Inter-professional Perspectives

Autism is one of the fastest growing health conditions in the United States. In May 2012, the CDC reported that 1 in 88 children are diagnosed with autism by age eight1. Many individuals with Autism Spectrum Disorder (ASD) find it difficult to practice good oral hygiene due to their unique challenges, such as extreme sensations to the taste and texture of the toothpaste and toothbrush. A recent study2 reported that over 60% of the parents with ASD children experienced difficulty in their children’s oral care (tooth brushing) on a daily basis, significantly more than parents with typical developing children.

A routine visit at the dental office is even more challenging for individuals with Autism Spectrum Disorder. Thirty-seven percent of parents with children who have ASD reported that it is more difficult to find and access dental services for them when compared to their child(ren) without ASD2. When children with ASD finally arrive in a dental office, they often have difficulty with sensory stimuli (i.e., light and sound from the dental unit) as well as understanding expectations. These children were also very uncomfortable with the new environment at the dental office. When children with ASD are unable to effectively communicate their needs and wants, anxiety builds and in order to protect themselves, their behavior typically becomes uncooperative.

As a dental professional, my goal is to work with other healthcare professionals to discover different approaches to improve oral health in individuals with ASD. Many educational methods have been developed by other professions, such as Applied Behavior Analysis (ABA), TEACCH method, and Occupational therapy. We can apply the similar principles from these techniques and use them into our dental visits and procedures.

References:

1. CDC Health Reports, May 2012.
2. Stein, LI, Polido JC, et al. Oral care experiences and challenges in children with autism spectrum disorders. J Ped Dent Sep/Oct 2012;34(5): 387-91.

Vision Therapy

Many of the first signs and symptoms noted by parents of children with autism have a visual or perceptual component. Frequently, parents notice that a child with ASD does not look at their eyes and may prefer to watch their mouth when they are talking or may instead look at their ear or even view faces with their head turned. Individuals on the spectrum may tend to focus their eyes on a small detail while missing information from their surroundings or by using their peripheral vision. In early development, children on the spectrum may be missing the typical point response to indicate objects of interest or to share a visual experience in their environment with a parent. For example, they may not initiate pointing to indicate observation of a bird or they may not respond typically when a parent points out a neighborhood dog or the pretty flower across the sidewalk. Kids with autism frequently have difficulty both with visually recognizing facial expressions of emotions, but also even identifying individuals based on their facial features.

Each of these frequently encountered descriptions is an indicator of visual and perceptual differences between kids on the spectrum and children who are developing neuro-typically. Researchers have identified these differences in visual and perceptual functioning as a potential means for early and objective diagnosis. Individuals with ASD appear to be utilizing different cognitive strategies and even different brain areas to process responses to both visual and auditory stimuli. Differences in face recognition strategies and abnormalities in gaze fixation have been demonstrated using functional imaging techniques. In an effort to improve early detection, researchers have begun to note that children who develop autism show signs of different brain responses as early as the first year of life. A recent study conducted in Great Britain found that some babies showed unusual patterns of brain activity associated with the development of ASD. Babies who were found to be typically developing had a significant difference in the type of brain activity that occurred in response to a face looking towards them compared with a face that was looking away, as a simulation of social eye contact. Babies who later developed symptoms of ASD showed much less difference in brain activity when exposed to eye contact or a face that was looking away. The investigators hypothesize that direct brain measures might help predict the future risk of autism in babies as young as six months old. A variety of visual and perceptual therapies may be prescribed and integrated within the overall care for individuals with autism.

Stay tuned for future segments of “Autism Intersection” that will focus on examples of various types of therapies. Examples include:

• Therapies to improve visual motor integration
• Techniques to enhance eye focusing and eye aiming skills
• Strategies to improve eye tracking and peripheral awareness
• And enhancements in visual perception such as for improved depth perception or awareness of the space around them that could impact gait and balance or other behaviors such as toe-walking.
• Stayed tuned for more information from WesternU!

Osteopathic Medicine

Osteopathic medicine was founded in 1874 by Andrew Taylor Still, MD, who recognized that the medical practices of the day were often more harmful than beneficial. He developed an approach to medical care that focused on the body’s innate ability to heal itself. He called this system of medicine Osteopathy, now known as Osteopathic Medicine.

DOs work in partnership with their patients. They consider the impact of body, mind and spirit on the health of each individual, and they work to break down barriers to good health. DOs are licensed to practice the full scope of medicine in all 50 states. They practice in all types of environments, including the military, and in all types of specialties, from family medicine to obstetrics, surgery, pediatrics, and many others. DOs look at the whole person, which means they see each person as more than just a collection of organ systems and body parts that may become injured or diseased. This holistic approach to patient care means that the DO learns to integrate the patient into the health care process as a partner.

Osteopathic Medicine is based on the following four principles:

1. The body is a dynamic unit; the person is a fully integrated being consisting of body, mind, and spirit
2. The body has an inherent capability for self-regulation and self-healing
3. Structure and function are intimately interconnected; things that affect the structure of the body can affect how the body functions, and things that affect the body’s organs and functions can be reflected in the body’s structural system
4. Any rational treatment for a patient relies on the application of the above principles

How do we apply these osteopathic principles to the patient who has the condition known as autism spectrum disorder (ASD)?

First, according to the holistic viewpoint, osteopathic practitioners would not think in terms of treating autism, but rather in terms of treating a patient who has the signs and symptoms of autism. Osteopathic philosophy also states that the physicians’ job is to assist the patient in finding health. The overarching goal of Osteopathic treatment is to help the patient to achieve maximum structural, physiological and emotional potential. Osteopathic physicians work to determine the most effective treatment approach for each patient by considering all of the physical, mental, emotional, psychological and spiritual factors that may be affecting the patient. The osteopathic practitioner considers every patient to be unique. While we all want the best possible outcome for every patient, the goal of osteopathic treatment is not focused in the traditional sense on “curing” autism, but rather on helping the patient to reach his or her optimum potential.

With respect to the structure-function connection already mentioned, osteopathic practitioners know that any kind of illness or condition a patient may have is reflected not only in the internal organs of the body that may be affected, but also in the musculoskeletal, or structural, system of the body as well. Of particular interest with patients with ASD, osteopathic physicians know that birth trauma has been shown to be a factor related to the development of this condition. More specifically, when birth trauma affects the normal position and motion of the bones of the skull, this leads to interference with the proper arterial blood flow to the brain, and the venous drainage from the brain structures. All of this can lead to different types of neurological and developmental problems, including ASD. Osteopathic physicians can use their knowledge of the musculoskeletal system to diagnose these structural problems, and they can use a form of osteopathic manipulation, called cranial osteopathy, to remove these structural problems. This allows for normal motion of the cranial bones, resulting in improved arterial and venous flow to and from the brain. The end result is that we often see marked improvements in the child with ASD in areas such as language, coordination, and learning ability.

Cranial Osteopathy was developed many years ago by an osteopathic physician by the name of William Sutherland. Today, in addition to osteopathic physicians who can provide cranial osteopathy, there are also non-physician practitioners, such as massage therapists or physical therapists, who sometime provide a type of cranial therapy based on Dr. Sutherland’s techniques. This is referred to as craniosacral therapy.

Finally, osteopathic physicians recognize that treatment of the child with ASD is a team effort. In order to maximize the child’s self-healing cababilities, the osteopathic physician knows that, in addition to treatment of the structural problems described above, other forms of treatment will also be necessary. This may include medications, nutritional counseling, physical therapy, and many other possible options. To achieve this requires an open mind and close work and communication with a team of healthcare workers. The ultimate goal is to provide the child with ASD the best possible environment in which to achieve his or her maximum health.

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IF YOU ARE INTERESTED IN PEDIATRIC OSTEOPATHIC MEDICINE FOR ASD, PLEASE CONTACT:

 

Watch Dr. Magoun on Autism Intersection, now on The Autism Channel at theautismchannel.tv

Physician Assistant Perspective

 

A physician assistant (PA) is a medical professional who works as part of a team with a doctor. PAs perform physical examinations, diagnose and treat illnesses, order and interpret lab tests, perform procedures, assist in surgery, provide patient education and counseling and make rounds in hospitals and nursing homes. All 50 states and the District of Columbia allow PAs to practice and prescribe medications. By design, physicians and PAs work together as a team, and all PAs practice medicine with physician supervision. Supervision does not mean, though, that a supervising physician must always be present with the PA or direct every aspect of PA-provided care.

PAs are trained and educated similarly to physicians, and therefore share similar diagnostic and therapeutic reasoning. Physician-PA practice can be described as delegated autonomy. Physicians delegate duties to PAs, and within those range of duties, PAs use autonomous decision-making for patient care. This team model is an efficient way to provide high-quality medical care. In rural areas, the PA may be the only healthcare provider on-site, collaborating with a physician elsewhere through telecommunication. With respect to Autism Spectrum Disorder (ASD), PAs play a large role in the screening process. It is well-known that early intervention is correlated with better outcomes and higher functionality. As the incidence of ASD increases, early detection will become a very important piece so that early intervention can take place.

In Family Practice, Pediatrics, or other primary care settings, the PA seeing patients for well-child examinations can utilize autism screening tools, such as Ages and Stages Questionnaires (ASQ), Communication and Symbolic Behavior Scales (CSBS), Parents’ Evaluation of Developmental Status (PEDS), Modified Checklist for Autism in Toddlers (MCHAT), or Screening Tool for Autism in Toddlers and Young Children (STAT).

As PAs, we can advocate for autism screening if it is not in our practice’s current protocol. We can also work with our supervising physicians to determine which tool is appropriate for our practice. In addition, we can establish developmental screening flowcharts or treatment algorithms to help manage patient or provider concerns as well as positive screenings. Though it is a difficult topic to broach with parents because of so much that is unknown, it is our responsibility as healthcare providers to raise awareness of this epidemic so that the best possible outcomes can be attained.

References:

1. www.aapa.org
2. www.cdc.gov

Veterinary Medicine

 

The use of animals to assist people affected with Autism Spectrum Disorder (ASD) has increased exponentially over the last couple of decades. Different species are used, from the traditional companion animals to farm animals and horses, even the occasional exotic species like dolphins. The intervention of animals in the treatment of patients with ASD has proven to be beneficial for the human patient in different settings, from the home to the therapy office. At home the animal facilitates opportunities for social interaction with the ASD patient and provides emotional support. When used in a therapy session, the animal stimulates the interaction with the ASD patient, reduces the tension and improves the quality of the communication. Animal Assisted Interventions are also widely used by numerous other disciplines including physical and occupational therapists, as well as by speech and language therapists as they provide services for this population.

Recently, concerns about the impact that interacting with ASD patients in certain cases may have on the therapy animals have been raised. The need to define parameters to ensure the well-being of the animals used in therapy will obviously benefit the animals, but also the humans. A well-behaved, well-cared for animal will be more predictable, more gentle, more effective in the interaction with those affected by ASD and any others who are involved, from family members to the staff at the therapy centers.

To examine the needs of animals used in therapy sessions, Dr. Peralta collaborates with Professor Aubrey Fine Ed.D. of Cal Poly Pomona. Prof. Fine, a clinical psychologist, has used animals in therapy sessions for over 30 years and is the editor of The Handbook on Animal Assisted Therapy (3rd Ed., 2010), the authoritative book on the subject. More recently we started working on the development of a questionnaire to be self-administered by those using animals in therapy for a more thorough examination of behavioral cues that allow for a methodical assessment of the experience for the animal. The use of this questionnaire will facilitate a more conscientious use of the animals and a better experience for all involved, human and animal alike.

Autism-related research in Drs. Baudry and Bi Laboratories

1. Mechanisms implicated in long-term synaptic potentiation and depression in hippocampus and other brain regions
2. Regulation of glutamate receptors
3. Role of oxygen free radicals in central nervous system
4. Mechanisms underlying selective neuronal degeneration
5. Computational neuroscience

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Research in my laboratory seeks to understand how neurons develop, mature, and function properly and how they die when challenged by natural aging process, by intrinsic genetic defects, or by various insults. We hope that by understanding the basic molecular and cellular mechanisms that govern these processes we can develop better preventive and therapeutic strategies for central nervous system disorders in children as well as in elders.

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Drs. Baudry & Bi Laboratories is interested in understanding the molecular/cellular mechanisms underlying synaptic plasticity, which is the ability of the contacts between nerve cells to be modified by experience, and which forms the basis for learning and memory as well as for many cognitive processes. It is clear that this process is abnormal in autism and scientists have been searching for the cause or causes of these abnormalities. In particular, it is now apparent that many genes coding for proteins participating in synaptic plasticity are mutated in children with autism. Scientists can use these mutations to generate mice models of the disease, and mice exhibiting the same mutations as the humans affected by these mutations appear to have some of the symptoms of the autistic children. We are interested in understanding how the balance between protein synthesis, protein degradation and the mechanisms involved in protein quality control are modified during postnatal development in various models of neurodevelopmental disorders. In particular, we are studying one mouse model of a rare neurodevelopmental disease, the Angelman Syndrome. About 30% of Angelman patients are co-diagnosed with Autism.

Features of Angelman Syndrome include:

• Severe developmental delay
• Language and cognitive deficits
• Motor disorders

Angelman Syndrome is caused by maternal deletion of chromosome 15q11-q13. Interestingly, duplication of this region is a high risk factor for Autism. We are using a mouse model to understand the mechanisms underlying the abnormalities in neural connectivity that take place during postnatal development. We are making cultures of the neurons from different brain regions, such as the hippocampus, a brain structure particularly important for learning and memory, and cortex, a brain structure important for cognition, to discover the protein expression and the brain circults that are altered in Angelman Syndrome.

While we do know the particular mutation, and the nature of the protein which is modified, we do not understand why this mutation produces impairment in synaptic plasticity. Although we don’t know the mechanisms underlying the alterations in synaptic plasticity, we were recently able to reverse them by a short treatment of the mice with a drug, which had been previously shown to improve synaptic plasticity in another model of autistic syndrome, the Fragile X mice. This drug is called an ampakine, and it facilitates the functioning of a receptor for a neurotransmitter involved in synaptic plasticity. We were able to show that after 4 days of treatment with the drugs, synaptic plasticity in hippocampal slices was returned to the same levels found in the control mice, and the learning of a task requiring normal hippocampal function was also returned to the levels found in the control mice.

These findings give us hope that, despite the numerous causes underlying the various forms of autistic syndrome, it is possible to use drugs and potentially other manipulations, such as demonstrated by our colleagues at WesternU, to reverse the abnormalities found in children and even in adults.

See Drs. Baudry and Bi discuss their important work on Autism Intersection, coming soon to theautismchannel.tv