Friday, December 11, 2015

New Findings related to Attention and Gaze Give Us Clues to Differences in Social Development for Individuals on the Autism Spectrum

Difficulty interpreting social information is one of the defining characteristics of autism spectrum disorders (ASD), but  there is still a lot we don't understand about the underlying causes of some of these social differences.  A key aim of our research at CAR is to advance our understanding about the origins of difficulty with processing social information that is so common in ASD. This knowledge will help us devise better therapies.

There are four key areas of social development that are commonly disrupted by autism which, when taken together, describe much of what it means to have ASD. They include (1) theory of mind, or the ability to understand the thoughts, beliefs, or intentions of others (2) joint attention, or the inclination to pay attention to the same object of interest as someone else, as it relates to speech development; (3) social perception, or the ability to recognize facial expressions or speech inflections; and (4) social attention, or the tendency to prioritize important social information, such as an angry or distressed facial expression, over non-social information, such as pictures on a wall or furniture in a room.

In this the next couple of blog posts, we take you on a deeper dive into a group of CAR studies that are beginning to unlock some answers as to how social attention develops in autism.

"Why on earth would I want to do that?": The Basics of Social Motivation in Autism Spectrum Disorders

New CAR Research: Attention and Gaze Hold Clues to Social Development in Autism

 

Holly Robinson Peete Visits CAR

We were excited to have a visit last month from Philadelphia's own Holly Robinson Peete during a trip back to her hometown, where she was being honored for her efforts in support of autism awareness. Holly and her husband, former Philadelphia Eagles QB Rodney Peete, created the HollyRod Foundation to support families living with ASD and with Parkinson's disease, both of which affect their family directly.

The HollyRod Foundation made a very generous donation of Puzzlepiece tablets and toys for CAR's waiting room, along with several copies of "My Brother Charlie", a book Holly co-wrote with her daughter to help children understand classmates and loved ones with ASD. The book was inspired by Holly's son, RJ (now 19 years old) who was diagnosed with ASD as a child.

Here are a few great shots from our visit!

Holly Robinson Peete checks out our CAR logo- which was originally a quick sketch made by a boy with ASD while visiting the center!

Holly poses with 11-year-old Corinne, who is showing off her signed copy of  "My Brother Charlie".

Testing out the PuzzlePiece tablets!


CAR researcher Eli Kim explains one of our research studies aimed at understanding common physical behaviors associated with autism spectrum disorders.


 

CAR Research: Attention and Gaze Hold Clues to Social Development in Autism

Children with autism spectrum disorders (ASD) focus their attention on social information differently from their neurotypical peers, and this gives us a glimpse into social development as they mature. Improving our understanding of how these differences work may provide clues to developing treatments and interventions to ease some of the social symptoms of autism spectrum disorders (ASD).

CAR psychologist
Benjamin Yerys, PhD, studies attention, impulsivity, and distractibility in ASD, as well as in ADHD and anxiety- ASD’s frequent companions. A pair of his studies contribute to our understanding of how children with ASD prioritize and respond to social information in their environment.


“Now you see it….”: The Attentional Blink Effect in Autism


The first study tested what’s known as the “attentional blink effect” in 8-14 year-old children diagnosed with an autism spectrum disorder (ASD) vs. typically developing peers. Attentional blink refers to a gap in the brain’s ability to detect visual information when it appears in rapid succession. (Think about trying to identify a single card as someone shuffles the deck.) This is a result of a brief “overload” in the brain’s capacity to process information. Essentially, the brain needs a brief moment of unawareness, equivalent to a “blink”, to recover its ability to pay attention to new visual information. This idea is best explained with an example. Imagine you’re shown a series of images of different shapes on a screen, each appearing for a fraction of a second. You’re told to look for a triangle, and that a heart shape may also appear in the series. It’s highly likely that you’ll notice the triangle, but will miss the heart shape while your brain recovers its ability to focus on the images.

The exception to this rule is when the visual information carries emotional weight. For example, if an angry face is among the images shown after the picture of the triangle, you will be more likely to notice it, meaning the “blink” effect is overridden by a strong emotional stimulus. 

When this study was previously conducted in adults with ASD, those on the autism spectrum were less likely than neurotypical adults to pick up emotionally-charged images. However, when Dr. Yerys tried this same test with children using photos of dogs, neutral facial expressions, and angry facial expressions, the children diagnosed with ASD performed just as well as – or slightly better than - their typically developing peers. This was a surprising finding because the amygdala area of the brain is very important for processing emotional information quickly, and this area of the brain develops atypically in ASD starting in toddlerhood. This means that in children with ASD, the ability to prioritize social-emotional information is somehow preserved. Further research is needed to determine if this would also hold true for children more severely affected by ASD.

“Although we were initially surprised, this finding does make developmental sense,” said Dr. Yerys. “In general, adolescents and pre-adolescents tend to have a heightened response to emotional information. It is important that emotionally-charged information may grab attention to the same degree for kids on the spectrum as those considered to be typically developing, because it means that this age range may present a window of opportunity for possible interventions.”


“Inhibition of Re…what?” Visual Search for Social Information Differs for Children on the Autism Spectrum


In a related study published in November, Dr. Yerys and his colleagues explored social attention in 8-17 year-old children by looking at how children shift their attention to search their environment, instead of responding by reflex to the environment as we saw in the attentional blink study. When children (or adults) search their environment, the brain tends to favor searching new locations instead of going to old locations. For example, if you lost your keys then you may be more interested to look for them in your desk rather than searching your pocket a second time. This process is called “
inhibition of return” (IOR).

In neurotypical development, people tend to automatically skew their attention toward social information (facial expressions, body language, emotional cues), as opposed to objects in their environment which carry no social significance (an electrical outlet, a tree, a particular toy).

Earlier studies have established that photos of angry or upset faces hold the attention of neurotypical individuals longer than smiling or neutral faces (because anger and worry indicate a potential threat). The threat-related faces override or delay the brain process that would usually cue the brain to move on and scan for new visual information. Until now, no studies have carefully examined whether this “override” effect would also hold true for people with ASD.

To test whether children with ASD would prioritize socially or emotionally charged information in a similar way, children in this study were given a series of tasks to complete on a laptop. They were instructed to respond as quickly as possible to various combinations of non-social symbols and sets of photos showing either neutral or angry facial expressions.

Dr. Yerys and his team found that young people with ASD were less accurate in their responses; they also had longer response times when compared with their typically developing peers. Children who had the most severe ASD symptoms were also the slowest to shift their attention. This is the first large study to show that this visual attention mechanism (IOR) is disrupted in children with ASD, and that this impaired attention is directly related to some of the core social symptoms of ASD.


The study also ruled out the possibility that this difference in attention is related to ADHD or anxiety symptoms, which are common in children diagnosed with ASD. The study results support the overarching hypothesis that problems with how children prioritize social or emotional information in visual attention is associated with more severe social impairments.

Putting it all together
Taken together, the “attentional blink” study and the “inhibition of return” studies indicate that emotional information captured the attention of adolescent and pre-adolescent children with ASD to the same degree as it did for their typically developing peers, when information was being gathered from a single point in space. However, adding the task of scanning a given area for information and then determining its social meaning may prove more difficult for children with ASD.

It also appears that social-emotional processing proved more difficult for children with more severe symptoms of ASD. The findings of both studies suggest that impairments in early visual attention processes have a cascading effect on social development in ASD. This is further borne out when we consider that similar studies done with adults showed greater impairments for those with ASD; and in studies with infants at high-risk for ASD [by virtue of having an older sibling with a diagnosis], infants with slower attention orienting are more likely be diagnosed with ASD later in childhood, compared with those infant siblings who do not go on to receive a diagnosis.

The two studies offer insight into specific cognitive and brain mechanisms that may contributing to core symptoms of ASD. Our center’s long-term goal is to translate this knowledge into opportunities for improving both diagnosis and intervention, with the goal of diminishing the cascading effect of early impairments to social-emotional development.



Special Thanks...We want to thank the 100+ families that made these two studies possible by participating in research! We’d love to hear your questions and feedback about your participation at
autism@email.chop.edu.

To learn more about participating in research at CAR, visit
www.autismMatch.org or email us to learn about studies for neurotypical and autism spectrum participants from infancy through young adulthood.

"Why on earth would I want to do that?": The Basics of Social Motivation in Autism Spectrum Disorders

Differences in social development are among the core symptoms which define autism spectrum disorder (ASD). In the last few years, the Social Motivation Theory of autism has gained broad acceptance to explain some of the reasons why children with ASD may not profit from their social learning opportunities.

 In 2012, several CAR faculty members published a scientific review which indicates that individuals with ASD might be able to engage with social cues, but are less motivated to do so than their neurotypical peers.

Although children receive some explicit social instruction from their parents or caregivers, most social learning happens implicitly, from observation and experience. Children interpret positive social responses- a smile, a hug- as “rewards” and then repeat those behaviors.  The social motivation model suggests children with ASD have altered reward pathways in the brain, and do not feel as rewarded by the act of engaging with others. This reduces motivation for social experiences, and sets in motion a negative spiral of missing out on social learning opportunities which leads to fewer social rewards and even less interest in social interactions. In the authors’ words, “when social information is not prioritized, there are profound, cascading effects on learning about — and from — the social world”1.

Researchers across various disciplines- from neuroscience, biology, psychology and education – are using this framework to help inform their understanding of how behavioral or pharmaceutical therapies might be developed to target the motivational component of social skills- rather than focusing only on teaching specific social skills. In this way, it opens the door to powerful social learning opportunities by making the social information in children’s environment more meaningful and rewarding. To read a full commentary on Social Motivation, check out this article from SFARI’s “Spectrum” blog.

Wednesday, September 16, 2015

Getting an Evaluation for Autism Spectrum Disorder

Deciding that your child might need an evaluation for Autism Spectrum Disorder (ASD) is usually the culmination of a 3 step process.

STEP 1: THERE IS A CONCERN. A parent, family member, caregiver, teacher, speech-language pathologist, therapist, or pediatrician may be concerned that a child shows signs of developmental difference or delay. Sometimes parents have filled out a screening questionnaire that indicates a concern. Maybe a therapist, teacher, or doctor talks to a parent, or a parent expresses a concern to a healthcare professional or directly to an education agency.  If an individual expresses a concern to you, it is a good idea to contact your child’s pediatrician. The pediatrician may want you to complete a screening questionnaire or may want to observe your child. If a screening questionnaire and/or brief observation indicates there might be risk of delay or developmental differences, a referral for an in-depth evaluation is made. Even if screening questionnaires are not used, referrals might be made if a concern is expressed.

Screening Tools:
  • M-CHAT – Modified Checklist for Autism in Toddlers
  • Infant Toddler Checklist
  • SRS-2 – Social Responsiveness Scale
  • SCQ – Social Communication Questionnaire
  • ASRS – Autism Spectrum Rating Scale
  • Ages and Stages (of Child Development)
  • Denver (Developmental Screening Test)
  • SORF – Systematic Observation of Red Flags
STEP 2: REFERRAL. Parents, healthcare professionals, or therapists contact someone who is qualified to do an evaluation of development to make an appointment for an evaluation. The referral might be made to an early intervention agency or school district, a developmental pediatrician, a psychologist, a psychiatrist, or possibly a pediatric neurologist. Additional referrals may also be made to other professionals, such as audiologists, speech-language pathologists, physical therapists, and/or occupational therapists to evaluate other areas of development. Evaluations through early intervention and school districts happen relatively quickly. Sometimes the wait for a developmental pediatrician can be much longer. Parents should pursue both kinds of evaluations – educational and medical – at the same time. This is because children must be evaluated through the education system in order to receive educational services, and educational services can begin without a medical diagnosis.

STEP 3: THE EVALUATION AND RECOMMENDATIONS. There are two core elements that are necessary: (1) parent interview to gather information about the child’s birth, medical, and developmental history; and (2) clinical observation of the child’s behavior – preferably using standardized measures. Based on the information provided by a parent, the observations of the child, and the examiner’s clinical judgment, a diagnosis, if any, will be provided, along with recommendations for intervention.

Parent interviews might be done on paper, in person, or over the phone. An evaluation might take place in a home, a healthcare clinic, a medical office, a school, an early intervention center, or in a psychologist’s office. There may be more than one evaluator, who will usually meet as a team to make a diagnosis and/or recommendations for services, if needed. In-person observations are primarily play-based and are made up of various activities geared toward a child’s developmental level. Evaluators play and talk with the child and ask him or her to do simple tasks as part of the evaluation. For very young children, parents typically stay with their child throughout the evaluation.

Many of the developmental tests follow a progression of skills and include some items that the child will not be able to do. It is important to remember that this is the way development levels are determined, and all children eventually encounter activities that they do not know how to do as they go through an evaluation. At the end of the evaluation, or perhaps a week or so later, the clinician or the team will meet with the parents to discuss diagnostic impressions and recommendations for interventions and services to help the child make developmental progress. A report will be given or mailed to the parents with the full results of the evaluation and written recommendations.

Signs of Autism Spectrum Disorder: What to Look for, What to Do

As a parent, you are in the best position to notice early signs of Autism Spectrum Disorder (ASD). However, many first time parents have a hard time knowing what to expect in terms of their child’s development. Even parents with more than one child may not recognize developmental delay as all children develop at different rates. 

Sometimes parents have a “gut” reaction that something is different about their child. Some children seem more fussy and disagreeable, even when in no apparent distress from hunger, tiredness, or evident discomfort. Parents of these children may be more likely to seek early help from their child’s pediatrician.
Other times, a child seems “easy,” making few demands of caregivers and not requiring a lot of attention. Some children with ASD appear more advanced than their peers, displaying amazing academic skills or attentiveness beyond their years. Yet what seems like independence or precociousness may be masking an underlying developmental problem.

Red Flags and Risk Factors for ASD
Knowing what to look for is important for early identification of ASD. Early identification is important because the earlier ASD or signs of ASD are noted, the sooner treatment can begin. High quality early intervention services can change a child’s developmental trajectory and can improve outcomes.
Some of the early signs of ASD include:

  • Does not respond to name
  • At times, appears to be deaf
  • Speaks with an unusual tone or rhythm
  • Repetitive motions, such as rocking, spinning, or hand flapping
  • Easily upset with change of routine
  • Walks on toes
  • Unusual attachments to objects or schedules
  • Doesn’t know how to play with toys
  • Doesn’t return a smile
  • Doesn’t respond to cuddling
  • Doesn’t reach out to be picked up
  • Doesn’t look at mom when being fed (infants)
  • Poor eye contact
  • Prefers to play alone or with adults
  • Lines up toys or other objects; ordering of materials
  • Does not speak
Additionally, regression of any kind is a serious warning signal for ASD. If your child has begun to use words, but then stops using language entirely, or if your child stops playing social games like Peek-a-boo, contact your child’s pediatrician. Any loss of speech, babbling, gestures, or social skills should be taken very seriously.

Some children are at a higher risk for developing ASD, and these children should be monitored closely. In particular, if another family member has ASD, your child may be more likely than others to have it too. Genetic and family research studies have shown that ASD is heritable, increasing the likelihood of other family members having a diagnosis. Much research attention has been given to younger siblings of children with ASD, who are 10 – 20% more likely to develop ASD than the general population. Additionally, children born with low birth weights and children with certain genetic conditions have a higher risk for ASD.
Having one or even a number of these symptoms or risk factors does not mean that your child will be diagnosed with ASD. It is important to remember that children develop at different rates. However, do take note of any warning signs and bring them to your pediatrician’s attention as soon as possible.

Visiting Your Pediatrician
When you visit your pediatrician (make a special appointment if you have concerns and a routine visit is not in the near future), come prepared with examples of behaviors which concern you. This is important because your child may not exhibit the same concerns during a short office visit. If your child is between 16 and 30 months of age, your pediatrician should ask you to complete a developmental questionnaire to determine if your child exhibits red flags for ASD or other developmental problems.

The questionnaire usually used to screen for ASD is called the Modified Checklist for Autism in Toddlers, Revised (M-CHAT). The M-CHAT is a screener only, designed to identify children whose symptoms put them at risk for an ASD diagnosis. Depending on your child’s score on the M-CHAT, your doctor may recommend that your child receive further testing to determine if he or she has ASD.

Diagnosing ASD
ASD can only be formally diagnosed by a trained clinician after conducting formal diagnostic tests. Most pediatricians do not have this expertise. To be evaluated for ASD, your child may visit a developmental pediatrician, psychiatrist, psychologist, or other trained and experienced professional.

Tools created for the purpose of diagnosing ASD, including the Autism Diagnostic Observation Schedule (ADOS) and Autism Diagnostic Interview, Revised (ADI-R), rely on observing the individual with suspected ASD in structured settings and asking caregivers about the individual’s history and behavior. A clinician may also suggest a neurological evaluation or genetic testing, metabolic testing, and electrophysiologic testing. There is no definitive medical test for a diagnosis. Instead, a medical diagnosis of ASD will be based on whether the individual meets the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).

What You Can Do

  • Monitor your child’s development. Children with ASD tend to hit key developmental milestones a bit later than other children. Make note of when your child rolls over, sits up, stands, talks, etc. so that you can share these important timeframes with your pediatrician. However, missing milestones doesn’t mean your child has ASD, nor does hitting them on target mean your child does not.
  • Talk to your child’s doctor if you have concerns. Your child’s doctor is there not only to help your child, but to support your family as well. Your child’s doctor can help you understand typical development and help you determine if your child is off-pace. Don’t wait for a routine appointment if you suspect a problem; visit your child’s doctor right away.
  • Don’t “wait and see.” Too many concerned parents are told not to worry and to “wait and see” if their child grows out of the behaviors in issue or a delay. However, waiting is the worst thing you can do because it deprives your child of valuable time when he or she could be getting help. Regardless of whether the delay is caused by ASD or some other factor, children with developmental delays don’t usually grow out of them without appropriate intervention.
  • Consider getting a second opinion. Ideally, your child’s doctor will take your concerns seriously. But sometimes, even well-meaning doctors miss red flags or underestimate problems. Follow your instincts if you feel that something is wrong, and be persistent. Schedule a follow-up appointment with your child’s doctor, seek a second opinion, or ask for a referral to a developmental pediatrician. You should also contact your local Early Intervention agency or school district and ask for an evaluation. Evaluations are provided free of charge by your local intermediate unit or school district and can identify if your child is in need of special education services. Your child does not need a diagnosis of ASD to qualify for these services, and you should proceed with a special education evaluation even if your child is waiting to be seen by a developmental pediatrician or other ASD specialist.

Sunday, September 13, 2015

Should autism screening take place during pediatric check-ups?

In August, the U.S. Protective Services Task Force (USPSTF) - a federally-funded panel of experts in primary care and prevention- released a statement that concerned many in the autism community. The panel concluded that current evidence is not sufficient to prove that screening children under three years old  for autism spectrum disorder (ASD) during primary care visits results in better outcomes for those children who do go on to be diagnosed with ASD. The panel recommended extensive further research to determine whether there is a direct link between universal screening for ASD and better treatment outcomes. The panel's conclusions run counter to those of the American Academy of Pediatrics, which are considered best practice by most autism research and advocacy organizations. So, we asked 3 CAR scientists to help cut through the confusion. 


Susan E. Levy, MD, is a developmental pediatrician at CHOP and chairs the AAP's Subcommittee on Autism.
"My immediate concern is that parents and general pediatricians will misinterpret the recommendations to mean that universal screening isn’t worth it. And that is far from the truth.“If we wait for the perfect screening tool, we’re going to miss the opportunity for early identification - and therefore early intervention, which we know is the most important factor in improving ASD symptoms.”



David S. Mandell, ScD
, is Associate Director of CAR and  of the Center for Mental Health Policy and Services Research at the University of Pennsylvania's Perelman School of Medicine. 


"If you’re a physician who has 10-15 minutes with a patient, the screening is critical because it gives physicians information they just wouldn’t otherwise have a way to collect during that very brief interaction with the child.... I think the evidence we have available now is strong enough to suggest that screening identifies children with ASD and that high quality treatment is effective. I really think that should be enough to uphold the value of universal screening.”

 
 

Juhi Pandey, PhD, is a pediatric neuropsychologist at CAR and Clinical Assistant Professor of Psychology at the University of Pennsylvania's Perelman School of Medicine. 
"Targeted screening at specific ages- rather than screening only when the clinician or parent raises a concern- takes away any inherent bias. No matter how strong a practitioner's clinical judgment is, or no matter how well a parent knows their child, we are human. We need standardized testing at regular intervals to make sure our biases aren't causing us to over-or under-estimate a child’s developmental functioning."