Dr. Oswald's Corner

Periodically, Dr. Oswald shares his thoughts on the most recent research in autism.

There are indications that the emphasis on early diagnosis of autism spectrum disorder has produced important positive changes in screening and diagnostic practices. Universal autism screening leads to earlier referral for evaluation, earlier age of diagnosis, and earlier initiation of appropriate, autism-specific interventions (Valicenti-McDermott, 2016).

Along with these changes have come questions about how early it is possible to reliably detect and diagnose autism, including specific concerns about the impact of the DSM-5 definition on early identification (Barton et al., 2013; Christiansz et al., 2016)

The Toddler Module of the Autism Diagnostic Observation Schedule - 2nd Edition (ADOS-2) has shown considerable promise at helping clinicians make the diagnosis of autism spectrum disorder before age 30 months. However, even with the best tools available, there is continuing concern that some young children’s ASD diagnoses are missed, only to be picked up at a later evaluation.

A recent paper (Bacon et al., 2017) offer reflections on the state of the art, as well as new data further illuminating those concerns. Bacon and colleagues first summarize the literature supporting the following point:

“. . . during the first 12 months of life, babies who eventually develop ASD appear largely indistinguishable from those who do not: they exhibit similar levels of social engagement, babbling, and visual attention patterns. . . Then, between 12 and 24 months, reduced levels of social attention and social communication as well as increased repetitive behavior with objects emerges.” (p. 1)

A recent paper published in the Annual Review of Public Health (Lyall et al., 2017) offers a summary of the state of the science with respect to the epidemiology (i.e., the incidence, distribution, and possible control) of autism. This abstract quotes the main conclusions of that paper.

Onset of ASD symptoms typically occurs by age 3, although symptoms may not fully manifest until school age or later; symptoms can emerge between 6 and 18 months of age.

Common ASD-associated impairments include intellectual disability [currently estimated to occur in ∼30% of cases and historically estimated at ∼70%] and attention deficits (occurring in ∼30–40% of cases).

The conceptualization of ASD as a discrete phenotype is being increasingly questioned. The NIMH Research Domain Criteria initiative encourages researchers to focus on core behavioral and neurobiologic features that cross diagnostic categories.

PUBLIC HEALTH IMPACT

The annual total costs associated with ASD in the United States approach $250 billion

In an increasingly multicultural country, clinicians and educators in the US are often confronted with autism spectrum disorder in children from bilingual or multilingual families. A persistent concern has been raised as to whether the language development of children with ASD is further delayed or disrupted because of exposure to two (or more) languages in the home.

The November issue of the Journal of Child Psychology and Psychiatry includes a paper (Uljarevi et al., 2016) that addresses the question in a review of the empirical research on multilingualism and neurodevelopmental disorders. The focus of the review paper is not limited to ASD, but in this commentary we summarize the authors’ findings with respect to ASD only.

Uljarevi and colleagues located ten papers that reported on research regarding the language development of multilingual children with ASD (multiASD), compared to monolingual children with ASD (monoASD). Most of the studies examined the question in young (preschool-age) children. The authors report....

A recent report published on-line by Lancet (Pickles et al., 2016) maintains that a parent-mediated intervention for children with autism has produced the first “long-term symptom reduction after a randomized controlled trial of early intervention in autism spectrum disorder” (p. 1; on-line version). The follow-up study examined a range of outcomes for 121 children who participated in a randomized clinical trial of the Preschool Autism Communication Trial (PACT), conducted at three autism centers in the UK. PACT was compared to a group receiving treatment-as-usual. The PACT intervention was undertaken when the children were initially 24-59 months of age and the mean age of the children at the time of the follow-up study that served as the basis for the current report was 10.5 years.

The PACT intervention consisted of “biweekly 2 hour [one-to-one clinic sessions between therapist and parent with the child present] for 6 months followed by monthly booster sessions for 6 months (total 18). Between sessions, families were also asked to do 30 min. of daily home practice.” (Green et al., 2010; p. 2153) The content of the program targeted “core impairments in shared attention, communication, intentionality and pragmatics that are thought to underlie the abnormal developmental and language pathways of children with ASD.” (Green et al., 2010; Appendix, p. 4)

Transcranial magnetic stimulation (TMS) is a relatively recent technology that has been FDA-approved for the treatment of depression and migraine with aura. TMS uses a magnetic field to stimulate specific areas of the brain. In recent years, there has been interest in applying TMS to treat other conditions, including Autism Spectrum Disorder (ASD), on an experimental basis. The specific form of TMS that has been of most interest is called repetitive transcranial magnetic stimulation (rTMS)

The investigation of rTMS for people with ASD became more widely known following the 2016 publication of John Elder Robison’s account of his experience with the procedure. In his book, Switched On, Robison offers a fascinating story of the changes that he experienced following rTMS, including difference in what are thought to be core features of autism.

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About Dr. Oswald

Dr. Donald Oswald is the Director of Diagnostics and Research at Commonwealth Autism. Dr. Oswald is a licensed clinical psychologist with over 30 years of experience working with people with autism spectrum disorders. He obtained his PhD in clinical psychology in 1989 from Virginia Tech and completed a clinical internship at the Yale Child Study Center. Dr. Oswald has been active in teaching and research related to the diagnosis and treatment of individuals with autism spectrum disorders. For the past 20 years, he was on the faculty in the Department of Psychiatry at Virginia Commonwealth University. He currently directs the Commonwealth Autism Transdisciplinary Diagnostic Clinic and all training efforts to replicate the clinic model in communities across the Commonwealth.