Monday, March 9, 2009

Harbingers of Autism

Sharon Begley

The tragedy of autism is compounded by one fact that makes desperate parents wish they could turn back the hands of time: symptoms of the neurodevelopmental disorder typically show up when a child is 2 or 3 or even older, but by then it may be too late to prevent or reverse whatever glitches in brain development (still pretty much a mystery) underlie the disease. It is even on the late side for getting a child the behavioral interventions and special education that might mitigate some of the worst symptoms.

If scientists at the M.I.N.D. Institute of the University of California, Davis, are right, however, there may be a reliable warning sign of autism much earlier: how a child plays with his or her toys at the tender age of 12 months. In particular, scientists led by Sally Ozonoff will report in the journal Autism (it’s the October issue, but not out yet; keep checking the web site), children who were later diagnosed with autism were more likely to spin, repetitively rotate, stare at and look out of the corners of their eyes at toys such as a rattle.

There is a big research effort aimed at picking up the earliest harbingers of autism. One of the most promising discoveries came in 2003, when researchers led by neuroscientist Eric Courchesne of the University of California, San Diego, concluded that an odd pattern of skull growth might be a tip to autism, as they described in a paper in the Journal of the American Medical Association. Children with autism, the scientists found, had a smaller head circumference at birth than healthy babies, and by 6 to 14 months their head circumference was in the 84th percentile, a huge increase and greater than the rate of increase in healthy children. “The clinical onset of autism appears to be preceded by 2 phases of brain growth abnormality: a reduced head size at birth and a sudden and excessive increase in head size between 1 to 2 months and 6 to 14 months,” the scientists wrote. “Abnormally accelerated rate of growth may serve as an early warning signal of risk for autism.” Still, the correlation wasn’t perfect: 6% of healthy infants in the study also showed abnormal head growth from birth to 6 to 14 months, and 41% of babies later diagnosed as autistic did not show that pattern.

The American Academy of Pediatrics recommends that all infants be screened for autism twice before they are 2. Pediatricians look for language delays and lack of interest in people, such as not responding to their name and failing to make eye contact. But these can be present even when autism is not. The latest findings are not perfect either, but they are something parents can watch for every day rather than relying on—and waiting for—a short visit to the doctor. “There is an urgent need to develop measures that can pick up early signs of autism, signs present before 24 months,” Ozonoff says. “The finding that the unusual use of toys is also present early in life means that this behavior could easily be added to a parent check-list.”

For the study, Ozonoff recruited 66 1-year-olds; 9 were later diagnosed with autism. The children were given a metal lid, a round plastic ring, a rattle and a baby bottle, one at a time for 30 seconds each while being videotaped. Seven of the 9 later diagnosed with autism were more likely to repeatedly spin and rotate the objects. They were also more likely to look at them in unusual ways, like glancing sideways at them or staring intently at them for a long time—behaviors that were rare in babies not later diagnosed with autism. “About a third of parents notice signs [of autism] before a child’s first birthday,” Ozonoff said. “We felt that our field could do a better job at early diagnosis. Our results suggest that these particular behaviors might be useful to include in screening tests. The earlier you treat a child for autism, the more of an impact you can have on that child’s future.”

Monday, March 2, 2009

The Vaccine Dilemma: Many families, some fearing autism risk, choose to avoid children's immunizations

After Jayden Naughton lost his speech when he was 2 and was diagnosed with autism, his mother, Megan, made a crucial decision.

When the Avalon woman gave birth to her second son, Duncan, two years ago, she decided he would not be vaccinated, because she believed vaccinations might have had something to do with Jayden's regression.

Duncan is now 2, has never had a vaccination, and also has been diagnosed with autism.

Some might say that this suggests his autism has a genetic cause, but Mrs. Naughton doesn't buy it. In fact, she fears that starting to vaccinate him now could make his symptoms worse. And she's not particularly worried about him getting sick from the diseases the vaccines protect against.

"My grandparents had a lot of these diseases and they're fine," she said last week. "I think these childhood diseases are there for a reason. They're there to build up the immune system."

Whether you agree with her or not, Mrs. Naughton is part of a small but growing subset of parents who either won't vaccinate their children or want to space out their shots. Most of them believe there may be a connection between the vaccines and autism, despite a growing list of scientific studies that contend otherwise.

Even if they aren't worried about autism, some parents are bothered by what they see as an increasing assault on babies' immune systems.

"We do vaccinate, but they do scare me," one mother wrote on the Web site, which is owned by the Pittsburgh Post-Gazette. "[It's] not necessarily because of autism but just because they get so many of them now and I just wonder if they truly know that they are safe."

While many pediatricians and infectious disease experts feel that doctors should stand their ground in the face of such fears, there is an increasing number of doctors who are willing to accommodate these parents.

Tony Kovatch is one of them. Dr. Kovatch, of the Pediatric Alliance's Arcadia office in McCandless, doesn't agree with avoiding vaccinations altogether, and doesn't know any other pediatricians who do. But he is willing to delay certain vaccinations.

Under the standard schedule promulgated by the federal Centers for Disease Control and Prevention, children can get up to 27 doses of 14 different vaccines before they are 2. They often get up to six shots per visit.

Melinda Wharton, acting director of the immunization safety office at the CDC, said she sees no medical or scientific rationale for spacing out those inoculations.

But Dr. Kovatch responded that "I also don't see any biomedical justification for having to give so many all in one day." He said he believes the schedule was set up "to work into the template of the pediatric well-child visits at 2 months and 4 months and 6 months. But I think the anxiety and concerns of the well-informed public have trumped the convenience on the timing."

One physician who disagrees is Andrew Nowalk, an infectious disease specialist at Children's Hospital of Pittsburgh.

"One of the reasons we are so hot on the vaccination schedule as it is, is that otherwise, you can put your child at risk for some of these diseases, many of which are quite serious. My response to parents who say 'what's the harm in spacing them out' is that many of these diseases are quite devastating."

While they don't see eye to eye on the vaccination schedule, Dr. Kovatch and Dr. Nowalk do agree that some of the diseases the vaccines protect against are more of a threat than others.

Before age 1 children should get the diphtheria-pertussis-tetanus shot and those for haemophilus influenzae B (also known as Hib) and pneumococcal infections, Dr. Kovatch said.

The Hib and pneumococcal vaccines are designed to guard against bacterial meningitis, which used to infect 18,000 children in the United States each year and kill 1,000 of them in the era before the vaccines were available, Dr. Nowalk said.

The pertussis vaccine protects against whooping cough, which has not been eradicated in the United States. Before scientists developed a pertussis vaccine for older children in 2005, there were about 10 to 20 deaths from whooping cough in the country annually, and most were in young children, the CDC's Dr. Wharton said.

For those vaccines, Dr. Kovatch said, he will sometimes suggest to parents who are concerned about the frequency of immunizations that they come into the office more often, and get one vaccine each month rather than three at a time.

He's willing to delay past age 1 the hepatitis B vaccine and the polio vaccine, especially if the family isn't planning overseas travel.

Some doctors follow the schedule advocated by Dr. Bob Sears, a California pediatrician and author of "The Vaccine Book -- Making the Right Decision for your Child."

In his "selective schedule," Dr. Sears never gives more than two vaccinations per visit and delays vaccinations for measles, mumps, rubella, chickenpox and hepatitis A until age 10, and then only if a child's blood tests show a lack of immunity to these diseases.

Spacing out vaccines, he wrote in an e-mail, "allows parents who would otherwise refuse all vaccines to get their babies protected, and helps protect our nation as a whole by raising vaccination rates among worried parents."

Dr. Wharton said she is not a fan of spacing out immunizations, but isn't unalterably opposed.

The problem, she said, is that if too many parents avoid or delay vaccinations, it can allow clusters of childhood diseases to erupt. Outbreaks of measles in the Southwest last year and of haemophilus infections in Minnesota this year were both traced in part to families with unvaccinated children.

Underlying the vaccine delay is the idea that the current schedule puts too much stress on children's immune systems.

But Dr. Wharton offered two arguments against that.

First, she said, children's immune systems are exposed to far more challenges from daily living than they are from all the vaccinations combined.

Second, even though children get far more vaccinations today than they did 40 years ago, they are exposed to far fewer substances in those vaccines that trigger an immune reaction.

The particles in vaccines that build up immunity are called antigens. A 2002 study in the Journal Pediatrics said that the 11 vaccines children were getting in 2000 contained 123 to 126 antigens, while the five that children got in 1960 -- smallpox, diphtheria, tetanus, pertussis and polio -- contained 3,217 antigens.

The major reason for the huge decrease was eliminating the smallpox vaccine from the schedule after that disease was eradicated (it contained 200 antigens), and devising a new pertussis vaccine that dropped the antigen count from 3,000 to about five.

Tricia Baum, of Canonsburg, the mother of a 5-year-old son with autism, said she had not heard that information before -- but it still doesn't change her suspicion that vaccines may have triggered her son's condition.

When she took Nicholas for his 16-month doctor's visit, she said, he was sick and fussy, "and I asked whether he should get his shots, but the doctor checked his ears, and then he said, 'I'm his physician and we're going to go ahead with his vaccinations today and we're going to give him his flu shot as well.' "

She said Nicholas had been developing normally until then, except for a delay in his vocabulary, but not long after that visit, he began to lose what words he had and retreat into himself.

Ms. Baum recently switched to a pediatrician who agreed to measure Nicholas' blood antibody levels before deciding whether to give him a measle-mumps-rubella booster.

Nicholas hasn't had any booster shots yet, she said, and won't as long as his antibody measurements stay high enough.

Elliot Frank, who has a teenage son diagnosed with Asperger's syndrome, is the chairman of local support group ABOARD -- Advisory Board on Autism and Related Disorders.

Although he doesn't believe vaccines cause autism, he knows many families in his organization who do, and he understands the emotions that are driving that idea. "We talk to our parents about how you can't blame yourself for what has happened, but I think it's human nature that you've got to blame something, because you had this image of what your child would grow up to be and at a very young age it's taken away from you, and you've got to blame somebody for life being that unfair."

Dr. Nowalk, who has a child with Down syndrome, understands that as well, but said, he can't abandon his principles as a doctor over the vaccine issue.

"I know they work because I've seen them in my lifetime as a physician protect children against diseases. And they are safe."