Monday with Maureen: Treatment for autism – Is there a best one?

By Laura Dewey, Ph.D.

Laura Dewey, Ph.D., is a pediatric psychologist at Nemours/A.I. duPont Hospital for Children, and an assistant professor of pediatrics at Jefferson Medical College.

So your child has received a diagnosis of Autism Spectrum Disorder – now what? This is often the most pressing and distressing questions faced by families, especially since research shows that early and often intervention makes the greatest impact on improving outcomes.

It’s important to remember that, at its core, ASD is a social disorder. For individuals who are severely affected this could mean minimal eye contact and almost complete avoidance of interactions, but for individuals who are less severely affected (and are now making up the largest pool of new diagnosis!), this could be subtle differences in social perspective-taking or flexibility.

Regardless, supporting social development is the ultimate goal of treatments for ASD. Unfortunately, there is no “one” treatment, and ASD is considered to be lifelong. But if families can remember that slow and steady pressure to support and improve social interactions is the primary goal, they can work with their teams to come up with an individualized treatment plan.

Applied Behavior Analysis was developed in the 1970s and was traditionally geared toward severely affected children. Often, ABA used a “discrete trial” approach and took place one-on-one in a clinic setting. For example, every time a child correctly points to a picture, they are immediately rewarded with a reinforcer, such as a piece of candy.

However, over the past few decades, the scope of ABA has widened dramatically to include considerations such as providing interventions in a child’s natural environment (home instead of clinic), following a child’s lead (such as prompting labeling while playing with bubbles), and emphasizing natural and social reinforcers (such as a tickle game with caregivers). These types of behavior-based interventions go by many names; research has started to refer to them as Naturalistic, Behavioral, and Developmental Interventions. Overall, it is most important to ensure that children are receiving behavior therapies that are based on ABA, even if they go by different names.

Luckily, most providers with specialty in ASD are using behavior-based approaches. This means that preschool classrooms, psychologists, occupational therapists, speech therapists, and the whole spectrum of treatment providers are already using the appropriate interventions. And the more that parents can learn how to use behavior strategies, the more they can apply these principles in the home setting to increase frequency of intervention and support generalizing skills. Research shows that 25 to 40 hours a week of intervention is most effective before age five. This includes all of the therapeutic learning opportunities that occur throughout the day in all settings.

There are many simple strategies based on ABA that parents can learn and begin using immediately to support their child’s development.

1. Use of “first, then” statements. These should be kept simple and concrete and presented to the child in the same way every time. For example, a parent can say “first table, than food” to indicate that once the child sits, food will come next. This strategy is successful because it helps children to learn a pattern that can be used in a variety of settings.

2. Use of visual schedules. It is often easy to search online for pictures of basic routines, such as a bedtime routine. The schedule might depict a bathtub, pajamas, toothbrush, and a book to indicate the order of events. These schedules are helpful because it reduces uncertainty and language requirements to understand what is expected.

3. Use of a child’s unique motivators. If a child loves to carry a favorite stuffed animal, require the child to engage in a basic task before using the stuffed animal as a reinforcer. For example, the child could attempt to point to the stuffed animal while making eye contact to request. After this behavior is observed, the child could be rewarded with a tickle game involving the stuffed animal and their caregiver.

Learning and using behavior strategies is the ultimate goal and the active ingredient in treatment for ASD. So the treatment, such as ABA, is less important than the strategies used.


Monday with Maureen: A Novel Autism Treatment Strategy?

????????????????????????????????????????????????????????????????????????????????????????????It seems every week a new study is published touting the latest “cause” of autism. This one is pretty interesting. I hope you enjoy the article!

Children with autism ‘have too many synapses in their brain’

A new study by researchers from the Columbia University Medical Center in New York, NY, finds that children and adolescents with autism have too many synapses in their brain, which can affect their brain function. Furthermore, the team believes it may be possible to reduce this excess synapse formation with a drug, paving the way for a novel autism treatment strategy.

Researchers found higher synapse formation in the brains of children with autism (right) than the brains of children without autism (left).

Around 1 in 68 children in the US have autism – a developmental condition characterized by behavioral, social and communication problems.

Exactly what causes autism is unclear, but researchers believe that it is triggered by abnormalities in the structure of the brain that stop it from functioning properly.

In this latest study, published in the journal Neuron, co-author Guomei Tang, PhD, assistant professor of neurology at Columbia University Medical Center (CUMC), analyzed 26 brains of children and adolescents with autism who had died from other causes, alongside 22 brains of children without autism.

Of the brains from those with autism, 13 came from children aged 2-9 years, while the remaining 13 came from teenagers aged 13-20 years.

Dr. Tang then assessed synapse density in each of the brains by counting how many tiny “spines” extended from them. The researchers note that synapses are where brain cells connect and communicate with each other. Each of the spines connects with a brain cell through a synapse.

Brain cells unable to ‘eat’ unwanted components

She found that in the brains of individuals without autism, the number of spines had reduced by almost 50% by late childhood. However, the number of spines in the brains of those with autism had only reduced by 16% by late childhood.

Further investigation revealed that the brains of children with autism possessed neurons that consisted of old and damaged components, and showed deficiency in a pathway known as autophagy – a route that cells use to “eat” their own parts.

This may explain why the brains of autistic children had higher spine density – unwanted synapse connections had not been degraded.

Commenting on this finding, senior study investigator Dr. David Sulzer, professor of neurobiology in the Departments of Psychiatry, Neurology and Pharmacology at CUMC, says:

“It’s the first time that anyone has looked for, and seen, a lack of pruning during development of children with autism, although lower numbers of synapses in some brain areas have been detected in brains from older patients and in mice with autistic-like behaviors.”

Rapamycin restored autophagy, reversed autism symptoms in mice. The research team then analyzed mouse models of autism and found that the lack of “pruning” is down to overactivity in a protein called mTOR.

The investigators discovered that when this protein is overactive, the brain cells experience a reduction in their “self-eating” function. This means too many synapses are formed, which can impact brain function.

Dr. Sulzer notes that when it comes to learning abilities, the formation of new synapses is crucial. But he says this study shows that the removal of needless synapses may be just as important.

The team then tested a drug that is known to block mTOR activity – rapamycin – on the autism mouse models.

Autophagy was restored in the mice, leading to a reduction in synapse formation. In turn, this also reversed autistic-like behaviors in the mice, suggesting that a similar approach could be used to treat patients who have already been diagnosed with autism.

The researchers note, however, that rapamycin does have side effects, so this particular drug may not be suitable for human use. But Dr. Sulzer says that if a better drug is found that has the same effect, a new treatment strategy for autism could be in the cards.

Could autism-related genes ‘converge’ in the mTOR pathway?

In addition, Dr. Sulzer says it is possible that the array of genes that have previously been associated with autism development may work with the mTOR and autophagy pathway.

“What’s remarkable about the findings is that hundreds of genes have been linked to autism, but almost all of our human subjects had overactive mTOR and decreased autophagy, and all appear to have a lack of normal synaptic pruning,” he notes.

“This says that many, perhaps the majority, of genes may converge onto this mTOR/autophagy pathway, the same way that many tributaries all lead into the Mississippi River. Overactive mTOR and reduced autophagy, by blocking normal synaptic pruning that may underlie learning appropriate behavior, may be a unifying feature of autism.”

Alan Packer, PhD, senior scientist at the Simons Foundation who funded this study, says that the goal of future research is to understand how the hundreds of genes linked to autism “cluster” into a smaller number of pathways, adding:

“The mTOR pathway certainly looks like one of these pathways. It is possible that screening for mTOR and autophagic activity will provide a means to diagnose some features of autism, and normalizing these pathways might help to treat synaptic dysfunction and treat the disease.”

Written by Honor Whiteman

Monday with Maureen: Tips for Making Sound Treatment Decisions

Today’s Blog is courtesy of Juli Liske, a member of our advisory board & the founder/CEO of the Brown Center of Autism

Tips for Making Sound Treatment Decisions

JuliTo date, there remains no one best treatment approach that fits every child with autism. Before deciding upon a treatment approach, it is important to weigh the risks vs. benefits of an approach and consult with your child’s physician.

In the best interest of your time, your resources, and most importantly—your child, it is also helpful to become more knowledgeable in how to critically evaluate information and claims about autism treatments that you may find on the internet or otherwise.

It is helpful to consider the following basic guidelines:

• Search for information on .org, .edu, or .gov websites as these designations lend themselves to credible, peer-reviewed material more frequently than material found on commercial ( .com) websites

• Information should be supported by independent research (meaning research is not funded or conducted by those who have a vested financial interest in the outcome of the study) that has been published in peer-reviewed journals (i.e. New England Journal of Medicine, Journal of the American Academy of Pediatrics, etc….)

• Beware of resources utilizing the testimonials of other parents as a means of marketing a treatment approach—this strategy is generally considered unethical conduct because it preys upon the emotional vulnerability of parents.

• While parents may need to make multiple adjustments before finding the best treatment approach for their individual child, introducing multiple approaches simultaneously will make it difficult to determine the effectiveness of a given treatment strategy. The introduction of new approaches should be staggered by a 4-6 week interval in order to determine their effectiveness.

• Beware of alternative treatment approaches that insist that they be combined with a proven approach in order to be effective. This strategy is often used in an attempt to “piggyback” positive outcomes on the effectiveness of the research-based approach.

• Investigate potential conflicts of interest by inquiring of providers that require laboratory services (blood, urine, hair samples, etc…) and who also prescribe and dispense in-house treatments whether they utilize an internal laboratory. If so, ask if samples can be sent to an unaffiliated and independently contracted laboratory service for unbiased testing.

The following web pages contain additional guidance for families seeking to make educated treatment decisions:

Centers for Disease Control and Prevention–

National Institute of Mental Health–

Learn more about The Brown Center for Autism.