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 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

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

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...)

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.

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.