Know more about Autism

Some of you might have heard of Autism and want to know more about it, perhaps to pass on the information to the neighbour with an autistic child. Others may be closer to the complexity of the condition, as perhaps the mother of the child with Autism, and wish to follow guidelines to improve the approach to caregiving and follow the treatment options suggested here.

There are still many unanswered questions in Autism Spectrum Disorders (ASD), but this online publication of ‘Buddhi Clinic’ aims to present the specialist team understanding of ASD in simple terms for you to follow. We have stressed the guidelines for holistic caregiving for the person with ASD, the need to extend empathy and understanding, the role of behaviour therapy and the use of established modern technological methods in the management. We hope we have reached out to you, the reader, for a better understanding of this first topic of relevance in developmental disorder.

Developmental disorders, and Autism in particular, are detected more effectively globally over the past two decades. Studies published in early 2018 points to 1 in 8 children in India having at least one neurodevelopmental disorder. 1 in 100 children who are under the age of 10 years have Autism. In this appalling scenario, the one step forward is that the country is slowly leaning towards awareness of mental conditions and developmental disorders, and learning to accept the reality of their existence, which was not there before. With this initial acceptance, it is hoped that more people will seek advice and treatment where it is offered. Initially met with a lot of apprehension and stigma, ASD is better understood today. This is the result of a long process of handholding of patients and their caregivers by the medical team, better treatments offered with the progress in ASD research and through well-structured outreach awareness campaigns.

Chapter 1

What is Autism Spectrum
Disorder?

Definition: Autism Spectrum Disorder or ASD is a developmental disorder, the word ‘spectrum’ denoting the range in the neurodevelopmental disorder type and its varying severity levels. The basic symptoms of ASD are usually not hard to detect. Primarily ASD affects communication and behaviour. There is deficit in the development of language skills. Most persons of the Autism spectrum find it difficult to interact with people. They adopt a repetitive behaviour and are restrictive in terms of interactions and interests.In ASD language development & communication, emotional expression and socialisation are predominantly affected.

Under the spectrum, Asperger’s Syndrome (AS) and High Functioning Autism (HFA) are considered to be milder compared to others in the spectrum, especially with regard to the level of mental disability they present. In AS, the child presents apparent motor skill delays but less speech delay. S/he exhibits a strong tendency to obsessive interests. The diagnosis of HFA, on the other hand, is often reserved for people who come under the Autism spectrum but can manage basic functions such as reading, writing, speech and other life skills. The tendency to loosely club AS with HFA is misleading, and for proper patient management, these conditions must be recognised strictly as distinct diagnostic entities.

ASD may be given a diagnostic label for the first time by two years of age or a little earlier, as this may be the first time the parents may visit the specialist. However, As is usually diagnosed later in life, sometimes even well into adulthood, as coping mechanisms are better with the advantage of near normal language skill acquisition.

What causes

Autism Spectrum Disorder?

Vivek Misra B.Tech, MS (Neuroscience) a clinical neuroscientist who leads the Neuromodulation Lab at Neurokrish, succinctly brings out the initial understandings of Autism in his paper titled ‘The Social Brain Network and Autism’:

It has been suggested that Autism emerges from a developmental cascade in which a fundamental deficit in attention to social stimuli beginning as early as infancy leads to impaired interactions with primary caregivers. This results in abnormal development of the neurocircuitry responsible for social cognition, which in turn adversely affects later behavioural and functional domains such as language development which are dependent on these early processes.”

To break up this highly scientific statement for you, there are successive stages in normal child development, each stage having its profound effect on the next stage. The first observed abnormal stage in Autism is that the child does not respond to social stimuli as in a normal child, such as being given a hug by the mother or a gift toy by an aunt - this poor response can be noted even before the age of 1 year. As a result of this initial lack of response to social stimulus, the specialised nerve network, which is formed to look after social understanding and response, does not develop normally. This in turn affects the next phase of development and can present with marked deficit in language skills and other functions, and behaviour.

By now we have a child with a full blown diagnosis of Autism. If the mother had been to a specialist department even as she noted the earliest poor social response and remedial therapy were started right away, would the formation of the neural network for social understanding developed better? Our aim here is to create awareness that encourages diagnosis and therapy at the earliest phase.

These are some of the risk factors that may cause ASD:

Passed on from
parent to child

Through genetic
disorders or mutations

The child being born
to older parents

Through certain
metabolic imbalances

Foetal exposure to serious
toxins and heavy metals

Foetal exposure to
medications that are high
in Valproic acid or Thalidomide

Chapter 2

Autism Spectrum Disorder
Symptoms

Tracing the history of ASD Two clinical scientists, Leo Kanner and Johann ‘Hans’ Friedrich Karl Asperger, were instrumental in establishing the earliest definitions and description of Autism. Kanner’s astute clinical observations resulted in his noting a recognisable pattern of peculiar behaviour traits in some members of his child clientele. His study was based on his close follow up of 11 children who displayed “a powerful desire for aloneness”, were obsessive in their pursuits and exhibited repetitive behaviours. This led to his path-breaking treatise on Autism.

Asperger’s early studies and findings on developmental disorders, particularly in children, led to further understanding of Autism in the 1980’s. Such was his major contribution in this field that Asperger’s Syndrome was named after him.

Below are a few salient mental and physical symptoms that are common to Asperger’s and Kanner’s observations:

  • Poor eye contact, not sustained, with quick shift of glance
  • Lack of facial expression and hand gestures
  • Difficulty in initiating or engaging in conversation
  • Fragmented language flow, out of the usual norm
  • Impulsive behaviour without exhibiting thought out, planned action
  • Inflexibility with regard to time and routine
  • Lack of imaginative thinking and as a result not going beyond the literal sense

ASD symptoms often surface when a child or adult is unable to cope with the demands of school attendance or with activities which require extra attention or extra time. The management and the degree of care that is required in ASD can vary. It must be based on a detailed specialist team assessment of the degree of communication and language skill development and the social and behavioural patterns exhibited by the individual. The ASD classification falls into three broad levels acting as a guide to the specialist team in deciding the therapy and other treatment protocols and on how to advise the mother/primary caregiver on the care required.

Level 1:
High Functioning Autism (HFA) or Asperger’s Syndrome (AS) come under this classification level. They are the mildest forms of ASD and seldom affect everyday activities and functions.

Level 2:
In this level of the spectrum, the individual requires some assistance in the form of cognitive and behavioural therapy. The focus is on improvement of social skills and language.

Level 3:
This level of the spectrum warrants the employment of intense cognitive and behavioural therapy techniques and close nurture and caregiving. Most people under this spectrum find it difficult to perform daily functions and hence may require assistance on every front.

DIAGNOSIS

Asperger’s early studies and findings on developmental disorders, particularly in children, led to further understanding of Autism in the 1980’s. Such was his major contribution in this field that Asperger’s Syndrome was named after him.

Med Lab
An experienced Neuropsychiatrist / Child Psychiatrist examines the child using a qualitative approach

Mind Lab
A clinical Neuropsychologist examines the child using a range of structured tools for assessing cognition and behavior

Nerve Lab
An experienced electro physiologist carries out electroencephalography / brain mapping to understand brain function and its region of origin

Rehab Lab
An experienced Speech & Language Therapist assesses the child using structured tools

Mobility Lab
An experienced Neurodevelopmental specialist examines the child and quantifies gross and fine motor disability

CAM Lab
An Ayurveda / Naturopathy physician carries out a structured assessment of health and lifestyle factors and co-morbidities

Bio-Lab
A range of laboratory assessments are carried out using standard protocols and quality measures

Using this information the clinician develops a “bio-psycho-social” diagnosis and makes a comprehensive care and rehabilitation plan.

Chapter 3

Autism Spectrum Disorder
treatment

Children in the spectrum attend special schools, sometimes mainstream schools with special classrooms and inputs. In many instances, a child’s condition may demand after-school therapies as well.

ASD treatment and management remain an enigma, with no single, predictable cause. No drug or biological treatment has been identified as being effective. However, a range of neurological and psychotropic drugs are employed targeting symptoms like mood swings, impulsive or angry behaviours, impaired attention, altered sleep wake cycles, etc. as well as the frequent co-morbidities to ASD like epilepsy, ADHD, etc.

In this scenario, therapy continues to be a viable form of ASD management and includes psychological, behavioural, occupational and speech therapies, with clients also being prescribed a special diet. The role of Complimentary & Alternative Medicine (CAM) as a therapeutic option has been expanding, although it is often found outside the mainstream of ASD care. While CAM treatments do not have the same validity that mainstream allied modern medicine engendered treatments have, they seem to, nevertheless play a useful adjuvant role, especially addressing health and lifestyle factors in people with ASD.

Brain stimulation techniques have gained traction for being more reliable in investigating, modulating and treating abnormal neural circuitry and have been employed in adult ASD as well. Brain stimulation techniques are the following: Repetitive Transcranial Magnetic Stimulation (rTMS):
This brain stimulation technique focuses on studying the relationship between brain and behaviour and has been used in neuropsychiatric disorders. It has also been employed in the investigation of Alzheimer’s disease and mild cognitive impairments, fibromyalgia, multiple sclerosis, Parkinson's disease, and cerebrovascular disease. It is a non-invasive procedure with the absence of pain or stress, and does not require anaesthesia. rTMS has found a definite place in the management of ASD related behaviours today, especially in adolescents and older adults.

A typical rTMS session lasts for 30-45 minutes. The session has the client put on an electromagnetic coil held against the forehead, near an area of the brain that involves mood regulation. Magnetic pulses pass through the skull and cause small electrical currents to stimulate nerve cells in the targeted brain area. Studies show that rTMS helps in alleviating depressive symptoms.

Medication for Autism Spectrum Disorder treatment:
Medications do not treat Autism per se, but help in managing and providing relief for its symptoms and thus help in complementing treatment strategies devised to manage ASD. It is to be noted that medication does not work for everybody. Most parents and caregivers prefer non-medical treatments for their child or the person they are taking care of.

Thymoleptic Agents:
Lithium and some anti-epileptic drugs like carbamazepine, sodium valproate, topiramate, lamotrigine and oxcarbazepine are used to prevent mood swings, impulsivity and aggressive behaviours. Of these, Lithium as an agent to help in mood stability is best accepted.

Neuroleptic agents:
Drugs like risperidone are sometimes used to cut down hyperactivity and promote sleep.

Attention enhancers:
Drugs like Atomoxetine and Methylphenidate are employed in ADHD to enhance attention and in children with ASD have conjoint ADHD symptoms, they can be useful.

The Buddhi Clinic Management Approach to ASD:

The consultant (Behavioural Neurologist, Neuropsychiatrist, Child Psychiatrist) conducts a triage consultation. A comprehensive assessment is carried out by the Buddhi Clinic team and a “therapeutic program” prescribed.

Therapy is delivered as per a schedule: sessions typically include:

Mind Lab
Behavioural Management, Caregiver Training & Family Therapy

Mobility Lab
Neurodevelopmental therapy for fine motor skills and sensory integration

Brain Lab
Neuromodulation Treatments: rTMS, tDCS or other cognitive enhancement therapies as appropriate

Rehab Lab
Speech & Language Training

CAM Lab
Shiroabhyangam, Acupressure, Reflexology, Mud Therapy & Yoga- other treatments as appropriate

  • Periodic clinical reviews of progress: pre-therapy, mid-therapy and end-of-therapy are carried out.
  • Periodic scoring of symptoms to understand progress.
  • Periodic case-conferences with the consultant in order to assess and review progress and tweak the therapy plan.

Chapter 4

Conventional Autism
Therapy Techniques

To treat and manage Autism, the principal route is through diminishing the symptoms related to behaviour and speech/language. Behavioural therapy techniques are a huge support in terms of social growth, particularly beneficial for children as they can outgrow their diagnosis and find it easier to manage as adults.

Here are some of the behavioural therapy techniques used:

  • Applied Behaviour Analysis (ABA):

This behavioural therapy technique is used to make significant changes in grasping certain functions, usually taught through repetition and reinforcement. This technique helps a child learn and obtain certain life skills, communicative skills, social skills and keep difficult behaviour at bay.

  • Cognitive Behaviour Therapy (CBT):

This behavioural therapy technique is used to help remove any unhelpful cognitive distortion and ensure identification of the triggers and working around them. Particularly helpful for keeping anxiety and fear in check, CBT helps in identifying better coping strategies and changing the way one thinks or perceives things.

  • Verbal Behaviour Therapy (VBT):

This behavioural therapy technique focuses on communication and language, where the person learns how words are connected to their meaning. In VBT, language is divided into various operants consisting of Mand, Tact, Intraverbal, and Echoic.
Example: A boy named Tom is taught about the word ‘cookie’ and its meaning through VBT. In this case, whenever he asks for a cookie, it is a mand. Whenever he sees a cookie and tells someone about it, it is a tact. When he repeats the word ‘cookie’ after someone else says it, it is echoic. When asked a question and answering ‘cookie’, it is intraverbal. And finally, when he looks or points to a ‘cookie’ when someone asks him, it is listener behaviour.

  • Cognitive Enhancement Therapy (CET):

This behavioural therapy technique caters to individuals with cognitive and psychosocial impairments. These impairments are present in a number of neuropsychiatric conditions, especially seen among those with bipolar disorder, schizophrenia, Attention Deficit Hyperactivity Disorder (ADHD) and chronic autism of some form. This technique offers a comprehensive approach to treatment. A typical CET procedure involves some amount of computer training and group activity, aimed at improving brain development, social cognition and vocational abilities. This therapy includes neuro-cognitive exercises done on the computer, weekly group activities and even homework.

  • Other techniques:

Yoga:
Yoga therapy has been proven to reduce anxiety, behaviours that are impulsive, obsessive and aggressive. As a branch of the Ayurvedic System of Medicine, yoga therapy brings in a certain therapeutic value in correcting the imbalance in bodily deficiencies which lead to mental illness.

Naturopathy:
The concept of Naturopathy is driven by a non-drug treatment that combines various natural therapies (using water, mud, aroma, magnets, touch and pressure) that help the body and mind heal. Commonly used Naturopathy therapies are:

Reflexology:
This therapy stimulates nerve function, increases energy levels, improves circulation, enhances joint mobility, boosts immune responses and helps in relaxing the individual. Persons with a diagnosis of ASD can benefit from the use of this therapy to release tension, reduce anxiety and improve sleep patterns.

Acupressure:
This therapy to the scalp area boosts language skills. This method is particularly more effective in children than adults. It has been proven that Acupressure shows an improvement in attention and new learning.

Mud Therapy:
Mud, said to be an important element of nature, contains minerals that are beneficial for human health. Applied on the abdomen and around the eyes, mud therapy relaxes muscles, improves circulation, and leaves a positive impact on the digestive system.

Chapter 5

Diets to follow in ASD

Diet plays an important role in behaviour and here are some time tested methods to manage ASD symptoms with special diets and care.

Relationship between diet and behavioural problems:

Diets can affect the human body and mind. First established in the 1920s by the American Journal of Diseases of Children, diet has been found to modify one’s behaviour, especially among children. In the 1970s, the Feingold Diet came into play based on the research by Benjamin Feingold that focused on the link between children with behavioural problems and a salicylate and additive-free diet. The study showed a 50% reduction in behaviour problems. Almost 30 years later, in 2007, the paper ‘Diet and child behavior problems: fact or fiction?’ showed how sugar led to hyperactive and aggressive behavioural problems. This spurred on the next stage in the discovery dietary interventions, leading to the implementation of the Gluten-Free-Casein-Free (GFCF) diet.

Gluten-Free Casein Free Diet for Autism:

It has been reported that children who were given the GFCF diet showed improvements in terms of behaviour within three months. It is a restrictive diet and eliminates dairy products. Therefore one must ensure that children get their Vitamin D and calcium intake from other sources. For children brought up in India, this restrictive diet can be particularly difficult, as Indian food is high in gluten content.
The way a GFCF diet helps in Autism was established after a series of observations. Gluten and casein can cause damage to the lining of the intestine if the person is intolerant to such products. Regular intake can lead to certain toxic molecules to get absorbed through the defective intestinal lining. This in turn affects the brain and causes anxiety, mood swings, and other behavioural problems.

Foods to avoid as per the GFCF dietary paradigm:

Sugar can cause inflammation in the intestinal lining to flare up, thus leading to the behavioural problems and Autism Spectrum Disorder symptoms worsening. Sugar is addictive and is found in many pre-processed food products such as confectionery items, bread, juices, desserts, etc. Reducing sugar in the diet is thought to lead to a reduction in hyperactivity
Dairy products including milk, cheese, cream, butter, curd, milkshakes, etc. contain casein. Once dropped from the diet, bowel movements improve and hyperactivity is significantly reduced.

Gluten products including wheat, flour, barley, salad dressing, mayonnaise, ketchup, sausages, etc. are believed to be highly likely to cause inflammation once consumed. Artificial ingredients such as food colouring and dyes, preservatives, and sweeteners can aggravate behavioural symptoms, and should be eliminated from the diet.

While absolute proof that these dietary restrictions work for patients with ASD is missing, there is a school of thought that remains persuasive. The Buddhi Clinic approach is to encourage parents to understand and explore diets in a safe and conservative manner, while ensuring the child receives adequate nutrition, for a period of time (say 3 months), and to track symptoms objectively for such period. Children who derive clear benefit may continue with the diet for much longer with proper medical supervision and monitoring.

Chapter 6

Parenting a Child
with Autism

Family plays an important role in the intervention of children with ASD. Parents supporting and training their child leads to the child’s behaviour improving in terms of communication, cognitive performance and adaptive behavioural skills.

ASD individuals are not the only ones affected. Behavioural problems and developmental disorders in an individual affects the life of the whole family, parents and siblings as well. It requires the family to be supportive and patient. Families must come to terms with the fact that individuals with ASD aren’t “suffering from a disease”. Intervention for individuals should be incorporated in such a way that the parents are involved through informative psychoeducational programs. These interventions should aim to bring changes in the child, with parents adopting various tools and strategies to help treat the symptoms even at home, thus making progress in the child’s development.

Developmental disorders including ASD can be treated with the family’s help, special educators, vocational trainers, psychologists, speech therapists, occupational therapists, and support groups. The best part about present times is that information is readily accessible through support groups and on the net, the latter, for those who have its use. Parents can find support through these groups, read up on information and ways to cope with symptoms through online portals. Via these same portals, parents can also reach out to other parents in a similar situation.

Financially, it could get difficult for parents to take care of their child with Autism. However, financial support is always available and requires one to be aware of the kind of help they can get. Schemes are provided by the Central and State Government to provide families with a developmental disorder individual with financial support via concessions concerning public transportation, loans, income tax exemption, pension transfer, free legal aid services, house site allotments, and marriage allowance.

Highlights:

At Buddhi Clinic we see parents and families as key stakeholders in the journey of the child, adolescent and adult with ASD.

We involve the parents and family actively in our therapeutic program through transparent sharing of knowledge and information, education about the condition and enablement with tools.

We create for each client and family an active home program toolkit, one that they can use to schedule, deliver, track and manage the progress of their family member. Our approach has cultural consonance - weaving together, seamlessly, the rigour of Western medicine and the mindfulness of the East.

Chapter 7

Examining case studies
of Autism

In this chapter, we will look at the Autism case studies of two different individuals who endured a lot and fought their way to better therapy at Buddhi Clinic.
David’s and Ragini’s cases are different in many ways, yet similar in terms of their understanding, of seeking help, their family’s perseverance, and the effect of integrated treatment that combines modern medical techniques with ancient wisdom.
Understanding David and Ragini’s stories prove that there is hope of better days.

About David:

David is 7 years old, diagnosed with mild Autism. Attending special schooling, David never said a word since he was a child. Instead, he would engage in unintelligible sounds and meaningless words. In his special school, with emphasis on speech therapy and occupational therapy, David showed no interest in academics and would often run around, finding it difficult to stay in one place. In school, it was observed that he liked the word ‘H’, the digit ‘7’ and had a fondness for the colour ‘green’.

Assessment:
An assessment at Buddhi Clinic showed that he had intact higher mental functions, bilateral epileptiform dysfunction on the EEG, and the social age of 5 years, 4 months and 8 days, indicating borderline deficits in social adaptive functioning.

Treatment & Results:
David’s treatment began at Buddhi Clinic, wherein his overall improvement was exemplary. Various behavioural therapy techniques resulted in David’s attention span getting better, his coordination improving, his motor movements significantly better, and other positive signs in social functioning. During his treatment, David began Anti-Epileptic Drug medication (as a mood stabiliser) prescribed by Prof. Dr. Ennapadam S Krishnamoorthy, with further improvement all round.

About Ragini:

Ragini was born healthy, to an equally healthy mother. Her language was delayed until the age of 5, while, strangely, her musical expression preceded language. As she grew up, it was observed that she had poor communication skills, sub-average intelligence on the Wechsler Intelligence Scale for Children (WISC), language processing difficulty and social fears and phobias. By the age of 10, her behaviour became increasingly difficult to manage and she engaged in disruptive behaviour through aggression.

Assessment:
Having settled in the West, Ragini’s mother resorted to seeking help in the motherland when her condition went out of hand. A psychiatric assessment in the West revealed that she had the irritability of ASD, though a high functioning ASD, and she was put on Risperidone tablets till the age of 19. While she was off medication for two years, Ragini began to feel isolation and socially withdrawn. She became severely depressed, felt worthless, had suicidal thoughts, and would have rapid mood swings, crying, shouting, explosive episodes of dyscontrol and threats of leaving home.
Brought to India, Ragini’s treatment at Buddhi Clinic was not easy. Her Rorschach Inkblot test produced 22 responses, meeting the perceptual thinking and coping deficit index. The diagnosis was Autistic Spectrum Disorder (High Functioning) with Rapid Cycling Affective Disorder and Episodic Dyscontrol Syndrome.

Treatment & Results:
Her assessment led to an even more difficult process of coming up with a suitable drug regimen. Two anticonvulsants used as thymoleptic agents had to be rejected as Oxcabamazepine produced a moderate allergic reaction. Lamotrigine, on the other hand, produced Steven Johnson’s type of adverse drug reaction. Post recovery to the allergic reactions, the following were administered initially intensive and daily and then spaced out to 3-4 days a week:

- Antidepressants and anxiolytics medications
- 24 sessions of Cognitive Behavioural Therapy
- Individual psychotherapy
- Family education
- 11 physiotherapy (grade 2)
- 34 of Acupuncture
- 20 of Reflexology
- 34 sessions of Shirodhara
- Whole-body massage
- 24 sessions of Yogasana

In Ragini’s case, seeking help led to things looking up for her. Her self-esteem started to return. Her mood swings were minimal and the episodic dyscontrol vanished. Her ASD symptoms are much more under control after the management regimen with the Buddhi Clinic team. The family is also in a positive frame of mind to broach the subject of future plans for her life, including home and career.

In conclusion, we wish to impress upon the reader that treating and managing ASD is possible, going beyond the levels of basic care and therapy. When you merge modern Medicine and the tools of technology advancement with ancient wisdom, the benefits of treatment increases multifold. This is what we offer as a team at Buddhi Clinic, our level of expertise in integrated brain and mind care, having been honed over several years.

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