Monday, January 26, 2015

Brain Connections and Infant Behavior

The Infant Sibling (IBIS) Network studies infants and toddlers born into families where there is already an older sibling with Autism Spectrum Disorder (ASD). This network aims to understand the earliest manifestations of ASD in both brain and behavior. To do so, the study uses MRI and detailed clinical assessments to compare infants and toddlers from families with ASD to those without a family history of ASD. CAR is one of the primary centers in the IBIS network, an NIH Autism Center of Excellence.

A new IBIS study used eye tracking to measure how and when infants shifted their eye gaze to different objects in front of them. We found that 7-month-olds who went on to develop ASD were slower to shift their attention from one object to another when compared to 7‐month‐olds who did not develop ASD. Slow eye gaze shifts are believed to make it more difficult for the infant to learn about their environment, placing them at risk for developmental delays.

In this study, slower eye gaze shifts also correlated with the maturity of one part of the brain – the  “corpus callosum.” The corpus callosum is the largest group of fibers connecting the right and left halves of the brain. Sharing of information between both halves of the brain helps with shifting of eye gaze and attention. Using MRI, we were able to show that the corpus callosum was immature in 7-month-old infants who later were diagnosed with ASD. This finding is consistent with other MRI studies in older youth with ASD that show abnormalities in the brain’s “wiring.” However, prior to our IBIS studies it was not known to occur at such a young age. 

This research is important because it pinpoints a specific brain circuit that is developing atypically very early in life, prior to the child showing outward signs and symptoms of ASD. This early marker for ASD within the biology of the child (a “biomarker”) could be very helpful for earlier detection of ASD when combined with other biomarkers. All early detection markers are important for guiding the development of early treatments. Thus, our team is hopeful that these findings may lead to earlier diagnoses, intervention, and subsequent improved outcomes for individuals with ASD.

In addition to the Center for Autism Research at CHOP, other institutions that took part in the study include The University of North Carolina, University of Utah, Washington University in St. Louis, University of Washington, McGill University, and the University of Alberta. The National Institutes of Health, Autism Speaks, and the Simons Foundation Autism Research Initiative fund this research.

Source: Elison, J.T., Paterson, S.J., Wolff, J.J., Reznick, J.S., Sasson, N.J., Gu, H., Dager, S.R., Estes, A.M., Evans, A.C., Gerig, G., Hazlett, H.C., Schultz, R.T., Styner, M., Zwaigenbaum, L., Piven, J., & IBIS Network. (2013). White matter microstructure and atypical visual orienting in 7-month-olds at risk for autism. The American Journal of Psychiatry170(8), 899–908. PMID: 23511344


The Infant Sibling Study and MRI: Frequently Asked Questions

One of CAR’s longest running studies is our Infant Sibling Study (IBIS). IBIS’s goal is to understand how the brain develops in Autism Spectrum Disorder (ASD) compared to typical development. We hope that better understanding will improve methods for early detection of ASD and early intervention. For this reason, the study is enrolling infants with an older sibling who has an ASD diagnosis and is comparing this group to a group of infants with an older sibling who is developing typically. We are actively recruiting families who fit either category.

Because this study is focused on brain development, all participants receive an MRI scan of their brain. This allows for an extremely sensitive view of your child’s brain. The IBIS study has already found a number of very important differences in the brain and behavior of young children who eventually develop ASD, and we will discover more before the study concludes in 2017.

If you have questions about the MRI procedures, please see our frequently asked questions (FAQ) below!

For other questions about the IBIS study, please do not hesitate to reach out to the study team. Their contact information is located here.

What is an MRI? Is it like an X-ray?
Magnetic Resonance Imaging, or MRI, is a method for taking pictures of the brain (and other body parts). There is no X-ray or other radiation involved.

Is it safe for my infant to receive an MRI?
Yes! We don’t put your child to sleep with medications (sedation), and research has shown that there are no short- or long-term negative side effects of MRI.

Is my child awake for the MRI scan?
No, we complete the MRI scans at nighttime, allowing your child to fall asleep naturally and sleep through the scan. 

You mentioned that the scans take place at nighttime and that kids should follow their regular bedtime routine. How can I put my child to bed in a hospital setting?
We offer different approaches depending on your child’s age and individualized bedtime routine. For young infants, we offer a rocking chair where you can nurse/feed/rock your child to sleep. For older infants and toddlers, we have a bed with safety railings. You can read to your child or complete any other bedtime rituals. Some parents have brought a Pack ‘n Play with them because that is where the child is comfortable falling asleep.

How will I know if my child wakes up?
We will be in the room with you and your child the entire time and will be watching your child’s eyes and movements to monitor his/her sleep. If your child wakes up, we immediately stop the scan. If time allows, we wait until your child is soothed back to sleep and resume the scan. If time does not allow, we may invite you to come back another night to complete the scan.

Aren’t MRI machines loud? How do you protect my baby’s ears?
All babies wear protective earmuffs, and extra foam padding is placed around their ears to reduce the sound of the MRI. 

How long is the MRI appointment?
MRI appointments are on average two hours long. About an hour of that time is provided for you to complete nighttime routines and to get your child to sleep. Once your child falls asleep, they will be in the scanner for about 45 minutes.

How frequently will my child receive an MRI as part of this study?
Every time your child has a study visit, he/she will receive an MRI scan. There will be four scans in total throughout your participation in the study.

What can I do to prepare my child for the MRI scan?
We provide each family with a CD of MRI sounds, so you can play it for your child ahead of time to become familiar with the sounds. Also, one of our clinicians will be in touch with you about a week before the scan to review soothing techniques specific to you and your child and to answer any of your questions. 

Where will I bring my child for the MRI scan?
All scans take place at The Children’s Hospital of Philadelphia.

What do I need to bring with me to the MRI appointment?
You should bring anything you need for your child’s bedtime routine, as noted above. An MRI-safe outfit will be provided to your child, which is comfortable and metal free.   

Monday, January 12, 2015

Unstuck and On Target

A study found that children who were diagnosed with Autism Spectrum Disorder (ASD) as well as ADHD had more impairment in day-to-day life. The impairments were observed in executive function (EF) skills, daily living skills, and behavior problems (what psychologists refer to as “maladaptive behaviors”).  The findings were significant for researchers and providers because it suggests that a co-occurring condition, like ADHD, influences autism symptoms. Understanding this link can help professionals develop interventions that better target these impairments and lead to better outcomes.

In 2013, a team from Children’s National Medical Center published their findings on a new EF intervention they developed for children diagnosed with ASD. The program, called Unstuck and On Target, is a cognitive-behavioral, school-based intervention that teaches what flexibility, goal setting, and planning are, why they are important, and how to use self-regulating scripts that guide these desired behaviors. Children with ASD (and those with co-occurring ADHD) often have difficulties with these EF skills, and those difficulties interfere with their adaptive behavior (communication, daily living skills, and socialization).  

For the study, the researchers randomly assigned participating elementary schools to the Unstuck and On Target intervention or to a social skills intervention. Over the course of one school year, both interventions were provided in 28, 30-40 minute lessons with games, visual supports, role-plays, and positive reinforcement. Parents were given tips on how to employ the assigned interventions at home as well.

At the end of the intervention, the researchers found that while both groups showed improvements, the participants who received the Unstuck and On Target curriculum showed more improvement in their ability to follow directions, transition smoothly, problem solve, and avoid getting stuck. Unexpectedly, the Unstuck and On Target kids also showed improvement in social skills. By learning how to be flexible, the children learned how to better regulate their behaviors. This led to a decrease in negative classroom behaviors, which is thought to have led to less social alienation by their peers.

While the study size was relatively small, the initial findings are encouraging. They showed that an intervention based on cognitive-behavior therapy can effectively target specific impairments associated with ASD. This study is also important because it is the first to tackle EF and self-regulation impairments in ASD with a community-based intervention. The researchers are currently funded by the Patient Centered Outcomes Research Initiative (PCORI) to test this intervention in low-income children with both ASD and ADHD.

Source: Kenworthy, L., Anthony, L. G., Naiman, D.Q., Cannon, L., Wills, M.C., Luong-Tran, C., Adler Werner, M., Alexander, K.C., Strang, J., Bal, E., Sokoloff, J.L., Wallace, G. L. (2013). Randomized controlled effectiveness trial of executive function intervention for children on the autism spectrum. Journal of Child Psychology and Psychiatry55(4), 374–383. doi:10.1111/jcpp.12161


ASD and Co-Occurring ADHD

Children diagnosed with Autism Spectrum Disorder (ASD) often have co-occurring conditions including ADHD and anxiety. In fact, it is estimated that over 30% of children with high functioning ASD meet criteria for ADHD and an additional 25% exhibit some ADHD symptoms.

A study by Dr. Yerys of the Center for Autism Research showed that children diagnosed with ASD and ADHD had more problems with executive function (EF) skills compared to children diagnosed with ASD or children who were developing typically. EF is a set of skills that help children complete everyday tasks and goals. This includes the ability to follow multiple-step directions, wait their turn, transition between activities, organize their desk/room, or proof their work for mistakes. Furthermore, parents reported more problems with daily living skills, such as feeding, dressing, toileting, cleaning, cleaning room/home, and knowing how to purchase needed goods or services (make change for a dollar, buy groceries or clothes). Finally, the children diagnosed with ASD and ADHD were observed by parents to have more difficulty with easily visible or externalizing behaviors (attention problems, physical aggression, and disobeying rules) than not easily visible or internalizing behaviors (social withdrawal and feelings of loneliness, guilt, or sadness).

The study found that the presence of ADHD symptoms in children with ASD increased their impairments in several areas as compared to the ASD group and the typically developing group. The ASD+ADHD group received higher autism symptom ratings. They also exhibited more difficulty with the adaptive behaviors related to daily living skills. Finally, they received higher ratings for externalizing problems, but not internalizing problems.

Dr. Yerys’s study was replicated recently by the Autism Speaks’ Autism Treatment Network (ATN) with more than 2000 children. The ATN found that the children who had ASD and ADHD had more problems with adaptive function behaviors, which includes daily living skills.

These findings are significant because they show clearly for the first time that children with ASD who also have ADHD have greater difficulties adapting successfully at both school and home. They suggest that the ADHD symptoms should be prioritized for treatment.

Source: Yerys, B. E., Wallace, G. L., Sokoloff, J. L., Shook, D. A., James, J. D., & Kenworthy, L. (2009). Attention deficit/hyperactivity disorder symptoms moderate cognition and behavior in children with autism spectrum disorders. Autism Research, 2(6), 322–333. doi:10.1002/aur.103