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The autism ‘epidemic’ no more

17 Aug

OK, so its well known to LBRB readers that I don’t think its ever been scientifically established that there has been such a thing as an autism epidemic but even so, looking at why autism numbers have changed over a certain period of time – the period of time people believe is part of the ‘epidemic’ – should be a good way to determine what contributed to that time periods rise in autism.

So thats what Peter Bearman did. Summed up well in this weeks New Scientist, Bearman’s study offers the first look at what actually did cause the ‘epidemic’.

Better diagnosis
Diagnostic changes are the most important influence. After 1987, the definition of autism used in California was broadened several times. Bearman and his colleague Marissa King examined the medical records of around 7000 Californian children with autism and found that one in ten had initially been diagnosed with mental retardation. Extrapolated to the state as a whole, they estimate that this change in diagnosis created almost 5000 extra cases of autism between 1993 and 2005, or 26 per cent of the increase of recorded over that period.

Greater awareness
Social influence accounts for another big chunk of the overall increase. Parents are more aware of the disorder than they used to be, and so those whose children who have mild forms of autism have become more likely to seek out diagnosis.

Bearman and his colleague Ka-Yuet Liu quantified this effect. They first estimated how the chances of a child being diagnosed with autism increase if he or she lives close to a child that has already been diagnosed. They then plotted the addresses of children with and without autism in California to calculate the number of children who had grown up close to a child diagnosed with the condition. They were then able to calculate the fraction of extra cases that would have been diagnosed as a result of social interactions. They put this figure at 16 per cent.

Older parents
The final contribution to the rise in diagnoses comes from demographics. Couples in California are having children later in life, as they are in much of the rest of North America and Europe. That is pushing up autism rates, because autism is triggered by genetic mutations that older parents are more likely to pass on to their children.

Bearman and King calculated that these older parents are responsible for 11 per cent of the extra autism cases.

So these total 53% of the so-called ‘epidemic’. What about the missing 47%? Well, Professor Roy Grinker says:

Autism used to be highly stigmatised, in part because it was thought to be due to poor parenting. The removal of that stigma has made doctors and parents more willing to recognise the disease, which will have contributed to [some of] the extra cases…This and other social causes, together with uncertainty in the number of cases that can be attributed to the factors already studied by Bearman, could account for much or all of the unexplained half

But note Grinker doesn’t say it definitely does. This is because he knows as a careful scientist it hasn’t been looked at.

So what can we take from Bearman’s work? In my opinion we can take the fact that as soon as the questions regarding non-environmental causes were actually looked at and studied, there were numerical values that could be applied to their contribution. There are other non-environmental causes which Bearman didn’t look at which would probably be found to contribute to the other half.

What about the alleged environmental causes? It would not surprise me in the least if it were found that there were some. But as to what they are, the environmental lobby are still so hung up on vaccines they don’t seem to want to look at other possible environmental issues. Maybe its time they dropped the vaccine nonsense and got involved in some decent research. Just a thought.

Autism is not murderous

12 Aug

Lives lost to autism is a new website with what seems at first glance to have an excellent reason for existence – to record all the non-natural deaths of autistic people.

But the name ‘Lives lost to autism’, the strapline ‘For many, autism can be deadly.’ and most particularly the statement ‘This site tells the story of the precious lives cut short by autism.’ are very misleading. Blaming autism for murder is utterly misleading. Autism didn’t murder any of the children listed as murder victims – or the ones that haven’t been listed either.

The site seems to be set up and run by Ginger Taylor (left) who’s position on autism has grown more and more extreme over the years. It seems now she is happy to denigrate autism itself as a murderous entity.

Should there be a site where victims of murder AND natural deaths are remembered? Of course there should, its a great idea. But to politicise it so graphically and so ham-fistedly is wrong. Its a testament to the ideas of Ginger Taylor and not a lot more right now.

New study – “90% diagnostic accuracy”

11 Aug

According to study author Christine Ecker in today’s Guardian:

We know already that people with autism have differences in brain anatomy and some regions are just bigger and smaller or just different in shape…[o]ur technique can use this information to identify someone with autism.

The study used 20 non autistic controls and 20 autistic people – all adults – and found ‘significant differences’ in the grey matter areas of the brain which control behaviour and language. This is nothing new in itself, differences in brain structure have long been known about in regards to autism. Whats new in this study is the method – and resultant accuracy – of the detection of autism.

In the experiment, Ecker showed that her imaging technique was able to detect which people in her group had autism, with 90% accuracy. “If we get a new case, we will also hopefully be 90% accurate,” she said. The research, supported by the Medical Research Council, Wellcome Trust and National Institute for Health Research, is published today in the Journal of Neuroscience.

If this is established as a viable method (Carol Povey of NAS states that further testing is still required) then it’ll be the first true objective test for autism ever developed. So far, as everyone knows, autism is diagnosed based on the opinion of a clinician (or team of specialists). Whilst they will probably still play a role, this test offers an objectivity that would be unparalleled. It would also have the interesting effect of making the DSM diagnosis largely obsolete.

Evidence of Harm

9 Aug

A new Cochrane Review looks at the issue of SSRI’s in use for autistic populations.

OBJECTIVES: To determine if treatment with an SSRI: 1. improves the core features of autism (social interaction, communication and behavioural problems); 2. improves other non-core aspects of behaviour or function such as self-injurious behaviour; 3. improves the quality of life of children and their carers; 4. has short and long term effects on outcome; 5. causes harms.

SSRIs (Selective serotonin reuptake inhibitors) do exactly what they say – they combat depression by ‘boosting’ serotonin. They are usually fairly effective in that role, although not all people with depressive tendencies use SSRIs, the majority tolerate them well. The most famous SSRI is Prozac.

The outcome of the study was:

There is no evidence of effect of SSRIs in children and emerging evidence of harm. There is limited evidence of the effectiveness of SSRIs in adults from small studies in which risk of bias is unclear

This is worrying. It indicates to me that autistic people are being treated for autism with SSRIs. Bearing in mind I haven’t read the full paper, it does read to me as though we are verging into the territory of chemical cosh.

A chemical cosh is shorthand for the administration of drugs to people who don;t actually require its benefit but who are kept quiet by its effects or side effects. This isn’t the fault of the drug or even the manufacturer but the prescriber. This is also not a situation unique to autism but is frequently found throughout all areas of mental health.

Upcoming IACC Services Subcommittee Conference Call – August 10, 2010

6 Aug

I just got this announcement:

The Interagency Autism Coordinating Committee (IACC) Services Subcommittee will be holding a conference call on Tuesday, August 10, 2010 from 2:00 PM – 3:30 PM ET. For more information see: http://iacc.hhs.gov/events.

The purpose of this meeting will be to discuss plans for the IACC Services Workshop that will be held on November 8, 2010 in Rockville, Maryland. (More information about the workshop is posted on the IACC website and will continue to be updated.)

To access the conference call:

USA/Canada Phone Number: 800-369-3340
Public access code: 8415008

Members of the public who participate using the conference call phone number will be able to listen to the meeting, but will not be heard.

I’ve been offered a job as a paid blogger to promote a medical website!

5 Aug

“Pharma shill!” I get called that fairly often. People claim (incorrectly) that I am paid for what I do here at LeftBrainRightBrain. That I only write what I write because I am a shill.

When this comes up I point out that, no, I am not paid. I find the idea that there are many paid bloggers like that to be a bit of a stretch anyway.

I just found this email in our spam comment queue:

“Hi! We are browsing for potential future writers, would likely you be intrigued? This process is not going to get you rich yet unfortunately there is an alluring pay and if you literally appreciate publishing then now this gig is for you.”

Yes, I could get “alluring pay”.

All I have to do is write for a blog that touts HBOT. Yes, a hyperbaric oxygen therapy blog.

I could be an alt-med-pharma-shill!

I think I’ll pass.

Communicating Effectively About Vaccines

4 Aug

A new study is looking at how messages regarding vaccines are assimilated by the US public.

Immunization rates continue to be high but concerns about vaccine safety are increasing. Current communication methods do not appear to lead to more comfort with vaccines, making it more important than ever that state and territorial public health agencies, charged with promoting, monitoring and tracking vaccine use, understand the growing reluctance among parents and guardians to fully vaccinate their children and identify effective messages about the benefits of vaccines.

According to this report 5% of all respondents mentioned autism-related concerns and above average amount of people designated the statement:

Vaccines can cause serious health problems like…autism

‘convincing’.

and the conclusion states:

…Current communication methods based on scientific research do not appear to lead to more comfort with vaccines…

Reading this blog post one would tend to think it was a bad report for vaccines. Far from it, its wholly positive, which one will gather if one reads the whole thing. However, the aspect of the report I’m particularly concerned with (autism) shows that there is a growing trend of belief and a shrinking trend of science in what leads a parent to make up their mind. And apparently autism plays a relatively large percentage in that decision making process.

So what do we do about that? The science is clear that vaccines don’t cause autism but the US public seem to be ignoring such science. What else is there available that we can use? Because take note, we in the autism community have an obligation to society as much as they do to us. Their obligation is to do right by autistic people. Our obligation is continue to fight the idea that vaccines cause autism. If we do not then the public will believe that *all* parents of autistic people and autistic people themselves believe that vaccines cause autism – thats a very dangerous place to be.

Microglial Activation and Increased Microglial Density Observed in the Dorsolateral Prefrontal Cortex in Autism.

4 Aug

Here is a study that will likely be discussed for a long time to come. There has been a lot of interest in the study by John’s Hopkins researchers (Pardo, et al.) on microglial activity in the brains of autopsied autistics. A paper just released by Prof. Pardo together with Prof. Courchesne at UCSD shows markedly increased microglial cell activiation in 5 of 13 autistics, including children under 6.

The exact implications of this are not yet determined. The authors conclude the abstract with

“Given its early presence, microglial activation may play a central role in the pathogenesis of autism in a substantial proportion of patients. Alternatively, activation may represent a response of the innate neuroimmune system to synaptic, neuronal, or neuronal network disturbances, or reflect genetic and/or environmental abnormalities impacting multiple cellular populations.”

Here is the full abstract:

Biol Psychiatry. 2010 Aug 15;68(4):368-376.
Microglial Activation and Increased Microglial Density Observed in the Dorsolateral Prefrontal Cortex in Autism.

Morgan JT, Chana G, Pardo CA, Achim C, Semendeferi K, Buckwalter J, Courchesne E, Everall IP.

Department of Neuroscience, School of Medicine, University of California, San Diego, La Jolla, California.
Abstract

BACKGROUND: In the neurodevelopmental disorder autism, several neuroimmune abnormalities have been reported. However, it is unknown whether microglial somal volume or density are altered in the cortex and whether any alteration is associated with age or other potential covariates. METHODS: Microglia in sections from the dorsolateral prefrontal cortex of nonmacrencephalic male cases with autism (n = 13) and control cases (n = 9) were visualized via ionized calcium binding adapter molecule 1 immunohistochemistry. In addition to a neuropathological assessment, microglial cell density was stereologically estimated via optical fractionator and average somal volume was quantified via isotropic nucleator. RESULTS: Microglia appeared markedly activated in 5 of 13 cases with autism, including 2 of 3 under age 6, and marginally activated in an additional 4 of 13 cases. Morphological alterations included somal enlargement, process retraction and thickening, and extension of filopodia from processes. Average microglial somal volume was significantly increased in white matter (p = .013), with a trend in gray matter (p = .098). Microglial cell density was increased in gray matter (p = .002). Seizure history did not influence any activation measure. CONCLUSIONS: The activation profile described represents a neuropathological alteration in a sizeable fraction of cases with autism. Given its early presence, microglial activation may play a central role in the pathogenesis of autism in a substantial proportion of patients. Alternatively, activation may represent a response of the innate neuroimmune system to synaptic, neuronal, or neuronal network disturbances, or reflect genetic and/or environmental abnormalities impacting multiple cellular populations. Copyright © 2010 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.

PMID: 20674603 [PubMed – as supplied by publisher]

Diagnosis of autism occurs much later than it should among Medicaid-enrolled children

4 Aug

This from a recent study by Prof. David Mandell’s group. The abstract is below:

Psychiatr Serv. 2010 Aug;61(8):822-9.
Age of diagnosis among medicaid-enrolled children with autism, 2001-2004.

Mandell DS, Morales KH, Xie M, Lawer LJ, Stahmer AC, Marcus SC.
Abstract

OBJECTIVE: This study examined child- and county-level factors associated with age of diagnosis of autism among Medicaid-enrolled children and the change in age of diagnosis over time. METHODS: National Medicaid claims from 2002 to 2004 were used to identify age of diagnosis and characteristics of children younger than ten years old with a diagnosis of autism (ICD-9 codes 299, 299.0x, or 299.8x). These data were linked to county-level education and health care variables. Linear regression with random effects for state and county was used to examine associations between these variables and age of diagnosis. RESULTS: A total of 28,722 Medicaid-enrolled children newly diagnosed with an autism spectrum disorder were identified. Their average age of diagnosis was 64.9 months. Adjusted average age of diagnosis dropped 5.0 months for autistic disorder and 1.8 months for other spectrum disorders during the study period. Asian children were diagnosed earlier than children in other racial or ethnic groups, although these differences were much more pronounced for other spectrum disorders than for autistic disorder. Children eligible for Medicaid through the poverty category were diagnosed earlier, on average, than children who were eligible through disability, foster care, or other reasons, although this difference decreased over time. Children in large urban or rural counties were diagnosed later than children in small urban or suburban counties. CONCLUSIONS: Findings showed that diagnosis of autism occurs much later than it should among Medicaid-enrolled children, although timeliness is improving over time. Analyses suggest that most of the observed variation is accounted for by child-level variables, rather than county-level resources or state policies.

PMID: 20675842 [PubMed – in process]

The age of diagnosis in California for the general population was 3 years by 2000 (falling from 6 in 1992) according to a recent paper by Bearman’s group at Columbia. Why are medicaid children diagnosed later?

I find it odd that children on medicaid due to poverty are diagnosed earlier than children “eligible through disability, foster care, or other reasons”. Naively, I would expect the opposite: that children already identified with a disability would be under greater scrutiny and more likely to receive evaluations to determine an ASD diagnosis.

Much more can be said about this, but I will stop with “Diagnosis of autism occurs much later than it should among Medicaid-enrolled children”. This is just wrong. We as a society should take better care of our most vulnerable.

The California pertussis outbreak of 2010

4 Aug

If you haven’t already heard, California is in the midst of a major outbreak of pertussis (whooping cough). The California Department of Public Health is predicting that this could be the biggest outbreak in 50 years.

Here is a graph from the CDC (via the LA Times) which shows the number of pertussis cases in the entire US as a function of time up to and including the 2004/5 outbreak:

That was not just the sort of cyclic bump seen every 4-5 years even with vaccines. That was a big outbreak. And, now, California is set to see an even bigger outbreak.

So far 7 infants have died. They were too young to be vaccinated. What is especially troublesome is that usually the worst part of the year starts in August. Here is a figure from the CDPH comparing this year to last year:

By this time last year, no children had died.

Why bring this up on an autism blog? Because unfortunately much discussion focuses on vaccines and pertussis is a vaccine-preventable disease. Many autism organizations promote under vaccination or skipping vaccination. Also, groups such as the self-named “National Vaccine Information Center” (NVIC) use autism as a major part of their message touting the dangers of vaccination. Because of this, these groups react strongly to accusations that these outbreaks are due to their activism. Such an accusation came from Nancy Snyderman of MSNBC

http://www.msnbc.msn.com/id/32545640

Visit msnbc.com for breaking news, world news, and news about the economy

Dr. Snyderman is an “unabashed advocate” for vaccines and points out that people who selectively undervaccinate put people like the immune compromised and the very young at risk.

As you might imagine, these strong comments brought a strong response. Becky Estepp of Talk About Curing Autism gave her response at the at the Age of Autism blog.

Barbara Loe Fisher of NVIC defended her group’s positions even before the MSNBC spot aired:

After watching the NVIC video I had a lot of questions. I posed a few of them to the California Department of Public Health. I appreciate them taking the time to reply:

NVIC states that there are outbreaks every 4-5 years and that “this is nothing new”. I asked CDPH:

There is an outbreak every 4 to 5 years (implying this is no big deal). I think this is correct as far as it goes, but the magnitude of this outbreak appears to be large. Is there public data on the size of previous outbreaks to compare this one to? I realize that will likely involve an estimate of the size of this year’s outbreak.

Yes, historically, there are “peak years” for pertussis every 3-5 years. This was true for other vaccine preventable diseases as well before they were controlled by vaccination. This is because once a disease sweeps through a population it takes at least a few years for adequate numbers of susceptible people to accumulate again in the population to allow sustained, widespread transmission of the disease. What is different about pertussis than other vaccine-preventable diseases such as measles, is that, unlike measles, neither pertussis vaccine or disease confers lifelong immunity. Pertussis susceptible people accumulate in the population via birth cohorts who are too young to be vaccinated, people whose immunity from vaccine or disease has waned, and people who are eligible to be vaccinated, but are unvaccinated.

The last peak year for pertussis in the U.S., including California was in 2005. This was a nationwide peak year with over 25,000 cases in the U.S, the most cases in 45 years, and over 3,000 cases in California, including 8 deaths. Although Tdap was first licensed in June 2005, not many people received it that year and it did not have an effect on the outbreak. We now have Tdap to use as a control measure that was not available in other peak years. Therefore, we are trying to increase the level of pertussis immunity in the population by encouraging the use of Tdap, particularly in people who have contact with infants.

California is having a peak year/epidemic in 2010. If current trends persist, there will be more cases in California this year than in 2005 and more cases than in 52 years (see attached document, which has been released to the public). Although some other states are reporting increases this year, no state has reported an increase similar to that seen in California, which has now had a six-fold increase from the numbers reported during the same time period in 2009, a non-peak year.

NVIC seems to be implying that parapertussis is the cause of the outbreak and that is not covered by the vaccine. Aren’t many cases, especially those hospitalized or the deaths, confirmed by PCR?

Parapertussis is also circulating and pertussis vaccine does not provide protection against parapertussis. However, we do not think parapertussis is the cause of our epidemic because most of the reported pertussis cases in California are laboratory confirmed to be pertussis. In addition, parapertussis does not kill healthy young infants. Tragically, there have been seven infant deaths in Calfornia this year, all of whom had laboratory confirmed pertussis.

NVIC is also claiming that B. Pertussis may be mutating away from the vaccine strain, so the vaccine would be failing. Besides being at odds with her own assertion that the outbreak is due to parapertussis, is there evidence for this? Are the outbreaks in unvaccinated individuals? The comparison is, of course, most valid in the very young, where immunity will not have had the chance to wane.

We are not aware of any evidence that the currently circuclating strains of pertussis are not covered by the vaccine. Of the reported cases for whom we have vaccination information, most were unvaccinated or undervaccinated. None of the seven infants ❤ months of age who died had received any pertussis-containing vaccines.

I have a lot more questions and there is much to deconstruct in the NVIC and TACA statements, but this is not the time for that.

Is the current outbreak due to the activities of groups like NVIC, TACA and the Age of Autism? Let me put it another way since accusations bring on such strong reactions from these groups: does it matter right now if they are at fault? People are dying. The goal right now is to minimize suffering and death. Vaccines do offer protection and could limit this outbreak.

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