Sedentary behaviours and autism

Standing up is better for your health than sitting down according to the BBC website. As one of those people known to wear a pedometer pretty regularly and generally be quite 'obsessive' about my 10,000 steps per day (or should that be 6000 steps per day [1]), I wasn't surprised by some of the discussions on this topic and how quite a proportion of the population at large could really do with standing up and indeed, moving a little more each day.

 The Ministry... @ Wikipedia 

We are all seemingly bombarded these days with information mixed in with a healthy sprinkling of science suggesting that one needn't be pounding the streets for hours on end in order to get a little bit more healthy. It's all about making sure that we aren't too sedentary and perhaps enjoying a little more of the great outdoors even if at a leisurely pace.

With this in mind, I was very interested to read the paper by Avivia Must and colleagues [2] who upon comparing a small-ish group of children diagnosed with an autism spectrum condition (n=53) with typically developing peers (n=58), found that "children with autism spectrum disorder spent an hour more in sedentary behaviors on weekdays compared to typically developing children". Further Must et al also reported quite a bit of that increase in sedentary behaviour was apportioned to an increase in screen time (TV and computer) and "sedentary behaiour is linked to relative weight status" in the group of children with autism. Think screen time and autism and I think about the work of Micah Mazurek as exemplified by this paper [3] and more recently with the issue of sleep in mind [4].

Some more digging into the various research done on exercise and autism revealed some equally interesting findings. The same authorship group have looked at this issue before as per the article by Bandini and colleagues [5] who suggested based on the same spread of participants (autism, n=53, not-autism, n=58) "moderate and vigorous activity was similar in children with ASD (50.0 minutes/day and typically developing children 57.1 minutes/day)". That being said, the authors did report that children with autism participated in "fewer physical activities and for less time according to parental report" highlighting potential issues with the measurement schedule employed to examine activity levels.

These and other similar research on activity levels and autism perhaps represent the other side of the research coin in terms of the increasing interest in the use of technology to improve quality of life for those on the autism spectrum. The rise and rise of the use of tablet technology for example, whilst often a significant step forward for some on the autism spectrum, not necessarily being great news for levels of physical activity if replacing time that could be used on non-sedentary activities.

The question of whether physical activity might also have some added benefits outside of just physical health has also been looked at. Oriel and colleagues [6] reported that "aerobic exercise prior to classroom activities may improve academic responding in young children with autism spectrum disorder". I'm not for one minute suggesting that every classroom should be installing a treadmill so as to increase 'correct' responses to I assume, questions posed by the teacher. But as I've indicated on a previous post about stress (see here), physical exercise often goes so much further than just improving physical health and that applies to autism too [7]. Other research reviews whilst highlighting a lack of good quality evidence in this area, have nonetheless suggested that exercise participation might have a least some short-term bearing on the presentation of facets of autism also [8].

With all the mind, the question of what kind of activities might increase activity levels in cases of autism in childhood has similarly been examined in autism research circles.

Walking is often a good place to start when it comes to increasing activity levels. The paper by Pitetti and colleagues [9] reported that even for those at the more severe end of the autism spectrum, the implementation of a walking program may well have some important benefits. Correspondingly, I've heard a few people talk about young people and adults with autism (again towards the more severe end of the autism spectrum) who very much enjoy long (sometimes very long) walks in all weathers. One wonders whether they might know more than us about what makes them feel good?

Swimming is another option to consider as per the paper by Fragala-Pinkham and colleagues [10]. Granted their results weren't astounding in terms of fitness outcomes for some participants (although contrasted with previous work of theirs [11]) but one might suggest that anything which increases activity is worthwhile. That and the often life-saving skills that are gained by learning to swim. Indeed, Pan [12] reported on some other potentially important changes noted following implementation of a water exercise swimming program with a small group of children with autism.

And then there are other exercise options to consider. Horseback riding (see here) assuming no fear of such animals and something which has cropped up before on this blog, the various martial arts (see this post) might also be good ways of increasing activity levels and decreasing sedentary behaviours. I suppose it's all about finding something that the individual enjoys.

Recognising that a sedentary lifestyle is not really ideal for anyone, there are perhaps some important lessons to be learned about increasing activity levels among children and adults with autism. Physical activity is an important part of physical health, and as we've seen in relation to schizophrenia, there is an emerging gap appearing in terms of health inequality which includes the issue of physical activity levels. That physical activity levels may also have important knock-on effects for things like bone health (see this post) and possibly exposure to sunshine and that all-important vitamin D (see this post) are also important considerations too.

To close, a song about walking by two brothers who are talking about walking an awfully long way. Oh and for those who were also wondering about the word 'haver', some background can be found here.

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[1] Tudor-Locke C. & Bassett DR Jnr. How many steps/day are enough? Sports Med. 2004: 34: 1-8.

[2] Must A. et al. Comparison of sedentary behaviors between children with autism spectrum disorders and typically developing children. Autism. 2013 Oct 10.

[3] Mazurek MO. & Wenstrup C. Television, video game and social media use among children with ASD and typically developing siblings. J Autism Dev Disord. 2013 Jun;43(6):1258-71.

[4] Engelhardt CR. et al. Media Use and Sleep Among Boys With Autism Spectrum Disorder, ADHD, or Typical Development. Pediatrics. November 2013.

[5] Bandini LG. et al. Comparison of physical activity between children with autism spectrum disorders and typically developing children. Autism. 2013 Jan;17(1):44-54.

[6] Oriel KN. et al. The effects of aerobic exercise on academic engagement in young children with autism spectrum disorder. Pediatr Phys Ther. 2011 Summer;23(2):187-93.

[7] García-Villamisar DA. & Dattilo J. Effects of a leisure programme on quality of life and stress of individuals with ASD. J Intellect Disabil Res. 2010 Jul;54(7):611-9.

[8] Petrus C. et al. Effects of exercise interventions on stereotypic behaviours in children with autism spectrum disorder. Physiother Can. 2008 Spring;60(2):134-45.

[9] Pitetti KH. et al. The efficacy of a 9-month treadmill walking program on the exercise capacity and weight reduction for adolescents with severe autism. J Autism Dev Disord. 2007 Jul;37(6):997-1006.

[10] Fragala-Pinkham MA. et al. Group swimming and aquatic exercise programme for children with autism spectrum disorders: a pilot study. Dev Neurorehabil. 2011;14(4):230-41.

[11] Fragala-Pinkham M. et al. Group aquatic aerobic exercise for children with disabilities. Dev Med Child Neurol. 2008 Nov;50(11):822-7.

[12] Pan CY. Effects of water exercise swimming program on aquatic skills and social behaviors in children with autism spectrum disorders. Autism. 2010 Jan;14(1):9-28.

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Must A, Phillips SM, Curtin C, Anderson SE, Maslin M, Lividini K, & Bandini LG (2013). Comparison of sedentary behaviors between children with autism spectrum disorders and typically developing children. Autism : the international journal of research and practice PMID: 24113339

Assessing autism the ADTree classifier way

The Autism Diagnostic Observation Schedule (ADOS) has a hallowed place in autism research and practice. At 23 years of age, ADOS and its counterpart, the Autism Diagnostic Interview (ADI), have pretty much cornered the gold-standard autism assessment market over the years. ADOS in particular with its sliding scale of modules covering the spectrum of language and developmental ability and generous assortment of 'props', resides in quite a few cupboards of child development centres and research institutes worldwide.

One of the nice things about ADOS aside from the hands-on, interactive tasks particularly in the more 'early-years' modules, is the way that it valiantly attempts to standardise behaviour and codes autism, autism spectrum or not via the use of an algorithm. This paper headed by one of the primary architects of ADOS, Cathy Lord, summarises the development of that algorithm based on the ADOS-G (generic). Said algorithm having fairly recently been revised by Katherine Gotham and colleagues to amalgamate some features (communication + social interaction = social affect) potentially tied into the proposed revisions for autism diagnosis in DSM-V.

Perfect you might say, so if it ain't broken why fix it? Well, gold standard or not, ADOS can be quite time-consuming to deliver (but not as time-consuming as the ADI I might add). Assessors also need to be properly trained and kept up-to-date with their ADOS training, and despite all its standardised prowess, people are people and sometimes mistakes are made - which is partly why ADOS is an assessment tool and not an all-encompassing diagnostic tool. Of course there are other 'issues' that have been raised with ADOS in mind (e.g. comorbid ADHD interfering, assessing Asperger syndrome) but I'm not here to start that critique.

Enter then a study by Dennis Wall and colleagues* (full-text) and their suggestion that based on some clever machine-learning algorithms, 8 out of the 29 items normally used in the delivery of a module 1 ADOS (no speech present) might just have the ability 'to classify autism' with complete or near 100% accuracy.

• Wall and colleagues constructed 16 possible machine-learning algorithms based on the 29 coding items of the ADOS module 1. For anyone really interested, these 29 items are spread across several domains including: (a) language and communication (9 items including vocalisations, response to name, pointing and use of gestures), (b) reciprocal social interaction (11 items including eye contact, giving, requesting, showing and response to joint attention), (c) play (2 items - functional object play and imagination), (d) restricted, repetitive behaviours and interests (4 items including unusual sensory interests and hand / finger mannerisms) and (e) 'other abnormal behaviours' (3 items including overactivity and anxiety). I should point out that when it comes to the final algorithm, only 17 of these 29 items are actually used (at least according to the original pre-Gotham algorithm - the revised algorithm uses 14 items I think??) and even then, only 12 items contribute to the autism / autism spectrum cut-off scores used based on items in the communication and social domains.
• Based on the use of data from a group of children with autism with module 1 ADOS scores from the AGRE dataset (autism: n=612; non spectrum: n=11), 90% of participants were used as part of a training set and the remaining 10% as a tester set as part of the proposed algorithms (much the same way that other studies have used). 
• Further validation of the best classifiers was undertaken based on other independent samples who reached cut-offs from module 1 ADOS to include data from the Boston Autism Consortium (autism: n=110; non spectrum: n=4) and the Simons Simplex Collection (autism: n=336; non spectrum: n=0).
• Although 2 out of the 16 algorithms "operated with perfect sensitivity, specificity and accuracy", one of them, the ADTree classifier, was selected as the best option because it relied on only 8 items of the module 1 ADOS to produce such results (the alternative used a whopping 9 items). Validation using the Autism Consortium and Simons Simplex Collection data correctly classifying all but 2 participants (from the Simons collection) who exhibited "... the potential presence of non spectrum behaviours".
• Drum-roll for the 8 distinguishing module 1 items isolated: (i) frequency of vocalisation directed to others, (ii) unusual eye contact, (iii) responsive social smile, (iv) shared enjoyment in interaction, (v) showing, (vi) spontaneous initiation of joint attention, (vii) functional play with objects and (viii) imagination/creativity. Use of these 8 items would also reduce the number of activities needed to elicit behaviours; so goodbye 'response to name' and 'response to joint attention'. I'm glad to say that the 'birthday party' activity remained!

Despite the obvious issues concerning a reliance on pre-ADOSed children and the use of only a handful of non spectrum controls, I find myself very interested in these results and the performance of the ADTree classifier. As per the study conclusions "The ADTree classifier consisted of eight questions, 72.4% less

than the complete ADOS Module 1". Purely from a practical point of view and the quite significant levels of concentration needed to manage tasks and elicit scores from the original module 1 ADOS, there is an obvious advantage to focusing on 8 items as opposed to 29 items. I do wonder exactly how much time will be shaved off an assessment bearing in mind that the majority of module 1 activities still need to be covered in order to elicit proper responses to items. So activities like 'free play', 'functional and symbolic imitation' and 'birthday party' are still required and can often take up the lion's share of assessment time.

Whilst the 8 selected items are interesting, there are some notable absences from the classifiers based on things like issues with pointing, the use of gestures and the use of facial expressions directed to others. I was always under the impression that these were important facets of autism, or at least autism in the early years but this study suggests not so in terms of classification. What exactly this might say for other results linking pointing, proto-declarative pointing for example, to autism is source for speculation. 

Homing in on those classifier items also opens a number of doors to things like quick and early screening and even where attention perhaps needs to be focused with regards to measuring outcome - that is how maturation and/or intervention may impact on core symptoms (at least for young and/or non-verbal people on the autism spectrum). Whether also this type of machine-analysis is applicable to other schedules related to autism screening and assessment is another question.

* Wall DP. et al. Use of machine learning to shorten observation-based screening and diagnosis of autism. Translational Psychiatry. April 2012.
DOI: 10.1038/tp.2012.10

Asperger syndrome and hacking

A very, very short post this one in response to a recent news item here in the UK.

First it was Gary McKinnon. Now it is Ryan Cleary. Two young men diagnosed with Asperger syndrome. Two young men under Police and media scrutiny for their (alleged) computer activities. You can imagine that this has been the topic of some discussion and questions are starting to be asked about the relationship between Asperger syndrome and hacking. I am not getting too far into the debate at this time because the facts have not been proven, and until they are, it is conjecture and speculation.

One question I would perhaps raise: does Asperger syndrome predispose to hacking or does it predispose to getting caught?