EEG Brainwave test could improve autism diagnosis and classification

A new study by researchers at Albert Einstein College of Medicine of Yeshiva University suggests that measuring how fast the brain responds to sights and sounds could help in objectively classifying people on the autism spectrum and may help diagnose the condition earlier.

The paper was published today in the online edition of the Journal of Autism and Developmental Disabilities.

The U.S. Centers for Disease Control and Prevention estimates that 1 in 68 children has been identified with an autism spectrum disorder (ASD).

The signs and symptoms of ASD vary significantly from person to person, ranging from mild social and communication difficulties to profound cognitive impairments.

"One of the challenges in autism is that we don't know how to classify patients into subgroups or even what those subgroups might be," said study leader Sophie Molholm, Ph.D., associate professor in the Dominick P. Purpura Department of Neuroscience and the Muriel and Harold Block Faculty Scholar in Mental Illness in the department of pediatrics at Einstein.

"This has greatly limited our understanding of the disorder and how to treat it."

Autism is diagnosed based on a patient's behavioural characteristics and symptoms.

"These assessments can be highly subjective and require a tremendous amount of clinical expertise," said Dr. Molholm. "We clearly need a more objective way to diagnose and classify this disorder."

An earlier study by Dr. Molholm and colleagues suggested that brainwave electroencephalogram (EEG) recordings could potentially reveal how severely ASD individuals are affected.

That study found that children with ASD process sensory information, such as sound, touch and vision, less rapidly than typically developing children do.

The current study was intended to see whether sensory processing varies along the autism spectrum. Forty-three ASD children aged 6 to 17 were presented with either a simple auditory tone, a visual image (red circle), or a tone combined with an image, and instructed to press a button as soon as possible after hearing the tone, seeing the image or seeing and hearing the two stimuli together.

Continuous EEG recordings were made via 70 scalp electrodes to determine how fast the children's brains were processing the stimuli.

The speed with which the subjects processed auditory signals strongly correlated with the severity of their symptoms: the more time required for an ASD individual to process the auditory signals, the more severe that person's autistic symptoms.

"This finding is in line with studies showing that, in people with ASD, the microarchitecture in the brain's auditory center differs from that of typically developing children," Dr. Molholm said.

The study also found a significant though weaker correlation between the speed of processing combined audio-visual signals and ASD severity. No link was observed between visual processing and ASD severity.

"This is a first step toward developing a biomarker of autism severity, an objective way to assess someone's place on the ASD spectrum," said Dr. Molholm.

"Using EEG recordings in this way might also prove useful for objectively evaluating the effectiveness of ASD therapies."

In addition, EEG recordings might help diagnose ASD earlier. "Early diagnosis allows for earlier treatment, which we know increases the likelihood of a better outcome," said Dr. Molholm.

"But currently, fewer than 15 percent of children with ASD are diagnosed before age 4. We might be able to adapt this technology to allow for early ASD detection and therapy for a much larger percentage of children."

More information: The paper is titled "Neurophysiological Indices of Atypical Auditory Processing and Multisensory Integration are Associated with Symptom Severity in Autism."

Autism: Diagnosis and Treatment

In the US April is National Autism Awareness Month.

The Child Development Clinic at Children's Hospital of Richmond at VCU (CHoR) provides comprehensive assessment for pediatric patients with developmental delays or disabilities, including those with autism spectrum disorders.

The medical, psychological, social work and educational testing offered by the clinic leads to a diagnosis and recommendations to help patients and their health care providers with care planning, referrals, follow-up care coordination and treatments.

Pasquale Accardo

We sat down with Pasquale Accardo, M.D., professor and chief of the Division of Developmental Pediatrics at CHoR, to learn more about autism, including symptoms, diagnosis and treatment.

What is autism?

Autism is a neurodevelopmental disorder, this means that it is a chronic brain problem, a difficulty that the brain has with processing certain kinds of information.

In the case of autism, typically the greatest difficulty is dealing with social interaction.

What are the common signs and symptoms of autism?

Common signs of autism vary with age:

• Young children often first present with language issues.
• Preschool and school-age children often exhibit attention deficit hyperactivity disorder (ADHD) symptoms and other challenging behaviours.
• Older children have significant socialization problems, repetitive and obsessive compulsive behaviours.

Symptoms of autism do change with time; certain delays are more common in younger children whereas socialization and processing problems are more common in older children and adults.

How is autism diagnosed?

Autism is diagnosed using a variety of approaches:

• A clinical history and examination may be sufficient.
• Formal testing can include a variety of questionnaires, including the Gilliam Autism Rating Scale, now in its 3rd edition (GARS-3) and the Childhood Autism Rating Scale, now in its 2nd edition (CARS-2) administered to the parents and teachers.
• Autism Diagnostic Observation Schedule (ADOS) testing is considered the gold standard.

How is autism treated?

Autism is best treated with a variety of Early Intensive Behavioural Interventions (EIBI); speech language therapy and occupational therapy can also be used.

Applied Behaviour Analysis (ABA) is considered the standard for behavioral intervention, but most other effective behavioral programs are variants on ABA.

Dyslexia: Is it time to rethink or examine the diagnosis?

Some years ago, a student informed me that she was encountering a problem with my classes.

When asked to explain a little further, she told me that she had been diagnosed as dyslexic.

I asked if she could be a little more specific about the particular difficulties she was encountering.

Responding, “I can’t understand what you are talking about”, she explained that the ideas I was expressing were complex and she found them difficult to grasp.

I enquired how I might help her with this problem. She replied that she would welcome a single sheet of A4 for each lecture containing a set of bullet points that summarised the key points.

This anecdote exemplifies some of the confusion that surrounds “dyslexia”, a term used to describe a variety of problems. Researchers tend to describe as dyslexic all those who struggle to decode text.

Others, often clinicians, argue that only some poor decoders are dyslexic. Still others contend that decoding difficulty is but one part of a much broader dyslexic condition.

It is hardly surprising, therefore, that diagnosis is deemed to be highly subjective and lacking in scientific rigour. 

While special tests and symptom profiles are commonly used, there is no means of making a consistent and meaningful judgement.

As the list of so-called signs and symptoms is lengthy, most people reporting reading difficulties will demonstrate some of them.

Many such symptoms are found in good readers, and those diagnosed as dyslexic often differ substantially from one another.

Many clinicians still employ IQ tests as a basis for diagnosis, even though this practice has been discreditted and no longer has any scientific support.

Meanwhile, research studies in neuroscience and genetics, often used by proponents to justify the dyslexia construct, are typically conducted with poor decoders (not a so-called dyslexic subgroup), and currently offer no additional diagnostic information.

The key problem is that dyslexia diagnoses have moved far away from their original focus (severe reading difficulty) to incorporate an ever-increasing range of cognitive and self-regulatory deficits including poor working memory, processing speed limitations, attention/concentration problems, difficulties in analysing and synthesising complex information, and in organising and expressing ideas.

For any students who struggle to cope with academic demands for such reasons, there are obvious equity issues within our highly competitive higher education sector between those who are diagnosed dyslexic and those who are not and, instead, are considered to be academically weaker performers.

Read the full article here

New guidelines employ a team approach to autism diagnosis and care

Fred Volkmar

Improving diagnosis and treatment for individuals with autism has been the focus of a growing body of research. 

New information from these studies led the American Academy of Child and Adolescent Psychiatry (AACAP) to revise key parameters for evaluating and treating autism. 

Researchers led by Yale Child Study Center director Dr. Fred Volkmar have published the new practice parameters in the Feb. issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

"Early diagnosis of children with autism spectrum disorders means treatments will be introduced that lead to more positive outcomes for children," said Volkmar the Irving B. Harris Professor of Psychiatry, Pediatrics, and Psychology at the Yale School of Medicine.

According to the parameters, clinicians should routinely look for symptoms of autism spectrum disorder in young children undergoing developmental assessments, and in all psychiatric evaluations.

If significant symptoms are detected, clinicians should then coordinate a careful medical, psychological, and communication evaluation.

These evaluations should differentiate between autism and a variety of developmental and other disorders, as well as intellectual and behavioral disabilities.

"Our goal was advocacy for individuals with autism and their families, and to ensure that services are coordinated across clinical care," said Volkmar.

"Our field is changing rapidly, and these parameters are meant to promote effective care and move professional medical methods closer to current practices."

Volkmar and his co-authors reviewed abstracts from 9,481 research articles on autism that were published between 1991 and 2013.

They then fully studied 186 of those articles based on their quality and ability to be applied more generally.

"Treatment should involve a team approach," said Volkmar, who notes that under these treatment parameters, psychiatrists will closely coordinate diagnosis and treatment with teachers, behavioural psychologists, and speech and language pathologists, and look for commonly occurring conditions.

A key addition to the new parameters is a focus on how clinicians should address the use of non-traditional therapies, like chelation and secretin.

Clinicians are urged to ask families if they are using alternative/complementary treatments and to discuss the therapies' risks and potential benefits.

Volkmar estimates that about 90% of parents of children with autism use some kind of alternative or complementary therapies.

"It is important to encourage a discussion with parents about the potential harms of some of these therapies, as well as to educate them about evidence that supports what they're doing."

More information: Journal of the American Academy of Child & Adolescent Psychiatry: www.jaacap.com/article/S0890-8567(13)00819-8/fulltext

Facial Palsy in Children: Bell's Palsy

About 40,000 people in the United States develop facial paralysis each year with children comprising a small percentage of that population.

There are more than 50 known causes of facial paralysis but the most common in children is “Bell’s palsy,” the cause of which is not certain.

This disorder effects one side of the facial muscles due to dysfunction of the seventh cranial nerve, usually thought to stem from a viral infection; Bell’s palsy is found in 20 out of 100,000 Americans, with the incidence increasing with each decade of life.

What causes Bell’s palsy?
In Bell’s palsy, facial paralysis results from damage (e.g., possibly from viral infection) to the facial nerve.

Adults and children will either wake up to find they have facial paralysis or palsy, or have symptoms such as a dry eye or tingling around their lips that progress to Bell’s palsy during that same day.

Occasionally symptoms may take a few days to progress to facial weakness or paralysis. Physical trauma to the head and neck region at birth and during childhood may cause facial paralysis.

Other causes are:

• Chicken pox: Chicken pox and shingles are both caused by a single virus of the herpes family known as varicella-zoster virus (VZV). Varicella is the primary infection that causes chickenpox; Herpes zoster is the reactivation of the virus that causes shingles. Research studies suggest that Bell’s palsy may be due to a reactivation of herpes simplex virus (HSV). Between 75 percent and 90 percent of chickenpox cases occur in children under 10 years of age. According to a 2001 study, about 10 percent of children between ages five and nine and about two percent of 10 to 14 year olds get chicken pox each year.
• Infectious mononucleosis: This condition, with a peak incidence in the 15- 17 age group, can be caused by several different viruses. The leading causes are the Epstein-Barr virus and cytomegalovirus, both members of the herpes virus family. The infection is transmitted by saliva, sexual contact, respiratory droplets, and blood transfusions.
• Lyme disease: Lyme disease is an infection that’s spread by Ixodes ticks (black-legged or deer ticks in the eastern United States, and western black-legged ticks in the west). The second stage of Lyme disease usually appears two to three months after the tick bite, and may include facial palsy or paralysis among other symptoms.

Treatments for Facial Paralysis:
If infection is the cause, then an antibiotic to fight bacteria (as in middle ear infections) or antiviral agents (to fight syndromes caused by viruses like herpes zoster (Ramsay Hunt Syndrome) may be used.

The prognosis for children with facial paralysis is generally very good. The extent of nerve damage determines the extent of recovery.

With or without treatment, studies indicate that most pediatric patients with the disorder begin to get better within two weeks after the initial onset of symptoms and recover completely within three to six months. Adults may find residual symptoms remaining for an indefinite period of time.

What happens during the diagnosis?
After an examination, the otolaryngologist- head and neck surgeon may conduct a hearing test to determine if the cause of damage to the nerve has involved the hearing nerve, inner ear, or delicate hearing mechanism.

Additional tests in the physician’s office include a balance test and a tear test, to measure the eye’s ability to produce tears.

Eye drops may be necessary to prevent drying of the surface of the eye cornea. In some circumstances, the physician may recommend a CT (computerized tomography) or MRI (magnetic resonance imaging) test to determine if there is infection, tumor, bone fracture, or other abnormality in the area of the facial nerve.

An additional diagnostic tool is the Electro neuronography (ENOG), which stimulates the facial nerve to assess how badly the nerve is damaged. This test may have to be repeated at frequent intervals to see if the disease is progressing.

Sources:
National Institute of Neurological Disorders and Stroke
Bell’s Palsy Research Foundation (US)
Bell's Palsy Association (UK)

Parents of sick kids distrust online medical help - ‘Dr. Google’

Parents of children with cancer not only don’t trust online medical sites, but fear them as well, preferring instead to receive information from a trusted source, like a doctor.

“Respondents were telling us they were uncertain of the information online and that they were afraid of the unknown,” says study co-author Elizabeth Gage, professor of community health and health behavior at the University at Buffalo. “They didn’t want to run into stories about ‘the worst case scenario’.”

Gage, along with Christina Panagakis, a UB graduate student in sociology and colleagues at Roswell Park Cancer Institute, interviewed 41 parents of pediatric cancer patients in the U.S. to learn how caregivers use the Internet as an information source about their child’s illness, its prognosis, and potential treatment options.

Published in the journal Sociology of Health and Illness, the study suggests that beyond a distrust and fear of health-related Internet sites, online searching for information about an illness might vary between patients dealing with routine conditions and those faced with life-threatening problems.

“The likelihood of a patient going online might depend very much on context,” Gage explains.

Previous studies looked at what Gage described as routine, contested, or stigmatized illnesses, while her research contributes a piece of knowledge relative to severe pediatric illnesses.

“One of the reasons we were interested in exploring this issue is that so much research and media coverage had examined how the Internet was breaking down barriers between patients and caregivers and their physicians,” Gage says.

“But that wasn’t the case in our study. Perhaps because of the severity of the diagnosis, parents and caregivers preferred to receive their information from sources other than the Internet.”

The information-seeking behaviour of parents and other caregivers appears to be influenced by the volume of available information, Gage says.

Patients with routine illnesses might find minor details online that better inform their conversations with health care providers, but respondents in this study who were confronting a more serious diagnosis were overwhelmed by the often conflicting sources of online material.

“Families in our study did not know where to begin or how to sift through such a huge mound of information,” Gage says.

Those who did look for information through the Internet tended to limit their searches to what they considered more credible sources, such as medical journals and hospital libraries, the study says.

“A lot of families used the Internet to establish connections with other families in a similar situation, as much for emotional support as for reasons to share medical information,” Gage says.

“However, many families ascribed a certain expert status upon these individuals, almost elevating the experience of what they call “the veterans” to the same level as that of a trusted hospital-based site.”

More news from University at Buffalo: www.buffalo.edu/news

Bipolar diagnosis in children may do more harm than good

Troubled children diagnosed with bipolar disorder may see more improvement with a different diagnosis, according to researchers at The Hastings Center.

The researchers support an emerging approach, which gives many of those children a new diagnosis called Severe Mood Dysregulation (SMD) or Temper Dysregulation Disorder with Dysphoria (TDD).

The findings come soon after proposed revisions to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) were opened to public comment.

In a paper published in Child and Adolescent Psychiatry and Mental Health, Erik Parens and Josephine Johnston examine the evolution of the diagnosis of bipolar disorder in children and its dramatic increase since the mid 1990s, after the criteria for diagnosis broadened.

They emphasize that there is vigorous debate in pediatric psychiatry about whether symptoms in children accurately reflect the criteria for bipolar disorder, particularly for mania.

The increase in cases has led to concerns about accurately defining psychiatric disorders in children as well as the safety and efficacy of resulting pharmacological treatment.

It is difficult to diagnose psychiatric disorders in children, Parens and Johnston write, and many children receiving bipolar diagnoses exhibit behaviors that do not closely fit the disease's criteria.

"Using new labels such as SMD or TDD reflects that physicians do not yet know exactly what is wrong with these children or how to treat it," said Johnston. "Facing up to this uncertainty could lead to better treatment recommendations and more accurate long-term prognosis." A new diagnostic category would also help reframe the research agenda.

Their findings come from an interdisciplinary series of workshops funded by a grant from the National Institute of Mental Health. Participants included psychiatrists, pediatricians, educators, bioethicists, parents, and social scientists. Erik Parens is a senior research scholar and Josephine Johnston a research scholar at The Hastings Center, a bioethics research institution.

Among the workshop conclusions:

• The bipolar label may fit poorly many of the children who have received it over the last decade.
• There is debate about what children's symptoms represent. For example, what is characterised as mania in children is very different from its features in adults. Mania is a hallmark feature of bipolar disorder, formerly known as manic-depressive disorder.
• The bipolar label, which has a strong genetic component, can distract from addressing the family or social context.
• Physicians must be forthcoming with families about uncertainties and complexities in the diagnosis and treatment of bipolar disorder in children.
• Current training practices and reimbursement policies may leave some psychiatrists and pediatricians unable to deliver the comprehensive care that these children need.

The authors also note that, while experts sometimes disagree about labels, the workshop group universally agreed that "children and families can suffer terribly as a result of serious disturbances in children's moods and behaviours," and that these troubled children desperately need help.

They also write, "It is a deeply regrettable feature of our current mental health and educational systems that some DSM diagnoses are better than others at getting children and families access to needed care and services."

The Hastings Center is a nonpartisan bioethics research institution dedicated to bioethics and the public interest since 1969. The Center is a pioneer in collaborative interdisciplinary research and dialogue on the ethical and social impact of advances in health care and the life sciences.

The Center draws on a worldwide network of experts to frame and examine issues that inform professional practice, public conversation, and social policy. Learn more about The Hastings Center at: www.thehastingscenter.org

To read the full paper, click on this link

Autism: Is there really an increase diagnosis

According to a recent study by The Centre for Disease Control and Prevention(CDC) the rate of autism in the US has jumped 40% from 1 in 154 to 1 in 110 between 2002 and 2006.

The study also found that ASD was 4 to 5 times higher in boys than in girls. The CDC estimates 1 in 70 boys and 1 in 315 girls have an ASD.

What accounts for this staggering increase?
The CDC admits that they can isolate no one factor at this time, without further research and conclusive evidence.

Recent developments in earlier detection might account for the rise in autism diagnoses and the CDC confirms that improved community awareness, the widening of diagnostic criteria to include more mild cases and out right earlier identification have added to this increase.

So the CDC are keen to acknowledge that is not yet conclusive that the condition is on such a steep rise, but the recognition of symptoms and labeling has drastically increased.

The AAP
The American Academy of Pediatrics recommends systematically screening children for autism at 18 months and 24 months even when a concern or risk is not conclusively recognised. Their philosophy is to screen children early and often.

However, parents are either the first to identify symptoms or the most likely and they need to be vigilant in helping track a child’s development. Close scrutiny will help determine how well they are progressing and ensuring they are not regressing in their skill development.

ASD
A child with ASD will develop symptoms before the age of 3. These symptoms can be detected as early as a few months of age, or not show up until 24 months or later. Some children develop normally until around 18 months and then stop gaining new skills, or they lose the skills they once had. Common symptoms are:

• Avoid eye contact and want to be alone
• Not respond to their name by 12 months of age
• Experience delayed speech and language skills
• Repeat words or phrases over and over (echolalia)
• Be extremely agitated by minor changes
• Have obsessive interests
• Flap their hands, rock their body or spin in circles
• Have unusual reactions to the way things sound, smell, taste, look or feel

There are three different types of ASD:

• Autistic Disorder: Significant language delays, social and communication challenges and unusual behaviors and interests. Some may have intellectual disability.
• Asperger Syndrome: Milder symptoms of autistic disorder. Typically do not have problems with language or intellectual disability.
• Pervasive Developmental Disorder (atypical autism): Usually have fewer and milder symptoms than those with typical autistic disorder. Symptoms might pose only social and communication challenges.

If you have concerns about possible delays in your child's developmental, contact your doctor in the first instance. If you are not satisfied with your doctor's response or if he confirms your suspicions, ask for a referral to a qualidied specialist. Someone that will be able to perform a more in-depth evaluation of your child.