Autism The Brain,thinking And Behavior Executive Function

Autism: the Brain, Thinking and Behavior Executive Function Mary Jo Lang, Ph.D., A.B.P.N. Beacon Day School Orange, California

Autism Defined Autism is a brain development disorder that impairs social interaction and communication, and causes restricted and repetitive behavior, all starting before a child is three years old. This set of signs distinguishes autism from milder autism spectrum disorders (ASD) Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Autism—According to the NIH • Autism is characterized by three distinctive behaviors.  – difficulties with social interaction – problems with verbal and nonverbal communication – repetitive behaviors or narrow, obsessive interests. 

  • These behaviors can range in impact from mild to disabling.  Autism varies widely in its severity and symptoms and may go Jo Lang, Ph.D., A.B.P.N.unrecognized, Mary especially in mildly affected Beacon Day School-Orange, California debilitating children or when more

Systemic Approach to Understanding the Brain In order to understand an individual with Autism, it is necessary to understand him or her as an individual from a systems approach: Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

• How do mind and body function?

Breaks in the System • It is becoming clear that the normal trajectory of neurodevelopment is altered in autism. Abnormalities in brain growth, neuronal patterning and cortical connectivity are often seen. • Changes to the structure and function of synapses and dendrites have also been strongly suggested in the pathology of autism . • Finally, environmental factors are likely to interact with the underlying genetic profile, and foster the clinical heterogeneity seen in autism spectrum disorders. Mary Jo Lang, Ph.D., A.B.P.N.•

Beacon Day School-Orange, California *reference: Pardo CA, CA, Eberhart CG, CG, “The neurobiology of autism,” Brain Pathol. 2007

Course Objectives: Part I • Understanding the Body, the Brain and the Environment as a System • Understanding How the Brain Works • Identify Factors which Influence the Brain, Thinking and Behavior (intro to framework) Part II • Explore Brain Behavior with Regard to Attention, Memory, Language, Visual-Spatial Functioning, Executive Function and Emotional Functioning Part III • Examine a Framework within which Individuals with Autism can Maintain Maximum Independence and Quality of Life Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

PART I—Objectives • Understanding the Body, the Brain and the Environment as a System • Understanding How the Brain Works • Identifying Factors that Influence the Brain, Thinking and Behavior (intro to framework) Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Systems Theory A system is greater than the sum of its parts. Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Systems Theory— Common Elements:                            

input output throughput (or process) feedback control environment goal Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Systems Theory • Open--capable of growth, development & adaptation. Interaction occurs within the environment. • Closed--relationships among system components are set and inflexible; no interaction with the environment Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Human Body Systems System

Location

Nervous System Brain and Nerves Skeletal System Bones and Skull Muscular System Skeletal, Cardiac and Smooth Muscles Endocrine System Glands and Hormones Cardiovascular System Heart and Blood Lymphatic and Immune Systems Lymphocytes and Macrophages Respiratory System Lungs and Airways Digestive System Mouth and Gastrointestinal Tract Urinary System Kidneys and Bladder Reproductive System Male and Female Organs Integumenary System Hair, Skin and Nails Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

The Nervous System • The nervous system is the most complex of all the body’s systems.  • Together with the endocrine system it controls everything the

Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

The Nervous System • The nervous system reaches almost every part of the body, from muscles and sense organs to the insides of teeth and bones. • The body has more than 80 major nerves, and each one can obtain more than a million neurons.

Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

The Nervous System Peripheral Nervous System Divisions: • The Sensory Division gathers information from sensors to update the CNS about events occurring inside and outside the body. (Autistic children may have sensory integration issues, such as hearing, vision, etc.) • The Somatic Division carries instructions to skeletal muscles, enabling the body to respond under conscious control to outside events. (Skeletal-motor issues, muscule/skeletal, sensory-seeking, etc.) • The Automatomic Division delivers messages to the body’s internal organs to Mary Jo Lang, Ph.D., A.B.P.N.control their activities. (Intestinal issue, Beacon Day School-Orange, incapricous, bed wetting, etc.) California

The Nervous System The Spinal Cord • How does information travel to and from the periphery and respond to cues from the brain? Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

The Nervous System— The Brain • Evidence firmly links autism with abnormalities in the brain stem, the cerebellum, the medial temporal lobe, and the frontal lobe. (Reference: Penn, HE; Clinical-

Developmental Psychology Program, York University, Toronto, Ontario; “Neurobiological correlates of autism: a review ofMary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, recent research,” Child California Neuropsychol. 2006 Feb;12(1):57-

Systems Theory—The Senses Sensory Systems— all are affected by Autism  Taste Smell Hearing Sight Touch                

Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

The Digestive System • The job of the digestive system is to turn food into fuel that the body can use for energy, growth and repair. • The body processes carbohydrates, fats and proteins into fuels, and expels any undigested waste materials. Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

The Digestive System Functions: Ingestion Propulsion Mechanical Digestion Chemical Digestion Absorption Egestion Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

The Digestive System • The gastrointestinal tract is a long tube-like system called the alimentary canal. • It is divided into – The esophagus and stomach – The small and large intestines Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

The Digestive System • Accessory organs are attached to the digestive tract: – – – –

Teeth, tongue and salivary glands Liver Gallbladder Pancreas

– Cells lining the canal last only three to four days—due to excessive use, and constantly rebuild. Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

The Digestive System • Food on the Move – Muscles power the Digestive System, which pushes food through the system at varying speeds. – Food is made up of nutrients, most of with are complex molecules that the body does not absorb. These molecules must be broken down into simpler chemicals byMaryenzymes —which cut up Jo Lang, Ph.D., A.B.P.N.Day School-Orange, molecules atBeacon specific California points.

The Digestive System • Surveys published in the gastroenterology literature have stated that gastrointestinal problems, such as chronic constipation or diarrhea, occur in 46% to 85% of children with ASD. • In a recent cross-sectional study that used structured interviews and matched control groups, a lifetime history of gastrointestinal symptoms (including abnormal stool pattern, frequent constipation, frequent vomiting, and frequent abdominal pain) was elicited in 70% of the children with ASDs, compared with 42% of the children with other developmental disabilities (P = .03) and 28% of the children without developmental disabilities (P < .001). •

Reference: Scott M. Myers, MD, Chris Plauché Johnson, MD, MEd the Council on Children Mary Lang, Ph.D., With Disabilities, “Management of Jo Children WithA.B.P.N.Autism Spectrum Disorders,” PEDIATRICS Vol. 120 No. 5 November 2007, pp. 1162-1182 Beacon Day School-Orange, California

The Digestive System Gluten-Free, Casein-Free Diets are advocated by some practitioners. Their Theories are unproven, but are based on: • The human digestive system did not evolve on a diet containing large quantities of wheat and dairy products. Guten (in wheat, rye, barley and possible oats) and casein (dairy) can cause problems: – They are common food allergens. – Certain peptides can bind to opioid-receptors in the brain.

• Causing sleepiness, giddiness, inattention and aggression. •

Mary Jo Lang, Ph.D., A.B.P.N.-

Reference: Adams, James B., PhD, “summary of Biomedical Treatments for Autism,” ARI Publication 40; Beacon Day School-Orange, April, 2007.

California

The Immune System The human body defends itself from disease and infection with its Immune System. People with autism often suffer from compromised immune systems. Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

The Immune System Antibodies (immunoglobulins) are found in blood, lymph and other tissue fluids. • These Y-shaped molecules have unique “arms” that are programmed to a specific antigen carried by specific pathogens. • The molecules can target Mary Jo Lang, Ph.D.,destruction. A.B.P.N.harmful pathogens for Beacon Day School-Orange, California

Part II—Objectives To Explore Brain Behavior with Respect to: • Memory • Language • Visual-Spatial Functioning • Attention • Executive Function, and • Emotional Functioning Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Brain-Behavior Relationships 1. 2. 3. 4. 5. 6.

Cognition Educational Achievement Adaptive Behavior Participation, Social Roles Health Context

Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Executive Function

Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Executive Skills • Skills that select and achieve goals or develop problem solutions. – – – –

Planning Organization Time Management Working Memory • The ability to hold information in mind while performing complex tasks.

– Metacognition • Observing how you problem solve (bird’s-eye view) Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Executive Skills • Skills that guide or modify behavior as one moves along the path. – Response Inhibition

• Think before you act

– Self-regulation of Affect • Managing emotions

– Task Initiation

• Begin a task without undue procrastination

– Flexibility

• Revise plans when obstacles arise

– Goal-directed Persistence

• Capacity or drive to follow through to the Mary Lang, Ph.D., A.B.P.N.completion of a Jogoal Beacon Day School-Orange, California

Executive Function • Parallel between brain development and the child’s ability to think, act, and feel. – Important in understanding how executive skills develop.

• Frontal brain systems make up the neurological base for executive skills. – Prefrontal cortex contains the executive skills. Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Prefrontal Brain Systems • Play a preeminent role in the relationship between brain structure and executive function. • Among the last to fully develop in late adolescence • Final, common pathway for managing information and behavior from other brain regions. Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Frontal Lobe Functions • As summarized by Hart and Jacobs (1993): – The frontal lobes decide what is worth attending to and what is worth doing. – The frontal lobe provides continuity and coherence to behavior across time. – The frontal lobes modulate affective and interpersonal behaviors so that drives are satisfied within the constraints of the internal and external environments. Mary Jo Lang, Ph.D., A.B.P.N.– The frontal lobes monitor, Beacon Day School-Orange, evaluate, and adjust. (pp. 2, 3) California

Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Developmental Tasks Requiring Executive Skills • Preschool Age – Run simple errands (e.g., “Get your shoes from the bedroom”). – Tidy bedroom or playroom with assistance. – Perform simple chores and self-help tasks with reminders (e.g., clear dishes from table, brush teeth, get dressed). – Inhibit behaviors: don’t touch a hot stove; don’t run into the street; don’t grab a toy from another Mary Jo Lang, Ph.D., A.B.P.N.-child; don’t hit, Beacon Day School-Orange, bite, push, etc. California

Developmental Tasks Continued • Kindergarten-Grade 2 – – – – – – –

Run errands (two to three step directions). Tidy bedroom or playroom Perform simple chores, self-help tasks; may need reminders (e.g., make bed). Bring papers to and from school. Complete homework assignments (20minute max. ) Decide how to spend money (allowance). Inhibit behaviors: follow safety rules, don’t swear, raise hand before speaking in class, keep hands to self. Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Developmental Tasks Continued

• Grades 3-5

– Run errands (may involve time delay or greater distance, such as going to a nearby store). – Tidy bedroom or playroom (may include vacuuming, dusting, etc.). – Perform chores that take 15-30 min. (e.g., clean up after dinner, rake leaves). – Bring books, papers, assignments to and from school – Keep track of belongings when away from home. – Complete homework assignments (1 hour max. ). – Plan simple school projects such as book reports. – Keep track of changing daily schedule. – Save money for desired objects, plan how to earn money. Mary Jo Lang, Ph.D., A.B.P.N.– Inhibit/self-regulate: Beacon Day School-Orange, behave when teacher is out California of the classroom; refrain from rude comments,

Developmental Tasks Continued • Grades 6-8

– Help out with chores around the home, including both daily responsibilities and occasional tasks (e.g., emptying dishwasher, raking leaves, shoveling snow); tasks may take 60-90 min. to complete. – Baby-sit younger siblings or for pay. – Use system for organizing schoolwork, including assignment book, notebooks, etc. – Follow complex social schedule involving changing teachers and changing schedules. – Plan and carry out long-term projects, including tasks to be accomplished and reasonable timeline to follow; may require planning multiple large projects simultaneously. – Plan time, including after school activities, homework, family responsibilities; estimate how long it takes to complete individual tasks and adjust schedule to fit. – Inhibit rule breaking the absence Mary Join Lang, Ph.D., A.B.P.N.- of visual authority. Beacon Day School-Orange, California

Developmental Tasks Continued • High School

– Manage schoolwork effectively on a day-to-day basis, including completing and handling assignments on time, studying for tests, creating and following timelines for long-term projects, and making adjustments in response to feedback from teachers and others (e.g., grades on tests, papers). – Establish and refine a long-term goal and make plans for meeting that goal. – Make good use of leisure time, including obtaining employment or pursuing recreational activities during the summer. – Inhibit reckless and dangerous behaviors (e.g., use of illegal substances, sexual acting out, shoplifting, or vandalism). Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Assessing Executive Skills

• Assessing executive skills in the context of a formal evaluation is difficult. Some examples: – Two critical executive skills are initiation and sustained attention. In standardized testing situations, the examiner cues the student to start and presents tasks that are necessarily brief in nature, thereby reducing the demand for sustained attention. – Standardized testing situations require the presence of an adult performing a monitoring function. With the tester Mary Jorole, Lang, Ph.D., A.B.P.N.performing this the student does not Beacon Day School-Orange, California have to monitor his or her own

Assessing Executive Skills • Continued… – In the context of a highly structured, if not ritualized, set of tasks, the need for planning and organization on the part of the student is reduced, if not in many cases eliminated. – Executive skills are most in demand in the face of complex, open-ended tasks requiring problem solving and creative or unique solutions. Standardized tests are designed to be easily scored with a catalog of right and wrong answers that are Mary Jo Lang, Ph.D., A.B.P.N.straightforward and invariant, again Beacon Day School-Orange, California minimizing demands on executive skills.

Assessing Executive Skills Continued • Absence of evidence is not evidence of absence. A child’s strong performance on a clinic measure of executive function does not necessarily mean that the same child applies good planning ability in the context of daily performance at home or at school. Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Informal Assessment Measures • Case History/Interview – How does the child manage homework and other chores and responsibilities at home? How organized is the child?

• Classroom Observations – Sets the stage for a clear definition of the executive skill as a specific behavior, points to the direction for intervention, and provides the gold standard for evaluating effectiveness.

• Work Samples – Tests, writing assignments, and agenda pages • Assess skills such as error monitoring, planning, and Mary Jo Lang, Ph.D., A.B.P.N.organization and yields ideas for interventions such Beacon Day School-Orange, as cue questions and templates. California

Behavior Checklists • Behavior Rating Inventory of Executive Functions • Brown ADD Scales- Adolescent Version • Comprehensive Behavior Rating Scale for Children • Child Behavior Checklist- Teacher Report Form Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Formal Assessment Measures • NEPSY • Porteus Mazes • Matching Familiar Figures Test • Trailmaking Tests • Wisconsin Card Sorting Test • Connors Continuous Performance Test-II • Delis-Kaplan Executive Function Scale • Cognitive Assessment System Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Behavioral Observations With Formal Assessment Measures • Self-Regulation • Response of • • • • •

Affect Inhibition • Planning/ Metacognition Prioritization Goal-Directed • Time Persistence Management Flexibility • Organization Sustained • Task Initiation Attention Working Memory Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Steps in Executive Skill Intervention Planning • Step 1: Collect assessment information from a variety of sources. • Step 2: Review data; list specific problem behaviors and connect them to the most appropriate executive skill domain. • Step 3: Select one executive skill domain for initial intervention and identify a specific behavioral goal. Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California

Steps Continued… • Step 4: Design the intervention, incorporating one or more of the following elements:

– Environmental supports or modifications that will be put in place to help support the development of the skill. – The specific skills the child will be taught and the procedure used to teach them. – What incentives will be used to help motivate the child to use or practice the skills.

• Step 5: evaluate intervention effectiveness by looking at each intervention component and answer the following questions: – – – –

Was the component put in place? Was it effective? Does it need to be continued? What is the plan for fading this component. Mary Jo Lang, Ph.D., A.B.P.N.Beacon Day School-Orange, California