Sensory and Autism - Differences in Brain Wiring

Today is a good day for research results. Here is a science digest synopsis of research showing that sensory and autism issues can be distinguished from each other using MRI DTI techniques. The entire article is open access and can be found here.

2012 Journal Tidbits - Autism

Here are some study findings from the Journal of Autism and Developmental Disorders - one of my favorite journals - that struck me as worth sharing. By the way, you have until Dec. 31st (2012) to browse this journal for free on line.

 1. Is picky eating due to sensory issues or due to food rigidity?
This article suggests that some picky eating problems are due entirely to rigidity in the child's food selection patterns. Treatment in this case is motivational. A child is told they will try a certain food. They are offered a choice of reinforcers (rewards). If they eat the food, they receive the reinforcer. They are also rewarded with accolades.  If they do not eat the food, they do not get the reinforcer.

When trying a new food, the authors followed a hierarchical pattern similar to Kay Toomey’s SOS Approach method:

1. Touches the food
2. Puts food to the lips,
3. Bites the food, bites
4. Puts in mouth but does not swallow
5. Chews but does not swallow
6. Swallows reluctantly
7. Accepts food without signs of displeasure.

After18 weeks, children were spontaneously requesting the new foods they had tried. The three children in the study, Ken, Robbie and Daniel accepted 5, 9 and 8 new foods respectively at the completion of the 22 week study.

Source: Koegel, R. L., Bharoocha, A. A., Ribnick, C. B.,Ribnick, R. C., Bucio, M. O., Fredeen, R. M., et al. (2012). Using individualizedreinforcers and hierarchical exposure to increase food flexibility in childrenwith autism spectrum. J Autism Dev Disord, 1574-1581.

  
2. What causes self-injurious behaviors in autism? The seven risk factors for self-injurious behaviors are 1) poor sensory processing, 2) low cognitive skills, 3) poor language / communication skills 4) poor social function, 5) age (18 mo. - 19 yrs.), 6) rigid behaviors and 7) gender. However, these factors account for just 29% of the self-injury cases seen, with sensory being the greatest factor of these (5-7%). The authors hypothesize that chronic pain and psychosocial factors may play a large factor in the remaining 71%. Clearly, there is more work to be done.

Source: Duerden, E. G., Szatmari, P., & Roberts, S. W.(2012). Toward a better understanding of self injurious behaviors in childrenand adolescents with autism specturm disorders. J Autism Dev Disord,2515-2518.

3. Is there a relationship between anxiety and repetitive behaviors? Yes, repetitive behaviors appear to be a cause of anxiety. "It is possible that, for some individuals, interventions focused on a reduction of behaviors, promoting flexibility and reducing repetitive play may consequently reduce anxiety." See the next article for more on this.

Source: Rodgers, J., Glod, M., Connolly, B., & McConachie,H. (2012). The relationship between anxiety and repetitive behaviors in autismspectrum disorder. J Autism Dev Disord, 2404-2409.

4. Are there interventions for quieting repetitive behaviors? Yes, if the child's behavior can consistently be triggered. For example, give a child with autism six cars, he will line them up. That behavior is triggerable and can be replaced with functional behavior. How about if the behavior is not triggerable? That's a harder problem. Not only do we not have interventions, we are not doing the research to look for them.

Sources:

1.  Boyd, B. A., McDonough, S. G., Rupp, B., Khan, F.,& Bodfish, J. W. (2011). Effects of a family-implemented treatment on therepetitive behaviors of children with autism. J Autism Dev Disorders,1330-1341.
2.  Boyd, B. A., McDonough, S. G., F., & Bodfish, J.W. (2012). Evidence-based behavioral interventions for repetitive behaviors in autism.J Autism Dev Disorders, 1236-1248.

5. Do children with autism also qualify for anxiety disorder? Yes, the diagnoses overlap often in children and young people (40-45%). Specifically, in children with high functioning autism, anxiety should be treated (medicine or stress reduction techniques) as a way of supporting other methods of increasing social skills.

Source: White, S. W., & Roberson-Nay, R. (2009). Anxiety, social deficits and loneliness in youth with autism spectrum disorders. J Autism and Dev Disord, 1006-1013.

Patterns of Early Development in Autism

Follow this link to a short article on the normal development cycle for a child with autism. In fact, there are two development cycles - one for children with an early diagnosis of autism (14 months) and the other for children who are typically identified between 24 - 36 months of age.
 
References:

1. Rebecca J. Landa, Alden L. Gross, Elizabeth A. Stuart, Ashley Faherty. Developmental Trajectories in Children With and Without Autism Spectrum Disorders: The First 3 Years. Child Development, 2012; DOI: 10.1111/j.1467-8624.2012.01870.

 

2. http://www.sciencedaily.com/releases/2012/10/121030062401.htm?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+sciencedaily%2Fmind_brain+%28ScienceDaily%3A+Mind+%26+Brain+News%29

Do Weighted Vests Work? Two Studies

Last year, two widely different studies published in AJOT (American Journal of OT) looked at the effectiveness of a weighted vest in increasing the on-task behavior in children with poor attention. One study showed an effective protocol, the other showed a protocol that did not work.  Let's look at the methods used in the studies.

What didn’t work

In study 1, by Collins and Dworkin, children wore a standard commercial vest (based on the size of the child) for 15 or more minutes (the length of an activity). Filming of the child’s behavior was started after a 5 minute adjustment period. The recording was 10 minutes long. A total of 9 sessions were recorded over a period of 3-6 weeks.   To make that clear, each child wore a weighted vest for approximately 15 minutes on each of 9 days. They did not wear a weighted vest at other times. The authors report that their weighted vest protocol did not improve attention to task. By the way, these children were typical children in elementary school. No further information is given about them including whether or not they were known to have sensory issues or had been diagnosed with ADHD.

What appears to work

Study 2, by Fertel-Daly, et. al., had children with autism ages 2-4 in a pre-school program wear similar vests for 2 hours on and then two hours off. Children wore the vests 3 days a week. They were given 3 weeks of this protocol to adjust to the vests prior to filming behaviors. All participants had an increase in attention. The smallest child had the best increase, suggesting that the ratio of the child’s body weight to the weight in the vest made a difference. Teachers noted that the level of aggression and self-stimming behaviors were noticeably reduced at the end of the study. The children's attention skills improved overall by the end of the study and did not return to baseline once the vest was discontinued.

Conclusions that Need Re-Validation

1.       The art of “how much weight to use in a vest” says that 5-10%  of the child's bodyweight works best. In study 2, the smallest girl used weight equal to 4% of her body weight – and it worked. Other students who had less vest weight still had good results, but not as good.

2.       Vests are more effective when used consistently over time. Even 3 days a week is effective, but the gains increase as the weeks go by.

3.       The method of 2 hours on and 2 hours off appears to work. A vest that is worn for 15 minutes (as needed) is not effective.

4.       The weighted vests  appear to help pre-schoolers with autism. Would it help elementary children with autism?

5.   Children with autism tend to have sensory issues. It makes sense that a vest (a sensory solution) was successful for them.  Would it also work for a small child with ADHD?

 

6.  In the second study, the children's attention skills improved - and did not return to baseline. What would happen if the protocol were continued? Would the children lose those symptoms?

So many questions, so few answers. Ah, to have a large group, long term study!

 

References

1.       Collins, A., & Dworkin, R. J. (2011). Pilot study of the effectiveness of weighted vests. American Journal of Occupational Therapy, 65, 688–694.

2.       Fertel-Daly, D., Bedell, G., & Hinojosa, J. (2001). Effects of a weighted vest on attention to task and self-stimulatory behaviors in preschoolers with pervasive developmental disorders. American Journal of Occupational Therapy, 55, 629–640.

Landfills and Autism

Driving back today from an errand, I passed a garbage hauler headed for the landfill 4 miles away. It reminded me that our landfill not only serves the S.E. Michigan area (including Detroit), but garbage from the city of Toronto is also hauled there. This arrangement has been in place for about 10 years. That's a big landfill.

It appears to me that the rate and severity of autism are higher in my area than in other areas where I've lived and worked. If so, is the proximity of this landfill a coincidence? It will be a while before epidemiologists are able to answer my question. But I did find one preliminary study addressing the topic. When I googled "autism" and "landfills," this article appeared first:
Autism Spectrum Disorders and Identified Toxic Land Fills: Co-Occurrence Across States, by Xue Ming, Michael Brimacombe, Joanne H. Malek, Nisha Jani and George C. Wagner in Environmental Health Insights 2008:2. It was dated Aug 20, 2008. In their words:

We hypothesize that ASD are associated with early and repeated exposures to any of a number of toxicants or mixtures of toxicants. It is the cumulative effects of these repeated exposures acting upon genetically susceptible individuals that lead to the phenotypes of ASD.

In a nutshell, the authors found that the occurrence of autism is higher near Superfund landfill sites than in areas without landfills. They go on to give results of a simple first look at the situation.

The residence of 495 ASD patients in New Jersey by zip code and the toxic landfill sites were plotted on a map of Northern New Jersey. The area of highest ASD cases coincides with the highest density of toxic landfill sites while the area with lowest ASD cases has the lowest density of toxic landfill sites. Furthermore, the number of toxic Superfund sites and autism rate across 49 of the 50 states shows a statistically significant correlation...

There is a superfund site within 20 miles of where I live (in addition to the big landfill down the road). It's quite a complex situation and I'm not sure that we want to wait for the epidemiologists. Last week, the health advocate, Dr. Weil (DrWeil.com), wrote:

Environmental toxins such as lead, mercury and dioxin are serious hazards to human health. Fortunately, there are ways to both minimize your exposure to and lower the quantity of toxins in your body ... Avoid living or working near hazardous sites such as reclaimed landfills or toxic waste dumps.

In my opinion future parents should truly think about where they work, what they do and where they live in order to decrease their likelihood for genetic mutation and the risk of autism in their children.

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
-----Visual
-----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.

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.

Interactive Metronome Research

I wrote earlier of being "blown away" by the capabilities of the Interactive Metronome™ (IM) product. The literature shows that IM increases mental fluency which in turn increases the efficiency (and skill level) of many brain and body functions including motor planning. (See the TickTockBrainTalk blog and the IM site, for much more on this!)

There has been substantial research done on IM for children. (The article cited below finds that IM "appears to facilitate a number of capacities, including attention, motor control, and selected academic skills in boys with ADHD.) There are a few studies on the effects of IM on adults in rehabilitation recovering from varied disabilities such as stroke, TBI and loss of limb. None of the studies I've seen address softer issues such as stress, organization, or well-being.

I have launched a small research project studying the effects of the IM protocol on parents of children with special needs. It's a convenience study being done at Building Bridges therapy Center, where I work. I am asking the question: Does IM help parents of children with special needs become better organized such that they are better able to accomplish their goals. And does this is turn help reduce their stress levels? These parents operate at a very high level of challege and stress (lots 0f OT journal articles have documented this).

I may also look at another factor -- SI. Since many of the children at my clinic have autism and sensory integration issues, as a result, I may assess parents for sensory integration issues using the Adult/Adolescent Sensory Profile. If indeed they do, I wonder if any symptoms lessen at the end of the study....and if not, perhaps, I could re-enlist them in another short study with a different intervention. H-m-mm.

Article

Shaffer, R. J., Jacokes, L. E., Cassily, J. E., Greenspan, S. L., Tuchman, R. E., & Stemmer, P. J., Jr. (2001). Effects of Interactive Metronome™ training on children with ADHD. American Journal of Occupational Therapy, 55, 155-162.

Abstract

(This was copied from the IM site)
The purpose of this study was to determine the effects of a specific intervention, the Interactive MetronomeÒ, on selected aspects of motor and cognitive skills in a group of children diagnosed with attention-deficit/hyperactivity disorder (ADHD).

The study included 56 boys, age 6 to 12 years, pre-diagnosed as having ADHD who were pre-tested and randomly assigned to one of three matched groups. The 19 children receiving 15 hours of Interactive MetronomeÒ rhythmicity training exercises were compared with a group receiving no intervention and a group receiving training on selected computer video games.

A statistically significant pattern of improvement across 53 of 58 variables favoring the Interactive Metronomeâ treatment was found. Additionally, several statistically significant differences were found among 12 factors on performance in areas of attention, motor control, language processing, reading, and parental reports of improvements in regulation of aggressive behavior.

Sensory Profile Factors

Article

Ermer, J. & Dunn, W. (1998). The sensory profile: a discriminant analysis of children with and without disabilities. American Journal of Occupational Therapy, 52, 283-290.

Here is an older study done in Kansas that looks at the factors (1-9) in the Sensory Profile for positive correlations to autism and ADHD. (The authors note that this process can be done for other disabilities, as well. I vote for Fetal Alcohol Syndrome!)

ADHD can be distinguished by high scores in Factors 1 and 5, sensory seeking and inattention/distractibilty and low scores in factors 4 and 9, oral sensitivity and fine motor perceptual.

Autism can be distinguished by high scores in Factors 4, 5 and 9, sensory seeking, inattention/distractibilty and oral sensitivity and low scores in factor 4, fine motor perceptual.

The study results had a statistical error, the assumption of homogeneity of variance was violated for the control group, and so these results must be used conservatively.

Questions for research:
1. Will these results pass muster on a larger population?
2. What does the factor profile look like for FAS, ODD, CD, etc.?

Modulation Case Study

Article Review

Roberts, J.E., King-Thomas, L., & Boccia, M. L. (2007). Behavior indexes of the efficacy of sensory integration therapy. American Journal of Occupational Therapy, 61, 555-562.

The authors performed a single-case study on a boy age 3 years and 5 months with sensory modulation disorder (as diagnosed by the Sensory Profile which noted tactile and auditory processing issues and sensory seeking behaviors) and delayed communication skills. He had been given a reduction in school hours due to classroom behaviors of phycial and verbal aggressive, throwing objects, mouthing objects and touching others within a classroom setting. Treatment was given in an ABAB format: 2 weeks of no treatment, 5 weeks of intense SI therapy (3 times per week), 2 weeks of no treatment, and 2 weeks of treatment. Success was gaged by teacher report of observed behaviors. The SI treatment was provided by a therapist trained by Jean Ayers.

At the end of the study all aggression and mouthing behaviors had diminished. There was a 50% decrease in teacher intensity needed to manage the child's behavior and he was engaged in classroom activities for 70% of the time, a 40% increase from the start of the study.

The child continued with once per week OT which was reduced to once per month over a 3 year period. At the age of 6 he was diagnosed with ADHD.

My Thoughts

This is a nice look at the early stages of a boy with ADHD and the affect of intense early intervention.

See also the article by Ermer & Dunn regarding the using the Sensory Profile to differentiate typically developing children, children with ADHD, autism, and other disabilities.

Ermer, J. & Dunn, W. (1998). The sensory profile: a discriminant analysis of children with and without disabilities. American Journal of Occupational Therapy, 52, 283-290.

Therapeutic Listening

Article

Hall, L. & Case-Smith, J. (2007). The effect of sound-based intervention on children with sensory processing disorders and visual-motor delays. American Journal of Occupational Therapy, 61, 209-215.

Leah Hall conducted a study with 10 children ages 5y 8m - 10y 11m who were diagnosed with sensory processing disorder (they were rated "Definitely different" in 3 or more areas of the Sensory Profile). Children were given home programs of four weeks with a sensory diet followed by 8 weeks of continued sensory diet with Therapeutic Listening. Significant results were found at the end of the first 4 weeks and at the end of the 12 weeks. Children gained an average of 71 points on the Sensory Profile with the biggest gains in the area of auditory processing and behaviors associated with sensory processing. Children with specific issues (such as auditory hyper-sensitivities, tantrums and hyperactivity made significant gains in some of those areas, as well). In addition, significant gains were made in handwriting (as assessed by the Etch program, and visual processing (as assessed by the VMI). Parents noticed large changes in overall behavior included improved attention, social interactions, self awareness, communication and sleep patterns. One child on medication for ADHD was given a reduction in dosage.

Comparing AS and HFA Sensory

Here is a thought provoking article that compares the sensory status of children with Asperger syndrome (AS) with those with high functioning autism (HFA) using the Sensory Profile.

Article 1: Auditory & Attention; Tactile and Motor Planning

Myles, B.S., Hagiwara, T., Dunn, W., Rinner, L., Reese, M., Huggins, A., & Becker, S. (2004). Sensory issues in children with Asperger syndrome and autism. Education and Training in Developmental Disabilities, 39, 283-290.

Summary

A comparison of Sensory Profile assessments on 76 children ages 6 y 9 m to 16 y 8 m. Half were diagnosed with Asperger's syndrome, the other half with autism. There were no restrictions to the study based on intellectual capabilities. The purpose was to discover sensory differences between the 2 groups. Statistical significance was found in the areas of auditory processing, tactile processing, "modulation of sensory input affecting emotional responses and activity level" and emotional/social responses. Children with AS were more severely impacted than children with autism in all of the above areas.

The authors conclude

1. Higher rate of social/emotional behavior for children with AS may be due to greater capacity for language. They are attempting to interact and are doing a poor job.

2. The poor auditory processing skills are associated with decreased attention levels. Children with AS may hear just portions of verbal information and this create a confused message which they then try to make sense of. The authors go on to posit that this may lead to rigidity in behaviors because the children latch onto the portion of the message that they heard.

3. Children receive inaccurate tactile information causing a distortion in their body perception which in turn causes poor motor planning. The authors explain that this may thus explain poor coordination in children with AS.

My Thoughts

A previous article () classified children with autism into 4 catagories. Children with high functioning autism (HFA) do not have communication problems. This would suggest that they need to be separated into a third group for this study to make sense. Another article (hmm, have to find that one...) I read found that children with AS and HFA have similar sensory issues -- and yet there truly are differences ... I for one, want to know more.

Response Patterns

Here are more blocks in the foundation of self regulation. Today I am reviewing and commenting on 3 interesting pieces of research that describe response patterns in children with autism and "typical" children. The articles cover 3 different areas: sensory input, affect and joint attention (a social skill).

Article 1: Response to Tactile & Vestibular Patterns
Bar-Shalita, T., Goldstand, S., Hahn-Markowitz, J., & Parush, S. (2005). Typical children’s responsivity patterns of the tactile and vestibular systems. American Journal of Occupational Therapy, 59, 148-156.

Summary
The article describes typical 3-4 year old responses to tactile and vestibular input. There was no noted differences in gender response. There was no significant difference in responses from age 3 to age 4. Children in this study showed no sensory modulation issues. That is, they were not seekers of this input and did not appear to be hypo-reactive and/or hyper-reactive in response to the input.

Comments
The study was performed in Israel, and so is valid for that population, but in fact supports data collected from U.S. researchers including Dunn, Ayers, Blanche and others.

The article is noteworthy for the excellent review of past and current literature in the areas of sensory modulation, tactile defensiveness, and hypo- and hyper-reactivity to movement.

Article 2: Response to Mood
Begeer, S, Meerum, T. Rieffe, C., Stegge, H., & Koot, H. M. (2007). Do children with autism acknowledge the influence of mood on behaviour? Autism, 11, 503-521.

Abstract
"We tested whether children with and without high-functioning autism spectrum disorders (HFASD) differ in their understanding of the influence of mood states on behaviour. A total of 122 children with HFASD or typical development were asked to predict and explain the behaviour of story characters during hypothetical social interactions. HFASD and typically developing children predicted at equal rates that mood states likely result in similar valenced behaviour. `Explicit' descriptions were used to explain predictions more often by children with HFASD than by typically developing children. However, `implicit' and `irrelevant' descriptions elicited fewer mood references among HFASD children. Furthermore, they less often referred to the uncertainty of the influence of mood on behaviour, and less often used mood-related explanations, in particular when they had to rely on implicit information. This may indicate a rote- rather than self-generated understanding of emotions in children with HFASD. "

Article 3: Response to Novel Input on Joint Attention Skills
Gulsrud, A.C., Kasari, C., Freeman, S., & Paparella, T. (2007). Children with autism’s response to novel stimuli while participating in interventions targeting joint attention or symbolic play skills. Autism 11, 535-546.

Abstract:
"Thirty-five children diagnosed with autism were randomly assigned to either a joint attention or a symbolic play intervention. During the 5—8 week treatment, three novel probes were administered to determine mastery of joint attention skills. The probes consisted of auditory and visual stimuli, such as a loud spider crawling or a musical ball bouncing. The current study examined affect, gaze, joint attention behaviors, and verbalizations at three different time points of intervention. Results revealed that children randomized to the joint attention group were more likely to acknowledge the probe and engage in shared interactions between intervener and probe upon termination of intervention. Additionally, the joint attention group improved in the proportion of time spent sharing coordinated joint looks between intervener and probe. These results suggest that generalization of joint attention skills to a novel probe did occur for the group targeting joint attention and provides further evidence of the effectiveness of the joint attention intervention."

Other Points Made
The authors conclude that the intervention worked for these reasons:
1. It violated the established routine for the child's session.
2. The focus of the session was already on engagement with other people, and so the child was not required to do something new (beyond engaging).
3. Children in the joint attention group were becoming more adept at shifting their attention and responding with flexibility to the environment, so the surprise intervention was simply an increase in the level of challenge.

Although there was an increase in initiation and duration of joint attention there was no significant change in the child's affect, non-verbal gestures and verbalizations.

The authors note that "sustained engagement in joint attention states has been linked to language development in typical children... may be important for the language development of children with autism."
Here is a working definition for sensory modulation.

My Comments
This is a very important finding that can be applied to SI interventions in that we can add a joint attention component to activities such as a swing or a trampoline, and add a surprise element into the mix. The authors treated for 30 minutes and interjected the random stimulus during the last 2 minutes - timelines that could easily work in a typical OT session.

A question worth asking is "If the children were engaged in an intervention aimed at increasing affect, would there have been a significant change in that area (and not in joint attention)?

Creating a Foundation

Today's post lays a stone in the foundation of this site with a review of a journal article about modulation and visual attention. My comments follow the article summary.

Article review: Liss, M., Saulnier, D.F., & Kinsbourne, M. (2006). Sensory and attention abnormalities in autistic spectrum disorders. Autism, 10, 155-172.

I read the article by Liss, et al. this afternoon. The authors conducted a large study looking for patterns in modulation, overselective attention and exceptional memory in children with autism. They hypothesized that sensory overreactivity is a response to over-arousal. They expected to see that children with sensory overreactivity will additionally show these attributes: not being able to quickly shift attention, perseveration due to unshifting attention and exceptional memory for "self-selected material". In a population of 144 children with autism, 12% of the children did indeed exhibit a correlation of these behaviors. These children tended to be older (11 years) than the average age in the study (8.5 years) and higher functioning, but with poor social skills. The authors divided the 144 children into 4 clusters based on scores (from many tests).

Cluster 1: (12%) labeled, "Overfocused". The children displayed sensory overreactivity inability to quickly shift attention, perseveration due to unshifted attention and exceptional memory for "self-selected material". They demonstrated poor social and imitative play skills and showed the best fit to the DSM-IV definition of autism. They also displayed the least impairment of receptive and expressive communication skills, but the highest functioning level. They also demonstrated sensory seeking behaviors.
Cluster 2: The second cluster (25%) was labeled "No sensory problems" and was relatively high functioning with few functional issues.
Cluster 3: (30%), labeled "Low functioning". These children registered low in adaptive functioning, high in underreactivity and also in sensory seeking. They had poor social skills and poor receptive and expressive communication skills.
Cluster4: (33%) "Mildly overfocused", was quite similar to cluster 1 but higher functioning and only mildly over-focusing.

Cluster 1 had social skills equally impaired as cluster 3.

There was a lengthy and interesting discussion section. Here are some highlights:
1. Cluster 1's sensory seeking behaviors might be explained as a way for them to create soothing stimuli in the face of noxious sensory input.
2. Kinsbourne is cited in an earlier article (1991) as saying that the overfocused subgroup represents a "dimension of personality that extends the continuum of autistic behavior into normality". That is, it is also found in normally functioning individuals without autism.
3. Hussman (2000) described over-arousal as occurring due to noise in the cortex. Normal sensory input must compete with this noise and causes overreactivity.
4. Finally, the authors suggest that overselective attention and perseverative behaviors help an individual to create predictable and repetitive events for themselves as a way of moderating over-arousal. This group had the oldest mean age - a little less than 12.

Thoughts on unshifting attention:
Given that there is a continuum in shifting attention to unshifting attention, how long does it take the average person to shift thoughts? What is the reason that others shift more slowly? Are they absorbed in thought? Are they emotionally engaged? Are they enjoying sensations?

The authors said that the condition of overfocused attention occurs in the typical population - presumably scholars and meditators are among this group. The ability to shift attention will probably vary according to how deeply enmeshed in thought a person is as well as to cognitive function.

1. Emotional shifting: I have a friend, Kate, who needs 20 minutes to return to her normal state after seeing a scary film. You can't talk to her about anything during that time because she is reactive. Kate says that she is still emotionally involved in what she saw. It seems that Kate is over-aroused by the events in the film and then over engages with the emotional content and then overreacts (by not being able to return to normalcy) in turn -- just as Liss, et al., suggest happens in clusters 1 & 3 above. (Does she also have an excellent memory for emotional content? Good question!) Kate tells me that she tends to read books with predictable stories. Her hobbies are solitary: solving puzzles, work on her house and crafts. Kate is an example of a person with poor modulation of emotional input. She is able to lead a normal life by limiting emotional input.

2. Activity shifting: Children with autism have difficulty moving from one activity to another unless they are given time to adjust to the change. Likewise, they often overreact to loud noises or disruptions. There are a number of techniques used to help them with transitioning from one activity to another in a classroom setting - the chief being to follow a schedule (be it a picture schedule or a written schedule). However, on-the-spot interruptions are hard for them and can cause meltdowns. I work with a boy (Lonnie) who will not work in therapy unless he follows a schedule - and then he is quite compliant. I have begun the process of unstructuring the schedule. I create a written schedule (a list of numbered activities) and then beside the list write other possible (alternate) activities. Part way through our therapy session, I substitute an alternate activity for the next thing planned. I put it on the list, and Lonnie does it without complaint. He is able to shift within just a few seconds that way. He has been given warning, even though it was not highly structured. My next step with him is to make an unordered list of activities. I think that he is ready to follow it.

3. Sensory shifting: When kids seek sensory stimulation (swinging, visual perseveration, crashing against things), they can have difficulty pulling away. They are getting input that they apparently need (or so our sensory integration (SI) literature tells us). They are presumably calming themselves (i.e. self-regulating!). For some reason it takes a while for them to do so. Think of Kate and her slow movement out of an intense place and back into the real world. The SI theory states that if we can finally satiate the sensory need, the seeking will abate ... and this is true for many of the kids I treat. (Amazing to see, actually!)

4. Habit/addiction/compulsion: Other topics that comes to mind are addiction and compulsion. So many people are addicted to video games. We exhibit seeking behaviors when we do it ... however, it is not input that is necessarily good for us (certainly not when it interferes with our life, or with having a life). Worse, not all of us are able to finally become satiated and get back to our lives.

5. Cognitive shifting: I think that all of the above topics fall also fall under the heading of cognitive shifting, with habit and addiction being the most relevant.

It's all here. My friend Kate appears to demonstrate a similar pattern to clusters 1 & 4. She is not and never was autistic, but she certainly is able to focus deeply (is forced to due to over-arousal). Is she on the continuum of behaviors that eventually become described as autism? Probably. I read recently that we tend to over diagnose autism (and ADHD) in kindergarten. Not all kids are equally social - and teachers become worried by those who are more solitary. Perhaps those children grow up to become Kate or a skate-boarder (Sensory seeking), a habitual video game user or a gambler. When we fail to learn to modulate our inner and outer experiences, we fail to develop habits that allow us to find peace within ourselves - and this is all at the expense of typical social interaction.