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Making neuroimaging accessible for more autistic children

Many autism researchers use neuroimaging techniques to better understand how the brain differs between autistic and non-autistic people. But much of that work excludes autistic people who are minimally verbal or have intellectual disability — largely because researchers have assumed scanning such individuals would too difficult, says Emily Kuschner, assistant professor of psychology in psychiatry at the University of Pennsylvania in Philadelphia.

“That’s 30 to 40 percent of the population not being represented in neuroscience findings,” Kuschner says.

Some autistic children with limited verbal or cognitive abilities may have trouble following directions about scanning or lying still for long periods of time, for example. So Kuschner designed a protocol to help researchers using magnetoencephalography (MEG) ease the experience for these children.

Researchers often turn to MEG, which captures the brain’s electrical activity using magnets, to study how the brain responds to sound. Some research hints that delays in such responses could contribute to speech and language difficulties in some people with autism. But without the ability to study these responses in autistic people who are minimally verbal or have intellectual disability, whether those findings apply to them has been unclear.

MEG is also increasingly being used to study face processing, social cognition and motor function, Kuschner says. And researchers may be able to use the new scanning approach she developed with other imaging techniques, such as electroencephalography (EEG) and magnetic resonance imaging (MRI).

Kuschner talked to Spectrum about how she and her team designed the protocol and how it will help researchers include more autistic people in imaging studies.

Spectrum: What motivated you to develop this new protocol?

Emily Kuschner: Studies have excluded a large portion of children on the spectrum who have limited language or intellectual disability. From a social-justice, ethical perspective, it is an inequity we really wanted to address. It also limits the generalizability of results.

Our lab has found that kids on the spectrum who have mild language impairment show delays in processing auditory tones. But we had never looked at children with an [intelligence quotient] below 70 or with more severe language impairments. Do they have a further delay or is something different happening in the brain? We knew that needed to be the next step in our research. But we also knew that we needed to bolster how we prepare for and execute visits with these children and their families.

S: How does MEG differ from MRI or other kinds of imaging?

EK: What I like to say to families is that it’s somewhere in between the physical structure of an MRI and an EEG. Your head is in a machine, but not the rest of your body — which allows you to have a little more freedom with body movement.

The other benefit of MEG is that children and adults can be scanned while lying down or sitting up. In a pilot study, we found that this population of children in particular was just really nervous about lying down. Now we ask them or their parents their preference up front. So it gives you some really nice flexibility, which you don’t get with an MRI.

S: What was your process like for developing and testing the protocol?

EK: We took a collaborative approach with our families. We brought in parents or individuals on the spectrum who have intellectual disability or are minimally verbal or nonverbal, as well as some professionals and providers who work with that group of children. We did something called “walking interviews.” We would meet them in the garage at the hospital and then walk through every step of the process. And at each step we would ask them questions like, “What do you think about this aspect of the process? What would go well? What might be challenging?” We used that feedback to develop our protocol.

S: What are the steps of the protocol?

EK: The protocol is executed in three phases: an assessment phase, a plan and preparation phase, and then the MEG visit. At each stage, we get to know the child and the family better and can tailor exactly what’s going to happen at the MEG visit.

We start by having a behavior specialist call the family and get to know more about their child. What are their likes and dislikes? What are their triggers or any challenging behaviors that might be present? How do you respond to them in these situations? What are the best communication strategies to use?

We also give the families something we call practice plans, which describe the scan process and include personalized exercises for families to practice at home.

And then at the visit, we actively desensitize and help kids adjust to the environment. We do a lot of individual tailoring. There are many differential reinforcement strategies that we can use, figuring out what makes kids tick, what motivates them. If they’re a kid who has an obsession with elevators, we’re going to show them a video of elevators while they’re in the MEG, and maybe we’re going to use the elevators down the hall as rewards on breaks. Or maybe we’re going to avoid those elevators, if they’re going to be too distracting. You really try to understand who the child is.

On the technical side, the task in the MEG machine is passive, so the children are not making an active response. They can watch a video, with the sound off, while they’re listening to the tone. And everything is brief, so that you can have usable data in under 20 minutes.

On the clinical and behavioral side, a really key factor is to connect with parents and providers as partners in the process. They attend the scan with the child and help us every step of the way.

S: Is this approach more time-intensive than a usual scan?

EK: We budget three hours for the visit, which is a little bit longer than our usual slots. For the most part, each step we take is part of our process for any other imaging visit. We’re just more in depth and leave more time for whatever support is needed.

S: Do you think this could work for studies in which you need the children to be more actively engaged?

EK: I think the protocol will still apply. You need to make sure that your instructions are aligned with the child’s cognitive and language performance. Some of what we found to be really successful is that if they are a kid who is captivated by a screen, if we could just get their favorite movie or their favorite video on that screen and get them engaged in it, the other pieces were a bit easier. Depending on what active task you’re asking them to do, it’s a different kind of demand than “Hey, just sit here and look at your favorite video.” I don’t think it’s impossible. You just have to try to align your tasks with what the child is capable of and what they’re going to be interested in.

S: Is there a specific age group for which this approach works best?

EK: I think it can be widely used. We’ve adapted it for preschoolers and infants, and the same concepts all apply in terms of preparing and desensitizing. When you have younger children or children who have more limited performance in the language and cognitive areas, in some ways you’re desensitizing the parent as much, or more than, the child because they’re really your partner in the process.

S: What are your next steps for refining and disseminating the protocol?

EK: We’re happy to share all of our materials as a template for people to adapt for their own environments and technologies. Our next step is to figure out if we can predict how we need to personalize and tailor our protocol. Is there further screening we can do ahead of time to understand who is going to need which type of support? Where are we going to need to spend more time preparing this particular child? And can we get any better at predicting who is going to be successful when they reach the lab?

S: What response did you get from families about the experience?

EK: A lot of these families have always been excluded from research in the past. Their child had an intellectual disability diagnosis or an intelligence quotient under an eligibility cutoff, and so they just were never involved. They never got to come in and participate in research. Mostly, they were just excited to be there and wanting to contribute. They were happy to be part of the process and gain a little more information about their child during the evaluation.

The post Making neuroimaging accessible for more autistic children appeared first on Spectrum | Autism Research News.

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Compleat KiDZ

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this Notice of Privacy Practices, please contact our Privacy Officer, by telephone at (704) 824-7800 or in writing at 2675 Court Drive, Gastonia, NC 28054.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

A. WE MUST PROTECT YOUR PROTECTED HEALTH INFORMATION

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our Notice of Privacy Practices at any time. The new Notice of Privacy Practices will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised version by calling or writing our Privacy Officer and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

B. USE AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by our office staff others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you.
Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of our practice.
Following are examples of the types of uses and disclosures of your protected health information that we are permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

1. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider.
For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other healthcare providers who may be treating you.
For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to other health care providers (e.g., a specialist or laboratory) who become involved in your care by providing assistance with your health care diagnosis or treatment to us.
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3. Healthcare Operations: We may use or disclose, as needed, your protected health information for healthcare operations. These uses and disclosures are necessary to run Compleat KiDZ and make sure that all of our patients receive quality care. For example, we ma)'use protected health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine protected health information about many patients to decide what additional services Compleat KiDZ should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes, we may remove information that identifies you from this set of protected health information so others may use it to study health care and health care delivery without learning the identities of specific patients.
We may share your protected health information with third party "business associates" that perform various activities (for example, billing or transcription services) for our practice. Whenever an arrangement between our practice and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.
We may use and / or disclose protected health information to contact you to, remind you about an appointment you have for treatment or medical care.
We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health--related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you.
4. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree and Object:
We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. These situations include:
(i) Required by Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited d to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.

(ii) Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability.

(iii) Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

(iv) Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies t-rat oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

(v) Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

(vi) Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process.

(vii) Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes, these law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on our premises) and it is likely that a crime has occurred.

(viii) Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

(ix) Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

(x) Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

(xi) Workers' Compensation: We may disclose your protected health information as authorized to comply with workers' compensation laws and other similar legally established programs.
5. Other Permitted and Required Uses of Disclosures That Require Providing You the Opportunity to Agree or Object
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then we may, using professional judgment, determine whether the disclosure is in your best interest.

Others Involved in Your Health Care or Payment for our Care:

Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
6. Uses and Disclosures of Protected Health Information Based upon Your Written Authorization Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization.
C. YOUR RIGHTS
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights
1. You have the right to inspect and copy your protected health information
This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that we use for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records.
2. You have the right to request a restriction of your protected health information
This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

We are not required to agree to a restriction that you may request. If we agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your health provider.

You may request a restriction by making your request in writing to our Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
3. You have the right to request to receive confidential communications from us by alternative means or at an alternative location
We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer.
4. Your may have right to amend your protected health information
This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record.
5. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to make the disclosure, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure. The right to receive this information is subject to certain exceptions, restrictions and limitations.
6. You have the right to obtain a paper copy of this notice from us
upon request, even if you have agreed to accept this notice electronically.
D. COMPLAINTS
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint

You may contact our Privacy Officer at (704) 824-7800 for further information about the complaint process.

This notice was published and becomes effective on August l, 2011.