I had the pleasure of treating a wonderful young girl that was adopted from China. This was actually my introduction into the world of international adoptions and possible complications. The next few sentences highlight some of the issues I have been informed of. Many times the ratio of caretaker to child in some of these orphanages can be as high as 40 to 1. Many times, these children only have their diapers changed once daily. There is the possibility that their hands may be tied as the hands may be considered dirty. Children may never have been taken out of that crib. In fact, they may just have a drip type tube from which to get sustenance. This I was told described the conditions in one of the better orphanages. I was given a copy of a book relating to a term “the dying rooms .” This is a term relating to some of the horrible conditions in the Chinese orphanages during a certain time period. The phrase “Dying room” can be googled and you will be able to find information regarding a book and a television program relating to the same subject. This particular child had not been out of her crib until she was adopted at 18 months old. Therefore, she could not crawl or walk and certainly could not feed herself. When I saw her she was approximately 12 years old.

In the functional neurology model we look at the motor system as being an important driver to brain function. Naturally then development of the motor system is considered paramount development of brain function. Any Situation in which a child did not scoot on time or crawl on time or misses any of their motor milestones becomes a red flag. Primitive reflexes and lower areas of the brain become inhibited as higher areas of the brain develop. If there are inefficiencies in this process, there tends to be inefficiencies in optimal brain function at the highest levels which is what we see in autism spectrum disorders. Therefore, this child was a perfect model for this concept. The fact that she was never out of the crib until she was 18 months old. She had no motor or movement stimulation. She had very little sensory stimulation whatsoever the first 18 months of her life. It is common to see these children stimming and head banging in their cribs looking for some environmental stimulation from the outside world. As I have often said in my presentations to parents and professionals alike, most people realize that if you affect the brain such as in a stroke, you will affect the body. Most, however, do not realize that it is to the receptors from the environment that drives brain activity. Therefore this child’s very limited environmental stimulation had a high probability of presenting with developmental delays, sensory issues and autistic like symptoms.

This child’s functional neurologic examination was exactly as one would expect. She still had primitive reflexes present. She had sensory integration issues mostly related to touch and sound. She had incoordination and a balance disorder. With the appropriate functional neurological examination I was able to localize her functional lesion. Thanks to great cooperation from a dedicated and loving mother, we were able to implement a treatment program to correct her deficits. What is seen most commonly in regard to the application of hemispheric integration therapy with these children is that the ADHD and sensory type symptoms seem to improve first. I then began to get reports from her mom that her cognitive skills were also improving. This child was home schooled and had tutoring. Fairly quickly I began to get reports from mom stating that her reading level had moved up several grade levels. So once again, we got to see the motor cognitive link in action. I recall being in a functional neurology class and hearing the instructor say that “plants don’t have brains, only things that move have brains!” It was something obvious but that had never occurred to me. And so, this wonderful child was an excellent example as to how motor training can drive brain development. Of course, it was not quite as simple as just motor training. We have to incorporate the sensory stimulation and eventually layer her treatment together with cognitive exercises also so as to allow for multi modal processing. However, with the appropriate examination and monitoring of her treatment program allowed us to quickly adapt the program to her rapidly changing findings mostly on a weekly basis but at times on a daily basis.

In my office, we see many boys, as boys tend to be affected by autism spectrum disorders more than girls. However, we have seen quite a few girls and a disproportionate amount of them have been internationally adopted children. So today I got to kill two birds with one stone. I was able to write about functional neurology and hemispheric integration therapy with regard to autism spectrum disorders and inform prospective parents about a not commonly discussed situation with regard to international adoptions.

We know that the same pathways and  circuits that smooth and coordinate movements also smooth and coordinate thoughts. This is the essence of motor cognitive binding. I like to tell people in my presentations, whether I am speaking to parents or professionals, that if you look at a child on the autism spectrum and observe how uncoordinated his movements are, this gives you a window into how uncoordinated their thoughts might be. The beauty of this concept is that it works backwards also. By smoothing and coordinating their movements ,we tend to smooth and coordinate their thoughts also. So we can use this as a window into the child’s mind in order to help him synchronized the timing and processing of sensory inputs and thoughts. This concept is partially responsible for some of the results of studies that one may read regarding the interactive metronome and improvements with regard to children with ADHD. Thus, any activity which improves coordination, rhythm, timing and targeting tend to be helpful in these cases.

This is a generality of course. Whether I am speaking to parents or professionals, I am always trying to make the point that specificity is the key with regard to helping these children. There are few generalities but each child tends to be different and unique with regard to his signs and symptoms. For this reason, when stimulating any sensory receptor in order to drive brain activity is imperative to be specific as you may inadvertently stimulate an area which can cause the child to regress or overstimulate that child and cause a regression also. Therefore, I always recommend before undertaking any type of activity involving a functional neurology approach that the patient consult with not only a doctor trained in functional neurology but also one that has experience dealing with children on the autism spectrum.

When dealing with children on the autism spectrum two common questions often come into play. They are “what does the child need to do to improve” and “what can the child do.” The second question at times can be further subdivided into “what the child can or cannot do and/or what will the child do.” Many times the children are capable of performing the exercises but are not willing to do so. This may be a matter of motivation and/or the child’s way of trying to maintain some control over the situation. Therefore, many times we use rewards in order to motivate the child to cooperate. I always say that the parents are the ones that know the child best and here is where they can be a great help. Thus, you have to find appropriate motivation for the particular child you are treating at the time. Also, the doctor must take into account that is the child advances and matures in thought. Therefore the same reward that motivated him in month one may not be enticing in month two. One particular reward that we like to use if possible with children is the Whac-a-mole game. We tend to use this toward the end of the treatment session or between activities which the child finds difficult. This game tends to be fun for the child and serves as a dual purpose of requiring some coordination, rhythm and timing. There are unlimited ways to stimulate various weakened pathways and circuits that are found in these children. The job of the doctor is to find out which path way needs to be stimulated, design a therapy to stimulate that pathway and then match it to the child’s level of function and behavior. We always like to make the therapy sessions fun so that the children do not dread coming in for therapy. This makes it pleasant for all involved. Below is a link to the Amazon site where the Whac-a-mole game can be purchased. Maybe you can use it to help motivate your child. Please remember that although this is a toy, if you’re using it for therapeutic purposes it is not a toy.

http://www.amazon.com/Hasbro-40509-Whac-A-Mole-Game/dp/B0001GDP00

This relates to Autism Spectrum Disorders in that many children with autism in fact do have sensory integration issues with regard to their vestibular system. So, if we look at the fact that the senses feed the brain and we have sensory integration issues then as is often said in the computer world “garbage in, garbage out.” I have many parents that when asked if the child has any vestibular issues respond “Oh no, he can spin and spin and spin and never get dizzy.” They also tell me how they can go to amusement parks and never get dizzy. But is this a normal response? If I take a neuro typical child or adult and spin him in a chair should he not get dizzy and perhaps nauseous? The answer of course is yes. So, this is an actual weakness and not strength with regard to these children. If vestibular input is a strong input to the brain and these children are not getting any vestibular stimulation then it follows that their brains may not be functioning optimally.

Such is the case with a 10-year-old boy that I’m currently treating. The most obvious issues that the child has upon meeting him is that he scripts (repeats verbiage from movies and video games) as well as toe walks. This child has wonderful parents who are both hard-working and a great support system relating to their grandmother and aunt. My approach to functional neurology with regard to the nervous system is that the lower areas are cleared up first. That is we look at the nervous system from the outside in, for example, we ask the question, “Is it in the receptor, peripheral nerve, spinal cord, brain stem, etc?” So if you look at comparative anatomy between the species, we see that lower life forms have brain stems and vestibular systems while only humans have well developed prefrontal cortex. The vestibular system is really fairly low on the comparative anatomy scale, as I stated previously, all animals need to balance in order to survive. So, in my opinion in this child’s case, his vestibular system was the starting point. In our office, we sometimes have parents tell us that they see changes after one visit. Perhaps after a couple of weeks or a couple of months. This particular child has been very difficult to treat. His response has clearly been slower than expected. This child has been treating for approximately 6 months. He has shown some small vague type signs of improvement, but has not really made the typical improvements that we are accustomed to seeing in the office. We have seen his scripting going from out of context to in context. That is to say, that previously he might have been scripting a happy birthday scene from a movie while we were doing therapy. More recently he has begun to script a scene where a cartoon character is scared of the dark if we shut the lights off in the treatment room. That’s not what I call huge progress.

His mom is amazing with her compassion and dedication to her children. But what she does most well and is helpful to me, is that she knows when her child is just avoiding behavior and when he cannot do something. She has a great sense of how to motivate him to do the activities necessary to make him improve. She also has been very consistent with this treatment even though the progress has been less than expected. Consistency is a major factor with regard to making changes in the brain using the techniques of Hemispheric Integration Therapy.

Within the last few weeks after vestibular stimulation the child has been wanting to lay on the floor. This is a very typical vestibular response. That is, when you feel you are losing your balance or the world is spinning, you tend to want to get closer to the earth. Those that have had vertigo will be able to relate to this statement. But that was still vague in that we weren’t sure if this was a new behavior or that if he was finally feeling the vestibular stimulation. More recently after his last three visits the child did not want any further vestibular stimulation and was nauseous even vomiting on one occasion. For me, this is a sign to celebrate. This signifies that we have finally reached a threshold with regard to his vestibular system and that our stimulation is finally getting through and registering in his brain.

Again, vestibular stimulation, proprioception (joint position sense) and balance are powerful stimulations to one’s brain. And with this system now providing more appropriate stimulation to his brain, we hope to see more positive changes in the future. So yes, I am celebrating the fact that I was able to make a 10-year-old boy vomit. So if you have a child who is on the Autism Spectrum notice if he ever gets dizzy or if you can make him dizzy. If you cannot, this is not a normal response and is an important sign.

]]> http://www.hitautism.com/medical-articles/autism-spectrum-disorders-the-sixth-sense/feed 3 http://www.hitautism.com/medical-articles/aspergers-syndrome-tips-from-a-recent-case http://www.hitautism.com/medical-articles/aspergers-syndrome-tips-from-a-recent-case#comments Sat, 22 Aug 2009 13:33:47 +0000 admin http://www.hitautism.com/?p=394 Asperger’s Syndrome is a milder condition on the autism spectrum where the individuals are known for being highly intelligent yet have difficulty with social situations. Often as a child they are known as “Little professors” as they are smart and may show interest in scientific subjects such as dinosaurs or science fiction themes such as Star Wars. These individuals tend to be able to integrate into society fairly well as their verbal skills may be quite high and again the major deficiency relates to social interaction and social awkwardness i.e.  little Johnny can’t seem to make friends.  They may have difficulty with displaying appropriate sensitivity to others’ feelings. It is difficult at times for them to understand abstract concepts such as humor. Reading facial expressions and maintaining eye contact may be an issue. Usually, they show coordination difficulties and are not considered very athletic as children i.e. the goalie on the soccer team not the star forward.

This particular case relates to an adult with Asperger’s Syndrome. When someone with Asperger’s syndrome  grows up they tend to be attracted to computer fields. Such was the case in this situation. The reason for this being that many times these individuals are very detail oriented and intelligent while they tend to avoid social interaction. Therefore, many computer-related jobs fit those aspects comfortably. Many computer-related jobs can be done at home on a computer without having to go to an official workplace on a daily basis. This allows them to feel accomplished at work, intellectually, while avoiding social contact with others.

The problem is that screen time, television, video games and the Internet have been shown to have negative effects on individuals that are on the autism spectrum(attention deficit disorder, attention deficit hyperactive disorder , Sensory Integration Disorders, Processing Disorders, Asperger’s  Syndrome, Tourette’s syndrome , Pervasive Developmental Disorder and Autism.) This particular patient who also has attention deficit disorder relates to “being on the computer and then coming out of an almost trance like state realizing 20 hours have gone by and more than 20 tabs are open.” He also has made statements such as “now that I’m aware of the issue with screen time, I feel as if the computer screen is like kryptonite, sucking the life out of me.” In a perfect world, the best thing for this patient would be to discontinue all screen time.” The problem is he is now in his thirties and this is how he makes a living.

In a hemispheric integration model, Asperger’s Syndrome tends to be a right hemisphere deficiency. This does not mean that all Asperger’s Syndromes are a right hemisphere deficient and certainly the only way to determine this is with an appropriate functional neurological examination. In this particular case however, he did indeed have a right-sided deficiency with the basis of his issues localized to a left vestibular lesion. He in fact had played football in college. He was a running back. At first, I thought this somewhat unusual as Asperger’s  patients tend not to be athletic. However, upon further questioning it was determined that the reason he was a running back was that he could not catch a ball. This then tended to fit in well with the common associations of balance issues  and uncoordination with Asperger’s patients. Apparently, he was tough and determined but not the most coordinated. This was confirmed throughout the physical examination process . This was addressed with appropriate modalities relating to functional neurology and hemispheric integration therapy. These treatments were performed at the office on a regular basis during his therapy sessions.

The issue was that he had to go back home and go back to work. That meant that in this imperfect world, he would have to continue working at a job that required him to be on a computer to earn living. This was the only way he could maintain the standard of living that he was accustomed to. He may be able to make long-term changes into a field that does not require so much screen time, however in the near future that was not an option. In the hemispheric model postural muscles and proprioception are extremely important as is the side of the lesion. He did in fact work from home. This gave us a little bit more flexibility. Together we discussed what his workday was like and tried to come up with some adaptations he could make to lessen the impact of the computer screen on his condition. A treatment program at our office always involves in office treatments and what we like to term “homework” for the patient. We were able to come up with five adaptations which were helpful for him.
These were as follows:

1. He was to use the mouse with his left hand.
2. He was to do some core exercises for several minutes every hour as they break away from the screen.
3. He was to use a standing desk.
4. If he was in a sitting position he was to sit on a Swiss ball.
5. He was to place the screen slightly off center to the left.

These seemingly small and insignificant changes had a considerable effect in his ability to concentrate and be productive at work as well as his overall Asperger’s condition. As always, this is an illustration of  home modifications that were made on a particular case. This is not to imply that all Asperger’s Syndromes are right functional hemisphere deficiencies of left vestibular origin and should be treated and prescribed the same home modifications. These types of changes should only be done with appropriate physician supervision.