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.
Wednesday, December 30, 2009
Monday, November 16, 2009
Weighing in on Asperger's
With the DSM-V powers-that-be thinking about removing the Asperger's diagnosis from the DSM next edition, it's time for all of us to weigh in our two cents. Here's mine.
The Asperger label is critical to the people who are diagnosed as such. With the label, researchers can more readily target them as a group for study and treatment. Employers see the label and understand the constraints. Therapists see the label and can get right to work on appropriate therapies.
Let's look at it. There are 3 categories of autism that make a difference to me when I treat children:
- True autism with it's social and communication issues.
- PDD-NOS - a form of high functioning autism in which children can get rid of many, many symptoms with multiple therapies to the degree that you can no longer tell that it's autism.
- Asperger's - the other form of high functioning autism with good language skills, the desire to interact with others and a lack of understanding social rules (making interaction very challenging).
The authors of the DSM complain that it is difficult to distinguish Asperger's from autism and that that is the reason that the diagnosis can be removed. I disagree. A child with Asperger's has very good language skills (and in fact can be a chatterbox). Also, he/she lacks social skills in a different way than a child with typical autism does. The child with autism does not typically care to have social interaction and is content in his/her world. The child with Asperger's desperately wants friends but is often clueless on how to get and keep them.
These are easily observed differences. I say leave Asperger's in. And by the way, the same set of arguments are going to apply to PDD-NOS. Leave it in, too.
On another day, I'll talk about the impact of sensory, modulation, ADHD and obsession/compulsion comorbidity.
The Asperger label is critical to the people who are diagnosed as such. With the label, researchers can more readily target them as a group for study and treatment. Employers see the label and understand the constraints. Therapists see the label and can get right to work on appropriate therapies.
Let's look at it. There are 3 categories of autism that make a difference to me when I treat children:
- True autism with it's social and communication issues.
- PDD-NOS - a form of high functioning autism in which children can get rid of many, many symptoms with multiple therapies to the degree that you can no longer tell that it's autism.
- Asperger's - the other form of high functioning autism with good language skills, the desire to interact with others and a lack of understanding social rules (making interaction very challenging).
The authors of the DSM complain that it is difficult to distinguish Asperger's from autism and that that is the reason that the diagnosis can be removed. I disagree. A child with Asperger's has very good language skills (and in fact can be a chatterbox). Also, he/she lacks social skills in a different way than a child with typical autism does. The child with autism does not typically care to have social interaction and is content in his/her world. The child with Asperger's desperately wants friends but is often clueless on how to get and keep them.
These are easily observed differences. I say leave Asperger's in. And by the way, the same set of arguments are going to apply to PDD-NOS. Leave it in, too.
On another day, I'll talk about the impact of sensory, modulation, ADHD and obsession/compulsion comorbidity.
Monday, November 2, 2009
NAC National Autism Report
I am still coming to grips with the National Autism Center's 2009 report on effective treatments for autism. The group is very influential, but it is a self-interest group made up primarily of behavior analysts. The executive director, Susan M. Wilczynski, Ph.D., BCBA, is a certified behavior analyst (think ABA-style therapies), as are the bulk of the project team that designed the study and reviewed the research articles. I question the impartiality of this study.
Here is my main beef: Articles were only considered for review if they were specifically about autism. From an OT perspective, that leaves out the bulk of our research since the research we do is broad and includes children with many disorders. Our research typically works with specific symptoms rather than patient groups. So when the NAC study looked for effective treatments for motor skills, they did not include the considerable wealth of research performed by OTs and PTs. In fact, the study's outcome did not see the need for OT intervention. Somebody missed something, I think.
And there is a parallel case for considering the area of sensory processing research. There are many, many studies in this area. If you look at my last blog entry, you will see that children with ADHD and anxiety have many of the same symptoms as children with autism. So again, our research covers, as it must, broad groups of children.
Now ABA treatments, on the other hand, were all developed specifically for children with autism, and so the study appears to be biased in favor of this treatment research. But unfortunately other psychology-based treatments such as Floortime and P.L.A.Y. (also developed for children with autism) did not make it through the study review process in as good a standing. Their treatments were found to be "emerging". I hope that this is not yet another case of "convenient" study design.
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.)
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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.) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Thursday, October 22, 2009
Match, Repeat and Emote
This past summer I attended a wonderful workshop by James McDonald, PhD. His latest book is Communicating Partners and it demonstrates his technique of how to increase communication skills in non-verbal or lo-verbal children. The gist of his method is to engage the child in an activity by imitating the child's sounds and gestures and then adding meaningful words and phrases about the activity itself. The example of an activity that he uses is to rock a sleeping doll in it's cradle. The outcomes that Dr. MacDonald has experienced for the past 30 years is true speech and social interaction from the child.
The clinic I work at (Building Bridges Therapy Center, in Plymouth, MI) sponsored Dr. MacDonald and encouraged our parents to take part in family sessions with him while he was in residence. One of my non-verbal clients, Jack, was part of this, and we began to see increased interaction. More than that, we saw a way "in" to a highly challenged child.
As the weeks went by, goals came and went, and we therapists sometimes forgot to use the match and repeat method. But Jack is so challenging, that I continued to make this therapy my number one form of treatment for him.
Jack will answer to his name and display joint attention for a few seconds. He can speak multiple words at a time (not necessarily sentences), but is mostly lost in his own experience. His primary interest is in stimming with his favorite object. It is possible to get Jack's attention by putting him into a Belkin suit and demanding his presence. With a great deal of pressure and persistence he can be made to work in this mode. However, he does not like it, and he screams and whines to make sure that the therapist knows this.
Right after the workshop with Dr. MacDonald, I tried to hone my skills in the new practice with Jack. He responded fairly well, but he still screamed his ear-splitting screams, making it all a lot of work. The resistance I received was so strong as to make me question continuing this approach.
Then I tried something a little different. Jack came in and went to our big, green bench swing near the mirror. I gently pushed him back and forth. He spoke some words, I repeated. We made faces, we even had an amazing eight "sentence" interchange. After that, we kept swinging, while I said words like "happy", which he repeated with a smile. This lasted 8-10 minutes, then he was done and ready to run around the clinic aimlessly like a wild guy.
I took his hand and we went to a cabinet to get a worksheet. He grabbed one of my card decks. We sat at the table, I took the deck and placed it aside, telling him it was time to work. (I don't typically take things from kids.) He protested, tried to grab it back and looked like he was going to have a meltdown. Without even thinking about it, I held him tightly, rocked him and then began to emote for him. I very calmly said what I thought he was thinking. "I want the cards. What do you think you are doing? Gimme those. Who do you think you are? Those are my cards. I am very unhappy about this." and on and on. We stayed this way for 4-5 minutes with me holding him. He squirmed and protested but did not melt.
The remainder of the session went much the same with breaks every now and then for him to play freely. At the end, he went out to his mother, protesting (but not screaming) to her. She had a favorite transition object (we had agreed on) to catch his attention. We got his shoes on and got him out the door. The transition object was a God-send. He had worked hard enough. No one wanted a meltdown at this point.
It was a very difficult session, I was going by the seat of my pants the entire way. But it felt like a success for both of Jack and I. We had conversations, shared our feelings and played. There were no meltdowns. That's a lot for a feisty, non-verbal guy who is buried inside.
(Followup one week later: Jack's mother reported that he had had a very good week with behavior. His session this week was memorable in that he was happy the entire time. No melt downs, no transition issues. Let's see if this is a fluke or it continues to hold...)
The clinic I work at (Building Bridges Therapy Center, in Plymouth, MI) sponsored Dr. MacDonald and encouraged our parents to take part in family sessions with him while he was in residence. One of my non-verbal clients, Jack, was part of this, and we began to see increased interaction. More than that, we saw a way "in" to a highly challenged child.
As the weeks went by, goals came and went, and we therapists sometimes forgot to use the match and repeat method. But Jack is so challenging, that I continued to make this therapy my number one form of treatment for him.
Jack will answer to his name and display joint attention for a few seconds. He can speak multiple words at a time (not necessarily sentences), but is mostly lost in his own experience. His primary interest is in stimming with his favorite object. It is possible to get Jack's attention by putting him into a Belkin suit and demanding his presence. With a great deal of pressure and persistence he can be made to work in this mode. However, he does not like it, and he screams and whines to make sure that the therapist knows this.
Right after the workshop with Dr. MacDonald, I tried to hone my skills in the new practice with Jack. He responded fairly well, but he still screamed his ear-splitting screams, making it all a lot of work. The resistance I received was so strong as to make me question continuing this approach.
Then I tried something a little different. Jack came in and went to our big, green bench swing near the mirror. I gently pushed him back and forth. He spoke some words, I repeated. We made faces, we even had an amazing eight "sentence" interchange. After that, we kept swinging, while I said words like "happy", which he repeated with a smile. This lasted 8-10 minutes, then he was done and ready to run around the clinic aimlessly like a wild guy.
I took his hand and we went to a cabinet to get a worksheet. He grabbed one of my card decks. We sat at the table, I took the deck and placed it aside, telling him it was time to work. (I don't typically take things from kids.) He protested, tried to grab it back and looked like he was going to have a meltdown. Without even thinking about it, I held him tightly, rocked him and then began to emote for him. I very calmly said what I thought he was thinking. "I want the cards. What do you think you are doing? Gimme those. Who do you think you are? Those are my cards. I am very unhappy about this." and on and on. We stayed this way for 4-5 minutes with me holding him. He squirmed and protested but did not melt.
The remainder of the session went much the same with breaks every now and then for him to play freely. At the end, he went out to his mother, protesting (but not screaming) to her. She had a favorite transition object (we had agreed on) to catch his attention. We got his shoes on and got him out the door. The transition object was a God-send. He had worked hard enough. No one wanted a meltdown at this point.
It was a very difficult session, I was going by the seat of my pants the entire way. But it felt like a success for both of Jack and I. We had conversations, shared our feelings and played. There were no meltdowns. That's a lot for a feisty, non-verbal guy who is buried inside.
(Followup one week later: Jack's mother reported that he had had a very good week with behavior. His session this week was memorable in that he was happy the entire time. No melt downs, no transition issues. Let's see if this is a fluke or it continues to hold...)
Monday, October 19, 2009
ADHD Overfast Response to Tapping
When I have children with ADHD get started on an IM program, I automatically adjust the tempo to 63 beats per minute rahter than the standard tempo of 54. Why, they almost always over-anticipate the beat with the standard tempo and so miss clapping or tapping in rhythm. But when I change it to 63, most find their sweet spot and can perform admirably. IM's recently released bibliograpy of temporal studies points to research that came to the same conclusion. Check it out. That paper and others are found at this site. Here is the citation:
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.
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