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Parents’ Interest in Predictive Genetic Testing for Their Children When a Disease Has No Treatment

25 Aug

If you are a parent, would you have asked for a genetic test for autism on your child before his/her diagnosis?

Consider an article in today’s issue of the journal Pediatrics, “Parents’ Interest in Predictive Genetic Testing for Their Children When a Disease Has No Treatment”.

This is not about autism specifically, but about an unnamed “disease”. The researchers posed two “vignettes” and asked the parent to respond to them.

Before people heap criticism over bringing up a paper with the word “Diseases” in the title (and throughout the paper) in relation to a discussion of autism: I am not saying autism is a disease.

Here are the two vignettes:

Vignette 1: Disease With Severe Symptoms and Uncertain Time of Onset
Imagine that a genetic test exists that can identify people at increased risk for developing a certain disease for which there is currently no treatment. Disease symptoms are severe and sometimes lead to early death. People may develop symptoms either as an adult or as a child, and it is not possible to predict how old a person will be when he or she develops symptoms.
Would you want to have your child get this genetic test? Please answer for your youngest child.

And

Vignette 2: Disease With Uncertain Symptoms and Uncertain Time of Onset
Imagine that a genetic test exists that can identify people at increased risk for developing a certain disease for which there is currently no treatment. Some people with this disease will develop severe symptoms, whereas others will develop only mild symptoms. It is not possible to predict how severe the symptoms will be or at what age they will develop.
Would you want to have your child get this genetic test? Please answer for your youngest child.

I would argue that the public’s perception of autism (especially with regression) would fit into Vignette 2. I would further argue that if “disease” were replaced with “developmental disability”, it would have been an even more relevant to the public’s perception of autism.

The results surprised me. There was little if any difference in the responses to vignette 1 and vignette 2. Somehow, I figured more people would want the test for conditions that were always severe and could result in death (vignette 1).

For both vignettes, the responses were fairly evenly split into 3: “probably/definitely”, “unsure” and “probably not/definitely not”.

In other words, about 1/3 of parents say they would want a genetic test and about 1/3 say they would not, with the remainder unsure.

It would be very interesting to formulate “vignettes” that are targeted to developmental delays in general and autism in specific.

What if instead of “diseases” they asked about “developmental delays”? What if instead of “no treatment” they said, “no cure, but some therapies (e.g. speech and occupational) could be beneficial”? What would the responses be like?

The main reason this paper caught my eye is the fact that the study begs the question: if the genetic test can be performed on child, why not prenatally? What would be the difference in the responses from the parents if they were asked about prenatal testing?

Or, to put it very specifically, what if parents were told to consider a genetic test for autism?

How would the responses vary depending on the parents’ perception of autism?

Autism Epidemic? Not in the NSCH data

17 Aug

There is an epidemic of vaccine-induced autism. Must be, we’ve been hearing this for about 10 years. During that time, many datasets have been manipulated to “prove” the epidemic. The two datasets that come to mind most readily are the U.S. special education data (IDEA data) and the California Department of Developmental Services data (CDDS). Neither were intended for true epidemiology.

That intro should be a warning: be prepared for more armchair epidemiology. Interested in the short answer? A new dataset is out that just doesn’t fit the idea of an “epidemic” of vaccine induced autism. No huge increases in autism counts.

The new dataset available is the 2007 National Survey of Children’s Health. The NSCH data includes questions about autism. So it should come as no surprise that it was spun into support for the “epidemic” already.

As a bit of background, let’s start with the US special education data. It’s a favorite dataset for those pushing the epidemic. Here’s a graph hosted on the Thoughtfulhouse website (click to enlarge):

special ed data supposedly showing an epidemic

special ed data supposedly showing an epidemic

Wow. That’s an epidemic. 16 year olds have an “incidence” (their word) of 0.4 per 10,000 while younger kids are at nearly 20? That’s an increase of 50 times. Impressive. Until we look at the NSCH data.

By coincidence the Thoughfulhouse data are from 2007, the same year as the NSCH data. What happens if we plot the NSCH data like the graph above? Again, click to enlarge. Sorry, I couldn’t format it to look just like the ThoughtfulHouse graph.

National Child Health Survey data on autism

National Child Health Survey data on autism

Doesn’t even look close to the data on the Thoughtfulhouse website. First, the “incidence” numbers for around age 16–0.4 for ThoughtfulHouse’s graph, 93 for the NSCH data. I wanted to graph the data on the same graph, but the newer, NSCH numbers just dwarf the IDEA numbers that ThoughfulHouse used.

Besides the difference in overall magnitude, what about the “epidemic”. What about the huge increases in autism “incidence” or “prevalence”. Numbers like 273% increase, or more, in autism are commonly quoted for the increase in autism diagnoses in the 1990’s. Well, those increases just aren’t observed in the NSCH data. Keep in mind, the 17 year olds in the NSCH data graph were born in 1990. There just isn’t the dramatic increase in an autism count in those data.

There is a a much smaller trend of increased autism count when moving from about age 17 down to about 12. The “incidence” increasing by about 40%. That’s a big number. Not hundreds of percent, but a big number.

The “incidence” goes down for younger kids–which must be partially or completely due to the average age of diagnosis being about 5. There is at least one blogger who is “sparking the debate” that this could be a sign that the removal of thimerosal has resulted in lower autism counts. The same blogger has stated at different times that we should have already seen any drop in the CDDS data and, later, that we won’t be able to see any trends until sometime well past 2010. That’s covering your bases! Either we saw it already, we are seeing it now, or we need to wait until the future to see it.

But, back to the NSCH data. Pretty much, those data are flat for birth year 1995 to 2003. Noisy but flat. That’s when the “epidemic” was in full force.

Or, another way to put it–there is no good evidence of an epidemic in the NSCH data.

Evidence of autism recovery

14 Aug

There’s evidence of autism recovery on a vast scale. That is what we are being told by bloggers covering the latest survey from the National Survey of Children’s Health. The survey showed that some parents are told that their kid is autistic, but the kid doesn’t isn’t currently autistic.

The survey is an intersting thing. They call homes and ask a lot of questions about one of the kids in that home. The questions are not just about autism, but about lots of medical topics. They do this survey every few years.

They added some new questions to the survey this time. In the past they just asked if your kid had autism. Now, they have a two part question:

Has a doctor or other health care provider ever told you that [the child] had Autism, Asperger’s Disorder, Pervasive Developmental Disorder, or other Autism Spectrum Disorder?

followed by

does [the child] currently have autism or ASD

Many of the people who responded “yes, someone told me my kid had an ASD” later responded “No” to “does you child currently have Autism or an ASD”.

Bloggers are saying this means that kids “lost their original diagnosis”. Well, we can’t say that. We don’t know what the *original* diagnosis was. Consider this. We don’t know if a kid had a diagnosis of developmental delay, then someone suggested autism, then later retracted the autism on a formal diagnosis. In that example, the kid still has his “original” diagnosis: developmental delay.

I can feel the eyes rolling as people think, “there he goes, trying to weaken the evidence of recovery with vague statements”.

So, let’s look a data. Let’s dig a little deeper than most. I’m not so good at SAS (the statistical package that is used to read the data), but I think I did OK. Let me know if you catch a mistake and I will correct it.

How many kids had a diagnosis (or just a statement) that they were autistic?

Answer: 1427

How many kids were told they were autistic and later were told they were not?

Answer: 459. About 1/3 of the total.

People stop there and leave it implied that the kids don’t have any diagnoses any more. Bad assumption. Let’s check on that. Let’s look at some of the other diagnoses given in the NCHS.

How many of the 459 now have other diagnoses? Here’s a sample of a few other diagnoses:

219 Developmental delay
27 Speech delay and no developmental delay
8 Brain injury and no developmental delay
65 ADHD and no developmental delay

There may be some crossover between, say speech delay and brain injury or ADHD, but for simplicity I’ll just add them all together to get:

319 of 459 (70%) have one of the diagnoses I listed.

A more simple check: how many of the 459 need supports in school? 97%. All but 14. Yes, parents are being told that their kids “have autism” and the parents are later finding that the kid does not “have autism”. That doesn’t mean that the kids are “recovering”.

Is it possible these kids really qualified for an autism diagnosis at one time? Sure. But, I would assert it is as likely or more that a lot of misdiagnoses were made. That’s if autism diagnoses were ever made. Remember that question?

Has a doctor or other health care provider ever told you that [the child] had Autism, Asperger’s Disorder, Pervasive Developmental Disorder, or other Autism Spectrum Disorder?

Well, if you pediatrician said, “I think this kid may have autism. Go see a psychologist”, may parents would anwer “yes” to the question. The kid wasn’t diagnosed. Pediatricians can’t diagnose. But his parents were told he/she had autism.

Be that as it may, the bottom line: the idea that the NCHS data shows that kids are recovering from autism is weak at best. The data certinainly doesn’t show kids recovering from autism and becoming typical. Most of the “recovered” kids still have a diagnosis of some sort. Almost all are receiving some sort of support in school.

There is more information in the dataset. A couple of blog posts more, at the least.

Chelation challenge testing: not scientific, not beneficial, may be harmful

13 Aug

Who knows about the toxic effects of mercury? Toxicologists. The premier toxicology group in the U.S, the American College of Medical Toxicologists, represents the doctors who test and treat people suffering from real heavy metal poisoning.

By contrast, many doctors have added chelation to their treatment options due to the false theory that autism is caused by heavy metal poisoning (specifically, mercury). These alternative-medicine practitioners usually depend on non-standard test to “prove” heavy metal poisoning. The favorite seems to be the “challenge” chelation test. In this test, a chelator is given to a person before a urine test. Chelators are chemicals which bind to metals in the body and allow them to be excreted more easily. Thus, if you give a chelator to a person, you expect their urine to show higher levels of heavy metals.

This has been discussed on this blog and elsewhere for a long time.

And now the American College of Medical Toxicologists has come out with an official position statement.

The practice is not scientific. There are no reference values for post-challenge urine metal testing. There is no correlation between actual metal exposure and post-challenge test results.

It is, therefore, the position of the American College of Medical Toxicology that post-challenge urinary metal testing has not been scientifically validated, has no demonstrated benefit, and may be harmful when applied in the assessment and treatment of patients in whom there is concern for metal poisoning.

It’s time for post challenge urine testing to end. It is time for chelation as a “treatment” for autism to end. It is time for those who promoted the “autism is mercury poisoning” theory to step forward and admit their mistakes.

Autism Omnibus: Snyder appeal denied

12 Aug

The appeals for the MMR phase of the Omnibus are now concluded: all three were denied.

The Autism Omnibus Proceeding is the way the “Vaccine Court” has taken on the task of deciding the merit of the theory that autism is a vaccine injury. The petitioners had two basic theories: (a) the MMR vaccine can cause autism and (b) the vaccine preservative thimerosal can cause autism.

Three hearings were heard for each theory. In each hearing a single individual took the role of a “test case”. So, each hearing not only represented the case of a single child, but also presented “general causation” evidence as to whether MMR or thimerosal could cause autism.

The six test cases (three MMR and three thimerosal) have been heard. The MMR cases were ruled upon, and all three were denied. All three were appealed. And, now, all three appeals have been denied.

Here is the conclusion of the appeal for the last of the MMR test cases, that of Colten Snyder:

As the special master’s decision makes clear, Colten, and by extension, his family, have dealt with significant adversity for many years, and, like the special master, the court is very sympathetic to their circumstances. However, the court cannot be ruled by emotion and base its determination solely upon the adversity endured by petitioners’ family. Moreover, it is not the task of this court to determine whether vaccines cause autism or other neurodevelopmental disorders. Rather, the court must decide whether the special master, considering the record as a whole, rendered a decision that was arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with the law. She did not. Her decision was entirely rational and fully supported by the record. Thus, the court DENIES petitioners’ motion for review. Pursuant to Vaccine Rule 30(a), the clerk is directed to enter judgment in accordance with this decision.

Very solid decision. The appeal was denied.

Looking back through the document one finds that the Judge noted that the case for MMR causing an injury was clearly not supported, and that the Special Master did not make an error in her decision:

The court finds no error in the special master’s findings. The special master’s conclusion that petitioners did not present a biologically plausible medical theory is clearly supported by the record. She found that the various aspects of petitioners’ theory were not scientifically sound and that the lynchpin of their theory was wholly unreliable. See id. at *87-93 (petitioners’ theory),
116-35 (Unigenetics’ reliability). Next, the special master’s conclusion that petitioners had not established a logical sequence of cause and effect is also supported by the record.

In a statement reminiscent of the Cedillo hearing (first MMR test case) the Judge noted that the medical records show that the “onset of symptoms” did not occur when the petitioners thought:

She [the special master] found that based on the medical records, the onset of Colten’s symptoms did not occur at the time suggested by petitioners.

It is worth reading or skimming the decision. It is a good summary of the case and the evidence presented. I don’t want to quote much more of the document here, with this exception.

Petitioners’ charge–that the special master feared a public backlash against vaccines if she ruled in their favor–is preposterous. There is not a shred of evidence to support petitioners’ claim;70 it rests solely on petitioners’ speculation. Merely because the special master found that petitioners did not carry their burden of proof does not diminish her integrity or render her decision unsupported. Claims of error by a losing party against a decision maker are hardly unusual, but should be grounded in reality.

One thing that bothered me greatly was the implication in the appeals that the Special Masters were acting improperly out of some hidden motive such as trying to protect the vaccine program or fear of public backlash. Sometimes it is difficult for a lay person like myself to understand whether such arguments are expected and “just part of the game” or whether they are attempts to impugn the integrity of the Special Master. I have read enough comments on other blogs to see that many readers are willing to accept that members of the judiciary could act to deny children due process.

I’m glad the Judge in this appeal took the time to respond to these false allegations.

Moving Toward a New Consensus Prevalence of 1% or Higher

12 Aug

When I first started reading autism blogs, I was very impressed by many of the writers on what has become the Autism Hub. Amongst them, Joseph of the Natural Variation – Autism Blog.

There are a lot of armchair epidemiologists in the autism world. Joseph has always impressed me with his careful and thorough approach.

One blog post of his is where I got the title for this post: Moving Toward a New Consensus Prevalence of 1% or Higher. That post impressed me then. It impresses me even more now.

Take a look at that blog post. It is from February of 2007. Here’s a line from his intro:

The current consensus prevalence of ASD is roughly 1 in 166 or 60 in 10,000, as widely known. I believe this is still an underestimate.

Here’s a later paragraph:

Nevertheless, it appears that when ASD is screened thoroughly in a population, or when there’s a lot of awareness and good ascertainment, prevalence is found to be closer to 1%. This is not new. The following is what Lorna Wing and David Potter said on the subject as early as 1999.

Why bring it up now? Because Joseph is (once again) proven correct. The “new” consensus is about 1% or more.

The National Survey of Children’s Health shows about 1% of children aged 2-17 currently have an Autism or Asperger Syndrome diagnosis. The rumor mill has it that the CDC will release a report with about 1% soon as well.

Anyone surprised? At the least, is anyone surprised that the “official” numbers may be going up? It has been long recognized and discussed that the “official” CDC numbers are an under estimate. The regional variations alone show that to be the case (with the autism “rate” varying by about a factor of 3 between Alabama and New Jersey).

Again, lifting liberally from Joseph’s blog post: he quotes Lorna Wing and David Potter from…1999. Yep. 10 years ago.

Because we concentrated on the children with learning disabilities (IQ under 70) we saw very few with the pattern described by Asperger. We had to wait for the study by Christopher Gillberg in Gothenberg to find out how many children with IQ of 70 and above were also in the autistic spectrum. As described above, combining the results of these two studies gave an overall prevalence rate for the whole autistic spectrum, including those with the most subtle manifestations, of 91 per 10,000 – nearly 1% of the general population.

and,

Kadesjö et al (1999) report a study in Karlstad, a Swedish town. Although this was small scale it was very intensive (over 50% of the 7 year old children seen and assessed personally by the first author). The study found a prevalence for all autistic spectrum disorders for all levels of IQ, of 1.21%!!! Children were followed up four years later and had the diagnoses confirmed.

Joseph also listed the following studies in his post:


About 1% of children in the South Thames region have an autistic spectrum disorder

and


Pervasive Developmental Disorders in Montreal, Quebec, Canada: Prevalence and Links With Immunizations by E. Fombonne, et al.. This 2006 study showed 1.076%.

More recently, we have the study by Simon Baron-Cohen’s group that showed a prevalence about 1.5%

At the time that I started reading autism blogs there was a recurring theme. Every three months the California Department of Developmental Services would publish their latest data. Rick Rollens would put out comments for the press and David Kirby would blog it, both concluding that the data showed evidence of an “epidemic”. As I recall, one quarter there were simultaneous claims of “See the autism rate went up, there’s an epidemic” and “see the autism rate went down, there’s an epidemic”. Every quarter, bloggers like Jospeh, D’oC and Prometheus (and others) would debunk the claims of epidemic.

Little has changed except that the CDDS isn’t publishing quarterly reports. Now we have more infrequent reports on autism prevalence, so we have to do the debunking less often.

The real question here is whether the prevalence of autism is really increasing. It is a very good question. It just isn’t one that we can answer with the data we have. That won’t stop people from claiming they have proof of an “epidemic”.

Penn looking for Post Doc in Autism Services Research

4 Aug

There is a great need for more and better research into services for autistics.   At the same time, there aren’t that many groups looking at services.

That’s why I was pleased to get the following job announcement in my email today. I’m glad to see more research and more people being brought into the field.  The announcement is for a post-doc position at U. Pennsylvania on “Interstate Variation in Healthcare Utilization among Children with ASD”.

This job is to work with David Mandell’s group, with the contact being Lindsay Lawer.  Name sound familiar?  She was first author on the paper Vocational Rehabilitation and Autistic Adults, which I blogged.

I don’t know if anyone will find the job from this blog. But, then again, I want as many good people as possible pulled into researching questions important to the autism community. So, here is the job posting:

University of Pennsylvania School of Medicine

Postdoctoral Training Fellowship in Autism Services Research

The Center for Mental Health Policy and Services Research (CMHPSR) invites applications for one- and two-year post-doctoral fellowships in children’s health services research, with a specific focus on the organization, financing and delivery of care to children with autism spectrum disorders. The fellowship is funded through a research grant from the National Institute of Mental Health entitled, “Interstate Variation in Healthcare Utilization among Children with ASD (5R01MH077000).” This study combines national Medicaid claims data, information on local healthcare and education resources, and state-level policy data to examine associations between policies and healthcare delivery to children with autism.

Fellows will receive training in health policy and services research methods and in the clinical presentation and care of children with autism. Training activities include intensive mentorship from a multi-disciplinary team of faculty, participation in didactic courses and lecture series, clinical observations, and guided research activities.

We seek applications from persons with a PhD or equivalent in psychology, sociology, public health, economics, social welfare, or other related fields. Preference will be given to applicants with strong statistical skills and those with previous experience analyzing administrative data. Knowledge of children with autism or other psychiatric/developmental disabilities is preferred but certainly not required.

Applications will be accepted throughout the year. Recent graduates and those seeking to enhance their skills in new areas are welcome to apply. Applications should include: 1) Cover letter and CV; 2) List of degrees, dates of conferral, focus of study & institutions; and 3) Current and permanent contact information (address, phone number, e-mail). Please e-mail complete applications to Lindsay Lawer at llawer@mail.med.upenn.edu.

For further information, please view our web sites at http://www.med.upenn.edu/cmhpsr and http://stokes.chop.edu/programs/car/.

(note: edited to correct who the principle investigator is on this project)

It’s time for David Kirby to disavow the autism epidemic

3 Aug

The idea that mercury caused an epidemic of autism is both wrong and very damaging to the autism communities. Many contributed to this damaging notion., but David Kirby without a doubt carries a good quantity of the blame for his book “Evidence of Harm: Mercury in Vaccines and the Autism Epidemic: A Medical Controversy” and efforts since.

Mr. Kirby often tries to hide behind the notion that he is just “trying to spark a national debate”. Sorry, but that is nonsense. He actively promotes the idea that vaccines cause autism. It is unclear to this reader whether Mr. Kirby is currently being paid for his efforts. In the past he cherry picked information and packaged it in seemingly self-consistent packages to convince people that an epidemic did occur.

He has now moved to a tag-team approach for presentations to the US congress. He presents information to support the idea that vaccines could cause autism. He then let’s Mr. Mark Blaxill take over to promote the epidemic with the old, tired arguments.

It’s like Mr. Kirby still wants to be able to say, “I never really said there was an epidemic. I was just sparking a discussion.” It’s Mark Blaxill that is actually calling it an epidemic.

Nonsense.

This has been bothering me for some time. It came up again strong when Mr. Kirby commented on a blog piece. David Kirby doesn’t generally participate in the online discussions-even to the point of not answering comments on his own blog pieces. He broke that tradition recently in a blog piece on the Mother Jones website: Breaking: Vaccines still don’t cause autism

My response to Mr. Kirby incorporated much of what I was considering for a future blog post. So, rather than paraphrase what I wrote, here it is in full:

Mr. Kirby,

I see your usual arguments above. I see, also, the usual gaps in your discussion. Over the years, you have gone from promoting the “vaccines caused an epidemic of autism” to dancing around the subject of the false “epidemic”, neither stating that there was an epidemic, nor admitting your mistake. Could you comment somewhere, on the record: was there an “epidemic” of autism caused by mercury? You seem to leave that to your colleague, Mr. Blaxill, giving yourself some form of plausible deniability. It is irresponsible.

You rely heavily now on the NVAC recommendations. Why do you leave out so many comments by NVAC?

The NVAC is assured by the many epidemiological studies of the effects of mercury exposure done in a variety of populations, which have demonstrated that thimerosal in vaccines is not associated with autism spectrum disorders in the general population.

Are you prepared to agree with NVAC that the data are in and that there has been no epidemic of mercury caused autism? It would be the honest thing to do.

You rely heavily on the idea that mitochondrial disorders are related to autism. You pushed heavily on your blog the idea that mitochondrial disorders are caused by mercury, without substantiation. In fact, this idea is strongly rejected by the very experts you rely upon.

Further, you leave it implied that children with mitochondrial disorders and autism indicate a link to autism as a vaccine injury. This is clearly not the case.

Why do you leave out the fact that most children with mitochondrial disorders and autism do not show regression. Without regression, it is clear that vaccine injury is not causing autism in these individuals?

Why do you leave out the fact that in the one study of children with mitochondrial disorders and autism, it is clear that vaccines are not causal in the vast majority of cases, and could be questionable in the one case cited so far?

You cite that there could be a sizable population of autistics who have a mitochondrial dysfunction. Yet you leave out the public statements by one of the very doctors who supported the Hannah Poling case in vaccine court that any such injuries are rare. This from the few doctors who support the idea of mitochondrial disorder as a vaccine injury. Other specialists have stated that it is far to early to draw a conclusion that mitochondrial disorders caused by vaccination is even “rare”.

Why have you not removed your blog piece that was so erroneous that you were forced to rewrite it within a day, with an admission that you seriously erred? Isn’t that a form of dishonesty?

Are you prepared to join Rick Rollens, one of the strongest proponents of the vaccines-cause-autism notion, in stating that the idea that MMR causes autism has been tested and MMR is no longer suspect?

I will ask again, if you are going to cite NVAC, are you willing to join them and state that mercury did not cause an “epidemic” of autism?

Would you at least be willing to include quotes from NVAC that are, shall we say inconvenient, to the notion of a vaccine induced “epidemic” of autism? Quotes such as:

Vaccination almost certainly does not account for the recent rise in ASD diagnoses; however, public concern regarding vaccines and autism coupled with the prevalence and severity of ASD warrant additional study in well defined subpopulations.

This quote makes it clear that
a) NVAC does not support the idea of an autism “epidemic” caused by vaccines
b) NVAC is not calling for studies of vaccines and autism due to evidence presented so far, but, instead, by public concern.

Mr. Kirby, your half truths and misleading arguments cause great harm to the autism communities, as well as to public health. You personally are responsible for much of the public’s misconception that mercury caused an “epidemic” of autism. Don’t you agree that you personally should publicly refute your previous stance?

Being wishy-washy on the epidemic question and letting your colleague Mark Blaxill push the idea in your tag-team briefings is just dishonest. Either you still believe in the mercury-caused-epidemic (and you are wrong) or you should be clear that it was a mistake.

It was a mistake. Earn some respect. Admit it.

Autism Omnibus: Hazelhurst appeal denied

29 Jul

The Autism Omnibus Proceedings is, for better or worse, one of the big stories in the world of autism news. Hearings have been held, using the best science and arguments that could be brought to bear. The two theories were (1) does MMR cause autism and (2) does thimerosal cause autism.

Each theory was tested using three “test cases”. Essentially, three trials for each theory, each discussing an individual child plus arguments on “general causation”.

So far, the decisions are only in on the MMR question. The answers were clear and decisive: “this is not a close case”.

The Omnibus decisions are not the end of the vaccine/autism lawsuits. Not by a longshot. The first step was an appeal, and the first appeal has been decided.

Here is the conclusion of the Judge who heard the appeal for the Hazelhurst case:

In hearing this appeal, the court is not without sympathy for Yates, the Hazlehursts, and the other children and families dealing with autism and autism spectrum disorders. And this court, like the special master, acknowledges both the burdens many of these families have faced and the tremendous love and support they have shown their children. The facts, however, do not support petitioners’ appeal and we have no choice but to deny their motion. Accordingly, for the reasons set forth above, the special master’s decision of February 12, 2009, is AFFIRMED.

I.e. the appeal failed. The decision stands. The Court holds that MMR does not cause autism.

The judge’s decision in the appeal gives a good summary of the original case. If you want to read about the Hazelhurst case, it would be the first place I would send you.

From the appeals judge’s ruling, here are the two “cardinal” flaws in the petitioner’s case:

1) First, the special master explained that petitioners’ experts based their opinions on the characteristics of the “wild-type” measles virus rather than on the characteristics of vaccine-strain measles, despite the fact that the measles vaccine is distinguishable from the wild-type measles virus in several key respects.

2) Second, the special master observed that petitioners’ experts further based their opinions on studies (detecting the presence of the measles virus in the gut tissue of autistic children) that the special master found to be unreliable.

The special master considered the presence of the measles virus in the gut to be the “linchpin” of the petitioner’s case. In other words, they needed to show reliable data or studies demonstrating that the virus was still in the tissues of the children long after the vaccination.
The two studies they had to rely on were (a) that by Dr. Wakefield’s team and (b) an unpublished study by Dr. Stephen Walker, presented as a poster at the 2006 IMFAR conference. Well, the Wakefield study was pretty well discredited, and the Walker study was never published.

In the appeal, the Hazelhurst’s lawyer argued that the testimony of Dr. Stephen Bustin should not have been considered. Amongst the arguments were that some of the information was submitted at the last minute.

No arguments were made that Dr. Bustin was wrong in his analysis of the O’Leary laboratory. That was one of those strange moments in law–no one challenged Dr. Bustin on being right. The judge hearing the appeal noted that the rules for the Vaccine Court are different from a typical court of law. Specifially, the rules are designed specifically to allow more information in to inform the Special Master. The judge further noted that under the typical rules of evidence, the Walker study would never be admitted anyway.

If you haven’t read about Dr. Bustin’s testimony, you should consider it now. Dr. Bustin basically discredited the entire “persistent measles in the gut” idea by showing that the O’Leary laboratory that made tests had serious methodological flaws and, basically, couldn’t make the tests at all.

The Hazelhurst’s lawyer then argued that the Special Master failed to include all the relevant evidence., In specific, that the Walker study wasn’t given due weight.

Again, one of those strange moments in law. The laywers moved directly from trying to get the Special Master to exclude evidence that was clearly relevant, to claiming that the Special Master had to include all relevant evidence. I guess that’s why I am not a lawyer. I couldn’t pull that off with a straight face.

As it turns out, even the witness for the Hazelhurts’ side stated that the Walker study wasn’t reliable:

Respondent additionally notes that Dr. Hepner herself acknowledged that the preliminary data from the study was “not useful at this time” (Cedillo Tr. at 682), declined to draw any conclusions about the biological significance of the Walker group’s findings (Cedillo Tr. at 682), and identified what respondent describes as several significant drawbacks to the study, including that the experiments had not been “blinded”28 and had lacked negative controls.

So, it is rather moot as to whether the Walker study was considered, since it doesn’t really provide substantial evidence to support the MMR theory.

The third main argument used in the appeal was that the Special Master failed to decide on a “critical issue”. Namely, whether regressive autism exists as a separate phenotype.

The Special Master wrote in his decision, and the appeals judge agreed: since the decision held that MMR doesn’t cause autism, there was no point in deciding on the question of regressive autism as a separate phenotype.

Given that the expert testimony was against this idea, it is probably better for the petetioners that this question was left unanswered.

The main result is, of course, the original decision was upheld. Looking forward, it doesn’t look good for the MMR theory to win in civil litigation from my perspective. The Bustin testimony is very damning to the little evidence there is, and that will be allowed in a civil case. The Walker study, however, will almost certainly not be allowed as it is unpublished and has severe limitation

Autism and Gastrointestinal symptoms: two new studies

28 Jul

Autism and poop. You hear those two words in the same sentence a lot on the net. People have been asking for studies on whether autistics have a higher incidence of gastrointestinal (GI) problems for a long time. Well, two papers came out in the last week with answers…and many parents are not happy.

The two papers are:


The early stool patterns of young children with autistic spectrum disorder

by B Sandhu, C Steer, J Golding, A Emond of the University of Bristol

and

Incidence of Gastrointestinal Symptoms in Children With Autism: A
Population-Based Study

by Samar H. Ibrahim of the Mayo Clinic.

The Bristol group’s study came out last week. Given that the Mayo Clinic study was on the way, I figured I’d wait and blog them both at the same time. Actually, I considered not blogging them at all. These papers are more nails in the coffin for Andrew Wakefield’s hypothesis that MMR causes “autistic enterocolitis” and the belief by many that this drove much of the “autism epidemic”. But, tired as that story is, the question of whether autistics have GI problems at a higher rate is important and worth discussing.

The Bristol study has free pdf access. Not so the Mayo Clinic study: abstract only, but I have a copy. Rather than go through the studies in detail (if you are that interested you will likely read the paper for yourself), let’s just look at the results and conclusions sections of the abstracts:

Bristol group:

Results: Comparison of the ASD and control group during the first 3.5 years of life showed no major differences in stool colour or consistency, or in frequency of diarrhoea, constipation, bloody stools or abdominal pain. The ASD children had similar stool frequency up to 18 months, but there was a trend for ASD children to pass more stools at 30 months (OR 3.73, 95% CI 1.11 to 12.6; p=0.004) and at 42 months (OR 6.46, 95% CI 1.83 to 22.7; p,0.001), although only three children passed more than 4 stools/day. Repeating the analysis on only those cases diagnosed as having classical childhood autism resulted in very similar findings.

Conclusions: During the first 42 months of life, ASD children had a stool pattern that was very similar to that of other children, apart from a slight increase in stool frequency at 30 and 42 months. There were no symptoms to support the hypothesis that ASD children had enterocolitis.

Mayo Clinic:

RESULTS: Subjects were followed to median ages of 18.2 (case subjects) and 18.7 (control subjects) years. Significant differences between autism case and control subjects were identified in the cumulative incidence of constipation (33.9% vs 17.6%) and feeding issues/food selectivity (24.5% vs 16.1). No significant associations were found between autism case status and overall incidence of gastrointestinal symptoms or any other gastrointestinal symptom category.

CONCLUSIONS: As constipation and feeding issues/food selectivity often have a behavioral etiology, data suggest that a neurobehavioral rather than a primary organic gastrointestinal etiology may account for the higher incidence of these gastrointestinal symptoms in children with autism.

Or, to put in a single sentence: there is no evidence that children with autism have GI problems at a greater rate than the general public.

How about repeating that with emphasis: there is no evidence that children with autism have GI problems at a greater rate than the general public. They are not saying that there are no children with autism and GI issues. Quite the contrary. You wouldn’t know that to read some comments on the internet about these studies.

I’m a little surprised by these results. No, I don’t think that Wakefield was right. But, I wouldn’t be surprised if children with autism have other medical concerns at higher rates. Also, there were two abstracts from IMFAR 2008 that stuck in the back of my mind.

In the first, a team from the University of Connecticut presented a study suggesting that GI issues may be more common in children with children with ASD’s (but at a similar rate to children with other developmental delays).

No evidence for higher rates of gastrointestinal problems in young children with ASDs versus those with other developmental delays

Conclusions: In this sample of young community-based children with ASDs and other developmental delays, no significant group differences in parentally reported feeding problems and gastrointestinal symptoms were found at age two or at age four. Most published research has been conducted at specialty GI or DD/ASD clinics with older children. The results of this study suggest that their findings may not be applicable to young children or to children evaluated in community settings. While GI problems may be increased in children with developmental disorders, we found no evidence that they were specific to autism spectrum disorders.

The second abstract (which later became a paper that was discussed on this blog): David Mandell’s group presented a paper suggesting that a significant fraction of adults hospitalized with schizophrenia diagnoses might actually have autism:

Evidence of autism in a psychiatrically hospitalized sample

Their IMFAR presentation (and later published paper) showed an increased number of GI problems in their adult group. 36% of their adults had GI problems vs. 23% of the general psychiatric hospital population.

Unfortunately, these latest studies are getting the usual “online-autism-parents” community welcome. It follows the same pattern as vaccine/autism research:

a) Ask for studies to be done
b) Studies are done
c) Disagree with the data
d) try to slime the authors

Is it a surprise to anyone that some researchers have opted out of working on autism?

(note: minor edits were made shortly after publishing this article)

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