Response to Dr . Ari Brown and the Immunization Action Coalition

04 February 2009 1 Informed consent is a crucial element of the foundation upon which ethical medical practice rests. Providing patients, parents, or guardians with an honest assessment of the risks and benefits of any medical procedure requires the physician to be, to the best of his or her ability, “informed.” This document is produced by Thoughtful House Center for Children in response to one written by Dr. Ari Brown titled “Clear Answers and Smart Advice About Your Baby’s Shots,” which attempts to deal with the vaccineautism controversy. Brown is an official spokesman for the American Academy of Pediatrics. Her document [1], is endorsed and published by the Immunization Action Coalition (IAC), a US organization funded by the Centers for Disease Control (CDC) and the vaccine manufacturers. In short, it is the public relations arm of those who are legally and ethically responsible for vaccine safety. Given this background, one might reasonably expect a comprehensive, well researched, and persuasive overview. Since the topic of vaccination is so important and because we have major concerns about the accuracy of much of what this document says, we are providing a point-by-point response. (Note: Dr. Brown’s comments are italicized.) “I’ve heard autism is on the rise. Why?” Brown begins by addressing the rise in autism diagnoses. The question of whether the rise is real or not is an important one that has profound political and policy implications. It matters because if the increase is real, there must be an environmental contribution to the cause. There’s no such thing as a purely “genetic” epidemic. If there’s an environmental cause(s), then it, or they, can be found and eliminated, thereby preventing many new cases of autism. The search for an environmental cause might also inform treatment strategies for existing cases. Denial of the epidemic takes resources away from looking for an environmental cause. Brown proposes alternative explanations for the rising number of cases: “Displacing one diagnosis for another: In previous generations, many children were diagnosed with mental retardation, schizophrenia or some other psychiatric disorder. Today many of these same kids are diagnosed with severe autism.” Brown’s position is not supported by the scientific evidence. In 2002 a study of California children, born 1987–1994, examined the degree to which improvements in detection of autism and changes in diagnostic guidelines have contributed to the observed increase in autism prevalence [2]. The study also evaluated any change in prevalence of mental retardation (MR) without autism over the same period. The authors reported that autism prevalence increased by 9.1 per 10,000, while during the same period the prevalence of mental retardation without autism decreased by a similar amount. They initially concluded that diagnostic substitution (displacing one diagnosis for another) accounted for the observed increase in autism. The authors’ conclusions were amended, however, after Blaxill, et al. pointed to several fundamental analytic errors, including the failure to account for age-related ascertainment biases in the mental retardation category [3]. After a re-analysis in which these factors were taken into account, Croen, et al. withdrew the conclusion of their original paper, stating instead that “diagnostic substitution does not appear to account for the increased trend in autism prevalence” [4]. A larger study reported by Newschaffer, et al. also failed to find a decline in either mental retardation or speech and language disability, while autism spectrum disorders (ASDs) continued to rise [5]. Finally, in 2006 Shattuck sought to revive the hypothesis of diagnostic substitution that by then had been either proposed and retracted [2-4], disavowed [6], or falsified [7-10] in previous studies [11]. Again, it was Mark Blaxill who pointed out that in constructing a set of diagnostic categories that showed a declining trend in MR, Shattuck omitted developmental delay (DD), a category that was added to US special education in 1997 and was often used interchangeably with MR [3,10]. A simple analysis was drawn up showing the effect of adding DD cases to the data on the supposed substitution of autism for MR, which is shown on the following page. The inclusion of the DD category eliminated Shattuck’s hypothesized substitution effect between MR and autism. “Changing criteria, broader diagnosis: The definition of autism has changed over the years. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the authoritative bible for psychiatric disorders in the US. The first two editions never even listed autism as a diagnosis...it was not until 1980 when psychologists recognized autism. That’s when the DSM for the first time listed criteria for diagnosis of autism. The autism diagnosis broadened again in 1994 when several more disorders were officially added to the DSM: Pervasive Developmental Disorder (PDD), PDD-NOS (not otherwise specified, Childhood Disintegrative Disorder)... By expanding the definition of autism, suddenly many more kids were declared autistic...” This is incorrect. PDD was included in the DSM-III in 1980 [12]. PDDNOS appeared in the DSM-III-R in 1987 [13], and Childhood Disintegrative Disorder was included in DSM-II in 1968, as a psychosis of infancy and early childhood [14]. The only addition has been the specification of Asperger’s syndrome in 1994, a condition previously recognized and subsumed under DSM classifications from 1980 onwards as either Childhood Onset Pervasive Developmental Disorder, Atypical Developmental Disorder (DSM-III) or as PDD-NOS in DSM-III-R. In fact, the diagnostic criteria for autism underwent a corrective narrowing in 1994 [15], adjusting for apparent false-positives noted in DSM-III-R, and converging with ICD-10, which made the autism diagnosis more exclusive and the non-autistic spectrum disorders more clearly defined. Despite this, the dramatic increase in numbers of children with both autism and non-autistic spectrum disorders has continued. “Unfortunately, many states don’t break out where kids are on the auResponse to Dr. Ari Brown and the Immunization Action Coalition