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This blog is reposted with permission from the ASA San Francisco page.  It is written by Steven Prutsman, board member of ASASF and co-founder Autism Bay Area Fun.   It outlines his opinion on the differing needs and advocacy priorities for individuals on both sides of the autism spectrum.

At the end of a keynote speech at this summer’s national Autism Society of America conference, authors Caren Zucker and John Donvan implored the audience to quell the infighting among various autism advocacy factions. (Rodney King’s “Can’t we all get along” immediately came to my spectrum-y mind).Their point was that instead of squabbling among ourselves, we should be working toward the same objective: a better quality of life for all on the spectrum, so that all autistics may be safe, happy and thriving.

Their wonderful book “In a Different Key” touches on the fact that throughout its history, the word autism has lacked a clear and universally accepted definition, unlike many other conditions. Instead, the autism spectrum covers a multitude of differences. On one extreme, what I’ll call Camp A, are those who are independent, but different and quirky. Some leading self-advocates are in this group and some have described geniuses like Nicola Tesla, or even Socrates, as falling under this umbrella. And way on theother side, Camp B hosts the severely developmentally and cognitively impaired, the non- or semi-verbal, those with a host of often painful co-morbid conditions. And of course, there are myriad variations within and between these two extremes, each adding their own flavor to the word “autism.”
 
For those of us closer to Camp A the autism label has an almost philosophical meaning, a description of how we process the world, of an identity we have embraced. “I got to be me,” we say. “Accept me for who I am, with all my quirks.” “Support me with the accommodations I need.”  “Woe to those who use the A-word to describe in a negative way a severe disability.”

Others, in particular the parents of the Camp B, or classic autism, have seen their children and families suffer beyond measure as a result of the demands of autism. Head-banging, self-injury, heart-wrenching scenes of agony and tears: these are not “Rain Man” moments. These are bona fide PTSD parents, with stress levels like combat soldiers—always on guard, waiting for the next crisis, the next aggressive, injurious and bloody episode; parents who have dedicated their lives and savings to a myriad of medical interventions, therapies and care-giving.

They advocate for their children because their children often have no or limited spoken language and cannot do so themselves, and worry constantly for their children’s futures, their long-term housing and care. “Autism is a debilitating disability, not simply a quirky difference. Woe to those who put a cute and cuddly face on all of those excruciatingly painful moments, days and years we and our children have endured,” they say, exasperated.

In Camp A there are various unique personalities. In Camp B, the unique personalities are coupled with substantial developmental challenges. Camp A sees attempts to prevent, or treat autism as a form of judgment, a direct attack on the intrinsic self-worth of its members. Camp B sees the “embrace and celebrate autism” dogma as simplistic, demeaning, and lacking empathy for their families’ enduring painful struggles.

The medical and scientific communities are currently struggling toward clarity on how to draw lines and labels around the various forms of autism, meanwhile leaving those of us in the trenches with no choice but to make our own definitions, and tailor our advocacy efforts to where we or our loved one fit within theextremely diverse population that is currently broadly labeled as autistic.

“Full employment at a competitive wage for all autistics” becomes a priority for Camp A, while “Assurances that our severely developmentally disabled sons and daughters will be well cared for, and those without language and a voice will not be abused after we’re dead” becomes the plea from the other side. Why so different? Because, fundamentally and quite obviously, we are talking about extremely different underlying conditions, and not just one. The blind and deaf have different terms, not just a lumped-together “sensory input disorder.” We in the autism world have no such luck, yet. We are still lumped together, despite having such vastly different conditions and needs.

Until the folks of the DSM (Diagnostic and Statistical Manual of Mental Disorders) come out with a better labeling system for the autism varieties, it seems unlikely the bickering and polarization will go away: everyone will continue to think of the A-word as it relates to their own experience, and advocate accordingly.

Meanwhile perhaps the best thing we can do is to simply recognize these differences and not get into each other’s way. Parents of the severely developmentally disabled should not involve their time and resources in fighting against efforts to improve the lives of those of us for whom autism is a positive identity. And those in that camp should not spend their time attacking efforts of parents who labor to help their children.

Zucker and Donvan were right: autism infighting is unnecessary, we are wasting our precious time skirmishing over a fluctuating lexicon. So until the day our vocabulary catches up with the diverse biological, neurological, and functional realities that lay underneath the A-word, take off the gloves, and give each “autism” story the respect it deserves.

Stephen Prutsman is a concert pianist, composer, member of the Autism Society San Francisco Bay Areaboard, and co-founder of Autism Fun Bay Area, a nonprofit providing concerts and recreational events for special needs families. He lives with his family in San Francisco.

Preface:  Recently, the practice of Applied Behavioral Analysis, or ABA, has come under fire in the autism blogosphere for being abusive and manipulative with the purpose of mind control.  Instead of defending the practice, or pointing out the factual errors in recent articles, ASF realized the most productive way to address some of the issues is to reprint an editorial written by expert clinician Aubyn Stahmer, PhD.  The editorial first appeared in the journal Autism in 2014.  Please take time to read it below.  Thank you to Dr. Stahmer at UC Davis for this original article and for allowing it to be reprinted here.

In this issue of Autism, we are pleased to continue our “Myth Busters” series designed to provide a forum for discussion of common misconceptions in our field. This month, we examine the idea that applied behavior analysis (ABA) is synonymous with discrete trial teaching; we will also explore the false dichotomy between behavioral and developmental approaches to treating autism spectrum disorders (ASDs).

It is common practice for intervention researchers to state that ABA has the highest level of evidence of any intervention to support its effectiveness for children with autism. This view is supported in recent reviews by the National Autism Center (2009)and the National Professional Developmental Center for Autism Spectrum Disorders (Odom et al., 2010). The National Autism Center authors concluded that over 90% of the published studies reviewed relied on intervention strategies or comprehensive models based on behavioral principles (Suhrheinrich et al., in press). Evidence supporting ABA also has led to increased coverage for ASD services through both public service and insurance agencies. In fact, at least 37 states have laws that mandate coverage of autism services (http://www.ncsl.org/research/health/autism-and-insurance-coverage-state-laws.aspx). There are, therefore, urgent policy implications that necessitate a clear and accurate understanding of what is included in ABA.

Unfortunately, interpretation of the available research has led to a very narrow view of what is considered effective intervention for individuals with ASD and what ABA means (Dillenburger and Keenan, 2009). In fact, ABA is not a specific type of teaching but rather a particular approach to scientific inquiry, characterized by certain research designs (Cooper et al., 2007). The use of ABA has identified effective interventions for a wide variety of individuals to address an even wider variety of behaviors. Unfortunately, this generality has been all but lost. When people refer to the intervention received by a child with ASD as “ABA” or as “applied behavior analysis,” they typically are referring to a specific, highly structured form of behavioral teaching more appropriately referred to as discrete trial training (DTT; Chiesa, 2005). DTT was first described in the 1960s and was the first specific intervention shown to be efficacious for children with ASD (Schreibman, 1988). It is more correct, however, to describe DTT (and other behavioral interventions subsequently developed) as a product of the science of ABA. That is, ABA allowed for the identification of the specific principles that comprise DTT and other behavioral interventions. This misunderstanding and misuse of the term ABA hinders the ability of service providers, funders, and parents to fully appreciate the full potential of ABA and utilize its enduring principles. Just as crucially, it may limit access to effective interventions for individuals with ASD.

Fully understanding the range of interventions based on ABA is essential, as technique should be determined by the needs of an individual with ASD, the behavior or skill being addressed, and the context in which the intervention is implemented. Research points to the inadequacy of one single treatment approach for all areas of learning for children with ASD (National Research Council, 2001Schreibman, 20002005), or for all children with ASD (Stahmer et al., 2011b).

While DTT was one of the first behavioral interventions to show effectiveness with children with ASD, the field has evolved significantly since that time and now includes a variety of interventions, ranging from highly structured programs that require one interventionist for each child, to behaviorally based inclusion programs that involve typically developing children as models (e.g. Odom et al., 2010Vismara and Rogers, 2010). Many of these interventions have been developed (via ABA) to specifically address short-comings of traditional DTT, including limited generalization and maintenance of skills. Some ABA-based programs are distinguishable by “brand names,” such as DTT and Pivotal Response Training (PRT), while other programs utilize the principles of ABA broadly. Some programs address specific behaviors such as toilet training or aggression while others are comprehensive, intended to address a range of learning domains or complex behaviors (e.g. social skills). There has been particular growth in naturalistic behavioral strategies, which use the principles of behavior analysis but also incorporate techniques influenced by developmental theory.

Similar to the limited view of ABA, there is confusion in the field regarding the relationship between developmental and behavioral interventions. Traditionally, there has been minimal communication and even animosity between developmental and behavioral “camps” around autism interventions. However, this hard line between approaches appears to be a false dichotomy in many cases. In fact, although the vocabulary and theory are different, developmental and behavioral interventions have many common features in practice. For example, child initiation of the teaching episode, the use of natural reinforcement, responding to a variety of behaviors as meaningful communication (loose shaping), and an emphasis on reciprocal interaction can all be seen in both developmental and naturalistic behavior interventions. As described by Ingersoll (2010), a lack of understanding of the underlying philosophies and evolution of interventions across fields has limited potentially fruitful cross-fertilization. This absence of collaboration and at times outright competition between advocates on either side has also caused a great deal of confusion for families and community providers who implement interventions for children with ASD. In many cases, this confusion limits access to a full range of intervention options.

A growing number of interventions straddle the divide and combine techniques from both developmental and behavioral interventions. Research on these approaches has shown promising results (e.g. Dawson et al., 2010Ingersoll and Wainer, 2013Stahmer et al., 2011a). These interventions highlight the utility of both models and reveal the pointless nature of the debate over which side is “best” for ASD. The heterogeneity and developmental nature of the disorder make it unlikely that one specific treatment will ever be best for all children with ASD, or will work for any one child throughout his or her educational career. Interventions that combine techniques from both developmental and behavioral backgrounds may offer “the best of both worlds” and the most comprehensive support for learning. It is imperative that we, as a field, begin to understand the range of effective interventions available and learn more about the specific active ingredients necessary to optimize outcomes based on individual characteristics of people with ASD, their families, and environments.

Aubyn C Stahmer
Editor

Acknowledgments

Special thanks to my colleagues Sarah R Rieth, Laura Schreibman and David S Mandell for helping to shape this editorial with their excellent comments and brilliant discussions around this issue.

References

  1. Chiesa M

By Alison Singer

I tend to judge people based on how nice they are to my daughter Jodie. It’s amazing how many people dismiss Jodie, ignore her or barely tolerate her because of her severe autism.  But no one was ever nicer to her than Suzanne Wright.  There was a time when I saw Suzanne almost every day, and almost every day she would ask about Jodie. When I didn’t see her, she’d email me to ask “Did she sleep?”, “How did it go with the new para?”, “Did she try the apricots?”. She knew all the details of her therapy, her schooling, even her clothing and food preferences. If she saw a toy she thought Jodie would like, she sent it to her. Her questions were never the perfunctory “How’s Jodie?” She genuinely cared.  And she cared about everyone’s child at this deep level. At Autism Speaks, at all the walks, wherever she went, she knew every child’s name, age, birthday, and favorite color. Her memory was astonishing.

This is why I have always found it odd when people criticized Suzanne for not caring about people with autism, when nothing could be further from the truth.  She, and I, have both said things we wish we could rephrase, but never with malice, and always with the hope of helping others understand that they were not alone in their feelings, whatever those feelings were.  Suzanne devoted the best years of her life to building autism awareness, creating a compassionate community, and turning a community of heartbreak into a community of hope.  She designed the now ubiquitous blue puzzle piece and made “autism” a household word. She focused not only on the children with autism but on their whole family, especially siblings.  I remember one afternoon she took her grandson and my daughter Lauren, the so called “forgotten” children, to the circus so that they could have a special afternoon away from the “parade of therapists”.

Suzanne’s tremendous presence, her work and her spirit have made an indelible impression on those fortunate enough to have known and worked with her. I know I will think of her often, and will try to emulate her extraordinary compassion, though I know I will never come close. All I can do is thank her for loving my daughter, and all our children, and thank her family for sharing her with our community.
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Dr. Daniel Messinger, University of Miami

Last year, a study in Molecular Autism published by the Baby Siblings Research Consortium, or BSRC, led by Dr. Daniel Messinger at the University of Miami, examined characteristics of male and female siblings of those with an autism spectrum disorder. These younger siblings have a 20 fold increased probability of an autism diagnosis themselves. Because of this, they are the perfect group for studying early signs and symptoms of autism, biological markers before behavioral features emerge, and risk factors.   Around 20% of the time they will develop autism, 20% of the time they show symptoms of developmental problems but not ASD, and the rest are on a normal trajectory by 36 months1, therefore this is also the perfect group to study the female protective effect. This protective effect, if it exists, is most likely to be seen in the siblings of individuals with autism, and if there is something protecting females against an autism diagnosis, possibly the female sisters is the place to start looking.

A previous study in the general population looking at the co-occurrence of symptoms in twins observed female protection through what is known as the Carter Effect. The Carter Effect is defined by the higher incidence of a disorder in relatives when the person affected is the least commonly affected by sex. In other words, since females are less commonly affected, the Carter Effect was seen in the twin of a female with autism. If the co-twin did not have autism, autism symptoms were likely to be higher if they had a sister with autism compared to a brother.2

The BSRC study on the infant siblings looked for the Carter Effect in the infant siblings by looking at ASD diagnosis, scores on instruments like the Mullen (which tests IQ in younger kids) or severity scores of autism behaviors.   They did not find that the sex of the person with autism had any effect on these variables in the sibling, and therefore did not observe the Carter Effect.

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Dr. John Constantino, Washington University School of Medicine

But that does not mean a protective effect was not there. When John Constantino from Washington University in St. Louis (who is also involved in infant sibling research) took a look at the data, he found evidence of a protective effect. Despite the absence of the Carter effect, there remains a very substantial male/female difference in ASD diagnosis.3 As it turns out, while there were equal numbers of male and female siblings in the study, boys were three times more likely to be diagnosed with autism than girls. In this sample where there is a high genetic liability of autism, there is a higher probability of boys to be diagnosed with autism vs. girls. This is not the first time the nature of the female protective effect has been seen in this way. Dr. Constantino has also shown a protective effect for females in other cohorts in which the absence of the Carter effect was simultaneously observed: these include the AGRE and IAN cohorts.4-7

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The female protective effect can be seen in the difference between the two arrows

The original BSRC paper also found higher Mullen scores and lower autism repetitive symptoms in high-risk girls, mirroring other studies8,9. This may contribute to a protective effect which explains some of the reason why fewer females are diagnosed. There area also questions around the age of onset of symptoms, male bias in diagnostic instruments, and social perceptions of male and female specific behaviors. However, this protective effect, if it can be defined and described biologically, may lead to treatments and prevention of debilitating symptoms seen in both males and females.

The healthy and productive debate and conversation on this issue is exactly the sort of scientific conversations that move scientific discovery forward.   Not squabbling or one-upping one another, but carefully and thoughtfully discussing these ideas on an open forum for even others to comment on.   If this had not happened, these new insights would never have been shared with the community. Thank you to the editors of the journal Molecular Autism, Simon Baron-Cohen and Joseph Buxbaum, as well as BSRC and to Dr. John Constantino for making sure this happened.v4

 

References:

  1. Messinger D, Young GS, Ozonoff S, et al. Beyond autism: a baby siblings research consortium study of high-risk children at three years of age. Journal of the American Academy of Child and Adolescent Psychiatry. 2013;52(3):300-308 e301.
  2. Robinson EB, Lichtenstein P, Anckarsater H, Happe F, Ronald A. Examining and interpreting the female protective effect against autistic behavior. Proceedings of the National Academy of Sciences of the United States of America. 2013;110(13):5258-5262.
  3. Constantino JN. Data from the Baby Siblings Research Consortium confirm and specify the nature of the female protective effect in autism: A commentary on Messinger et al. Molecular autism. 2016;7:32.
  4. Goin-Kochel RP, Abbacchi A, Constantino JN, Autism Genetic Resource Exchange C. Lack of evidence for increased genetic loading for autism among families of affected females: a replication from family history data in two large samples. Autism : the international journal of research and practice. 2007;11(3):279-286.
  5. Constantino JN, Charman T. Diagnosis of autism spectrum disorder: reconciling the syndrome, its diverse origins, and variation in expression. The Lancet. Neurology. 2016;15(3):279-291.
  6. Constantino JN, Zhang Y, Frazier T, Abbacchi AM, Law P. Sibling recurrence and the genetic epidemiology of autism. The American journal of psychiatry. 2010;167(11):1349-1356.
  7. Virkud YV, Todd RD, Abbacchi AM, Zhang Y, Constantino JN. Familial aggregation of quantitative autistic traits in multiplex versus simplex autism. American journal of medical genetics. Part B, Neuropsychiatric genetics : the official publication of the International Society of Psychiatric Genetics. 2009;150B(3):328-334.
  8. Szatmari P, Liu XQ, Goldberg J, et al. Sex differences in repetitive stereotyped behaviors in autism: implications for genetic liability. American journal of medical genetics. Part B, Neuropsychiatric genetics : the official publication of the International Society of Psychiatric Genetics. 2012;159B(1):5-12.
  9. Hartley SL, Sikora DM. Sex differences in autism spectrum disorder: an examination of developmental functioning, autistic symptoms, and coexisting behavior problems in toddlers. Journal of autism and developmental disorders. 2009;39(12):1715-1722.

 

Blog written by Christine Matthews

We all brag about our children on FB from academic achievements, to proms, graduations, and sporting events, but we don’t get to post those things about Casey.

See we live in a world where Casey is regarded by some as a retard, and sometimes unfortunately, as a freak, or as a young man who will never amount to much. I am thankful that he seems unaware of the brutality of this reality.

But yesterday’s MRI changed how some very important people view him. No Casey did not became an All-Star, or make honor roll, or recite the words we so long to hear him speak. Yesterday my friends Casey became a TRAILBLAZER. See this MRI was for the brilliant men and women the MD’s, PhD’s, & Researchers at The Mount Sinai Medical Center who are desperately seeking answers with regards to the autism epidemic.

They needed him. They needed his mind.
You see without investigation/research there are no cures, no miracles, and no hope.

The information they gather is not expected to help Casey, but what we do passionately believe is that future generations will have a life with perhaps fewer challenges and possibly less heartache then we have had to endure.

Remember NOT all superheroes wear capes.

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ASF funded fellow Nick Goeden from USC examines the role of the placenta.  

Blog written by Priyanka Shah, ASF intern 

Many researchers are studying various factors during pregnancy that can lead to an increased risk of autism and other neurodevelopmental disorders in children. Maternal infection and inflammation have been shown to be risk factors for autism and schizophrenia. For example, in recent news, we have seen how expecting mothers infected with the Zika virus have given birth to babies with a high-risk for brain damage and other abnormalities. So, studying how maternal health (in this case, a viral infection) affects the fetus can help us predict for possible disorders and possibly even prevent them.

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Nick Goeden, graduate student and lead researcher

In particular, at the University of Southern California, Nick Goeden and colleagues studied how the placenta was affected after the mother experienced inflammation. The placenta is a tissue in a woman’s uterus that provides nourishment to the fetus through the umbilical cord. The placenta also produces an important chemical messenger, called serotonin, which is transmitted to the fetus and plays a role in organizing the brain during development. After birth, it helps regulate emotions and has been implicated in depression and anxiety.

Researchers decided to use a mouse model to see how maternal inflammation can affect the production of serotonin in the placenta and brain development in the fetus. To do this, they used a chemical that induces inflammation in pregnant mice, and mimics flu-like conditions seen in humans. They found that the amount of serotonin in the placenta drastically increased, leading to increased amounts of serotonin in the fetal brain. During brain development, brain cells migrate and become connected together like an electric network. The formation of certain brain cells that specifically help move serotonin around was disrupted, which means that the fetus’ brain became wired differently. Because of this, some of the behaviors serotonin helps control could have been affected. And in fact, other studies have shown how maternal infection during pregnancy can lead to increased anxiety or depression-like symptoms in the offspring.

This study shows that even mild inflammation during pregnancy can induce a series of events that eventually disrupts the development of the fetal brain. Although these children will have a higher risk for known mental disorders such as ASD or schizophrenia, these diagnoses are not guaranteed. Our next steps in this line of research should be to see the long-term effects of inflammation on the serotonin-specific brain cells and related behaviors. Researchers should also look at how other infections and viruses might be changing the production of other chemical messengers or molecules in the placenta. Understanding the biological mechanisms of the placenta and of fetal brain development can help direct new research into prevention and therapy for neurodevelopmental disorders in children.

stamova2

Sex differences are found in the brains of people with autism in particular regions

Though autism spectrum disorder (ASD) is diagnosed more frequently in boys than in girls, experts do not understand why. There is some evidence that gender differences exist, but more needs to be done to understand specifically what is happening at the cellular and network levels. So few brains of people with autism are available for study that this has been a very hard question to answer – but with the progress of the Autism BrainNet (www.takesbrains.org), this is becoming a possibility.

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Boryana Stamova, PhD, lead researcher

Researchers at UC Davis, led by Boryana Stamova and colleagues, focused on understanding non-coding RNA molecules (sncRNA, including miRNA), which are parts of the genome that control gene activity, rather than “coding” for new proteins. New studies are showing that these “non-coding,” non-protein forming RNA molecules are as important as “coding, protein forming” RNA molecules for brain development. Moreover, selected non-coding RNA can target and regulate multiple “coding” molecules in different regions of the brain.

This study looked at these molecules in two areas of the brain known to be involved in autism. First, the superior temporal sulcus (STS) association cortex which participates in circuits necessary for understanding social cues and facial expressions. Secondly, the primary auditory cortex, which is involved in sound processing. They looked at 5,000 sncRNAs in brains of people with ASD and compared them to the brains of people without autism. The sncRNA that were studied included those involved in cell to cell signaling, axon guidance, and formation of synapse which affect the core autism deficits. The goal was to see if there are different patterns of the sncRNAs between male and female brains with ASD.   As expected, the sncRNA expression was different between those with autism and those without autism. In addition, there were differences of sncRNA in brains of males and females with autism including those that affect the axon guidance pathway.

Could this explain why females have different symptoms, or that they may be able to mask their symptoms through more adaptive social abilities? There is much more work that needs to be done. Unfortunately there are so few brains of people with autism, and even fewer brains of females with autism, that this question has been hard to study.

You can make a difference in understanding the brains of people with autism. Even if you do not have autism yourself, you can register with the Autism BrainNet to learn more about post-mortem donation. There is no obligation.  You receive a quarterly newsletter that provides important information, scientific discoveries, and resources for the community. It’s easy, go to www.takesbrains.org.

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