Thu 31, Mar 2016

Fourteen-year-old Joshua Rudd from Perth was diagnosed with autism when he was four years old. According to his father, Wayne, Joshua was toilet trained at the normal age, but then “didn’t seem to have the usual warning signs, and consequently wore nappies a lot longer than other children”.

At the age of 12, Joshua was still soiling himself regularly. Wayne said his son’s behaviour began to become challenging from about the age of two.

Growing up, Joshua was a difficult, noncompliant child and appeared to be disinterested in adopting socially appropriate behaviours. He struggled academically and at the end of grade five, at age 12, was diagnosed with a mild intellectual disability. He has always attended regular school, and now receives educational support.

According to Wayne, soiling himself didn’t appear to bother Joshua, and he showed little interest in using the toilet, even when he started school. When Josh was in grade five, his father was still being regularly summoned in to school to take Josh home and return him freshly showered and changed.

Four-and-a-half years ago Wayne retired early so he could take over the role of Joshua’s primary carer from his wife.

“I had absolutely no treatment strategies. Once I retired I was on the phone constantly to see what information I could access,” Wayne said.

Joshua’s doctors presumed his habitual soiling was due to his autism. “I talked to other parents of autistic children and their children did the same sort of thing; it appeared to be a common factor,” he said.

Wayne looked into a process called neurofeedback (also called EEG biofeedback), which has been shown to help children affected by ADHD. He thought it might help Joshua’s general behaviour, and so approached Perth-based NeurOptimal neurofeedback practitioner and forensic psychologist, Denise Cull.

“After he’d been to about four or six sessions, I noticed I didn’t have to pick him up from school any more, and he wasn’t soiling himself at home either,” Wayne said.

Ms Cull, who was not aware of Joshua’s soiling history, was taken by surprise. “He didn’t come along for his incontinence; he came because of his disruptive behaviour and his defiance,” she said.

Adelaide neuropsychologist, neurofeedback practitioner and Flinders University School of Psychology Professor Richard Clark said that neurofeedback involves operant learning, a form of learning that helps the brain change in response to positive and negative feedback to how the brain is functioning.

“One way we acquire new memories involves unconscious learning through positive versus negative reinforcement,” Dr Clark said.

“When we have positive outcomes during a learning process, brain dopamine and serotonin is released in those parts of the brain involved, which reinforces the networks that have been active so that learning occurs and memory is strengthened. Neurofeedback exploits that process.”

The brain activity associated with positive and negative reinforcement and related learning has been long studied and well documented, and much is now understood about the many brain rhythms critical to such learning.

Neurofeedback training monitors brain function through measurement of the EEG rhythms and patterns occurring in a person’s brain via electrodes placed on the head. It processes them mathematically in real time and can even compare them against databases of normal function, Dr Clark said.

The purpose of neurofeedback is to normalise and/or stabilise the brain rhythms underlying what we sense, feel and do. When the EEG patterns and rhythms move in the desired direction, neurofeedback provides immediate positive feedback to help strengthen the production of such rhythms; when it goes in the non-desired direction, negative feedback is provided to prevent such learning. This kind of brain learning is akin to what takes place when we acquire new skills, such as reading and writing, driving a car or playing tennis.

In neurofeedback, the learning occurs while the patient is engaged in a pleasant activity, such as watching a movie or listening to music. Negative feedback about ongoing brain activity involves modifying how the entertainment is presented – such as darkening, obscuring or stopping it. Positive feedback about ongoing brain activity ensures the entertainment continues unobscured and is clearly presented.

Dr Clark said the ongoing neurofeedback process helps the brain self-correct through this process and strengthen desired patterns of brain activity. The underlying learning processes occur subconsciously, although conscious awareness of, and interest in, the meaning of the positive and negative feedback is essential.

He speculated that the change in Joshua’s toileting behaviour might have come about because the neurofeedback may have been focussing, by chance, on brain wave patterns associated with anxiety.

Joshua’s neurofeedback therapist, Ms Cull, speculated that Josh’s brain had rewired itself so he could now make the connection to go to the toilet when he felt the impulse to defecate. “Maybe it restored the developmental interruption caused by autism. Or maybe it was just laziness,” Ms Cull said.

Joshua, now in his second year at high school, puts his changed behaviour down to maturity. “I probably got older,” he said.“It’s better now. It’s easier for my mum and dad.”

Wayne said the impact on Joshua’s life had been dramatic. “He’s much improved, a lot happier, a very social boy.”

So much so that Josh’ talents as an athlete and performer are only now becoming evident. Last year Joshua won his school’s boy sports champion of the year, a remarkable achievement considering he hadn’t participated in sports until high school. As a result of this extraordinary turnaround, he was chosen to be ambassador of Perth’s most recent annual City to Surf, sponsored by the disability support organisation, Activ Foundation (see newspaper cutting above).

In addition, he is one of the six finalists in Activ Foundation’s Ability Idol and will sing Abba’s Mama Mia in the final.

“We’re very proud of Josh, so proud,” Wayne said.

Dr Clark stressed that the resolving of Josh’s faecal incontinence was probably an “accidental outcome” of the neurofeedback, but that there may also have been other factors contributing to Joshua’s improved behaviour.

“We don’t know what other influences there were in his life at the time; what else was going on, but it’s a good outcome for him,” Dr Clark said.

The American Academy of Paediatrics has endorsed biofeedback as a Level 1 (Best Support) treatment for ADHD. However, more research was required to determine its efficacy with autism, Dr Clark said.

He stressed that autism was a systemic problem, associated with impairments incurred during the development stages of the central nervous system and brain.

“We cannot resolve autism per se, but we can alleviate many of the associated symptoms,” he said.

“What happened to Joshua is not evidence that it will work for all cases. As it is a single case, it can only need to be taken as a testimonial, so parents need to be aware of that.”

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