Psychology Today Blogs - Lindsay M. Oberman, Ph.D.

The use of TMS for ASD

Lindsay M. Oberman, Ph.D. — Sun, 21 Sep 2008 12:18:17 -0700

I haven't posted an entry in a while because I have been incredibly busy with collecting data for my studies. When thinking about what I was going to write about for this posting, I realized that I haven't really talked about my research, which is in and of itself arguably a controversial topic in autism. I am currently a research fellow at Beth Israel Deaconess Medical Center of Harvard University. My research involves the use of transcranial magnetic stimulation to explore and influence brain plasticity in adults and adolescents with autism spectrum disorders. Essentially, my goal is to understand the mechanism that developmentally are affected in individuals with ASD that leads to the behavioral symptoms.

We believe that the mechanisms of plasticity (essentially how the brain changes in response to experience) is abnormally high in individuals with ASD. We use transcranial magnetic stimulation to induce a "change" to the brain and measure how it influences responses following this change. Transcranial magnetic stimulation is a technique like none other. It is capable of targeting a small (about 1-2 cubic centimeter) section of brain and either enhance the functioning or reduce the functioning of that section for a period of time. It is noninvasive and only has very limited risk of side effects. It is an extremely powerful tool for a researcher to be able to manipulate the functioning of a specific area of the brain and track the effect of this change over time. So far we have done some amazing things. We have found evidence that we can improve the functioning of the mirror neuron system and some communication skills following repetitive application of TMS and we can explore what is leading to the functional brain changes present in individuals with ASD.

Though TMS has the potential to be an invaluable research tool and potentially the source for novel therapeutic interventions, many are afraid of TMS. It is somewhat scary to think that we have the capability of changing the functioning of the brain for the better or for the worse, but I think it is only scary because of the direct connection. In essence this is the same thing that drugs do (changing the firing of the neurons in the brain), but in an arguably indirect way. Essentially, TMS takes advantage of the fact that the brain functions via electrical impulses and creates a focused fluctuating magnetic field which changes the firing of the neurons directly. Fortunately and I suppose unfortunately (depending on your perspective) the changes that are induced by TMS are not permanent. Typically sessions of TMS (which last between 1-30 minutes) will lead to changes on the order of minutes to several days. So, it's potential as a therapeutic intervention is limited by the participant's willingness to come back for "maintenance stimulation sessions," but it certainly has a great potential for researchers interested in seeing how the brain responds to stimulation in different regions.

I look forward to your questions and comments on TMS and how we may be able to learn about ASD by utilizing this technique.

Neurodiversity: Does ASD need treatment or does society need to accept autism as an "alternative way of being?"

Lindsay M. Oberman, Ph.D. — Wed, 02 Jul 2008 12:36:08 -0700

A friend of mine recently sent me an article from New York Magazine that discusses the neurodiversity movement, which believes that society should accept autism as "another way of wiring the brain." This is a topic that I am often faced with as a researcher trying to understand the neural basis of autism with the long-term goal of developing more effective treatments. Here is the ethical dilemma...

Currently, autism spectrum disorders are lumped into one category. Whether this is appropriate or not is topic for another entry, but does create a circular problem in that we recruit participants for our studies attempting to understand the neural basis of ASD based on a behavioral diagnosis. However, given the variety of behavioral symptoms across the spectrum, it is possible and in fact probable that the brain basis of Asperger's Disorder is different from that of lower-functioning autism. Additionally, though few would argue that the population that would benefit most from the research is children who have severe impairments, there are many ethical and practical reasons why these individuals are often excluded from studies.

Ethical Issues:

1. Consent. Since 1976 Informed Consent has been a requirement of all ethical research studies. This means that the participant has to be given enough information about the procedures and risks in the study in order to make an informed decision of whether they wish to participate. These consent documents have to be written in language that is comprehensible to the participant based on their age and reading comprehension level. Finally, the participant himself (or herself) has to give voluntary consent free of coercion or undue influence, meaning a parent or guardian's consent is not sufficient.

Thus, it is often difficult to create documents that describe the research procedures in a way that would ensure that the participant is giving voluntary informed consent.

2. Children and people with disabilities are protected populations. In general this means that according to the National Commission for the Protection of Human Subjects these individuals can only be involved in research studies if they are the only population that can be used for the study, the study poses minimal risk and has a strong benefit directly to the individual.

Therefore, it is extremely complicated and difficult to get approval for studies with these populations as again ASD is currently thought of as one group of individuals.

Practical Issues:

1. Often times research requires the person to pay attention to a task. Do a task for an extended period of time. Or do a task that requires a certain degree of cognitive skill. These requirements often makes it practically difficult to include lower-functioning children in these studies.

I realize that I have somewhat digressed from my original topic of neurodiversity, so I will get back on topic. Do higher functioning people need to be "fixed" or should society accept them for who they are? My two cents...

We all have strengths and weaknesses and hope to be appreciated for our strengths. I often give the example that I am tone deaf. I will never be an opera singer. Luckily for me, musical talent is not required on a day to day basis in my work and home life. It is not something that has limited my ability to have a successful career, make friends, or find a mate. Alternatively, the social and communicative deficits that define autism spectrum disorders create road blocks to these life goals. I have spoken with many individuals with Asperger's Syndrome (even very high functioning people) who feel unfulfilled because of their difficulties in finding a job commensurate with their intellectual level as a result of difficulty with the interview process, and difficulties in sustaining friendships and romantic relationship as a result of their difficulties with communication and empathy.

Thus, though I commend the neurodiversity community for promoting self-esteem in this population and encouraging acceptance by the general population, it is also quite distressing for researchers like myself who are working tirelessly and often thanklessly to understand and develop treatments for autism spectrum disorders to be told that their life's goal (which I believe to be quite noble) is being opposed by the exact population we are trying to help.

As a final thought, as research continues and we get closer to a "cure" for autism there will certainly be an ethical dilemma of how to treat the deficits without loosing the savant abilities and creative thinking that is often present in conjunction with the social and communicative deficits. We certainly would not want to deny the world of people like Bill Gates and Albert Einstein.

Just my two cents. I look forward to your opinions on the topic.

Do Casein Free and Gluten Free Diets really work?

Lindsay M. Oberman, Ph.D. — Sun, 25 May 2008 14:01:53 -0700

Many parents of children with autism choose to restrict their child's diet to eliminate Gluten (wheat protein) and Casein (milk protein). Claims have also been made that once a child has been put on this restrictive diet, their autism has been "cured", so is there any truth to this?

Well, first, let me state that unlike other "alternative treatments" for autism, if the parent ensures that the child still gets adequate nutrition, restricting gluten or casein from the diet (as far as I know) does not cause any significant risk or harm to the child. But does it help?

The jury is still out. To my knowledge, there have only been two controlled studies investigating the effect of this type of diet on children with autism. The first was a small study that did find fewer "autistic behaviors" in children on the gluten and casein free diet, however, one major criticism of this study was that it was only a single blind study, meaning the parents knew whether their children were on the GFCF diet or not, and this information may have influenced their reports. Another more recent study that was double blind found no significant difference between the group with the GFCF diet and another group without this diet.

So, what should parents do? In my opinion, this diet could help with digestive problems that some children with ASD might have, and if the child is uncomfortable because of the digestive problems, this could be contributing to their behavioral symptoms. So, if you believe that your child (as some children with ASD) has trouble digesting certain foods, and there is a way to eliminate this food without any harm to the nutrition of your child, it may be worth a try. Also, parent should be smart, read up on the topic, and realize that this type of diet is extremely hard to diligently stick to and can get quite expensive.

In the end, do I believe this diet cures autism? No. But could it help? Maybe. And could it harm? Assuming your child gets enough calcium, vitamin D, and other nutrition from the rest of their diet, as far as I know, this diet does not have detrimental effects.

As usual, I am open to any comments you have regarding this or any other topic relating to autism spectrum disorders.

Do Mercury or Vaccines cause Autism?

Lindsay M. Oberman, Ph.D. — Tue, 13 May 2008 11:36:12 -0700

Very hot and very controversial topic in the autism literature is whether mercury or vaccines or mercury in vaccines cause autism. In my opinion, No. Now a different question is whether mercury or vaccines are harmful to certain children either in utero or later in development. To this, my answer is maybe. Let's first look at the statements commonly used to support the belief that vaccines cause autism.

1. My child seemed ok, then shortly after he/she received a number of vaccinations (age 1.5-2 years old) he began showing the behavioral signs of autism.
2. There have been studies linking vaccines to autism.
3. Jenny McCarthy said that her son was "vaccine injured"
4. A case was won in Federal Court to a family whose daughter developed autism after receiving vaccines.

Ok, now I will try to discuss each point in turn.

1. To my knowledge there is not any study that has been conducted in a way that would be able to conclude that autism is CAUSED by vaccines. So, what is the difference between saying vaccines caused autism and there is a relationship between vaccines and autism. It is not just semantics! Most of the studies that have been done, including a recent study entitled "Proximity to point sources of environmental mercury release as a predictor of autism prevalence" (which by the way did not look at vaccines, but rather mercury in the air) are what are called correllational studies. Meaning as one factor goes up the other goes up. But this does not mean that the first factor causes the second. My favorite example of this is the relationship between foot size and vocabulary. In childhood as food size increases so does vocabulary. This does not mean that the increasing foot size has anything to do with vocabulary, just that they both increase at the same rate. There are many examples of this. So just because the two things occur at the same time, does not mean that one caused the other. There have been several studies over the years finding contradictory findings. The truth is if your goal is to find studies that support the vaccine theory...you will. If your goal is to find studies that reject the vaccine theory, you will. All studies have flaws and if you are provaccine, you will find flaws with the antivaccine studies and vice versa. Please see http://www.sciencebasedmedicine.org/?p=111 for a critical review of the above study. In my opinion, vaccines do not cause autism. We find differences in brain development in children at risk for autism well before their 2nd birthday when the behavioral symptoms begin to appear and when the vaccines are thought to be "causing" the symptoms. However, could vaccines (or something in the vaccines) cause harm to a developing brain, maybe in some cases. Please note, this is only my opinion, there is no conclusive data on this. But we also need to consider the benefit of vaccination and the prevention of other deadly diseases. In that vein, PLEASE vaccinate your children. But you can ask the doctor to spread out the vaccinations over time so that the baby's little body does not get bombarded with multiple things for their immune system to process at the same time. Many pediatricians will accommodate.
2. Please see above.
3. Unfortunately Jenny McCarthy, and other celebrities are able to more easily get on TV and to get their message to the general public. I on the other hand have yet to be invited to be on Oprah. This is a problem for scientists. We tend to publish our studies in journals that are not accessible to the public and present new data at conferences that are only open to those with membership to specific scientific societies. On the other hand, celebrities have much more of a platform to promote their beliefs to the general public. This does not, however, mean that their beliefs are any more justified than the scientists. For the reasons stated above, amongst others, the scientific method is used by researchers to try to objectively find causal relationships between factors. So I am sorry to let Jenny McCarthy know that despite her own beliefs (and statements on Larry King Live) "parents' anecdotal information IS NOT science-based information."
4. This is a very specific case in which the child was not healthy prior to the vaccines. What the documents of the case actually read are "In sum, DVIC has concluded that the facts of this case meet the statutory criteria for demonstrating that the vaccinations CHILD received on July 19, 2000, significantly aggravated an underlying mitochondrial disorder, which predisposed her to deficits in cellular energy metabolism, and manifested as a regressive encephalopathy with features of autism spectrum disorder." Thus, this would not apply to most children with autism who do not have this underlying mitochondrial disorder. Also, the fact that a legal case found that there was statutory evidence for compensation, is again, not scientific evidence for a connection.

The take home message here, is that we DO NOT KNOW what causes autism. And if you believe it is bad parenting, you will find evidence for that theory, if you believe it is genetics, you will find evidence for that theory and finally if you believe it is vaccines you too will find evidence for that theory. But please take this "evidence" with very critical eyes. I am very open to hearing your opinions!

Has the prevalence of ASD actually increased over the past several years, or are we just better at diagnosing it?

Lindsay M. Oberman, Ph.D. — Sun, 04 May 2008 17:20:26 -0700

After telling people that I am a researcher studying autism, I am often asked the above question. Unfortunately, there is no straight answer for this question. If one goes back in the literature, it is true that for decades (several studies conducted from 1966-late 1990's) the prevalence estimates were on the order of 4-5:10,000 while studies conducted over the past decade have estimated the prevalence on the order of 2-6:1,000 with one study showing as high as 12:1,000. So, why this difference? Is it a real increase in the prevalence of the disorder or something else?

My opinion, and I stress this is only an opinion is that it is likely a combination of several factors in no specific order.

1. We are certainly more aware of the specific deficits defining ASD now as compared to 10 or 20 years ago. Children who previously may have been given a general "Mental Retardation" diagnosis (on the lower end of the spectrum) or just considered socially awkward and not given a diagnosis are now recognized and being correctly diagnosed as having autism and Asperger's Syndrome.
2. The diagnostic criteria for Autism and Autism Spectrum Disorders have changed over the years with Asperger's Disorder only being included in the DSM in 1994.
3. There is now less of a stigma to being diagnosed with autism. In fact if the child has a diagnosis, they are likely to receive extra services from the state including educational services and therapy. Given this change in the stigmatization and opportunity for benefits, parents are perhaps more likely to actively request a diagnosis.
4. Children growing up now are exposed to many more environmental stimulation than children in the previous decades. The influence of the environment on neural development is clear and changes in the environment are much more likely to cause changes in prevalence than changes in genetic mutation over the course of several years.
5. ...?

So, the answer is, yes there seems to be an increase in prevalence over the past several years. But the cause of this apparent increase is still unclear. Whatever the cause, if approximately 24,000 children (just in the U.S. alone) are being diagnosed with a disorder, this is clearly a major public health concern that needs to be studied in an effort to understand the disorder, establish the necessary services for both the children and adults with ASD, and hopefully curtail the current epidemic.

Let Me Introduce Myself

Lindsay M. Oberman, Ph.D. — Tue, 22 Apr 2008 17:53:36 -0700

I first want to introduce myself. My name is Dr. Lindsay Oberman. I am a researcher in Boston Massachusetts and am currently working at Beth Israel Deaconess Medical Center of Harvard Medical School. My research over the past several years has focused on the brain basis of autism spectrum disorders. If you are interested in reading about some of my research I invite you to visit my website where I have posted some of my recent papers that are available for downloading. My website is tmslab.org/faculty/loberman. I can also be reached by e-mail at loberman@bidmc.harvard.edu.

Now a few small caveats. 1. I will be posting topics for the blog that are intentionally somewhat controversial. My opinions on these topics are just that, and should be taken as such. 2. The most truthful answer to most of the topics I will post is "We don't know" but I will try to share some of the research that I am aware of that speaks to the topic. 3. Often times I will speak of autism spectrum disorders, or ASD. Though I acknowledge that autism is qualitatively different than Asperger's Syndrome (a topic that I look forward to discussing in the future) for the purposes of certain topics, I will be speaking of them as a spectrum of one disorder. 4. I am neither a clinician, nor an expert on every child with autism. I cannot diagnose your child nor recommend the best treatment for any given child or adult with ASD. Each individual's diagnosis and treatment plan should be discussed with a local clinician trained in working with individuals with autism spectrum disorders.

That being said, I invite you to share your thoughts, stories, and questions with the blog and look forward to a lively discussion on topics related to autism spectrum disorders.

Topic 1.

Are Autism Spectrum Disorders really just varying degrees of the same disorder or could Asperger's Disorder be a result of a completely different etiology than autism?

Autism Spectrum Disorders are currently categorized under the Diagnostic and Statistical Manual... as mental disorders. As such they are diagnosed based on behavioral symptoms. Though it is appreciated that atypical behavior (and for that matter behavior in general) is a result of activity in the brain (no one will claim that autism is a result of a problem in your big toe!) the exact neurological origin of autism is not currently known. There are certainly more theories out there than one can count, but the data is extremely messy and there are very few markers that all or even most individuals with ASD show.

Why is this? Well, let me give an analogy. Imagine instead of ASD we are talking about a fictitious disorder that I will call "Can't Walk Disorder." Imagine your child is around 12-18 months and you notice that most of his playmates are beginning to walk, but your child does not. You bring the child to the doctor and he asks you a list of questions "Can he walk if his weight is supported?" "Can he move his legs in any way" "Can he crawl?" You answer "No" to all the questions and the doctor says "Well, your child meets the criteria for ‘Can't Walk Disorder.' The current treatment for this is crutches. They will help your child function better in the world and compensate for his deficits." Though this treatment is better than nothing, it treats the symptoms, not the fundamental biological basis of the problem. It is possible in this example that the child broke his legs, or perhaps he is paralyzed, or perhaps he has a muscular problem.

Research into the brain basis of autism spectrum disorders is thus somewhat of a circular problem. We define our inclusion criteria for our study based on a behavioral diagnosis of ASD and try to find a biological marker that all or most participants share. However, if there is not a singular etiology that leads to the behavioral disorder, then looking for a singular marker may be fruitless if in fact we have a heterogeneous group. So, why even try? Well, I believe that crutches aren't good enough. I feel that in order to effectively treat (and perhaps some day cure) autism spectrum disorders, then one needs to identify the underlying cause.

So, what do I think? I have known many children and adults with autism and Asperger's Syndrome and though each is unique, I find not simply quantitative, but rather qualitative differences in their behaviors. For example while some individuals with autism do not interact socially, while individuals with Asperger's Syndrome tend to make social overtures, but these overtures are often scripted, inappropriate or narcissistic in nature (relating to the individual's specific interests). As with many of the topics I will discuss in this blog, the truth is we don't know, but if I had to make a guess, I would predict that the underlying cause of ASD will be as complex as the disorder itself.