passionless Droning about autism

Archive for the ‘Hilarious’ Category

Hello friends –

There used to be a poker room about twenty miles from my home; it sat above a run down greyhound racing track and smelled like an old shoe on the best day.  But they had poker.   They hosted an accumulating jackpot hand, usually worth a couple of thousand dollars, sometimes quite a lot more, which you could win if you got a royal flush in the current suit; i.e., if the suit was hearts, and you wound up with 10-J-Q-K-A hearts, you’d win the Jackpot.  This could lead to some unusual cost/reward analysis scenarios.

Let’s say you sit down to play and buy in for a hundred dollars.  Then, three hands later, you look at your two hole cards and you have 10-J hearts.  Not really a great hand, but if the board winds up showing Q-K-A hearts somewhere in the next five cards, you win fifteen thousand dollars (or whatever the Jackpot had accumulated to).   Almost everyone folds, but before you get a chance to see the next three cards for the two measly dollars you put up as a blind, an aggressive, serial over-better to your right raises to fifteen dollars.  You are in a tough spot, you know the guy bets like crazy anytime he thinks he can steal a pot, but you still are losing to anyone with a queen.   If you had 10-J spades, or clubs, or mixed, or (nearly) whatever else, this is easy; you dump your shitty cards.  But with your two royal heart cards, you *could* win the jackpot; your odds still totally suck, even if you were getting paid off a thousand to one you still didn’t have the ‘right’ odds to make the call, but if you inhabit a place where losing fifteen dollars won’t kill you, but winning fifteen thousand would definitely be a game changer, the magnitude of the potential winnings must be part of your decision making process.

I called the raise a few times, but never hit the jackpot.  Or even came close.

I keep coming back to the idea of incorporating the scale of potential outcomes when I think about the non event of the hilarious prevalence numbers that came out a while, one in fifty with ‘autism’.  Nobody outside of Journey Autism fucking cared and the responses were depressingly predictable; the media and the Internet skeptics went ‘full awareness’, and found nothing of any alarm in these numbers, the Internet vaccine crazies went ‘full autism’, and assumed the numbers were solely comprised of individuals who would need 24×7 assistance for forever.  It was all a big joke.  Haha.

I don’t know how large the real increase in autism is (the older parental age data tells us unambiguously that some of the increase is non-imaginary), but I do know that as our best efforts at figuring this thing out has left us skipping from one in two hundred and fifty, to one in a fifty in eight short years.  To my eye, this means a real increase of fifty percent (or more!) could easily be hiding in the static and we’d never know.  Most everyone doesn’t seem to care, that is the way of the Prevalence Hookup, quickly embracing whatever prevalence numbers come out, coupling until a set of newer, bigger, even more ‘greater awareness’ numbers come along.

But my thoughts continue to be formed by concept of a sort of missed jackpot opportunity when I see a sense of complacency about our ever growing autism population; it isn’t that I don’t believe that diagnostic changes and the watering down of what a diagnosis means in terms of life skills aren’t affecting rates, those factors are clearly at play, but the ramifications of just “some” of the increase being real seems like a big, big, big deal to me.  When your population of interest is every child, a small real increase means a lot of individual children are affected.  Sure, it is, possible that older parental age is the only recent development that is affecting rates upward, with all of the rest being diagnostics, but I find little comfort in this notion.  If the soft social scientists are wrong, even a little, and there is a true increase in incidence, we may come to regret the solace provided by our collective bobbleheading at the mantra of ‘greater awareness’, for it enabled us to waste a great amount of precious time.

The thing is, it doesn’t really cost us that fucking much to apply more resources to the unimportant, nagging question on the neurodevelopment of a generation of infants.  In 2006, Bush signed the ‘Combating Autism Act’, a bill included a billion of dollars for ‘research, surveillance, and treatment’.  That’s two hundred million a year.  Last year, The Avengers, a stupid and shitty movie, made over a billion dollars.  Now, I know there are other funding sources for research, surveillance, and treatment, but there were also a lot of other stupid movies.

I believe that this prioritization is the equivalent of folding 10-J hearts to a dinky four dollar raise; the knowledge we could gain from a relatively small outlay is worth a lot.  We shouldn’t be worrying about the cost, we should be considering the payoff; the question we are trying to understand, “are today’s infants neurobiologically different than infants of the last generation?” has a difficult to understate payoff. We shouldn’t be embracing reasons to stop playing, we should chomping at the bit to see the next three cards.  This is an easy call.

And yet, there was a collective yawn when the CDC announced 2%.

Funny enough, it was just a few years ago that the UK NHS study of adults found a prevalence of 1%, a finding which was heralded as remarkably strong evidence that autism rates are stable (at the time, 1% was the general value for US children.  Oh well.).  For some reason, the robustness of the NHS adult findings didn’t cause anyone to exclaim that there is a sort of epidemic-lite, what with US kids having autism as twice the rate as NHS adults.  It was a classic case of doublethink; US kids have autism at 2%, England adults have autism at 1%, and autism rates are stable.  (Believing that any of the numbers have validity might be closer to triplethink!)

A while ago I saw an interview with Fombonne on the SFARI site that contained the unsurprising byline: ‘Eric Fombonne says that the new CDC report does not necessarily mean that prevalence is increasing’.   [Note: This was BEFORE the 2% numbers were reported!]  Anyway, he made some interesting points about the messiness of the autism data showing how silly the state by state numbers are; Utah has four times the cases that Alabama does, and utilized different diagnostic methods.  In the text of the interview, he reveals Utah also had very low levels of MR (~ 13% instead of ~ 28%), AND had a creepy low male to female ratio.  Either there is something really weird going on in Utah, or the ‘numbers’ from Utah and Alabama are not measuring the same thing.  It could also be that the numbers are measuring some of the same thing, and there are a couple of weird things going on in Utah (heh).  But the bigger point should be that we shouldn’t expect to get a decent understanding of autism rates at a national level by clumping together Alabama numbers, Utah numbers, and whatever other numbers, shaking up them up, and averaging them out.  Maybe the headline ought to read, ‘Pretty much somewhere between half a percent, and two percent of children might have something a psychologist, or a doctor, or both, have something called autism, the manifestations and lifelong impact of which vary considerably individually and regionally’, or maybe ‘Autism Rates: Your guess is as good as ours!’.

I don’t trust any set of numbers more than an educated stab in the dark.

[Note: for a slightly different take on ADDM numbers, you can see this interview on SFARI, where Walter Zahorodny reports that detailed analysis of NJ data indicates a likely real increase in rates.  Doh!]

I began to wonder; if almost nobody really seems worried about an ‘epidemic lite’, if no almost no one is alarmed that the confidence intervals in our data could incorporate huge numbers of actual people, why am I so concerned?  Is my version of the precautionary principle overly cautious?  I don’t know the answer to these questions, but I think that part of the answer lies within my journey autism, watching my son’s challenges (and triumphs) unfold, and the knowledge that whatever we find about autism incidence, he will be reliant on other people for his survival for his entire life.  That is the gift autism has given him; it doesn’t mean he can’t be happy, it doesn’t mean he can’t experience love, but so far, we cannot detect that autism has provided him anything other than near debilitating OCD, an imperfect sense of dangerous situations, and a lifelong requirement of the kindness and capabilities of others.

I am filled with a pervasive and soul crushing sadness at the possibility of one ‘extra’ child having the same challenges because of changes we have collectively made to the environment, and that is the heart of the semantic dance over how much of the increase is real.  That is the Jackpot.

But, your mileage may vary.  I know that there are some parents and people out there who have challenges as heavy as my son’s, and they don’t share my sense of panic over the issue.  A lot of people credit their autism with benefits.  I won’t discount their experiences.  Part of the reason we don’t see eye to eye may be that we look at the same question, but see different risks, and different payoffs.

– pD

Hello friends –

These have been rough times for the people who are heavily invested in the kissing cousin theories of autism as a predominantly genetic disorder and the static, or near static rate of autism.  The California twin study that is old news by the time I get this finished showed much different rates of genetic participation than previously believed.  These findings exposed the underlying frailty of gene-based causation theories, namely that some of the most widely referenced studies in the autism literature, studies used repeatedly as a basis for the notion that autism was ‘the most highly heritable neurodevelopmental disorder’, were, in fact, relatively underpowered, and suffered from serious temporal and methodological shortcomings.    

By contrast, the California study looked at two hundred twin pairs, a lot more twins than any previous study and actually performed autism diagnostics on all of the participating children, whereas other studies relied on medical records.  Performing dedicated ADOS diagnosis prospectively on the children allowed the researchers to discern between autism and PDD-NOS, something that not all previous studies were not able to perform, if for no other reason than the DSM-IV wasn’t even released when several of the most often cited studies were published.   This is from the Comment section of the California twin study:

The results suggest that environmental factors common to twins explain about 55%  of the liability to autism. Although genetic factors also play an important role, they are of substantially lower magnitude than estimates from prior twin studies of autism. Nearly identical estimates emerged for ASD, suggesting that ASD presents the same liability spectrum as strict autism.

This is on top of the fact that there is a quiet, but growing acknowledgement of the fact that literally decades of genetic studies have failed to be able to explain more than a fraction of autism cases despite sequencing of tens of thousands of genomes.   This is a very similar situation to a great number of other disorders which we thought we would cure once the human genome was decoded.   [Note: That isn’t to say that we haven’t learned a lot from sequencing the genome, just that we didn’t quite get what we thought we were going to get.]

This ‘double hit’, so to speak, has reached a critical mass such that health officials are making politically shrewd, but refreshingly realistic statements, and dare I say, a sliver of common sense may be about to infiltrate the discussion about autism prevalence.  For example, as pointed out by Sullivan, Tom Insel, head of the National Institute of Mental Health keeps a blog where he recently blogged ‘Autism Spring’, which included this nugget within the context of continued failure of genetic studies to explain any substantial part of autism, “It is quite possible that these heritability estimates were too high. . .” Ouch. (I would recommend the entire blog posting by Mr. Insel.) 

The high heritability estimates, and implicit genetically-mediated cause of autism, are foundational pillars of the argument that autism rates have not changed over time.  Though overused, or used wrongly in many instances, there is a kernel of dispassionate reality behind the statement, ‘there is no such thing as a genetic epidemic’.  Without the crutch of exceedingly high heritability to rely on, the notion of a stable rate of autism loses the only hard science (read: replicable, biologically-plausible), i.e.,genetics, it ever had, and must place complete reliance on the softer sciences (read: unquantifiable, ‘greater awareness’), i.e.,sociology.  This is great news if you love impossible to verify estimates of prevalence and anecdotes about crazy uncle George who would have been diagnosed with autism forty years ago.  However, if you think we should be relying less on psychologists and cultural anthropologists to answer critical questions, and rely more on hard science, this means that the old narrative on autism prevalence holds even less allure than it did in the past, for those of you who thought this was possible.

Before Kid Autism came around, I would occasionally read discussion boards on the creationism versus evolution ‘debate’.  One thing that I noticed was that the creationists would often employ a ‘God of the Gaps’-style argument: anything that couldn’t be explained by science (yet), or anything necessary to support whatever fanciful construct had been erected to protect biblical creation fables, was ascribed to the work of God.  That’s one thing you have to give to God, he (or she!) can handle it all; it didn’t matter what primitive logical test biblical creation was failing to pass, the golden parachute clause was always that God could have just made things that way.  It was a nifty out on the part of the creationists, kind of like a get out of jail free card. The autism prevalence discussion has been working just like this, and the funny part is that the people that are always claiming to have the intellectual high ground, the supposed skeptics, are playing the part of the creationists!  Zing! 

Here is how it works:

Concerned Parent: It sure does seem like there is more autism than there used to be, what with there being X in a thousand kids with it!  That’s much, much more than even ten years ago!  My brothers, sisters and I all knew kids with mental retardation and Down’s syndrome, but we just don’t remember kids like we see today.

Supposed Skeptic: It is diagnostic substitution and ‘greater awareness’; autism incidence has been stable.  The DSM was changed which resulted in more children being labeled.

Concerned Parent:  It sure does seem like there’s more autism than there used to be.  Now there are Y kids in a thousand having autism!  Why does my son’s preschool teacher keep insisting something is changing?

Supposed Skeptic: It is diagnostic substitution and ‘greater awareness’; autism incidence has been stable.  The DSM was changed which resulted in more children being labeled.

Concerned Parent:  What the hell?  Now there are Z kids in a thousand having autism!  When are those genetic studies going to figure autism out, anyway? 

Supposed Skeptic: It is diagnostic substitution and ‘greater awareness’; autism incidence has been stable.  When does the new DSM come out again? 

(Replace X/Y/Z with any progressively larger numbers.)

It doesn’t matter what prevalence number is thrown about–even the astronomical one in thirty-eight figure bandied about for South Korean children didn’t cause so much as a raised eyebrow; the autism equivalent of God of the Gaps, greater awareness and loosening of diagnostic criteria can handle any amount of increase gracefully.  It is the equivalent of an uber-absorbent autism paper towel, capable of soaking up any number of new children with a diagnosis; there is, literally, no amount of an increase that the God of the Gaps can’t handle.   

If, instead the question was posed like this, ‘How much of the apparent increase in autism is real?’, the answer was always, ‘Zero’, regardless of what the current rates of autism were when you asked the question

Then a funny thing happened, a series of studies from several researchers showed a consistent trend of older parents giving rise to more children with autism than younger parents. There were differences between the studies on just how much of an effect an older parent had, but the overall direction of association was clear.  In this instance, there was also the luxury of a plausible biological mechanism that involved the mediator in favor, genetics.  The idea is that advancing age in the parent meant more years for gametes to get knocked by a random cosmic zap or other environmental nastygram and this disturbance created genetic problems down the line for the offspring, a theory I think is probably pretty good.   Once a couple of these studies started to pile up, there was a small shift in the narrative regarding autism prevalence; after all, nobody could bother to try to deny that parents were getting older compared to past generations.  Here is how it looked:

Concerned Parent:  What the hell?  Now there are X kids in a thousand having autism! 

Supposed Skeptic: Greater awareness and diagnostic substitution are primarily responsible for our observations of increased autism, although, ‘a real, small increase’ cannot be ruled out.   

And with that, there was a little less autism prevalence for the God of the Gaps to handle.   It never seemed to bother anyone that implicit in this argument is an impossible to quantify concept ‘small increase’.  If you were to ask someone what rate of autism ‘a small increase’ amounted to with more precision, the answer is whatever amount rises to the level of autism minus the difficult to quantify effect of older parents.  That is some lazy stuff.

Here are some examples of prominent online skeptics discussing the possibility of a true rise in autism.  See if you can detect a pattern.

Here is Stephen Novella pushing The Fairytale in 2009:

While a real small increase cannot be ruled out by the data, the observed increase in diagnostic rates can be explained based upon increased surveillance and a broadening of the definition – in fact autism is now referred to as autism spectrum disorder.

[Here we see the notion that everything can be explained by the God of the Gaps.]

Here is an example of Orac toying around with this filibuster just the other day, in August of 2011:

True, the studies aren’t so bulletproof that they don’t completely rule out a small real increase in autism/ASD prevalence, but they do pretty authoritatively close the door on their being an autism “epidemic.”

These aren’t the only examples, far from it.   Check it out:

It should be noted that the data cannot rule out a small true increase in autism prevalence. (Stephen Novella in 2008)

If the true prevalence rate of autism and ASDs has increased, it has not increased by very much. (David Gorski, 2010)

It should also be noted that all of this research, while supporting the hypothesis that the rise in autism diagnoses is not due to a true increase in the incidence but rather is due to a broadening of the definition  increased surveillance, does not rule out a small genuine increase in the true incidence. A small real increase can be hiding in the data. (Stephen Novella, 2008)

We should have the curiosity to wonder, what, exactly, does small mean in these contexts?  What percentage size increase should we consider small enough to hide within the data?  Five percent?  Ten percent?  What does ‘small’ mean, numerically, within a range?   Is a ten to twenty percent rise in autism rates reason for us to take comfort in the fact that the effect of greater awareness is real?  At what level does the percentage of ‘real’ autism increase mandate more than superficial lip service, more than a paragraph about ‘gene-environment interactions’ at the end of a two-thousand word blog post that takes pride in the intellectual chops of outthinking Jenny McCarthy?  You won’t get anyone to answer this question; they can’t, because they don’t really know what they mean when they say, ‘small’, other than, ‘it can’t be vaccination’. 

How do we know the amount of this increase must, in fact, even be ‘small’?  This becomes especially problematic when we consider the smackdown that the canard of autism as ‘among the most heritable neurological conditions’ has taken as of late.  If the high heritability estimates of autism are incorrect, yet so often repeated as gospel, why should we also assign confidence to the idea that the increase is trivial?  Isn’t one argument the foundation of the other?   Did either really have quality data behind them? 

This is a terrible, awful, horrible, completely fucking idiotic way to address a question as important as whether or not a generation of children is fundamentally different.  We cannot afford the ramifications of being wrong on this, but we seem to find ourselves in an epidemic of otherwise intelligent people willing to accept the pontifications of cultural anthropologists and the feebleness of social scientists on this critical question.   I am not arguing against the realities of diagnostic switching and greater awareness affecting autism diagnosis rates.  But we can understand that while they are a factor, we must also admit that we have little more than a rudimentary understanding of these impacts, and when we consider the implications of being incorrect, the potential disaster of a very real, not ‘small’ increase in the number of children with autism, we shouldn’t be overselling our knowledge for the sake of expedient arrival at a comforting conclusion.   We should be doing the opposite.

If we can’t have the robustly defendable values on autism rates right now, that’s fine, because that is the reality, but we should at least have the courage to acknowledge this truth.  This is the nature of still learning about something, which we are obviously doing in terms of autism, but in that situation, we don’t have the currency of scientific debate, decent data, to be saying with authority that any true increase in autism is small. 

Unfortunately for the purveyors of The Fairytale, things are going to get a lot worse.  The problem is that we are starting to identify extremely common, in some cases, recently more common, environmental influences that subtly increase the risk of autism.  These are further problems for a genetic dominant model and effectively mandate that the ‘small increase’ is going to have to start getting bigger as a measurement, with a correlated decrease in the amount of autism that cultural shuffling can be held responsible for.  Will anyone notice?

By way of example, we now have several studies that link the seasons of gestation with neurodevelopmental disorders including autism and schizophrenia; i.e., Season of birth in Danish children with language disorder born in the 1958-1976 period, Month of conception and risk of autism, or Variation in season of birth in singleton and multiple births concordant for autism spectrum disorders, which includes in the abstract, “The presence of seasonal trends in ASD singletons and concordant multiple births suggests a role for non-heritable factors operating during the pre- or perinatal period, even among cases with a genetic susceptibility.”  Right!  As I looked up some of these titles, I found that the evidence for this type of relationship has been well known for a long time; schizophrenia, in particular has a lot of studies in this regard, i.e., Seasonality of births in schizophrenia and bipolar disorder: a review of the literature, which is a review of over 250 studies that show an effect, and I also found Birth seasonality in developmentally disabled children, which includes children with autism and was published in 1989, which is like 1889 in autism research years. 

Our seasons have remained constant (but probably won’t stay too constant for much longer. . . ), but this still throws a whole barrel of monkey wrenches into the meme of a disorder primarily mediated through genetics. 

More damning for the Fairytale are some studies presented at this year’s IMFAR, and some others just published, that tell us that abnormal immune profiles during pregnancy appear to provide slightly increased risk for autism, roughly doubling the chance of a child receiving a diagnosis.  The groovy part is that the studies utilized both direct and indirect measurements of an activated immune system to draw similar conclusions, a sort of biomarker / phenotype crossfire.

From the direct measurement end, we have Cytokine Levels In Amniotic Fluid : a Marker of Maternal Immune Activation In Autism?, which reports that mothers with the highest decile of tnf-alpha levels in the amniotic fluid had about a one and a half times increased risk for autism in their children.  This makes a lot of sense considering the robustness of animal models of an acute inflammatory response during pregnancy and its impact on behavior. 

Another study, this one from the MIND Institute in California (which I love), is Increased mid-gestational IFN-gamma, IL-4, and IL-5 in women giving birth to a child with autism: a case-control study (full paper). They found that in pregnant mothers, increased levels of IFN-gamma led to a roughly 50% increased risk of an autism diagnosis.  Here is a snipet:

The profile of elevated serum IFN-γ, IL-4 and IL-5 was more common in women who gave birth to a child subsequently diagnosed with ASD. An alternative profile of increased IL-2, IL-4 and IL-6 was more common for women who gave birth to a child subsequently diagnosed with DD without autism.

This study took a lot of measurements, and goes to great lengths to explicitly call for additional analysis into the phenomena.   IFN-gamma is typically considered pro-inflammatory, while IL-4 and IL-5 are considered regulatory cytokines.  In order to determine if these findings were chance or not, the researchers determined if there was a correlation between the levels of IFN-gamma, IL-4, and IL-5, which they reported with very robust results.    Less clear is what might be causing these profiles, or how, precisely, they might give rise to an increased risk of autism.  The interconnectedness of the brain and the immune systemwould be a good place to start looking for an answer to the last question though. 

What about indirect measurements? It just so happens, another paper was published at IMFAR this year that observed the flip side of the coin, conditions associated with altered cytokine profiles in the mother and this study also found an increased risk of autism.  The Role of Maternal Diabetes and Related Conditions In Autism and Other Developmental Delays, studied a thousand children and the presence of diabetes, hypertension, and obesity in their mothers in regards to the risk of a childhood autism diagnosis.   The findings indicate that having a mother with one or more of those conditions roughly doubles the chances of autism in the offspring.  Obesity, in particular, has an intriguing animal model Enduring consequences of maternal obesity for brain inflammation and behavior of offspring, a crazy study that I blogged about when it was published.   A variety of auto immune disorders in the parents have been associated with an autism diagnosis in several studies. 

The obesity data is particularly troublesome for the idea of a ‘small’ increase in autism, just like parents have been getting older, parents have also been getting fatter, waaaay fatter, (and more likely to have diabetes)  the last few decades.  There isn’t any squirming out of these facts.  If, indeed, being obese or carrying associated metabolic profiles is associated with an increased risk of autism, ‘small’ is getting ready to absorb a big chunk of real increase.  But is there any clinical data to support this possible relationship, do we have any way to link obesity data with this autism data from the perspective of harder figures?

It further turns out, there are some very simple to navigate logical jumps between the above studies.  Remembering that our clinical measurements indicated that increased INF-gamma, IL-4, and IL-5 from the plasma of the mothers was associated with increased risk, we can see very similar patterns in Increased levels of both Th1 and Th2 cytokines in subjects with metabolic syndrome (CURES-103).  Here is part of the abstract, with my emphasis.

Metabolic syndrome (MS) is a cluster of metabolic abnormalities associated with obesity, insulin resistance (IR), dyslipidemia, and hypertension in which inflammation plays an important role. Few studies have addressed the role played by T cell-derived cytokines in MS. The aim of the tudy was to look at the T-helper (Th) 1 (interleukin [IL]-12, IL-2, and interferon-gamma [IFN-gamma]) and Th2 (IL-4, IL-5, and IL-13) cytokines in MS in the high-risk Asian Indian population.

Both Th1 and Th2 cytokines showed up-regulation in MS. IL-12 (5.40 pg/mL in MS vs. 3.24 pg/mL in non-MS; P < 0.01), IFN-gamma (6.8 pg/mL in MS vs. 4.7 pg/mL in non-MS; P < 0.05), IL-4 (0.61 pg/mL in MS vs. 0.34 pg/mL in non-MS; P < 0.001), IL-5 (4.39 pg/mL in MS vs. 2.36 pg/mL in non-MS; P < 0.001), and IL-13 (3.42 pg in MS vs. 2.72 pg/mL in non-MS; P < 0.01) were significantly increased in subjects with MS compared with those without. Both Th1 and Th2 cytokines showed a significant association with fasting plasma glucose level even after adjusting for age and gender. The Th1 and Th2 cytokines also showed a negative association with adiponectin and a positive association with the homeostasis model of assessment of IR and high-sensitivity C-reactive protein.

Check that shit out!  Seriously, check that out; increased IFN-gamma, IL-4, and IL-5 in the ‘metabolic syndrome’ group, comprised of people with, among other things, obesity, insulin resistance, and hypertension; the same increased cytokines and risk factors found to increase the risk of autism. 

If we look to studies that have measured for TNF-alpha in the amniotic fluid during pregnancy, we quickly find,  Second-trimester amniotic fluid proinflammatory cytokine levels in normal and overweight women

There were significant differences in amniotic fluid CRP and TNF-alpha levels among the studied groups: CRP, 0.018 (+/-0.010), 0.019 (+/-0.013), and 0.035 (+/-0.028) mg/dL (P=.007); and TNF-alpha, 3.98 (+/-1.63), 3.53 (+/-1.38), and 5.46 (+/-1.69) pg/mL (P=.003), for lean, overweight, and obese women, respectively. Both proinflammatory mediators increased in women with obesity compared with both overweight and normal women (P=.01 and P=.008 for CRP; P=.003 and P=.01 for TNF-alpha, respectively). There were significant correlations between maternal BMI and amniotic fluid CRP (r=0.396; P=.001), TNF-alpha (r=0.357; P=.003) and resistin (r=0.353; P=.003).

Nice. 

What we are really looking at are five studies the findings of which speak directly to one another; a link to metabolic syndrome during pregnancy and increased IFN-gamma, IL-4, and IL-5, a link to obesity and hypertension in pregnant mothers and autism risk, and an increased risk of autism in mothers wherein IFN-gamma, IL-4, and IL-5 were found to be increased outside of placenta.   Further, we have a link between amniotic fluid levels of TNF-alpha and metabolic syndrome, metabolic syndrome in mothers and autism risk, and increased risk from increased tnf-alpha in the amniotic fluid. 

As I have said previously, one thing that I have learned during this journey is that when we look at a problem in different ways and see the same thing, it speaks well towards validity of the observations.  What we see above is a tough set of data to overcome; we need several types of studies looking at the relationship between metabolic syndrome, immune profiles during pregnancy, and autism from different angles to have reached the same wrong conclusion, something that is increasingly unlikely.  We are in an epidemic of obesity and the associated endocrine mish mash of metabolic syndrome, there simply isn’t any diagnostic fuzziness on this.  It is happening all around us.  Even though the total increase in risk is relatively small, the sheer quantity of people experiencing this condition of risk mandates that the numbers game looks favorable towards a real increase in autism.  If we acknowledge this, how can we continue to have faith in the concept that any true increase in the autism rates must be ‘small’?

Is the next argument going to be that besides increased parental age, and heavier or more diabetic mothers, the rest of the autism increase is the result of diagnostic three card monte?  (Just how much is the rest, anyways?)

And even though these studies, and likely more in the future, expose the crystal delicate backbone of the ‘small true increase’ argument, I have great pessimism that the people so enamored with invoking this phrase will ever acknowledge its shifting size, much less the implications of being wrong on such a grand scale.

          pD

Hello friends –

The osmotic pressure of cool people and pop culture tells me that what we used to call one night stands are now called ‘hookups’, casual sexual encounters as convenient that don’t necessarily mean people are dating, but some release can be found, and everyone moves on with their lives until the next time.  This reminds me a lot of how people that ought to know better have been treating autism prevalence studies lately.  The results are useful in cementing an already reached conclusion, but ultimately, the findings are only used as isolated ejaculations of the same ideological tweets.  Last week’s hookup doesn’t mean anything come this Saturday night, and there is absolutely no reason, no reason, anyone should be troubled to compare this weeks findings used to trumped a static rate of autism with last weeks findings.  What we are witnessing is the equivalent of a scientific one night stand, and anyone who doesn’t think the scientific method should be framed for the sake of expediency ought to be furious.

These posts can oftentimes take me a long while to complete, so dating my start point a bit, about two weeks ago, the NHS study from England came out that described a near 1% prevalence of ‘autism’ in adults.  The ‘findings’ from this study actually came to light and received attention in the autism community over a year ago, but the real publication happened in May 2011, so there you are.  

About a week ago, the Korea ‘study’ on autism came out; it hit the web with a large footprint, and amazingly, described an atmospheric autism ‘prevalence’ of autism of near 2.5%, with 1 in 38 (!!!!) Korean children ‘estimated’ to be on the autism spectrum.   If it has not happened already, this study and ‘conclusions’ will soon became part of the autism lexicon; an uber-Kevlar argument, impervious to any concerns involving the possibility of an actual increase in the number of children with autism. 

Both of these studies share very similar methodologies; essentially a lot of people were screened through a questionnaire, a subset of people with ‘high’ scores on the questionnaire were subsequently retested with standard tools for assessing autism.  Based on how well the questionnaire did at predicting autism spectrum diagnosis, an extrapolation, with various ‘corrections’, was made as towards how many people in the general public are on the spectrum.  In both studies, the overwhelming majority of people ‘estimated’ with autism were previously undiagnosed and were not receiving any services. 

Here’s the thing that is driving me up the wall crazy, apeshit mystified and enraged. Nobody cared.  Let’s look again at what these studies found and see if we can detect anything of potential interest in their conclusions when compared between one another.

 

Nobody, and I mean nobody, took these two studies as evidence of an autism epidemic, despite the fact that here we have two supposedly (?) well designed studies that found entire spectrum sized differences in the number of children and adults with autism!  You could literally drive the old spectrum through the hole in the new spectrum!  If both of these two studies are meaningful, if both have accurately captured autism in their respective target populations, we have no choice but to admit that the epidemic is real, and we have proof that children have an autism spectrum disorder two and a half times more frequently than adults.  There is an epidemic of autism in our children; or at least, in Korean children!

Did anyone see those headlines that I somehow missed?  Did the online skeptical community acknowledge that we now finally have some solid evidence that indeed, autism rates are higher in children than adults, and somehow I failed to see those conversations? 

Here’s what really confuses me.  Some of the same people, same ‘skeptics’, and same news organizations breathlessly reported both of these findings without, apparently, understanding their implications alongside one another.  For example, in 2009, here’s a post from Stephen Novella at Science Based Medicine that touched on the England study that includes this nugget:

They found a consistent prevalence of 1% in all age groups they surveyed. This is remarkable for two reasons – first, they found the exact same 1% figure as the CDC US survey (assuming the CDC data is more accurate than the phone survey published in Pediatrics). This supports the conclusion that the 1% figure may be close to the true prevalence of ASD in the population.

Second, the NHS study found that the prevalence of autism was the same in all age groups, strongly suggesting that true ASD incidence has not been increasing over recent decades and supporting the increased surveillance and definition hypothesis.

Check out how ‘remarkable’ Mr. Novella thinks the 1% matchup between English adults and American children is in terms of making the case for a static rate of autism.  This is a guy whose posts outside the autism realm I tend to enjoy in many instances, he is clearly a superior intellect, and applies a very skeptical eye towards his non-autism posts.  My presumption is that he was well aware that the NHS study actually diagnosed a grand total of 19 adults, and had good reasons, which he declined to illuminate in that post, for why this relatively low number of results was immune to significant confounding problems, which is why it provided such ‘remarkable’ evidence ‘strongly suggesting that true ASD incidence has not been increasing’. 

Then, in May 2011, Mr. Novella posted Autism Prevalence Higher than Thought, concerning the Korea study.  Here is a snippet from the conclusions:

This study adds an interesting data point to the whole picture of ASD. If correct, then the theoretically upper limit of ASD prevalence is about 2.6% of the population, more than twice the previous estimate. It also indicates that when you undergo a program of thorough searching, you will find more diagnoses.

What is going on here?  The England study, which found a prevalence of 1%, the study that previously was found to be remarkable evidence of a static rate of autism was exactly the same type of study, wide-scale screening for likely candidates within the general population, followed by targeted autism assessment of people with high scores, and backwards extrapolation.  Does anyone think that the Korea study was that much more thorough than the England study?  If a study came out tomorrow that reported 5%, or 10% prevalance, would we simply assign this to a even more strenously executed methodology?   Is there any evidence that we might use to suspect a 5% prevalance reported next week in Columbia is faulty that could not also be applied against Korea?

For what reason should we, now, believe that the England study of adults was so fatally flawed that it missed more than one autistic adult for every one it found?  Surely a study capable of missing more than half of the autistic adults had some type of warning signs back in 2009 that might indicate that the evidence might be less than remarkable, maybe questionable, or that, in fact, it might be a Fairytale?

Am I cynical to suggest that what really made the England study such remarkably ‘strong evidence’ of a static rate of autism was that, at the time, it had findings within the statistical range of existing CDC numbers in children?   Was the online and media love affair with the England NHS study little more than prevalence hookup?  Have I reached the theoretical limit of jadedness?

There really isn’t a way to reconcile these two findings without either accepting a two and a half times increase in autism in children versus adults, a sort of epidemic-lite, or accepting that one or both of the studies suffer from serious flaws.  But if we start accepting that the studies might have serious problems, we shouldn’t be saying they are ‘strong evidence’ of anything, except, perhaps, the difficult to overstate problems of autism prevalence studies.  Of course, it is a different ballgame if you are relieved of the intellectual responsibility of actually trying to reconcile the two findings; if you allow yourself the prevalence doublethink that England has meaningful data, and so does Korea, and that the rate of autism isn’t increasing, then, no harm, no foul Big Brother.

One prevalence study that didn’t get the booty call was Brief Report: Prevalence of Pervasive Developmental Disorder in Brazil: A Pilot Study, which came out in February, 2011; just three months before Korea.  Methodology wise, this study is a kissing cousin to Korea and England, a screening was performed in the general population, and assessments were subsequently performed and then statistical extrapolations were performed to reach a prevalence rate.   Let’s see what these values look like up against each other, and see if we can detect a pattern.

 

Can anyone see a pattern here? 

Now the skeptic might tell you that the Brazil study was a lot smaller, which is true; the initial screening of children only contained a little less than 1,500 children.  But it hardly matters; just to get to the level of English adults ‘found’, they would have had to miss two children for every child they found, and to approach Korea values, they needed to have missed almost nine children for every child actually diagnosed.  Does anyone think this is reality?  Why would prospective screening and backwards extrapolation be so accurate in one population, and so wildly inaccurate in another population?  The Brazil and England study used versions of the same screening questionnaire!

I understand that being partially funded by Autism Speaks, and having a ‘cultural anthropologist’ with a book on the subject of autism carries some weight in the press conference area; so that might explain why one study got press, and another didn’t.  Forgetting the press issue, where are the calls that we should try throwing four thousand Brazilian genomes at a sequencer to see what in their genetic makeup appears to be protecting them from autism so effectively?  Why aren’t these studies meaningful evidence of some environmental force acting to create wildly different rates of autism in these different populations?  

I would note that the press releases, media regurgitations, and skeptical viewpoints nearly all contained the boilerplate note that more studies are needed.    Consider, however, if our need for ‘more study’ is so extensive, if we place so little confidence in our methodologies that papers published within months of each other, with nearly identical study methods, find literally nine times higher rates of autism in one population aren’t a warning sign of an real difference in incidence, what this ought to be telling us is that all of our prevalence data are crapshoots, at best.  We shouldn’t get to pick and choose which studies we think are meaningful because they happen to meet comforting quotas, or discard those that fail to support those palliative notions.

It is tempting to look at the Brazil study and evaluate for design or implementation problems that could cause such startlingly low rates of autism; the authors go into some discussion about the reasons their findings might seem so low.  Complicating matters along this line, however, is that the Brazil and Korea studies, shared a researcher, the relatively well known psychiatrist with a large pubmed autism prevalence footprint, Eric Fombonne.    It occurred to me that it might be a fun experiment to see how reliable Mr. Fombonne has been regarding autism prevalence. 

 

[Click on the image to get a bigger view / stupid wordpress template]  Note that I have omitted review papers, or papers that had no abstracts, but it doesn’t really help.  (How could it?)

All of these findings were wholly or partially authored by the same person.  Is there anything more damning for the state of autism prevalence research than this person continues to be considered a source of reliable information?  

I used to live with a fun dude in college; he went to engineering school and went on to work at a manufacturing facility near our town.  One of the funniest things he told me about engineering was this quote:

Dilution is the solution to pollution!

In other words, if you have a hundred pounds of diethyl-pthylate-poisonate to dispose of, ship in a hundred thousand gallons of water, and start pumping; if you have two hundred pounds to eject, ship in two hundred thousand gallons of water.  This is what is happening to the definition of autism, the quirky element, the ‘broad autistic phenotype’ is seeping into these studies.   After dozens, or hundreds of prevalence studies we are ultimately left with as many portraits of different entities as envisioned by the researcher and width of spectrum de jour.  The upshot of this, however, is that it makes no sense to try to compare these studies.  

In the meantime, we are told time and time again that even though our common sense, our memories of childhood, and the repeated lamentations from every person who has worked with children for the last few decades, all of which are warning us that something is different; all of these things are all supposedly subject to an array of biases so strong that we cannot trust them to reach any conclusions.  Only through carefully planned, objective analysis can we reach any conclusions on autism incidence.  The results of this choreographed investigation looks like this:

 

 Does anyone really think there aren’t some pretty serious biases operating here?  If we cannot use common sense to try to reconcile the picture above, what can we use?  If trusting common sense is dangerous to valid conclusions, so is trusting this. 

If anyone really thought that Korea and Brazil were measuring the same condition, a condition that until very, very recently has been considered lifelong and severely debilitating, the two wildly different findings would be cause for alarm, undeniable evidence of a massive environmental force influencing the development of autism in some populations.  But no one thinks this, no one cares, and that is because; no one really believes these studies are measuring the same thing.  But admitting this is dangerous to too many, it is the implicit acknowledgement of just how little we understand, how beholden our policies and research prioritizations are guided by the softest of science and scientists, and ultimately, how frequently we’ve been sold a narrative with the scientifically defendable value of a set of  monetized South Florida mortgages.

Such is the way of the prevalence hookup, transiently entertaining, but without meaning from week to week.   Until we can find a way past this, past reliance on the shifting sands of behavioral assessments that can vary from researcher to researcher (or by the same researcher!), we can perform all of the ‘thorough investigations’ that we can afford and repeat the ‘findings’ that support our meme until we are blue in the face.  None of it will mean a goddamned thing, though we may lose a generation of children while we bounce from one set of findings to another, feeling pleased with the ones that make doom seem unlikely, and discarding the ones that should be cause for great alarm.

-pD


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