Mindfulness for ADHD systematically reviewed

"According to presented descriptive results, all the studies (100%) showed improvement of ADHD [attention-deficit hyperactivity disorder] symptoms."

That was the standout sentence derived from the findings reported by Hélène Poissant and colleagues [1] who looked at "the available literature concerning MBIs [mindfulness-based interventions] in adult participants with ADHD." Mindfulness by the way, is described as a way of "reconnecting with our bodies and the sensations they experience" with a specific focus on "an awareness of our thoughts and feelings as they happen moment to moment." I'm no expert on mindfulness or mindfulness-based interventions but, from what I gather, the core of such intervention(s) is based around "somatically focused meditative techniques (body scan, sitting meditation, and mindful yoga) that are thought to help participants cultivate nonjudgmental, mindful awareness of present-moment experience." 'Focusing in on the present' seems to be the phrase that springs to mind.

Poissant et al examined the relevant peer-reviewed science on the application of the MBIs to ADHD upto June 2018. They specifically focused on adults with ADHD, and were able to track down "13 studies conducted with 753 adults (mean age of 35.1 years)" for inclusion in their systematic review. They observed that: "All the studies (100%) showed improvement of ADHD symptoms following an MBI." They also mentioned that: "mindfulness meditation training improves some aspects of executive function and emotion dysregulation" as per the findings of some of those studies.

Despite the '100% of studies showing improvement in ADHD symptoms' sentiments, I'm not falling hook, line and sinker for the value of MBIs in relation to ADHD. The main reason is the high risk of bias identified in quite a few of the studies reviewed by Poissant, related to things like performance bias ("blinding of participants and of personnel") and selection bias ("allocation concealment" and "selection bias"). One could argue that the examination of something like MBIs under research conditions is never going to be perfect. Unlike scientific investigation of a medicine, where a placebo can be formulated to look, smell and taste the same, it would be difficult to come up with something to approximate MBI and indeed, approximate what the 'active ingredient' of mindfulness actually is. Similar issues have been talked about on other occasions on this blog (see here).

That all being said, there is something appealing about MBIs both in terms of effect and also the fact that it can be learned by pretty much anyone, is cost-free and probably about as side-effect free as one could get. If such a simple technique helps with any one of the symptoms of ADHD and improves quality of life for those with ADHD, it's got to be something to be considered alongside the myriad of other possible interventions (see here and see here and see here) that *might* offset the risks that follow a diagnosis of ADHD (see here).

Oh, and it appears that mindfulness and ADHD is a topic in the ascendancy [2]...

----------

[1] Poissant H. et al. Behavioral and Cognitive Impacts of Mindfulness-Based Interventions on Adults with Attention-Deficit Hyperactivity Disorder: A Systematic Review. Behav Neurol. 2019;2019:5682050.

[2] Xue J. et al. A meta-analytic investigation of the impact of mindfulness-based interventions on ADHD symptoms. Medicine (Baltimore). 2019 Jun;98(23):e15957.

----------

Caring for the carer: what the science suggests

Papers such as the one published by Nikko Da Paz & Jan Wallander [1] I think represent one of the most important areas of autism research and practice when it comes to the practical translation of science to real-life. Tackling a very important topic - caring for the carers - the authors provide a "narrative review" of the peer-reviewed science literature looking at how "treatments that directly target parents' psychological well-being" in the context of autism are doing so far.

Personally, I don't like the use of the word 'treatment' in this context because it implies that caring for the carers is akin to tackling some sort of disease. It's not. It also 'medicalises' the experience of caring for/raising children on the autism spectrum which I don't think anyone really wants to do. I might suggest that 'intervention' could be a better word to use.

Da Paz and Wallander reported on "a total of 13 studies, seven randomized controlled trials (RCTs) and six pre-post test designs" that looked at various interventions pertinent to improving parent stress and reducing instances of depression and anxiety. They report: "Interventions that appeared promising included: Stress Management and Relaxation Techniques, Expressive Writing, Mindfulness-Based Stress Reduction, and Acceptance and Commitment Therapy" with some important caveats. Not least that if English is not your language of choice and/or you are not aged between 39-42 years old, the evidence base is rather sparse when it comes to what might be useful or not for managing your psychological health. In light of other research [2] there is quite a bit more to do in this area.

Accepting that the publishing journal - Clinical Psychology Review - gives a rather large hint as to why the listed 'psychological' interventions were focused upon, I might also add a few comments about how other science and practice might also aid parents raising children on the autism spectrum. I've for example, covered the topic of respite care and parent stress before on this blog (see here) and how depending on your definition of respite, there is perhaps some value in either the utilisation of short break facilities or the use of domiciliary care/support where available. As per my previous discussion of this area, there is a rather large stumbling block to any talk about respite care insofar as in these austere times in which we live, some of the first social services that seem to suffer when budgets need to be reduced are respite services.

I'm also minded to bring in the idea that outside of psychological techniques potentially impacting on parenting stress and any adverse outcomes, one might also look at more physical interventions too. So, for example, exercise is something that could be a rather useful intervention to look at given the pretty strong research links being forged between body and mind. The thing about exercise is that (a) depending on what regime you choose costs can range from free to expensive, and (b) there are a whole host of other factors potentially tied into a chosen sport, based on the choice of solitary sports vs. group sports for example and other factors. That various health agencies are already shifting when it comes to notions of potentially 'prescribing exercise' for something like depression and anxiety (see here for example) reflects how valuable moving a little more might be to lots of groups.

I would champion the idea that quite a few more resources need to be put into caring for the carers when it specifically comes to parenting and autism. This is not about further 'blaming autism' for parenting stress or adverse outcomes but rather acknowledging that parenting whether in the context of autism or not, is a sometimes difficult task. And nobody benefits if parents/carers are just left to fend for themselves without the appropriate help and support...

----------

[1] Da Paz NS. & Wallander JL. Interventions that target improvements in mental health for parents of children with autism spectrum disorders: A narrative review. Clin Psychol Rev. 2016 Oct 27;51:1-14.

[2] Zuckerman KE. et al. Pediatrician identification of Latino children at risk for autism spectrum disorder. Pediatrics. 2013 Sep;132(3):445-53.

----------

Da Paz NS, & Wallander JL (2016). Interventions that target improvements in mental health for parents of children with autism spectrum disorders: A narrative review. Clinical psychology review, 51, 1-14 PMID: 27816800

Transcendental meditation for autism: some case reports

I can appreciate that some people might have looked at the title of this post and rolled their eyes. When I first came across the paper by David Black & Norman Rosenthal [1] (open-access) I too felt a slight 'woo' like tingling given my unfamiliarity with transcendental meditation (TM) either personally or professionally. A bit of background reading and a reminder of some song lyrics - "sometimes truth is stranger than fiction" - and I decided that this is peer-reviewed science that perhaps needs a little bit of discussion.

The Black/Rosenthal paper begins with some important statements about autism insofar as (a) the numbers of people being diagnosed as on the autism spectrum is increasing for whatever reasons, and (b) of the numerous comorbidities that are over-represented when it comes to a diagnosis, the various forms of anxiety must surely rank up there as some of the most disabling aspects when it comes to quality of life day-to-day. That also there is a pretty sizeable gap in the research literature about how anxiety can be managed or treated when it comes to autism is something else to mention.

Then: "Transcendental Meditation (TM) may be beneficial for treating anxiety in individuals with ASDs [autism spectrum disorders] by reducing stress." Certainly a quick scan of the peer-reviewed literature with the words 'transcendental meditation and anxiety', does indeed reveal something of a trend insofar as as TM as a potential intervention option. Take for example the meta-analysis by Orme-Johnson & Barnes [2] that concluded: "Overall, TM practice is more effective than treatment as usual and most alternative treatments, with greatest effects observed in individuals with high anxiety" with the requirement for quite a bit more investigation in this area. I might also add that 'treatment as usual' might not necessarily be the best comparator when it comes to this kind of intervention as per other examples (see here)

Onwards to the case reports highlighted. Interviews were completed with six individuals, all diagnosed as being on the autism spectrum and all have practised TM "twice per day for 15–20 min, at least 10 times per week, for at least 3 months." The interview seemed to have been quite an unstructured affair whereby questions about the use of TM and "any changes in functioning observed since following consistent practice of TM" were intermixed with focused questions on specific symptoms. Obviously the kind of evidence garnered from this type of study is pretty subjective and provides little in the way of formal comparisons between before starting TM and where participants were at the time of questioning not also including issues such as blinding. But, and it is an important point, self-report under such circumstances can provide some important insights into personal experiences and we are [scientifically] poorer without them.

As it happens: "all participants reported that the consistent practice of TM was helpful in a number of ways." Indeed, stress and anxiety featured quite consistently in the reports provided, with other effects noted in areas of sleep and concentration for example. From what I can gather, no-one reported any adverse effects from such practice, which is also an important point. The authors conclude: "The experiences of this group of individuals suggest that at least for some individuals with an ASD, (1) TM is easy to learn and consistently practice, and (2) that it may be very beneficial in reducing stress and anxiety, thereby improving overall productivity and quality of life."

Reiterating the methodological issues associated with this study and the requirement for further investigations, I'm persuaded enough by the case reports that more research time might need to be devoted to this area of interest. Allied to other investigations on the whole mind-body bit with autism in mind (see here) including the continued interest in the concept of mindfulness (see here), a sort of 'what harm could it do' philosophy has started to leak into my thoughts about this. I don't think this kind of technique will be for everyone on the autism spectrum (no 'one size fits all' and all that) and I don't necessarily buy into the TM movement as a whole. But if anxiety is a disabling feature for some on the autism spectrum, the alternatives to treating/managing such issues are currently few and far between...

Music: Robbie Williams - No Regrets.

----------

[1] Black DO. & Rosenthal N. Transcendental meditation for autism spectrum disorders? A perspective. Cogent Psychology. 2015; 2: 1-5.

[2] Orme-Johnson DW. & Barnes VA. Effects of the transcendental meditation technique on trait anxiety: a meta-analysis of randomized controlled trials. J Altern Complement Med. 2014 May;20(5):330-41.

----------

Black, D., Rosenthal, N., & Walla, P. (2015). Transcendental meditation for autism spectrum disorders? A perspective Cogent Psychology, 2 (1) DOI: 10.1080/23311908.2015.1071028

Parental stress and autism: what's effective at reducing it?

Raising children is an extremely rewarding experience. That's not to say however that every minute of every day is spent with smiles and adoration of your offspring and their various endeavours: "Was that family heirloom that I just dropped on the floor really, really important Daddy?" Generally speaking the majority of parents I imagine though, would look favourably at the experience of going the family-way.

Gathering the light @ Wikipedia  

The rosy picture of having a family is however never truly complete without realising that having children can be quite a stressful experience. Whether as a result of those earliest days of sleep deprivation and almost constant nappy changing duties, through to some of the growing pains as puberty beckons and even onwards into the adult years, stress is a pretty constant companion to the family journey. And the amount of stress parents face in the child rearing odyssey is very much influenced by lots of other external variables such as money, job, relationships et al. Oh and also how many kids you're parenting (see here).

To have a child with additional needs, whether a physical disability or intellectual / developmental disorder, has been suggested to carry it's own unique challenges which can also impact on parental stress levels. I'm not saying that to somehow blame or stigmatise or anything like that, but merely to reflect the quite extensive body of research which has concentrated on that point (see here for example).

There is also quite a large evidence base to suggest that parents report greater levels of stress associated with raising a child with an autism spectrum disorder as per the example article by Koegel and colleagues*. Indeed it is with this area in mind that I stumbled across the paper by Dykens & Lambert** who noted: "Stress-reducing interventions are needed for parents of children with autism" as part of their analysis of cortisol levels in mums raising children, including those raising children with autism.

I've talked about stress and cortisol before on this blog (see here) as per the collected findings in relation to people with autism. The net result of that post was to say that yes, quite a few people on the autism spectrum present with an unusual stress profile (although not necessarily beyond the range seen in not-autism) but importantly, stress - as monitored via cortisol levels - seems to be a rather more continual process for many. Such results have obvious implications in relation to things like the anxiety issues often reported to follow autism.

The highlighted sentence from the Dykens paper on the need for stress reduction interventions for caregivers pinpoints a fairly obvious issue which I'm sure many people would take as read. Indeed with the suggestion from Osborne and colleagues*** that parenting stress might also potentially impact on the effectiveness of early intervention for autism, the questions are: what kinds of stress-reducing interventions are available and importantly, which ones work?

I don't claim to have some special insight into these questions, but a quick trawl of the research literature offers a few potentially important pointers.

(i) Social support. "With a little help from my friends" was a song by the Beatles but also the title of a rather interesting paper by Brian Lovell and colleagues**** on one potential route for tackling caregiver stress. Appreciating that to many this is not new news, it is perhaps little surprise that through the wonders of social media and the Internet, on-line social support groups for parents of children with autism are numerous and easily accessible in our digital age. With all the talk about how such resources might be 'changing our brains' (erm, or not), I'm minded to say that in this example, it might actually be a change for the better.

(ii) Mindfulness. I know, I know. It sounds like psycho-babble mumbo-jumbo to the nth degree when you first hear it. But actually I'm becoming a bit of a fan of mindfulness as per my previous post making mention of the BBC Horizon program 'The Truth About Personality' featuring the ever-intrepid Dr Michael Mosley. The basic idea is to think about the present, nay focus on the present, and manage the thoughts and feelings that are linked to stress. The evidence base for mindfulness for relieving caregiver stress is what might be described as emerging as per the study by Neece***** although with some potential bonuses for offspring too. It's also worth pointing out that mindfulness techniques are seemingly also finding a role in helping some people on the autism spectrum too (see Spek and colleagues******). Relations to mindfulness such as the use of relaxation techniques for caregivers have also been put forward as potentially useful*******. I wonder if something like blogging might also come under the description of 'managing thoughts and feelings'?

(iii) Parent training. I must point out that I am in no way trying to say that anyone is in need of "training" just in case anyone thinks I'm harking back to the bad old 'Bettelheim' days or casting aspersions about parenting style. I merely refer to the body of literature which 'suggests'******** that there may be some merit in looking into this option with stress relief in mind. Whether parent training might also fit under the banner of other programs such as RDI or more generic programs like Stepping Stones Triple P and any knock on effects this might have to parent stress levels is something perhaps requiring a little bit more study in order to define things like potential best responder characteristics.

(iv) Respite. I don't think this option really needs much explanation. Harper and colleagues********* said it best: "More respite care was associated with increased uplifts and reduced stress". Indeed, part of that reduction in stress was seemingly getting a little more quality time with your spouse or significant other... break out the Marvin Gaye. Seriously though, I can't stress enough how important respite care can be to some families. And if you happen to live here in Blighty (that's the UK), there are quite a few resources about respite and how to access the care: see here and here.

(v) A hobby or external interest. Although this is supposed to be an evidence-based post, there are a few other stress-relieving options that have been mentioned in a more anecdotal fashion. An interest involving physical exercise as a stress reducer seems to be a common theme. Indeed as I write this post, I'm just watching the preparations for the Great North Run on this slightly soggy Sunday morning and one parent of a child with Asperger syndrome running for the charity Ambitious About Autism. Using her running preparations as a way of getting some down time was mentioned in her interview. Other parents have talked about the use of activities like martial arts as being a stress reducing tool, which did make think back to some other work on the use of martial arts as a self-esteem builder for children with autism (see here). I'm not necessarily saying that every parent has to immediately join their local Jui-jitsu class or anything like that, but one can perhaps see how the process of physical activity might serve more than just a physical purpose.

I've only really scratched the surface with this post on parental stress and autism and how one might go about tackling / reducing it. If you want a perspective from a parent with autism who is also a medical doctor, look no further than these insights (see here) from a physician who's research has previously appeared on this blog (see here).

One might also argue that tackling some of the more 'disruptive' issues associated with autism which have been reported to be linked to greater parental stress (see here) might also be another route to reducing stress. The very interesting paper from McStay and colleagues********** reporting that "child hyperactivity was the only factor significantly related to parenting stress in parents of children with autism" might even tie into some of the observations we've made recently on the use of a GFCF diet (see here) and even explain some of the popularity of this approach. Indeed, I've not really approached the question of whether comorbidity (including ESSENCE) appearing alongside autism might also be a significant source of parental stress, as one might expect from something like epilepsy or seizure-related disorders for example. And then there is the increasingly common scenario of parents (one or both) with autism bringing up children with autism and how that situation might present additional unique parental stresses. Let us also not forget other siblings of the family unit too and how stress can affect them.

What remains apparent is that (a) parenting, as well as very rewarding, can be a stressful activity, (b) parenting a child with additional needs can carry some of its own unique stresses and (c) tackling or reducing that stress has got to be a win-win situation for everyone concerned; importantly not just for the child, but also for parents too (see here) including in relation to related aspects like fatigue.

To close, some music to dance to (dancing is also a very good stress-relieving activity I'm led to believe).... Wham and Wake Me Up Before You Go-Go. And for all you fathers out there who partake of a bit of 'dad dancing', a hypothesis for you to consider...

----------

* Koegel RL. et al. Consistent stress profiles in mothers of children with autism. J Autism Dev Disord. 1992 Jun;22(2):205-16.

** Dykens EM. & Lambert W. Trajectories of Diurnal Cortisol in Mothers of Children with Autism and Other Developmental Disabilities: Relations to Health and Mental Health. J Autism Dev Disord. 2013; 43: 2426-2434.

*** Osborne LA. et al. Parenting stress reduces the effectiveness of early teaching interventions for autistic spectrum disorders. J Autism Dev Disord. 2008 Jul;38(6):1092-103.

**** Lovell B. et al. With a little help from my friends: psychological, endocrine and health corollaries of social support in parental caregivers of children with autism or ADHD. Res Dev Disabil. 2012 Mar-Apr;33(2):682-7. doi: 10.1016/j.ridd.2011.11.014.

***** Neece CL. Mindfulness-Based Stress Reduction for Parents of Young Children with Developmental Delays: Implications for Parental Mental Health and Child Behavior Problems. J Appl Res Intellect Disabil. 2013 Jul 1. doi: 10.1111/jar.12064.

****** Spek AA. et al. Mindfulness-based therapy in adults with an autism spectrum disorder: a randomized controlled trial. Res Dev Disabil. 2013 Jan;34(1):246-53. doi: 10.1016/j.ridd.2012.08.009.

******* Gika DM. et al. Use of a relaxation technique by mothers of children with autism: a case-series study. Psychol Rep. 2012 Dec;111(3):797-804.

******** Bendixen RM. et al. Effects of a father-based in-home intervention on perceived stress and family dynamics in parents of children with autism. Am J Occup Ther. 2011 Nov-Dec;65(6):679-87.

********* Harper A. et al. Respite Care, Marital Quality, and Stress in Parents of Children with Autism Spectrum Disorders. J Autism Dev Disord. 2013 Mar 26.

********** McStay RL. et al. Parenting stress and autism: The role of age, autism severity, quality of life and problem behaviour of children and adolescents with autism. Autism. 2013. 8 October.

----------

Dykens EM, & Lambert W (2013). Trajectories of Diurnal Cortisol in Mothers of Children with Autism and Other Developmental Disabilities: Relations to Health and Mental Health. Journal of autism and developmental disorders PMID: 23468069

Mind-body exercise and self-control in autism?

Despite knowing a little something about the discipline of psychology and in particular, it's varied success/failure (delete as appropriate) when applied to a complicated condition like autism, I'll admit that I do have some difficulty in grasping certain ideas and concepts which make up the psychological research landscape.

Yin yang? @ Wikipedia 

Take for example the concept of mindfulness, which is definitely starting to be another 'big thing' when it comes to psychology stressing how the mind might be able to influence all manner of things including several physical 'frailties'. It's fascinating to me how something as simple as glorified meditation might be able to do so much.

A good example of mindfulness at work was seen in Dr Michael Mosley's recent BBC Horizon venture on 'The Truth About Personality'. Wherein the 5:2 diet (see here) was replaced by some interesting discussion on how we could all become much happier and less anxious through mindfulness and an interesting technique called cognitive bias modification (CBM). Aside from making an important mention of the concept of epigenetics and how we should be looking at the function of the genome as well as its structure, it was interesting to see Dr Mosley report some benefit from the interventions at the end of the program, measured also via more objective means over and above his subjective 'I feel better' sentiments.

This very long-winded introduction brings me to the topic of today's post on a mind-body exercise regime and autism following the publication of a study by Agnes Chan and colleagues* (open-access) who reported some success from their Chan-based mind-body exercise program on self-control (see here for the trial registration). The SFARI blog has also recently posted about this study (see here).

Before heading into the paper I should point out that this is not the first time that this type of program has been talked about with autism in mind. For example, I stumbled across this paper** by the same authorship group which talked about some potential effects from "a Shaolin-medicine-based dietary modification" which talked about removing foods which "will generate excessive internal heat and adversely affect the temper and cognitive functions" to include "ginger, garlic, green onion, spicy foods, eggs, meat, and fish". I don't really want to comment on the hows and whys of 'excessive internal heat' on autism in this post so will leave it there for now and allow readers to draw their own conclusions. I might also add that I've talked Chinese medicine and autism before on this blog as per the 'Jedi' massage (see here, lightsaber not required).

OK back to the Chan-based mind-body exercise program on self-control. The program is based on the practice of Nei Yang Gong and essentially includes "sets of slow movements that emphasize smooth, gentle, and calm movements". The authors suggest that these movement help with self-awareness and mental self-control but can also help in the reduction of stress (something all too familiar where autism is mentioned). They add that it is a slightly different program from just mindfulness and mediation. There are plenty of videos on the web illustrating the types of movements it includes.

The authors randomly allocated 46 children diagnosed with an autism spectrum condition to either the Chan-based mind-body exercise program under analysis or something called progressive muscle relaxation although only 20 kids in each trial arm completed the four-week study. Alongside measuring neuropsychological functioning, authors also ATECd the kids to pick up parent-reported behaviour changes and looked at event-related EEG results during "an inhibitory control test, namely, the Go/No-Go task".

The results: "the autistic children in the experimental group showed better self-control than those in the control group after the one-month intervention" based on the results of the neuropsychological tests. Analysis of the ATEC scores however were not so clean-cut as both groups were reported to show [variable] positive changes on the subscales (the experimental group generally however showing a more pronounced positive effect). The authors do note that when it came to looking at specific issues such as temper outbursts "the experimental group reported a significantly greater reduction" over the control group. Oh and did I mention that there were some changes on the EEG too? (bearing in mind my considerable non-expertise when it comes to this dark art).

OK, I know its tempting to look at this paper and its results and start to criticise based on things like the lack of blinding to group allocation / intervention regime and the use of the ATEC (but wait a minute...). There was also, for example, no treatment as usual group included in the study you might say. But just hold on a minute, when it comes to ascertaining medication in relation to autism and other conditions for example, on more than one occasion there has been criticism that researchers have been too over-reliant on drug vs. nothing (or placebo) over drug A vs. drug B. At least the authors in this study were able to say that their program was better than just muscle relaxation techniques. Perhaps the next study to be done would be comparing their program with something more pharmacological?

Likewise in our modern Western medical system which we all love, it is perhaps easy to rather disparagingly talk about things like 'internal heat' whilst carrying that little smirk on our faces as if 'we know better'. I don't know enough about Chinese medicine to say whether this is something real and tangible or just some ancient hand-me-down. All I can see is that the authors have made an attempt to (experimentally) bring their expertise to bear on a group of people who are probably more prone than most to issues with things like self-control and anxiety. And if it worked, well, it worked. That and I assume the fact that once one has been trained in the ways of Nei Yang Gong, it's probably going to be something that can done quite easily and certainly quite affordably in the longer term (probably also with minimum side effects I would imagine).

----------

* Chan AS. et al. A Chinese Mind-Body Exercise Improves Self-Control of Children with Autism: A Randomized Controlled Trial. PLoS ONE. 2013; 8(7): e68184. doi:10.1371/journal.pone.0068184

** Chan AS. et al. A chan dietary intervention enhances executive functions and anterior cingulate activity in autism spectrum disorders: a randomized controlled trial. Evid Based Complement Alternat Med. 2012;2012:262136. doi: 10.1155/2012/262136.

----------

Agnes S. Chan (2013). A Chinese Mind-Body Exercise Improves Self-Control of Children with Autism: A Randomized Controlled Trial PLoS ONE DOI: 10.1371/journal.pone.0068184

I am not condoning violence...

Mr Bruce Lee @ Wikipedia 

Name calling, spreading rumours, excluding from social groups, hitting, kicking and taking belongings. Bullying (definition courtesy of the UK National Autistic Society) covers quite a lot of ground.

I don't actually know if I had a bully or not at school. I mean, there was this one kid at school who always seemed to have it in for me until that is, one day I snapped (yes, we English are not all watercress sandwiches and afternoon tea) after which the kid in question didn't tend to come near me again. I never actually thought however that this kid was a bully per se; just someone who I didn't seem to get along with.

That was then. Nowadays the media is awash with news about cyber-bullying and the various new fangled ways that some kids use / have used to cause misery to other kids (albeit with questions about prevalence). I have to say that I'm kinda glad that I'm not a teenager in the Internet or cameraphone age after reading all this.

In this post I want to talk about the paper by Paul Sterzing and colleagues* reporting on the experiences of school year bullying (and bullying perpetration) in teens with an autism spectrum disorder (ASD). On purpose I've left it a while before I get to this paper in order to let the dust settle around this quite emotive topic before I stuck my oar in with this quite long post.

Needless to say that this study has from the initial press release and author profile created quite a few column inches as per headlines like this one: School bullies prey on children with autism and this one: Why autistic kids make easy targets for school bullies no doubt alongside hitting some really raw nerves for many people. I tread carefully.

A quick summary first:

• This was a survey study which asked parents (N=920) (and teachers) of teens with an autism spectrum disorder about the bullying (both victim and perpetrator) experiences of their children.
• Coming up to almost half of all teens with autism were reported to be the victims of bullying (46%) whilst 15% were perpetrators of bullying and about 10% combined bullying victims and perpetrators.
• Various factors correlated with bullying victim status including lower social skills, some level of conversational ability and a comorbid ADHD diagnosis. Being in mainstream education was also mentioned as a correlate.
• On the other hand, the presence of ADHD was also associated with being a bullying perpetrator alongside having some kind of friendship base.

This is not the first time that bullying has been studied with autism in mind. This paper from van Roekel and colleagues** (open-access) looked at bullying specifically within the special education school system, again reporting a figure of 46% on the prevalence of bullying and victimisation. Indeed not dissimilar from the findings from a recent UK report on the school experience and autism (see here).

I was also interested in the findings reported by Montes & Halterman*** on the influence of ADHD comorbidity, where dual presentation (autism & ADHD) seemed to confer the greatest risk for bullying behaviours. Not a million miles away from the Sterzing conclusions. As an aside, I do also wonder whether the paper by Susan Dickerson Mayes and colleagues**** on suicide ideation and attempts in cases of autism might also reflect a potential effect from bullying in some extreme cases.

I'm not an expert on bullying but I might add a few points potentially tied into these findings. Stick with me on this one.

Although there are probably lots of reason for bullying behaviour, I've always believed that, from the bully's point of view, it all eventually comes down to exerting power over another person/s. It's a two-stage process so please hear me out: (i) a bully, whether because of issues in their own life, at home, at school, at anywhere, either has lost some degree of 'power' over their own life and wants to recoup it over others perceived as less powerful, or in some cases, has an insatiable desire for power not readily satisfied by their current life. That's how (I think) it starts, accepting that other factors such as prejudice, jealousy, socio-economic status (see here) and popularity among peers also might carry influence. The second stage (ii) is all about maintaining a bullying control over someone; something where the more social side of things comes into play. Peer groups based on that bullying power, some degree of showing off to those peers and the notion of 'getting away with it' all contribute to keeping the cycle of bullying going.

Then there is the 'victim' perspective. As per the discussion above, victims generally have to be perceived by bullies as someone who is less powerful than them. This could take the form of being less physically powerful than the bully as per this study by Bejerot and colleagues***** on how poor performance in physical education classes might be a risk factor for being bullied or this study by Wildhaber and colleagues****** discussing asthma-related bullying. It could also be someone who 'stands out' from the crowd as discussed in this study by Kukaswadia and colleagues******* on obesity being a determinant of bullying. As per this editorial, "the symptoms of the disorder are the exact reasons that make young people with autism vulnerable". With that in mind, have a think about the suggestion of hyper vs. hypo-theory of mind (see here) with bullying and autism in mind.

Without trying to cherry-pick the evidence, other research on some of the hows and whys of bullying, victims and their behaviour (as per studies like this one and this one and this one) to some degree correlate with my view including this very interesting piece from the American Psychological Association.

I know some people might read all this psycho-babble and ask questions like 'why can't society be kinder?' and 'who would pick on a child with autism?'. I too ask those questions. The simple fact however is that children, like adults, whether with or without autism or other labels, are complicated and the way society like schools are set-up combined with that human nature means that bullying is probably always going to be present to some degree. Where there is social structure, there's always going to be people who want to be top dog. Where there are differences, there will probably always be some degree of prejudice. These aren't nice thoughts, but unfortunately it is current reality.

But that's not to say that something can't be done to moderate those bully and victim characteristics. Quite a few people seem to be talking about bullying prevention and interference strategies and I believe that when they work, they can work very well. So little things like bullying victims being able to tell someone about their experiences, through to proactive processes and policies at a school and even at a societal level designed to educate and stop would-be bullies from starting their 'give me your dinner money' ways. There are some obvious issues with some of these suggestions when applied to some cases of autism and the characteristic presentation of the condition but I don't really have the space in this post to go into specifics now.

If you're still reading this, I would perhaps also offer another tool in the anti-bullying arsenal: self-defence skills. As per the title of this post, I am not condoning violence in any way, shape or form by saying this and realise that bullying covers so much more than just physical action. But let's face it, with all the will in the world and support from parents, schools, whoever, there are always going to be situations where a child is on their own and potentially faced with a bully or bullies. Particularly when bullying turns from words and phrases to 'sticks and stones' is where perhaps some degree of self-defence might come in handy. Note the stress on defence before any charges of incitement to violence are levelled at me. And I'm not the only one suggesting this by the way.

Searching the literature on the use of martial arts / self-defence for people with autism, there are some interesting pieces of research to note. This poster presentation by Palermo and colleagues******** talks about how karate is not only a skill that can be taught to children with autism, but also a skill which might (in some cases) actually have some value-added benefits outside of just being able to 'take care of yourself'. Indeed other studies, whilst limited in quantity, have indicated similar potential gains from taking up martial arts as per this study by Bahrami and colleagues*********. If one takes the martial arts path to its natural progression in terms of the mental and physical discipline required and related concepts like mindfulness, you can perhaps see other potential benefits which might also accompany the various moves outside of just increasing self-confidence and physical empowerment.

I'll reiterate that I'm not suggesting that every child with autism trains up to be some kind of Keanu Reeves "I know Kung-Fu" warrior. And once again I am totally understanding of the voices of 'why would someone bully a kid with autism?' sentiments and the need to try and alter attitudes whether through education or indeed legislation. The trouble is that we live in a world where kids, some kids, can be very cruel and whether through ignorance or other factors, bullying is pretty much always going to be on the periphery of growing up just as it can, and often does, carry forward to the adult workplace. Having autism it seems, does not confer immunity to that premise. With all that in mind, does taking a wide ranging approach to managing bullying including an element of teaching self-defence really sound so un-PC?

---------

* Sterzing PR. et al. Bullying involvement and autism spectrum disorders: prevalence and correlates of bullying involvement among adolescents with an autism spectrum disorder. Archives of Pediatrics & Adolescent Medicine. September 2012.

** van Roekel E. et al. Bullying among adolescents with autism spectrum disorders: prevalence and perception. JADD. 2010; 40: 63-73.

*** Montes G. & Halterman JS. Bullying among children with autism and the influence of comorbidity with ADHD: a population-based study. Ambulatory Pediatrics. 2007; 7: 253-257.

**** Dickerson Mayes S. et al. Suicide ideation and attempts in children with autism. Research in Autism Spectrum Disorders. 2013; 7: 109-119.

***** Bejerot S. et al. Poor performance in physical education - a risk factor for bully victimization. A case-control study. Acta Paediatrica. 2011; 100: 413-419.

****** Wildhaber J. et al. Global impact of asthma on children and adolescents' daily lives: the room to breathe survey. Pediatric Pulmonology. 2012; 47: 346-357.

******* Kukaswadia A. et al. Obesity as a determinant of two forms of bullying in Ontario youth: a short report. Obesity Facts. 2011; 4: 469-472.

******** Palermo MT. et al. Karate and autism spectrum disorders: sports as treatment for social cognition deficits. Archives of Disease in Childhood. 2008; 93: ps540.

********* Bahrami F. et al. Kata techniques training consistently decreases stereotypy in children with autism spectrum disorder. Research in Developmental Disabilities. 2012; 33: 1183-1193.

----------
Sterzing PR, Shattuck PT, Narendorf SC, Wagner M, & Cooper BP (2012). Bullying Involvement and Autism Spectrum Disorders: Prevalence and Correlates of Bullying Involvement Among Adolescents With an Autism Spectrum Disorder. Archives of pediatrics & adolescent medicine, 1-7 PMID: 22945284