Kids need other kids (for social communication skills)

A quick post today bringing the findings from Angela Barber and colleagues [1] to your attention and the idea that both young children diagnosed with autism and young children not diagnosed with autism might similarly benefit from peer mediated intervention (PMI). PMI basically means that peers are active agents in the instruction of one or more skills (see here for further information).

For the Barber study, 3 pairs of pre-school children (one diagnosed with an autism spectrum disorder and one not) were brought together. The child not diagnosed with autism was taught a specific PMI - "the Stay, Play, Talk PMI" - which as the name suggests involves being instructed to "Stay with their friend, Play with their friend, and Talk to their friend." For two 20 minute sessions over 6-8 weeks features of social communication were monitored.

Researchers reported that all children - those with autism and this without - seemed to benefit from this type of approach in terms of social responsiveness. That being said, social initiations were described as "variable across dyads" and when examined 2-months post-interventions were are told that gains "were not maintained."

You might have read that last paragraph and thought 'what's the point' given that gains were not maintained and important things like social initiations did not seem to be uniformly affected by peer involvement. I don't share that view given a few important points: (1) in a real-world setting, peers (generally also known as friends!) don't just interact in two 20 minute sessions for 6-8 weeks, it's more of an on-going thing, and (2) other studies of PMI have come up with slightly more favourable and generalisable results [2] with the need for quite a bit more study. Indeed, in these days of searching for ever more cost-effective strategies for screening and intervention with autism in mind (see here), I'd be minded to suggest that peers (including siblings) represent valuable partners who might also benefit from the whole PMI process too...

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[1] Barber AB. et al. Peers as clinicians: Examining the impact of Stay Play Talk on social communication in young preschoolers with autism. J Commun Disord. 2015 Aug 7;59:1-15.

[2] Katz E. & Girolametto L. Peer-mediated intervention for pre-schoolers with ASD: Effects on responses and initiations. Int J Speech Lang Pathol. 2015 Apr 17:1-12.

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Barber AB, Saffo RW, Gilpin AT, Craft LD, & Goldstein H (2015). Peers as clinicians: Examining the impact of Stay Play Talk on social communication in young preschoolers with autism. Journal of communication disorders, 59, 1-15 PMID: 26606507

Karate and autism continued: Kiai!

Gichin Funakoshi

"We concluded that teaching Karate techniques to children with ASD [autism spectrum disorder] leads to significant reduction in their communication deficit."

That was the [research] bottom line from Fatimah Bahrami and colleagues [1] continuing their very interesting voyage into looking at how aspects of the martial arts might well benefit some people on the autism spectrum. I mention the word 'continuing' because this authorship group from Iran have some research form in this area previously covered on this blog (see here).

In their latest paper, the authors took to looking at how another core area of autism - communication issues - may also be impacted by kata training (that is, the various structured movements against an invisible opponent(s) practised as part of karate). This time as previously, the kata in question was Heian Shodan, the kata normally used to grade transition from orange belt to red belt in Shotokan karate. Helpfully, the authors also provide their own video of the kata used as supplementary material to their paper.

Their results, based on a similarly small group of children with autism assigned to kata training (n=15) or a control (n=15) as in previous papers, suggested that after 14 weeks of training the "Exercise group showed significant reduction in communication deficit compared to control group." Such gains seemingly persisted at 1 month follow-up too.

Appreciating that there is quite a bit more science to do in this area, including that taking on board how issues with simulative skills with autism in mind [2] might interact with the practise of martial arts training (being careful about over-generalisation [3]), I continue to find this an area of real interest. Associated research hinting that regular exercise and motor skills training might benefit quite a few aspects of autism (see here) emphasises how something like practising kata could represent a 'good fit' for quite a few children and adults diagnosed on the autism spectrum. This alongside the wider potential benefits to be had from martial arts training (see here), bearing in mind aspects like kumite might not be to everyone's taste. Dare I also even start to talk about the more 'spiritual' side of some of the martial arts (Zen played a role apparently) intersecting with some interesting case reports with autism in mind (see here)? (being careful not to fall into the bull**** trap [4]).

To close, I note that one of the national governing bodies for the martial arts here in Blighty has already come around to the idea of further opening up the sport to those on the autism spectrum.

Why not give it a try? Kiai!

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[1] Bahrami F. et al. The Effect of Karate Techniques Training on Communication Deficit of Children with Autism Spectrum Disorders. J Autism Dev Disord. 2015 Nov 17.

[2] Conson M. et al. Body Constraints on Motor Simulation in Autism Spectrum Disorders. J Autism Dev Disord. 2015 Nov 16.

[3] Torres EB. Atypical signatures of motor variability found in an individual with ASD. Neurocase. 2013 Apr;19(2):150-65.

[4] Pennycook G. et al. On the reception and detection of pseudo-profound bullshit. Judgment and Decision Making. 2015; 10: 549-563.

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Bahrami F, Movahedi A, Marandi SM, & Sorensen C (2015). The Effect of Karate Techniques Training on Communication Deficit of Children with Autism Spectrum Disorders. Journal of autism and developmental disorders PMID: 26577688

OCD and autism continued

The paper by Sandra Meier and colleagues [1] (open-access available here) is served up for your reading delight today and some continued discussion about the nature of any overlap between the autism spectrum disorders (ASDs) and obsessive-compulsive disorder (OCD).

To save my poor typing hands from further disrepair, I'm gonna refer you back to a post I wrote way back in 2011 on the topic of OCD and autism and the question of symptom overlap vs. discrete conditions (see here) as a sort of starting point for some of the issues to be resolved. More recent ramblings have also covered this topic too (see here).

The Meier paper "aimed to determine the patterns of comorbidity, longitudinal risks, and shared familial risks" when it came to autism and OCD based on the use (yet again) of one of those very useful Scandinavian population health registries. Denmark was the specific country in this case and: "Among the 3,380,170 cohort members followed from 1994 to 2012, we observed that 18,184 were diagnosed with an autism spectrum disorder and 11,209 with OCD." Further analysis of the data followed, leading authors to report that: "739 individuals were diagnosed with autism spectrum disorders and OCD; 281 were first assigned a diagnosis of OCD, 253 a diagnosis of autism spectrum disorders, and 205 were simultaneously diagnosed with OCD and autism spectrum disorders." The bottom line there was that those diagnosed with OCD had an approximate "13 times higher risk of having a comorbid autism spectrum diagnosis (6.6%) compared with individuals without OCD (0.5%)."

Meier et al also looked at parents of cohort members too, and the question of whether parental diagnosis of OCD or ASD impacted on the offspring risk of subsequent diagnosis. As it happens, it did seem to play some kind of role: "A parental diagnosis of OCD increased the risk specifically for childhood autism..., Asperger’s syndrome..., or other pervasive developmental disorder." This increased risk however has to be set in the context of how other parental diagnoses (including autism) also exerted some potential effects on risk.

With several other associations reported, these are interesting data illustrating how various different diagnostic labels seem to interact with one and another and strengthening the need for increased screening and clinical awareness of such comorbidity clusters. There is more to be done in this area specifically with the idea that psychiatric and/or developmental diagnoses might not be the only important factors mediating the relationship between autism and OCD as per other research findings (see here). That something like the presence of tics might also be something to examine (see here) and where this might lead in terms of 'novel' interventions (for some at least) (see here) is something else that I'd like to see added to the research agenda in this area. Indeed, on the theme of intervention for OCD specifically with the endogenous opioid system in mind, one wonders whether autism research might be able to offer some potentially interesting future research projects (see here)...

To close, an interesting article about brand names that are not easily forgotten...

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[1] Meier SM. et al. Obsessive-Compulsive Disorder and Autism Spectrum Disorders: Longitudinal and Offspring Risk. PLoS One. 2015 Nov 11;10(11):e0141703.

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Meier SM, Petersen L, Schendel DE, Mattheisen M, Mortensen PB, & Mors O (2015). Obsessive-Compulsive Disorder and Autism Spectrum Disorders: Longitudinal and Offspring Risk. PloS one, 10 (11) PMID: 26558765

Pattern-related visual stress in ME/CFS

At the time of writing this post, important discussions about ME (myalgic encephalomyelitis) and/or CFS (chronic fatigue syndrome) are coming thick and fast.

Years of talk about 'yuppie flu' and other even more derogatory terms to describe the often very disabling experience of ME/CFS (SEID if you wish) have seemingly been replaced by sensible discussion on things like a research agenda for CFS/ME (at least in some parts of the world). As per other blogging occasions where CFS/ME has figured, 2015 is proving to be a bit of a turning point...

Who do we have to thank for this shift in thinking? Well, my bet would be on the thousands of people who suffer with ME/CFS (yes, people do suffer with the condition) and their families and loved ones who have tirelessly campaigned down the years for appropriate recognition of the condition despite living an often torrid existence as a consequence of their symptoms. Patient power in action you might say. I'd also drop in a name or two for some research pioneers such as Jose Montoya (see here) and colleagues and the research tag-team that is Mady Hornig and Ian Lipkin (see here) (they have fingers in many research pies!) for their important contributions. A colleague of mine, Prof. Malcolm Hooper, also deserves a mention (see here) in that list of the great and the good, alongside countless other investigators and clinician folk.

Part of the shift in our thinking and understanding of ME/CFS, aside from some recognition that several states/conditions/diagnoses might reside under the umbrella terms ME/CFS, is the idea that the physiology and biology of the disease course are deserving of quite a bit more study over and above the focus on just the psychological 'effects' of the condition. Heated discussions about the PACE trial (see here) and its follow-up (see here) have served a useful purpose insofar as stressing that 'psychology' may be part and parcel of CFS/ME as an 'effect' (see here) but this does not mean that more fundamental biology and biochemistry should be ignored as potential aetiological and intervention options (see here).

The idea that there may be psychological 'effects' to cases of ME/CFS is something explored in a recent paper by Rachel Wilson and colleagues [1] who concluded that their findings "provide evidence of altered visual perception in ME/CFS." Based on data from a small group of people diagnosed with ME/CFS compared with age and sex-matched asymptomatic controls, researchers set out to "determine vulnerability to pattern-related visual stress." Pattern-related visual stress (PRVS) by the way, refers to problems stemming from looking at certain types of visual stimuli. For the purposes of their study, Wilson et al used the Pattern Glare Test to determine PRVS (further information can be read here although I am told that those with photosensitive epilepsy should resist any further temptations to look for the patterns used).

"Pattern-related visual stress may represent an identifiable clinical feature of ME/CFS that will prove useful in its diagnosis." That was the conclusion reached on the basis of the results obtained, and specifically that: "ME/CFS patients exhibited significantly higher pattern glare scores than controls for the mid-SF [spatial frequency] pattern" among other things. I might reiterate that this was quite a small study in terms of participant numbers and also in the context of assessing visual stress so I'm cautious about any claims of such a variable being somehow diagnostic at this time. Some media write-up of the study can be seen here.

Nonetheless, these are interesting results and perhaps map on to other related data from some of the authors on the Wilson paper [2]. Quite a few moons ago, my colleagues and I also talked about the possibility of visual manifestations included in the context of [some] ME/CFS [3]. On that occasion, we discussed the idea that light sensitivity or photophobia might be something to look at, allied to issues such as auditory hyperacuity (noise sensitivity) and other, more cognitive-related issues appearing alongside the more traditional fatigue-related aspects to presentation. I cannot say for sure that visual stress and auditory acuity issues are linked, but one might reason that within the wider context of perceptual issues being part and parcel of at least some cases of ME/CFS, there may be more research to do in this area with multi-sensory perception in mind. I might add that ME/CFS research might be able to learn a few things from other areas of research too (see here and see here) given some research history with ocular manifestations in mind [4].

The question is then: what are the biological underpinnings of such issues? Well, I have some ideas about that too including entertaining the potentially controversial notion that there may be an 'infectious' component to something like ME/CFS [5] at least in some cases...

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[1] Wilson RL. et al. Increased Vulnerability to Pattern-Related Visual Stress in Myalgic Encephalomyelitis. Perception. 2015 Nov 3. pii: 0301006615614467.

[2] Hutchinson CV. et al. Vision-related symptoms as a clinical feature of chronic fatigue syndrome/myalgic encephalomyelitis? Evidence from the DePaul Symptom Questionnaire. Br J Ophthalmol. 2014 Jan;98(1):144-5.

[3] Whiteley P. et al. Correlates of Overlapping Fatigue Syndromes. Journal of Nutritional & Environmental Medicine. 2004; 14: 247-259.

[4] Potaznick W. & Kozol N. Ocular manifestations of chronic fatigue and immune dysfunction syndrome. Optom Vis Sci. 1992 Oct;69(10):811-4.

[5] Underhill RA. Myalgic encephalomyelitis, chronic fatigue syndrome: An infectious disease. Med Hypotheses. 2015 Oct 19. pii: S0306-9877(15)00382-5.

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Wilson RL, Paterson KB, & Hutchinson CV (2015). Increased Vulnerability to Pattern-Related Visual Stress in Myalgic Encephalomyelitis. Perception PMID: 26562880

Toddler language and autism risk

I'm not going to keep you too long today as I introduce the paper by DeWayne Lazenby and colleagues [1] and some rather interesting data on whether early language use might help predict those toddlers who are at subsequent risk of being diagnosed on the autism spectrum.

Based on the prospective analysis of over 300 infants - "some of whom were at high risk for developing ASD [autism spectrum disorder]" - authors went about analysing various aspects of language using among other things, the MacArthur-Bates Communicative Developmental Inventories (CDI). They reported a few potentially interesting details including: "lower receptive and expressive language scores in infants who later were diagnosed with ASD" based on their testing round about 12 months of age. Further: "a Rasch analysis indicated that infants who later developed ASD had a higher degree of statistically unexpected word understanding and production." They concluded that there may indeed be more to see when it comes to language use in early childhood as a potential marker of subsequent autism diagnosis. Such findings accord with other data from some of the authors [2].

Accepting that within the very wide and heterogeneous autism spectrum probably better defined by the plural autisms (see here) there may be lots of factors influencing first presentation including the variable of regression (see here), these are important findings. Notwithstanding the notion that autism seems not to be protective against other language-related issues being potentially comorbid [3] and the effect that might have on early presentation of language, the idea that speech patterns might direct a child towards preferential early screening for autism is useful in light of the emphasis on early screening [4] and the 'clear benefits' of early intervention [5].

As part of the growing interest in aspects of telemedicine and mobile health, the recent news about ResearchKit being applied to autism (see here) might well provide something of an important platform whereby information about facial expressions is further combined with assessment of speech patterns and production (including aspects such as intonation [6] etc). This does not mean that every single early presentation of autism will be 'picked up' by such technology, but it does perhaps offer a way that technology can ease some of the significant pressures on clinical resources pertinent to identifying autism early and accurately.

And whilst we're on the topic of language and autism, I can recommend another article by Tager-Flusberg [7] worth a read...

Music: PJ Harvey - C'mon Billy.

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[1] Lazenby DC. et al. Language Differences at 12 Months in Infants Who Develop Autism Spectrum Disorder. J Autism Dev Disord. 2015 Oct 17.

[2] Talbott MR. et al. Diary Reports of Concerns in Mothers of Infant Siblings of Children with Autism Across the First Year of Life. J Autism Dev Disord. 2015 Jul;45(7):2187-99.

[3] Tager-Flusberg H. Defining language impairments in a subgroup of children with autism spectrum disorder. Sci China Life Sci. 2015 Sep 2.

[4] Zwaigenbaum L. et al. Early Screening of Autism Spectrum Disorder: Recommendations for Practice and Research. Pediatrics. 2015 Oct;136 Suppl 1:S41-59.

[5] Zwaigenbaum L. et al. Early Intervention for Children With Autism Spectrum Disorder Under 3 Years of Age: Recommendations for Practice and Research. Pediatrics. 2015 Oct;136 Suppl 1:S60-81.

[6] Nakai Y. et al. Speech intonation in children with autism spectrum disorder. Brain Dev. 2014 Jun;36(6):516-22.

[7] Tager-Flusberg H. Risk Factors Associated with Language in Autism Spectrum Disorder: Clues to Underlying Mechanisms. J Speech Lang Hear Res. 2015 Oct 20.

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Lazenby DC, Sideridis GD, Huntington N, Prante M, Dale PS, Curtin S, Henkel L, Iverson JM, Carver L, Dobkins K, Akshoomoff N, Tagavi D, Nelson CA 3rd, & Tager-Flusberg H (2015). Language Differences at 12 Months in Infants Who Develop Autism Spectrum Disorder. Journal of autism and developmental disorders PMID: 26476738

Health service use, autism and preventative medicine

Appreciating that the title of this post potentially offers the opportunity to write a long (very long) post, today I'm specifically focusing on two papers. The first by Janet Cummings and colleagues [1] discussing health service use "among youth with and without an autism spectrum disorder (ASD)" concluded that yes, young people with autism were more likely to experience health service use than not-autism control populations. Importantly however, was the suggestion that this group were "less likely to receive important preventive services including flu shots and other vaccinations."

The second paper to bring into discussions is that from Paul Carbone and colleagues [2] who examined "the prevalence of hospitalizations for ambulatory care sensitive conditions (ACSC) in children with and without autism spectrum disorder (ASD)." ACSC in case you did not click on the highlighted link, refers to chronic conditions "for which it is possible to prevent acute exacerbations and reduce the need for hospital admission through active management, such as vaccination; better self-management, disease management or case management; or lifestyle interventions."

Based on data derived from a '2009 Kids' Inpatient Database' researchers concluded that hospitalisations for ACSC were quite a bit more frequent than for those with either other chronic conditions outside of autism or those without any chronic conditions at all. Indeed compared with that 'no chronic conditions at all' group, those with autism were more likely to be admitted for a variety of issues including "a mental health condition, epilepsy, constipation, pneumonia, dehydration, vaccine-preventable diseases, underweight, and nutritional deficiencies."

Without over-analysing the results of these collected investigations, the primary issues presented seem to be: (a) that people diagnosed on the autism spectrum are more likely to use healthcare services than non-autism controls, and (b) although many of the 'ailments' for which treatment is sought have been previously recognised in the research and clinical literature, the idea of preventative medicine, and the potential benefits that it can bring, is still to some degree missing when looking at the wider picture of health and wellbeing with autism in mind.

Preventative medicine casts a wide net in terms of what is covered. Having previously discussed important lifestyle issues such as diet and exercise when it comes to the autism spectrum on this blog (see here and see here for example) I've been particularly interested in how science can offer some solutions for issues such as getting people more physically active or recognising the value of a balanced diet (and where certain dietary extremes can eventually lead). Discussions about bowel issues in relation to autism have also been ramped up in recent years as science cottons on to what many people have been saying: functional and pathological bowel issues are over-represented when it comes to a diagnosis on the autism spectrum (see here).

The associated findings that rates of "vaccine-preventable diseases" may be increased in some of the analysed cohorts with autism and/or that immunisation as part of a strategy of preventative medicine might be diminished are worrying trends. I know this area still attracts some discussion alongside more general debates about vaccines for example [3] but as part of the arsenal of initiatives to improve public and 'personal' health, one might see such findings as part of a wider issue with health inequality when it comes to autism. Indeed, if one looks to the future and the idea that autism is not generally a life-limiting condition (at least not for many), one wonders what the long-term future holds for older adults with autism in light of the potential seriousness of something like influenza for older populations (see here) for example?

Music to close and Axis of Awesome talk number 1 hits...

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[1] Cummings JR. et al. Health Services Utilization Among Children With and Without Autism Spectrum Disorders. J Autism Dev Disord. 2015 Nov 7.

[2] Carbone PS. et al. A Comparison of Ambulatory Care Sensitive Hospitalizations Among Children With and Without Autism Spectrum Disorder. Acad Pediatr. 2015 Nov-Dec;15(6):626-635.

[3] Suryadevara M. et al. Pediatric provider vaccine hesitancy: An under-recognized obstacle to immunizing children. Vaccine. 2015 Oct 31. pii: S0264-410X(15)01552-2.

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Cummings JR, Lynch FL, Rust KC, Coleman KJ, Madden JM, Owen-Smith AA, Yau VM, Qian Y, Pearson KA, Crawford PM, Massolo ML, Quinn VP, & Croen LA (2015). Health Services Utilization Among Children With and Without Autism Spectrum Disorders. Journal of autism and developmental disorders PMID: 26547921




Carbone PS, Young PC, Stoddard GJ, Wilkes J, & Trasande L (2015). A Comparison of Ambulatory Care Sensitive Hospitalizations Among Children With and Without Autism Spectrum Disorder. Academic pediatrics, 15 (6), 626-635 PMID: 26547543