Monday, July 27, 2015

Alexithymia and Emotion Recognition in Autism

Alexithymia is characterized by difficulties in identifying, describing, and processing one's own feelings, often marked by a lack of understanding of the feelings of others, and difficulty distinguishing between feelings and the bodily sensations of emotional arousal. Alexithymia is not a formal clinical diagnosis and is best conceptualized as a dimensional personality trait that is normally distributed in the general population (with estimates of 10%) and varies in severity from person to person. However, there is evidence to suggest that it is associated with an increased risk for mental health problems. For example, several studies indicate that even in childhood, alexithymia and difficulties in the domain of emotion processing are positively related to internalizing problems such as anxiety and depression.
Research indicates that alexithymia overlaps with autism spectrum disorder (ASD). Although alexithymia is not a core feature of autism, recent studies have found varying degrees of this trait in 50 to 85% of individuals with autism ASD. The alexithymia trait appears to have the following properties: (a) it is more common in individuals with ASD than in the general population (b) it is more common in parents of individuals with ASD than in parents of individuals with another developmental disabilities, (c) it is stable over time in ASD, and (d) problems in the domain of emotion awareness are positively related to depression, anxiety, somatic complaints, worry and rumination. There is also evidence to indicate that the alexithymia trait might be part of the broader autism phenotype and a significant component of the emotion processing difficulties observed in ASD. It is uncertain whether the problem of emotion recognition commonly attributed to individuals on the autism spectrum is a result of the disorder itself, or if it is due to the large co-occurrence (comorbidity) between alexithymia and autism.
Given the apparent association between alexithymia and autism, it’s especially important to investigate the relative contribution of this dimensional trait to the impairment in social functioning experienced by individuals with ASD. An important question for future research relates to the prevalence of high levels of alexithymia in ASD compared to neurotypical individuals and how to explain the high co-occurrence (comorbidity) between alexithymia and ASD. Is alexithymia a neuroanatomical structural consequence or is the result of a neurobiological impairment, or is it a distinctive personality trait of individuals with ASD? Does the level of alexithymia predict symptom severity in ASD? Although not a diagnostic feature of autism, would alexithymia be a useful diagnostic marker for ASD? Because alexithymia is associated with increased risk of mental health problems (i.e., anxiety and depression), should a measure of alexithymia be included in an assessment battery for ASD? As with most autism research, there are more questions than answers.
Bird, G., Silani, G., Brindley, R., White, S., Frith, U., & Singer, T. (2010).  Empathic brain responses in insula are modulated by levels of alexithymia but not autism. Brain, 133, 1515-1525.
Szatmari, P., Georgiades, S., Duku, E., Zwaigenbaum, L., Goldberg, J., & Bennett, T. (2008). Alexithymia in Parents of Children with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders, 38, 1859-1865.

Friday, July 10, 2015

Healthcare Providers Unprepared to Treat Adults with Autism

It is estimated that nearly a half million youth with autism will enter adulthood over the next decade. As children with autism become adults their primary medical care will move from pediatrics to adult medicine. A survey by the Autism Research Program at Kaiser Permanente Northern California found that many healthcare providers are ill prepared to treat adults on the autism spectrum. The findings were reported at the International Meeting for Autism Research in Salt Lake City, Utah.
Researchers polled providers of adult primary care, mental health, and obstetrics and gynecology services through the insurer’s network. Practitioners were asked about their ability to recognize autism, their knowledge of the disorder, their comfort level in treating those with the condition and their need for training and resources.
Of 922 providers surveyed, 77 percent rated their ability to treat patients on the spectrum as poor or fair. While more that 90 percent of the providers said they would investigate the possibility of autism in patients with limited eye contact, most under-reported the number of people on the autism spectrum who were actually under their care. In addition, only 13 percent of providers indicated that they had adequate tools or referral resources to appropriately accommodate those with autism.
To better understand the providers’ responses, follow-up interviews were conducted with nine primary care physicians. The researchers found that the majority had received limited or no autism training in medical school or during their residencies. All of the providers indicated a need for more education and improvements in the transition from pediatric care providers to adult medicine for those on the autism spectrum.
The preparation of healthcare providers is a pressing issue as an increasing number of individuals with autism are expected to enter adulthood in the coming years. Further research is urgently needed to study the transition from pediatric to adult healthcare and identify strategies that will lead to better medical care for adults on the autism spectrum.

Thursday, July 9, 2015

Sensory Processing and Eating Problems in Autism

Atypical or unusual sensory responses are common in children with autism spectrum disorder (ASD) and often one of the earliest indicators of autism in childhood. A large percentage of children with ASD (78 to 90%) have sensory processing problems. Sensory issues are now included in the DSM-5 symptom criteria for restricted, repetitive patterns of behavior, interests, or activities (RRBs). These are mostly problems of sensory modulation expressed as hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment. 
When present, sensory problems may interfere with performance in many developmental and functional domains across home and school contexts, including daily living activities such as eating. Research suggests that extreme reactions or rituals involving taste, smell, texture, or appearance of food or excessive food restrictions are fairly common and may be a presenting feature of ASD. This includes “selective” or “picky eating,” which is defined as eating a limited variety of food and refusal to eat or taste new foods.
A study published in the open access journal, Autism Research and Treatment, examined the relationship between sensory processing and eating problems in children with ASD. A total of 95 Children with a diagnosis of autism, pervasive developmental disorder not otherwise specified (PDD-NOS), or Asperger syndrome, aged 3–10 years, were included in the study. They had at least one other associated condition; the most common being attention deficit disorder (23%), hyperactivity (22%), and intellectual disability (23%). Parents completed two questionnaires: (a) the Eating Profile, which was developed by clinicians and focuses on developmental eating milestones, mealtime behaviors of the child, such as eating autonomy and impact on the daily life of the family and (b) the Short Sensory Profile (SSP), a standardized questionnaire consisting of 38 items that help clinicians and researchers to quickly identify children with sensory processing issues (e.g.., typical response, probable difference, or definite difference).
The results indicated that 65 percent of children in the study showed a definite difference and 21 percent a probable difference in sensory processing on the total score of the Short Sensory Profile. Overall, children with “definite” sensory problems had significantly more eating problems than those with “typical” performance. Children with tactile sensitivity, taste/smell sensitivities, as well as visual/auditory sensitivities had significantly more eating problems than children with typical performance. For the total score of the SSP and for three sections (taste/smell sensitivity; auditory filtering; visual/auditory sensitivity), having a definite problem was significantly associated with a greater number of eating problems as measured by the Eating Profile. Although not statistically significant, there was a tendency for tactile sensitivity to be associated with the number of eating problems. These results could not be explained by age, sex, intellectual disability, attention deficit disorder, or hyperactivity.
The results of the study suggest that certain sensory modalities may influence the number of eating problems more than others. For example, children who were classified in the “definite difference” category on “tactile sensitivity” showed problems with the social behaviors at mealtime, as well as having unusual food preferences with respect to commercial brands, specific recipes, color, texture, or temperature of the food. These findings support an association of tactile defensiveness and food selectivity in children with ASD. Exploration through touching is a preliminary step to the introduction of new foods in young children. Children showing sensory defensiveness might be less inclined to explore foods with their hands. Others may have difficulties with the feel of utensils, the close presence of other children, or the routine clean-up after a meal.
Children with taste and/or smell sensitivity issues had mealtime problems. Similar to tactile sensitivity, they demonstrated problematic mealtime behaviors, but even more pronounced food preferences. This affected the eating autonomy more than tactile sensitivity, primarily in eating without assistance and using eating utensils, such as a fork. Auditory filtering affected these behaviors to the same extent as taste/smell sensitivities. This confirms the notion that eating is a complex multisensory experience.
A significant association was also found between visual/auditory sensitivity and the number of eating problems. Mealtimes can indeed be noisy during the preparation of food, including the manipulation of utensils and ongoing conversations. Even the sound of their own chewing can upset some highly sensitive children. Whether at school, or in child care, the noise level is usually above the one experienced in a child’s home. Likewise, children with visual sensitivities may react more to the visual stimuli of foods which may evoke unpleasant memories of their taste or texture. In typically developing children the visual exploration of food may actually facilitate the expectation of their taste/texture and thereby ease the acceptance of new foods.
Because sensory hyper- and hyporesponsiveness may be observable in infancy, these findings have implications for early detection and intervention and suggest that children with ASD may benefit from timely interventions focusing on the sensory components of eating. Although it remains to be determined how these issues might be specifically addressed in therapy, the frequency and severity of eating problems perceived by parents highlight the need for systematic evaluation of this daily living activity in combination with the sensory processing issues associated with food preferences and their effect on adaptive functioning (e.g., daily living skills). Consequently, an examination of mealtime behaviors might be included as part of the diagnostic assessment, including a sensory profile, in order to provide guidance to caregivers and parents.
Although therapeutic interventions to enhance sensory processing functions are popular in the treatment of ASD, the efficacy of these treatments is mixed and continues to be debated among researchers. Nevertheless, best practice guidelines indicate that when indicated, treatment programs for children with ASD should integrate an appropriately structured physical and sensory milieu in order to accommodate any unique sensory processing challenges. Of course, all interventions and treatments should be based on sound theoretical constructs, robust methodologies, and empirical studies of effectiveness. Different approaches to intervention have been found to be effective for children with autism, and no comparative research has been conducted that demonstrates one approach is superior to another. The selection of specific interventions should be based on goals developed from a comprehensive assessment of each child’s unique needs and family preferences. A more detailed discussion of assessment domains (e.g. communication, social, RRBs, sensory, academic) can be found in A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Geneviève Nadon, Debbie Ehrmann Feldman, Winnie Dunn, and Erika Gisel, “Association of Sensory Processing and Eating Problems in Children with Autism Spectrum Disorders,” Autism Research and Treatment, vol. 2011, Article ID 541926, 8 pages, 2011. doi:10.1155/2011/541926

Wednesday, July 1, 2015

Video Game Use and Problem Behaviors on the Autism Spectrum

Research indicates that children with autism spectrum disorders (ASD) often have strong preferences for screen-based media, particularly video games. Although a large body of research has demonstrated a clear effect of both video game content and genre on behavior problems among typically developing children and adolescents, the relationship between these variables has not been previously examined among children with ASD. A recent study examined the relationships between aspects of video game use and problem behaviors among a sample of 169 boys (ages 8–18) with ASD. Parents reported on their children's behavioral functioning and video game habits and preferences, including the average number of hours spent playing video games per day, preferred game types (genres), and problematic (e.g., addictive) video game play patterns.  
 The results indicated that amount of game play alone (an average of 2.4 hours a day) was not associated with problem behaviors. Rather, the most reliable predictors of problem behaviors, even when controlling for age and amount of time spent playing video games, were video game genre and problematic, or addictive, qualities of play. Specifically, significant positive relationships were found between problematic video games use and both inattention and oppositional symptoms. Boys who played Role-Playing (genre) games had higher levels of both problematic game use and oppositional behavior. Interestingly, however, hyperactivity was not significantly associated with either problematic video game use or video game genre. Lastly, educational and sports games predicted less oppositional behavior. 
The results of this study are consistent, in part, with findings from the general population. For example, the significant association between problematic video game play, inattention, and oppositional behavior reported in the study is similar to those reported in adolescents and adults without ASD. The finding that Role-Playing games were highly associated with problematic video game play and externalizing problem behavior is also consistent with previous research among individuals without ASD

This study underlines the clinical importance of examining video game use patterns among children with ASD, and points to a need for future experimental and longitudinal research in this area. For example, Role-Playing games may contribute to an even greater potential for problematic game use patterns among children with ASD, given their particular game-design features. Since children with ASD tend to engage in restricted and repetitive behaviors (RRBs), they might be at higher risk for developing addictive game play patterns. Preoccupation with video games and trouble disengaging from them may serve as antecedents for disruptive behavior, as has been anecdotally reported among other children. It appears that for children with ASD, the potential for preoccupation represents a key game play quality that relates closely with the occurrence of problem behaviors. Future research in this area is critical in order to inform video game use recommendations for both parents and clinicians. As emerging research investigates the effectiveness of video-game based interventions for improving functional outcomes, it will be equally important to understand the mechanisms and nature of problematic aspects of game play among children with ASD.
Mazurek, M.O. & Engelhardt, C.R. (2013). Video game use and problem behaviors in boys with autism spectrum disorders. Research in Autism Spectrum Disorders, 7, 316-324.

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