UCLA Mindfulness Meditation

I found a source of Guided Mindfulness Meditation at UCLA. And best of all, the meditations (7 for PC, 15 for iTunes) are free. If you have an iPod, iPhone, iPad you can download them from iTunes. If you are using a PC, you will select to play the meditation on your computer. Bookmark the web page so that you can easily get back to it.

Remember, 15-20 minutes of Mindfulness Meditation a day increases attention skills in teenagers and adults with ADHD by 30% - with or without meds. And by the way, this is 30% over and above the effect they are getting from meds if they are on them. Meditation also decreases anxiety and makes people happier :)

If you want to learn more on the topic, there are two lectures on the UCLA site including a Ted lecture on Mindfulness Meditation by Diana Winston.

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.

In the News ...

Here are a couple of interesting news items you may have missed. I found these on the Science Daily news service over the weekend.

Second-Hand Smoking Affects Neurodevelopment in Babies
How does it affect the baby? ..."poor physiological, sensory, motor and attention responses". Read it - it's an eyeful.

Disorder of Neuronal Circuits in Autism Is Reversible, New Study Suggests
Scientists have found an impaired set of circuitry affecting many symptoms of autism and have reversed the problem in mice. This gives hope that we may be able to do the same in humans once we are better at pinpointing brain chemical therapy to a given small region. A breakthrough in that technique was also reported last week.

You can subscribe to email delivery of ScienceDaily at this site. They also have an RSS Newsfeed.

ADHD Meds and Therapies Update

I have mixed feelings about meds. Here is a little about the pros and cons, and an update on therapies.

The teachers who want to see a child with ADHD takes meds are right when they say it will help keep him from falling behind in school. Once behind he may have a hard time catching up.

However, meds do not cure , they only help with attention, etc. for the hours after the child takes the pill. And the side effects can sometimes be difficult. There is a new med out called Intuniv that works in a different way, lasts 24 hours and appears to have fewer side effects. This is an option for parents to consider and discuss with their doctor.

A lot of the experts these days are suggesting that you try to not go the meds route until you have tried other things for 6-12 months. Here are things to try:

1. Neuro-feedback, which is expensive but has the best results record around.

2. Interactive Metronome (IM) - usually found in a pediatric occupational therapy setting. I sometimes mix IM with sound therapy and get good results - but you'd have to find an OT who knows how to do that.

3. Cognitive therapy in which a psychologist or social worker helps the child to see what his challenges are and offers some approaches to meeting them.

4. Self Management techniques in the classroom in which the child scores himself for staying attentive and then is rewarded at the end of the day if he succeeded 75% of the time. (To get this started, another adult scores with him so that he understands what is expected).

5. There are also programs that help with working memory (another problem for kids with ADHD) - I do not have personal experience with this, but evidence is good.

6. Nutritional help - some children have food sensitivities that mimic ADHD symptoms. The best way to find out is to eliminate a variety of common allergens - milk (cheese, yogurt and whey), wheat, soy (soy oil is everywhere), and corn (don't forget corn syrup) are the usual culprits. Do them one at a time for 2 weeks and be religious about it - reading the labels of everything. And forget about eating out while you are doing it unless the restaurant you are going to has an allergy menu.

By the way, new research shows that a daily vitamin with minerals is very helpful. So is a high protein breakfast. And if he is a picky eater or has poor bowel movements, a visit to a DAN doctor (austim) may help to correct gastric issues.

The children who do best with getting rid of ADHD symptoms are those who have done multiple therapies. Which means that the parent has to shell out for lots of pricey therapy. How a parent with limited means accomplishes that is to browse the book store books, settle on an approach and go from there - working step by step through the book. And then on to another one.

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...)

The Meds Alternative

I see a very sweet 7 year old boy who has autism, OCD and ADHD. Whew, that's a lot. I've spent the better part of a year with him on modulation - and made a lot of progress - relative progress, that is. But then I hit the wall. His OCD and anxiety symptoms were too pronounced for him to attend to therapy. For example, when I tried to teach him to tie his shoes, he created a new OCD ritual around shoe tying.

His parents had him on a low-dose medication and were not certain about what to do next. I suggested going back to his doctor for a new approach. The boy was given an increase in his meds dosage, and finally, he was able to focus. His OCD settled down enough to do the more powerful interventions in my toolkit (IM and sound therapy), and now we are off and running again. We've been making incredible progress with social skills, modulation and play skills. Hooray!

I think that meds are a God-send for certain children. For my small buddy, it's the difference between running in circles much of the day versus significant interaction with adults and peers.

Will he be on them forever? Can't say, of course. I truly hope that he gets a reduction of symptoms with the next round of therapy ... and then maybe meds can be revisited.

Another Blog

I am starting up and new blog and that will slow my activities on this blog. The new blog will cover some of the same territory, but be focused on new interventions, technologies and clients aged 12 - 99. The new blog is called Brain Tune-Ups - that's the name of my Ann Arbor clinic. The blog is at http://braintuneups.blogspot.com/

A big factor for the change is that a small flood destroyed all of my research articles on peds and autism. But the change would have come in any event, since I am shifting my practice into teens and adults away from children. The title of this blog just doesn't do justice to where my practice is heading. I will continue to work with clients whose main concerns are self regulation or the symptoms of autism and so I will continue to have material for this blog.

On the Brain Tune-Ups site, I will continue to write about Interactive Metronome, Therapeutic Listening, Samonas, stress reduction, etc. And I'll publish the results of the adult study there.

By the way, my clinic's website is http://www.braintune-ups.com/

Vision, Attention & Autism

Article

Brenner, L. A., Turner, K. C., & Muller, R-A. (2007). Eye movement and visual search: Are there elementary abnormalities in autism? Journal of Autism and Developmental Disorders, 37, 1289-1309.

Summary
This article is an all-encompassing literature review on the topic of visual search and the ocular motor system in children with autism. Individual sections of the article describe:
1. The mechanisms involved (both vision and attention) for visual search.
2. Neuro-anatomical description of the vision system with regard to search and attention
3. Neuro-imaging studies of visual-systems on both children with autism and controls.
4. The ocular components of visual search including saccades and smooth pursuits and how they differ in children with autism.
5. The relationship between ocular motor and attention systems.
6. The impact of the ocular motor system on higher functions including face perception, joint attention and language acquisition.

This is not an easy article to read but it provides great insight into many underlying differences between the autistic and typical brain. The authors create a case for the possibility that the symptoms of autism (including joint attention, face perception and language acquisition) are the result of a defective ocular motor system. They warn that the current theory, the "lesion" view of autism in which autism is presumed to be caused by observed neural differences in many brain structures does not take developmental (and experiential) considerations into place. The authors call for research in the combined areas of ocular motor and joint attention to gather additional information in this area.

Another post in this blog will list the differences found in the brains and behaviors of children with autism and typically developing children.

Tuning the Brain

I am blown away by the capability of the Interactive Metronome (IM) as a way of improving motor planning, attention and overall processing speed and capacity. I've been certified on this tool for just a few months, but have seen dramatic results in kids with autism. One boy with good verbal skills but little desire to communicate now responds to his mother, follows directions and even - at the age of 11 - taught himself to tie his shoes. Another boy struggling with coordination and oral praxis is now able to use gym equipment with ease and is successfuly learning to move his mouth to generate "f", "v" and "s". A third child has much improved handwriting.

There is a great deal of latitude for therapists, and I find that it works both as a modality and as an intense therapy.

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.