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Children with Autism Deserve Education, but I don’t support C.A.D.E.

17 Jun

There is a charity called “Children with Autism Deserve Education“. C.A.D.E or CADE for short. I ran across them a few years ago and saw some expenses in their tax forms that I felt were, let’s say, interesting. So they stuck in my mind and I decided recently to check into them again.

The name suggests a strong focus on education. I know many who will take issue with the use of “with” autism. That aside, helping autistic kids get access to education is a good thing. The vast majority of the money I donate to charity goes to exactly that cause–providing education opportunity for autistic kids.

The tax records indicate that C.A.D.E. spends a lot of money on non educational projects. On alternative medicine, for example. It looks like they’ve spent money on vaccines-cause-autism research. And if I were donating money just based on the name of the org, I’d not be happy with that.

To be clear, C.A.D.E. is public about their support for non educational projects. That “medical interventions” and research into causes are part of their agenda.

Before we dive into the details of where money is spent, let’s take a look at how they present themselves to the public. If one goes to the C.A.D.E. website and checks the “about” page, the first thing one sees is this:

About C.A.D.E.
Helping Children With Autism Reach Their Full Potential Through Financial Support For Evidence-Based Education And Therapy.

More and more children in the United States are diagnosed with autism. In fact, 1 in every 59 children was identified with autism spectrum disorder in 2014—up from 1 in 150 in the year 2000.

While opportunities for high-quality therapy and educational resources are increasing to account for this growing prevalence, intensive treatments are often well beyond a family’s financial means and many public schools don’t have the resources to provide them.

According to a 2014 study, the total lifetime cost of supporting an individual with autism is an astonishing $1.4 million in the United States. If an intellectual disability is also present, the total rises even more to $2.4 million. Education alone can cost a family an extra $8,600 per year.

We Believe That Children With Autism Deserve To Obtain The Most Effective Means Of Education.
C.A.D.E. Exists To Help Them Access It.

Through grants, C.A.D.E. helps fund evidence-based education, therapy and medical interventions for children with autism that don’t have the financial resources. Since 2014, C.A.D.E. has provided more than $500,000 in financial support to families in Minnesota—helping kids reach their full potential to live healthy, happy, productive lives.

From my perspective, this sounded reasonable right up the the phrase “medical interventions”. Education is a worthy goal. Therapy can include speech and language therapy, for example.

“Medical interventions” tells me that they are probably supporting alternative medicine. Many in the autism community promote alt-med and this is a common way that they phrase it when trying to seem more legitimate. But a casual reader might not realize that this phrase opens the door to donations being spent on “treatments” that are generally considered unproven or ineffective.

But keep reading the about page and towards the bottom of the page you find:

Our founders, board and volunteers have personal family experience with autism, and are deeply committed to ensuring that children are able to access the education and medical treatments they need to live healthy lives—as well as supporting organizations exploring the causes of and interventions for this epidemic.

So, yes, they are making it public that the money donated will not all go towards education. But consider further the phrase “supporting organizations exploring the causes of and interventions for this epidemic” sounds like the usual code in the autism parent community for “supporting research which tries to support the idea (failed idea) that vaccines cause autism”.

Two questions come to my mind when I read this. First, are they actually spending money on vaccines/autism research. Second, would they lose donors if this were made more clear in their public statements? Would, say, “Children with Autism Deserve Education and to be subjected to Alternative Medicine” get the same level of donations?

I am particularly suspicious of C.A.D.E. because I know that one of the board members is Jennifer Larson. Ms. Larson is prominent in the “autism is a vaccine epidemic” and the alternative medicine communities. She owns at least two businesses that provide alternative medical services (the Holland Center and Minnesota Hyperbaric). She donated $40k to former congressional representative and committee chairman Darryl Issa. At that time he was hosting hearings on vaccines and autism. She also founded the tiny Minnesota based “Canary Party“.An early version of the Canary Party’s website states:

American children are over vaccinated and over medicated, over fed, undernourished and have record levels of chronic illness and developmental delay.

Emphasis added.

We can get more information from the public tax records. The most recent tax year for which I can get records (tax forms for charities are public record) is 2017. Here’s their tax form for 2017. More specifically, here’s the schedule O for 2017. Schedule O is where charities list “grants and similar amounts paid”. It’s where you can find a lot about where they are spending their money, aside from operating expenses and salaries and the like.

Let’s take a look at the schedule O entries sorted largest grant to smallest:

First we have “family assistance for medical and therapy paid directly to the provider”. Said provider is the Holland Biomedical Clinic. And they note that the Holland Biomedical Clinic is owned by a board member. Which appears to be Jennifer Larson. The Holland Center provides both ABA (which can be considered educational) and alternative medical (biomedical) treatment. This entry specifically says “Holland Biomedical Clinic”. So my guess is that this wasn’t for ABA. To my knowledge, the Holland Center is a for profit business, not another charity.

This was the largest grant given out this year by C.A.D.E.: $15,282.

Next we have a grant for $10,000 to Ken Stoller, M.D. as “Family assistance for medical and therapy paid directly to provider”. Ken Stoller is well known in the alt-med and anti-vaccine communities. It seems odd to me that the amount is an even $10,000. Odd as in, did the the bills for a family actually come out to an even $10k? Even more odd that a doctor in San Francisco is getting a grant I thought were for local families in Minnesota. The famous name alt-med autism doctors do get patients traveling to see them. We don’t know what medical services were purportedly provided for this grant, but it seems unlikely that he could provide something not available in Minnesota. So, the question in my mind was whether this was a specific grant for specific families, or was this some sort of general support for Dr. Stoller?

The next “family assistance for medical and therapy paid directly to the provider” is to the Lovaas Institute for $5,390. This would be on target for the C.A.D.E mission, as the Lovass Institute is a provider of ABA services.

Another “Family assistance for medical and therapy paid directly to provider” is to “Grantee Name: Minnesota Hyperbaric. Grantee relationship: none.” Amount was $4,000. Minnesota Hyperbaric is, I believe, a business owned by Jennifer Larson (board member of C.A.D.E.) and housed within the same Holland Center noted above. Which if true would make the “grantee relationship: none” statement a bit problematic.

There is a $3,000 entry for “family assistance for medical and therapy paid directly to the provider” where the provider is listed as “Laidas”. I can not find who “Laidas” may be. I wonder if this is somehow a misspelling for Lovaas?

Next is Autism Recovery Foundation. Two entries for $2,000 total. The Autism Recovery Foundation is primarily focused on ABA. Yes, there are those who oppose ABA, but this is, in my opinion, spending funds on education. Note that Jennifer Larson is on the board. These appear to be described elsewhere in the tax form as “DIRECT SUPPORT TO ORGANIZATIONS THAT HELP FUND EDUCATION AND AWARENESS OF TREATMENT OPTIONS FOR AUTISM.”

Another “family assistance for medical and therapy paid directly to the provider” grant was paid to James Neubrander, M.D. for $1,410. Dr. Neubrander is an alt-med practitioner in New Jersey.

By the way, take a moment and check out his website. Watch the images that flash by and read the messages. It’s not pleasant at all.

The New Bridge Clinic received a grant for “family assistance for medical and therapy paid directly to the provider” in the amount of $1,190. I believe that is this clinic, which is another provider of alternative medical treatments. This is not educational.

Lastly we have “family assistance” paying rent for a family in need. Paid directly to Chohan Properties. For $1,180. While not educational, I wouldn’t have a problem with this.

A quick summary of the grants which appear to me to be for alternative medicine providers:
Holland Biomedical: $15,282
Dr. Ken Stoller (California): $10,000
Minnesota Hyperbaric: $4,000
Dr. Neubrander (New Jersey): $1,410
New Bridge Clinic: $1,180.

The total for Schedule O is $43,452
The amount paid for alternative medical providers appears to me to be $31,882. Or about 72% of the total grants.

72%

I would be very unhappy were I donor and found that out. It’s not illegal. It is, in my opinion, misleading. I’d think an org named “Children with Education Deserve Education” would be spending my donations on, well, education.

All the above is just for tax year 2017, the most recent where the information is publicly available. What about the other years? I went through the tax forms I could find going back to 2010. Here’s a summary table:

Who are they giving money to? Here are the top 10 projects, by money committed, from what I can see:

1) $56,000: The Autism Treatment Foundation of Minnesota, which appears to be this organization. Jennifer Larson is currently on the board. This org supports ABA for autism, and would be considered on target for “education”. From what I could find this appears to be something like a lobbying organization.

2) $22,000: Generature Rescue. Widely considered an anti vaccine organization. I’m unaware of any education projects they’ve been involved in. They are mostly involved in promoting the failed idea that vaccines cause autism and also promoting alternative medicine for autism. However, it struck me that in 2010 Generation Rescue made a big ($100k) donation to Andrew Wakefield’s “Strategic Autism Initiative” (Mr.Wakefield was the top in Time Magazine’s list of research frauds). In my opinion the SAI was set up to provide support for Mr. Wakefield after his ouster from Thoughtful House. This raises the question in my mind–did C.A.D.E. send money to Generation Rescue as a way of providing funds to Mr. Wakefield? Jennifer Larson is a known supporter of Mr. Wakefield.

3) $19,678: University of Northern Iowa. researchers DeSoto and Hitlan at the University were prominent in the “vaccines cause autism” scene for a few years. The work was poor in my opinion. Prof. DeSoto lists $80k in grants from C.A.D.E. for “Study of Autism among Somali Immigrants in MPLS, MN Area.” Her vitae does not list any publications. There was great interest from the anti-vaccine community in the Minnesota Somali community. Besides apparently accomplishing nothing, this expense by C.A.D.E. appears to have nothing to do with education.

4) $15,282: Holland Biomedical Clinic. This is reportedly owned by Jennifer Larson. The clinic offers alternative medical approaches. An initial visit can run $995, and alternative medicine is rarely covered by insurance.

5) Autism Recovery Foundation. Same address as the Autism Treatment Foundation of Minnesota. ABA based. Would be on target for donations to “educational” orgs, in my option.

6) $12,102. Unnamed medical therapy. Unclear what this was spent on, although it’s a good guess it was alternative medicine.

7) $10,000. Autism Resource Network. Looks like it was a store (autismshop.com). Which had a leaning towards the failed “vaccines-cause-autism” idea.

8) $10,000: Dr. Ken Stoller. Discussed above. Dr. Stoller is well known in the anti-vaccine community. And is in California, not MN.

9) $9,380: The Holland Center. Discussed above. Business reportedly owned by Jennifer Larson. Largely ABA focused, but also houses the Holland Biomedical Clinic and Minnesota Hyperbaric. One of the entries was for iPads. Why they were distributed through Ms. Larson’s business rather than directly is unclear.

10) $7,661: iPad purchase. iPads are often used as alternative communication devices and otherwise educational devices by people with disabilities.

There are a lot of expenses above which, again, I wouldn’t be expecting on donating to a charity calling itself “Children with Autism Deserve Education”.

One last comment. Above you will find this quote from C.A.D.E.: “Since 2014, C.A.D.E. has provided more than $500,000 in financial support to families in Minnesota—helping kids reach their full potential to live healthy, happy, productive lives.” I find that hard to believe. I count about $112k spent on program expenses from 2014-2017. So unless they spent a lot more money in the past 2 years, $500,000 seems like much more money than they’ve spent. Perhaps I’m missing something in the tax documents. I’ll provide them below.

C.A.D.E. fundraises with a run (the Autism5k) and also golf events.

One last topic is interesting here. Here’s a copy of an older form they used to apply for their grants. The CADE Medical & Therapy Grant Application. They specify some interesting requirements:

“These grants are for CADE approved physicians & CADE approved therapy programs.”

“I understand that my child is required to follow the GF/CF diet or SCD diet for the 90-day grant period if the medical grant is awarded and the diet is recommended”.

“I understand that an approved Doctor will be assigned to my child and that I have no choice in this matter and cannot change the assigned doctor. This doctor will be a specially trained for autism. ”

“If you are chosen for the CADE Medical or Therapy grant, you agree to the following:” which includes: “Implement ASD diet such as GF/CF or SCD for the medical grant ” and “Document the child’s progress through a daily journal and pre and post photographs or a Flip video camera that will be provided if needed.”

First off, keep in mind that Jennifer Larson also helps run an organization called “HealthChoice.org”. Given that, I find the lack of choice in the above quote very ironic. You must follow a diet for 90 days. One must follow the doctor’s recommendation, even if one disagrees. The doctor is ” assigned to my child and that I have no choice in this matter and cannot change the assigned doctor”

Yeah, that’s health choice.

Second, they ask for a lot of information. Including one has to keep a log and take pictures/videos. I would be very worried if I were to see such an application that the org was thinking of some sort of study based on the kids going through the grant program. That would be highly unethical.

Under “Disclaimer” the application states:

If you are chosen for the CADE Medical or Therapy grant, you agree to the following:
• Implement ASD diet such as GF/CF or SCD for the medical grant
• Dropping out of the program once selected will make you liable for the following:
1. All postage costs
2. The fee(s) of 2(two) Medical visits (estimated at $750.00)
• Document the child’s progress through a daily journal and pre and post photographs or a Flip video camera that will be provided if needed. 

All dollars for therapy grants go directly to the provider.

So, where the application previously stated that a diet is required if “recommended”, here the parent is accepting that it they will implement a diet. And, let’s say you think the medical professional isn’t working out for your kid, and/or the diet isn’t helping (or is even bad) for your kid. You get to pay back $750. Remember, parents are selected based on need. So $750 (which by the language reads as though it could be assessed even if you didn’t actually go to one or both of the visits) is possibly enough to force a parent to keep his/her kid in the program.

And, as we saw above, sometimes the grants are paid to clinics run by one of C.A.D.E.’s leadership.

As I titled the article, I believe strongly in doing more to provide better educational opportunities for autistics. But after going through all the above research, I wouldn’t send any of my money to C.A.D.E.. Sadly, this makes me wary of most charities. Especially small charities where it’s unlikely that there is much oversight.

Below are the tax forms for years 2010 to 2017 if you wish to check for yourself. If you find any mistakes in what I reported above, please let me know.

CADE_2017
CADE_2016
CADE_2015
CADE_2014
CADE_2013
CADE_2012
CADE_2011
CADE_2010

—

By Matt Carey

Loving lampposts

30 Mar

Loving Lampposts is a film by an autism parent. I’m waiting for my copy (disclosure: I have asked for a review copy from the producer). In the meantime, reviews have come out by better prepared writers than I. Steve Silberman at Neurotribes has an interview with the filmaker: “Loving Lampposts,” A Groundbreaking Documentary About Autism, Love, and Acceptance. Shannon Des Roches Rosa at The Thinking Person’s Guide to Autism has Loving Lampposts: Accepting and Understanding Neurodiversity. Liz Ditz at I speak of Dreams has A Must-See Movie: Loving Lampposts.

I remember first hearing about this project some time ago when there was just a very sparse website. I had no concept of where the project was going. I was left with a couple of questions then, including: is this going to be a fairly shallow movie about a single quirk in a single autistic? (The idea for the title comes from the fact that the filmaker’s son, well, had a love of lampposts. )

From the reviews (above) and from the materials already available, this looks to be a good movie. A movie which presents some very important questions and gives thoughtful discussion to them. From the Loving Lampposts website:

What would you call a four year old who caresses all the lampposts in the park? Quirky? Unusual? Or sick?

Such labels are at the center of the debate about autism: is it a disease or a different way of being—or both? In Loving Lampposts, we witness this debate and meet the parents, doctors, therapists, and autistic people who are redefining autism at a moment when it’s better known than ever before. Motivated by his son’s diagnosis, filmmaker Todd Drezner explores the changing world of autism and learns the truth of the saying, “if you’ve met one autistic person, you’ve met one autistic person.”

Here is a video clip made available:

Loving Lampposts Trailer from Loving Lampposts on Vimeo.

In this short clip we see the wonderful boy, Sam, Prof. Richard Grinker (anthropologist, author of the book Unstrange Minds, and autism researcher), I believe that’s Kristina Chew’s voiceover in a clip of her son Charlie riding his bike, Jenny McCarthy, and parents at a National Autism Association meeting.

Press materials for the book do what they should: they make me want to see the movie. Yes there are the excellent photos of Sam and Lampposts:

But there are also photos of Stephen Shore working with a student:

And a photo of Dora Raymaker:

To point out only a few of the photos.

From the Press Kit, here is the list of participants in the film. It’s a very big and rather diverse group of people.

Featured

Nadine Antonelli and Noah: A resident of Wilmington, N.C. and a medical doctor, Nadine initially believed that she should try to cure her son Noah’s autism. Over time, though, she came to accept his diagnosis and she now works to provide support to other families with autistic children in Wilmington.

Simon Baron-Cohen: The Director of the Autism Research Centre at Cambridge University and a world-renowned expert on autism.

Kristina Chew, Jim and Charlie Fisher: Professors at St. Peter’s College and Fordham University respectively, Kristina and Jim are raising their autistic son Charlie in Cranford, NJ. Kristina is a popular blogger writing about her experiences with Charlie and advocating for neurodiversity.

Paul and Jackie Colliton and Billy: Residents of New York City, Paul and Jackie adopted their autistic son Billy when he was ten days old. He did not begin to speak until age seven.

Todd and Erika Drezner and Sam: The filmmaker, his wife, and their autistic son.

Roy Richard Grinker: A Professor of Anthropology at George Washington University, Richard is the father of an autistic daughter and the author of Unstrange Minds, a history of autism and an examination of how it is treated around the world.

Lila Howard and Lyndon: The 87 year-old mother of a 60 year-old autistic son, Lila raised Lyndon as a single mother at a time when there was no support for parents of autistic children. Ignoring experts who blamed her son’s condition on her and suggested he be institutionalized, Lila helped Lyndon learn to live independently. Today, he lives in his own apartment in New York City, where he has lived for 13 years. Lila remains his primary caretaker.

Jay Kochmeister: The father of Sharisa (see below).

Sharisa Kochmeister: An autistic adult who does not speak, Sharisa was believed to have an IQ of 30 from the time she was two until she turned 13. Almost by accident, her family discovered she could read, and she now communicates with a computer with text to speech capability. Her IQ is at a genius level, and she is a graduate of Denver University who advocates for autistic people.

Eileen Muniz, Gianna, Marz, and Vincent: The mother of three autistic children in Mohegan Lake, NY, Eileen and her husband recently separated.

Paul Offit: A doctor who is the Chief of Infectious Diseases at Children’s Hospital of Philadelphia. He argues strongly against the idea that vaccines cause autism, and is the author of Autism’s False Prophets, which exposes scientifically unsupported treatments for autism.

Dora Raymaker: An autistic adult who communicates using a computer with text to speech capability, Dora is working on her graduate degree in Portland, Oregon. She is the co-director of the Academic Autistic Spectrum Partnership in Research and Education.

Johnny and Chris Seitz: An autistic adult and performance artist, Johnny worked with his wife Chris to develop “God Does Not Make Garbage,” a 30 minute show that goes inside the world of autism.

Stephen Shore: Diagnosed with autism in 1964, Stephen was said to be profoundly ill and was recommended for institutionalization. Today, he is a Professor at Adelphi University. He also teaches music to autistic children and lectures about autism all over the world.

Cindy Walsh, Eric, and Robbie: The mother of twin boys with autism in Chantilly, CA, Cindy believes she has “recovered” her children with alternative treatments.

ALSO APPEARING

Elizabeth Avery: An autistic adult living in the Boston area.

Kenneth Bock: A doctor who treats patients with autism using alternative therapies.

Nancy Cale: The co-founder of the organization Unlocking Autism.

Paul Collins: The father of an autistic son and the author of Not Even Wrong, a history of autism.

Doreen Granpeesheh: The Executive Director of the Center for Autism and Related Disorders.

Kristin Holsworth: The mother of an autistic son, Troy.

Peter Hotez: A doctor who is President of the Sabin Vaccine Institute, Peter is the father of an autistic doctor. He says that there is no scientific evidence that vaccines cause autism.

Karen Hubert: A sales representative for New Beginnings Nutritionals, Karen markets vitamins and supplements to parents of autistic children.Dan Joyce: A representative of the organization Autism Speaks.

David Kirby: The author of Evidence of Harm: Mercury in Vaccines and the Autism Epidemic.

Estée Klar: The mother of autistic son Adam, founder of the Autism Acceptance Project, and writer of a blog called “The Joy of Autism.”

Robert Krakow: The father of an autistic son a plaintiffs lawyer in vaccine injury cases.

Jenny McCarthy: The celebrity actress is the mother of an autistic son and a leading proponent of the idea that vaccines cause autism.

Arnold Miller: The Director of the Language and Cognitive Development Center of Boston.

Barbara Moran: An autistic adult with a special interest in steam locomotives and old GE refrigerators.

Bob Morgan: The owner of Heavenly Heat Saunas, Bob believes that saunas can “detoxify” autistic children.

James Neubrander: A doctor who treats patients with autism using alternative therapies.

Christina Nicolaidis: The mother of an autistic son and the co-director of the Academic Autistic Spectrum Partnership in Research and Education.

Laura Rose: The mother of a “recovered” autistic son, Jason.

Ralph James Savarese: Ralph and his wife adopted a six year-old profoundly autistic boy who had been severely abused. Today, although Ralph’s son cannot speak, he is a straight A student in an Iowa high school.

Bill Schindler: The director of the Mild Hyperbaric Therapy Center, Bill works with parents who treat their children’s autism by giving them treatments in hyperbaric chambers.

Phil Schwarz: The father of an autistic son and an advocate of neurodiversity.

Kassiane Sibley: An autistic adult and advocate for neurodiversity.

Autumn Terrill: An expert in special education who works with Billy Colliton.

Anju Usman: A doctor who treats patients with autism using alternative therapies.

Urine test for autism? Hmmm

4 Jun

Following on from Lisa Jo’s well placed concerns about this study,I also have a few. Namely the references. Not being scientifically qualified to tackle the meat of the paper I look straight at what the researcher uses to support his ideas. So far I’ve found these references the authors base their paper on:

1) Kidd, P. M. Autism, an extreme challenge to integrative medicine. Part: 1: The knowledge base. Altern. Med. Rev. 2002, 7 (4), 292–316.

2) Ashwood, P.; Anthony, A.; Pellicer, A. A.; Torrente, F.; Walker-Smith, J. A.; Wakefield, A. J. Intestinal lymphocyte populations in children with regressive autism: evidence for extensive mucosal immunopathology. J. Clin. Immunol. 2003, 23 (6), 504–17.

3) Bolte, E. R. Autism and Clostridium tetani. Med. Hypotheses 1998, 51 (2), 133–44

4) James, S. J.; Cutler, P.; Melnyk, S.; Jernigan, S.; Janak, L.; Gaylor, D. W.; Neubrander, J. A. Metabolic biomarkers of increased oxidative stress and impaired methylation capacity in children with autism. Am. J. Clin. Nutr. 2004, 80 (6), 1611–7

At the very least, relying on studies from Alternative Medical Review, studies co-authored by Andrew Wakefield, studies from Medical Hypothesis and studies co-authored by Jim Neubrander should give rise to questions over the credibility of this paper. Is it enough to scupper it? Of course not. But when we take Lisa Jo’s questions into the bargain – that autism does not always, if ever, have a distinct GI component, I have to wonder about this paper.

Autism treatment: Science hijacked to support alternative therapies

23 Nov

Such is the title of the latest article in the Chicago Tribune by Trine Tsouderos and Patricia Callahan.

The article is subtitled: ‘Researchers’ fears about misuse of their work come true’.

Go now and read it. I’ll pull some examples here, but read the article. Send it to your friends. When a writer tells you to stop reading his own piece and go read something else, he means it.

The article reports on how the alternative medical community in autism has clearly misused some research to create and promote supposed therapies.

The prime example, the misuse of work by a John’s Hopkins team on neuroinflammation in autopsied brains of autistics (e.g. Neuroglial activation and neuroinflammation in the brain of patients with autism. by Vargas , Nascimbene , Krishnan, Zimmerman, and Pardo.)

The John’s Hopkins team showed that neuroinflammation was present in the brains of recently deceased autistics. What they did not show was that this was a cause of autism or that this was injurious to the autistics. As Dr. Pardo told the Tribune:

“We were concerned that the study would raise a lot of controversy and be misused,” Pardo said. “We were right.”

In one example from the article, Dr. Rossignol, one of the luminaries of the autism alternative medicine movement wrote a letter to support the use of intravenous immunoglobulin (IVIG) to treat an autistic child. He cites the Pardo study.

From the Tribune story:

Rossignol did not mention that Pardo’s team had written in its online primer, using capital letters for emphasis, that intravenous immunoglobulin “WOULD NOT HAVE a significant effect” on what they saw in the brains of people with autism.

“THERE IS NO indication for using anti-inflammatory medications in patients with autism,” the team wrote.

Another of the Hopkins team, Dr. Zimmerman is quoted:

Meddling with neuroinflammation could actually be a terrible mistake, said co-author Dr. Andrew Zimmerman, director of medical research at the Center for Autism and Related Disorders at the Kennedy Krieger Institute in Baltimore.

“It may actually be an attempt of the brain to repair itself,” said Zimmerman, a pediatric neurologist. Suppressing the immune response “could be doing harm.”

Another alternative-medical practitioner, and colleague of Dr. Rossignol, Dr. Bradstreet is not deterred by the experts in the field who warn him off of applying this experimental and possibly (likely?) useless treatment.

“Every kid with autism should have a trial of IVIG if money was not an option and IVIG was abundant,” Bradstreet said. “It makes sense to try and would be ideal to give every young child a chance at it.”

The Pardo paper has also been used to promote hyperbaric oxygen therapy (HBOT). Another big name in the alt-med world, Dr. Neubrander uses the Pardo study in his presentations and claims that HBOT will reduce inflamation.

Dr. Neubrander appears to acknowlege the slim backing he has on science. In the Tribune article:

“Science is slow,” he said. “I will use the safety of the science and, no, I will not throw the science out the window. But the science has to be balanced against the wisdom. And science says, ‘There is no wisdom from you, the mothers or fathers of the world, who depend on anecdote. Only science has wisdom.’ “

I am at a loss as to how to respond to that statement other than to point out that Dr. Neubrander (and Dr. Bradstreet and Dr. Rossignol) will never, ever be allowed to treat my child.

Again from the Tribune:

Few treatments are completely benign, said Dr. Steven Goodman of the Johns Hopkins Berman Institute of Bioethics. “Even an ineffective therapy is rarely harmless,” he said, “and sometimes that harm is worse than the disease.”

As an example, the Tribune article discusses how pure oxygen, assumed to be only beneficial, was given to premature babies. That is, until it was shown that it was causing blindness in a significant number of children.

The Tribune article concludes by acknowledging the fact that there is not a complete description of what is autism, or how or if it can be treated.

Research into autism has yet to find solid answers, but there is reason for hope, said Zimmerman, a co-author on Pardo’s paper.

“In the last five years, there has been a tremendous upsurge of activity,” he said. “It gives us a lot of new prospects. I think we will solve this problem in the next 10 to 15 years.”

And though autism advocates in the movement say they cannot wait that long for answers, a lack of options isn’t a valid reason to try something, bioethicists say.

“You have a duty to make sure there is good reason to believe it might work and not hurt your child,” said Douglas Diekema, a bioethicist at Treuman Katz Center for Pediatric Bioethics at Seattle Children’s Research Institute.

It is difficult to be patient while science does its work, Zimmerman said. But, he added: “Above all, do no harm.”

This is one in a series of articles on alternative medicine and autism from the Tribune. I hope to backtrack and discuss the previous articles soon. But, the responses are already coming in. Many frame the Tribune as anti-parent, anti-progress, biased…all sorts of things that the article is clearly not. The Tribune obviously took a lot of time to prepare these articles. They cite the experts in the field.

Let’s face it, the supposed experts in the alternative medical “treatment” of autism are clearly misunderstanding or misrepresenting the research they rely upon. The Tribune did the work, talked to the experts and clearly showed this.

More Hot Air about HBOT

6 Apr

A few weeks ago, BMC Pediatrics published an article that purports to show that Hyperbaric Oxygen Therapy (HBOT) can produce “…significant improvements in overall functioning, receptive language, social interaction, eye contact, and sensory/cognitive awareness..” in autistic children. This study (Rossignol et al, 2009) is billed as a “…multicenter, randomized, double-blind, controlled trial.”

It’s all that and much, much less.

Let’s start by looking at the six “centers” where this research was carried out.

The Centers

The International Child Development Research Center (ICRDC):

This imposing name is attached to a rather less imposing edifice. The ICRDC, brainchild Dr. Jeffrey Bradstreet, is located in a strip mall in Melbourne, Florida, where it not only carries out “cutting-edge research” but also sells a complete line of “supplements” and treats autistic children with a dizzying array of “alternative”, “biomedical” and “integrative” therapies, including HBOT.

Daniel Rossignol MD (Family Practice), Lanier Rossignol (Nurse Practitioner) and Scott Smith (Physician’s Assistant) were the authors from the ICDRC.

The Center for Autism Research and Education (CARE):

This “center” is located in Phoenix, Arizona and has – according to its website – a single practitioner, Cynthia Schneider, MD (OB/Gyn), who is also an author on this paper. One of the “integrative” therapies this “center” offers is HBOT.

One of the other authors, Sally Logerquist, is a PhD psychologist who – according to the paper – is also associated with CARE, but also appears to run social skills therapy groups for autistic children using the “Logerquist Excellent Attitude Program” (LEAP).

True Health Medical Center:

It’s rather difficult to find anything about this “center”, apart from the fact that it is located in Naperville, Illinois – in what appears to be an office complex. Anju Usman, MD (Family Practice) is the author associated with this location.

Neubrander Center:

Although not officially called a “center”, the office of James Neubrander, MD (Pathology) is apparently one of the “centers” of this study. His office is located in the Menlo Park Mall (near Macy’s) and offers – you guessed it! – HBOT as a treatment for autism.

Princess Anne Medical Associates:

A Family Practice medical group in Virginia Beach, Virginia, this “center” is the home of Eric Madren, MD (Family Practice). It’s not clear if this four-physician practice offers HBOT.

The Rimland Center for Integrative Medicine:

A small, one-physician “center” in Lynchburg, Virginia, this is practice location of author Elizabeth Mumper, MD (Pediatrics). Not surprisingly, this “center” sells HBOT services for autistic children.

So, of the six “centers” involved in this study, five are single-physician operations. The remaining “center” has two physicians (three, if you count the naturopath).

I’m underwhelmed.

Well, what about the research itself? Maybe that’s better than the “facilities” might suggest. Let’s take a look.

The Subjects

This study initially enrolled 62 children (33 treatment; 29 control), but only 29 of the treatment group and 26 of the control group finished all 40 sessions. For reasons that pass my understanding, one treatment subject who only finished 9 sessions was included in the analysis. The authors stated that including this subject did not alter results, which begs the question: “Why did they include this subject if it made no difference?”

Outcome measures

The authors used the Aberrant Behavior Checklist (ABC), the Clinical Global Impression (CGI) scale and the Autism Treatment Evaluation Checklist (ATEC) as their outcome measures. All except the ATEC are widely accepted for use in autism treatment trials.

The ABC is a 58-question checklist of – surprise! – aberrant behaviors which are each given a score from “0” (“not at all a problem”) to “3” (“severe problem”). This test has been use – and validated – in a number of disorders, including autism. It gives a global score as well as five subscales: a total of six measures.

The CGI is a generic rating scale used in a variety of clinical trials. For each parameter (e.g. “overall functioning”, “sleep pattern”), the rater gives a score of between “1” (“very much improved”) and “7” (“very much worse”). The authors had both the treating physician and the parents rate the subjects on overall improvement and eighteen discrete parameters: a total of 38 measures in all (19 by the physician and 19 by the parents).

The ATEC was developed by Bernie Rimland and Stephen Edelson and has not been validated. In fact, it has only been used in two published studies – one by Rossignol et al. The ATEC has 25 questions on which the evaluator rates the subject on either a three-point (“not true”, “somewhat true”, “very true”) or four-point (“not a problem”, “minor problem”, “moderate problem”, “serious problem”) scale. It provides a total score and four subscales: a total of five measures.

In all, each subject had a total of 49 evaluation measures (CGI scores and the change in ABC and ATEC scores), of which 47 are independent. The importance of this will become apparent in the section on statistical analysis.

Analysis

As I mentioned above, the decision to include one treatment subject who only completed nine sessions was curious. Why they included this subject and not any of the other three treatment subjects and three control subjects who also failed to complete the entire course of the study is concerning. The smart thing – and the proper response – would have been to drop this subject from analysis.

The authors’ method of analyzing the CGI scales was also curious. Rather than simply using the scores as they were provided, they took the scores and subtracted them from four (the “no change” score). There are a few problems with this.

For starters, the scores are not linear – the difference between “much improved” and “very much improved” is not necessarily the same as between “no change” and “minimally improved”. Nor is the difference between “no change” and “much improved” twice the difference between “much improved” and “very much improved”. For that reason, these types of numerical scores are often referred to as “pseudo-numbers”.

This may seem like nit-picking, but it is a serious concern. Imagine, if you will, that the numbers were replaced by colors. Is the difference between green and orange twice the difference between orange and red? If half of a population of birds are blue and the other half are yellow, is the “average” bird green? The simple fact is that it is not appropriate to treat these “scores” as though they were real numbers, to be added, subtracted and averaged.

Secondly, it appears that the authors used parametric statistics for their analysis of the CGI scores. This is a problem since – as I indicated above – it is nonsensical to do math on pseudo-numbers. I don’t have the raw numbers, so it isn’t possible for me to calculate the absolute impact of this mistake for all of the CGI subclasses, but I can figure out the raw numbers for one group, so let’s look at that one.

It took a little work, but the authors gave enough clues to tease out the raw numbers in the physician “overall functioning” CGI score. The treatment group had an “average” of 2.87 and the control group’s “average” was 3.62; using the unaltered data, a t-test [Note: not an appropriate use of the t-test] gives p-value of 0.0006, not far from what the authors report. When a more appropriate statistical test [Mann-Whitney U-test] is used, the p-value is 0.002, very different from the reported 0.0008. While this is still less than the threshold p-value of 0.05, see below for a discussion of multiple comparisons.

All of these statistical analyses of the CGI scores ignore the fact that these are pseudo-numbers and need to be treated as discrete groups rather than as actual numbers. In truth, even the ABC and ATEC scores should have been treated this way, as well, although it is fairly common practice to treat such multi-factor scores as real numbers. A Chi-square test or Fisher Exact test would be the ideal test, but the problem with that is that the treatment group has one score of “1” (very much improved) and the control group doesn’t. Likewise, the control group has two subjects with a score of “5” (minimally worse) and the treatment group has none. This prevents a Chi-square or Fisher test from comparing each score independently.

One solution is presented by the authors themselves, although they apparently didn’t use it. In their discussion of the CGI, the authors said:

“Children who received a score of ‘very much improved’ or ‘much improved’ on the physician CGI overall functioning score were considered to be ‘good responders’ to treatment.”

If we “bin” the scores into “good responders” and “others”, we find that there were 9 (out of 30 – 30%) “good responders” in the treatment group compared to 2 (out of 26 – 8%) in the control group. Unfortunately, this is not a statistically significant difference (p = 0.08) in the (Yates) Chi-square test and barely reached significance (p = 0.05, but see below) in the Fisher Exact test.

An even bigger problem in the statistical analysis was the failure to correct for multiple comparisons. This problem was brought up by one of the reviewers, and the authors responded by eliminating a table. They did not make the appropriate corrections.

The reason that multiple comparisons are a problem is that the analysis for statistical significance is based on probability. If the probability (the p-value) that the differences between the two groups (treatment and control) is due to random chance is equal to or less than 5%, that difference is considered to be “statistically significant” and accepted as real. That means that there is still a 5% (or less – look to the p-value) chance that the difference is due to chance and not real.

If multiple comparisons are made on the same group of subjects, the probability that one (or more) of them will be “statistically significant” by chance starts to climb. If 14 comparisons are made, the chance of an erroneous “statistical significance” is over 50%. If 47 independent comparisons are made – as in this study – the chance of an erroneous “statistical significance” is over 90%.

For this reason, it is standard procedure to apply a correction for multiple comparisons. The most well-known (and simplest) of these is the Bonferroni Correction, which changes the threshold for statistical significance by dividing it by the number of comparisons. In the case of this study, the threshold (normally p less than or equal to 0.05 or 5%) is reduced to 0.001.

Applying the appropriate correction for multiple comparisons changes the results of this study significantly. Only the physician CGI scores for overall functioning and receptive language reach significance – and these numbers are already suspicious because they were improperly handled to begin with. In fact, as I have shown above, the CGI “overall functioning” p-value wouldn’t reach significance. It is possible that – if the proper statistical tests were used – that the CGI score for “receptive language” would also not reach significance.

Another curious thing. The authors asked the parents after the study whether they thought their child was in the treatment or the control group. Rather than say that the parent’s guesses were no better than random chance (i.e. 50%), the authors stated:

“…there was no significant difference between the two groups in the ability of the parents to correctly guess the group assignment of their child.”

As I said, this was a curious way to put it. As I read this, all it says is that each group of parent were equally able to guess which group their child was assigned to. That could be a 50% accuracy (which would be equal to chance), but a 90% or 99% accuracy – if both groups were that accurate – would also fit that description.

Now, this could simply be an clumsy phrasing by the authors, or it could be a way to make it sound like their blinding was successful when it actually was not.

Summary

This study may have collected some useful data, but its analysis of that data rendered it useless. The CGI scores – where the only statistically significant result was (possibly) seen – were improperly manipulated and the wrong statistical analysis was used.

The other issue is that there is no discussion of why HBOT is thought to be superior to providing the same partial pressure of oxygen at room pressure. This study used 24% oxygen at 1.3 atm, which gives the same partial pressure of oxygen as 31% at sea level. This concentration of oxygen can be easily attained with an oxygen mask or simple oxygen tent – both of which are vastly less expensive than HBOT.

If the authors are arguing that the mild pressure of their inflatable HBOT chambers contributes to the treatment effect, they need to look at the literature on cell membrane compressibility. For those who want to do the calculations at home, the bulk modulus of water (the major component of cells) is 21,700 atm. This means that a 0.3 atm increase in pressure will reduce the cell volume by 0.0014%. The bulk modulus of the lipid bilayer in cell membranes is around 30,000 atm. This means that an increase of 0.3 atm pressure causes a 0.0010% reduction in membrane volume. These are well below the threshold for any clinical effects.

Real pressure effects on the central nervous system are seen at pressures over 19 atm. These effects are:

dizziness
nausea
vomiting
postural and intention tremors
fatigue and somnolence
myoclonic jerking
stomach cramps
decrease intellectual and psychomotor performance
poor sleep with nightmares
increased slow wave and decreased fast wave activity in EEG

None of these effects could be construed as “improvements”, even in autism.

So, this study fails to answer the following questions about HBOT and autism:

[1] Does HBOT improve any feature of autism?
[2] If so, is HBOT any better than supplemental oxygen (which is much cheaper)?

The only real effect of this study was to give a cover of legitimacy to practitioners who are already using HBOT to “treat” autism.

Prometheus

Mild hyperbaric therapy for autism – Shh!…don’t say it’s expensive

30 Mar

When I recently wrote about the new HBOT-for-autism study (Rossignol et al. 2009)1, I took issue with unlikely claimed treatment pressures for at least one of the study locations. While a potential methodological weakness, this is probably a fairly small problem in light of potential issues with blinding and interpretation of the results as quantitatively and objectively meaningful with respect to autism. But let’s set those potential issues aside for a moment.

Let’s assume that treatment with slightly enriched air (24% vs. 21% oxygen) in an inflatable hyperbaric chamber pressurized to 4 PSI2,3 above ambient atmospheric pressure, could confer some sort of benefit to an autistic child.

I’m not suggesting assumption that it does confer benefit. I’m asking readers to set aside any knowledge of hemoglobin’s role in oxygen transport, as well as any knowledge of real hyperbaric oxygen therapy (breathing 100% oxygen at greater than 1 ATA)4, and evaluate a simpler proposition. Accept the proposal that some sort of benefit is scientifically possible, but then ask yourself a fairly simple question:

Compared to 24% O2 at 4PSI above ambient atmospheric pressure in an inflatable hyperbaric chamber, equivalent oxygen delivery can be achieved with simple oxygen therapy (an oxygen mask) at a fraction of the cost5 – why is a study of the hyperbaric version of this increased oxygen important?

One possibility: studying what’s already for sale

While some might call it being on the “cutting edge”, others may consider it putting the cart before the horse. No matter how you see it, it’s no secret that some Defeat Autism Now practitioners were already selling this type of hyperbaric oxygen therapy well before this study came out. It should be noted that this study’s authors did disclose this conflict of interest with respect to derivation of revenue in their clinical practices from HBOT.

DAR, LWR, SS, CS, AU, JN, EMM, and EAM treat individuals with hyperbaric treatment in their clinical practices and derive revenue from hyperbaric treatment.

Lisa Jo Rudy over at autism.about.com6 had additional comments about the subject:

Dr. Rossignol is “the” proponent of HBOT, and has been speaking at conferences all over the world in support of the treatment. Clearly, he has a personal and professional stake in seeing that the outcomes of a research study are positive.

The present study was funded by the International Hyperbarics Association, a trade group of private hyperbaric therapy centers. Clearly, they have a similar stake in seeing positive outcomes.

While there may certainly be an aspect of genuine scientific interest in understanding if this type of hyperbaric oxygen therapy is beneficial for autistic kids, I think there may also be a certain degree of assumption that it is. After all, why would a practioner already be selling something if they didn’t “believe” it worked? Given the stated conflicts of interest, it doesn’t seem implausible that the authors might have an interest in seeing a long-term revenue stream that could come from additional, and deeper pockets than those of parents willing to “believe” and pay – despite the lack of really convincing scientific evidence at this point.

Consider the following portions of an interview with Dr. Dan Rossignol7:

We chose 1.3 ATA because a lot of children with autism are currently receiving this dose and we are hoping to prove that it works.

“Hoping to prove that it works.”

Dr. Rossignol’s point does not seem unclear. HBOT is popular, and he is, in his own words, “hoping to prove that it works”. This is a valid reason, I suppose, if he is also open to the possibility that it may not, or that it may be a completely moot point if something on the order of one tenth of the cost can do the same thing. Following Dr. Rossignol’s communication about the hope to “prove that it works”, the interviewer asks:

How is the insurance situation coming along?

Insurance situation? Coming along? Was this situation already a well-known “work in progress” back in 2006 (e.g. had it been decided by some, prior to the science, that “mild” HBOT for autism does work, and that insurance reimbursement is really the goal now? Let’s see if we can get Dr. Rossignol’s take on this.

Well, obviously, HBOT is not approved for autism, but we hope to get there. Interestingly, if you take the ABC scale and look at the lethargy subset score, we saw a 49% improvement in symptoms at 1.5 ATA with a p-value of 0.008. If you look at the New England Journal of Medicine study on risperidone from 2002, there was a 56.9% improvement on the ABC irritability subscale with a p-value < 0.001. So the results we had on these 6 children with 1.5 ATA approached the percentage improvement seen with a drug approved for the use in autism. We just need to be able to reproduce these type of findings in a placebo study.

Hopefully when we finish these studies and show that hyperbaric therapy works, then insurance reimbursement will follow.

I don’t necessarily see a geniune scientific perspective here, but that could just be me. I get more of a vibe (at least from this interview), that the interest may lie more in “finishing” the studies and showing “that hyperbaric therapy works”, rather that actually finding out, with really good quality scientific methodology, whether or not it really does work. I’ll acknowledge that I could be wrong about this. Do you think readers will have noticed that the study result mentioned for comparison, was from 1.5 ATA, and probably totally irrelevant to the 1.3 (or less) studies?

Is it just me, or would it seem naive to wish that a few studies like the recent one, are really going to catalyze insurance reimbursement in the long run? I get the impression that many parents may believe this. Insurance companies work to achieve cost efficiencies. One of the ways they do this is by reimbursing at higher rates for equivalent things at lower costs – hospital stays in contracted facilities, generic drugs as compared to name-brand versions, etc. Why on earth would an insurance company reimburse for a 4-5% increase in blood oxygen content for a couple of hours at a time, in an inflatable hyperbaric chamber (at a few thousand dollars a month), when the identical oxygen increase could be delivered with a simple oxygen mask (for under $200 a month)?

You don’t have to take my word for this comparison of oxygen delivery, you can take Dr. Rossignol’s acknowledgement in that same interview:

Some people have criticized using mild hyperbarics at 1.3 ATA because they state that when compared to this pressure, you can get just as high an oxygen concentration in the blood with oxygen by face mask without a chamber. And this may be true in some cases.

In fact, it’s true in most (if not all) cases. The physics of partial pressures does not discriminate. But there may be more to the story.

Squeeze in some hope

After acknowledging the reality of the partial pressure comparison problem, Dr. Rossignol continues:

However, we must remember we are dealing with 2 separate components with HBOT — the oxygen and the pressure. So it appears that many of the effects of HBOT are from the increased oxygen, but we cannot dismiss the pressure effect. I think we need more studies on this as well.

So “many of the effects” are from the oxygen increase, but we can’t dismiss the pressure effect? What pressure effect? Is there a demonstrated significant clinical effect for autism from a very slight, and very temporary, increase in atmospheric pressure alone?

Although I suppose it is possible, a clinically significant effect for autism at such low pressures doesn’t seem likely at all. If it turns out that I am incorrect, this may be good news for some of the parents of autistic children in several U.S. cities: Albuquerque, NM (5312′ AMSL), Aurora, CO (5471′ AMSL), Colorado Springs, CO (6035′-7200′ AMSL), Denver, CO (5280′ AMSL), Reno, NV (4505′ AMSL), and Salt Lake City, UT (4226′ AMSL), to name a few. Something as simple as a move to a closer to sea-level city might provide increases in atmospheric pressure not a lot unlike those provided by the inflatable hyperbaric chambers. If there were some beneficial effect of slight additional atmospheric pressure for autism, certainly there would have been some observations (anecdotal or media reports) over the years, of families with autistic children who moved from states like Colorado to lower elevation states like California – and noticed. Who knows? Perhaps this is something to yet be uncovered.

So, aside from the fact that an identical oxygen increase can be achieved with simple O2 therapy without a hyperbaric chamber at all (and at a fraction of the cost). And, aside from the point that the minute pressure increase (while certainly possible in a strict scientific sense) isn’t known to be a likely candidate to significantly clinically impact autism, is there anything else about this newest HBOT-for-autism study that may merit some critical thought? Maybe, but it’s really just a side-note (perhaps interesting to some, but not terribly relevant to the science itself).

Who farted in the HBOT chamber? (Shh!…Don’t say it’s expensive)

The original manuscript8 for this study contained what I thought was an appropriately realistic comment from the authors in the conclusion. This comment has value in terms of practical knowledge that readers who are not familiar with hyperbaric oxygen therapy would probably find useful. What follows is the first-draft conclusion of this study with that comment emphasized.

Hyperbaric treatment is a relatively time-intensive treatment and can be costly. However, given the positive findings of this study, and the shortage of proven treatments for individuals with autism, parents who pursue hyperbaric treatment as a treatment for their child with autism can be assured that it is a safe treatment modality at the pressure used in this study (1.3 atm), and that it may improve certain autistic behaviors. Further studies are needed by other investigators to confirm these findings; we are aware of several other planned or ongoing studies of hyperbaric treatment in children with autism.

Again, Lisa Jo Rudy over at autism.about.com notes:

No insurance company will cover the very high cost of HBOT for autism, as it is considered an experimental and unproven therapy.

But the above conclusion is not the conclusion that appeared in the peer-reviewed, edited version. Here it is:

Given the positive findings of this study, and the shortage of proven treatments for individuals with autism, parents who pursue hyperbaric treatment for their child with autism can be assured that it is a safe treatment modality at the pressure used in this study (1.3 atm), and that it may improve certain autistic behaviors. Further studies are needed by other investigators to confirm these findings; we are aware of several other planned or ongoing studies of hyperbaric treatment in children with autism.

Why would the authors remove that valuable bit of practical knowledge about time requirements and high cost? Apparently due to a comment from referee #3 for this paper.

Discretionary Revisions

Page 24 In view of the highly positive findings of this study and the fact that no other trial has demonstrated such benefits under strictly controlled conditions to open the conclusions with negative comments demeans the study. Many other inventions used for ASD children are equally time consuming and hyperbaric treatment need not be expensive.

Authors: “The negative comments were removed from the conclusion.”

Opening the conclusion with negative comments demeans the study? Such comments don’t really touch the content of the study itself, and what the now absent comment did do, was provide some practical perspective – quite likely, very accurate practical perspective. Why would it be suggested by referee #3 that the practical comments demean the study? Perhaps it was meant that the comments demean the use of mild hyperbaric oxygen therapy as an autism treatment (therefore actually demeaning a desired interpretation of this study)? That would seem a real possible concern, since the justification offered, has absolutely nothing to do with the study itself, and doesn’t amount to much more than logical fallacy and simple assertion.

“Many other inventions used for ASD children are equally time consuming…”

This is about as basic an example of the “two wrongs make a right” fallacy as can be presented. Two wrongs don’t make right. Just because other interventions are also time consuming, does not mean a researcher is unjustified, or shouldn’t add the point about practicality that HBOT is relatively time consuming. Further, if the authors are aware of such a potential practical issue, it could be argued that ethics would dictate that it is mentioned. Other treatments presenting similar impracticalities do not automatically relieve any potential ethical responsibility in this regard.

“…hyperbaric treatment need not be expensive.”

Compared to what? Hyperbarics in a gold-plated hyperbaric chamber? If there is no significant effect for autism from the brief, and small increase in added pressure in one of these inflatables, the increased oxygen delivered by providing 24% O2 at 4 PSI above ambient atmospheric pressure, is easily matched (or exceded) with simple O2 therapy. In short, this type of hyperbaric treatment would be the hard way, and the expensive way to achieve the results.

Referee #3 also added the following comment:

The reviewer has a preference for the word treatment rather than ‘therapy’. In view of the proven changes that relate to increased inpsired fractions of oxygen it is suggested that treatment would be preferable.

Authors: “The word “therapy” has been replaced with “treatment” throughout the paper.”

The “T” in the acronym “HBOT” does, in fact, represent the word “therapy” in medical usage. I happen to think the terms “treatment” and “therapy” are fairly interchangeable in the context of drug delivery, but I do wonder if there is any significance to such a preference. Is this a semantics issue that has the potential to impact perceptions of those who make decisions about insurance coverage for autism? But I digress. So what’s up with these comments from referee #3, comments with a little fallacious reasoning, that express possible concern about the perception of a high price tag for mild hyperbaric oxygen therapy, and a commment that communicates a preference for the word “treatment” over “therapy”?

I honestly don’t know. What I can tell you is that referee #3 was Philip James, MD. Dr. James is a professor in the field of hyperbaric medicine and hails from the U.K. He appears to have published quite a bit in the field of hyperbaric medicine as well.

According to the International Hyperbarics Association website:

Dr. James is responsible for founding the Hyperbaric Trust in the United Kingdom which promotes the treatment of cerebral palsy and the brain injured child and was responsible for having the National Health Service pay for this therapy.

Dr. James (Referee #3) appears to have been categorized (with a doctor profile) as a medical advisor to International Hyperbarics Association back in February of 2006 (shortly before this study9 began). Hey wait a minute, there’s that name again – International Hyperbarics Association. Where have I seen that before? Oh yeah, in the study itself:

We are grateful for the work of Shannon Kenitz of the International Hyperbarics Association (IHA) for an unrestricted grant which funded this study, which included use of hyperbaric chambers and funding for all hyperbaric technician salaries during the study. The IHA had no involvement in the study design, collection, analysis, interpretation of data, writing of the manuscript, or in the decision to submit the manuscript for publication.

I’m not sure how the International Hyperbarics Association defines itself exactly – are its listed medical advisors excluded from that definition? That would seem likely.

As of this writing, Dr. Rossignol is listed as a medical advisor at the IHA website. 10
As of this writing, Dr. Neubrander is listed as a medical advisor at the IHA website. 10
As of this writing, Dr. James (referee #3), is categorized as a medical advisor at the IHA website with a physician profile page.11,12

Side notes aside, where to, from here

So all in all, it seems that “mild” HBOT-for-autism researchers may have their work cut out for them. Although probably not very likely, it is possible that a small temporary change in atmospheric pressure could do something for autism, and that should be studied next, then, better replications should follow.

In the long run, it will be difficult to ignore the scientific fact that simple oxygen therapy alone can easily provide identical increases in blood oxygen content, at a fraction of the cost of mild hyperbaric oxygen therapy (as it currently being studied for autism). If HBOT-for-autism proponents think insurance companies should step up to pay for an expensive treatment that provides a 4-5% increase in blood oxygen (without scientifically establishing benefit of the small and temporary pressure increases), they might do well to consider these famous words (most recently from Barack Obama) – “You can put lipstick on a pig. It’s still a pig.”

Notes:

1 Hyperbaric treatment for children with autism: a multicenter, randomized, double-blind, controlled trial

Click to access 1471-2431-9-21.pdf

2 Medical device pre-market notification (FDA-cleared)

Click to access K001409.pdf

3 Manufacturer product sheet

Click to access vitaeris-lowres2007-8.pdf

4 Definition of Hyperbaric Oxygen Therapy
http://www.uhms.org/ResourceLibrary/Indications/tabid/270/Default.aspx

5 Hyperbarics and Hypotheses

Schooling and Statement

6 Hyperbaric Oxygen as a Treatment for Autism: Let the Buyer Beware
http://autism.about.com/b/2009/03/14/hyperbaric-oxygen-as-a-treatment-for-autism-let-the-buyer-beware.htm

7 Interview with Dr. Dan A. Rossignol: Hyperbaric Oxygen Therapy Improves Symptoms in Autistic Children

Click to access Rossignol%20HBOT%20Medical%20Veritas%202.pdf

8 Pre-publication history
http://www.biomedcentral.com/1471-2431/9/21/prepub

9 ClinicalTrials.gov Identifier: NCT00335790
http://clinicaltrials.gov/ct2/show/NCT00335790

10 Medical Advisors
http://www.ihausa.org/

11 Index of /docs
http://www.ihausa.org/docs/

12 International Hyperbarics Association Medical Advisor – Professor Philip B. James, M.D.
http://www.ihausa.org/docs/james.html

When High Does Mean Low: Autism, mHBOT, and Dan Rossignol

7 Oct

A while back on Autism Street, I questioned the claim by DAN! doctor, Dan Rossignol, that children he wrote about in an article that appeared in the pay-to-publish, not peer-reviewed journal Medical Hypotheses, were treated with “mild hyperbarics” at 1.3 ATA.

In hyperbaric medicine, the term “1.3 ATA” has the very specific scientific meaning of “1.3 Atmospheres Absolute”, and it is a likely overstatement (due to rounding) of the actual treatment pressure in that particular study. Put simply, “atmospheres absolute” refers to the total pressure, and includes that actual pressure of the atmosphere. It’s also an absolute pressure that is apparently beyond the physical capabilities of the equipment that was used (a Vitaeris 320), unless the chamber were located well below sea-level, or housed inside another, larger, and pressurized hyperbaric chamber. I suggested that he publish an erratum. He was kind enough to reply to my e-mail, in which he responded, in part with:

HBOT measurements are typically reported to 2 significant figures, i.e. 1.3, 1.5, 2.0, 2.4, 3.0 ATA, etc… Therefore, this properly rounds to 1.3 ATA (we did not report the pressure to 3 significant figures as would be the case with 1.30 ATA).

As it turns out, this may not be entirely true. I responded with the following:

At least two of the papers cited in your references (Collet et al., and Montgomery et al.) show treatment pressures of 1.75 atmospheres. There might even be more. Would those have been acceptable to be published at 1.8? Do you think a real peer-reviewed journal would be requiring that you publish an erratum? I think so, but I could be wrong. In many of the “typical” numbers you list, reporting to 2 significant figures does not change the accuracy anyway (2.0 ATA is stated instead of 2.00 ATA, 3.0 ATA instead of 3.00 ATA, etc.).

Dr. Rossignol, to my knowledge, did not publish an erratum. He did not comment on the apparent overstatement of treatment pressure further. So it would appear that he intends to stick with his assertion that,

HBOT measurements are typically reported to 2 significant figures, i.e. 1.3, 1.5, 2.0, 2.4, 3.0 ATA, etc…

That’s fine, we can work with that, but remember it. It’s going to be very important in a minute.

I later wrote a little more about the physics of so-called “mild hyperbarics” again, and included a notation of a new study that Dr. Rossignol, appeared to be working on.

There’s another “hyperbaric therapy as a treatment for autism” study underway. It appears to be headed up by Dr. Rossignol, and has three clinical locations supervised by Doctors Liz Mumper (Virginia), Cindy Schneider (Arizona) and Jeff Bradstreet (Florida) – none of which appear (according to a search at ABMS) to have board certification in Developmental-Behavioral Pediatrics, Child Neurology, Neurodevelopmental Disabilities or Undersea & Hyperbaric Medicine.

Well, it looks as though that study has wrapped up. Is there a forthcoming publication that will claim that the children in the study were treated with “mild hyperbarics” at 1.3 ATA? Will it be published in a journal like Medical Hypotheses, JAPandS, or Medical Veritas? If it’s headed for a respectable peer-reviewed medical journal, and the treatment pressure is claimed to be 1.3 ATA, there might be a problem.

You see, in the real world, a Vitaeris 320, is probably not a hyperbaric chamber that can produce a full 1.3 Atmospheres Absolute – even at sea-level. Its non-rigid construction means that it’s directly influenced by the ambient atmospheric pressure. To calculate the absolute pressure inside the chamber at any given time doesn’t require anything more than knowing the current actual atmospheric pressure outside the chamber, and the slight pressure added by the compressor that inflates it. Although it does vary slightly, at sea-level the average atmospheric pressure is about 14.696 PSI. According to the manufacturer’s spec sheet, the chamber introduces an operating pressure of 4 PSI, which would yield a total pressure of about 18.696 PSI – 1.27 ATA. Don’t forget, that’s at sea-level!

The study mentioned above, lists the following clinical trial locations:
Phoenix, Arizona
Melbourne, Florida
Charlottesville, Virginia
Lynchburg, Virginia

Are all of those cities at sea-level? No.

Will this matter? Absolutely.

It’s a simple fact of physics that as elevation increases, atmospheric pressure decreases. Although there are several influencing variables involved, this is probably most easily understood in layman’s terms by knowing that weight of the column of air above you gets smaller as your altitude increases (as you ascend, the column above you is shorter and simply weighs less – exerting less pressure).

So what does this mean for this study? It means that if the study used Vitaeris 320 chambers, and reports that children were treated with 1.3 Atmospheres Absolute, it should raise more than a few eyebrows.

Firstly, if the study does not report actual atmospheric data for pressure at the study locations during treatment, it will be incomplete. Remember, for a non-rigid chamber, treatment pressure is measured by adding the actual ambient pressure to the pressure added by the compressor used to inflate the chamber. There is no way to measure the actual treatment pressure without knowing the actual ambient atmospheric pressure at the time of treatment.

Side note: It could be tempting for one to read a weather report from the National Weather Service in the U.S. and simply think that the pressure reported is the actual ambient atmospheric pressure at the study location (station pressure). Unfortunately, that’s not how it usually works. The National Weather Service typically reports “altimeter pressure” and “sea-level pressure”. See section 11.6, Table 11-2 from the Federal Meteorological Handbook No. 1. These adjusted pressures (corrected for elevation and temperature) are done to make pressure systems on weather maps more meaningful (and not simply reflective of the topography), and to allow aircraft pilots to adjust their instruments to the current conditions. With an altimeter calibrated to what the pressure “would be” at sea-level, instruments can accurately reflect the actual altitude of the plane. This is important if you intend to land on a runway that is always 1135 ft. above sea-level.

Secondly, if the study does not claim to have “measured” the treatment pressure, but instead asserts that it is 1.3 ATA, it will be difficult for any publication to substantiate the claim that the treatment pressure was uniformly (or even approximately) 1.3 Atmospheres Absolute at all study locations, due to the varying elevations of the study locations.

Let’s use Phoenix, Arizona (one of the study locations) as an example. The elevation of Phoenix, Arizona is approximately 1135 ft. above sea-level. This means that the ambient atmospheric pressure is about 14.10 PSI simply due to the elevation. 14.10 PSI plus an added 4 PSI gives us a total of 18.10 PSI – 1.232 ATA! Using Dr. Rossignol’s statement,

“HBOT measurements are typically reported to 2 significant figures, i.e. 1.3, 1.5, 2.0, 2.4, 3.0 ATA, etc…”

1.232 ATA in Dr. Rossignol’s words, “properly rounds to” 1.2 ATA!

Will the study report this? Or will it claim a very unlikely (if not impossible) treatment pressure of 1.3 Atmospheres Absolute? Following Dr. Rossignol’s apparent rounding preferences, we’re talking about a potential overstatement of the pressure added by the hyperbaric chamber of 50% for Phoenix alone. The Lynchburg, Virgina study location will quite likely present similar problems (elevation 938 ft. above sea-level) for Rossignol’s work. Is Dr. Rossignol, really concerned about the accuracy of the science in his work? We might just find out soon enough.

For anyone interested, here’s a table of estimated total pressure provided by a Vitaeris 320 at selected U.S. cities. Keep in mind that these estimates reflect the manufacturer’s specification of 4 PSI of operating pressure, and the expected atmospheric pressure due to elevation alone, and do not account for the slight variations in the weather. (Elevations retrieved from Airnav.com).

Estimated total pressure provided by a Vitaeris 320 at selected U.S. cities

It’s no surprise that parents of autistic children who “believe” that “mild hyperbarics” will somehow provide benefit for autism itself, would seek insurance reimbursement. In fact, some may interpret a statement by Dr. Rossignol to express such a view:

One of the reasons we wanted to study the 1.3 ATA chambers is because this is something that is available at home. We hope that if it does work and is proven, we can begin to have insurance reimburse for hyperbaric and this is one of our goals, as well.

Source

Besides the obvious problem that scientifically “proving” that treatment with “1.3 ATA” will be difficult with chambers that likely don’t provide 1.3 Atmospheres Absolute, what are insurance companies supposed to think? Would insurance companies like the idea of reimbursing for HBOT treatment at a specific pressure that really isn’t?