The Saturday Paper
Developments in autism research suggest hormonal treatments could make expensive and time-consuming early behavioural therapies more attainable and successful, writes Lindy Alexander.
When Professor Adam Guastella was training to become a clinical psychologist in the 1990s, autism was believed to be an untreatable genetic and biological condition.
“You could work with people on behavioural change and socialisation, but that was regarded as fairly minor in the context of the entire condition,” he says. Now, that dogma has changed. Autism is currently understood to be a neurodevelopmental disability whereby people have difficulty processing social information. About one in 150 people in Australia has autism. “There are often problems in flexible thinking, responding to and identifying emotions, as well as stereotypic behaviours such as specialised interests,” says Guastella, who is based at the Brain and Mind Centre at the University of Sydney.
Interventions for autism provided in the early years of life tend to offer the best opportunity to improve long-term outcomes for children. “If you have a child with autism and you want to improve their social skills, then it’s recommended they have two years of treatment for 20 to 40 hours a week,” says Guastella. The time commitment is only one factor, however, as support such as this is expensive, with experienced therapists charging about $150 for a one-hour session. While Guastella believes all children with autism should have access to this kind of therapy, he acknowledges that not all will benefit and that the results are not conclusive.
Therapy has enormous potential and, paired with the plasticity of a child’s brain in their early years, Guastella and his colleagues wondered if they could use a medical intervention, in the form of oxytocin, to enhance the learning from social therapy. Oxytocin is a hormone that has been shown to propel maternal behaviour and, importantly, social attachment in various species.
Oxytocin is known as the “hug hormone” and Guastella wanted to see whether it might help young children to be more socially responsive. Oxytocin is believed to affect everyone in the same way, but because people with autism have difficulties in social interaction, it is thought the therapeutic effects may be clearer. Whether children with autism are different in the way they process or receive oxytocin is not established. “I’m not saying there aren’t differences in oxytocin biology in children with autism, it’s just the evidence is not clear yet,” says Guastella.
Guastella and his colleagues administered oxytocin or a placebo via a nasal spray morning and night for five weeks to 31 children with autism aged between three and eight years. The results were significant. Compared with the placebo, oxytocin was found to increase eye gaze and social memory. “This study is the first clinical trial to support the potential of oxytocin as an early intervention for young children with autism to help improve social interaction deficits,” says Guastella.
But once the children stopped receiving the oxytocin, the benefits didn’t continue.
“There was evidence that the oxytocin gradually wore off. Although the children showed increases in social responsiveness while on oxytocin, my hunch was that this wasn’t going to be long lasting.”
What oxytocin does offer, however, is a window of opportunity to utilise responsiveness to teach autistic children the social skills and rules that most of us take for granted. By helping children process social information in their early years when the brain is the most malleable, it’s possible that oxytocin offers children a chance to positively respond to early intervention.
Another striking outcome from Guastella’s research was that parents reported a kind of awakening in their child. “Their kids were able to understand information more effectively and seemed to be more engaged in their social relationships,” he says. “One of the families commented that their son would usually hop in the car and never have any conversation, but during the study he talked to his parents and asked them questions. It changed their view that their child was someone who wasn’t interested in social contact and was quite socially isolated. It improved the cohesiveness of the family.”
The findings from many autism studies are difficult to generalise because of small sample sizes. It’s an issue Guastella readily acknowledges. “You’re not going to get really definitive answers until you are looking at hundreds of children,” he says. “If you look at all the clinical trials that have been done, most are relatively small. But now we are starting to discuss doing studies where we can do trials of 300 people.”
Guastella’s findings have sparked a series of international collaborations. His next project is due to begin in 2018 with colleagues at Duke University in North Carolina. A combination of oxytocin together with a social learning therapy will be tested for 16 weeks in young children with autism. For Guastella, the study represents promising innovations in autism research. “It’s exciting to be part of research where we are doing so many different aspects of the science really well,” he says. “We are doing imaging, blood work, eye-tracking and looking at social interaction. We’re not just focusing on one thing.”
With autism, people may have the same diagnosis but they present in different ways. And there is no definitive test – an autism diagnosis is based on observable behaviours and developmental assessments. However, a growing number of researchers in Australia and worldwide are looking at biological markers of the condition.
Biological markers are physiological characteristics that may indicate the presence or severity of a disease or condition. “It’s likely that there are many biological underpinnings that drive the same sort of observable behaviours,” says Guastella. “We think there is actually more than one autism, but currently we classify it as a single disorder.” This may lend weight to the idea that Asperger’s syndrome is actually a separate condition, despite it being incorporated into the spectrum of autism disorders in the latest version of the psychiatric Diagnostic and Statistical Manual (DSM-5).
Using biology to predict the emergence of autismlike behaviours is an idea gaining traction among researchers. A study recently published in Science Translational Medicine explored whether brain function in infancy could be used to accurately predict which high-risk infants will later receive an autism diagnosis. By using a special type of MRI, researchers found they could predict with greater than 96 per cent accuracy whether a six-month-old infant would develop autism at 24 months of age.
The study size was small, with only 59 infants, and the findings need to be replicated, but one of the study’s researchers, Dr Robert Emerson, of the University of North Carolina, says the results are an important first step. “I think the most exciting work is yet to come, when instead of using one piece of information to make these predictions, we use many types of information in concert,” he says. “Our analysis is flexible enough to include other brain measures, genetics or early environmental exposures. I think that will be the future for developing pre-symptomatic predictive biomarkers for autism.”
This is the key to future developments in understanding the condition, says Guastella. “We are really trying to understand the biological systems of autism,” he says. “It may end up that we can use really intensive social therapy to activate the biological systems that we are interested in. The kind of studies that are being done now means we can start to give people answers instead of leaving them with hope that
• we might have something for the future.”