CHILDREN FIRST

What is ASD?

Autism Spectrum Disorder (ASD) is the most common neurological disorder affecting children and one of the most common developmental disabilities affecting Canadians in general. ASDs change the way the brain processes information and can affect all aspects of a person's development. Classic autism usually appears during the first three years of life. Autism is four times more common in boys than girls. Autism comes in many forms such as ASD, PDD, PDD-NOS, SDD, ADD, ADHD, CDD, Asperger Syndrom and Rett Syndrome.

Autistic Disorder (AD)

• Most common: ~20 in 10,000 Canadians
• Cognitive impairments
• Deficits in verbal and non-verbal communication
• Deficits in social understanding
• Unusual behaviours, restricted activities

General Characteristics of Autism

Autism varies tremendously in severity. Sometimes the syndrome is divided into low-, medium- or high-functioning autism (LFA, MFA, and HFA). Individuals with severe autism conditions may have serious cognitive disability, sensory problems and symptoms of extremely repetitive and unusual behaviours. This can include tantrums, self-injury, defensiveness and aggression caused by an inability to communicate. Without appropriate intensive intervention, these symptoms may be very persistent and difficult to change. Living or working with a person with severe autism can be very challenging, requiring tremendous patience and understanding of the condition. In its mildest form, however, autism is more like a personality difference caused by difficulties in understanding social conventions.

Children with ASDs develop differently and at different rates from other children their age in the areas of motor, language, cognitive and social skills growth. They might be very good at advanced or complex skills such as solving math problems but find the "easy" things, like talking or making friends' very difficult. Some children with ASDs develop large vocabularies and can read long words but may be unable to vocalize the sound of a single letter. A child may also learn new skills, such as saying a number of words, but lose this ability later on.

A Wide Spectrum of Disabilities and Different Abilities

Social Interaction:

• Some people with ASDs may prefer to be left alone, showing no interest in people at all. They may not notice when people are talking to them.
• Others may interact strangely with people. They might be very interested, but not know how to talk, play or relate to others. Difficulty "joining in" is common in ASDs because it is hard to "read" or understand other people. For adults, difficulty with verbal and non-verbal communication can make interaction with others very stressful.
• Children with ASDs may not relate to their own age group and prefer the company of adults.
• Some people with ASDs make no eye contact or are less responsive to eye contact. Some use peripheral vision rather than looking directly at others.
• They might not respond to or understand smiles and facial gestures.
• Touch may feel painful or upsetting to persons with ASDs and they might withdraw from family members. Children with ASDs might not like to be held or cuddled, or might cuddle only on their terms.
• People with ASDs often have trouble talking about their own feelings or understanding other people's feelings.
• Difficulty controlling emotion and excitement can also affect social interaction

Verbal and Non-verbal Communication:

• Speech and language skills may begin to develop and then be lost, or they may develop very slowly or they may never develop. Without appropriate intensive early intervention, more than 40% of children with ASDs do not talk at all.
• Some will communicate with gestures like pointing or reaching instead of words.
• It may be difficult or impossible to imitate sounds and words.
• Others have echolalia, which is repeating something heard. For example, if you ask, "Are you cold?" the response may be, "Are you cold?" instead of answering the question. The repeated words might be said right away or much later and may be repeated over and over. Or, a person might repeat something they heard on TV or in the past.
• Words may also be used without their usual meanings. People with autism may confuse gender, saying "he" when they mean "she" or vice versa, and/or pronouns (I, me, you).
• Non-verbal communication gestures such as waving goodbye or facial cues may not be understood.
• People with ASDs may have voices that sound flat and it might seem like they cannot control how loudly or softly they talk. There is often an unusual pitch and rhythm in speech.
• ASDs can make it very hard to initiate communication and to keep a conversation going. People with ASDs might stand too close to the people they are talking to. Some people with ASDs can speak well and have a wide vocabulary, but have a hard time listening to others. They might go on at length about something they really like, rather than have a back-and-forth discussion with someone.

Repeated and Unusual Behaviours, Interests and Routines:

• People with autism may have ritualistic actions that they repeat over and over again, such as spinning, rocking, staring, finger flapping, hitting self, etc.
• They may be overactive or very passive and can show intense anxiety or an unusual lack of anxiety. Anxiety, fear and confusion may result from being unable to "make sense" of the world in the usual way.
• They may take unusual risks with no fear of real dangers.
• Unusual postures, walking or movement patterns are common.
• They might fiercely depend on routines and want things always to stay the same so there are no surprises. Small changes in the environment or in daily routines that most people can manage (e.g. dressing in a different order, going to school by a new route or having new people around) might trigger acute distress or fear.
• People with ASDs often have a restricted pattern of interests and may have seemingly odd habits: they may talk about or focus obsessively on only one thing, idea, activity or person. Sometimes these habits or interests are unusual or socially inappropriate.

Responses to Sensations:

• People with ASDs may have both auditory and visual processing problems, and sensory input may be scrambled and/or overwhelming to them. Sensory sensitivities vary in autism, from mild to severe hyper and hypo-sensitivities.
• Unusual sensitivities to sounds, sights, touch, taste and smells: e.g. high-pitched intermittent sounds, such as fire alarms or school bells, may be painful. Rough or scratchy fabrics may be intolerable. People may have unusual sensitivities to the flickering of fluorescent lights. One or a combination of senses or responses can be affected.
• Some people with ASDs have very high pain thresholds (i.e. insensitive to pain) or very low pain thresholds.

Co-occurring Conditions:

Many individuals with autism have other health problems:

• Neurological disorders including epilepsy
• Gastro-intestinal problems, sometimes severe
• Compromised immune systems
• Fine and gross motor deficits
• Anxiety and depression

 

• Lack of spontaneous or imaginative play (e.g. may use only parts of toys; line up or stack objects; no imaginative/pretend play).
• An inability to imitate others. (e.g. sounds, gestures, gross or fine motor movements, etc.).
• Inability to focus on the task at hand. Some will have a very short attention span or concentrate only on one thing obsessively.
• Difficulty sharing attention with others.
• Difficulty with abstract ideas (e.g. difficulty using items or toys to represent real objects).
• Difficulty grasping the concept of time and order of events

Unique Abilities
Individuals with ASDs have their own strengths and unique abilities:

• Some people with an ASD have an accurate and detailed memory for information and facts, high visual recall and a superb ability to manipulate data for useful purposes.
• They may be able to concentrate for long periods of time on particular tasks or subjects and be far more attentive to details than most people.
• People with an ASD sometimes have unusually good spatial perception and exceptional long-term memories, allowing them to excel in areas of music, math, physics, mechanics, science and technologies, and architecture.

The main goals when treating children with autism are to lessen associated deficits and family distress, and to increase quality of life and functional independence. No single treatment is best and treatment is typically tailored to the child's needs. Families and the educational system are the main resources for treatment. Studies of interventions have methodological problems that prevent definitive conclusions about efficacy. Although many psychosocial interventions have some positive evidence, suggesting that some form of treatment is preferable to no treatment, the methodological quality of systematic reviews of these studies has generally been poor, their clinical results are mostly tentative, and there is little evidence for the relative effectiveness of treatment options.^[ Intensive, sustained special education programs and behavior therapy early in life can help children acquire self-care, social, and job skills, and often improve functioning and decrease symptom severity and maladaptive behaviours; claims that intervention by around age three years is crucial are not substantiated. Available approaches include applied behavior analysis (ABA), developmental models, structured teaching, speech and language therapy, social skills therapy, and occupational therapy. Educational interventions have some effectiveness in children: intensive ABA treatment has demonstrated effectiveness in enhancing global functioning in preschool children and is well-established for improving intellectual performance of young children. Neuropsychological reports are often poorly communicated to educators, resulting in a gap between what a report recommends and what education is provided. It is not known whether treatment programs for children lead to significant improvements after the children grow up, and the limited research on the effectiveness of adult residential programs shows mixed results.

Many medications are used to treat ASD symptoms that interfere with integrating a child into home or school when behavioral treatment fails. More than half of U.S. children diagnosed with ASD are prescribed psychoactive drugs or anticonvulsants, with the most common drug classes being antidepressants, stimulants, and antipsychotics. Aside from antipsychotics^, there is scant reliable research about the effectiveness or safety of drug treatments for adolescents and adults with ASD. A person with ASD may respond atypically to medications, the medications can have adverse effects, and no known medication relieves autism's core symptoms of social and communication impairments. Experiments in mice have reversed or reduced some symptoms related to autism by replacing or modulating gene function after birth, suggesting the possibility of targeting therapies to specific rare mutations known to cause autism.

Although many alternative therapies and interventions are available, few are supported by scientific studies. Treatment approaches have little empirical support in quality-of-life contexts, and many programs focus on success measures that lack predictive validity and real-world relevance. Scientific evidence appears to matter less to service providers than program marketing, training availability, and parent requests. Though most alternative treatments, such as melatonin, have only mild adverse effects some may place the child at risk. A 2008 study found that compared to their peers, autistic boys have significantly thinner bones if on casein-free diets; in 2005, botched chelation therapy killed a five-year-old child with autism.

Treatment is expensive; indirect costs are more so. For someone born in 2000, a Canadian study estimated an average lifetime cost of $3.74 million (net present value in 2010 dollars, inflation-adjusted from 2003 estimate), with about 10% medical care, 30% extra education and other care, and 60% lost economic productivity. Publicly supported programs are often inadequate or inappropriate for a given child, and unreimbursed out-of-pocket medical or therapy expenses are associated with likelihood of family financial problems; one 2008 U.S. study found a 14% average loss of annual income in families of children with ASD^. and a related study found that ASD is associated with higher probability that child care problems will greatly affect parental employment. U.S. states increasingly require private health insurance to cover autism services, shifting costs from publicly funded education programs to privately funded health insurance. After childhood, key treatment issues include residential care, job training and placement, sexuality, social skills, and estate planning.

 

What is PDD/PDD-NOS?

PDD-NOS is often incorrectly referred to as simply "PDD". The term PDD refers to the class of conditions to which the five disorders belong. PDD is not itself a diagnosis, while PDD-NOS is a diagnosis. To further complicate the issue, PDD-NOS can also be referred to as "atypical personality development", "atypical PDD", or "atypical Autism".

Because of the "NOS", which means "not otherwise specified", it is hard to describe what PDD-NOS is, other than its being an autism spectrum disorder (ASD). Some people diagnosed with PDD-NOS are close to having Asperger syndrome, but do not quite fit. Others have near full fledged autism, but without some of its symptoms. The psychology field is considering creating several subclasses within PDD-NOS.

Symptoms of PDD may include communication problems such as:

• Difficulty using and understanding language
• Difficulty relating to people, objects, and events; for example, lack of eye contact or pointing behavior
• Unusual play with toys and other objects
• Difficulty with changes in routine or familiar surroundings
• Repetitive body movements or behavior patterns, such as hand flapping, hair twirling, foot tapping, or more complex movements

There is no known cure for PDD. Medications are used to address certain behavioral problems; therapy for children with PDD should be specialized according to the child's specific needs. Some children with PDD benefit from specialized classrooms in which the class size is small and instruction is given on a one-to-one basis. Others function well in standard special education classes or regular classes with support. Early intervention, including appropriate and specialized educational programs and support services play a critical role in improving the outcome of individuals with PDD. PDD is very commonly found in individuals and especially in children with the range of 2 to 5 years of age. These signs can be easily detected within the classroom settings, home, etc.

What is ADHD?

ADHD may be seen as one or more continuous traits found normally throughout the general population. ADHD is a developmental disorder in which certain traits such as impulse control lag in development. Using magnetic resonance imaging of the prefrontal cortex, this developmental lag has been estimated to range from 3 to 5 years. These delays are considered to cause impairment. A diagnosis of ADHD does not, however, imply a neurological disease.

Attention-deficit hyperactivity disorder or ADHD is a common childhood condition that can be treated. ADHD may affect certain areas of the brain that allow problem solving, planning ahead, understanding others’ actions, and impulse control.

The American Academy of Child Adolescent Psychiatry (AACAP) considers it necessary that the following be present before attaching the label of ADHD to a child:

• The behaviors must appear before age 7.
• They must continue for at least six months.
• The symptoms must also create a real handicap in at least two of the following areas of the child’s life:
  • in the classroom,
  • on the playground,
  • at home,
  • in the community, or
  • in social settings.

If a child seems too active on the playground but not elsewhere, the problem might not be ADHD. It might also not be ADHD if the behaviors occur in the classroom but nowhere else. A child who shows some symptoms would not be diagnosed with ADHD if his or her schoolwork or friendships are not impaired by the behaviors.

Even if a child’s behavior seems like ADHD, it might not actually be ADHD; careful attention to the process of differential diagnosis is mandatory. Many other conditions and situations can trigger behavior that resembles ADHD. For example, a child might show ADHD symptoms when experiencing:

• A death or divorce in the family, a parent’s job loss, or other sudden change
• Undetected seizures
• An ear infection that causes temporary hearing problems
• Problems with schoolwork caused by a learning disability
• Anxiety or depression
• Insufficient or poor quality sleep
• Child abuse

Symptoms incude:

Inattention, hyperactivity, and impulsivity are the key behaviors of ADHD. The symptoms of ADHD are especially difficult to define because it is hard to draw the line at where normal levels of inattention, hyperactivity, and impulsivity end and clinically significant levels requiring intervention begin. To be diagnosed with ADHD, symptoms must be observed in two different settings for six months or more and to a degree that is greater than other children of the same age.

The symptom categories of ADHD in children yield three potential classifications of ADHD—predominantly inattentive type, predominantly hyperactive-impulsive type, or combined type if criteria for both subtypes are met:

Predominantly inattentive type symptoms may include:

• Be easily distracted, miss details, forget things, and frequently switch from one activity to another
• Have difficulty focusing on one thing
• Become bored with a task after only a few minutes, unless they are doing something enjoyable
• Have difficulty focusing attention on organizing and completing a task or learning something new
• Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities
• Not seem to listen when spoken to
• Daydream, become easily confused, and move slowly
• Have difficulty processing information as quickly and accurately as others
• Struggle to follow instructions.

Predominantly hyperactive-impulsive type symptoms may include

• Fidget and squirm in their seats
• Talk nonstop
• Dash around, touching or playing with anything and everything in sight
• Have trouble sitting still during dinner, school, and story time
• Be constantly in motion
• Have difficulty doing quiet tasks or activities.

Also these manifestations primarily of impulsivity:

• Be very impatient
• Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences
• Have difficulty waiting for things they want or waiting their turns in games

Most people exhibit some of these behaviors, but not to the degree where such behaviors significantly interfere with a person's work, relationships, or studies. The core impairments are consistent even in different cultural contexts.

Symptoms may persist into adulthood for up to half of children diagnosed with ADHD. Estimating this is difficult as there are no official diagnostic criteria for ADHD in adults. ADHD in adults remains a clinical diagnosis. The signs and symptoms may differ from those during childhood and adolescence due to the adaptive processes and avoidance mechanisms learned during the process of socialization.

A 2009 study found that children with ADHD move around a lot because it helps them stay alert enough to complete challenging tasks

A specific cause of ADHD is not known. There are, however, a number of factors that may contribute to ADHD. They include genetics, diet and social and physical environments.

Dietary supplements and specialized diets are sometimes used by people with ADHD with the intent to mitigate some or all of the symptoms. For example, Omega-3 supplementation (seal, fish or krill oil) may reduce ADHD symptoms for a subgroup of children and adolescents with ADHD "characterized by inattention and associated neurodevelopmental disorders." Although vitamin or mineral supplements (micronutrients) may help children diagnosed with particular deficiencies, there is no evidence that they are helpful for all children with ADHD. Furthermore, mega doses of vitamins, which can be toxic, must be avoided. In the United States, no dietary supplement has been approved for the treatment for ADHD by the FDA. There is however a pilot study done which shows that phosphatidyl serine (PS) can help against ADHD.

EEG biofeedback is a treatment strategy used for children, adolescents and adults with ADHD. The human brain emits electrical energy which is measured with electrodes on the brain. Biofeedback alerts the patient when beta waves are present. This theory believes that those with ADHD can train themselves to decrease ADHD symptoms. There is a distinct split in the scientific community about the effectiveness of the treatment. A number of studies indicate the scientific evidence has been increasing in recent years for the effectiveness of EEG biofeedback for the treatment of ADHD. According to a 2007 review, with effectiveness of the treatment was demonstrated to be equivalent to that of stimulant medication. The review noted, improvements are seen at the behavioral and neuropsychological level with the symptoms of inattention, hyperactivity and impulsivity showing significant decreases after treatment. There are no known side effects from EEG biofeedback therapy. There are methodological limitations and weaknesses in study designs however. In a 2005 review, Loo and Barkley stated that problems including lack of blinding such as placebo control and randomisation are significant limitations to the studies into EEG biofeedback and make definitive conclusions impossible to make. As a result more robust clinical studies have been strongly recommended. A German review in 2004 found that EEG biofeedback, also sometimes referred to as neurofeedback, is more effective than previously thought in treating attention deficiency, impulsivity and hyperactivity; short-term effects match those of stimulant treatment and a persistent normalization of EEG parameters is found which is not found after treatment with stimulants. There are no known side effects from biofeedback therapy although research into biofeedback has been limited and further research has been recommended. An American review the following year also emphasized the benefits of this method. Similar findings were reported in a study by another German team in 2004.

Aerobic fitness may improve cognitive functioning and neural organization related to executive control during pre-adolescent development, though more studies are needed in this area. One study suggests that athletic performance in boys with ADHD may increase peer acceptance when accompanied by fewer negative behaviors.

Art is thought by some to be an effective therapy for some of the symptoms of ADHD. Other sources, including some psychologists who have written on the subject, feel that cutting down on time spent on television, video games, or violent media can help some children. One study indicated a correlation between excessive TV time as a child with higher rates of ADHD symptoms. Other therapies that have been effective for some have been ADHD coaching, positive changes in diet, such as low sugar, low additives, and no caffeine. Children who spend time outdoors in natural settings, such as parks, seem to display fewer symptoms of ADHD, which has been dubbed "Green Therapy.

What is Asperger Syndrome?

Asperger syndrome is an autism spectrum disorder, and people with it therefore show significant difficulties in social interaction, along with restricted and repetitive patterns of behavior and interests. It differs from other autism spectrum disorders by its relative preservation of linguistic and cognitive development. Although not required for diagnosis, physical clumsiness and atypical use of language are frequently reported.

The exact cause is unknown, although research supports the likelihood of a genetic basis; brain imaging techniques have not identified a clear common pathology. There is no single treatment, and the effectiveness of particular interventions is supported by only limited data. Intervention is aimed at improving symptoms and function. The mainstay of management is behavioral therapy, focusing on specific deficits to address poor communication skills, obsessive or repetitive routines, and physical clumsiness. Most individuals improve over time, but difficulties with communication, social adjustment and independent living continue into adulthood. Some researchers and people with Asperger's have advocated a shift in attitudes toward the view that it is a difference, rather than a disability that must be treated or cured.

Asperger syndrome treatment attempts to manage distressing symptoms and to teach age-appropriate social, communication and vocational skills that are not naturally acquired during development, with intervention tailored to the needs of the individual based on multidisciplinary assessment. Although progress has been made, data supporting the efficacy of particular interventions are limited.

What is Rett Syndrome?

Rett syndrome is a neurodevelopmental disorder that is classified as an autism spectrum disorder by the DSM-IV. It was first described by Austrian pediatrician Andreas Rett in 1966. The clinical features include small hands and feet and a deceleration of the rate of head growth (including microcephaly in some). Repetitive hand movements such as mouthing or wringing are also noted. Girls with Rett syndrome are prone to gastrointestinal disorders and up to 80% have seizures. They typically have no verbal skills, and about 50% of females are not ambulatory. Scoliosis, growth failure, and constipation are very common and can be problematic. Some argue that it is misclassified as an autism spectrum disorder, just as it would be to include such disorders as fragile X syndrome, tuberous sclerosis, or Down syndrome where one can see autistic features. The signs of this disorder are most easily confused with those of Angelman syndrome, cerebral palsy and autism.

Signs of Rett syndrome that are similar to autism:

• screaming fits
• panic attack
• inconsolable crying
• avoidance of eye contact
• lack of social/emotional reciprocity
• general lack of interest
• markedly impaired use of nonverbal behaviors to regulate social interaction
• loss of speech
• Balance and coordination problems, including losing the ability to walk in many cases
• gastrointestinal problems
• sensory problems

Treatment of Rett syndrome includes:

• management of gastrointestinal (reflux, constipation) and nutritional (poor weight gain) issues
• surveillance of scoliosis and long QT syndrome
• increasing the patient's communication skills, especially with augmentative communication strategies
• parental counseling
• modifying social medications
• sleep aids
• SSRIs
• anti-psychotics (for self-harming behaviors)
• beta-blockers rarely for long QT syndrome
• Occupational therapy, Speech therapy and physical therapy are used to treat children with Rett syndrome.

 

What is CDD?

Childhood disintegrative disorder (CDD), also known as Heller's syndrome and disintegrative psychosis, is a rare condition characterized by late onset (>3 years of age) of developmental delays in language, social function, and motor skills. Researchers have not been successful in finding a cause for the disorder.

CDD has some similarity to autism, and is sometimes considered a low-functioning form of it, but an apparent period of fairly normal development is often noted before a regression in skills or a series of regressions in skills. Many children are already somewhat delayed when the illness becomes apparent, but these delays are not always obvious in young children.

The age at which this regression can occur varies, and can be from age 2-10 with the definition of this onset depending largely on opinion.

Regression can be very sudden, and the child may even voice concern about what is happening, much to the parent's surprise. Some children describe or appear to be reacting to hallucinations, but the most obvious symptom is that skills apparently attained are lost. This has been described by many writers as a devastating condition, affecting both the family and the individual's future. As is the case with all pervasive developmental disorder categories, there is considerable controversy about the right treatment for CDD.

A child affected with childhood disintegrative disorder shows normal development, generally up to an age of 2 years, and he/she acquires "normal development of age-appropriate verbal and nonverbal communication, social relationships, motor, play and self-care skills" comparable to other children of the same age. However, from around the age of 2 through the age of 10, skills acquired are lost almost completely in at least two of the following six functional areas:

• Language skills
• Receptive language skills
• Social skills & self-care skills
• Control over bowel and bladder
• Play skills
• Motor skills

Lack of normal function or impairment also occurs in at least two of the following three areas:

• Social interaction
• Communication
• Repetitive behavior & interest patterns

There is no permanent cure for CDD - loss of language and skills related to social interaction and self-care are rather serious. The affected children face permanent disabilities in certain areas and require long term care. Treatment of CDD involves both behavior therapy and medications.

• Behavior therapy: Its aim is to teach the child to relearn language, self-care and social skills. The programs designed in this respect "use a system of rewards to reinforce desirable behaviors and discourage problem behavior." The behavior therapy is used by a number of health care personnel from different fields like psychologists, speech therapists, physical therapists and occupational therapists. At the same time, parents, teachers and caregivers also use the behavior therapy. A consistent approach by all concerned result into a better treatment.

• Medications: There are no medications available to treat directly CDD. Antipsychotic medications are used to treat severe behavior problems like aggressive stance and repetitive behavior patterns. Anticonvulsant medications are used to control seizures.

What is Down Syndrome?

Down syndrome is a chromosomal disorder caused by the presence of all or part of an extra 21st chromosome. The condition is characterized by a combination of major and minor differences in structure. Often Down syndrome is associated with some impairment of cognitive ability and physical growth, and a particular set of facial characteristics. Down syndrome in a fetus can be identified with amniocentesis during pregnancy, or in a baby at birth.

Individuals with Down syndrome tend to have a lower than average cognitive ability, often ranging from mild to moderate developmental disabilities. Many of the common physical features of Down syndrome may also appear in people with a standard set of chromosomes, including microgenia (an abnormally small chin), an unusually round face, macroglossia (protruding or oversized tongue), an almond shape to the eyes caused by an epicanthic fold of the eyelid, upslanting palpebral fissures (the separation between the upper and lower eyelids), shorter limbs, a single transverse palmar crease (a single instead of a double crease across one or both palms, also called the Simian crease), poor muscle tone, and a larger than normal space between the big and second toes. Health concerns for individuals with Down syndrome include a higher risk for congenital heart defects, gastroesophageal reflux disease, recurrent ear infections, obstructive sleep apnea, and thyroid dysfunctions.

Early childhood intervention, screening for common problems, medical treatment where indicated, a conducive family environment, and vocational training can improve the overall development of children with Down syndrome. Although some of the physical genetic limitations of Down syndrome cannot be overcome, education and proper care will improve quality of life.

Treatment of individuals with Down Syndrome depends on the particular manifestations of the disorder. For instance, individuals with congenital heart disease may need to undergo major corrective surgery soon after birth. Other individuals may have relatively minor health problems requiring no therapy. Plastic surgery has sometimes been advocated and performed on children with Down syndrome, based on the assumption that surgery can reduce the facial features associated with Down syndrome, therefore decreasing social stigma, and leading to a better quality of life. Plastic surgery on children with Down syndrome is uncommon, and continues to be controversial. Researchers have found that for facial reconstruction, "...although most patients reported improvements in their child's speech and appearance, independent raters could not readily discern improvement...." For partial glossectomy (tongue reduction), one researcher found that 1 out of 3 patients "achieved oral competence," with 2 out of 3 showing speech improvement. Len Leshin, physician and author of the ds-health website, has stated, "Despite being in use for over twenty years, there is still not a lot of solid evidence in favor of the use of plastic surgery in children with Down syndrome." The National Down Syndrome Society has issued a "Position Statement on Cosmetic Surgery for Children with Down Syndrome" which states that "The goal of inclusion and acceptance is mutual respect based on who we are as individuals, not how we look.