Posts Tagged ‘Incidence’
The Fairytale of a Static Rate of Autism Part 5 – The Prevalence Jackpot Versus The Prevalence Hookup, Futilely Struggling To Making Sense Out of Static, And How Journey Autism Flavors Our Path Of Moving Forward
Posted April 17, 2013on:
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.
The Fairytale of a Static Rate of Autism Part 4: Troubling Realities Acknowledged, The Incredible Shrinking Gods of the Gaps, and Otherwise Rational People Using ‘Small’ As An Empirical Measure To Answer A Critical Question
Posted August 19, 2011on:
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 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)
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).
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.
Hello friends –
This post really ought to be Chapter 1, but since I wrote the other post first, and sort of liked the title, so we’ll just pretend; these posts are all about make believe in any case, right?
There is only one valid reason not to vigorously pursue environmental causes of autism; you need to believe that our observation of an increased rate of autism, one hundred percent of it, is an artifact of the four horsemen of the imaginary increase:
- Diagnostic Substitution
- Greater Awareness
- Increased Accessibility to Diagnosis
- Widening of Diagnostic Criteria
Lets start off with a couple of honest admissions and the reason they don’t make a whit of difference if our goal is to expose the notion of a static rate of autism as a fairytale, and a dangerous one at that.
- I have read very few papers regarding prevalence fully. In fact, I can’t think of the title of a single one. In the context of a precautionary principle, however, the methods and discussion for this type of study don’t really matter much; because the brush strokes used to craft the results are so necessarily broad and imprecise that they are admitted as meaningless even by people who believe in the fairytale. Think about it. The only way we have a static rate of autism is if all of our previous studies utilized methods of such poor quality that they missed ##-## per 100,000 cases of autism, where you get to replace ##-## with any set of numbers lower than 100 as you move backwards in time. The conclusions in our previous prevalence studies are so discordant over time that the flaws in their methodology are the super strings of the fairytale; responsible for all of our observations of increased autism rates while having natural physical properties that render them impossible to elucidate on completely. Given that even the proponents of the fairytale don’t give the methods of previous studies any currency, why should anyone?
- I cannot provide meaningful estimates on what percentage of the observed increase in rates is real versus artifact. Again, however, in the prism of a precautionary principle, it doesn’t matter, because any amount of real increase is alarming, and the only possible unalarming possibility is a zero percent increase. Here is a little thought exercise to illustrate this; imagine you are on a debate team and the topic is; “Autism rates have risen by X percent, health crisis or not?” and your team has drawn the ‘not a crisis’ side. Insert any number greater than zero for X, and then try to construct debate points to make this argument to a crowd of skeptics. This argument is implied whenever the fairytale is invoked, sometimes with the assertion that any real increase is “minor”, but one surefire way to get a storyteller to dissolve from a discussion is to try to get a value more concrete than “minor” for X. Autism is a disability, and while there are arguments to be made that it is also a ‘difference’, it isn’t a difference like having red hair or being left handed anymore than dyslexia is a different way of reading; any true increase has broad implications for us all.
- I have no doubt that the four factors listed above are, indeed, responsible to one degree or another towards what we are observing in autism rates. Unfortunately, unless we are able to explain our ever rising rates of autism completely with these explanations, we still must contend with ramifications of a true increase.
Even with the above caveats, a compelling case can be made that what we are observing is comprised of an actual increase in behaviors consistent with an autism diagnosis, and the argument that autism rates are static is long on faith and very low on the lifeblood of science; reliable data.
My original intention on starting this blog was to try to create more comprehensive, wide ranging screeds on autism than you might usually see in the blogosphere. Alas, this has seemed more difficult and time consuming that I was hoping it might, and my posts have been small. It was suggested to me by Kev at Left Brain / Right Brain that I ‘get my own blog’ if I didn’t like what he was interested in. While I’m not exactly taking his advice, it did occur to me that the post I intended to write back in response to a couple of posts there was lengthy enough and had thoughts I wanted to have stored more accessible that I could go ahead and double post it.
The thread on LBRB is here, wherein I mentioned that familial commonalities may not necessarily be the result of genetics per se, and was consequently challenged by dueling interpretations of the twin study fallacy. Here was my response:
Hello friends –
I’m not here to deny a genetic component to autism, but the lightning fast gunslinging of twin studies hinges on the notion that there is only one way to get to a particular developmental endpoint – genes. If we accept that there are other ways to achieve a particular developmental endpoint, a reliance on twin studies shows itself as a fallacy. You can have genetic and environmental mechanisms affecting neurodevelopment if we allow ourselves to believe that autism rates are increasing, but you can’t have the opposite; to believe that autism rates are stable, completely stable, we can’t allow any intrusion of changes to our environment to be affecting neurodevelopment.
Of course, when pressed, say with studies involving something like valporic acid, as mentioned by Socrates, and a whopping increased risk, you can get the acknowledgement that there are some things that can cause autism that aren’t genes, quickly followed by the impossible to substantiate claim that the amount of increase is very minor.
Unfortunately, we need to start ignoring mounting reams of clinical evidence from a galaxy of sythentic chemicals for this to make any sense.
Take the study I posted above, Prenatal Exposure to Organohalogens, Including Brominated Flame Retardants, Influences Motor, Cognitive, and Behavioral Performance at School Age, which, curiously, got left out of any discussions so that we could discuss twin studies. To illucidate briefly the frailty of an argument exhonnerating our influx of chemicals into the environment, lets examine one of the proposed mechanisms by which organohalogens are believed to affect neurodevelopment; affecting thyroid metabolism.
OHCs are known to exert their neurotoxic influence by affecting thyroid hormone homeostasis. It is hypothesized that OHCs affect thyroid hormone homeostasis by interfering with thyroid hormone signaling in the developing brain, by changing intracellular thyroid hormone availability, and by interacting directly at the level of the thyroid hormone receptors. On the one hand, OHCs have a high affinity for thyroid hormone receptors and lead to a decrease in thyroid hormone levels, whereas levels of TSH increase through hormonal feedback mechanisms. Previous studies on pregnant women and their infants found that PCBs are associated with higher levels of TSH and lower levels of T4 (Koopman-Esseboom et al. 1994). We found that PCP correlated with lower levels of thyroid hormone but brominated flame retardants correlated with higher levels of thyroid hormone. It is unknown whether the underlying mechanism by which PCBs affect thyroid hormones is the same for these OHCs. Our study disclosed consistent relations between thyroid hormones and outcome. We found that TSH correlated with worse neuropsychological functions. Thyroid hormones (T3 and T4), by contrast, correlated with better outcome. These findings, together with the negative correlations between OHCs and development, seem to confirm the hypothesis that thyroid hormone homeostasis may be involved.
Having thyroid metabolism interferred with during pregnancy is associated with a variety of bad outcomes, inclding, Pervasive developmental disorders, autism, reduced cognitive abilities , ADHD and many, many other condtions.
Unsurprizingly, when we look for associations between levels of these chemicals and development outcomes, we find results that should surprise no one, such as the study I linked to above, or another, here.
The facts on the ground are that these chemicals are completely novel to our planet in the past few decade and many have reached environmental ubiquity. We have a growing understanding of the mechanism(s) by which these chemicals can affect developing brains, and association studies that indicate that our clinical observations have merit for a variety of conditions, including autism. Finally, we seem to be observing an explosion of ever increasing behavior patterns that no one can really explain without necessarily invoking an the ever hopeful idea of progressing decrease in uncertainty of our diagnostic as rates continue to go in a single direction. The fact that twins have autism more frequently does absolutely nothing to change any of this if we allow ourselves to believe our observances of increase are not completely an artifact; but the inverse does not hold true. We must find a reason to believe that all of these studies, and many, many others are all wrong in exactly the same way for our environmental engineering to be without consequence.