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1 in 100 adults are autistic

30 Sep

A recent report by the Information Centre of the UK’s National Health Service says that the autism prevalence for adults is about 1 in 100.

The report, Autism Spectrum Disorders in adults living in households throughout England, states:

Using this recommended threshold score on the ADOS, 1.0%of the adult population had ASD. The rate was higher in men (1.8%) than women (0.2%), which fits with the profile found in childhood population studies.

This isn’t very new news, Anthony Cox and Kev Leitch on this blog have already discussed this.

I would suggest that the first reaction from pretty much everyone (including myself) was wrong.

What should the take-away message be from this?

Simple–there are a lot of unidentified adult autistics who are likely getting little, no, or inappropriate support.

From the report:

“Perhaps most important of all is the finding that adults with ASD are socially disadvantaged, less well educationally qualified, less able intellectually and possibly under-supported by services. Much of this could be alleviated with greater involvement of existing established social, educational, welfare and health care services.

Another point that really sticks out to me is:

There was no indication of any increased use of treatment or services for mental or emotional problems among people with ASD.

We don’t know if this is because they don’t need more services or they just aren’t getting them.

Two more statistics are also worth pointing out: 4.5% of unmarried male adults are identified as ASD. 8% of male adults in social housing are identified as ASD.

That’s huge. Imagine walking through a specific housing complex and 1 in 12 men you see are autistic.

Now that I am done lecturing everyone (including myself) about what I think the important message is from this report, let’s take a look at the report itself. Specifically, let’s consider the complaints that are being levied against it.

The first thing that struck me is that this is a report, not a published study. It is not, to my knowledge, peer reviewed in the same sense as a journal article. It is in the same class as the MMWR reports that the CDC puts out (a government report) that are used by almost everyone to discuss the prevalence of autism. So, if you use 1 in 150 or 1 in 166 prevalence numbers, don’t complain about this UK report being non-peer reviewed.

People are complaining about how the study was conducted. Here is the basic process:

A. Phase one AQ-20 self-completion screen
B. Selection of cases for phase two assessment
C. Phase two ADOS assessment of a subset of cases
D. Weighting to adjust for selection probabilities and non-response.

This was not worded well, since many people assume that the phase one screen only used the AQ-20. As I will discuss below, this is not the case.

The initial screen started by identifying addresses that were residences, and selecting some by random selection. They selected 13,171 possible households for phase-1. Of these, 57% agreed to respond.

9% of sampled addresses were ineligible because they contained no private households, while 4%were addresses of unknown eligibility (see Section 3.2.5). This left an estimated base of 13,171 known eligible or probable eligible households for the phase one interview. The proportion of selected adults who agreed to take part in an initial interview is shown in Figure 3B. At the phase one interview, 57% of those eligible agreed to take part in an interview. This included 50 partial interviews where the respondent completed the service use and CIS-R modules, but did not reach the end of the interview.

These interviews were not just the AQ-20 screen, as noted below:

The phase one interviews were carried out by NatCen interviewers. These included structured assessments and screening instruments for mental disorders, as well as questions about other topics, such as general health, service use, risk factors and demographics. These interviews lasted about 90 minutes on average.

90 minutes per interview, with 7,353 full interviews works out to 5.3 man-years of labor.

This was no small effort.

Many complaints I have seen concentrate on the AQ-20 test. The full AQ test, or Autism Quotient, is a product of the Cambridge Autism Research Centre, and has been studied already. It is usually a 50 question test, but it was shortened to 20 questions (hence AQ20) and adapted for the NHS survey. They shortened the AQ to save time.

Many people have been confused that this short questionnaire was the method used to make the autism diagnoses. People pull questions out and question whether they could be used to diagnose autism. The AQ20 wasn’t used to make the diagnoses. It was only a part of the phase-one, pre-screen, part of the study. The diagnoses were made using the ADOS.

They used the information from phase 1 to select a smaller subgroup for the more intensive phase-2 part of the study. Amongst this smaller group, the researchers chose people they thought were more likely to have psychosis, Asperger syndrome or personality disorder.

7461 respondents provided a productive phase one interview. Of these 58 were proxy respondents and therefore not eligible for the phase two interview (see Figure 3E). A probability of selection was calculated for each respondent based on their answers to the phase one screening questions on psychosis, Asperger syndrome, and personality disorder: as outlined in Section 3.2.6. 5,329 respondents had a probability of selection of greater than zero: 4050 of these also agreed to be recontacted for a phase two interview (76%). After the application of the highest of the four disorder specific sampling fractions, 849 respondents were selected for a phase two interview. Phase two interviews were conducted with 630 of these (74%).

618 of the 630 people who underwent the phase-2 interviews were given the ADOS test. A score of 10 on the ADOS was chosen to indicate a diagnosis of an ASD. Of these, 19 scored above 10 on the test and were diagnosed as having an ASD.

If one took these data to calculate a crude prevalence, a value of 19/618 or about 3% (1 in 32) would be obtained. No one is saying this is an accurate estimate, but it is worth noting for this reason: quite obviously, the phase-1 screen was successful in finding a larger number of autistics than

These data were weighted to estimate a prevalence for the overall study group, including non-responders. They came up with a prevalence of 1% (1.8% for males 0.2% for females).

Here are some of the complaints I have read about this report:

1) They define adult with ages as young as 16.

this is supposed to be a sign that they are trying to fudge the data by including people who are really part of the so-called “epidemic”.

Well, the UK Census defines adults as people age 16 and over. If including 16 and 17 year olds were a problem, one would expect the younger age category to have a much higher prevalence. It doesn’t.

age group 16-44: prevalence 1.1%
age group 45-74: prevalence 0.9%
age group 75+: prevalence 0.8%

(from table 2B)

Another complaint is that there were no ethnic or racial minorities in the group of 19 identified autistics. This is a good check for internal consistency, but it isn’t a valuable check in this case.

The UK has about 90% white population. They tested 618 individuals with the ADOS. If the selection were random in ethnicity, they would have 61 minority participants. A 1% autism rate would lead us to expect 0.6 ethnic minority autistics.

People have complained that the study only shows adults in residential housing. I.e. they didn’t check institutions.

The report is very clear about this (it is even in the title). They note:

The sample for APMS 2007 was designed to be representative of the population living in private households (that is, people not living in communal establishments) in England. People living in institutions are more likely than those living in private households to have ASD, however this group was not covered in the survey reported on here and this should be borne in mind when considering the survey’s account. At the time of the 2001 Census, 2% of the English population aged 16 years or over were resident in a communal establishment.

So, yes, by leaving out those in institutions they didn’t measure the prevalence in the total UK population. That is a limitation of this report. The prevalence in the institutions is very likely to be higher than in residential settings. I.e. they would have found more autistics had they look in institutions and they would have found a higher prevalence overall.

One complaint is that they only identified 19 adult autistics in phase two. This is definitely worth considering as that puts some big error bars on the results. This becomes especially when they try to break the results down by age, gender, or other category.

It has been proposed that one can’t extrapolate from the 19.

But, just for fun, let’s make the assumption that the 19 adult autistics ID’d in phase 2 group (of about 618) are all there would be in the entire group studied (7353).

That would give a prevalence of 25 per 10,000.

This is much higher than people have been claiming the prevalence should be amongst adults. Many people claim the prevalence rate for adults should be about 1 in 10,0000 or 3.3 in 10,000.

To put it simply, those claiming there is an epidemic of autism are off by at least a factor of 7.

Or, to put it another way,

It isn’t a question of whether there are factors such as widening of the criteria or diagnositic substitution/accretion that have caused some of the rise in the autism “rates”. The question is what factors have been in play and how big of an effect did they have.

Another criticism I have seen is that the male:female ratio is quite high, 18:1, as opposed to the 3:1 or 4:1 found in most studies. They found 19 autistics. A 3:1 male:female ratio would lead us to expect 5 females. I’ll let the statisticians tell me if this is significant, but they did find fewer women than I would expect. The report notes repeatedly that the small number of women limits the analysis.

I have been told in the comments on this blog that the study was done cheaply. I wouldn’t be surprised. However, it does represent a significant effort. I am impressed that anyone undertook to do a prevalence study on adults.

This isn’t a definitive or end-all study. Far from it. But it is a reasonable study and a very good start. I hope this is the beginning of a much greater effort to gather more information on adult autistics. It is pretty frightening to think that a very large segment of the autistic population could be undiagnosed and possibly receiving inappropriate supports.

Fever Plus Mitochondrial Disease Could Be Risk Factors for Autistic Regression

24 Sep

Autism, regression, mitochondrial disease and vaccines. With a combination like that, this paper is likely going to be very important.

Fever Plus Mitochondrial Disease Could Be Risk Factors for Autistic Regression

Here is the abstract:

Autistic spectrum disorders encompass etiologically heterogeneous persons, with many genetic causes. A subgroup of these individuals has mitochondrial disease. Because a variety of metabolic disorders, including mitochondrial disease show regression with fever, a retrospective chart review was performed and identified 28 patients who met diagnostic criteria for autistic spectrum disorders and mitochondrial disease. Autistic regression occurred in 60.7% (17 of 28), a statistically significant increase over the general autistic spectrum disorder population (P < .0001). Of the 17 individuals with autistic regression, 70.6% (12 of 17) regressed with fever and 29.4% (5 of 17) regressed without identifiable linkage to fever or vaccinations. None showed regression with vaccination unless a febrile response was present. Although the study is small, a subgroup of patients with mitochondrial disease may be at risk of autistic regression with fever. Although recommended vaccinations schedules are appropriate in mitochondrial disease, fever management appears important for decreasing regression risk.

The authors note neurologic regression in general (not just autistic regression) is observed with patients who have metabolic diseases:

Patients with mitochondrial diseases, like many patients with metabolic diseases, are at increased risk of neurologic regression in conjunction with stressors such as fever, infection, and dehydration.

They studied 28 patients who met DSM-IV criteria for autism and diagnostic criteria for mitochondrial disease.

They define regression and whether it is related to fever thusly:

Autistic regression was defined as loss of developmental skills that included speech, receptive skills, eye contact, and social interests in individuals ❤ years of age. A relationship between fever and autistic regression is defined as regression beginning within 2 weeks of a febrile episode without the suggestion of infectious meningitis or encephalitis.

One comment–the definition of regression is somewhat vague to me. What is also critically important in this discussion is whether there were any signs of autism before the regression. Or, as some may put it, is this regression into autism or autistics undergoing regression? Is there a mix of pathways?

They state that 17 of the 28 patients studied underwent an autistic regression. This is higher than the roughly 25% value for autistic regression they assumed for the general autism population, and statistically significant.

In other words, they are saying that autistic regression may occur more often with kids with mitochondrial diseases.

They note that some of the fevers could be linked to vaccination:

The 17 individuals with autistic regression could be divided into 2 groups, those who regressed with fever (70.6%, 12 of 17) and those who regressed without identifiable linkage to fever or vaccinations (29.4%, 5 of 17).

And,

No individual showed regression with vaccination unless a febrile response was present.

They discuss the concerns with vaccination in the conclusion, noting that vaccination is still recommended for children with mitochondrial diseases. My experience in discussing this issue with mitochondrial disease experts is that they find vaccination to be extremely important. If, for some reason, they decide to not vaccinate a child with mitochondrial disease, they insure that all family members are vaccinated to protect the child.

Children with identified mitochondrial diseases are routinely managed carefully by their physicians with aggressive fever control and hydration. In this context, vaccination of children with mitochondrial diseases is recommended. In our experience, the vast majority of patients with mitochondrial diseases receives a full vaccination schedule according to American Academy of Pediatric guidelines without consequences, particularly when physicians are sensitive to fever control and hydration. In our patients with mitochondrial disease and autistic spectrum disorders, the vaccines did not appear related to the neurologic regression.

I will note again that I feel autistic regression as defined is too vague. Were the patients on the spectrum before the regression? Were they typically developing before the regression?

At least two children were noted to have multiple regressions (a sibling pair). That indicates that at least in some cases, regressions occurred in people already autistic. There just isn’t other information on this.

Another area I would like to see discussed further is on siblings:

Affected siblings were identified in 35.7% (10 of 28).

Affected how? Mitochondrial disease. But, are they also autistic? It would seem not since they included one sibling pair.

This is a big question to me. While the spotlight has been shown on the possibility of mitochondrial disorders being linked to autistic regression, the more general question is more important: could fevers induced by vaccination result in any regression (autistic or otherwise) in people with mitochondrial disorders.

Another question in my mind in this study. Are there patients who underwent regression from non-autistic to autistic) after age 3? According to the Johns Hopkins group, this doesn’t happen. According to them, there is an age window where the regressions could result in autism. This is a very important question in how these patients might fit in to the broader spectrum of autism.

Apply for Autism Research Grant

23 Sep

The Autism Science Foundation announce their first RFA:

The Autism Science Foundation invites applications for its Doctoral Training Award from graduate and medical students interested in pursuing careers in basic and clinical scientific research relevant to autism spectrum disorders.

The proposed training must be scientifically linked to autism and may be broadened to include training in a closely related area of scientific research. Autism Science Foundation will consider for training purposes all areas of related basic and clinical research including but not limited to: human behavior across the lifespan (language, learning, communication, social function, epilepsy, sleep, repetitive disorders), neurobiology (anatomy, development, neuro-imaging), pharmacology, neuropathology, human genetics/genomics, immunology, molecular and cellular mechanisms, and studies employing model organisms and systems.

Truth and Consequences – The Anti-Vaccination Movement Exacts a Price

23 Sep

“I feel like getting in my car, driving away and never coming back. I can’t stand it anymore. If the screaming, howling, humming, and screeching doesn’t stop I will lose my mind. 14 hours a day. From the second he open his eyes until the second he closes them there is noise. Even if you tell him to be quiet he sits there and says “be quiet…be quiet” over and over. Not more than 10 seconds goes by where some ridiculous sound isn’t coming out of my son. He talks in a high pitched screechy voice that makes every nerve ending stand on end. He screeches and screams for no reason. The humming, the high pitched humming all day long. I can’t take it. My head hurts so bad and there are only so many things I can take for a headache. I wake up at 7 am, or rather I am awakened by screeching at 7am and get no peace until about 9pm. By then my head hurts so much it doesn’t matter. I can’t get anything done because I can’t focus with the noise in the background. I can’t have a phone call. I can’t have a conversation in person. I know this is going to upset some people but I swear, I miss the days when he didn’t make a peep. not a single peep. I remember when I used to cry and ask him to talk to me, to say anything. I should have been more specific and wished he’d speak and make meaningful sentances rather than walk around all day and say meaningless phrases over and over, and scream and screech when he didn’t. know what meaningless phrase to use at the moment. I have about 40 minutes before he goes to bed then I get to listen to him hum himself to sleep for an hour. By then I should be ready to jump off a roof.

Thanks for letting me vent. Not sure if it made me feel better but at least if I jump off the roof someone knows why”

Posted by “Mary”, mother of “Saul”, age 7.9 (7 years, 9 months), to an autism “biomedical treatment” yahoo group in August 2009.

The idea that vaccines might be a cause of autism has received a great deal of attention from the media. Scientifically, the question has been thoroughly investigated and thoroughly discredited.

Legally, the idea has also been rejected. The Autism Omnibus case bundled the claims of almost 5000 children against the Vaccine Injury Compensation program. In the hearings for the first of three theories of causation, the lawyers for the parents and their children chose the strongest three cases to illustrate their claim that MMR vaccines and thimerosal-containing vaccines can combine to cause autism. On February 12, 2009, all three cases were dismissed. The decisions were scathing, stating that “the overall weight of the evidence is overwhelmingly contrary to the petitioners’ causation theories.” Moreover, parents were characterized as a “loving, caring, and courageous” family “misled by physicians who are guilty of gross medical misjudgment. In June and July of 2009, all test cases were appealed, and all three were dismissed.

The yahoo group “Environment of Harm” formerly “Evidence of Harm”, was established to discuss the book of the latter title, written by journalist David Kirby. The focus of the group is to discuss

“issues of government public health negligence and corruption and the various political efforts by parents to end the spectrum of epidemics that is being revealed as mercury poisoning, especially autism.”

From March 2005, the date of the book’s publication, until February 2009, when the Omnibus legal decisions were rendered, the group received an average of over 2000 posts per month. Since the rulings, the posting rate has dropped to only 800 per month, perhaps indicating that the issue is also losing momentum from a political point of view.

The mainstream media, the groups such as the AAP, and the blog sphere have also pushed back in an effort to educate the public on the harm done by the vaccines cause autism groups.

But behind the scientific and legal consensus that vaccines do not cause autism lies a hidden world, the autism “biomedical” yahoo- and chat-group world. There is no decline in the number of posts in this world. It’s a thriving, and growing community, one that has fueled the popularity of the anti-vaxers, and the certainty of those parents who consider their child “vaccine-injured”. It has spurred the spending of millions of dollars on supplements, hyperbaric treatments, off-label prescription medications, and myriad other autism “biomedical treatments”. These “treatments” are almost all of no proven benefit, some are ridiculous, some relatively benign, and many potentially dangerous. This article will explore the journey of one mother, “Mary” in her efforts to cure her son “Saul”. While the case of Mary and Saul, documented in her own words is shocking and appalling, Mary is not alone nor is she an extreme case. She is one of thousands of parents seeking autism “biomedical treatments” on the internet.

We first meet Mary in October 2003, when her son Saul (born November 2001) was only 22 months of age. She began posting on the group NLT (for a description of the yahoo groups discussed in this article see the section at the end). She stated that her son

“is basically non verbal. He said his first word, duck, at 7 months old. About a month later he said light, off , and on, but dropped duck. This set a pattern for him. Anytime he learned a new word he dropped any old words he had used at that point. Now, his only real words are Mama and Dada. He will on a rare occassion say car. He has had and lost about 20 words since 7 months of age.”

Shortly thereafter, he was evaluated by early intervention, and psychologist wrote PDD on his evaluations, along with the term Autistic-like. Mary was told that he was not autistic, but he’s autistic like. 10-20 hours a week of intensive in home therapy (ABA) was recommended.

So, Saul is a very young child, showing speech delay and signs of autism, evaluated very quickly, and almost immediately started on early intervention. Of course, Mary is understandably upset:

“I don’t know why I’m so upset. He (the psychologist) didn’t say anything I didn’t already know or suspect. I guess its just because my fears were realized. Rather than come in and say “oh no, he’s fine, he’s just a late talker” I heard what I was hoping not too. I’m sure that somehow to some degree this is my fault. Saul was such a quiet content infant, and he was content to play by himself as he got older I sort of went with it. I figured he was happy let me go do dishes, or laundry or whatever and let him entertain himself. Yeah that was great but now he is only happy by himself and turns in to himself and its my fault I know it is.”

Recent research (two links:here and here) has looked at the impact of parental acceptance of their child’s autism diagnosis. It was found that parents who do not come to a resolution (i.e. come to terms with and accept the diagnosis and its implications) find raising their child more difficult. In the case of Mary, we will see a real-life example of a mother failing to come to terms with her child’s PDD.

Here’s Mary again:

Thank you everyone for your support. I’m sorry I forgot to mention Saul’s age. He will be 2 at the end of the month.

I’m feeling a lot better but still overwhelmed. I want to read as much as possible so I can do the best to help him but I think I need a little time to come to terms.

A few questions though if anyone knows…Do kids diagnosed with PDD always end up as special ed or is their hope with therapy he main go mainstream. The reason I ask is that my cousin teaches 5th grade special d and the majority of her kids are PDD kids, and have been in special ed since kindergarten. What are the odds that my child will grow up, go to college and lead what is considered a normal life?

Also, I was reading about a special diet that gluten free that is supposedly helpful. Has anyone tried this?

Should I just go with the system for say 6 mos or so and see how he responds and progresses before trying anything different like diet changes or supplements.

Sorry if I’m asking a million questions. My brain is spinning and all the websites I go to just overwhelm me more. Everyone here seems to have such a wealth of knowledge, and more importantly personal experience and understanding.”

This message signals the start of a frightening journey into the realms of woo. The “treatments” inflicted on Saul are very painful to read. Mary joined numerous autism “biomedical treatment” yahoo groups. She is presently a member of all the groups in the box, see below (except EoH), and more besides. She has posted more than 3500 messages to these groups. Mary reveals her willingness to accept medical advice from strangers on the internet, and her trust in doctors employing “gross medical misjudgment”. Between the ages of 3.6 and 7.9, Saul has been “treated” with the following (in alphabetical order):

Acetyl L Carnitine –
acetylated form of L-carnitine
(quaternary ammonium compound biosynthesized from the amino acids lysine and methionine)
Actos (pioglitazone)
-prescription drug which carries a black box warning
Cal/Mag Butyrate – mineral supplement
Candex
– marketed as an enzymatic remedy to treat the yeast infection candida
Carnosine -amino acid
Chelation – process of removing heavy metals
Andrew Cutler protocol (at least 50 rounds)
DAN protocol for 2 1/2 years.
15 IVs of EDTA & Glutathione
5 IVs of DMPS and glutathione
5 combined IVs DMPS/EDTA/Glutathione
Chiropractic
Diflucan – prescription anti-fungal
Dimethyl glycine – modified amino acid
Enhansa – Enhanced absorption curcumin supplement
Epsom salt baths
Essential fatty acids
Flagyl (Metronidazole) – prescription anti-fungal
Folinic acid – modified folic acid
Folapro – highly absorbable folate
Galantamine
prescription drug used for the treatment of mild to moderate
Alzheimer’s disease and various memory impairments
GFCF diet – gluten-free-casein-free diet (3 years)
GFCF diet with digestive enzymes for infractions
HBOT
hyperbaric oxygen treatment
(Mary owns her own Mary owns a Vitaeris 320)
HLC MindLinx Powder by Pharmax – probiotic
IM Bicillin – prescription intramuscularly injected form of penicillin
Inositol – a nutrient
IVIG – Intravenous Immunoglobulin
prescription
used to treat immune dysfunction
contains the pooled immunoglobulin G (IgG)
immunoglobulins from the plasma of approximately a
thousand or more blood donors
Klaire Labs Detoxification Support and Factor 4 – probiotic
Liquid Bodybio PC – phosphatidylcholine with essential fatty acids
Liquid grapefruit seed extract
Low dose Naltrexone – an anti-opiod
L-theanine – amino acid
Magnesium supplements
MB12 – Methylcobalamin, vitamin B12 – shots
MB12 – Methylcobalamin, vitamin B12 – spray
Nicotine patch
Nizoral – antifungal
Nystatin – antifungal
OLE – olive leaf extract
OSR
(N,N’-bis (2-mercaptoethyl)isophthalamide,
also know as 1,3-benzenediamidoethanethiol)
an untested synthetic chemical
Oxytocin nasal spray
PCA-Rx – purports to remove toxins from the body
Phosphatidylcholine
Pro Bio – probiotic
Quercetin – antioxidant flavinoid
Reduced glutathione cream
Threelac -probiotic
Transdermal NAC (N-Acetyl Cysteine)
Valtrex (valacyclovir)
used to treat infections caused by herpes viruses
Vitamin C
Vitamin E
Zithromax – antibiotic

Mary has been tireless in “treating” Saul. But what about Saul? One would think that he must be very impacted by autism in order for her to go to these extraordinary lengths to cure him. Actually, no. He’s an extraordinary kid, and a wonderful one. Saul could identify all of the letters in any order and count to 40 at age 2.2. He started sight reading words at about 2.3 and at age 2.8 could sight read about 30 words. He started kindergarten in a segregated setting at age 4.9, , talked to the teacher, “he sat nicely through circle time, sat at his desk during class, and even raised his hand and answered questions. He was pointing to shapes on the wall and quizzing the teachers!” Here is Mary’s description of Saul at age 4.7:

“I woke up this morning and he was in bed with me. I’m not sure what time he came in because I never heard or felt him get into bed which is unusual. I woke up and felt him there. I rolled over and his little face was right there. He looked so peaceful and really has the face of an angel. I just laid there and stared at him for about 20 minutes. He yawned and opened his eyes. He saw me and his face lit up with a HUGE ear to ear grin. “Good morning Mom. Love you. Gimme a hug.” He gave me such a big strong hug. “Gimme a kiss.” I gave him a kiss. A second later his gears kicked in and he was off and running on full speed. After a few minutes he came back in the room and said “GIMME BREAKFAST! ! !””

But the “biomedical treatments” have not always been kind to Saul. Here’s Mary describing him at age 5.11

My son is on a ton of supplements. We haven’t really changed anything. Starting August 30, for three weeks we had to stop all enzymes, antifungals and probiotics in preparation for a endoscopy/colonoscopy. He is back on everything since he was scoped on Sept 20. Also at the beginning of August he had a high fever and a nasty rash that was diagnosed as Fifth’s Disease. I’m not convinced it was Fifths. He didn’t have the bright red cheeks and the rash was gone in 3 days.

After being sick he became clingy and a little whiny. In the past month its become horrible. I can’t even stand up without his whining “mommy..moooommmmmy, mommy will come.” I hear this the entire time I’m out of the room. Even if I tell him what I’m going to do and that I’ll be right back he continues saying it over and over. He whines over every little thing. Usually just lets out a big “WWWAAAAHHH” and it goes on and on. He cries over everything. He’s driving me insane. We are also seeing a decrease in spontaneous expressive language, asking repetitive questions, and repeating back questions instead of answering them.”

Nor have the “biomedical treatments” been kind to the family budget. In one message, Mary admitted that each month she spent $2800 – $3500 for IVIG, plus about $500 in supplements including the cost of chelation.

In a rare moment of insight, in May 2008, Mary posted:

“Sometimes I feel like a mad scientist and my poor kid is my guinea pig.”

Finally, a year later, she posted the preamble to this article (see box at top). How’s that “biomedical treatment” working out for you, Mary?

Such are the real costs of the anti-vaccination movement, the “biomedical treatment” internet groups. And the real costs of a parent unable to accept their child’s diagnosis. In her last message to the NLT group, Mary is still in denial about her son’s diagnosis:

RE: Sowell Traits
My son is 5 and is diagnosed PDD-NOS fits 7 of these to a T! ! ! The only one that doesn’t fit is # 7

Makes me wonder what we are really dealing with.”

Thousands of parents are members of these yahoo groups. Once inside the cozy echo chamber of the group, there is general acceptance that vaccines cause autism. Members expressing opposing views are drummed out of the group. It is taken as an article of faith that there are children recovering from autism by the use of these biomedical interventions. The parents get poorer, the quacks get richer, and the innocent children are the victims of often dangerous and painful experimentation at the hands of the people who are supposed to care for them the most.

Some Yahoogroups

A-M – Autism-Mercury. Membership 8400, 2000 messages/month (archives public)

“To discuss current issues related to the increasing incidence of autism the potential link between excessive mercury exposure via thimerosal in infant vaccines. Topics include: mercury detoxification (“chelation”), mercury-related issues/news, and vaccination-related issues/news. Most members are parents of children with autism, aspergers, ADD, ADHD, PDD, PDD-NOS, SID, oppositional defiance disorder, apraxia, speech disorders, and/or other related symptoms. There are many labels: you are welcome regardless of particular label(s). In addition to mercury, we also discuss other heavy metals (for example: arsenic, antimony, lead). Many parents here are in the process of chelation, with a child. This process is discussed in detail. Also welcome: mercury poisoned adults; other disorders/issues related to mercury poisoning; other biomedical treatments for ASD.”

Comment: Primarily discusses Andrew Cutler heavy metal chelation protocol. This protocol relies on faux “counting rules” applied to hair testing to purportedly prove that people are “mercury toxic”. Andrew Cutler has a PhD in Chemical Engineering.

CK2 – Chelatingkids2. Membership 6600, 3000 messages/month

“This list is for parents and/or family members of children with autism who are seeking biomedical intervention, The main focus of treatment here follows the DAN! or Defeat Autism Now.”

Comment: Mercury chelation according to the DAN! protocol. This protocol relies on provoked urine tests to purportedly prove “mecury toxcicity”. This very active group has been recently closed to new postings for an unspecified period of time.

EoH – Environment of Harmformerly Evidence of Harm. Membership 2300, 600 messages/month (archives public)

“This is the Environment of Harm discussion list focusing on vaccine damage and mercury poisoning as it relates to autism. Of keen interest to participants are the issues of government public health negligence and corruption and the various political efforts by parents to end the spectrum of epidemics that is being revealed as mercury poisoning, especially autism.”

Comment: Politically active group originally supporting the autism is caused by mercury poisoning hypothesis, but now openly anti-vaccine.

GFCFKids– Membership 14000, 3500 posts/month

“The principle aim of this list is to provide a discussion forum for parents of children on the autism spectrum who are avoiding gluten and casein and other substances in their children’s diets. We hope that the discussions will include practical information and tips on following a GFCF(etc) diet; scientific research and opinion; the latest developments in understanding GFCF(etc) diet-related health problems; your personal stories and experiences with relation to GFCF(etc) problems; information on what food is GFCF(etc)and what is not; tips on how to eat out of the house; recipes and tips on how to cook and prepare GFCF(etc) food; what vitamins, minerals, herbs and other supplements may be appropriate for a child with autism, how to cope with difficult diet demands, plus support for parents.”

Comment: One of the largest “biomedical treatment” yahoo groups. While the GFCF diet has substantial anecdotal support, clinical trials have not shown any benefit. The GFCF diet appears relatively harmless, however, it can result in weakening of bones due to nutritional deficiencies. Moreover, it often acts as a first step on the path to more dangerous “biomedical treatments”.

NLT – NaturalLateTalkers. Membership 2900, 500 messages/month

“This list is a support for parents of latetalkers or speech delay with some or all traits of latetalker listed in the book Late Talking Children by Thomas Sowell. . . Here parents ARE and will be able to discuss their problems, concerns, and dissatisfaction with the over diagnosing done by various systems, such as speech therapists, doctors, schools, etc. Parent’s choice helping with speech through parent or another source is to be respected.” (sic)

Comment: This list supports those in deep denial about their child’s autism. While such support groups appear to be relatively benign, offering mutual support to parents of children with disabilities, they are often an entry point for parents to learn about the autism “biomedical treatment” and anti-vaccination movements. These groups are replete with examples of parents taking medical advice from strangers over the internet, many of whom are accorded more credibility than the medical professionals who have actually seen their children.

Childhood Serum Anti-Fetal Brain Antibodies Do Not Predict Autism

18 Sep

One of the big new concepts in autism research in the last two years is the idea that maternal antibodies might be involved in developing autism.

Two groups, one from Johns Hopkins, the other from California showed that in some mothers with autistic children, their blood sera had antibodies against fetal brain tissue.

This raised the question of whether maternal antibodies, transferred during pregnancy, could influence the risk of autism.

One big question raised was the possibility that this could lead to regressive autism. Could something prenatal be linked to regressions in children who were age 1 or 2?

One big question raised (and unanswered) by these studies was the question of antibodies in the autistic children themselves. Do they have antibodies against fetal brain tissue? Could this be a biomarker? And, if so, could this be involved in developing autism in some cases?

The Hopkins team has just published a paper looking into this question.

Autoimmune hypotheses for autism include in utero transplacental exposure to maternal antibodies and acquired postnatal insults. Previous work demonstrated that some mothers of children with autistic disorder have specific antibodies against human fetal brain that differentiate them from mothers with typical children. In the present study, Western immunoblotting was used to determine whether children with autistic spectrum disorders (n = 29) have serum reactivity against human fetal brain that differs from that of controls (n = 14). There was no significant difference in reactivity, corrected for serum immunoglobulin G content and brain actin content and with special attention to reactive bands at 36, 39, 61, and 73 kDa, between autistic children and normal control subjects. Thus, in contrast to mothers, antibody reactivity against human fetal brain as measured in children ages 3-12 years does not appear to be a useful biomarker for autism.

The paper is fairly brief as they don’t find any evidence that the children’s blood sera reacted with fetal brain tissues. Here is a quote from the discussion section:

The present data indicate that the measurement of serum antibody reactivity against human fetal brain in children with autistic spectrum disorders does not predict an autistic diagnosis, either for idiopathic autistic disorder or for those individuals with identified etiologies. These data differ from previous findings in mothers of autistic children, which indicated that anti-human fetal brain antibodies reactive against proteins at 36, 39, 61, or 73 kDa appear to be a biological marker for the disorder in some individuals

Before anyone jumps on me for denying the possibility of any immunological effects in risk of autism, here is another quote from the paper:

The present study does not rule out the possibility that other anti-brain antibodies in the children may be important for postnatal effects. For example, children with autism have been shown to possess antibodies against various central nervous system self-components such as glial fibrillary acidic protein, myelin basic protein, neurofilament proteins, cerebellar neurons, and brain endothelial cell proteins [6-9,23,24]. We hypothesize that, rather than a direct association, there is a complex relationship between maternal anti-fetal brain antibodies and various intrauterine genetic, metabolic, and environmental factors.

Papers that don’t show a connection, show a “null” or lack of an effect, are somewhat unsatisfying. They are certainly not unimportant. I look forward to more research from Dr. Zimmerman’s group at Johns Hopkins,

Another weak study “proves” vaccines cause autism

17 Sep

I am constantly amazed at the low level of proof people use to demonstrate that vaccines cause autism.

Case in point, David Kirby and his recent post on the Age of Autism blog (and, a I write this, The Huffington Post).

He takes an abstract from a poster session and declares victory in the war to prove vaccines cause autism.

Here’s the abstract:

HEPATITIS B VACCINATION OF MALE NEONATES
AND AUTISM
CM Gallagher, MS Goodman, Graduate Program in Public
Health, Stony Brook University Medical Center, Stony Brook, NY
PURPOSE: Universal newborn immunization with hepatitis
B vaccine was recommended in 1991; however, safety
findings are mixed. The Vaccine Safety Datalink Workgroup
reported no association between hepatitis B vaccination
at birth and febrile episodes or neurological adverse
events. Other studies found positive associations between
hepatitis B vaccination and ear infection, pharyngitis, and
chronic arthritis; as well as receipt of early intervention/
special education services (EIS); in probability samples of
U.S. children. Children with autistic spectrum disorder
(ASD) comprise a growing caseload for EIS. We evaluated
the association between hepatitis B vaccination of male
neonates and parental report of ASD.
METHODS: This cross-sectional study used U.S. probability
samples obtained from National Health Interview Survey
1997–2002 datasets. Logistic regression modeling was used to
estimate the effect of neonatal hepatitis B vaccination on
ASDrisk amongboys age 3–17 years with shot records, adjusted
for race, maternal education, and two-parent household.
RESULTS:Boyswho received the hepatitis B vaccine during
the first month of life had 2.94 greater odds for ASD (nZ31
of 7,486; OR Z 2.94; p Z 0.03; 95% CI Z 1.10, 7.90)
compared to later- or unvaccinated boys.Non-Hispanicwhite
boys were 61%less likely to haveASD(ORZ0.39; pZ0.04;
95% CIZ0.16, 0.94) relative to non-white boys.
CONCLUSION: Findings suggest that U.S. male neonates
vaccinated with hepatitis B vaccine had a 3-fold greater risk
of ASD; risk was greatest for non-white boys.

What did they do? They looked at data from the National Health Interview Studies, and looked at autism and hepatitis B vaccination. They used surveys from 1997 to 2002, with children aged from 3 to 17.

Mr. Kirby was kind enough to post an image of the poster to the EOHarm group.

The autism group had 33 kids total. Of these, 9 of 31 (29%) were given the HepB vaccine. Compare this to 1,258 of 7,455 (17%) of the non-autism group who were given the HepB.

9 out of 31.

Are the red flags up yet? They should be.

Take for example kids aged 17 in the 1997 survey. When were they born? That’s right, 1980.

When was the Hepatitis B vaccine introduced? 1991. According to Mr. Kirby himself, the HepB vaccine didn’t get fully implemented until about 1996.

A lot of the kids were born before the “epidemic” of autism. No one disputes that the number of people identified with autism has gone up significantly in the last 30 years.

So, pretty much anything that changed in that time would “correlate” with autism.

This is how we get studies that “show” that Cable TV causes autism. And, now, the Hepatitis B vaccine causes autism.

Sugar-coaters and Straight Talkers: Communicating About Developmental Delays in Primary Care

17 Sep

How should a pediatrician tell you your child may have a disability?

That’s a big question. This is one that comes up a lot in the autism world. Many people say, “my doctor told me that my kid would never be able to talk, walk or take care of him/herself but he/she made big gains” Others complain that diagnosis of disability was missed, delayed or downplayed.

The AAP has issued guidelines on screening for autism, for example. But what is the correct balance of how to warn a parent that his/her child may have autism or another disability?

That is a question that is addressed in a recent paper, Sugar-coaters and Straight Talkers: Communicating About Developmental Delays in Primary Care.

Here’s the abstract.

OBJECTIVES: The goals were to investigate parents’ and early intervention (EI) specialists’ beliefs and experiences regarding discussing child development in primary care and to identify communication barriers and opportunities.

METHODS: Focus groups were held with (1) mothers of young children with typical development, (2) mothers of young children who received EI services, and (3) EI specialists. Seven groups (N=46 participants) were conducted in the greater Cleveland, Ohio, area. Meetings were audio-recorded, transcribed, coded, and analyzed, to identify themes.

RESULTS: Most mothers reported a preference for a nonalarmist style of communication when developmental delays are suspected. In contrast, some mothers preferred amore direct style, including the use of labels to help them understand their child’s development. The importance of preparation to accept information about developmental delays emerged as a theme in all groups. Elements contributing to preparedness included information about expected developmental skills, suggestions for promoting skills, and a specific time frame for follow-up evaluation. Mothers of children with disabilities perceived that early reassurance of normalcy by providers in response to their concerns led to self-doubt and increased difficulty accepting the diagnosis.

CONCLUSIONS: Mothers and EI specialists have clear ideas about factors that promote or impede communication regarding child development. This information can inform primary care providers’ approaches to monitoring and screening the development of young children and to communicating with parents regarding suspected developmental delays. Pediatrics 2009;124:e705–e713

The researchers worked with focus groups of parents of children who were in early intervention, parents of children who were not in early intervention and early intervention professionals.

Separate focus groups were held with 3 types of participants, that is, (1) mothers of children who were receiving/had received EI services (EI parents), (2) mothers of children <5 years of age who had not received EI services (non–EI parents), and (3) EI specialists.

The groups were small (the total number of participants in all groups was 46).

The study found that most parents don’t express concerns directly. Rather than say, “Is my child delayed?” a parent is more apt to say, “Should my child be talking by now?”.

It is important that providers recognize that parental expressions of concern may be stated subtly, indirectly, or briefly. A related theme that emerged was the perception of not being heard. Previous studies indicated that providers’ failure to acknowledge or to address patient concerns is unfortunately widespread.

That isn’t going to be a shocker to any parent reading this–some parents feel like their pediatricians aren’t listening.

But, how should a doctor approach the issue of possible developmental delays? Unfortunately, there isn’t a clear answer. Some parents say go slow and gentle, others say be direct.

Parental preferences for direct (straight talk) versus indirect (sugarcoating) communication approaches seemed to be related to preparation to hear about suspected delays. Some
parents needed weeks to months to prepare to hear such news, beyond the brief “warning shot/forecasting” recommended for medical encounters

The sugar-coater parents recommended:

Nonalarmist wording by providers, maintaining optimism and acknowledging that the child’s development might not be delayed, was recommended. Parents also recommended providing information regarding what to observe, possible next steps for further evaluation, and a plan to check in with the provider within a short time

I am not a sugar-coater. But, I like the idea of giving information of what to observe. I don’t really see the value in just saying, “Let’s wait and see”. Let’s wait and see what, exactly? Give parents some homework, things to watch for.

The “straight talkers” recommended a more direct approach:

Other parents cautioned against sugarcoating and favored a direct approach, emphasizing the importance of straight talk. By inquiring systematically about parents’ developmental concerns, providers can obtain information regarding parents’ readiness to hear about suspected developmental delays and can tailor communication to the level of preparation.

I’d probably go even beyond the “straight talkers”. I’d say it’s better to hear the possible situation as soon as the doctor has suspicions rather than to wait for the parent to be prepared.

What’s the value to “let’s wait and see”? Is there any downside to early intervention besides the logistics of getting a kid here and there for therapies and the worry about possible delays? I don’t think so. OK, there is the financial cost to an already overloaded system. But in general, what’s wrong with saying, “Well, junior is now 3 and the speech and occupational therapy is no longer needed”? Compare that to, “Well, Junior is about to turn 3 and, yep, we should have gotten him started in early intervention last year”.

In other words, since doctors are going to make mistakes in their suspicions they should err on the side of possibly “alarming” a parent.

One problem doctors face is that parents are not always going to give the doctors accurate information:

Negative communication experiences included parents’ feeling blamed by providers for the child’s developmental delay. In 1 group, mothers reported that they might respond in the affirmative to questions regarding developmental milestones even when their child was not yet demonstrating a skill, out of concern that lack of attainment would be seen as evidence of neglect.

Doctors are definitely faced with a dilemma. There is no one approach that will fit what all parents want. Some don’t want to be alarmed. Some want to know all suspicions right away. Some are not going to express their fears or questions. Doctors are going to make “mistakes”.

Again, I am more in favor of a “straight talker” as my kid’s pediatrician. Yes, I am a consumer when I go to the doctor. But what I am paying for is to be told what I need to hear, not what I want to hear. It isn’t whether I am prepared to hear that my child may be delayed, but whether my child may need to start therapy. I can get over the shock. Even if I can’t, my kid counts more.

What are the allegations against Dr. Wakefield?

16 Sep

Dr. Andrew Wakefield, not of Thoughtful House in the U.S., has recently been called before the General Medical Council for a “fitness to practice hearing”. The allegations stem from activities related to his research of about 10 years ago on children (many autistic).

I recently discussed two of incidents being investigated: a birthday party where blood was drawn from typically developing children (for controls) and activities related to his invention and the subsequent patent his hospital (the Royal Free) applied for. I found it interesting to see these layed out, so I decided to post them here for others to read as well.

These are allegations. The process has not concluded, nor has any decision been reached.

This is a short version. A detailed list (93 pages) can be found on Brian Deer’s website. Note that these 93 pages include allegations against Doctors Murch and Walker-Smith.

Dr Andrew WAKEFIELD GMC Reference number: 2733564

Professor John WALKER-SMITH GMC Reference number: 1700583

Professor Simon MURCH GMC Reference number: 2540201

The GMC’s statutory purpose is to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine.

We investigate complaints about individual doctors in order to establish whether their fitness to practise is impaired and whether to remove or restrict a doctor’s registration.

The GMC does not regard its remit as extending to arbitrating between competing scientific theories generated in the course of medical research.

The following is a summary only of the allegations which will be made before the Panel at the forthcoming hearing.

The Panel will inquire into allegations of serious professional misconduct by Dr Wakefield, Professor Walker-Smith and Professor Murch, in relation to the conduct of a research study involving young children from 1996-98.

Dr Wakefield, Professor Walker-Smith and Professor Murch, were at the relevant times employed by the Royal Free Hospital School of Medicine with Honorary Clinical contracts at the Royal Free Hospital.

It is alleged that the three practitioners were named as Responsible Consultants on an application made to the Ethical Practices Committee of the Royal Free Hospital NHS Trust (“the ethics committee”) in 1996 to undertake a research study involving children who suffered from gastrointestinal symptoms and a rare behavioural condition called disintegrative disorder. The title of the study was “A new paediatric syndrome: enteritis and disintegrative disorder following measles/rubella vaccination”. The Panel will inquire into allegations that the three practitioners undertook research during the period 1996-98 without proper ethical approval, failed to conduct the research in accordance with the application submitted to the ethics committee, and failed to treat the children admitted into the study in accordance with the terms of the approval given by the ethics committee. For example, it will be alleged that some of the children did not qualify for the study on the basis of their behavioural symptoms.

It is further alleged that the three practitioners permitted a programme of investigations to be carried out on a number of children as part of the research study, some of which were not clinically indicated when the Ethics Committee had been assured that they were all clinically indicated. These investigations included colonoscopies and lumbar punctures. It is alleged that the performance of these investigations was contrary to the clinical interests of the children.

The research undertaken by the three practitioners was subsequently written up in a paper published in the Lancet in February 1998 entitled “Ileal-Lymphoid-Nodular Hyperplasia, Non-Specific Colitis and Pervasive Developmental Disorder in Children” (“the Lancet paper”).

It is alleged that the three practitioners inaccurately stated in the Lancet paper that the investigations reported in it were approved by the ethics committee.

The Panel will inquire into allegations that Dr Wakefield and Professor Walker-Smith acted dishonestly and irresponsibly in failing to disclose in the Lancet paper the method by which they recruited patients for inclusion in the research which resulted in a misleading description of the patient population in the Lancet paper. It is further alleged that Dr Wakefield gave a dishonest description of the patient population to the Medical Research Council.

The Panel will inquire into allegations that Dr Wakefield and Professor Walker-Smith administered a purportedly therapeutic substance to a child for experimental reasons prior to obtaining information about the safety of the substance. It is alleged that such actions were irresponsible and contrary to the clinical interests of the child.

The Panel will inquire into allegations that Dr Wakefield was involved in advising solicitors acting for persons alleged to have suffered harm by the administration of the MMR vaccine. It is alleged that Dr Wakefield’s conduct in relation to research funds obtained from the Legal Aid Board (“LAB”) was dishonest and misleading. It will be alleged that Dr Wakefield ought to have disclosed his funding from the LAB to the Ethics Committee but did not.

The Panel will inquire into allegations that Dr Wakefield ordered investigations on some children as part of the research carried out at the Royal Free Hospital from 1996-98 without the requisite paediatric qualifications to do so and in contravention of his Honorary Consultant appointment.

The Panel will inquire into allegations that Dr Wakefield failed to disclose his involvement in the MMR litigation, his receipt of funding from the LAB and his involvement in a Patent relating to a new vaccine to the Editor of the Lancet which was contrary to his duties as a senior author of the Lancet paper.

The Panel will inquire into allegations that Dr Wakefield acted unethically and abused his position of trust as a medical practitioner by taking blood from children at a birthday party to use for research purposes without ethics committee approval, in an inappropriate social setting, and whilst offering financial inducement.

We cannot guarantee that all those wishing to attend the hearing will be able to do so, as seating is limited. If you plan to attend the hearing please email the GMC press office press@gmc-uk.org. In the event that we have to allocate seats those people who have notified the press office will be seated before others.
-Ends-

Greater detail can be found in this document, hosted on Brian Deer’s website. It is 93 pages of details of the allegations against Dr. Wakefield, Dr. Walker-Smith and Dr. Murch.

Listen in to IACC conference calls

12 Sep

The Interagency Autism Coordinating Committee is preparing for a two day session to discuss their Strategic Plan for autism research.

That workshop will be held on September 30 and October 1.

Before that meeting the workshop panels will hold conference calls. You can listen in. See the note below.

The Interagency Autism Coordinating Committee (IACC) will be holding a Scientific Workshop to discuss the updating of the 2009 IACC Strategic Plan for Autism Spectrum Disorder Research on September 30, 2009 and Thursday October 1, 2009 at the Bethesda North Marriott Hotel and Conference Center in Bethesda, MD. Information about the 2009 IACC Scientific Workshop, including the workshop agenda and logistical information can be found at the Scientific Workshop Announcement Page on the IACC Website.

In preparation for the workshop, each of the five workshop panels will be holding pre-workshop planning conference calls from September 14, 2009 to September 25, 2009. These phone calls will be open to the public via conference call lines. Members of the public who call-in will be able to listen, but will not be heard.

The pre-workshop planning conference call schedule and call-in numbers for the public are posted on the following web page: http://iacc.hhs.gov/events/2009/iacc-scientific-workshop-conference-call-sept30-oct1.shtml. If there are any changes to the call schedule, they will be listed on that page as soon as they are available.

The IACC can now be found on Twitter (www.twitter.com/IACC_Autism).

The Contact Person for this meeting is:
Ms. Lina Perez
Office of Autism Research Coordination
National Institute of Mental Health, NIH
6001 Executive Boulevard, NSC
Room 8200
Rockville, MD 20852
Phone: 301-443-6040
IACCPublicInquiries@mail.nih.gov

Diagnostic change and the increased prevalence of autism

11 Sep

ResearchBlogging.orgHow real is the “epidemic” of autism? How much of the increase in the number of diagnoses have to do with factors other than a real increase in the number?

I am going to take some time with this paper. If you want the short version of this post–about 26% of the increase in autism counts in California can be attributed to changes in diagnositic practices leading to people being classified autistic (or autistic plus MR) who were classified with mental retardation by pre-1992 standards.

Perhaps the most used dataset for exploring the increase in autism, especially by amateur epidemiologists, is that of the California Department of Developmental Services, or CDDS. The CDDS serves people with developmental disabilities (not just autism) within the state of California. The CDDS made much of its data freely available. While the CDDS data show a large increase in the number of people getting services for autism as a developmental disability, it is difficult to ascertain how much (if any) of this is due to a real increase in the number of people who actually are autistic. This is because it is very hard to know how important external factors are in changing the administrative prevalence of autism.

Many factors influence the prevalence of autism. These include broadening of the criteria for what is called “autism”, such as the change in the 1990’s to include PDD-NOS and Asperger Syndrome in the Autism Spectrum Disorders.

Recently, Hertz-Picciotto and Delwiche found that “three artefacts—younger age at diagnosis, change in the accepted criteria and inclusion of milder cases—accounted for about one-third of a 12-year rise in incidence in California.”

Many people have misrepresented Hertz-Picciotto and Delwiche as showing that there has been a “true” increase in the autism prevalence when, in fact, they state quite clearly “Other artifacts have yet to be quantified, and as a result, the extent to which the continued rise represents a true increase in the occurrence of autism remains unclear.”

One of the artifacts that was not quantified by Hertz-Picciotto and Delwiche was the possibility of diagnostic change and accretion. When diagnostic practices change, a person who would have one diagnosis in one time period might get a different diagnosis in another.

For example, a common question that comes up is this: how many people diagnosed with autism today would have been given a diagnosis of mental retardation 20 years ago?

That is essentially the question posed by Marissa King and Peter Bearman of Columbia University in the paper
The paper, Diagnostic change and the increased prevalence of autism.

This has the possibility to be a very important paper. I don’t think I am stretching when I state this as this paper was published together with commentary from no fewer than five four well known research groups.

Here’s the abstract:

Background Increased autism prevalence rates have generated considerable concern. However, the contribution of changes in diagnostic practices to increased prevalence rates has not been thoroughly examined. Debates over the role of diagnostic substitution also continue. California has been an important test case in these controversies. The objective of this study was to determine the extent to which the increased prevalence of autism in California has been driven by changes in diagnostic practices, diagnostic substitution and diagnostic accretion.

Methods Retrospective case record examination of 7003 patients born before 1987 with autism who were enrolled with the California Department of Developmental Services between 1992 and 2005 was carried out. Of principal interest were 631 patients with a sole diagnosis of mental retardation (MR) who subsequently acquired a diagnosis of autism. The outcome of interest was the probability of acquiring a diagnosis of autism as a result of changes in diagnostic practices was calculated. The probability of diagnostic change is then used to model the proportion of the autism caseload arising from changing diagnostic practices.

Results The odds of a patient acquiring an autism diagnosis were elevated in periods in which the practices for diagnosing autism changed. The odds of change in years in which diagnostic practices changed were 1.68 [95% confidence interval (CI) 1.11–2.54], 1.55 (95% CI 1.03–2.34), 1.58 (95% CI 1.05–2.39), 1.82 (95% CI 1.23–2.7) and 1.61 (95% CI 1.09–2.39). Using the probability of change between 1992 and 2005 to generalize to the population with autism, it is estimated that 26.4% (95% CI 16.25–36.48) of the increased autism caseload in California is uniquely associated with diagnostic change through a single pathway—individuals previously diagnosed with MR.

Conclusion Changes in practices for diagnosing autism have had a substantial effect on autism caseloads, accounting for one-quarter of the observed increase in prevalence in California between 1992 and 2005.

The authors started by looking at the individual records for the 7003 clients of the CDDS born before 1987 who had diagnoses of autism at any time in their CDDS records. These individuals would be at least 8 years old by the time the DSM-IV criteria for autism came out in 1994, so they should have already been diagnosed with autism by that time.

What they found was that 631 individuals started out with a diagnosis of mental retardation and later received a diagnosis of autism. 95% of these individuals retained the MR diagnosis. I.e. most moved from “autism” to a dual diagnoses of autism+MR.

They also found that 89 individuals “lost” their autism diagnosis. They are not discussed in detail, so we can’t tell if they held other diagnoses after “losing” their autism diagnosis.

The authors plotted the number of individuals who changed from MR to autism or autism+MR by year. They claim that the number is higher in years when significant changes in diagnostic practices were introduced.

Figure 1 from King and Bearman paper

Figure 1 from King and Bearman paper

A peak is fairly clear for 1994, when the DSM-IV was issued. Whether this peak and the others are real is a matter for discussion (as in Dr. Hertz-Picciotto’s commentaruy)

Some of the findings the authors reported are very interesting.

Examining the control variables, we see that the level of intellectual impairment of clients had a significant effect on the likelihood of observing diagnostic change. The relationship between severity and the odds of change appears to be non-linear with moderate and profound severity to be at greatest risk for diagnostic change.

The CDDS lists intellectual impairment by the categories mild, moderate, severe and profound. It strikes me as strange that mild ID is not the area with the highest odds of change. It is very strange that there is no clear trend that the odds of change/accretion go up (or down) with severity of intellectual disability.

Another interesting observation:

Changes in evaluation scores, which capture many of the requirements for an autism diagnosis, surprisingly had little discernable effect on the likelihood of diagnostic change [OR 1.02; 95% confidence interval (CI) 1.00–1.04].

This is quite strange to me as well. One would think, perhaps, that the lower the evaluation score, the more likely that someone would have been undiagnosed.

Or, to put it another way, why weren’t the more “obviously” autistic individuals identified before the diagnostic changes?

Finally, race and year of birth were also significantly associated with the odds of change. Persons born in later years, who were younger, were more likely to experience diagnostic accretion or substitution. Finally, African–Americans
were considerably less likely than Caucasians to have a change in diagnostic status.

To me, this speaks to the idea that not everyone who qualifies for an autism diagnosis under the changes is getting one. I.e. the CDDS still has a clients in this older cohort who are misclassified as MR instead of autism. For example, 0lder clients are less likely to have a family member to advocate for them, and are less likely to see a change in services under autism vs. MR classifications.

The authors then take this “micro level” data (looking at individuals) and apply their findings on a “macro level” (looking at groups of people). In other words, the usethese data to predict how much of the increase in CDDS caseload is due to this one pathway–shift from MR to autism. The results are shown in Figure 4, copied below.

Figure 4 from King an Bearman paper

Figure 4 from King an Bearman paper

They find that by 2005, 26% of the increase in the CDDS caseload can be attributed to the shift from MR to autism.

One important point the authors make is the difference between diagnostic substitution and diagnostic accretion. An example of substitution is an individual having his/her diagnosis change from MR to autism. An example of accretion is when an individual has autism added to the already existing MR diagnosis.

Accretion is harder to discern on a group (macro) level, since one would not see the MR count drop coincident with the autism increase. The authors have included both in their definition of diagnostic change.

The authors note that the MR to autism pathway is not the only possibility.

Diagnostic substitution and diagnostic accretion along other pathways, such as developmental language disorder or other learning disabilities, may be contributing to an increase in higher functioning cases. In a study applying contemporary diagnostic standards and practices to persons with a history of developmental language disorder 21% (8/38) of the individuals met the criteria for autism and 11% (4/38) met the criteria for milder forms of ASD. Thus, there are multiple pathways to an autism diagnosis from multiple disorders that contribute to increases along various parts of the spectrum. In this article, we have considered only one pathway and one part of the spectrum

In other words, more of the increase in the CDDS caseload may be due to diagnostic changes, but in ways not covered by this paper.

One factor the authors do not appear to be taking into account is the large regional disparities within California. The administrative prevalence in the CDDS system varies wildly depending on which part of the stat one looks at. In general, rural areas have much lower administrative prevalence values than urban areas, for example.

The authors’ concluding paragraph:

We have estimated that one in four children who are diagnosed with autism today would not have been diagnosed with autism in 1993. This finding does not rule out the possible contributions of other etiological factors, including environmental toxins, genetics or their interaction to the increased prevalence of autism. In fact, it helps us to recognize that such factors surely play an important role in increasing prevalence. There is no reason to believe that any of these frameworks are wrong and many reasons to believe that the increase in autism prevalence is in fact the outcome of multiple self-reinforcing processes. However, this study demonstrates that subsequent explanations for the increased prevalence of autism must take into account the effect of diagnostic change.

I think this is quite good–the paper does not rule out a true increase in autism prevalence. It does demonstrate that factors like diagnositic change and accretion are real and significant.

Many factors are involved with the increase in autism prevalence, including that in the CDDS data. Just because the number of people identified with autism went up doesn’t mean that all of that number is due to a real increase in the number of people who are autistic.

King, M., & Bearman, P. (2009). Diagnostic change and the increased prevalence of autism International Journal of Epidemiology DOI: 10.1093/ije/dyp261

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