ASA's 37th National Conference on Autism Spectrum Disorders (July 13-15, 2006)

• Audio
• Recorded Presentation

By the end of the program, attendees should be able to: 1. Understand the role of stress in the lives of persons with autism, and various ways for measuring the stress response. 2. Discuss the preliminary research conducted on the effects of dextromethorphan in persons with autism. 3. Better identify signs of ritual behavior or behavioral rigidity in persons with autism and the related research on Exposure Response Prevention therapy.

1) Cardiovascular Assessment of Arousal in Persons with Autism Spectrum Disorders. Presenter: Matthew S. Goodwin, M.A.

(Additional authors: June Groden, Wayne Velicer, Grace Baron, Stephan Hofman, Gerald Groden)

It has been suggested that behavioral and neurophysiological factors implicated in Autism Spectrum Disorders (ASD) can contribute to arousal modulation problems that interfere with this population's ability to attend to, process, and interact with the environment. Despite these hypothesized links, there is a lack of single subject research that directly assesses arousal responses to novel stimuli or social situations in this population. The current presentation reports on an experimental study using a wireless heart rate monitor to compare arousal responses to potentially stressful events in five persons with ASD and five age- and sex-matched typically developing individuals. All of the participants were found to tolerate the wireless monitor and heart rate proved to be a measure sensitive enough to capture arousal responses. It was hypothesized that the group with ASD would show significant cardiovascular responses to a greater number of environmental stressors than the typically developing control group. However, results revealed just the opposite. The group with ASD showed significant heart rate responses only 22% of the time compared to the typically developing group who showed significant heart rate responses 60% of the time. Also, on average, the participants with ASD had mean heart rate responses 20 bpm higher during baseline and nearly every potentially stressful situation compared to the typically developing group. Interpretation of these results and considerations for future assessments that employ wireless heart rate monitors as a direct measure of arousal in persons with ASD will be discussed.

2) A Placebo Double-Blind Pilot Study of Dextromethorphan for Problematic Behaviors in Children with Autism. Presenter: Cooper Woodard, Ph.D.

(Additional authors: June Groden, James Bodfish, Matthew Goodwin)

Dextromethorphan is an antitussive preparation with glutamate antagonist and neuroprotective properties that is an active ingredient in a number of over-the-counter cough medications. It is the d-isomer of the codeine analog levorphenol, has no analgesic or addictive properties, and does not act through opioid receptors. Although not indicated as a psychotropic agent, previous uncontrolled case reports have suggested that dextromethorphan may be effective in treating behavioral disorders in persons with neurodevelopmental disorders. We used a double-blind, placebo-controlled, ABAB design to examine the safety and efficacy of the glutamate antagonist dextromethorphan for the treatment of problematic behaviors and core symptoms of autism in eight children diagnosed with autism. All participants had increased levels of irritability at baseline as measured by the Aberrant Behavior Checklist (ABC), and demonstrated a wide variety of problematic behaviors.

None of the main effects on the rating scale data for treatment (dextromethorphan, placebo) or setting (school, home) were found to be significant. However, three of the eight participants showed a positive ABC response („d 25% reduction in subscale scores on the ABC), and two of the three responders also demonstrated significant reductions in directly observed behaviors during dextromethorphan treatment as compared to placebo. Each of the three responders had been identified as having a behavioral profile consistent with Attention-deficit Hyperactivity Disorder (ADHD) prior to the research study, or demonstrated behavioral problems often associated with ADHD. Mild improvements in the core symptoms of autism were seen in two of the three responders. Putative mechanisms to explain the effects on this subgroup of participants include the glutamate antagonistic properties of dextromethorphan, as a significant relationship between glutamate and ADHD has recently been suggested in a number of research projects. Further, this research suggests a novel treatment for a sub-group of persons with autism, supports the move away from °¥autism general' treatments, and offers preliminary support for a non-sedating medication that has very limited side-effects.

3) Rituals and behavioral rigidity in children with autism: Experimental analysis of a novel form of behavioral treatment. Presenter: James Bodfish, PhD.

(Additional authors: Cooper Woodard, June Groden, Matthew Goodwin, Meredith Phelps)

Autism is a severe neurodevelopmental disorder with few established forms of treatment. Selected medications are effective in diminishing the problematic behaviors associated with autism. A variety of behavioral interventions have been demonstrated to promote skill acquisition in persons with autism, and intensive behavioral instruction programs have been shown to be effective forms of early intervention to diminish social, communication, and adaptive behavioral deficits in at least a subset of cases. With few exceptions, little attention has been paid to the possibility that forms of behavioral therapy that are established for other childhood psychiatric disorders may have application to children with autism. Along these lines, autism shares several clinical characteristics with childhood OCD and so established treatments for OCD may be reasonable candidates in the search for potential new treatments for autism. With regard to medication treatment, the serotonin reuptake inhibitors which effectively treat childhood OCD are among the more effective medications used in the treatment of autism. To date, the efficacy of behavior therapies that are established treatments for childhood OCD has not been examined in children with autism. In this study we examined the efficacy of a form of behavioral therapy based on exposure-response prevention (ERP), a validated form of treatment for childhood OCD, as a treatment for behavioral rigidity in children with autism.

Behavioral rigidity encompasses several of the characteristics of autism including a restricted range of interests, insistence on sameness, difficulty with transitions, and adherence to ritualized patterns of behavior. In autism, behavioral rigidity presents as a set of associated problems for parents and teachers including: (1) a child's singular, ritualized focus on specific items or activities, (2) behavior problems that result when the parent or teacher attempts to limit these rituals, and (3) the child's poor compliance and engagement with alternative activities such as academic or self-care tasks. As such, the presence of behavioral rigidity would appear to have profound deleterious effect on behavioral, cognitive, and adaptive development in children with autism. For the present study, we designed a variant of ERP to address these aspects of behavioral rigidity in children with autism. The treatment consists of a block of 10 discrete trials. During each trial the child is: (1) allowed to engage in a highly preferred activity or ritual for 1 minute, (2) then switched from the ritual item to an academic task, and (3) then given hand-over-hand prompting and praise during a 1 minute period of academic task demands with the preferred/ritual item present. This is designed to simulate ritual blocking, transition from a preferred / ritual or activity to a nonpreferred activity, and compliance with academic training during exposure to the preferred / ritual item. We have examined this form of therapy in an experimental manner for a sample of 12 children with autism using a single-subject A (academic task baseline with therapist) - B (treatment with therapist) - A' (academic task baseline with parent) - B' (treatment with parent) treatment trial design. All sessions are videotaped and then coded for the occurrence of disruptive behavior, task engagement, social orientation and communication .

In 10 of the 12 children evaluated to date, the therapist treatment condition was associated with a significant decrease in child disruptive behavior coupled with an increase in task engagement behavior relative to the therapist baseline condition. Within session (trial-by-trial) analysis typically revealed a clear "extinction burst" with gradually increasing disruptive behavior associated with terminating the ritual activity over the first 3 - 4 trials, followed by a decrease in disruptive behavior across the remaining trials. Six of the 12 children evaluated also showed a pattern of increased social and communication behaviors during the treatment condition. These results (treatment-related improvements in disruptive, on-task, and social behaviors) were replicated in the parent conditions for all children who showed a response to therapist treatment. Overall these results suggest that ERP-based behavioral treatment for rigidity in autism can produce short-term behavioral changes under experimental conditions, and thus appears to warrant evaluation under more naturalistic conditions.

Supported by NICHD PHS Grant # HD30615