Everything is unexpected At autism’s core may lie a reduced ability to predict what will happen next, suggests a new theory in neuroscience. The theory may help explain why a sensory-laden experience like visiting the dentist can be so terrifying for children on the spectrum—and how prediction support could quell their fear. Features
Free
Features  |   April 01, 2015
Everything is unexpected
Author Notes
  • Bridget Murray Law is editor-in-chief of The ASHA Leader and mother of a son on the autism spectrum. bmurraylaw@asha.org
    Bridget Murray Law is editor-in-chief of The ASHA Leader and mother of a son on the autism spectrum. bmurraylaw@asha.org×
Article Information
Special Populations / Autism Spectrum / School-Based Settings / Healthcare Settings / Professional Issues & Training / Features
Features   |   April 01, 2015
Everything is unexpected
The ASHA Leader, April 2015, Vol. 20, 42-48. doi:10.1044/leader.FTR1.20042015.42
The ASHA Leader, April 2015, Vol. 20, 42-48. doi:10.1044/leader.FTR1.20042015.42
Not long ago, Lisa Cicchetti spent most of her energy just getting her 6-year-old son through the day. Kenny is on the autism spectrum, and his unusual behaviors dominated their lives: He’d run off without warning, scream uncontrollably when she ran the vacuum cleaner or throw a tantrum because she’d fixed a meal he didn’t like (which was most of them).
So getting Kenny to the dentist was not at the top of her list. Navigating physician check-ups had been ordeal enough; the pediatrician had said it was like wrestling an animal on a farm. “His sensory issues were so bad, so intense, it was all we were dealing with,” Cicchetti says. “And the dentists in our town of Wichita, Kansas, were just not equipped for it, so we put it off.”
This was a familiar story to Trisha Self, an associate professor of communication sciences and disorders at Wichita State University who treated Kenny and others on the spectrum in WSU’s speech-language-hearing clinic. She had long noticed oral health problems among children with autism spectrum disorder, and she wanted to help them and their parents. But how?
It just so happens that what she and her colleagues decided to do—intervene by helping these kids “see” what would happen in the dental chair—jibes with an emerging theory of how autism fundamentally operates.
Developed by a team of Boston-area researchers, “predictive impairment” theory holds that autism’s underlying deficit might be an impaired ability to anticipate what might reasonably happen next. This core deficit may explain the constellation of autism traits, from sensory hypersensitivity to problems with perspective-taking to motor difficulties and insistence on sameness, according to the theory’s architects—including Pawan Sinha and Richard Held of the Massachusetts Institute of Technology and Margaret Kjelgaard of the MGH Institute of Health Professions. They base this theory on 30 years of autism research and computational modeling of autism behaviors.
Through the theory’s lens, it could be that clinicians have for years been unknowingly targeting prediction deficits in ASD treatment. The WSU dental program is certainly an example. It was mainly through assistance with prediction, notes Self, that the WSU program sought to save the dental health of Kenny and his peers.
Prediction breakdown
To understand how inability to predict could play such an important role in autism, it helps to retrace the path of researchers in cognitive science and neuroscience. Sinha and Held in MIT’s Department of Brain and Cognitive Sciences and Kjelgaard at MGH’s Communication Sciences and Disorders Department had been wrestling with what could explain autism’s “laundry list” of clinical characteristics, says Kjelgaard. For example, people with ASD often struggle with perspective-taking, explained by “theory of mind”—a difficulty with seeing things as others do. But how does theory of mind connect to other autism characteristics, such as sensory hypersensitivity or insistence on sameness? Pawan Sinha, MIT professor of vision and computational neuroscience, had an idea. To investigate the team’s question, Sinha applied a computational formalism, the Markov model—to autism.
Researchers have used Markov models to model information processing across such domains as language, social functioning and play behavior in neurotypical people. These are all areas considered difficult for people with ASD, and seem unrelated.
However, when Sinha, together with neuroscientist Richard Held and other colleagues, applied the model to existing research on autism, the model showed that these behaviors share underlying probabilistic relationships that can unify them. The theory relates to another research team in Belgium, which independently proposed a similar hypothesis (Sander Van de Cruys models autism as a disruption in flexible processing). Comparatively, the MIT team proposes a theory characterizing the common thread among disparate traits as “outcomes of predictive impairment.”
“So if there’s fundamental difficulty among people with autism with predicting B, given A, over a period of time, then this can explain everything from hypersensitivity to sensory stimuli, to language difficulties, to problems in interacting with dynamic objects,” explains Kjelgaard, an associate professor of CSD.
Predictive impairment, for example, is suspected in difficulty with motor tasks like ball-catching. This is at first puzzling, especially because those on the spectrum are thought to excel in visuospatial areas—map navigation, block construction, puzzle-solving and so forth. The predictive-impairment hypothesis proposes an answer to this conundrum, too: In ASD there are “islands of proficiency”: enhanced areas of ability that tend to cluster in rule-based disciplines like math, drawing and music. In all these areas, outcomes are certain—and predictable.
Sensory onslaught
Zooming in through the predictive lens, consider what the world must be like when all is uncertain. Predictive-impairment theory’s authors describe it as a “magical world.” The unexpected events in a magic show are what make it engaging. However, if your daily experience is “magical” in that you don’t expect most of what happens, this naturally prompts avoidance and anxiety, Kjelgaard explains.
“Unpredictability is very strongly associated with anxiety,” Kjelgaard says, “and when individuals experience anxiety, they use strategies to cope. In autism, we see coping strategies, such as ritualistic behaviors, and self-stimulating or ‘stimming’ behaviors.”
Common stimming behaviors include repetitive humming, weaving, head bobbing or arm-flapping. Other coping strategies include reliance on routine, bonding with familiar adults and carrying familiar objects to new activities. When predicable routines change or unfamiliar figures replace familiar ones, anxiety surfaces and tantrums can result.
A particularly tough area for many on the spectrum is handling loud noise. Kjelgaard explains: “Imagine if you heard a loud fan in the background, but you could not predict whether that sound was going to be the same over time. Then you wouldn’t be able to ignore it, and this fan would therefore interfere with your ability to process other input. It would be an unrelentingly salient world of sensory information coming at you. That’s why we see these kids putting their hands over their ears.”

“Imagine if you heard a loud fan in the background, but you could not predict whether that sound was going to be the same over time ... It would be an unrelentingly salient world of sensory information coming at you. That’s why we see these kids putting their hands over their ears.”

Prescription for prediction
Now consider the prospect of a dental visit for a child who already finds the world unrelentingly uncertain. First there’s the unfamiliar masked figure in the white coat. Then there’s the table of sharp metal instruments. And now the masked figure is looming with one of those instruments.
Of course, dental visits can be anxiety-producing even for those of us experienced with them. The difference is a neurotypical child will more likely comply when taught about dental health benefits. Such explanations tend to go nowhere with children on the spectrum, possibly because of the prediction problem.
It’s no wonder that parents like Lisa Cicchetti balk at taking their child with ASD to the dentist, and that professionals like Trisha Self see so many oral health problems in these children. The data bear this out: Parents of U.S. children with ASD are more likely than parents of neurotypical children to describe their child’s dental health as fair or poor (almost a half versus 30 percent), found Dorota Kopycka-Kedzierawski and Peggy Auinger in a 2008 study published in Pediatric Dentistry. This a problem that has scale, considering that one in 68 children has ASD, according to data from the U.S. Centers for Disease Control and Prevention.
To intervene at WSU, Self enlisted the help of fellow speech-language pathologist Terese Conrad, clinical educator at WSU’s speech-language-hearing clinic, and Kelly Anderson, associate professor in the university’s dental hygiene department.
Like Self, Conrad had noticed parents’ reluctance to take their kids to the dentist, and understood why. They feared having to use sedation. And many already struggled just to have their children brush their teeth.
“A family would try one approach to tooth-brushing, and it would go badly,” Conrad says. “And when you’re choosing between that and getting the child to eat and sleep at night, naturally you’re going to prioritize.”
Now, working with Self and Anderson, Conrad saw a chance to ease the oral-health battles for these families. And for her part, Anderson—once Self’s dental hygienist—saw a chance for her students to learn how to serve these children and avoid needing to sedate or hospitalize them to treat advanced cavities and infection.
“Textbooks for dental professionals don’t include information on treating kids on the spectrum,” Anderson says, so it made sense to partner with the speech-language clinic. The team launched its eight-week joint program in 2011, for four children, ages 7 to 9, including Kenny. The team aimed to successfully get the children through an initial visit, navigate future visits without problems and regularly brush their own teeth. And the central tools in their arsenal—social stories, role-playing and visual schedules—appear to dovetail with predictive-impairment theory because they help the children actually see what happens during a visit.
To understand exactly what the WSU team did, let’s walk through some key challenges in autism, considering how the predictive impairment theory explains each one—and how the dental program targeted it.
Insistence on sameness
Predictive impairment
Studies indicate that more than a third of people on the spectrum display this insistence (see sources), which manifests as repetitive thoughts and actions, rigidity, a need for routine, and resistance to change. As proposed in predictive-impairment theory, a person with ASD may seek the familiar because it is predictable, allowing the person some control over an otherwise unpredictable world.
Dental program
Trisha Self and Terese Conrad know that, to feel safe, children on the spectrum need constant, familiar adult figures seen regularly in reassuring circumstances. So they built their dental intervention on this platform: The dental preparation (and ultimate examination) happened right in the speech-language clinic, with students even hauling in folding dental chairs and dental instruments. A pair of speech-language and dental-hygiene students worked with each child. “Developing a bond and trust between clinician and child was absolutely key,” Conrad says.
Sensory hypersensitivities
Predictive impairment
More than 90 percent of people with autism experience extreme sensitivity to loud noise, bright light, unpleasant textures and other sensory discomforts (see sources). According to predictive-impairment theory, this sensitivity may be because the person cannot predict whether and how the sensory assault will continue, change or end. Thus, it cannot be blocked out as it can by a neurotypical person. The authors of predictive-impairment theory compare the experience to “acoustic bombardment” in the world of torture, where unpredictable and unfamiliar stimuli are shown to be particularly effective. Torturers expose listeners to unfamiliar patterns and types of music, unexpectedly varying the volume until the listeners are racked with anxiety and learned helplessness.
Dental program
Sensory invasion is perhaps the toughest aspect of a dental visit for children on the spectrum, so the program focused intensively on what they would see, hear and feel. The keys to desensitization here were the social story and the work system, essentially a visual schedule. The social story describes and illustrates exactly who attends the dental visit, using photos of real children and students. The story also shows what instruments are used and for what purpose, and who wears what: bib and glasses for the patient, and mask and gloves for the dentist. Meanwhile, the visual schedule outlines the exact examination steps, which the child checks off as each is completed. These visual tools initially prime children for a simple oral examination, and ultimately prepare them to get their teeth cleaned and learn to brush their teeth.
Perspective-taking difficulty (theory of mind)
Predictive impairment
Another autism hallmark is difficulty understanding another person’s motivations in a given situation, and tailoring one’s own behavior accordingly. This deficit creates social difficulties. The predictive-impairment theory proposes that a person with ASD experiences another’s behavior and actions in a momentary context, not in terms of history and likely probabilities. It is difficult for a person on the spectrum to predict how a person might act based on the context of the interaction.
Dental program
The child with autism likely doesn’t see the dentist as somebody who wants to help. He or she just sees a scary white-coated person on the attack. To counter this perception, the students held several short sessions with the children before introducing masks and gloves. The students let the children try on the masks and gloves too, so that they could take on the hygienist’s role of helping them. They even looked inside the students’ mouths. Conrad notes that in a similar program to help children with doctors’ visits, the children initially bond with the nurse during short “happy visits” before they are ever examined.
So … what’s next?
Speaking of prediction, what’s the current status of the WSU dental program and where is it headed? As the university installs a dental residency program, the dental hygiene and CSD departments seek to partner with these dentists. They hope to provide them with tools needed to work successfully with children on the spectrum. All involved aim to continue the program, as it benefited both children and students.
For instance, the program opened CSD student Corissa Shelite’s eyes to the ways predictive visual aids can apply outside the treatment room—to such tricky areas as restaurants, hair salons and public transportation. In the case of a school bus ride, it could address “the seat belts, the loud noise from the motor, the bumpy ride, the kids talking, the smells, all those factors keeping the child from successfully participating with peers,” she says.
Meanwhile, WSU’s dental/CSD collaboration extends its tendrils: Anderson’s dental students visit the speech-language clinic to learn about ASD sensitivity, and Anderson incorporates the visual support preparation into her lectures. Anderson’s students also work with Self’s students on an autism early-identification program (see sidebar below).
As for what’s ahead for predictive-impairment theory, Kjelgaard and her colleagues are hard at work validating it in new studies of people with ASD across different age ranges. They hope this work ultimately contributes to earlier ASD diagnosis and more effective ASD treatments that address underlying causes rather than higher-order symptoms.
Though not tied to Kjelgaard’s work, WSU’s prediction-based dental program already shows anecdotal signs that addressing predictive impairments can benefit children with ASD.
Kenny, for one has made major progress.
He’s visited the dentist three times since he graduated from WSU’s program because he knows exactly what to expect, says his mother, Lisa Cicchetti. “All went smoothly,” she says. “His only concern was that the dentist might yank his teeth. That, of course, did not happen, but Kenny did undergo anesthesia so the dentist could apply sealant. He endured it, no problem. And his mother is forever grateful to the WSU program.
“Every child on the spectrum is different, so you can’t say this program is going to work exactly the same for each child,” Cicchetti says. “But what you can say, with certainty, is that any child on the spectrum will benefit from this preparation. Absolutely.”
Program Helps Children Jump the Waiting List to Receive Earlier ASD Diagnoses

It’s a familiar story: Every day the developmental pediatrician’s waiting list for new patients grows longer. And every day another child on the autism spectrum waits months, even years, for the initial diagnosis—time that child could have been getting services.

To Trisha Self, that situation is unacceptable. And there’s no better place to start a change than locally. So Self, associate professor in the Communication Sciences and Disorders Department at Wichita State University, spearheaded an interdisciplinary screening program to catch children earlier.

With support from department chair Kathy Coufal, Self tapped faculty and students from CSD (speech-language pathology and audiology), clinical psychology, physical therapy, early childhood, dental hygiene, physician assistant and social work to screen young children on the waiting list of a developmental pediatrician in their town of Wichita, Kansas. Each month an advanced practice registered nurse flags a child for the team to screen, and if the team suspects ASD, that child gets an immediate appointment with the pediatrician. To learn more about the program, watch the ASHAsphere blog this month for a post from Self.

Sources
Auinger, P., Kopycka-Kedzierawski, D. T. (2008). Dental needs and status of autistic children: Results from the National Survey of Children’s Health. Pediatric Dentistry, 30(1), 54. [PubMed]
Auinger, P., Kopycka-Kedzierawski, D. T. (2008). Dental needs and status of autistic children: Results from the National Survey of Children’s Health. Pediatric Dentistry, 30(1), 54. [PubMed]×
Gray, K. M., Tonge, B. J. (2005). Screening for autism in infants and preschool children with developmental delay. Australian and New Zealand Journal of Psychiatry, 39(5), 378–386. [Article] [PubMed]
Gray, K. M., Tonge, B. J. (2005). Screening for autism in infants and preschool children with developmental delay. Australian and New Zealand Journal of Psychiatry, 39(5), 378–386. [Article] [PubMed]×
Leekam, S. R., Nieto, C., Libby, S. J., Wing, L., & Gould, J. (2007). Describing the sensory abnormalities of children and adults with autism. Journal of Autism and Developmental Disorders, 37, 894–910. [Article] [PubMed]
Leekam, S. R., Nieto, C., Libby, S. J., Wing, L., & Gould, J. (2007). Describing the sensory abnormalities of children and adults with autism. Journal of Autism and Developmental Disorders, 37, 894–910. [Article] [PubMed]×
Sinha, P., Kjelgaard, M. M., Gandhi, T. K., Tsourides, K., Cardinaux, A. L., Pantazis, D., … Held, R. M. (2014). Autism as a disorder of prediction. Proceedings of the National Academy of Sciences of the United States of America, 111(42).
Sinha, P., Kjelgaard, M. M., Gandhi, T. K., Tsourides, K., Cardinaux, A. L., Pantazis, D., … Held, R. M. (2014). Autism as a disorder of prediction. Proceedings of the National Academy of Sciences of the United States of America, 111(42).×
Van de Cruys, S., Evers, K., Van der Hallen, R., Van Eylen, L., Boets, B., de-Wit, L., & Wagemans, J. (2014). Precise minds in uncertain worlds: Predictive coding in autism. Psychological Review, 121(4), 649–675. [Article] [PubMed]
Van de Cruys, S., Evers, K., Van der Hallen, R., Van Eylen, L., Boets, B., de-Wit, L., & Wagemans, J. (2014). Precise minds in uncertain worlds: Predictive coding in autism. Psychological Review, 121(4), 649–675. [Article] [PubMed]×
1 Comment
April 30, 2015
Janice Nathan
Everything is Unexpected
Bridget, Thank you so much for publishing this article! I have read some research about this, and have been explaining this to families and professionals, so as to veer away from looking at an individual with "behavior" that needs to be extinguished, but rather as an individual with anxiety that needs to be supported and learn how to interpret his/her feelings so as to understand them, and thereby decrease the "anticipatory" anxiety. Janice Nathan, M.S., CCC-SLP
Submit a Comment
Submit A Comment
Name
Comment Title
Comment


This feature is available to Subscribers Only
Sign In or Create an Account ×
FROM THIS ISSUE
April 2015
Volume 20, Issue 4