Autism and Other Neurodevelopmental Disorders

Autism and Other Neurodevelopmental Disorders

R.L. Hansen & S.J. Rogers (Eds.)

Washington, DC:  American Psychiatric Association, 2013.

 

As an educational psychologist working in Hong Kong I am often asked by parents as well as colleagues to recommend books and or websites that may be useful for children that have various developmental difficulties such as ADHD, dyslexia and autism spectrum disorders. The book that is reviewed below is one of the more concise available that deals with autism. It is from some very respected authors particularly from our research standpoint.

Sometimes it is more practical to have reference books that are small and light and easy to transport and are thus readily accessible.  Autism and other Neurodevelopmental Disorders is an up-to-date concise reference book written by high profile medical members of the MIND institute, California and other colleagues spanning related fields.  The book is divided into 11 chapters, clearly summarising evidenced based detail on the most common neurodevelopmental disorders.

Chapters are structured in a guise that seems logical given the medical authorship of the book.  The autism chapter is, as expected, proportionally the most substantial and sits at the start of the book.  As a psychologist reviewing the book, the discussion of evidence based approaches versus the more speculative approaches reassuringly appears well balanced and informed.  Chapters are finished with ‘key point’ summaries, which allow for quick consolidation of information and increase appeal across the span of audience types.

Such a book would be useful when preparing training, or when referencing clinical work.  The book may be quite expensive for non-clinical individuals, but more easily justified by clinicians with a specialist focus who anticipate regular reference to the book or for shared use within clinical teams.

 

 

Emotion Regulation in Autism Spectrum Disorders

Difficulty regulating emotions has not always been defined as a significant feature of autism spectrum disorders, but there is growing evidence that emotional problems play a prominent role in this disorder. Hong Kong is no different as many children who are referred have difficulties with controlling their mood and emotions. This is also the case for children that have related disorders such as ADHD.

In a recent study published in the Journal of Child psychology and psychiatry a wide range of emotional regulation strategies were examined in children and adolescents with autism spectrum disorders and were compared to typically developing peers in 3 emotional domains (anger, anxiety, and amusement). Parent interviews and child daily diaries were used to examine emotional experience in the use and efficacy of 10 emotional regulation strategies. Children and adolescents with autism spectrum disorders had significantly different emotional regulation profiles compared to typically developing children in all 3 emotional domains, characterized by less frequent use of adaptive methods (problem solving, cognitive reappraisal) and more frequent use of maladaptive strategies to control their emotions (repetitive behaviors).

This study adds to the already growing body of literature documenting that individuals with autism spectrum disorders (as well as ADHD) have maladaptive emotional regulation profiles. The above study is consistent with with my clinical experience working with both children that have autism spectrum disorders as well as ADHD in Hong Kong. In most cases when high functioning individuals on the autism spectrum (Asperger’s syndrome) are referred when they are adolescents or young adults, one of the common concerns is how to deal with high levels of anxiety that are having a negative effect on their functioning.

Hopefully the above research will offer some insight that will improve individual interventions that promote wider understanding and contribute to the evelopment of more adaptive strategies to help individuals with ASD manage their mood and emotions.

Peer Training for Children with Autism

A recent study (journal of Child Psychology and Psychiatry) found that when children with ASDs received playground social skills training from other children rather than a teacher or therapist, they showed greater improvement in social connectedness.  Specifically, children with ASDs in general education classrooms who received peer coaching were less isolated, more likely to make friends and showed greater social skills in the classroom.  “The model where an adult works directly with a child with autism just wasn’t as effective” as lessons from peers, says the study’s principal investigator, Connie Kasari.

As a strong advocate for using peers as trainers to help ASD children socialize I’m pleased to see additional research supporting this as a viable treatment option. I have used this methodology in our inclusive kindergarten programme extensively and my research also provides strong support for using peers. Please refer to the main website under Services “Inclusive Kindergarten Programme” for details.

Announcement of Psychology Service in Cantonese (and Three Important Things I’ve Learned Working in a Multi-Cultural Environment)

We at the Child and Family Centre are pleased to announce that we now offer educational psychology services in Cantonese to the Hong Kong community. A range of services similar to those offered in English, such as psychological/educational assessments, consultation for parents and teachers as well as counselling are available. Ms. Mandy Chan, an Educational Psychologist with 10 years of experience, will be offering the services in Cantonese. Ms. Chan has spent her career working in Hong Kong primary and secondary schools that offer instruction in both Cantonese and English. Ms. Chan is also a doctoral candidate at the University of Hong Kong. Additional information regarding the service is available by clicking on the Chinese listing in the navigation bar above.

As the centre is expanding to Cantonese language service, I felt that it would be appropriate to share some comments on my experience working in a multicultural environment such as Hong Kong over the past 15 years. At last count, I have worked with children and families from 80 different countries, with a wide variety of ethnic and language backgrounds.

1) Common Problems: Honestly what strikes me the most are the similarities between people and their difficulties. A problem is a problem is a problem. All of the common diagnoses that I’ve come across in practising psychology are the same no matter where you come from or what language you speak. When I work with young Psychologists or Counsellors to whom I provide supervision, my best advice on working in a multicultural environment is keep an open mind. Know a little bit about the values of the particular group you are working with and try not to hold any preconceived notions about their values or ideas. Everybody loves and cares about their children and wants what is best for them.

2) Level of Denial: However, the level of denial in parents when a child has a serious developmental difficulty such as an Autism Spectrum disorder is harder to get around in Asian families. Typically they are not as familiar with diagnostic criteria and labels, and there is always the looming social stigma of having to go to a mental health professional to seek help for their child.

3) Looking past language as a barrier to assessment: If you’ve had a lot of experience working with children and families from various language and cultural backgrounds you can still make a proper diagnosis of a developmental difficulty. When I attend conferences in western countries I am often asked if I am able to test children in their native language. Most of the parents and children that come to me can speak fluent if not passable English. If you ask the right questions and make the proper observations and you know what to look for, you can figure out what the child’s difficulties are. Standardised testing that gives you numbers is always helpful, but it’s no substitute for a good interview that asks the right questions, experience and good sound clinical judgement.

Computer-Based Cognitive Training Programme For ADHD And Other Disorders: Are They Effective?

It is an intriguing thought to consider that we may be able to improve the cognitive and executive function difficulties associated with disorders such as ADHD without using medication. Over the last seven to ten years a number of commercially available cognitive training programmes are now available to the public. In Hong Kong there are several psychology clinics that promote these interventions. The programmes are marketed as having research evidence documenting their effectiveness for children. They involve “brain training” in systematic and repetitive game style activities that target some specific cognitive domain such as attention or working memory. These skills are sometimes referred to as “Executive Functions” of the brain. Executive function is a term that is becoming more and more familiar to parents and educators. This refers to persons’ internal capacity to regulate their attention, working memory, organisational skills and emotions. Research has clearly shown that these skills are impaired in children with ADHD, Autism/Asperger Syndrome and Dyslexia. Computer based cognitive training programmes make claims that they can increase or improve a child’s abilities related to executive function.

These programmes can be quite attractive to parents and even schools as they seem a low risk, less invasive treatment versus medication or traditional behavioural intervention that requires a lot of increased adult involvement in a child’s life. The theoretical background for development of these programmes comes from the increasing body of evidence from neuroscience that environmental experiences and interventions can alter brain development. But do these programmes really work? Is there enough solid research evidence such that professionals working in mental health and education should be recommending these as an evidence based treatment for attention or other cognitive difficulties?

There are several commercially based cognitive training programmes that have some research published on their effectiveness including: Cogmed, Jungle Memory, Captain’s Log and Brain Fitness Pro-Junior. Cogmed which utilises computer games that are targeted at increasing working memory has the largest number of studies in the research literature. The problem is that in many of these studies the research methodology is somewhat lacking making it difficult to draw specific conclusions about the programme’s effectiveness. What some studies do show is that computerised cognitive training programmes result in short term performance improvements on the tasks that are involved in the programme and can also increase working memory and attention if the tasks are similar to those that are used in the training programme. Providers of these commercial training programmes suggest that this indicates that there are changes in brain structuring as a result of the programme. Therefore this increases the efficiency of a participant’s working memory and attentional systems. That should then transfer to related abilities such as attention and organisational skills in the classroom, regulating behaviour and increased academic performance.

The best study to date that document the effectiveness of cognitive training programmes on working memory is by Dr M Melby and will be published in the Journal of Developmental Psychology. This is a meta-analysis which means thirty studies that met crucial research criteria such as inclusion of a control group and randomised assignment were analysed. Results suggested that there were some immediate training effects for verbal and visual spatial working memory tasks. The evidence was strongest for children that were 10 years old or younger but overall there were no long term benefits after implementation of the programme. They found some small effects and generalisation to related reasoning tasks but the effects disappeared when a control group or randomised design was utilised. There were no improvements on verbal reasoning, word reading or arithmetic and it was concluded that the evidence does not support the notion that working memory, computer based cognitive training programmes produced significant positive outcomes on related tasks that typically involve working memory.

There were only a handful of studies attempting to document the effectiveness of computer based training programmes on core ADHD symptoms. These are studies that included control groups and had random assignment. One study included thirty six 6 to 13 year olds with ADHD and utilized a combination of non commercial attention training tasks The outcome suggested that those in the treatment group had increased reading comprehension and passage copying skills and parent’s ratings indicated a reduction in attention problems. The intervention took place for eight weeks but there was no follow up data or teacher ratings or measures of school performance included as measurement criteria.

In the second study utilising Captain’s Log, 6 and 7 year old children who were rated as inattentive by their teachers were randomly assigned to a computerised training programme, a computerised academic intervention or a waitlist. Results suggested that the children participating in the computerised training programme significantly reduced their inattentive behaviour based on teacher ratings. However, positive gains in their attentional skills did not sustain at follow up.

In another study, forty one middle school age students with ADHD were assigned one of three conditions (Neuro Feedback, Captain’s Log Computer Training or Wait List). There were various rating scales used as outcome measures. Children in both the Neuro Feedback and Computer Training Programme a lot of evidenced improvement in their behaviour based on parent’s ratings but this was also the case for the Wait List control group. However, teacher’s ratings suggested that there were no significant improvements for any of the three groups before and after the interventions.

The pattern appears to be same for studies on the outcome of improving attention as it is for working memory. Short term immediate effects on some measures of similar tasks are noted but there is not solid evidence for long term improvement. Evidence for overall improvement in academic functioning was only noted in one study.

Putting all of these results together, it appears that computerised cognitive training programmes can produce some changes in attention and overall executive functioning in the short term but to say that they are reliable and valid and there is evidence of transfer to improved school functioning does not appear to be the case at present. This is in marked contrast to the claims of the vendors of commercial cognitive training programmes. Overall, there are many questions that remain about the clinical utility of these programmes. The problems with the studies that are put forward as evidence by the marketers of these programmes is that they have methodological flaws such as lack of control groups, single measures of cognitive constructs and inconsistent transfer to tasks across studies. Researchers question whether the short term benefits of cognitive training programmes are really evidence of underlying changes in brain function as opposed to something as simple as a practise effect with certain tasks.
In looking at the working memory tasks that are included in many of these programmes they are relatively simple. Researchers question how potent they can really be given that executive function and related cognitive skills are quite complex and involve many components of our nervous system. Intuitively it can be hard to accept that a relatively simple cognitive task could have a significant overall impact on a complex system such as executive function and lead to significant changes in a person’s day to day ability to focus, attend, block out distraction, regulate behaviour and perform academically.

Perhaps computerised cognitive training programmes could someday help remediate cognitive and behavioural deficits associated with ADHD, Autism and other related disorders and continued development of research in this area should be encouraged. Unfortunately, at present the existing research with properly designed peer reviewed studies is limited. Parents and professionals should therefore be careful in recommending commercially available computer based cognitive training programmes and consider the costs versus the potential benefits before making a decision in utilising them for treatment of their children’s difficulties.

References:

Melby-Lervåg, M., & Hulme, C. (2012). Is working memory training effective? A meta analytic review. Developmental Psychology. Advance online publication. Doi: 10.1037/a0028228
http://www.apa.org/pubs/journals/releases/dev-49-2-270.pdf

Shalev, L., Tsai, Y., & Mevorach, C. (2007). Computerized Progressive Attentional Training (CPAT) program: effective direct intervention for children with ADHD. Child Neuropsychology: A Journal on Normal and Abnormal Development in Childhood and Adolescence, 13,382-388
http://www.ncbi.nlm.nih.gov/pubmed/17564853?log$=activity

The Changing Face of Autism

The diagnosis of autism spectrum disorders (ASD) has been on the rise in Hong Kong and around the world since the mid 1990s. In the upcoming version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), research evidence is indicating that autism is not a black or white categorically defined condition, but something that is on a spectrum and has grades of severity. Persons on the autism spectrum range from severely impaired with low cognitive ability, minimal or no verbal skills and a high degree of rigid restricted behaviours, social deficits and difficulties with emotional control, to those at the higher end (most commonly referred to as Aspergers Syndrome) who have cognitive ability that is in the average range or above but still have social impairment and rigid restricted behaviours and interests as well as difficulty with emotional control.

One of the most important defining characteristic of ASD is social problems, which is now being viewed as a quantitative trait that is genetic in origin. Much of the research establishing autism as a quantifiable genetic disorder is reviewed in a study published by Dr John Constantino in the Journal of Paediatric Research.

This research is having a profound impact on the conceptualisation of autistic disorders as part of a continuum of social variation in nature and views autism as fundamentally a quantitative disorder. In order words, the symptoms and traits of ASD are distributed normally in the population and this research has also been validated in cross cultural studies outside of North America.

The reason for the rise in diagnosis of autism spectrum disorders has been documented as being due to changes in diagnostic criteria in the middle of 1990s in which higher functioning individuals (particularly Aspergers Syndrome) were being listed as persons on the autism spectrum. Environmental causes such as the MMR vaccine were implicated as causing a rise in autism but subsequent research in several different countries over the last decade suggested that the rise was due in part to the change in diagnostic criteria.

More and more genetic studies are providing evidence that autism is clearly an inherited disorder. A lot of this evidence comes from family and twin studies. The concordance rate for autism in identical twins is about 88% and 30% in non identicals. It is also found that siblings of children diagnosed with autism have about 15% chance of also being diagnosed on the autism spectrum. Current studies now suggest that 90% of autism symptoms are inherited though it is possible for the genes to skip a generation and some researchers have theorised that the gene can sometimes be dormant (particularly in females) and skip a generation before being expressed. It is believed that 5% to 10% cases of children that are diagnosed with autism may be due to what is known as a genetic “denovo mutation” in which there can be no traceable hereditary link. In cases of denovo mutation it is also suggested that the chances of a child having autism are increased with advanced paternal or maternal age. In other words, the older the age of the parent the higher the chance that the child may have autism. This does not completely rule out the possibility for environmental causes but it is postulated that they only account for a very small number of the cases of children that are diagnosed on the spectrum.

Because there are now reliable quantitative measures such as the Social Responsiveness Scale that provide a valid estimate of the severity of an autism spectrum disorder, it is becoming much easier to carry out genetic and population study research and sheds light on some possible causes for the increase besides diagnostic criteria. One theory put forward is that the selection of mates or partners is different now than it was in the 1950s to 1970s. Dr Constantino suggests that one possible factor is that persons with similar autistic traits may be drawn to each other and with increasing numbers of women attending university and joining the work force since the 1960s as well as social networking on the internet, it increases the odds for “birds of feather flocking together” so to speak. The idea behind this as being one causative factor for the increase is due to research that utilizes Social Responsiveness Scale adult ratings and self-report measures. The outcomes suggest that parents of autistic children will often rate themselves and each other as having autistic like traits and this can be correlated with the degree of autism that may be expressed in their child.

Taken together this information gives professionals better insight into the causes of autism spectrum disorders. Hopefully this will lead to preventative treatment measures in the future as well as giving us better tools for early identification which significantly increases the chance for a positive outcome.

References:
The Quantitative Nature of Autistic Social Impairment, Constantino, J. 2012, Pediatric Research.
http://www.ncbi.nlm.nih.gov/pubmed/21289537