The Brain's Way of Healing
BY DR. NORMAN DOIDGE
AUTISM AND LISTENING THERAPY
……Paul doesn't claim to perform such wonders with all autistic children. But he has found that most of the autistic patients who he thinks will benefit from listening therapy do improve significantly, though many will still have remnants of the condition.*
A boy I'll call "Timothy" is a more typical case. He has made huge improvements but still has some remnants of autism. Like Jordan, he was at first generally healthy, but then, at eighteen months, he had an autistic regression. His initially normal mental, emotional, and language development regressed. He seemed to lose interest in relationships with people: he stopped speaking or responding to his name, stopped making eye contact, stopped normal play, and began to have rages. As he approached three, he was stuck in his own world, and his mother, "Sandra," and her husband felt the acute loss of their son: "We just want to have a relationship with him." He had all the core symptoms of autism and was diagnosed by several expert physicians as having severe autism. Sandra told me that she and her husband were told that "he would not have a normal life, would never go to a normal school, or train for a job."
At the Listening Centre, Timothy immediately settled down. On day one of the program he stopped his constant movement; on day two he slept for ten hours, the longest since his autistic regression. On the third day, his mother told me, "He seemed like a different person. Then my husband comes home, and Timothy goes over and hugs him for the first time since we lost him to autism." Timothy's progress was slow and steady and took a number of years. He came to see Paul once a year, for ten hours of listening and working on expressive speech, and for help in dealing with the new issues that arose at every stage of growing up, especially puberty. Listening therapy is not simply hooking a person up to a machine. It requires a therapist like Paul who understands how to
* Paul Madaule has found that listening therapy can help about two-thirds of children with autism who come to the Listening Centre. "Help" means improvements ranging from a Jordan-like outcome (not frequent) to a Timothy-like outcome (more typical) to a more modest but very welcome improvement that permits the child to make better use of existing therapies, and to participate more in school and in social and family life, in such a way that he or she is far more regulated, self-aware, and independent. Generally, the younger the child with autism is when therapy begins, the better. Ongoing yearly "boosts" are helpful, and often the children themselves ask to go back to the center, saying, as did one child, "I need the music again, to calm down inside."
connect to the mind and heart of someone with autistic or other learning problems.
Timothy went from needing educational assistants in class to being on his own. By seventeen, he had become an A student, even in English—a stunning accomplishment for a boy who had lost his speech. He has a steady friend and is moving toward being more independent from his family. He has gone from severe to mild autism, and he is on track to graduate from a normal school with his peers and to get a job. His parents, who had only wanted to "have a relationship with him," now have one.
Though autism has been thought to be incurable, Martha Herbert, M.D., Ph.D., a pediatric neurologist and researcher at Harvard Medical School, and author of The Autism Revolution, also documents cases of children with autism who have made life-changing improvements. "For decades, most doctors told parents that autism was a genetic problem in their children's brain," she writes, "and that... they should expect their toddler's troubles would be with him/her forever." But autism, she demonstrates, is frequently a dynamic process. It is not only genetic, not only a brain problem, not caused by any one thing, and is not always beyond help, especially if the therapy is begun when the child is very young.
In some cases, autism is present at birth or soon after; but in "regressive autism," the child's mental development at first seems fairly normal, and then, typically between the second and third year of life, the symptoms begin.
Autism rates are now skyrocketing. Fifty years ago, one in 5,000 people had it. In 2008 the Centers for Disease Control had the rate at one in 88. In 2010 it rose to one in 68 (and one in 42 for boys). While some of the increase may be caused by a heightened awareness among physicians, so that they diagnose it more frequently, many clinicians who treat it believe that more children are developing the disorder. Certainly, the rise is happening too quickly to be explained by genetic factors, which take generations to unfold. As Herbert points out, "Hundreds of genes are now associated with autism. Most of them are not of major effect. In most cases they probably create modest vulnerability.... Even genes that cause autism in a strong way... will only affect a fraction of a percent of the total number of people with autism... and some with that gene don't get autism."
Genes put a child at risk of autism, but environmental factors are generally required to turn that risk into an illness. Many of these factors turn on the child's immune system, causing it to release antibodies and produce chronic inflammation that affects the brain. Many autistic children have immune system abnormalities and overactive immune systems. They have high rates of gastrointestinal infections and inflammation, food sensitivities (often to grains, gluten, dairy, and sugar), asthma (which involves inflammation), arid inflammation of the skin. Anti-inflammatory drugs are known to decrease autistic symptoms. True, there are other noninflammatory factors, too, such as chemical deficiencies, but inflammation is emerging as a key factor. Herbert gives many examples of children who made radical improvements when inflammation was addressed. Caleb, a boy who had many signs of inflammation and many infections, then developed regressive autism, but his autism went away at age ten, when his mother eliminated gluten from his diet.
Another stressor is toxins, which also can irritate the brain and cause inflammation. Today's babies are exposed to toxins in the womb, and they are born prepolluted. Children at birth have on average two hundred major toxic chemicals in their umbilical cord blood, including some that were banned thirty years ago. Many are direct neurotoxins. Toxic chemicals, because foreign to the body, trigger immune reactions.
The Inflamed Brain Is One in Which Neurons Don't Connect
Autism is not only, as was once thought, a brain disease. Herbert shows it is an expression of a whole body disease that affects the brain's health, too. Chronic inflammation in the body can have an impact on all the organs, including the brain. In 2005 a team from Johns Hopkins University School of Medicine showed that autistic brains are frequently inflamed. Autopsies found inflammation in the cortex (the outer layer of the brain) and the brain axons; the inflammation was "particularly striking in the cerebellum"—the subcortical area with close links to the vestibular system (which is targeted by sound therapy). Recall, as I discussed in Chapters 4 and 5, that the cerebellum fine-tunes thought and movement; it is also stimulated by newer versions of sound therapy.
Since 2008 five studies have shown that a significant number of autistic children have antibodies coming from their mothers that targeted their brain cells while they were still in the womb. One study found that 23 percent of mothers of autistic children had such antibodies. By comparison, only 1 percent of mothers of children without autism had these antibodies. Scientists don't understand what triggers the antibodies, but likely the mother was exposed to an infection or toxin that altered her immune system. When this kind of antibody was injected into pregnant monkeys, their offspring showed behaviors similar to those of autistic children. Autistic children also have high levels of antibodies in their blood. (Whether vaccinations, designed to trigger antibodies, can trigger problematic inflammation in a subgroup of children is controversial and is dealt with in the endnotes.) Herbert's theory is that all these stresses and inflammation affect the brain and damage the neurons.*
Chronic inflammation disturbs developing neuronal circuits. Brain scans show that many neuronal networks of autistic children are "under-connected" and that neurons at the front of the brain (which deals with goals and intentions) are poorly connected with those neurons at the back (which process sensation). Other brain areas show "overconnectiv-ity," a problem that can lead to seizures, also common in autistic children. Underconnection and overconnection combined may make it hard
* Herbert's theory is that when "demands are placed on the whole body by a combination of poor food, toxins, bugs, and stress, likely with genetic vulnerabilities in the mix," the brain's support system is overwhelmed. Herbert and Weintraub, The Autism Revolution (New York: Ballantine Books), p. 119. Inflammation produces a lot of waste. The brain, like the rest of the body, always has to clear away waste products and dead cells, then rebuild and resupply new nutrients to the neurons. The brain's glial cells perform this task. When glial cells are overwhelmed, they swell and can't adequately support their neurons; the blood supply to the neurons is decreased, and their mitochondria (the energy generators in the cell, discussed in Chapter 4) are stressed. Eventually some neurons, no longer properly supported by their glial cells, start "idling" and stop performing their normal signaling functions. As I have emphasized, when neurons are dysfunctional or injured, they still fire, producing "noise," or they become overexcited or dysregulated. When the glial and neuronal system is overwhelmed, Herbert points out, a brain chemical, glutathione, which normally excites neurons, is released in large quantities. This contributes to neurons becoming too excitable and may lead to hypersensitivities and, in my terms, a noisy brain.
for the brain to synchronize its activities between areas. In summary, autism is the product of genetic risk factors and many environmental triggers, which can sometimes affect the child before birth, sometimes after, and immune reactions and inflammation are prominent. These combined factors overwhelm the developing brain, so that neurons don't connect properly and can't communicate well with one another.
Neuroscientists have recently learned more about "wiring issues" in autism, which help explain how listening is affected by the condition. In July 2013 Stanford University scientists led by Daniel A. Abrams and Vinod Menon showed that in autistic children, the area pf the auditory cortex that processes the human voice is underconnected to the brain's subcortical reward center. When a person accomplishes a task, the reward center fires and secretes dopamine, triggering a good feeling and reinforcing the motivation to repeat that task. The study, which used a special MRI that shows linkages among brain areas, found that speech areas in the left hemisphere (which process the more symbolic parts of speech) and speech areas in the right hemisphere (which process the musical and emotional components of speech called prosody) were underconnected to the brain's reward center. The outcome? A child who can't connect the brain areas that process the voice with the reward center will be unable to experience speech as pleasurable.
How Listening Therapy Helps Autism
This loss of the pleasure of speech, I believe, has a devastating impact on a child's ability to bond with his or her parents or with anyone else. Leo Kanner, who in 1943 first described autism, noticed that these children seemed indifferent to the human voice and made no attempt to speak; one of his patients "did not register any change of expression when spoken to." It is now clearer that the voice plays a role in parent-child bonding, and that indifference to it has implications for the bond. A 2010 study revealed that when a nonautistic child is stressed, then hears his or her mother's voice, oxytocin is secreted in his brain. Oxytocin is a brain chemical that induces a calm, warm mood and increases tender feelings and trust, allowing parents and children to bond with each other. The parents' voices soothe the child and promote the development of communication. But oxytocin levels are significantly lower in people with autism. (The cause of the lower oxytocin is not yet worked out, but I suspect it is often secondary: as I will describe shortly, in many children it may be a result of auditory sensitivities making listening painful, leading to an undercon-nectivity between the auditory areas and the brains reward center.) Whatever the cause, no "vocal bonding," to coin a phrase, occurs.
While many autistic children are indifferent to the pleasure of the voice, they are not indifferent to sound. Most are hypersensitive to sounds, which is why they so often cover their ears in great distress, and their nervous systems go into fight-or-flight mode. To understand why this reaction occurs, and how music can help bond a mother and an autistic child, I wish to emphasize a few key points about evolution.
The neuroscientist Stephen Porges has shown that specific sound frequency ranges are tied to our sense of safety or danger. Each species has different predators, and the sounds made by those predators turn on the preys fight-or-flight reaction. A direct link exists between the auditory cortex and the threat systems in the brain, which is why unexpected, startling noise can trigger immense, immediate anxiety. Species also evolved to communicate in sound frequencies that their predators are unable to hear. (Reptiles, which have preyed on medium-size mammals such as humans for millions of years, cannot detect the frequencies of human speech.)
When people feel safe, the parasympathetic nervous system turns off the fight-or-flight reaction. As Porges has brilliantly demonstrated, the parasympathetic system also turns on a "social engagement system," as well as the muscles of the middle ear, allowing people to listen to, communicate with, and connect with others. The parasympathetic system helps us connect with others precisely because it regulates the brain areas that control the middle ear muscles, which are used to tune in to the higher frequencies of human speech and also turn on the muscles used for vocal and facial expression. Being in "parasympathetic mode" is about being calm, collected, and connected.
Tomatis showed that many children with autism, learning disabilities, and speech and language delays—and also those who have had multiple ear infections—cannot tune in to the frequencies of human speech because they cannot use their middle ear muscles to dampen the lower frequencies. When lower frequencies are at full volume, they mask the higher sounds of speech, leaving autistic children hypersensitive to sound, especially continuous sound, such as vacuum cleaners, and alarms. In humans low-frequency sounds also trigger anxiety because they remind us of predators. Battered by sound, these children remain in fight-or-flight and cannot turn on the social engagement system-Training the circuit that controls the middle ear muscles can decrease hypersensitivity and increase social engagement (as Tomatis said) so that attachment to others can become pleasurable.*
The findings of Porges, Tomatis, and others, I believe, mean that it is time to rethink the theory that the core feature of autism is an inability to empathize and apprehend the existence of other minds. This may not always be the case. Children who are constantly battered by their sensations, and who are in constant fight-or-flight, cannot turn on or develop their social engagement systems or be aware of other minds. Their inability to be aware of other minds may often be secondary to the brains sensory processing problems. As Paul puts it, the purpose of our sensory systems is "both to reach out to the world, but also protect u$ from the world of sensation. But if you are too sensitive, you develop mechanisms to cut the world off."
* Porges points out that one can tell when children are hypersensitive to sound by looking at them. The "facial nerve," which regulates the middle ear muscle, the stapedius, also regulates the muscles that lift the eyelids and control facial expression. When we are interested in what a person is saying, our middle ear muscles contract, allowing us to tune in on the person's speech frequencies and keep our eyelids open wide. We look interested. By reading facial expressions, an experienced teacher can tell whether a student is listening in class or whether the lesson is falling on deaf ears. In many autistic children, this circuit isn't working, so they look vacant: their facial muscles are flat and unexpressive.