New Frontiers in Language Restoration by Harry D. Schneider, MD

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6 10 12 Letters Polly’s Piece by Polly Tommey My Daughter, Hannah Poling by Terry Poling, RN, JD Springtime by Jordan Segal Orlando Hudson Interview by Polly Tommey Healing the Gut in Teenagers ...and Beyond by Pam Ferro, RN The Case is Not Closed on Vaccines & Autism by Robert J. Krakow, JD DIR/Floortime: Becoming more Matthew by Joshua D. Feder, MD The Science Behind Treatment Strategies by Elizabeth Mumper, MD Bibliography by Elizabeth Mumper, MD Recovering Mark by Cynthia Macluskie Mark Makes a Difference by Mark Macluskie Progress & Hope in Italy by Ornella Guadalupi Defeat Autism Now! by Karen Dana, Michelle Puopolo & Jim Small 50 60 18 20 64
What’s in this issue ...
New Frontiers in Language Restoration by Harry D. Schneider, MD New Jersey Rally for Conscientious Exemption to Vaccination by Teri Arranga Moving Toward a MultiTreatment Approach to Autism by Jonathan Alderson, EdM Open Your Eyes to Autism by Allison Edwards Treating the Common Cold & Flu by Kim Gould, RPh, MS Confessions of a Sibling of a Child with Autism by Amanda Hintz Worthwhile Causes... by Chantal Sicile-Kira Parallels between Dyslexia & Autism by Richard E. Frye, MD, PhD Vaccine Damage Denial & The British Press by Martin J. Walker Subscribe to The Autism File Successful Sensory Diets by Chris Vinceneux, OTR/L A Star and Smiles by Robin Shipman 96 101 Down Syndrome and Autism Part 1 by Laurette Janak Down Syndrome, Autism, Leukemia & Emily Part 2 by Laurette Janak Back Issues Getting Started with the Verbal Behavior Approach by Mary Lynch Barbera, RN, MSN, BCBA Autism on Stage by Valerie Paradiz, PhD & Danielle Ferrante How the Dramatic Arts Helped Me by Elijah Wapner It’s Time We Had A Talk -- About Talk by Marion Blank, PhD, & Mary Beth Cull Diary Social and Academic Inclusion through Accommodations and Modifications to Curriculum by Stephen Shore, EdD
107 108
78 81
128 130
41 44 45 46
91 92 94
132 Diet for Autism by Julie Matthews 136 Forcing Change: Autism Advocates’ Long To-Do-List by Laura Bono 140 Ask Chantal by Chantal Sicile-Kira 143 The Doctor Is IN
Scientific Advisory Board: Federico Balzola, MD; Mark Blaxill, MBA; Jeff Bradstreet, MD; Stephen Edelson, PhD; Wendy Edwards, MD; Sonja Hintz, RN; Julie Matthews, CNC; Lyn Redwood, RN; Harry Schneider, MD; Paul Shattock, OBE; Carol Stott, PhD; Anju Usman, MD; Andrew Wakefield, MD Editorial Advisory Board: Marion Blank, PhD; Becky Estepp, Talk About Curing Autism (TACA); Temple Grandin, PhD; Jane Koomar, PhD, OTR/L; Stephanie Lord; Laurie Mawlam, Autism Canada; Lori McIlwain, National Autism Association (NAA); Jim Moody, Esq; Valerie Paradiz, PhD; Stephen Shore, EdD; Jill Stacey, Autism South Africa; Kim Stagliano, Age of Autism; William Welsh, Autism Treatment Trust Columnists: Dean Beadle; Laura Bono; Robert Krakow, JD; Chantal Sicile-Kira The Doctor is IN: Kenneth Bock, MD; Dan Rossignol, MD; Amy Yasko, PhD
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BY HARRY D. SCHNEIDER, MD Dr. Harry Schneider splits his day between working in the Neuroscience Functional MRI Laboratory (now called the Program for Imaging and Cognitive Sciences, P.I.C.S.) in New York City investigating autism (very specifically using functional MRI to investigate the brain areas of the language parts of autism) in the mornings, and in the afternoons, Harry goes to his medical practice in Long Island, New York where he treats his medical patients using conventional and complementary medicine and administers language treatments to children with autism.
New FroNtiers iN LaNguage restoratioN
with you easier.) We have chosen to limit our study to these LFA children who need the most help. Parts of what I describe in this article occur at Columbia and part at my medical practice. With new language rehabilitation techniques and technology we are studying, from using music to engage pre-verbal language and early grammar, to using electric neuromodulation of brain areas to re-activate or re-create dormant language neural networks, we can begin to say that many children can one day be “declassified” as autistic. They can become functioning adults who will be able to communicate in the society around them. The meaning of recovery from ASD differs from researcher to researcher as much as it does from parent to parent. Most scientists seem to agree that it encompasses recovering functional language and communication. Some researchers have said that recovery is impossible because they view ASD as a lifelong process. Although there is no published data, I suspect that close to 20 percent of the LFA children we are treating will be able to make the leap into a successful adulthood, and the rest will at least have acquired enough language to
uring an interview I did for The Autism File in May 2008, I was talking about our research at Columbia University’s neuroimaging center, now called the Program for Imaging and Cognitive Sciences (P.I.C.S.), where we have been examining for many years what parts of the brain function for comprehending, producing, and memorizing different aspects of language. These language and memory investigations encouraged us to develop a research program to use functional MRI (magnetic resonance imaging) together with diffusion tensor imaging (DTI) (a technology used to examine the connections between brain areas that are functioning for a specific task, like language) to examine the brains of children who suffer with the frustration of autism spectrum disorder, specifically those who do not have the luxury and comfort of language or communication – and to develop a treatment intervention that will help to restore both. (For the purpose of this article, children labeled as “low-functioning” children with respect to language or “nonverbal”/ minimally verbal children, I am calling “low-functioning autism children” or “LFA children,” just to make my communication
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recover sufficient activities of daily living to be more or less independent. This is all based on one important hypothesis: when a child finally does acquire a grammar template for language, he or she still needs to be able to communicate thoughts and ideas to another person - each child both listens and initiates the conversation. Communication means having a language platform that is functional enough for a child to communicate with someone else. “Mommy, I just made two new friends today.” Since my last interview for The Autism File, many parents have asked me to elaborate on how one actually goes about restoring lost language, especially the language of infancy. They want to know how the neurotypical infant acquired it, why did LFA children not acquire it, and how we can give it back to LFA kids. To begin with, you might ask yourself how you learned to speak English. No one taught you how to speak; you just automatically did speak by around age two. I have been studying this issue for a long time, as have other linguists, and we still have not unearthed the magic of spontaneous unaided language learning by infants. We do know that neurotypical infants often spend two years unconsciously learning how to discriminate between sounds they hear (phonology), sound pieces that make up words (“play” + “ing” make up “playing”; these pieces are called “morphemes”), and eventually just automatically know what composes a sentence. At a basic level, a sentence tries to put the world they see into an order that makes sense. This is an advanced brain concept - understanding unconsciously that a sentence is conceptually made up of a subject, a verb, and an object, in that order. For example, infants see a ball moving in the air, and they see who threw it and who caught it. They are trying to interpret the concepts of the world they see, attach them to sounds and words, and eventually call upon their inborn “language -acquisition device” (Chomsky, 1998) to generate even more complicated sentences such as, “Mommy is throwing the ball that the doggie likes.” Unfortunately, children can’t always tell us what they do or how they do it, but we are getting better at scientifically studying the language-acquisition things they do: for example, using eye tracking while they are looking at objects to help figure some of it
out. If we think of English as a basic subjectverb-object (SVO) grammar template, like a “Lego” template, once children “get it down” and unconsciously know what part of the sentence goes where, they can easily insert hundreds of words each into the subject, verb, and object positions in this language template. When they later grasp another idea – inserting additional “little” words of language (called “functors”) needed to make a longer sentence, such as the “is,” “of,” “to,” “if,” “–ing,” etc. - they can produce quite a large vocabulary very soon and produce a large number of spontaneous sentences; they might even tell their parents after two years that they do not want to go to bed at their bedtime. Successfully acquiring a grammar together with nonverbal parts of language (e.g., stress on a particular word, inflections of voice, and the rhythm of language) will automatically become communication between children and others around them! All of this is true of neurotypical infants. These are universal grammar functions that will develop in all languages in stages in all infants of the world, stages that reflect the biological maturation of a child’s brain. The fact that these stages of language development are identical and predictable in all languages of the world is evidence that language is a biological phenomenon - something “hardwired” into human brains at birth. However one chooses to describe this language module we are born with, I had referred to this module in the previous Autism File interview as the “language instinct” (Pinker, 1987). Let’s think a bit more about this instinct because it is the foundation of what we address at our foundation, The Autism Family International (TAFI). As you are reading this article, you are actually interacting with me through our mental language. The mental language you are using while you are reading might make you think about what I am “saying” and maybe even consider a mental response - if you could actually tell it to me now. This is a natural phenomenon of the human condition: to affect each other’s thoughts and emotions with our words. This is the remarkable ability we simply call “language,” which we use to communicate to others. We use it, and we need it to belong to and communicate with the world we are in, although we sometimes take for granted
that we are able to do it. It is the nature of people to want to talk -- to their friends and family, to their pets and, in the case of infants, to anything that is around. There are different brain areas for the different parts of memory and learning we have been speaking about: one system for words (called the “mental lexicon”) and another system for grammar. The first system is called the explicit memory system (what neuroscientists call the “declarative” memory system), which is made up of brain areas responsible for learning and committing to memory the notion of words. This “declarative” memory system involves the conscious learning, representation, and use of knowledge about facts (“semantic knowledge”) and personal events (“episodic knowledge”). It is important for very rapid learning of things we want to remember so that much of it can be consciously recalled later on when we need it. Declarative memory depends mainly on a brain region called the hippocampal region, which is connected to surrounding cortical areas in order to “encode” whatever names we choose as representations for what we see (e.g., something round that goes up and down might be labeled or encoded as “ball”). This conscious lexical memory system also supports associative memory, which allows for generalizations, which are very important for LFA children. For example, the memorization of phonologically similar past tense pairs (e.g., “spring–sprang,” “sing–sang”) may allow for memory-based generalizations to new word irregularities, either from real words (“bring–brang”) or from novel, made up words (“spling– splang”). This ability to generalize words and word meanings underlies the enormous productivity we expect from the regular memory system; it allows language to increase faster. Language grammar, on the other hand, can be thought of as emanating from different parts of the brain: a piece of biological machinery - something we are born with in our brain - in which grammar develops spontaneously, unconsciously acquiring a set of rules about how to use all the different parts of language. There is no formal instruction or conscious effort on the part of the infant or the parents, and it is used without the infant’s awareness of any formal set of rules of the language.
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This is the called the implicit learning/ memory system, called by neuroscientists the “procedural memory” system. The “procedural memory” system controls the learning of all new “habits” and “skills,” such as riding a bicycle and skilled game playing. Most interesting is that the knowledge of how to recall these skills is generally not available to conscious access: we can’t always tell someone what goes into riding a bicycle, much less all the rules of speaking a language. Learning in this unconscious, procedural system is gradual over weeks and months. The relations in this automatic system are rule-like, in that they are rigid, inflexible, and not influenced by other mental systems. These rules are applied and used quickly, such as what happens in grammar learning. The procedural memory system is composed of a network of brain structures rooted in deeper brain areas (which we sometimes call the “reptile brain”) than those that we use for regular memory: names like basal-ganglia and substantia nigra (which makes dopamine, by the way) and some portions of the surface brain. See Figure 1 below:
language input that parents make available to them. The infant brain, however, is only forty percent developed at birth, and its brain will not achieve its final shape for two years. Noam Chomsky pointed out two basic facts about child language learning that changed the way we think about it: 1) young children often respond to questions and statements with sentences of their own creation that are not a reflection of all the types of words and combinations they had learned before: they use brand new sentences of their own. Chomsky also felt the brain must have some built-in machinery, which he called an innate “language-learning device” that can make an unlimited amount of sentences out of a limited amount of words; and (2) infants develop the ability to put these sentences together without any formal instruction (such as that which we might receive in a classroom when we are learning a foreign language). Other infants, however, are not so fortunate to make use of the language instinct that neurotypical children have. The children we call “autistic” are those who cannot simply tell us with their words what they are feeling or thinking or make us share what they feel;
Having the grammar module functioning in tip-top shape allows a child to make an infinite number of sentences he may have never actually heard from a limited or finite amount of sentences he has actually heard: no memorization needed! The idea of what a sentence is becomes available to children at the start of their learning and is also the main guiding principle in their attempts to organize and interpret all the complex
they do not have a sufficient language as a base with which to communicate their feelings to us. LFA kids do not have full use of the language instinct that neurotypical children have. They do, however, possess the requisite biological machinery all children have for language; they were born with it. Some of these brain areas and their connections were damaged during their development - that is why they have trouble using it. The LFA kids
never learned grammar! We have all seen the effect on the children and the families that have to cope with life without language. We have witnessed the devastation of families of LFA children who do not have language and their desperation to find a treatment for their children. At P.I.C.S. we have chosen to study the language defect in these LFA children. Whether a child on the spectrum can produce 5 or 150 words, if they cannot consistently initiate or maintain (casual) conversation or use novel ways of speaking, such as slang, or their own unique ways of talking, and if they cannot communicate with others naturally (“Hey, Dad, what’s happening?”), we have chosen to classify all these children as LFA children. Almost all the words these children use are consciously memorized. Parents can often tell me they know their child’s whole repertoire of words and phrases. The LFA kids never learned grammar! To better study language in ASD, we use functional MRI technology to see what language areas of the brain become active when listening to language, combined with diffusion tensor imaging (DTI) technology to examine the integrity of the connectivity of the fiber tracts from one language area to the other (the “wiring,” so to speak). We get a look at how the language areas of the brain actually function – not just a picture of what it looks like, which we also get from standard MRI imaging - when these areas are being used for language. We have demonstrated that not all language areas are functioning correctly and that the connections between certain language-specific areas are not completely connected. This is in part why, during the first two years of infancy, the LFA child could not make full use of his language machinery to unconsciously acquire his natural language. The question I am often asked – especially after parents view the functional MRI imaging results of their child – is “what do we do about it?” In other words, how do we make it work now when it didn’t before? What we do at TAFI is try to restore a child’s grammar module to function again, to stimulate it with novel language-learning protocols so that they can begin to reacquire the grammar they never had and, slowly but surely, acquire what it took a neurotypical infant two years to do: talk spontaneously, maintain a conversation,
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generalize their grammar to new sentences, and communicate to others. We have created a grammar acquisition teaching system that we believe approximates what a neurotypical infant seems to be able to do naturally when unconsciously acquiring grammar. We aid and amplify the child’s re-introduction to the new world of grammar with various modalities: movement and language, musicology and language, and stimulation of the brain together with language – all in an effort to acquire a grammar template with which to communicate! Every modality we use is in conjunction with carefully designed sessions of explicit (conscious) and implicit (unconscious) language sessions involving learning and memory. I will review some of this for those of you who have not read the first interview in The Autism File and expand on how this process works, what we have seen and documented so far in terms of the outcomes for these children, and what to expect for your child. Remember the title of this article: “‘Mommy, I just made two new friends today.’ Is this possible in ASD kids?” Can nonverbal children not only eventually speak, but also communicate to others? We think it is possible, given the new technologies we have been fortunate enough to use. OVERVIEW OF THE COMPONENTS OF THE AUTISM RESEARCH PROGRAM The language rehabilitation program begins with a two-hour neurolinguistic evaluation, the results of which will be used to correlate with the functional MRI/DTI that is later performed on the child. One of the neurolinguistic evaluations we use is The Autism Diagnostic Interview-Revised (ADI-R), a clinical diagnostic instrument for assessing autism. The test focuses on behavior in three content areas: qualities of reciprocal social interaction (emotional sharing, offering and seeking comfort, social smiling and responding to other children); repetitive, restricted and stereotyped interests and behavior (unusual preoccupations, hand and finger mannerisms, unusual sensory interests); and communication and language (e.g., stereotyped utterances, pronoun reversal, social usage of language). Within the area of communication, for example, the concept of “delay or total lack of language not compensated by gesture” is further broken down into specific behavioral items: pointing to express interest, conventional
gestures, head nodding, and head shaking. This test is supplemented by the Bilingual Aphasia Test (BAT), Monolingual Version, in which all aspects of language comprehension and production are uniformly measured. There are many language tests used to assess the abilities of both neurotypical and children with developmental disabilities; there is no perfect test to assess the language capabilities in the child with ASD. We have chosen the BAT test after considerable discussion with other linguists throughout the world because it is one test that seems to encompass much of the information found in many tests. After language testing in Long Island, parents then schedule a meeting with me and the Director of Columbia’s functional MRI lab, Dr. Joy Hirsch, at the Columbia University Medical Center’s Program for Cognitive Sciences in New York City. Dr. Hirsch will explain in more detail the mission at Columbia where we do the functional MRI/ DTI imaging part of the program. After the meeting, I take parents on a tour of the lab, answering all questions before the parents return home. Although patients may elect to participate in research on autism, their subsequent treatment intervention is guided by standard medical procedures by me at my medical practice. The next step is scheduling a scan date for the child. For all scans, parents will be shown how to make a recording of their voices for their children to listen to in the
scanner, along with the music of their choice. We always investigate music and language together, because music is such a powerful tool that affects many parts of the brain, including the language centers. After a period of about a week after the scan, we will review with the parents the findings of the brain images and their interpretations at the office. They will be discussed at length, and a treatment plan will be formulated together. This is a team effort. From the images we have done thus far on LFA children (almost 30), we are beginning to see common patterns: brain areas that should be activated (functioning) for language but are not; areas that are activated on both the right and left side of the brain (language is usually located in the left side of the brain); and areas that should be activated for language that become activated only when listening to music. When we examined the neural fiber connections between these areas using DTI, we found that some connections between known language areas either go in the wrong direction or do not completely go to their target - there is a disconnect from one language area to the other. In the picture below, you can see that the language comprehension area, Wernicke’s area, in the back of the brain, does not reach all the way to the front of the brain where Broca’s area is located and where speech production takes place. Below is a functional MRI/DTI image of two of our patients. See Figure 2.
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Reprinted with permission of The Autism File
Neurotypical: the yellow-orange “blobs” in the middle of the brain on the left is Wernicke’s area (the language comprehension area, right where the ear is) and in the front of the brain (left side) is a small orange blob that represents Broca’s area (language production area); both are active when listening to language by nerve fiber bundles. In the autistic six- and seven-year-old brain on top, we can see smaller activations of Wernicke’s area, but NO activations of Broca’s area. In the connectivity images from the two autistic images in the bottom panel, the connections head either backwards or do not fully connect Wernicke’s and Broca’s areas. The connections in the six-year-old are headed backwards, and in the sevenyear-old they go backwards and frontwards from Wernicke’s area but never quite connect completely with Broca’s area. OVERVIEW OF THE LANGUAGE INTERVENTION “It looks like someone took a pair of scissors and cut the wiring” (KW, parent). What can we do about it? Language interventions consist of novel teaching methods directed to brain areas that are not functioning to stimulate language networks for language production. This is language plasticity! Our goal is to restore grammar to the child that was never acquired during infancy, to turn that grammar into a natural language, and to have the child use it to communicate to others: “Mommy, I just made two new friends today.” The language interventions and protocols focus on explicitly/consciously learning sounds and words and combining these basic fundamentals with implicitly/unconsciously acquiring the rules of language. With respect to sounds and words, we know that neurotypical Infants have a unique ability to discriminate between different speech-sound (phonetic) differences. Babies learn not only individual speech sounds but also the auditory forms of words; that is, babies are not only aware of the pieces that make up a word, but they are aware of the entire word. Although they may not know what the words mean, neurotypical children as early as eight months old start learning the phonological (sound) forms of words and are able to recognize
them. These auditory forms of words allow children to increase their vocabulary and help them to eventually develop grammar. We teach LFA children the differentiation of sounds and parts of words and full words reinforcing their conscious memory system to recall these words for the next lesson. This type of conscious memorizing in word learning may be enhanced by many different methods, for example by association of visual clues to word sounds. The words we first teach are nouns and verbs. This is best accomplished by pairing the correct noun with the correct verb. For example, we teach and show “daddy throws ball,” or “mommy eats carrot,” or “Dylan bounces [the] ball,” using as many sensory modalities during the session as possible, together with lots and lots of motivation – it’s all about dopamine! Although we aim for complete sentences as soon as possible, Dr. Marion Blank, also here at Columbia University, has pointed out that the nouns and verbs must also be paired with the “little” words as soon as possible, such as “daddy throws the ball” and “Dylan is bouncing the ball.” Once a child has learned the minimal amount of words, that is, enough words to form a sentence (usually four words are appropriate for a child to learn successfully), we begin to approach the concept of grammar: our children unconsciously acquire the rules of grammar. This is the process through which infants become sensitive to certain regularities in sequence in the environment: the relationship of subjects (“man”) to the things that they do (verbs - “throws”) and to whom or for what those things are done (object - “ ball”). This is a very difficult concept for a child’s brain to grasp initially. This is all accomplished implicitly: (1) in the absence of conscious intention to learn about those regularities; (2) in the absence of the child’s awareness that there is learning happening; and (3) in such a way that the resulting knowledge the child gains is difficult to express (even if they could express them, but adults can’t either; they just say they know “how to do it” and don’t know why). The notion that LFA children may never become fluent or be able to communicate is incorrect: fluency is based on their getting their grammar back – which they are slowly doing - and communication is based on having enough language and motivation to use it – and they are beginning
to do just that in our program! What we have learned about LFA children is based on what we have learned about the LFA child’s absent or incomplete acquisition of language. The neurotypical child acquires a grammar - the correct ordering of words - in their language, because the grammar template was “hardwired” into their brains, and they used the template to figure out the rules of the language. The LFA children, however, did not completely and neuroanatomically acquire this fundamental grammar. The template for grammar is in their brain, but, as we have seen, it does not always interconnect correctly. In short, the reason that some children speak and some children do not depends on how fortunate the child is to have enough fiber connections hooked up correctly together in both memory systems in the first 12 to 15 months of life in order to produce speech. If the language comprehension areas of the brain do not connect in the right way to the language production areas, the child may not become very fluent, spontaneous, or able to engage in conversation and spontaneous communication. The result is that instead of being able to apply the order of a subject, object, and verb, they have had to memorize all of the words and the correct “grammatical” order they are supposed to be in – not an easy task. They have had to rely on their regular memory system (the explicit/ declarative system) – not the unconscious grammar template. Unfortunately, our conscious memory system is not big enough to handle all the data (it’s unfortunate we cannot just put in a bigger computer chip – yet). Just imagine if you had to memorize a whole foreign language to work in another country -- not an easy task! Our goal is to restore grammar that was never acquired during infancy to the LFA child. We provide grammar in context. We expose children to this without alienating them to the learning process, something very delicate for an LFA child who has been frustrated and often angry about their inadequacies with respect to other children. We use short, grammar-based sessions immediately followed by additional functionbased lessons in which the new grammar is applied. The fundamental principle of our implicit grammar protocol is having the LFA children unconsciously acquire the grammatical patterns of language with
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constant enjoyable, game-like repetition of a grammatical point using child-specific motivations, sometimes accompanied by pleasant distractions, such as a video. These distractions enable our children to learn the rules inadvertently, without always paying much attention - rather than directly telling them anything about them. (It must seem odd to the reader that children can often learn more without paying attention, but it is often very true!) At first, some children may seem confused about how to perform our activities, because they have never encountered language learning like this, but they quickly adapt to these novel routines: we ensure that they are very motivated to want to participate! By way of examples, we may guide implicit grammar learning through the physical manipulation of color-coded grammar elements in which students are purposefully led to discover grammar rules. Implicit learning integrates grammar more deeply into students’ long-term memory. Another rather interesting way of teaching grammar implicitly is to have children watch their favorite video (Blues Clues, Baby Einstein) while we are conversing about the child right next to him, perhaps engaging in conversation about things the child did recently that were enjoyable. Invariably, the child will begin to engage in the conversation with or without disengaging from the video. One of our most fascinating implicit teaching sessions was one that we came upon by accident: water therapy. (Don’t many LFA children enjoy playing with water?) Some children enjoy playing at the sink, pouring water in and out of cups. While they are doing that (and perhaps wearing the brain-stimulation device at the same time), their mother reads the alphabet (to reinforce phonology) to one of our instructors. The instructor and mom make the alphabet appear as if it’s the most fun thing in the world to say. Then they might introduce one-, two-, and three-syllable words or pictures from a book. This water “theme park” often concludes with recounting the day’s events, using communicational chit chat, not just formal language. These children entered the program with no words - maybe “dada.” After two water therapy sessions, they could say “cup,” approximate “water,” offer to “share” the water, and perhaps another 10-15 words. This example of finding out what motivates
The self-reinforcement of a child hearing his own speech has led to spontaneous language, in some cases the beginnings of maintaining a conversation, and stepping out of the box of the language they have memorized for speech into a world in which they enjoy using their own language.
the child and letting the child perform that action while talking around and about him, actually motivates the child to begin to want to verbally respond to the things about him. This may be one of the best, if not the cutest, example of implicit learning we have been fortunate enough to use. Although implicit learning is a scientifically well-documented learning/memory system, the ways in which we conduct the lessons are flexible. Our experimental research program is, in part, a work in progress with “on the job training” for all of us. With the help of parents, we conduct some sessions in an impromptu fashion, often with enjoyable, motivational, and new inspirational ideas, most of which yield good language production. Another example of the successful use of this strategy was with a 22-year-old man, JL, from the midwestern United States. He had spent 17 years without uttering more than “d, d, d, d” to his mom. The parents said they had “tried everything” beginning at age four. When he came to the office we chose to use the tDCS (transcranial direct current stimulation) unit at the outset, concentrating first on explicit word learning networks so he could begin to name at least four pictures clearly. After that, we placed the tDCS unit on brain areas involved in implicit learning networks so he could begin to acquire grammar with the nouns and verbs he had memorized. At the end of the session, his mother took away his CD player with his favorite music and gave it to his sisters (all loving and caring siblings who chose to become accomplices in our “game” to motivate their brother to “ask” for his CD player back). After 20 minutes of coveting the CD, speaking about it, giving and taking it from others, and always nodding at JL to see if he wanted to engage in the activities, JL finally was motivated enough to verbalize, “give me CD!” This happened within four days of beginning the therapy! JL had between 8-15 words that he retained and was able to verbalize upon request looking at a picture as a result of four days of therapy. Children generally seem to enjoy these grammar play activities and stay on task. The production of verbal output is our main goal, a verbal output slightly above the level that students can already produce on their own. When this is combined with the meaning of what they are saying, the two elements combined constitute successful language acquisition. Implicit, unconscious grammar learning, the way we believe a neurotypical infant has accomplished this remarkable feat, is not an easy task. It is being successfully accomplished at the TAFI foundation learning center – especially with the help of dedicated parents, family, and friends who will carry on at home what we all do together during rehabilitation language sessions. Thus far, all of our students are beginning to re-acquire the backbone of their language, the grammar of English. Many are beginning to answer specific questions with generalized answers. The self-reinforcement of a child hearing his own speech has led to spontaneous language, in some cases the beginnings of maintaining a conversation, and stepping out of the box of the language they have memorized for speech into a world in which they enjoy using their own language. This protocol will be combined with musicology. It is necessary in research on autism to study music, something that the brain treats as so similar to language. Music is known to stimulate both speech comprehension and production areas, as well as motivational areas that help language learning. Children are thought to hear music not just as a series of individual notes, but rather to assemble these notes into logical structures. This is what we have called “syntax,” and it is the same principle in music as it is in language. A common understanding of such patterns between music and language is dependent upon there being a commonly understood system of syntax for a particular style of music, just as there is for language. The syntax of the sentence structure is made simpler by its organization into three levels:
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the word, the phrase, and the sentence. The syntax of the musical structure of tonal music is also made up of three levels: the structure of chords, the rules for voice leading (the relationship between the successive pitches of simultaneous moving parts or voices), and the syntax of chord progressions. As far as Broca’s area of the brain is concerned, it reacts to good and bad syntax of music and language in the same way: the detection of the correct structure of how words (and notes) are put together. This is one of the fundamental reasons why the addition of aspects of music has been working so well to help LFA children re-learn their grammar. The LFA children who come to our facility often present with significant limitations in conventional forms of verbal and nonverbal communication. They respond positively to music therapy interventions, which involve active, improvisational, and receptive music interventions. These programs include listening to certain types of music during an implicit language-learning session, using music therapy in the form of games in which language has to be produced, and combining movement and music in singing and dancing. Certain types of musical combinations called “chords” have different effects on different parts of language. A “major” chord may facilitate one type of verb and a “minor” chord may facilitate another. Certain rhythms of music, particularly if they match the rhythm of the language that a parent is speaking, facilitate acquisition of grammar – especially with a metronome ticking not far away! We have children learn to play simple tunes on the piano by reading letters on the keys and matching them to letters on a sheet of music – transforming the joy of music production into the joy of grammar production. We have found that employing musical activities facilitates motivation, communication skills, and social interaction, as well as sustaining and developing attention. This has led to faster acquisition of the basic sentence structure and its grammar. When a child is engaged in a movement game involving music, the cerebellum is also being activated for language acquisition, which we will discuss next under movement therapies and language. Almost all of the children in our program have responded to one form or another of music interventions. The protocol will also be combined with movement therapies directed at
cerebellar stimulation. In spite of known cerebellar pathology in ASD (often seen as walking imbalances in some children, known as gait ataxia), we have demonstrated functional MRI cerebellar activations during language listening in many of the LFA children we have scanned. Knowing that the cerebellum becomes functional for language has enabled us to use cerebellar activations for our language acquisition program. The cerebellum has been found to be part of the early grammar-learning machinery of the infant. With respect to movement and language therapy, we have to understand the importance of the cerebellum. Traditional neurological teaching has been that the cerebellum, a region in the back of the brain, principally plays an important role in the integration of sensory perception, coordination, and control of physical movements. We have seen, nonetheless, with the help of functional MRI, that cerebellar function, specifically the interactions of the cerebellum with other frontal parts of the brain (such as Broca’s area for speech production), is also responsible for a variety of cognitive functions including grammar learning. Ontogenetic evidence suggests that the cerebellum is an important organ for speech, a part of the learning machinery of the infant for early language. It has been demonstrated to have a long-distance connection or circuit to Broca’s area for speech. It establishes phonologic representations during early language development, such as how the infant learns to process and distinguish meaningful sounds, for example, the difference between “d” and “p.” An infant’s ability to articulate and process sounds remain closely coupled: speech requires sequencing of articulatory gestures, mediated by parts of the frontal cortex and the cerebellum. After prenatal or early injury to the cerebellum, as in ASD, cases have been frequently presented in the medical literature: dysprosodia (difficulty in the expression or comprehension of the emotional components of speech, such as melody, emphasis, inflection, and gesturing); agrammatism; anomia (the inability to name objects or to recognize the written or spoken names of objects); reduced verbal fluency and poor articulation with deficiencies in understanding and producing certain sounds. The cerebellum is very involved in the
early grammar of the child helping to make large sentences into “chunks” of sentences (i.e., smaller fragments such as “kind of,” “a lot of people“) so that a long sentence can be more easily understood. These language chunks may be even smaller in size, such as a “syllable” within a word. When seen from this perspective, cerebellar participation during language production can be easily seen as a close partnership between the language and the motor system. Our goal with movement therapy is to activate the cerebellum during implicit language learning. A child watching a video with a lot of movement generates the same cerebellar stimulation as does actually spinning in a chair. When we have our grammar learning immediately during and after the cerebellar stimulation, we always note a clear increase in word production, often leading to two- and three-word sentences, sometimes with the beginnings of pragmatic effects and generalizations. We have tested sequence learning ability both before and after movement exercises, and we have seen that children are better at learning sequences after movement exercises. All sequences, even using physical objects in place of words, are important in learning correct grammar: the ability to know what the correct sequence of subject, verb, and object is, without memorizing the rule. We have also seen evidence of a child’s ability to cope with other nonverbal elements of language: prosody and pragmatics. Prosody may be thought of as reflecting the emotional state of the person speaking to the child: whether an utterance is a statement, a question, or a command; whether the speaker is being ironic or sarcastic; emphasis, contrast, and focus; and other elements of language, which may not be encoded by grammar. Pragmatics is the ability to communicate more than that which is actually said. The ability to understand another speaker’s intended meaning is called pragmatic competence. Pragmatics deals with the ways we reach our goal in communication. Suppose a child wanted to tell his parents to “go away” for the session (as some children do when they come with their parents to a language session). A neurotypical child could do this by using formal language, such as “please go, Daddy,” or even “Daddy, please go and make me lunch.” Many of our children just say “bye bye” to their parents to get them
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Thus far, we have seen a 500% increase in language production using the tDCS unit alone
to leave. This is often the most that our LFA children can currently do when they enter the program. This example shows how important it becomes to teach pragmatics so that children can speak with real-life communicative forms and be capable of engaging in social conversation. The language-intervention protocol may be combined with neuromodulation, specifically, the use of transcranial direct current stimulation to increase language production. A portable brain stimulator using the technology of transcranial direct current stimulation is used. that nerve cells in the Language Performance Data pre and post brain react to direct tDCS treatment current electrical 100 fields by altering their firing rates. Nerve cell 80 firing increases when 60 pre the positive pole or post 40 electrode (anode) is 20 located near the cell 0 body or its dendrites 1 2 3 4 and decreases when groupA groupB groupA groupB the field is reversed. spontaneous total words Because the electrodes Patients are placed on the scalp All bars represent matched groupings of 8 with two-inch sponges wetted with saline, similar patients per group (group mean seen the current actually produced in the brain above, CI 99%: N= 16). This graph reflects is exceedingly small, producing small but only the results of the children’s response to noticeable changes in the way the brain neuromodulation: the use of tDCS. cells in the stimulated area fire. Transcranial for publication so the rest of the autism direct current stimulation does not appear community can benefit from the use of to cause nerve cell firing on its own and neuromodulation for LFA kids (see bar graph does not produce discrete effects, such as above). the muscle twitches associated with classical Article for publication: The article for electrical stimulation. It is also important to publication will reflect the results of using the distinguish it from electroconvulsive therapy tDCS unit alone in our office: a 500 percent (shock treatments), which is used to treat increase in verbal output. See Figure 4. mental illnesses such as major depression with We will include in the article all patients electrical pulses 1,000 times more powerful who failed to respond to 3-4 years of than the tDCS unit we use. standard Applied Behavior Analysis (ABA) Transcranial direct current stimulation is a language interventions (or any other safe, non-invasive, and inexpensive means of language interventions), speech therapy, and achieving activations of specific brain areas. school-mandated language therapies. The It has been shown to be a highly useful brain results of initial assessments of these children stimulation technique for investigating a indicated that their language performance variety of visual and cognitive phenomena, was limited to a total production of a mean of as well as clinical conditions such as loss of 12 words for group A and 19 words for group function and language after brain injury, B and spontaneous requests of 1 for group affective disorders such as depression, and A and 3 for group B. Both groups had mild mood disorders and chronic pain conditions. apraxia of speech, and words were included It is being used to help people recover use in assessments only if understood by a nonof limbs. It has been shown to be effective in family member. Over the course of 12 weeks, increasing memory and language functions. patients were treated in our office with 20-40 We are investigating its use for restoration minute sessions (2 days/week) of tDCS. of language in LFA children. Thus far, we At the end of 12 (pre- and post-bar have seen a 500 percent increase in language graph) weeks, the total number of words production using the tDCS unit alone. We increased from 12 to 66, and spontaneous discuss with all parents if and when to use the (self-initiated) words increased from 1 to 12 device to prime language areas that are not for group A; group B increased from 19 to 92 functioning as well as they should: speech total words and from 3 to 29 spontaneous production areas, motor planning areas, words. In addition, parents confirmed that articulation areas, and comprehension areas. weekly improvements in speech production We are preparing to submit these findings
number of words
Transcranial Direct Current Stimulation (tDCS)
Debra Schneider working with patient, Michael Schindlar
The scientific research being done at Columbia on neuromodulation has shown it to be a very useful treatment modality for certain brain disorders. Clinical research with tDCS is being conducted at the TAFI foundation. This simple-to-use device attaches easily to the child’s scalp over brain areas that may increase verbal production (as revealed by each child’s functional MRI images), painlessly stimulating select brain areas using a small amount of direct current. The electrodes are placed on the scalp with two-inch sponges wetted with saline (salt water). The unit applies weak electrical currents (1-2 mA) over the scalp, which is used to modulate the activity of brain cells below. Several generations of neurophysiological experiments have shown
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are the ongoing results of the combined effects of all our modalities on word and 140 sentence production. There is at 120 100 least an additional 33 percent 80 pre improvement above using tDCS 60 post alone when all modalities are 40 20 combined for the two groups 0 labeled A and B – the total and 1 2 3 4 spontaneous words produced. group A groupB groupA groupB spontaneous total See graph left (Figure 5): Patients I would like to conclude this article with an informative anecdote This graph reflects same cohort of children with presented from parents who have recently verbal responses from all language-learning joined our program. They had gone to a modalities combined (musicology, movement, and tDCS). well-known university medical center to see a physician about how best to deal with the language issue (nonverbal) in their were maintained at home. Parents also LFA child. They told him that they were reported enhanced language comprehension strongly considering coming to Columbia for such as following 2-3 sentence commands functional MRI in order to see what parts of (i.e., do a, b, and then c) and decreased their son’s brain were being used for language response time to performance of tasks asked and how they were connected, and then of the child. No adverse behavioral changes would possibly go to Long Island to utilize a were noted by examiners or parents. novel intervention for restoring language. The Not yet included in the study is the data dad said to me that he was told that seeing above being prepared for publication. These
Language Performance Data pre and post All Modalities Treatment
number of words
how the brain functions was “not science but science fiction”... to believe there was such a diagnostic tool (i.e., functional MRI) to do that. The mom said to me that that she was told that even if such a neuroimaging tool existed, there was nothing to do about their child’s lack of speech production because nothing can help an LFA child restore language. I have since heard many similar anecdotes. I hope that this article can bring together all those involved in the treatment of autism -- parents and health care providers alike. Some researchers today often credit earlier diagnosis and treatment for creating positive outcomes in ASD children, but I believe early intervention is not the whole story. The rest of the story is diligence and hard science leading to novel, safe treatment approaches. I always ask all parents to learn as much as they can in advance about whatever they hope or plan to do for their children. It is only if we work as a team, share our knowledge, keep an open mind, and cooperate in a dedicated spirit to solving the issues of ASD that we will get the job done. “Good job!”
March with us in London Saturday 28th March 2009
Bring banners. Bring placards. Bring your family.
Route: Gather for 1.30pm, 2pm Set off behind the bagpipers at Temple Place (By Temple Tube Station) Via Victoria Embankment, Whitehall and ending at Trafalgar Square. Join our call on Trafalgar Square at 2.45pm for better services for autistic children and adults.
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