Autism Treatments: Parent-Child Interaction Therapy.

Study provides evidence of the effectiveness of the Parent-Child Interaction Therapy for children with Autism.

A review of: Solomon, M., Ono, M., Timmer, S., Goodlin-Jones, B. (2008). The Effectiveness of Parent–Child Interaction Therapy for Families of Children on the Autism Spectrum. Journal of Autism and Developmental Disorders DOI: 10.1007/s10803-008-0567-5

The authors of this ‘in press’ manuscript reported the results of a study examining the effectiveness of Parent-Child Interaction Therapy for children with autism. This intervention was first proposed by Eyberg et al in 1995 and consists of a manualized parent coaching intervention for children age 2 to 7. This intervention was not initially developed for children with autism and instead was focused on helping parents with children with behavioral disorders. The intervention consists of live coaching sessions, during which parents interact with their children inside a room with a one way mirror. Behind the mirror a parenting coach provides live feedback via a microphone that is linked to earphones provided to the parents. The goal of the sessions is to help parents provide immediate reinforcement of positive behaviors while ignoring (extinguishing) dysfunctional behaviors. This study used a waiting-list control group design. That is, families were randomly assigned to one of two groups: a treatment group receiving the intervention, or a control (waiting-list) group which would receive the intervention later. The study included 19 children with an ASD diagnosis obtained via ADI-R. Ten children were assigned to the treatment group (6 AS,6 HFA)and nine were assigned to the waiting list group (2 AS, 4 HFA, 2 PDD). The treatment lasted 12 sessions. After the intervention the children in the treatment group showed a statistically significant reduction of problem behaviors as reported by parents when compared to the control group. There was also a statistically significantly reduction of ‘atypicality’ and an increase in adaptability. Marginal significant differences were also observed in hyperactivity. Although these results are all based on parental reports, which is a methodological problem, the authors also found differences in affect display as coded from video tapes of the sessions. Specifically, the authors found an increase in positive affect by the parents and an increase in how many times child positive affect followed the parents’ positive affect. In sum, this study provides early but compelling evidence of the effectiveness of Parent-Child Interaction Therapy for children with Autism who experience behavioral problems.

Autism and Cholesterol: A possible link?

Low levels of cholesterol associated with autism-like symptoms in Smith-Lemli-Opitz Syndrome.

A review of: Aneja, A., Tierney, E. (2008). Autism: The role of cholesterol in treatment. International Review of Psychiatry, 20(2), 165-170. DOI: 10.1080/09540260801889062

The Smith-Lemli-Opitz Syndrome (SLOS) is a genetic disorder characterized by alterations in the processing of cholesterol. Specifically, people with this disorder do not produce enough cholesterol resulting in a variety of morphological, physiological, and behavioral symptoms. Of interest to autism researchers is that people with SLOS have many of the same symptoms that characterize autism spectrum disorders, including language impairments and stereotyped behaviors. How is cholesterol related to ASDs within and outside the SLOS syndrome? In this article, Aneka and Tierney (2008) present a succinct summary and conceptualization of the possible role of cholesterol in the phenomenology of Autism. The authors reviewed the physiological mechanisms by which low levels of cholesterol may play a role in the behavioral phenotype found in kids with SLOS. The following mechanisms were discussed:
1. Cholesterol is necessary for normal embryonic and fetal development.
2. Cholesterol is a precursor of neuroactive steroids (possibly affecting anxiety)
3. Cholesterol is required for the growth of myelin membranes (affecting brain maturation).
4. Cholesterol can be a modulator in oxytocin receptor functioning (Oxytocin plays an important role in social behaviors).
5.Cholesterol is a modulator of the ligand binding activity and G-protein coupling of the serotonin1A (5-HT1A) receptor (affecting serotonin neuron development).

An examination of these factors is beyond the scope of this review, but they represent a sensible theory regarding the possible mechanisms by which low levels of cholesterol may lead to many of the behavioral symptoms present in autism. The authors then discussed the implication of these findings for assessment and possible treatment interventions. First, most comprehensive evaluations of autism may include genetic and laboratory testing, including testing for fragile X, heavy metals, etc. The authors stated that biochemical testing can be utilized to assess for low level of cholesterol (actually low levels relative to another compound - 7DHC). In my experience, requesting this test within a neuropsychological evaluation is not common. Actually I don’t remember ever conducting an evaluation of someone who had been recommended this test by anyone (neurologist, pediatricians, psychologist, etc). Finally, the authors reviewed previous studies that have examined the effectiveness of cholesterol supplementation in children with SLOS. Previous studies have found that children with SLOS that receive cholesterol supplementation show a reduction of autistic behaviors, irritability, attention problems, and improved affect.

Should cholesterol testing become a part of the standard assessment procedures of children with Autism?

A teacher training program for children with Autism.

A review of: Probst, P., Leppert, T. (2008). Brief Report: Outcomes of a Teacher Training Program for Autism Spectrum Disorders. Journal of Autism and Developmental Disorders DOI: 10.1007/s10803-008-0561-y

This is a brief report of a preliminary study conducted in Germany examining the effectiveness of a training program for teachers of children with ASDs. The study included 10 children (7 boys; mean age 10) receiving services from 10 teachers (8 females). Each teacher taught one child with ASDs in a special education classroom for children with Mental Retardation (MR). Based on the Childhood Autism Rating Scale (CARS), six of the 10 child participants had severe autism, three had moderate autism, and one had mild autism. The training of the teachers consisted of understanding a basic theoretical model for ASD and learning a series of evidence--based skills to address the needs of children with Autism.

It also taught practical methods and educational skills for everyday life in the classroom by focusing on ‘‘antecedent interventions’’ (Bregman et al. 2005) and comprised methods of ‘‘structured teaching’’ (Mesibov et al. 2006) as well as related techniques of ‘‘visual supports’’ (Prizant et al. 2006). The ‘‘structured teaching’’ method contains five main content areas: (1) spatial and (2) temporal structuring of the child’s social and school environment, (3) implementation of a work-learning system, (4) structured design of tasks, and (5) implementation of visual communication aids.

The training included 3 sessions provided to 2 groups of 5 teachers each. Teachers assessed the behavior of the children before the training and 9 month after the initial training session. Assessment instruments included the Classroom Child Behavioral Symptoms Questionnaire (CCBSQ) and the Classroom Teacher’s Stress Reactions Questionnaire (CTSRQ). The results showed a significant reduction of behavior problems as measured by the CCBSQ and a significant reduction of teachers’ stress as measured by the CTSRQ after the 9 month period. This study provided some early, preliminary, evidence for the effectiveness of this teacher training program. However, when evaluating preliminary research reports such as this, readers should be aware of the standard limitations of this specific methodology. First, this study was conduced with volunteer participants who were all assigned to the experimental (teacher training) methodology. Thus, it is impossible to know whether the improvement was due to the teacher training program or simply to characteristics of the children participants. For example, it is possible that these children could have improved at the same rate in other classrooms with teachers who did not attend the training program. In addition, the outcome was determined by the same teachers who were not blind to the experiment. Thus, it is possible that their reports of improvement were affected by a subjective perceived (placebo-like) effectiveness that may or may not be reflective of actual behavioral changes.

More evidence against the Leaky Gut theory of Autism?

A review of: Cass, H., Gringras, P., March, J., McKendrick, I., O'Hare, A.E., Owen, L., Pollin, C. (2008). Absence of urinary opioid peptides in children with Autism. Archives of Disease in Childhood DOI: 10.1136/adc.2006.114389

Should parents of children with autism stop purchasing commercially available test of opioid-peptides?

In this previous POST I reviewed a simple study that examined the intestinal system of children with autism in order to test specific hypotheses related to the “Leaky Gut” theory. As is mentioned before, this theory suggests that children with autism have increased permeability of their intestinal track leading to faster absorption of peptides which could disrupt neural development during the early stages of life. However, the Robertson et al. (2008) article did not find evidence that would support the Leaky Gut theory. In this similar study, the authors compared 68 males with autism between 4 and 11 years of age to 202 typically developing males of similar ages. Autism was diagnosed via ADI-R based on ICD-10 diagnostic criteria. Only 6 of the children with autism were on special diets (gluten free or gluten and casein free). The researchers compared the levels of putative opioid peptides in the urine of all participating children. There was no significant difference between the peptide levels of children with autism when compared to typically developing children. The authors concluded that, given this apparent normative absorption and processing of peptides in children with autism, the presence of high opioid -peptides should not be used as a marker for autism or as an estimate of the possible effectiveness of gluten free diets. The researchers also indicated that previous studies showing high levels of opioid peptides in children with autism prior to the start of a gluten free diet (See for example Knivsberg et al 2002), have not been replicated mostly because of possible inadequate methods used in previous studies. The authors feel strongly that “Children with autism should not be subjected to investigation of urinary opioid peptides or their parents to the expense of the assays which are still widely advertised on the internet by commercial laboratories around the world”.

UPDATE: After I reviewed this study I received several emails from parents with different perspectives on the Gluten Free diet issue. I want to briefly note two things. The data from the Cass article do not directly address the issue of effectiveness of the gluten free diets or the issue of the use of peptide tests to predict treatment effectiveness (despite their strong statement against such tests). Their data simply fails to find support for one of the underlying assumptions of the Leaky Gut theory.

Someone also pointed me to what seems to be the only clinical controlled study of these treatments:

Elder JH, Shankar M, Shuster J, Theriaque D, Burns S, Sherrill L.( 2006) The gluten-free, casein-free diet in autism: results of a preliminary double blind clinical trial. J Autism Dev Disord. 36(3):413-20.

In this study, the authors also failed to find statistical evidence for improvement in children exposed to the gluten free diet for 12 weeks. However, this 2006 study was very preliminary with an extremely small sample size. There is no doubt that additional research is needed to help clarify the possible effectiveness of these diets.

Autism services in Canada and Neuropsychological evaluations

A review of:McLennan, J.D., Huculak, S., Sheehan, D. (2008). Brief Report: Pilot Investigation of Service Receipt by Young Children with Autistic Spectrum Disorders. Journal of Autism and Developmental Disorders DOI: 10.1007/s10803-007-0535-5

This is a brief report published in the Journal of Autism and Developmental Disorders. The authors contacted over 1,100 families who had obtained services from specialized clinics for children with developmental disabilities. The centers were located in Alberta, Canada. Sixty four of these families reported having at least one child with ASD. The authors examined the different services that these families received and compared these with the recommended practice guidelines. The percentage of families receiving specific services were as follows: Speech and Language assessment (94%), Psychological Assessment (42%), Genetic Testing (31%), Speech and Language therapy (88%), occupational therapy (78%). The authors concluded that the rates of services received did not correspond with the recommended practice guidelines. The authors reported the post-diagnosis evaluation guidelines as proposed by the American Academy of Child and Adolescent Psychiatry, the National Research Council, the American Academy of Neurology, and the child Neurology Society:
1. Screening for lead, tuberous sclerosis, and Fragile X
2. Neuropsychological testing (audiological function, cognition, adaptive function, and expressive-receptive language)
3. Occupational and physical therapy assessment if needed.

My clinical practice is in pediatric neuropsychology. While working at a large hospital in Michigan conducting mostly neuropsychological evaluations for children with ASD, I assumed that most families received this service. However, once I left that setting and was exposed to clinics that do not have neuropsychological services, I realized that only a small portion of these families receive a full neuropsychological evaluation. The reasons for this vary, from limited access to trained neuropsychologists, unfamiliarity with the possible benefits of these evaluations, and sadly, limited insurance coverage in some States. In my experience, if families are informed about the nature and limitations of these evaluations, Neuropsychological evaluations are very useful in helping coordinate and determine interventions that are targeted to the pattern of strengths and weaknesses of each child, and monitor the progress of the child over time. But I also agree that some families do not find these evaluations as useful.

Here are the sources of the guidelines:

Filipek, P. A., Accardo, P. J., Ashwal, S., Baranek, G. T., Cook, E. H. Jr., Dawson, G., et al. (2000). Practice parameter: Screening and diagnosis of autism: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society. Neurology, 55(4), 468–479.

National Research Council (2001). Educating children with autism. Washington, DC: National Academy Press.

Volkmar, F., Cook, E. H. Jr., Pomeroy, J., Realmuto, G., & Tanguay, P. (1999). ractice parameters for the assessment and treatment of children, adolescents, and adults with autism and other pervasive developmental disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 38(12 Suppl),
32S–54S.

The use of Virtual Reality in children with Autism

Title:Development of symbolic play through the use of virtual reality tools in children with autistic spectrum disorders
Source:Herrera, G., Alcantud, F., Jordan, R., Blanquer, A., Labajo, G., De Pablo, C. (2008). Development of symbolic play through the use of virtual reality tools in children with autistic spectrum disorders: Two case studies. Autism, 12(2), 143-157. DOI: 10.1177/1362361307086657

In general, I tend to stay away from case reports (studies using one or just a couple of participants). Usually I don’t even read them, since most of the time I feel that, given what we know about methodology today, case reports should not even be published. I say ‘most of the time’ because once in a while a case report is published that reminds me why case reports are important: to provide us with insight as to where future research could focus. So I want to briefly review a case report published in the last issue of Autism as simply food for thought.

Clinically, the absence of pretend play in early childhood is one of the most common features of ADSs. Parents report that their children do not engage in imaginary or pretend play and do not use toys as expected when play requires symbolic understanding. For example, when provided with a box of Star Wars figurines, a child may simply line up the figures making patterns on the floor and may not use the figures to recreate situations or scenes as expected. The assumption is that the child does not view the figures as symbolic representations of people. The authors of this paper wanted to use Virtual Reality as a tool to teach children with autism to use symbolic play. There is some evidence that suggest that symbolic play is of significant importance for the development of several cognitive skills including language, spontaneity, intention, etc. Thus, the authors argued that interventions that teach children to use symbolic play could be of benefit to children with ADSs.

The authors used a computer virtual reality game “the Virtual Supermarket” to teach children to move from physically manipulating the objects (picking up items from the shelves), to engaging in functional play (dressing a doll with miniature clothing), to finally engaging in symbolic play (using a pair of trousers as an imaginary road). The authors used this game with two children, age 8 and 15, who had been diagnosed with Autism based on DSM-IV criteria. The two individuals received 28 sessions of this type of games during 2 ½ months. They were tested on a variety of measures before and after the intervention period. The authors stated that after the intervention period the children demonstrated improvement in functional use of objects, functional play (measured via the Test of Pretend Play – ToPP), symbolic play (ToPP), imagination understanding, and magic understanding.

Although this study suffers from the common limitations of case studies, it is extremely interesting, and it should encourage future research in the use of virtual reality as an intervention tool for the teaching of symbolic understanding.

Autism and Spontaneous Communication

Title: Communicative spontaneity of children with autism: A preliminary analysis
Source:Chiang, H. (2008). Communicative spontaneity of children with autism: A preliminary analysis. Autism, 12(1), 9-21. DOI: 10.1177/1362361307085264

The author of this preliminary study wanted to explore the factors that are associated with communicative spontaneity in children with autism. Communicative spontaneity usually refers to “uncued communication”, or communication that is child-initiated and not elicited by direct prompts (questions, requests, etc). The author commented that although current treatments interventions have been effective in teaching communication skills in some non-verbal children, teaching spontaneity has been much more difficult. The participants included 32 children and pre-adolescents with a previous autism diagnosis (unclear how this was determined) but the diagnosis was confirmed via the Childhood Autism Rating Scale (Mean 38.9 with a range of 30-48.5). The children were observed in various naturalistic settings at school, including class time, lunch time, free play, circle time, etc. The video tapes of these kids were then analyzed to determine the type of communication interactions observed. The author divided communication spontaneity into 4 levels representing degrees of spontaneity as a function of the antecedents of the communication. Level 1 represented the most spontaneous communication, that is communication that was merely preceded by natural cues, such as the simple presence of an object or person. Level 4 represented the least spontaneous communication, such as communication preceded by a direct prompt (instruction, physical prompt, etc). The authors found that “surprisingly” most acts of communication coded were at the highest level of spontaneity (unprompted). This may reflect the frequency of antecedents available. For example, a child may have many more opportunities to make spontaneous comments about an object (high level of spontaneity) than in response to a teacher instruction (low level of spontaneity). But the results clearly show some level of spontaneous communication in this sample of children. The authors also found that most spontaneous communicative actions were in the “rejecting” or “requesting” domains as opposed to other domains such as greeting, farewell, or comments. From a behavioral perspective, the rejecting and requesting communicative actions have a more clear reward contingency (immediate result), which may help increase the rate of these behaviors. On the other hand, the contingency for "greetings" and "farewell" actions seem less clear, and arguably more social, which may explain the low rates of these behaviors. This is an interesting (I know, albeit a bit predictable) finding that could inform the design of communication interventions in children with autism.

Clonidine and Sleep problems in children with Autism

Title:Use of clonidine in children with autism spectrum disorders.
Source:MING, X. (2008). Use of clonidine in children with autism spectrum disorders. Brain and Development DOI: 10.1016/j.braindev.2007.12.007

In this study the authors wanted to evaluate the effectiveness of clonidine in the treatment of insomnia and other behavioral difficulties in children with autism spectrum disorder. The researchers evaluated 19 children with a diagnosis of ASDs obtained via ADI and ADOS. The researchers assessed sleep and behavioral problems as reported by the parents before and during the initiation of the treatment. Seventeen of the 19 children had sleep difficulties including prolonged sleep initiation and or difficulty maintaining sleep. All children with difficulty falling asleep (16) were able to fall asleep faster after taking the medication. In addition 16 of 17 children with sleep maintenance problems had a reduction in the frequency of awakening during the nights. The authors concluded that clonidine was effective in managing sleep difficulties in this sample of children with ASDs. However, the authors also correctly noted some major limitations of this study. This was an open label retrospective study. Open label means that all participants knew which medication they were taking. Under ideal conditions, such as in a randomized double-blind placebo study, both the clinicians and the patients are blind to what medication (or placebo) they are taking, which greatly increases our ability to reach conclusions about the true effects of the medication. In an open label study, there is always the possibility that the results are not due to the actual effect of the medication but to a ‘placebo’ effect.

Autism, Services, and Co-morbidity: Insights from Kansas. PART I

Title: Characteristics of children with autism spectrum disorders who received services through community mental health centers.
Authors: Stephanie A. Bryson, Susan K. Corrigan, Thomas P. Mcdonald, and Cheryl Holmes
Source: Autism 2008 12: 65-82. (January).

Note: Co-morbidity refers to the presence of two conditions simultaneously. For example, depression has high co-morbidity with anxiety, since often people with depression also have anxiety. In research, we use the term to refer to the presence of two separate diagnoses simultaneously.

NOTE 2: This is such an interesting paper that I decided to break it into at least two review posts.

This is a basic epidemiological study from the University of Kansas that gives us some interesting data about co-morbid psychiatric disorders in children with ASDs. What services and diagnoses are obtained by children with autism, Asperger’s, PDD NOS and other childhood developmental disorders? In order to answer this question the authors examined community mental health records of 26 community centers in Kansas, through the use of a new electronic health record system that allows for the sharing of medical information between the different health centers(the great importance of such system and its possible implications for privacy violations is a very interesting topic, but a better match for a different blog). The researchers compared children who in 2004 received a diagnosis of Autism with children who received a diagnosis of a different ASD (PDD-NOS, Asperger’s). The two groups were then compared in a number of demographic factors, service use, and co-morbid diagnoses. The first amazing finding: Using very conservative estimates of autism rates (5.5 in 1000 CDC), the authors found that the Kansas community mental health system served less than 3% of children with Autism in the State and less than 15% of children experiencing other types of ASD. What happened to the 97+% of children with autism who did not receive services through the community mental health system? The authors indicated that it is possible that most children with autism in Kansas receive adequate services through the school or other State systems, so they have no need to seek services through the community mental health system. It is also possible that these children receive services privately (private ABA, therapists, evaluations, etc). Finally, a number of these children may simply not be receiving services at all. Unfortunately, the data in this paper do not help us clarify these issues. The data only tell us that less than 3% of children with autism received services through the community mental health system in the State. Is the community mental health system simply underutilized by parents of children with ASDs? Or is it simply that this system does not meet the needs of children with ASDs so that essential services are actually obtained somewhere else?

Facial Expression Recognition in Autism

Title: Recognition of immaturity and emotional expressions in blended faces by children with autism and other developmental disorders.
Author: Thomas Gross. University of Redlands. California
Source: Journal of Autism and Developmental Disorders (2008) 38, 297-3111.
Note: This article consisted of 2 studies. Here I present only the results of study #1.

A refreshing break from the vaccine controversy. In this wonderfully designed study Dr. Gross examined the ability to recognize “immaturity” (age) and emotional expressions by children with a variety of developmental disorders. The researcher compared children with autism (20), mental retardation (18), language disorders (18), and a group of typically developing kids (18). After some necessary training, the children were presented a series of 3.5 x 5 photographs. For the testing of emotional expressions, the pictures consisted of a person’s face showing a specific emotion (happy, sad, or angry) followed by a group of pictures of a blended faces. Blended faces were created by uniting the top and bottom of two photographs so that the eyes (upper part) of the face belong to someone, while the lips area came from someone else’s photograph. These faces sometimes matched in their emotional presentation (for example top angry –bottom angry) while sometimes they presented a mismatch (for example top angry – bottom happy). The child was then asked which of the pictures (blended faces) showed someone feeling just like the picture presented before (non-blended face). For the testing of immaturity (age), the first photographs consisted of pictures of a child’s face or that of an adult’s face, followed by a blended face (for example top child – bottom child or top child – bottom adult). The child was then asked which of the blended faces showed someone the same age as the picture presented before (non-blended face). Children with autism identified fewer correct pairings (first picture to blended picture) of both “emotion” and “age” than typically developing children and children with language impairment; but their performance was not significantly different (statistically) than that of children with mental retardation. However, there was a qualitative difference in the type of errors made by the groups. When identifying facial expressions, children with autism were less likely to attend to the upper portion of the face and more likely to attend to the lower face than children in all other 3 groups. This suggests that the deficit in facial expression recognition unique to children with autism may be due to differences in the processing of facial feature information. These results suggest that while typically developing kids, as well as kids with MR and language delays use the entire face to make decisions about facial expressions, children with autism seem to focus only on the lower portion of the face, possibly missing key social information presented by other parts of the face. This may inform treatment intervention design.

Autism and Fevers: First scientific evidence of improved functioning during fever episodes.

Title: Behaviors Associated with fevers in children with Autism Spectrum Disorders
Authors: Curran, L., Newchaffer, C., Lee, L., Crawford, S., Johnston, M., Zimmerman, A.
Source: Pediatrics 120, 2007.

This article was published in the January issue of Pediatrics by a team at Johns Hopkins University. The study attempted to examine a unique observation commonly reported by parents and clinicians: children with autism seem to improve when they have fevers, especially in regards to their social behaviors. The authors followed about 100 children with autism. During the duration of the study 40 of these children developed a fever. These 40 children were then compared with other children with autism of similar ages but who did not develop a fever during the same time. The authors found that during the episodes of fever the parents reported a significant improvement in irritability, hyperactivity, stereotypy, and inappropriate speech. This was not simply the result of the kids being so sick they couldn’t move, since these children also experienced less lethargy! Unfortunately all improvements were temporary, and ended after the children no longer had a fever. This is the first study to show empirically a phenomenon that parents and clinicians have been reporting. Unfortunately, currently there is no cohesive theory that would explain how or why kids with ASD improve during episodes of fever. We need to wait for more specific research to could show the possible mechanism by which fever temporarily helps to improve these behaviors.

Relationship Development Intervention and the Cure controversy

Title: Evaluation of the Relationship Development Intervention Program
Authors: Steven E. Gutstein, Audrey F. Burgess and Ken Montfort
Source: Autism 2007; 11; 397

The Relationship Development Intervention (RDI) program was created at the Connections Center in Houston, Texas. The program consists of an intense parent-based training system that helps children improve in domains that are usually challenging for children with ASD (sensory, cognition, emotional processing, etc). The program is administered primarily by parents after completing a number of training sessions. This particular study, conducted by the same creators of the RDI at the Connections Center, examined the effects of the program in 16 children who were originally diagnosed with ASD via ADOS assessment. The researchers found that 2 years after the initiation of the program, NONE of the 16 children met ADOS criteria for Autism. Specifically, 10 children were now in the “non-autism” category and 6 met criteria for “autism-spectrum” only. That is, they had some symptoms but not enough symptoms to receive a full Autism diagnosis. This provides us with some early promising data on the effectiveness of this program but there is still much we need to know about this system. For example, how does it compare in effectiveness to a traditional ABA program, a school intervention program, etc? I am sure that the authors will eventually conduct the necessary comparative studies that will then help us answer these questions. This study also brings another more philosophical issue; a sensitive question that is beyond the purpose of my notes: if a child no longer meets the criteria for autism, does the child still have autism? If not, does this mean the child was ‘cured’. Most clinicians and researchers will say No. The fact that the child is functioning as a typically developing child does not necessarily mean that the child does not have the bio-social markers of autism. The general consensus is that autism can not be “cured” but that some children can, with proper intervention, eventually function as any other typically developing child. Although some people will argue this is just a debate over semantics (what is the meaning of “cured”), some researchers will argue that the question of “curability” goes well beyond something as simple as differences in definitions, and really speak to the nature of autism as a neurological disorder.

Small Group Training in High Functioning Autism

Title: Improving question asking in high-functioning adolescents with autism spectrum disorders.
Source: Autism 2008; 12; 83

An interesting study by Annemiek Palmen, Robert Didden and Marieke Arts in the Neatherlands. They implemented a 6-weeks small group training program with young adults with high functioning autism. The sessions were 60 minutes long once per week. The focus of the sessions was improving “question asking” techniques, which were practiced mostly during role play situations. The authors found that the total number of appropriate questions asked by the participants during mock naturalistic conversations increased significantly after the short training program.

There was something very unique about this study and training method. The clinicians taught the participants to use a flowchart that helped them make decisions regarding when and how to ask questions during conversations. The flowchart was not specific to any topic so that the participants could apply it to any conversation. It is promising that, not only there was a clear improvement in how well the participants asked questions during normal conversations, but that this improvement seemed stable, at least 3 weeks following the study. That is, the researchers conduced a follow up evaluation 3 weeks later and found that the participants continued to show improvements in their question asking skills.

Joint attention training seems effective

Title: Children with autism's response to novel stimuli while participating in Interventions targeting joint attention or symbolic play skills
Authors: Amanda C. Gulsrud, Connie Kasari, Stephanny Freeman and Tanya Paparella
Source: Autism 2007; 11; 535

In this well designed study the researchers randomly assigned 35 children (average age 3.5 years) to one of two treatment groups: a group focused on joint attention training or a group focused on symbolic play training. After the 8 week training program the children were exposed to a new visual and auditory stimulus (bouncing ball for example). The researchers found that kids involved in the joint attention training program showed better shared interactions as measured by joint attention behaviors (following someone's else gaze, pointing, etc). The major implication of this study is that specific joint attention training interventions seem to be effective in improving joint attention skills in children with autism. Here is a nice graphic example of joint attention: Joint Attention Picture

Difficulty coping with changes may lead to anxiety in adults with Autism.

Title: Levels of anxiety and sources of stress in adults with autism.
Authors: Gillott, Alinda; Standen, P. J.
Source: Journal of Intellectual Disabilities. Vol 11(4) Dec 2007, 359-370.

Almost all research in autism is done with children, so it is always great to see new studies being conducted with adults. This study compared 34 adults with autism with 20 adults with intellectual impairment only. Although the two groups were equal in their intellectual abilities, adults with autism had much higher (3 times) levels of anxiety than adults with intellectual impairment but not autism. The factor that was most highly associated with stress for the adults with autism was their inability to cope with change. That is, those adults with autism who had most difficulty coping with change were also the adults who experienced the most anxiety. This has implications for treatment focus, specially for adults experiencing significant levels of anxiety. Specifically, adults with autism who experience anxiety may benefit from treatment interventions that address their ability to cope with changes.

More evidence for early intervention.

Title: Early intensive behavioral intervention: Outcomes for children with autism and their parents after two years.
Author: Remington, Bob; Hastings, Richard P; Kovshoff, Hanna; degli Espinosa, Francesca; Jahr, Erik; Brown, Tony; Alsford, Paula; Lemaic, Monika; Ward, Nicholas. University of Southampton UK.
Source: American Journal on Mental Retardation. Vol 112(6) Nov 2007, 418-438.

A well designed study from the UK provides some evidence of the effectiveness of intense early behavioral intervention. The researchers compared two groups of pre-school children with autism. The first group consisted of children undergoing, by parental choice, an early intense behavioral intervention program. The second group consisted of children undergoing “treatment as usual”. This mean, these children were not denied treatment, but instead simply experienced the treatment and or resources generally available to parents. Although these two groups were not different from each other when the treatment began, 2 years later the group undergoing intense behavioral intervention showed greater improvements in intelligence, language, daily living skills, and positive social behavior. One thing should be noted though. This was not a traditionally experimental study during which the kids were randomly assigned to either the intense treatment group or the treatment as usual group. Instead, the groups were identified based on what parents “preferred”. This means that there is a remote possibility that part of these findings are due to differences related to parents who chose to be in the intensive program as compared to parents who did not opt for the program. That is, it is possible (but unlikely) that kids in the intense behavioral program did better than the other kids not necessarily because of the effectiveness of the program, but because of some family-parental characteristic that also made the parents more likely to choose the intense behavioral program. This alternative interpretation must always be considered when studies can’t conduct a full random assignment of the families to the groups that will be compared.

UPDATE: I was asked to clarify what was the nature of the intense behavioral program. This was a classic 20-30 hours per week one on one program based on applied behavior analysis.