Field of Science

New Pediatrics paper: specious rationales to recommend against early autism screening

In work published in the journal Pediatrics (PDF available here), an assistant professor and co-authors have recommended against early-screening for autism. He's quoted as saying that screening is not accurate enough and could misidentify children as having autism when they don't. In one article, for example, he says,

“You could miss-label (sic) a child,” said McMaster researcher Dr. Jan Willem Gorter. “We know that a child can be over diagnosed based on symptoms. For example, if a young child doesn’t respond to its name it could well be an early sign of autism.

“But it could also be something as simple as a hearing difficulty.”

Yes, he's right. Wouldn't you want to know either way? A screening is a screening. It's not tantamount to a diagnosis. Diagnosis comes, as many of us know, after hours and hours of forms and scales and evaluations by, in our case, developmental pediatricians, audiologists, speech-language pathologists, and occupational therapists. There's no way--NO WAY-- a screening in a pediatrician's office would do anything except potentially lead to a referral. Pediatrician's don't diagnose autism. And the referral would distinguish between autism and a hearing difficulty. This argument on his part is invalid.

The study author says that his review of the literature turns up no good screening tools for autism and no data indicating that the benefits of early screening outweigh the harm. I assume the harm is parental worry or unnecessary expenditures within the healthcare system. So...do we throw up our hands and say, "Oh, well. Never mind."?

The authors also argue that there are no effective treatments for autism. That argument carries an air of, "Why bother?" This entire paper baffles me. It's framed as as series of questions, including whether or not screening has been demonstrated as effective in a randomized trial. Given the urgency of early intervention--which has proved effective, despite the authors' argument--do we have time to wait for an RCT for a screening that, as the author quoted in the story himself says is "harmless"?

How do such children get referred now? It's not a clean system. It's hit-and-miss and largely driven by parental concern or pediatrician instinct or both. But screening in some way or another, as currently recommended by the American Academy of Pediatrics, lets the pediatrician, who only sees a child either in ear-infection crisis or during brief well checks, take the pulse, as it were, of the child's development in some sort of concerted, organized way. Whether screening is done with a validated screening tool or gut instinct, it needs to happen, and I find it rather questionable that a pediatrician would come out against it.

Gayle DeLong, SafeMinds Board member and a Vax = Autism study?

(Image: A boy in Afghanistan receives a life-saving polio vaccine, not having the first-world luxury of going without and relying on wealth and herd immunity to protect himself).

Two things for your consideration:

From SafeMinds:

Gayle DeLong - Board Member

Dr. Gayle DeLong is a parent of two girls with autism. Starting in May 2005, her family began biomedical interventions to treat the girls' illness. Both girls have benefited greatly from supplements, diet, chelation, and hyperbaric oxygen therapy. Gayle holds a Ph.D. in international business and finance from New York University as well as an International Master's in Business Administration from the University of South Carolina. She teaches international finance at Baruch College, City University of New York. She serves on SafeMind's research committee. She has attended rallies in Washington, DC to promote safer vaccines and spoken against adding vaccines to New Jersey's mandated schedule at a public hearing in Trenton, NJ. She lives with her husband and two daughters in Morristown, NJ.


A Positive Association found between Autism Prevalence and Childhood Vaccination Uptake across the U.S. Population

Abstract

The reason for the rapid rise of autism in the United States that began in the 1990s is a mystery. Although individuals probably have a genetic predisposition to develop autism, researchers suspect that one or more environmental triggers are also needed. One of those triggers might be the battery of vaccinations that young children receive. Using regression analysis and controlling for family income and ethnicity, the relationship between the proportion of children who received the recommended vaccines by age 2 years and the prevalence of autism (AUT) or speech or language impairment (SLI) in each U.S. state from 2001 and 2007 was determined. A positive and statistically significant relationship was found: The higher the proportion of children receiving recommended vaccinations, the higher was the prevalence of AUT or SLI. A 1% increase in vaccination was associated with an additional 680 children having AUT or SLI. Neither parental behavior nor access to care affected the results, since vaccination proportions were not significantly related (statistically) to any other disability or to the number of pediatricians in a U.S. state. The results suggest that although mercury has been removed from many vaccines, other culprits may link vaccines to autism. Further study into the relationship between vaccines and autism is warranted.

Author: Gayle DeLong.

How did this abstract even get past reviewers for this journal?

Let's take it on, piece by piece.
Statement: "The reason for the rapid rise of autism in the United States that began in the 1990s is a mystery."
Not really. Much of it has been attributed to better diagnosis. And it's not only in the United States, as a recent study based in South Korea found. As study author Young-Shin Kim said about that huge study, “It seems that many children with autism-spectrum disorders have been here all along but haven’t been counted in previous studies."

Statement: "Although individuals probably have a genetic predisposition to develop autism, researchers suspect that one or more environmental triggers are also needed."
Which researchers "suspect" that? Studies actually suggest a strong genetic component to autism, but it is likely to be multifactorial. The thing is, one factor that has been clearly ruled out, over and over and over again, is vaccines.

Statement: "One of those triggers might be the battery of vaccinations that young children receive."
That. Horse. Is. Dead. Stop beating on it. See commentary on huge Pediatrics study (noted above) and others. This statement alone should have stopped any reviewers dead in their tracks.

Statements: "Using regression analysis and controlling for family income and ethnicity, the relationship between the proportion of children who received the recommended vaccines by age 2 years and the prevalence of autism (AUT) or speech or language impairment (SLI) in each U.S. state from 2001 and 2007 was determined. A positive and statistically significant relationship was found: The higher the proportion of children receiving recommended vaccinations, the higher was the prevalence of AUT or SLI. A 1% increase in vaccination was associated with an additional 680 children having AUT or SLI.."
First, she included "any speech or language impairment." That's a large population that extends well beyond autistic people. Second, given that this isn't Denmark, none of this information could possibly be very complete; several U.S. databases were used, but they're by no means complete. Third, one author alleges to have done this study. Really? Fifty states, data for ALL diagnoses of autism, speech/language impairment, vaccinations received, from 2001 and 2007? In the paper itself, the author actually states that her map results present "an ambiguous picture: Some states,such as Texas, have low vaccination rates and low prevalence of autism, while other states, such as Indiana, have low vaccination rates and a high prevalence of autism. Conversely, Wyoming has a high vaccination rate and high prevalence of autism, while Vermont has a high vaccination rate and low prevalence of autism." These statements do not seem to support the title of this paper or really any conclusions at all. Also, note that the author continuously references "autism" in the paper even though the data included all speech and language impairment diagnoses.

Statement: "Neither parental behavior nor access to care affected the results, since vaccination proportions were not significantly related (statistically) to any other disability or to the number of pediatricians in a U.S. state"
Vaccination proportions were not related statistically to *any other disability*...that does not take into account that autism is notoriously difficult to diagnose and usually isn't before age 3 and does often require access to care and specific parental behaviors to diagnose. Children of parents who are more aware and have greater access to care, as studies indicate, will be more likely to have an autism diagnosis. Relating this in the context of diagnosis of other disabilities that probably have pathognomonic features is irrelevant. Why did no reviewer catch this?

Statement: "The results suggest that although mercury has been removed from many vaccines, other culprits may link vaccines to autism."
And they do it again. These are the most flexible goalposts in the history of research. For years, it was the mercury, the thimerosal. Now that these bugbears have been killed off, well...it must be something else in the vaccines. Can't be any other environmental exposure. It's vaccines! Every time one of these pet vaccine-related ideas gets debunked, the antivax obsseso-posse moves the damned goalposts. Let. It. Go. We have so many more and better places to look.

Statement: "Further study into the relationship between vaccines and autism is warranted."
No. No, it's not.

In this paper, DeLong cites, among others, SafeMinds' Mark Blaxill once and the Geiers three times. Yes, those Geiers. Oh, and a paper from Med Veritas and one paper published in 1995 in a veterinary journal, "Are we vaccinating too much?" And this somehow escaped reviewers' attention?

Now let's look at the title: "A Positive Association found between Autism Prevalence and Childhood Vaccination Uptake across the U.S. Population." Even if the correlation is valid, the title is incredibly misleading. The author included all diagnoses of speech and language impairment in this analysis. It's not only autism that's included here.

The conclusion of this paper also should have received more reviewer notice, as it is wall-to-wall careless and unsupported speculation, in many cases about ideas that have been debunked:

"Evidence presented in this paper suggests a possible link between susceptible children receiving a battery of vaccinations and developing autism or speech disorders. Although Hg has been removed from many childhood vaccines, other ingredients could link vaccines to autism. Aluminum, which is found in at least 20 U.S. childhood vaccines (Centers for Disease Control and Prevention, 2010), is not only a neurotoxin, but also an immunosuppressant that may allow measles-containing vac-cines to create cytokines that damage the brain. Enhanced exposure to aluminum via vaccines may be associated with an increase in the prevalence of neurological disorders such as autism, especially if an aluminum-containing vaccine is administered along with a measles-containing vaccine. Reducing thimerosal and observing an increase in autism exonerates neither thimerosal nor vaccines from being potential links to autism (italics mine). Further research into the relationship between vaccines and autism is warranted."

Bye-bye, Hg. Look out, Al. You're next, you old, old, old vaccine preservative, you. And what level of denial must one have achieved to make that italicized statement? Of greater importance...why did no reviewer take the author up on it?

The acceptance and publication of this paper appear to have been careless to an extreme. I'd like to know who the reviewers were.

The paper notes DeLong's association with SafeMinds, the organization responsible for this irresponsible attack on public health. I also note that nowhere in DeLong's bio does it mention expertise in epidemiology, vaccines, autism, biology, toxicology, or other related research.

Conflict of interest disclosure: I have a paper published in this journal. Now, I'm wondering just how little that paper is worth.

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ETA...As I find other writeups of this paper, I'll link them here.

  • Sullivan, at LBRB, takes a closer look at the paper and shows how the inclusion of speech and language impairments simply swamps the autism data.
  • Here is Neuroskeptic's take on it, specifically looking at the statistical analyses.
  • Autism parent and in-depth analyzer Kim Wombles takes it on here.
  • The ever-humble and scathing Orac scathes away here.