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.

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.

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.

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 Communication 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 No Stereotyped or repetitive motor mannerisms No Preoccupation with parts of objects Yes Yes

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.

TED Video on Right/Left Brain

There is an amazing video by Jill Bolte Taylor, (http://www.ted.com/talks/view/id/229) a Harvard-trained and published neuroanatomist who teaches at the Indiana University School of Medicine in Bloomington, IN. Dr. Taylor witnessed and then recorded her experience of undergoing a stroke. As a brain scientist, she has incredible insight. She discusses the differences between the left and right brains.

Dr. Taylor describes the right brain's organization as a parallel processor ... that is, it has it's pulse on all the senses, but has no structure to make sense of the input it receives. For example, she talks about hearing "wah, wah-wah, wah-wah", rather than "Hi, my name is Joe". Another example, she had difficulty distinguishing numbers on paper. She couldn't discriminate figure/ground.

She described the left brain as a serial processor (a typical computer) that is able to analyze, organize and communicate. She says that the left brain has the sense of self (ego?) whereas the right brain is cosmic / in touch with energy. This is all very interesting, quite fantastic, and depending on your religion and training, may make a lot of sense. It did for me.

I wonder if autism doesn't have some sort of right/left brain connection .... I've seen a number of children without verbal skills who struggle with reality and appear to be content in their inner world of songs, touch, lights, and spinnng (right brain with left brain missing). And then there is true Asperger's Syndrome, which seems to be all left brain.

Dr. Taylor has a book, "My Stroke of Insight", that covers this same ground in depth.

Working with adults and teens

I plan to move into an adult practice during the next year. My husband and I are looking at a possible site for the clinic today. We will offer Interactive Metronome, Therapeutic Listening, Samonas Listening, psycho-therapy, and sensory integration therapy.

It is interesting for me to see and compare the difference in working with adults versus children. The poor folks who were sensory kids, but did not get therapy are now sensory adults who have self-adapted to the world around them and may still have a lot of difficulties in coping, adapting and interacting. The therapies that I use with children work with adults. The biggest problem is simply reducing the accumulated baggage that an adult has from years of dealing with physical, mental and sensory issues in the form of praxis, autism/Asperger's syndrome, and/or overall poor inter connectivity to the world and other people. Having access to psycho-therapy will help.
I am expecting to see fewer adult clients with autism than I do in my pediatric practice, but this will be offset by clients with traumatic brain disorder (TBI) and aging-related problems including stroke. I expect the same number of sensory-related issues and the issue of self-regulation will still play out strongly. For outcomes: those with auditory issues will be able to relax and be less volatile, those with vestibular issues will appear to be smarter and will probably act-out less. Those with social issues will lose fear of social situations and pay attention to social rules. Folks with TBI will find increased organization.

I'm not sure what to expect with teenagers. Probably a mixture of everything but stroke. And probably plenty of clients with autism.

My study of the adult parents of children with autism is near completion. There are still 2 post-tests to complete and then we can look at the results.

Sensory Profile Score Gains

I had an opportunity to check gains in the sensory processing skills of a 7 year old girl who had undergone 6 months of SI. Her clinic-based OT consisted primarily of vestibular & tactile interventions was 1/2 hour weekly sessions with modulated music playing in the backgound. This was followed by 1/2 hour sessions with a music therapist. In addition, she received 6 weeks (so far) of Therapeutic Listening and a very good sensory diet program at her school.

She made significant gains in her parent's eyes and it also registered on the Sensory Profile (SP). She now accepts hugs from her family without tactile defensiveness (talk about huge!). On the SP, She gained 10 points overall (from 497 to 487). Her Touch Processing score moved from definite difference to probable difference and the Sedentary Factor moved from probable difference to typcial.

Getting IM Training

A reader of this blog wrote and asked about getting IM Training. Here is some info for those who are thinking about getting started.

There are 2 modes of training: Interactive (alone) and Workshop (in a group). As usual, there are tradeoffs.

If you have access to the IM equipment, then doing the interactive training is a great option. For $225 (or so), you are sent an excellent training manual with 12 lessons, each 30-90 minutes in length, of hands-on training. Most people complete the training in 4-6 weeks. The beauty of doing this is that you will experience the effects of using the product 2-3 times per week for several weeks. The OTs in my clinic found that doing our own course of IM helped us to get our own gears in sync and allowed us to move forward with projects. (For me, it was my blog.)

The workshop is very vaulable for the instructor contact. (I'm sure I missed a lot by not attending the workshop!) and you learn how to facilitate IM in just 48 hours. (And of course, you can then do your own hands-on training later).

Be aware that the IM equipment costs over $3,000. For that price you get hardware (that hooks to your computer), software, headphones, and hand and foot triggers. In addition to the initial equipment cost, the company charges about $6-8/hr for use of the system. You buy blocks of time from IM so that you can treat your clients. In fact, the real cost for a client's session is much less than $6-8, because the IM clock runs only during active clapping.

By the way, the trainees who purchase the Interactive course are given enough minutes to complete the course.

Parents of kids with Autism

I mentioned in an earlier blog that I am engaged in a small research project. There are 10 parents doing a course of Interactive Metronome. At the start of the study, we gave the parents 2 assessments: The Parental Stress Inventory (PSI) and the Sensory Profile for Adults. I recently scored the PSI and was surprised to see just how high the stress levels are. All of the scores were high and some were literally off the scoring charts. Our clinical director, a psychologist, has analyzed the PSIs and she said that she was gratified to see that in spite of the high stress, there was equally high parent-child attachment levels.

As for the Sensory Profile, most were typical. But 2-3 showed sensory issues.

White Matter

This month's Scientific American (March 2008) has an article called, "White Matter", by R. Douglas Fields about myelination in the brain and how that process affects development. As you know, myelin is white matter - the sheathing around neural axons that protects signals and speeds them up. Turns out that myelin has other properties/functions, too, of which I will just briefly describe.

In order to be effective, myelin must have exactly the right amount of sheathing around its neuron's axis. Too much or too little and the signal's timing gets messed up. Pretty critical! It turns out that neurons have a constant ratio (.6) for the thickness of an axon to the thickness of myelin sheathing wrapped around it. Somehow the developing brain cells are able to place the myelin down to the exact prescribed thickness. Except, of course, when they get it wrong, which they do with various developmental disorders, cerebral palsy, ADHD, language disorders, autism, bi-polar disease, schizophrenia and so on, including pathological lying(!).

The brain puts the myelin in place slowly over the years starting in the back (shirt collar) at an early age to the front (temples) by age 28-30. The brain forms and prunes itself until the sheathing is done, and then things are pretty well set - barring the phenomena of plasticity, which is a much subtler process. By the time a child turns 4, the myelin has been fully wrapped around the neurons in the visual cortex (so that is the optimal time to have vision therapy complete - but we rarely note problems by then!)

The author explains that the lack of sheathing on the pre-frontal cortex - executive function - is what prevents teenagers from making mature decisions -- that area is still developing and the lack of myelin means that the timing in the area is just not working yet.

The implication for practice with children is that there are critical times for completing therapies. Just as a person learning a second language after age 11 will retain an accent whereas a 10 year old child will not, there are developmental (and other) issues that can be repaired, adapted, etc. if caught before the final myelination takes place. Intensive practice in certain ways (Fields uses learning a musical instrument as a child for the example) will increase myelin thickness (probably because the axon grows wider, too), and this may allow for an impacted area to correct itself.

We can see why early intervention is critical. The author did not identify the critical age for various regions in the brain other than those given above. We will be waiting with baited breath for more particulars!

Fields also discussed the role of insufficient myelination in the pre-frontal cortex (during the teenage years) on the onset of bi-polar disease and schizophrenia. He described the failed process and the role of mutated genes.

Good article - can't wait for greater detail.