagnoses. The new nosology for sensory processing disorder (SPD) has several layers. There are 3 types of SPD: Sensory Modulation, Sensory Motor Issues (motor planning and posture) and Sensory Discrimination. Here is a quick look at it. See the Miller article referenced below for details.

Sensory Processing Disorder (SPD):
1. Sensory Modulation
------Over response
------Under Response
------Seeking/ Craving
2. Sensory Motor Issues
-----Dispraxia (Motor Planning)
-----Posture Disorder
3. Sensory Discrimination
-----Auditory. touch, vestibular, proprioception, etc.

The reason I taxed you with the nosology is to highlight the modulation piece. Modulation from sensory causes appears similar to ADHD, but ADHD is not caused by sensory issues. An assessment such as the Sensory Profile can tease out which is which.

ADHD as you probably know has characteristics of impulsivity, poor attention, hyperactivity, etc. that can also be found in SPD. Typically, ADHD is treated with therapies, patience, etc, etc or meds. SPD is treated with sensory therapy. Completely different.

Now we get into autism. What they are finding is that 42-88% of children with autism have sensory processing disorder. Some also have a sensory modulation disorder. 50%-80% of children with autism have ADHD. However (back to nosology) ADHD in the DSM-IV (Psychiatric Manual) is a level 2 disorder. Autism is a level 1 disorder and takes precedence. So technically, if a child has autism, they cannot be also diagnosed with ADHD (a disservice in my opinion).

Children with ADHD have communication and social issues, but they are not the same sort of issues as those found in autism. Hartley & Darryn (2009) pose the question "Is high functioning autism distinguishable from ADHD and from anxiety in older children?" The short answer is yes, but they share a number of seemingly similar characteristics in the areas of communication skills, social skills, and repetitive behaviors. Lots of overlap to sort through with children who are neurotypically different than their peers.

1. Miller, L., Anzalone, M., Lane, S., Cermak, S., & Osten, E. (2007). Concept evolution in sensory integration: A proposed nosology for diagnosis. American Journal of Occupational Therapy , 61, 135-140.
2. Hartley, S., & Darryn, M. S. (2009). Which DSM-IV-TR criteria best differentiate high-functioning autism spectrum disorder from ADHD and anxiety disorders in older children? Autism , 13, 485-509.

Monday, November 16, 2009

Weighing in on Asperger's

With the DSM-V powers-that-be thinking about removing the Asperger's diagnosis from the DSM next edition, it's time for all of us to weigh in our two cents. Here's mine.

The Asperger label is critical to the people who are diagnosed as such. With the label, researchers can more readily target them as a group for study and treatment. Employers see the label and understand the constraints. Therapists see the label and can get right to work on appropriate therapies.

Let's look at it. There are 3 categories of autism that make a difference to me when I treat children:

- True autism with it's social and communication issues.

- PDD-NOS - a form of high functioning autism in which children can get rid of many, many symptoms with multiple therapies to the degree that you can no longer tell that it's autism.

- Asperger's - the other form of high functioning autism with good language skills, the desire to interact with others and a lack of understanding social rules (making interaction very challenging).

The authors of the DSM complain that it is difficult to distinguish Asperger's from autism and that that is the reason that the diagnosis can be removed. I disagree. A child with Asperger's has very good language skills (and in fact can be a chatterbox). Also, he/she lacks social skills in a different way than a child with typical autism does. The child with autism does not typically care to have social interaction and is content in his/her world. The child with Asperger's desperately wants friends but is often clueless on how to get and keep them.

These are easily observed differences. I say leave Asperger's in. And by the way, the same set of arguments are going to apply to PDD-NOS. Leave it in, too.

On another day, I'll talk about the impact of sensory, modulation, ADHD and obsession/compulsion comorbidity.

Monday, November 2, 2009

NAC National Autism Report

I am still coming to grips with the National Autism Center's 2009 report on effective treatments for autism. The group is very influential, but it is a self-interest group made up primarily of behavior analysts. The executive director, Susan M. Wilczynski, Ph.D., BCBA, is a certified behavior analyst (think ABA-style therapies), as are the bulk of the project team that designed the study and reviewed the research articles. I question the impartiality of this study.

Here is my main beef: Articles were only considered for review if they were specifically about autism. From an OT perspective, that leaves out the bulk of our research since the research we do is broad and includes children with many disorders. Our research typically works with specific symptoms rather than patient groups. So when the NAC study looked for effective treatments for motor skills, they did not include the considerable wealth of research performed by OTs and PTs. In fact, the study's outcome did not see the need for OT intervention. Somebody missed something, I think.

And there is a parallel case for considering the area of sensory processing research. There are many, many studies in this area. If you look at my last blog entry, you will see that children with ADHD and anxiety have many of the same symptoms as children with autism. So again, our research covers, as it must, broad groups of children.

Now ABA treatments, on the other hand, were all developed specifically for children with autism, and so the study appears to be biased in favor of this treatment research. But unfortunately other psychology-based treatments such as Floortime and P.L.A.Y. (also developed for children with autism) did not make it through the study review process in as good a standing. Their treatments were found to be "emerging". I hope that this is not yet another case of "convenient" study design.

High Func. Autism vs ADHD vs Anxiety

Research by Hartley & Sikora in a recent issue of Autism Magazine:

Can you distinguish high functioning autism from ADHD and
from anxiety in older children? Here is a list of the DSM criteria
for autism along with the results from a study that tested for each
criteria in children with autism, ADHD and anxiety. It turns out
that many of the problem areas are shared by the three groups.
Check out the list below. (Note: DSM does not allow duel diagnoses
such as ASD and ADHD or ASD and anxiety.)

ADHD Anxiety

Delay/lack of speech Yes Yes
Impaired conversational ability No
Stereotyped/repetitive language Yes Yes
Lack of make-believe play Yes Yes
Social Behaviors

Non-verbal social behavior No No
Failure to develop peer relationships No No
Lack of seeking to share Yes Yes
Lack of social & emotional reciprocity No No
Restricted/repetitive/stereotyped patterns

Stereotyped/restrictive patterns of interest No
Non-functional routine or ritual
Stereotyped or repetitive motor mannerisms
Preoccupation with parts of objects Yes Yes

Telling the difference: ASD, ADHD and Anxiety

Research by Hartley & Sikora in a recent issue of Autism Magazine:

Can you distinguish high functioning autism from ADHD and
from anxiety in older children? Here is a list of the DSM criteria
for autism along with the results from a study that tested for each
criteria in children with autism, ADHD and anxiety. It turns out
that many of the problem areas are shared by the three groups.
Check out the list below. (Note: DSM does not allow duel diagnosies
such as ASD and ADHD or ASD and anxiety.)

ADHD Anxiety

Delay/lack of speech Yes Yes
Impaired conversational ability No
Stereotyped/repetitive language Yes Yes
Lack of make-believe play Yes Yes
Social Behaviors

Non-verbal social behavior No No
Failure to develop peer relationships No No
Lack of seeking to share Yes Yes
Lack of social & emotional reciprocity No No
Restricted/repetitive/stereotyped patterns

Stereotyped/restrictive patterns of interest No
Non-functional routine or ritual
Stereotyped or repetitive motor mannerisms
Preoccupation with parts of objects Yes Yes

Thursday, October 22, 2009

Match, Repeat and Emote

This past summer I attended a wonderful workshop by James McDonald, PhD. His latest book is Communicating Partners and it demonstrates his technique of how to increase communication skills in non-verbal or lo-verbal children. The gist of his method is to engage the child in an activity by imitating the child's sounds and gestures and then adding meaningful words and phrases about the activity itself. The example of an activity that he uses is to rock a sleeping doll in it's cradle. The outcomes that Dr. MacDonald has experienced for the past 30 years is true speech and social interaction from the child.

The clinic I work at (Building Bridges Therapy Center, in Plymouth, MI) sponsored Dr. MacDonald and encouraged our parents to take part in family sessions with him while he was in residence. One of my non-verbal clients, Jack, was part of this, and we began to see increased interaction. More than that, we saw a way "in" to a highly challenged child.

As the weeks went by, goals came and went, and we therapists sometimes forgot to use the match and repeat method. But Jack is so challenging, that I continued to make this therapy my number one form of treatment for him.

Jack will answer to his name and display joint attention for a few seconds. He can speak multiple words at a time (not necessarily sentences), but is mostly lost in his own experience. His primary interest is in stimming with his favorite object. It is possible to get Jack's attention by putting him into a Belkin suit and demanding his presence. With a great deal of pressure and persistence he can be made to work in this mode. However, he does not like it, and he screams and whines to make sure that the therapist knows this.

Right after the workshop with Dr. MacDonald, I tried to hone my skills in the new practice with Jack. He responded fairly well, but he still screamed his ear-splitting screams, making it all a lot of work. The resistance I received was so strong as to make me question continuing this approach.

Then I tried something a little different. Jack came in and went to our big, green bench swing near the mirror. I gently pushed him back and forth. He spoke some words, I repeated. We made faces, we even had an amazing eight "sentence" interchange. After that, we kept swinging, while I said words like "happy", which he repeated with a smile. This lasted 8-10 minutes, then he was done and ready to run around the clinic aimlessly like a wild guy.

I took his hand and we went to a cabinet to get a worksheet. He grabbed one of my card decks. We sat at the table, I took the deck and placed it aside, telling him it was time to work. (I don't typically take things from kids.) He protested, tried to grab it back and looked like he was going to have a meltdown. Without even thinking about it, I held him tightly, rocked him and then began to emote for him. I very calmly said what I thought he was thinking. "I want the cards. What do you think you are doing? Gimme those. Who do you think you are? Those are my cards. I am very unhappy about this." and on and on. We stayed this way for 4-5 minutes with me holding him. He squirmed and protested but did not melt.

The remainder of the session went much the same with breaks every now and then for him to play freely. At the end, he went out to his mother, protesting (but not screaming) to her. She had a favorite transition object (we had agreed on) to catch his attention. We got his shoes on and got him out the door. The transition object was a God-send. He had worked hard enough. No one wanted a meltdown at this point.

It was a very difficult session, I was going by the seat of my pants the entire way. But it felt like a success for both of Jack and I. We had conversations, shared our feelings and played. There were no meltdowns. That's a lot for a feisty, non-verbal guy who is buried inside.

(Followup one week later: Jack's mother reported that he had had a very good week with behavior. His session this week was memorable in that he was happy the entire time. No melt downs, no transition issues. Let's see if this is a fluke or it continues to hold...)

Monday, October 19, 2009

ADHD Overfast Response to Tapping

When I have children with ADHD get started on an IM program, I automatically adjust the tempo to 63 beats per minute rahter than the standard tempo of 54. Why, they almost always over-anticipate the beat with the standard tempo and so miss clapping or tapping in rhythm. But when I change it to 63, most find their sweet spot and can perform admirably. IM's recently released bibliograpy of temporal studies points to research that came to the same conclusion. Check it out. That paper and others are found at this site. Here is the citation:

Hilla Ben-Pazi, Ruth S. Shalev, Varda Gross-Tsur, and Hagai Bergman. (2006). Age and medication effects on rhythmic responses in ADHD: Possible oscillatory mechanisms? Neuropsychologia 44: 412–416

This question came up for me recently. Does ADHD meds suppress timing? In this case, the meds are Adderall. I see a 6 year old girl who had excellent scores on IM prior to starting Adderall. Afterward, her score fell into the severely deficit range. Interesting. The above study found that there was no difference in timing skills for those on Methylphenidate (i.e. ritalin). I'd love to see a study on Adderall. Adderall is a combination fo amphetamine and dextroamphetamine. It has a known side effect of appetite suppression.

Sunday, September 13, 2009

Timing Literature Review Source

Improved brain timing is at the heart of most of the big breakthroughs for clients in my practice. I've tried to keep up with the literature, but it is vast and complex. Now Kevin McGrew and Amy Vega have put together a review of theory, diagnosis and treatment research. It is available here in PDF format. There are additional appendices for those who wish to delve deep into the literature. The appendices can be accessed via Kevin McGrew's August 14th blog. In that blog, he gives an interesting introduction to the paper. Check it out.

More on Calming Rhythms

I was recently asked about using Calming Rhythms by REI Institute in the school setting, so I revisited the REI Inst. site to see what is new. Jeff Strong has updated his web site and formalized his program offerings. He offeres customized programs for children, training for therapists and non-customized CDs that can be used for calming.

The REI program is noteworthy because it does not require headphones. The thearpy is less for auditory processing than for rhythm and structure. OTs and SLPs that have clients using the program say that the children are more grounded, calmer and happier. The customized CDs been used for many children with autism and ADHD.

A therapist can get trained for $275. Parents can have a 10 week custom program created (and edited, if necessary) for their child for $495. Not bad. I would try the custom program on children from whom the traditional sound therapy does not work (due to head phones).

As for non-customized solutions: The "Calming Rhythms" CD is a powerful recording that I found to work for some children and to be counter-productive for others. It is not a one-size-fits-all solution. REI Institute claims that it can be used with groups, but from what I've seen, it is not appropriate for the classroom. In any event, at $35, it may be worth a try. Here is my earlier blog entry on the Calming Rhythms CD.

Tuesday, July 14, 2009

Finding Words for the First TIme

George is a third grader with special needs. He says just a few words: yes, no, mad - simple words. However, he reads, writes and spells. He is in love with art history and can spell some very long words correctly. His mother was concerned about his fine motor skills and behaviors. He had had OT services in the past. She had purchased a listening therapy, but he had refused to listen to it. George listened to the Early Mozart CD (therapeutic Listening) in my office, and so we decided to try him on it to help with behaviors.

As part of the fine motor therapy, we decided to add into the mix a little Interactive Metronome (IM). The IM was tricky. George became rigid. He had no rhythm of his own, and was reluctant to do hand-over-hand clapping with me. Desperate to engage him, I began to make faces at him in a mirror placed behind the IM unit. He made faces back at me, and then we continued for 200-300 repetitions of IM (about 5-6 minutes).

The next week, we tried it again. But before we had gotten very far, George burst out with a littany of art history names. I looked at his mother who had wide eyes. This was a first. The following week, his mother gave a report. After they had gotten home that day, he pointed to all of the things in the living room and named them. He had never done that before. He was now speaking 2 word sentences. Needless to say, we continued with IM during that session. Before he left, he spoke a 3 word sentence: noun, verb, and adjective. Wow.

I am used to seeing great results from IM and slower but great results from Therapeutic Listening. This one blew me away.

Wednesday, May 6, 2009

12 year old boys with autism

Fortunately, I like adolescent boys with autism, because I see quite a few of them. In fact, I really like them. They see that they have some catching up to do personally and socially and suddenly they care (just like their typical peers) about bathing, dressing and getting it right. So I get compliance from them and they, in turn, make gains. One of my guys is willingly learning to fold towels and make his bed (honest!), another is trying new foods and weaning himself off of the "white foods" diet, another is working hard to keep up in a private school where he tries to fit in. I've written about all of these (and a few other) guys before, but they never cease to amaze me.

Recently, I started one boy on Somanos CDs. He had been through Therapeutic Listening as a child, and completed an IM program this past year. His dad told me the other day that his YMCA swim instructors want to know what happened to him. Suddenly, he is swimming like a champ, and has good form, too. I told dad it was the Samonas. In particular, Carulli. This same boy (who was a true couch potato just a few months ago) is now dribbling a basketball all around the house. His father is amazed at this, and is installing a hoop in the yard.

Then there is the other 12 year old, who only pretended to listen to his Therapeutic Listening CDs. In fact, he turned the CD player off within seconds of putting the headphones on. I had asked dad, "How is he doing". Dad said, "Well, we can see some changes, but it's subtle. " Subtle indeed, a few seconds of listening makes for very subtle changes. Mom caught him out. The boy was chagrined, but took it well. He started over with his listening program about 6 weeks ago. Last week he told me that his emotions felt a lot calmer, and that his aggressiveness (a problem for him) was going away. Not so subtle any more.

Finally, there is the boy who acted like his body weighed a ton. He just drooped to the floor when asked to stand. He is now proud of his strength and shows off exercises that he can perform.

It's hard not to like these guys.

Sunday, May 3, 2009

Autism and IM

I found a new case study about IM and autism. Here is the link. The 12 year old girl in this study had 25 sessions of IM over 9 weeks. Her results were very dramatic.

Friday, May 1, 2009

Food Chaining

I went to the Food Chaining workshop in Chicago last weekend put on by Cheryl Fraker and colleagues. She uses a fairly simple method of expanding a child's diet by slowly increasing the number of flavors and textures that the child will accept.

There are a number of rules for therapists and parents to follow.

1. All meals (3 meals and 2-3 snacks) are scheduled and limited. 15 minutes for a snack and 20-30 minutes for a meal.
2. Children are fed foods that they like along with the new foods, so there is always something "good" on the plate.
3. New foods are chosen based on a rating system.
4. The child rates new foods on a 1 to 10 scale going from "love it" to "I gagged".
5. Force feeding is not allowed. The child picks up the food and puts it in her mouth.
6. If a child acts out and does not eat, then she must stay in the room until mealtime is over. Then she is not offered food again until the next meal.

It's a reasonable arrangement. The choice of which new foods to try is determined in a fairly simple manner - but I won't try to repeat it here in this small blog entry, you can get their "Food Chaining" book and read about it.

The book and the workshop also cover food allergies, and medical issues related to feeding and nutrition.

Tuesday, January 27, 2009

Cocaine - Prenatal Exposure

A New York Times story, "'Crack Babies': An Epidemic That Didn't Happen" (January 27, 2009) gives good news on this topic. Children ages 4 - 13 who had prenatal exposure to cocaine have recovered from initial slow growth (both body and brain) and show no statistically significant difference in IQ. As a group, they are more likely to have decreased visual attention and executive function. They also have an increased frequency of defiant behavior and poor conduct. However, their symptoms are so subtle as to make it impossible to pick them out of a group of typical children. It appears that prenatal exposure to cocaine is similar in effect to that of tobacco, and thankfully, not at all similar to the effect of alcohol.

Eating Dirt

There is one less worry for parents - especially parents of children who lick or eat everything in sight (pica).

Jane Brody's New York Times' column today reviews the case for ingesting dirt. Children who run barefoot in the dirt, and eat with dirt on their hands are less likely to develop allergies and asthma. Children who are exposed to farm animals (or to household pets) with worms are less likely to get inflammatory bowel, Crohn's diseases and other autoimmune diseases. This is not to say that we should not wash our hand after using the toilet. We should. But just plain soap and water, please.

Dr. Brody asked immunologist, Dr. David Elliott, about intestinal worms. "There are very few diseases that people get from worms", he said. In fact, in Argentina, persons with Multiple Sclerosis who were infected with human whipworm had fewer recursions and with decreased severity. And pig whipworms, which stay for just a short time in the human intestinal tract, are beneficial for treating IBS, Crohn's and ulcerative colitis.

More reading: "Why Dirt is Good", Mary Ruebush, (Kaplan).

Sunday, January 25, 2009

Winter Depression and Low Dose Melatonin

Over the Counter Treatment for Seasonal Affective Disorder

I published this on my Brain-TuneUps blog, and am duplicating it here.

The short story: Low daily doses of liquid melatonin taken every day for 4 weeks once SAD has set in, can lift the mood. A low dose of melatonin - .3 mg - can be obtained by using small amounts of liquid melatonin. The time of day it is taken is important. For most people it is in the afternoon. For some (30%) it should be taken in the morning. (Per research (2) cited below)

Melatonin is available over the counter, but one should consult a doctor regarding usage.

Long Story: I live in a gray winter climate. Last week, I felt SAD creep into my brain. I used Natrol melatonin 1 mg liquid purchased from my local health food store. The dropper that came with my bottle holds .25 mg. of melatonin. I put the drops into a glass of water and drank it slowly during two hours in the afternoon. I noticed a positive effect in 24 hours and continued to see improvements over the next few days. I feel 85% back to normal. Light therapy in the morning would probably take care of the remnants of grogginess. I plan to continue until the end of February when daylight returns here and I am more active outside.

A running theory of the cause of seasonal affective disorder (SAD) or winter depression, is that a person's circadian rhythms are out of sync. NIHM defines this: "A person's rhythms are synchronized when the interval between the time the pineal gland begins secreting melatonin and the middle of sleep is about 6 hours. (1)" There are a number of therapies aimed at correcting the problem including lights, exercise, anti-depressants and melatonin. (See the Wikipedia entry.)

The synchronization can be off in two ways: - a longer-than or a shorter-than 6 hour interval. A study by Lewy, et al (2), showed that subjects who took low dosages of melatonin every day for 4 weeks found an improvement in mood. The dosage was as follows: for those who's interval is less than 6 hours, .3 mg in the afternoon. For those with a longer than 6 hour interval, .3 mg in the morning. If you have to guess which you are, the odds from the study favor the short interval (71% to 29%). The study gave 2 small doses adding up to .3 mg in 2 hours.

Melatonin is available over the counter, but generally in high dose formulations. The study used capsule formulation. There are liquid forms of melatonin available in some health food stores. (Again, I found Natrol 1 mg, and adjusted the amount.)

Both articles cited are available on line.

1. April 2006 article from the National Institute of Mental Health, "Properly Timed Light, Melatonin Lift Winter Depression by Syncing Rhythms".

2. Lewy AJ, Lefler BJ, Emens JS, Bauer VK. The circadian basis of winter depression. Proc Natl Acad Sci U S A. 2006 Apr 28.

Monday, January 19, 2009

Imitation as therapy

Last week, a colleague passed along the book, "Mirror Neurons and the Evolution of Brain and Language", by editors Stamenov and Gallese. Mirror neurons exist in specific regions in the brain and have a unique mission: learn how to copy someone else's movements as a way of learning to do something new. For a child this might be: take a lid off of a jar, play hopscotch, or hopefully, for one of my clients, brush your teeth.

Alicia, a 5 year old girl with autism, refuses to let mom brush her teeth (without a big fight). Mom and I want to desensitize her mouth a bit, so that she more readily accepts brushing. I put a glove on my hand and played games with Alicia while she was swinging. I managed to touch her mouth, and even get a finger onto her gum without too much of a struggle. But she was done with the game long before I managed to massage her gums.

During the next session, after playing our game for a few minutes, I guided her fingers to her teeth. I touched my teeth with my fingers and asked her to touch hers. To make this easier for her to understand, we moved to chairs in front of the mirror and kept practicing touching teeth, then gums. Alicia "got it" and her mom, who had been watching, felt comfortable with following through with the game. It's too early to say, but we have hopes that Alicia will learn to desensitize her own mouth, and then learn to brush her own teeth. Whew.