Research Proposal

Research Proposal:

Autism Spectrum Disorders and their relation to Traumatic Brain Injuries

Name: Heather Browne 5893177

Class: Professional Research Internship RSCH74000

Professor: T. Wideman-Johnston

Date: February 24, 2017

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Introduction/Rationale

The goal of this paper is to take examine the various similarities that might exist

between the symptoms of Autism Spectrum Disorders (ASD) and Traumatic Brain Injury

(TBI) in children, and what opportunities that may present to improve treatment.

Although Singh et al. (2016) states that TBI and ASD share not only similar symptoms

but also some of the same biologic mechanisms that cause these symptoms (p. 1), the

true nature of these similarities, and what they might mean for future treatments,

therapies, supports and medications are yet to be known. Ultimately, the object of this

research is to illuminate some of these areas where similarities in symptoms exist. If

there is value in this research then the possibilities could be many for children and

adults who are on the autism spectrum, so that their daily lives can be enhanced.

Presently because these conditions are still very much a mystery to medical

professionals and researchers, actual solutions are virtually unheard of.

One reason for this discrepancy, as noted by Dean et al. (2017) is that the term

spectrum reflects that it is not yet possible to reliably distinguish or validate clinically

meaningful subcategories of ASD at the clinical, biomarker, or neuroimaging level (p.

55). ASD are usually treated through a lens of behavior and behavior management and

not much is done to address the underlying causes of those behavior problems. This

suggests that even with the enormous amount of research available, that autism

research is still, very much, in its infancy. As a result of these uneven methods of

treatment, many adults and children must go through a process of trial and error with

medications that can sometimes be long, before they find a course of treatment that

addresses their most significant symptoms. While this plan of action may seem

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inadequate, it is the best that many can hope for when dealing with a wide spectrum of

symptoms ranging from very mild to very severe.

Still, similarities between the symptoms of TBI and ASD can almost be seen as

interchangeable. Wang et al. (2014) describes ASD as highly heterogeneous and

encompassing a wide range of deficits including social impairment, communication

difficulties, and repetitive and stereotyped behaviors (p. 518); while in very similar

language Benedictus describes TBI as "impairments consisting of physical limitations,

but also cognitive, social, and behavioral limitations (p. 1436). Not yet known is how

these similarities can be a way to improve treatment for both conditions moving forward.

In reaching its goal, this research hopes to pinpoint the areas where there are

parallels between the symptoms of ASD and those of TBI. The research will focus on

the specific areas where these parallels are most pronounced, or where they are seen

most frequently. The symptoms of both conditions are most often seen in the behavior

profiles of those diagnosed with both conditions, brain differences that may contribute to

symptoms for the conditions, and the cognitive impairments that are present with both of

these conditions.

Definition of Terms
Autism Spectrum Disorders (ASD) -- Autism Spectrum Disorder (ASD) is a

complex neurobiological condition that can affect the normal function of the

gastrointestinal, immune, hepatic, endocrine and nervous systems. It impacts normal

brain development leaving most individuals with communication problems, difficulty with

typical social interactions, and a tendency to repeat specific patterns of behavior. There

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is also a markedly restricted repertoire of activity and interests. The term spectrum

refers to a continuum of severity or developmental impairment (About Autism, 2016).

Traumatic Brain Injuries (TBI) -- "Traumatic brain injury" means an acquired injury to the

brain caused by an external physical force or by other medical conditions, including but

not limited to stroke, anoxia, infectious disease, aneurysm, brain tumors and

neurological insults resulting from medical or surgical treatments. The injury results in

total or partial functional disability or psychosocial impairment or both, that adversely

affects a child's educational performance (Traumatic Brain Injury, n.d.).

Research Question

The question that the article poses and intends to answer: What are the

similarities and associations between the symptoms of ASD and TBI? And, can existing

research into the symptoms and treatments of one condition be used to benefit children

who are diagnosed with the other? In Ontario, 36% of all hospital visits for TBI were

among children and youth (Chan et al., 2013); while ASD rates in the US, according to

the Centers for Disease Control are as many as 1/60 children (Theoharides, 2015). This

is a significant issue for the Waterloo Region, and specifically, school boards in the

Region which are struggling to provide the best services for the children in their care.

Many of these children are facing deficits in domains of cognitive, behavioral/social,

physical, psychological, and emotional; a range so wide that it is an insurmountable task

on the part of school boards to provide adequate care specific to each childs needs.

A significant part of this problem is the lack of intervention at an early age,

Autism Canada has talked to thousands of parents and there has been a similar

refrain. Early diagnosis didnt happen because practitioners dismissed early red flags

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(The Waterloo Record, 2016). As there is much uncertainty around the condition, the full

effects of a wait and see approach is still not yet known. Often, services under financial

strain may not have many options available when it comes to working with the growing

demand in this area. Combined with this late detection of autism with the months or

years-long wait times for diagnosis in the public health system, followed by months or

years-long waits for treatment, there are children who miss the opportunities for early

intervention affords (The Waterloo Record, 2016).

Additionally, there are instances where accommodations that could be helpful to

students with ASD are refused because they are not specifically stated in school board

policy statements. In one such instance, parents of a student with the Waterloo Region

School Board has petitioned the provinces human rights tribunal on their sons behalf.

They believe that the boards policy which states that requests for the use of

Companion Dogs and Service Animals will only be considered as a last resort to

accommodate the students demonstrated disability needs (The Waterloo Record,

2016) impedes their sons right to an education.

At present, in the Waterloo Region and in countless other communities,

thousands of children are subsisting on substandard care because not enough is known

about their conditions to provide the specific care that they may need. Or, in some

cases, age old policies have not yet caught up with the rising rates of ASD diagnoses.

As it stands, this system, while it may be functioning, may also interfere with the type of

education that children may receive, and in the longer term, the quality of life they will

have in adulthood. If children with these diagnoses are unable to access an education

then, it stands to reason that their futures will be compromised.

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Presently, there are numerous voids in the management of ASD, these exist in

the services that are offered and the coordination of those services, the types of

treatments and therapy possibilities available, as well as the ways that the education

system is dealing with children with these conditions. Ideally, these new solutions will

not only benefit the children involved who are facing these diagnoses but the entire

community. In order for adults on the autism spectrum to function as contributing

members of society, they must be sufficiently equipped maneuver obstacles in their

personal and professional lives. The most efficient way of accomplishing these tasks is

if there is adequate information available on their conditions, and if they are provided

with workable remedies to their symptoms that will permit them to be productive

citizens.

Theoretical Framework

The object of this research is to compare and contrast aspects of both conditions

from a physiological standpoint, looking at the various ways that both affects the body

and functioning of the body. The point of focus is autism, the condition itself is not the

area of study, but how it is studied and how the results of those studies might be

beneficial. As such, this could be seen from a constructivist point of view. The current

research seeking to build on existing knowledge while simultaneously broadening the

scope as a way of adding to the knowledge base.

While TBI is known to be a medical condition that is assessed, diagnosed, and

treated as such, ASD presents a much more complicated picture, is categorized as

psychological disorders, and often diagnosed as such. Largely, ASD is uncategorized,

and symptoms are often treated individually instead of being considered as part of a

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larger whole. Currently, the method used to diagnose ASD is the American

Psychological Association Diagnostic Statistical Manual 5 th Edition (a standard

classification of mental disorders), which states that essential features of autism

spectrum disorder are persistent impairment in reciprocal social communication and

social interaction, and restricted, repetitive patterns of behavior, interests, or activities.

These symptoms are present from early childhood and limit or impair everyday

functioning (DSM-5, 2013 p. 53). The manual does not take into consideration any

medical factors that may be present, but there is a requirement for clinicians to record

when such factors are present (DSM-5, 2013 p. 51). While the DSM-5 makes mention

of TBI, it does so only as a contributing factor to other conditions such as Bipolar

Disorder.

The guiding theory in this instance is that the source of the difficulties with both

conditions lie in the brain, and as such, it could be conjectured that the answers would

also be found in the brain. For too long, ASD, because of its vast range of disorders and

symptoms, was given over to the field of psychology, an inexact science. However,

should brain scans be given to children suspected of being on the autism spectrum as a

matter of routine? At this point, there is a vast amount that is unknown about how and

why the brain affects behavior and other physical functions, and yet, it seems that in a

situation where research by Wang et al. (2014), Dean et al. (2017) and Theoharides et

al. (2015) points to the brain as a major player, that is all but ignored and given over to

the area of psychology. When a possible TBI presents itself to medical professionals, no

one questions whether or not the brain should be examined. It would seem that the

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same courtesy should be given to those who are suspected of being on the autism

spectrum.

Literature Review
In looking at the research on TBI and ASD, it is clear that some of the ways that

both conditions affect the body are quite similar. This review will show the how both

conditions are marked by the same symptoms, and also show how those symptoms

have been extensively studies separately as they relate to each condition. For the

purposes of contrast and comparison, this review will focus on behavior symptoms,

brain differences and cognitive irregularities. While these areas are not the only ones

where common bonds exist, they do provide the most evidentiary basis for this study.

While many studies focus on the brain, they each focus on a different section of

the brain, and how activities in that section may affect a particular set of symptoms. For

example, Wang et al. (2014) focused their research on the role of the cerebellum in the

maturation of non-motor circuitry, and cognitive development. They also noted the

susceptibility of the fetal brain to hundreds of autism risk factors (p. 519). As counter

point to this research, Chan (2013) points to the role of retinal hemorrhage as a

predictor of TBI in children, making the argument that retinal hemorrhage is often the

result of swelling in the brain (p. 4). In these instances, both researchers are pointing to

the same area of the brain as the source for each condition. Fauzan and Amran (2015)

had a different interest altogether, namely, the effect that brain waves may have on

language and behavior. In contrast, Mottron et al. (2015) concentrated on the way that

the protective cerebral plasticity in female brains may account for the lower ratio of

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females to males in autism. And in another area, Dean et al. (2017) focused on the

diversity of the brains white matter on autism.

In certain ways, Mottron et al. (2015) and Dean et al. (2017) are in agreement

because, even though they may not have featured the same area of the brain in their

research, their ultimate goal was to show how activities in the brain are directly related

to symptoms of ASD. As the former looks at cerebral plasticity and the latter looks at

white matter, the myopic view would suggest that there are no commonalities. On the

contrary, the broad view would suggest that every exploration is significant as it

presents answers to questions that were previously unanswered. But, such is the nature

of the literature in relation to ASD, the spectrum provides an infinite amount of areas

were exploration and discoveries are necessary. There are no specific groups of studies

that focus on any one part of the brain seeking a given outcome. In the end, the result is

a mapping of the brain that resembles a puzzle with many parts still missing.

In the area of cognition, Ryan et al. (2016) concluded that associations between

severe pediatric TBI and reduced synaptic networks may point to early identification in

cases of cognition difficulties. (p. 690). This is significant for future ASD studies as the

main area of focus behavior problems is also one that has a considerable impact on

patients of ASD. Of note, Ryan et al. (2016) pointed out that participants needed to

show that there was no prior history of ASD before they could be approved for the

research (p. 684). This is understandable as the researchers may have been seeking to

create definitive lines between the conditions and the nature of the outcome that they

would have.

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Benedictus et al. (2010) found that TBI was responsible for cognitive impairments

that included mental slowness, attention deficits, as well as memory and executive

problems; they concluded that in the cognitive domain, more studies were necessary to

fully understand the impact in these areas (p. 1440). This research was one of the few

that focused on adult patients and how TBI might impact their lives. Even though the

scope of this study was outside of the focus of the present research, it was just as

significant as it helped to bolster some of the other literature and their findings. For

example, Knigs et al. (2015) who also concluded that lapses in attention were one of

the major deficits that resulted from TBI (p. 1). The domain of behavior followed the

pattern of the two previous domains with many similarities of symptoms between TBI

and ASD. Rao et al. (2009) concluded that aggression is a common occurrence in TBI

patients and is often characterized by verbal attacks. Findings also suggest a

correlation with depression (p. 428).

Overall, the literature that document similarities found that brain differences that

occur in TBI patients produce the same effects as those seen in children with ASD

(Singh, 2016 p. 2). This is a marked difference compared to most of the other studies.

Singh et al., (2016) concludes that these differences creates the susceptibility in both

groups towards sensory processing dysfunction (p. 9).

Methodology
A grounded theory method will be used to create a theory and to arrive at

answers to the research questions. Grounded theory has been described as a

methodology for developing theory that is grounded in data systematically gathered and

analyzed (Strauss and Corbin, 1994, p. 273). This method was most compatible with

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the subject matter because it approaches the established literature with an unbiased

perspective. Strauss and Corbin (1994) suggests that grounded theory should not be

restricted by its boundaries, but should maintain an air of openness and a consideration

of multiple perspectives (p. 276). This framework allows the researcher to follow the

path of the findings to their natural conclusion, this is vital to the research process.

Strauss and Corbin (1994) further maintained that disregarding unforeseen possibilities

was to obstruct any new or innovative meaning that might be achieved (p. 276). These

concepts align with the current research because coding and analysis brings with it new

ways to unearth undiscovered ideas.

The process of collecting articles for this research was arduous at times,

especially when titles that seemed to have enlightening and substantive input were

unavailable. It is unfortunate that valuable information in past research that might inform

this process swill remain unseen. In many ways, that was also the impetus for more

fine-tuning and shaping of search terms and the expansion of possible databases for

use. These databases were used extensively to access the newest and most relevant

research on the topic. There is a wealth of research on autism and brain injuries,

however, accessing the ones that would offer useful insights into the intersection of both

areas is a very daunting process. One particular roadblock that was encountered was

the specificity of the majority of the research. While this may not necessarily be a

negative, it often turned into a hindrance when topics related to isolated areas of the

brain were examined in isolation, without regard to context to other factors, ideologies,

or concepts. As Strauss and Corbin (1994) noted, knowledge is linked to time and

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place, so efforts -- whether intentional or not -- to disregard those similarities can only

be a detriment to the field and advances that could be made (p. 276).

Conclusion
Even though there is much research to be done in this particular area, it would

appear that a germ is present on which a more solid foundation could be built. With

each new study, on any of the aspects associated with this topic, another piece will be

added to the structure that, on day, will create a complete building. The long view with

research is for children who are diagnosed on the autism spectrum to have all the

resources available that would make their world more manageable, even if those

therapies were originally created as solutions for TBI. Ultimately, children with

diagnoses on the autism spectrum should be able to have access to everything that

they need to ensure that they can fully participate in the society of which they are a part.

Additionally, there is the possibility that existing research that focused on only one these

condition may now be looked at in a new light to be beneficial to both.

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References
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