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Preventing autism? Not so fast, Dr. Mumper…

Dug the Dog strikes again, as he did three weeks ago. I had a couple of ideas for a post this week, but none of them were time-sensitive or timely. Then, over the weekend, I saw a post on the antivaccine crank blog Age of Autism by Dan “Where are the Autistic Amish” Olmsted entitled Weekly Wrap: Another Medical Practice with a Sane Vaccine Schedule – and No Autism. Given the tendency towards a—shall we say?—lack of accuracy of Olmsted’s previous reporting, it’s no surprise that he’d latch on to this study. I’m also seeing it appear around other antivaccine websites. I had gotten wind of it late last week, a few of my readers having sent it to me but hadn’t decided yet whether to blog about it. Then it appeared on AoA. Thanks, Dan.

So let’s see how this study is being spun by the antivaccine movement:

When we at Age of Autism talk about ending the epidemic, the “to do” list seems almost overwhelming – funding a vax-unvaxed study, getting mercury out of flu shots, proving the HepB shot is nuts, wresting control of the agenda from pharma, fixing Vaccine Court (this time in the good sense of “fix”), establishing that biomedical treatments help kids recover, and on and on.

But there’s a shortcut to all this, and it goes straight through pediatricians’ offices. The evidence is growing that where a sane alternative to the CDC’s bloated vaccine schedule is offered, and other reasonable changes adopted, autism is either non-existent or so infrequent that it doesn’t constitute an epidemic at all.

The latest example comes from Lynchburg, Va., and the pediatric practice of Dr. Elizabeth Mumper. She noticed a frightening rise in autism in the 1990s. Concerned that vaccines and other medical interventions might be playing a role – concerned in other words that SHE was playing a role — Mumper changed course.

Fewer vaccines. Fewer antibiotics. No Tylenol. Breast-feeding. Probiotics. Good, pesticide free diets.

Since then, hundreds more children have been seen in her practice, Advocates For Children. But no more autism.


In essence, this study is being spun to imply that doing all of these things will eliminate autism, or at least dramatically decrease its prevalence.

You can see one thing just from this description that makes me doubt this study, and that’s something very simple: Changes in too many variables being tested at once. Even if Dr. Mumper’s study shows what she claims it shows (and what Dan Olmsted advertises it as showing), there’s no way of knowing which, if any, of these things was responsible for the changes observed. I could say this quite easily before I even read the study. Fortunately, all of you can read along, because Mumper’s study is available online for all. Or maybe unfortunately, because, as you might expect, it’s not a very good study. Its hypothesis is diffuse and unclear, and it’s based on dubious science. Its methodology isn’t so hot either. Let’s take each in turn.

First, though, I have to make a general observation about this paper. That general observation is that it’s very sloppily put together. One notices that there are only 52 references listed, even though citations number up to over 100 in the text. It really does look as though the reference list is incomplete or wrong, as just a brief perusal showed me citations that do not appear to relate to the text in which they are being cited. For instance, after a sentence mentioning fecal transplants, Mumper cites references 35 to 37, none of which has anything to do with fecal transplants. One paper is about the consolidation of memory in the amygdala, while the others are about neurocognition in schizophrenia and impaired inhibitory control in children with ASDs. That’s just one example. To me it looks as though the wrong reference list might have been printed, or that Mumper didn’t bother to make sure that the citation numbers match the references.

Mumper starts with standard “autism epidemic” exaggerations and misinformation, in which she states in the very first paragraph that during the time she has been a practicing pediatrician the prevalence of autism has increased from 1 in 5,000 in 1975 to as high as 1 in 50 in 2013. As we’ve pointed out here many times before, the increase in the reported prevalence of autism and autism spectrum disorders (ASDs) is almost certainly accounted for by three things: (1) the broadening of the diagnostic criteria for ASDs in the early 1990s; (2) diagnostic substitution, in which conditions that were formerly classified as something else are reclassified as an ASD; and (3) intensive screening programs. We’ve noted that recent studies examining adult cohorts for ASDs using current-day criteria have produced estimates of autism prevalence similar to what is being reported in children now (for example, this one). Not surprisingly, antivaccinationists don’t like these studies. They also don’t like it when I point out that screening for a medical condition—any medical condition—will result in an apparent increased prevalence of that condition, as previously subclinical and undiagnosed cases are discovered. My favorite example of this is ductal carcinoma in situ, a precancerous condition in the breast whose incidence and prevalence have skyrocketed, largely thanks to mammographic screening programs, which I explicitly compared to autism and ASD prevalence. The bottom line is that, although we can’t rule out a modest increase in the true prevalence of ASDs, there almost certainly is no “autism epidemic.” Worse, from the view of antivaccinationists, if there is no “autism epidemic,” then vaccines almost certainly can’t be a significant cause of or contributor to autism.

Mumper then goes on to cite several papers that are either dubious, don’t support the vaccine/”toxin” hypothesis, or are unrelated, starting with various papers that claim a correlation between ASD prevalence and airborne pollutants. I’ve discussed at least a couple of these papers before, such as this one looking at mercury emissions from coal-burning power plants and this one claiming a correlation between proximities to freeways and ASD prevalence. Virtually every one of these studies that I’ve ever read suffer from one of the same flaws: The ecological fallacy or inadequate controlling for major confounders, in particular urbanicity and access to services. Mumper also tries to link breastfeeding to decreased ASD prevalence, but even she has to admit that there’s no evidence. In any case, I don’t know any scientist or pediatrician who would argue that breastfeeding is in general not good for babies (quite the contrary); so I’m not sure why she has focused on breastfeeding. Actually, upon further thought, I rather suspect that I do know. She tries to relate breastfeeding to the almost certainly nonexistent entity known as autistic enterocolitis, presenting in Table I gut biopsy results from 21 children in her practice with autism and noted that 13 had evidence of lymphoid nodular hyperplasia. Of course, there would be significant selection bias here, as presumably only children with GI symptoms would undergo colonoscopy and ileal biopsies. (At least, I hope that’s the case; it’s not as though certain practitioners who practice “autism biomed” haven’t been known to be a little quick to biopsy autistic children for questionable indications.) Then it was a community pathologist who examined the specimens; we have no idea if he was skilled in pediatric GI pathology. As Wakefield has taught us (thanks to Brian Deer), it’s very easy to mistake normal lymphoid nodule development for inflammation.

Next up, Mumper cites studies suggesting that probiotics during pregnancy and infancy result in less irritable bowel disease, allergic rhinitis, asthma, and various other disorders. All of this might or might not hold up to further scrutiny, but it’s really not related to autism and ASDs. None of this stops Mumper from trying to relate these studies to ASDs through the “immunological actions” of probiotics. To say that this is speculation is to be kind. That’s what it is at best: Speculation. At worst, it’s completely unfounded speculation. And so it goes. Mumper goes on and on about nutritional factors that might or might not be related to ASDs, the use or overuse of antibiotics, the claim that acetaminophen might be related to ASDs when given after vaccination. It’s all terribly thin gruel upon which to build a study.

Then, of course, there’s the vaccine issue. In justifying looking at vaccines, Mumper cites the tired, old familiar litany of bad science and pseudoscience:

The CDC and AAP have issued statements that vaccines are not associated with the risk of autism and that there are epidemiologic studies suggesting no causal role.58-60 Under immunization as a result of parental perceptions of vaccine safety remains a primary concern of the American Academy of Pediatrics.61 As a result, primary care physicians are taught ways to address parents’ vaccine concerns, take opportunities to vaccinate, and use recall methods to catch patients up on vaccines.62 Despite having one of the most aggressive vaccination policies in the developed world, specifying 22 vaccine doses for a total of 12 diseases by 1 year of age,63 the United States had higher infant mortality rates in 2009 than 33 other nations.64

Notice that the numbering of all the references cited starts at 58. The reference list only goes up to 52. I know, I know. I’m repeating myself. But I had to keep looking at it again and again, because I couldn’t believe that such a blatant error was made and had to keep going back to look at the paper and its reference list. In any case, I couldn’t look up the references cited in the passage above. I could, however, guess at what reference 64 might have been. I bet it was this execrably bad study, or another by the same authors. Reading the next paragraph, I realize that it almost certainly was one of those horrible studies by Neil Z. Miller, because Mumper mentions his name:

In 2009, five of the 33 nations with the lowest infant mortality rates required 12 vaccine doses, the least amount, while the United States required the most vaccine doses. Using linear regression analysis of unweighted mean infant mortality rates, Miller calculated a statistically significant high correlation between increasing number of vaccine doses and increasing infant mortality rates (r = 0.992 p value 0.0009).64 Correlation does not equal causation. But since the United States spends more money per capita on medical care than the rest of the industrialized world,65 it seems prudent to examine all possible contributions to the relatively poor health of our most vulnerable citizens – children.

Yup, Miller’s cherry-picked data dredging is definitely one of Mumper’s citations.

But enough of the unconvincing rationale for this study, what, exactly, did Mumper do? Well, she basically describes her strategies for “preventing” autism in her practice, which include:

  1. Minimizing environmental toxicant exposures. What this means, apparently, is “avoidance of pesticides and herbicides during pregnancy, feeding children and pregnant women a whole food diet that is as organic as possible, and using less toxic ‘green’ cleaning products in the home in hopes of preventing some cases of neurodevelopmental disorders and in the knowledge that it seems to be safe and reasonable anticipatory guidance for all children.” That’s all very nice, but based on little or no evidence.
  2. Maximizing breastfeeding prevalence. Again, I’m not sure that any pediatrician would argue with trying to encourage breastfeeding.
  3. Recommending probiotics. This is done, of course, based on the flimsiest of evidence.
  4. Nutritional counseling. To Mumper this means “1) pre-natal vitamins containing folinic acid, ideally in the active form such as 5 methyl- tetrahydrofolate, 2) eating locally grown organic fruits, vegetables and protein as much as possible 3) avoiding processed foods, preservatives, monosodium glutamate, aspartame, nitrites and 4) avoiding mercury containing fish.” None of this is bad, although there’s no evidence that organic fruits and vegetables are of any higher nutritional value than regularly farmed produce. There’s also no good scientific evidence that any of this correlates with autism.
  5. Antibiotic stewardship. No one is likely to argue that minimizing antibiotic exposure is a bad thing, but I’d also be concerned that Mumper doesn’t use antibiotics when they are actually indicated. Nor is there any good scientific evidence that antibiotic exposure has a causative or predisposing relationship with autism.
  6. Minimizing use of acetaminophen. Again, few would argue that we should use lots of acetaminophen, but, again, there is no good evidence that use of acetaminophen correlates with autism/ASDs or its complications or comorbid conditions.
  7. Allowing/implementing a modified vaccine schedule. Here’s the tropes come in. Dr. Mumper’s schedule is basically a variant of the delayed vaccination schedule based on the “too many too soon” trope. (See below.)

So, here’s the vaccine schedule advocated by Dr. Mumpers (click to embiggen):

Mumpertable2

Now, let’s compare Dr. Mumper’s schedule to the CDC-recommended vaccination schedule (click to embiggen):

CDCschedule2013

Prominent differences between Dr. Mumper’s proposed schedule and the CDC-recommended schedule are that Dr. Mumper doesn’t give flu vaccines, the hepatitis A or B vaccines, or the rotavirus vaccine. The MMR vaccine is pushed back to age 2, and the varicella vaccine (chickenpox) is pushed back to age 5. My initial guess was that the only reason Dr. Mumper requires the varicella vaccine is because it’s required in Virginia to enter school. In fact, this whole vaccine schedule strikes me as being the bare minimum to meet the Virginia state requirements for vaccines required to enter school or day care.

So what’s the bottom line? Mumper basically selected these patients:

Patient Selection
Inclusion criteria were: 1) all general pediatric patients born in 2005 or later; 2) presented for well child care prior to 2 months of birth and 3) followed until at least the age of 2 years and 2 months. Totally 294 patients qualified for the inclusion criteria and have been selected in the current research.

They were treated according to Dr. Mumper’s procedures listed above, and this is what Dr. Mumper found:

In the current research, there are no new cases of autism out of the 294 cases recognized and recorded, resulting in 0% prevalence of ASD. Based on the CDC background risk of autism of 1 in 50 for the cohort born around 2005 we would expect to have about 6 new cases of autism in our practice. We calculated our statistics using a Chi-squared test with 1 degree of freedom. Using the CDC autism rate of 1 in 50 reported in 2013 (but based on surveys of eight year old children), the expected rate for our 294 patients starting in 2005 would be 5.88 children with autism. Zero new cases of autism would occur by chance 1.4% of the time (p-value 0.014, significant at 0.05).

That’s it. That’s Mumper’s finding. That’s all there is to this paper. It’s a retrospective study with no control group that claims that she found no cases of ASDs in her practice since 2000 (but doesn’t have a patient number for the period between 2000 and 2005) and has found no new cases in the 294 patients followed in her practice from 2005 to 2013 from under two months of age at least to two years.

Just to check further into this, I took my handy dandy statistics program and played around with some numbers. Encouragingly (I suppose), when I ran a chi-squared test on Mumper’s numbers comparing them against a 1 in 50 prevalence reported earlier this year, I got a p-value of 0.0143. Of course, given that Dr. Mumper’s sample size is so small, it doesn’t take much for her “statistically significant” result to drop from statistical significance. For example, if I insert the autism prevalence of 1 in 88 from last year’s CDC study, the p-value jumps up to 0.071, no longer statistically significant. Given that last year’s study and this year’s study used different methodologies, it isn’t clear which figure is closer to the true prevalence of ASDs. Nor is the latest study evidence of an “autism epidemic,” but rather evidence that we are getting better at not missing any cases. In any case, playing around with different numbers, I found that the autism prevalence at large has to be at least 1 in 77 to make Dr. Mumper’s results statistically significant compared to the general prevalence of ASDs. I also found out that if she found just one case of ASD, the p-value would jump to 0.043, which would barely be statistically significant and is close to what Dr. Mumper reported in this case (0.042), which reassured me that I chose numbers for the control group similar or identical to what she chose. Two cases in Dr. Mumper’s practice would cause that p-value to skyrocket to 0.108.

Not surprisingly, Mumper reports that, after her paper was reviewed, one child was referred on suspicion of autism based on expressive language delay, but no diagnosis has been made. This brings up another issue (besides the fragility of her “results”). In a retrospective study like this, the control group has to be chosen to be as close as possible to the observation group, and Dr. Mumper just didn’t do this. The apparent prevalence of ASDs can depend on the availability of services (which is one reason why urban/suburban populations often appear to have more ASDs), screening, and socioeconomic factors. Dr. Mumper didn’t even attempt to compare the prevalence of ASDs in her practice to that of the surrounding area. For instance, in 2011, the prevalence of autism/ASD in Virginia was reported to be 0.8%. I realize that the more recent numbers are much higher and that the prevalence is increasing in Virginia, as it is for the rest of the country, but the latest figures that I could find for Virginia show a lower prevalence rate. The point is that we have no idea whether the number Dr. Mumper chose is a valid one to compare her practice to. That’s the problem with retrospective studies using existing prevalence as a control. They rarely tell us anything, particularly with such small numbers.

That is, of course, the very problem with small numbers. An N of 294 is way too small to make any hard and fast conclusions. Indeed, reading this paper I was amazed at how small the number was. An active pediatrician should have more than 37 new infant patients a year over nearly eight years. That’s less than one a week. Even if we take into account that all of these patients were seen before two months and followed at least until age 2 years, that’s still a small number for a pediatrics practice. One wonders how her practice can survive on those numbers. Be that as it may, what we have here is a dubious set of observations based on no clinical prior plausibility looking at a vaccine schedule that is based in no science and seems tailored to meet the minimum requirements of the Virginia school system’s vaccine requirements. On the other hand, given that Dr. Mumper appears to spend most of her effort treating children with developmental disorders with “autism biomed”, perhaps well baby visits are a small part of her practice. Then there’s the issue of the age range studied. The age range at which autism and ASDs are most commonly diagnosed is over the age of two; so how did Dr. Mumper assure that she captured all the diagnoses after age 2?

And did I mention that the center where these observations were made, the Rimland Center, appears to be, to my observations, a wretched hive of “autism biomed” quackery? Just take a look at its offerings: hyperbaric oxygen, reflexology, DAN! protocol treatments (that’s “Defeat Autism Now!” for those who aren’t familiar with “autism biomed”), gluten-free, casein-free, special carbohydrate diets, and more. All of this is consistent with the DAN! protocol, which includes pretty much every form of autism quackery known to quacks under its rubric, including chelation therapy, hyperbaric oxygen, and a wide variety of other quackery, such as Bioset supplementation, and Diflucan to “get the yeast out.” It’s no wonder that I’ve described “biomed” treatments like the DAN! protocol as uncontrolled and unethical experimentation on autistic children. It’s not for nothing that autism biomed has been referred to as an “autism cult.”

Finally, there’s Dr. Mumper herself. It’s not surprising that such a bad study would come from Dr. Mumper, as she is a vaccine-autism true believer to the point that she is cited in Whale.to and has presented at the yearly antivaccine quackfest Autism One and, most recently, at the 2013 Biomedical Conference. Also of note, Dr. Mumper has had her testimony dismantled in front of the Vaccine Court as one of the expert witnesses for the plaintiffs in the Autism Omnibus hearings.

In the end, Dr. Mumper’s study tells us a whole lot of nothing. Certainly, it is no evidence that doing what Dr. Mumper advocates doing has any effect whatsoever on the risk of developing autism in infants. The study will, however, be trotted out (as it has already been) as “evidence” that if we’d only decrease the number of vaccines, encourage breastfeeding more, decrease antibiotic usage and indulge in various unscientific interventions, we could virtually eliminate autism. It is evidence of nothing of the sort. Amusingly, however, this study is unlikely to be embraced by the hard core antivaccinationists. Why? Because even the decreased number of vaccines in Dr. Mumper’s proposed vaccine schedule are too many vaccines. (Just look at some of the amusing and depressing antivaccine comments after Dan Olmsted’s post.) To such antivaccinationists, one vaccine is one vaccine too many.

Posted in: Neuroscience/Mental Health, Public Health, Vaccines

Leave a Comment (28) ↓

28 thoughts on “Preventing autism? Not so fast, Dr. Mumper…

  1. elburto says:

    More anti-science hypocrisy. Rigorous studies disproving any vaccine-autism link are scoffed at, one biomeddling quacktitioner slaps together some nonsense, and VOILA! “Proof” that there’s an autism epidemic.

    I’d hope that someone who’d managed to earn the title ‘Dr’ would be able to figure out that the maternal/neonatal death rate in the US has so many confounders that simple comparison to other developed nations requires a study in its own right.

  2. lilady says:

    Mumper states her inclusion criteria…

    “Patient Selection Inclusion criteria were: 1) all general pediatric patients born in 2005 or later; 2) presented for well child care prior to 2 months of birth and 3) followed until at least the age of 2 years and 2 months. Totally 294 patients qualified for the inclusion criteria and have been selected in the current research.”

    Then Mumper states what her study conclusions are…

    “In the current research, there are no new cases of autism out of the 294 cases recognized and recorded, resulting in 0% prevalence of ASD. Based on the CDC background risk of autism of 1 in 50 for the cohort born around 2005 we would expect to have about 6 new cases of autism in our practice. We calculated our statistics using a Chi-squared test with 1 degree of freedom. Using the CDC autism rate of 1 in 50 reported in 2013 (but based on surveys of eight year old children), the expected rate for our 294 patients starting in 2005 would be 5.88 children with autism. Zero new cases of autism would occur by chance 1.4% of the time (p-value 0.014, significant at 0.05).”

    Really Dr. Mumper? Why the cutoff at age 2 years and 2 months…when every recent study, including this one, has found the age of diagnosis of children with autism or an ASD to be quite a bit older:

    http://health.usnews.com/health-news/news/articles/2013/04/15/age-of-autism-diagnosis-may-depend-on-symptoms-study

    “Age of Autism Diagnosis May Depend on Symptoms: Study

    MONDAY, April 15 (HealthDay News) — Specific symptoms influence the age at which children are diagnosed with autism, according to a new study.

    Children who displayed only seven of 12 recognized autism symptoms were diagnosed more than four years later on average than kids with all 12 symptoms, researchers found.

    ‘When it comes to the timing of autism identification, the symptoms actually matter quite a bit,’ study lead author Matthew Maenner, of the University of Wisconsin, Madison, said in a university news release.

    ‘Early diagnosis is one of the major public-health goals related to autism,” Maenner said. “The earlier you can identify that a child might be having problems, the sooner they can receive support to help them succeed and reach their potential.’

    The research team looked at the medical records of more than 2,700 children with autism at age 8 and found a significant connection between age of diagnosis and how many symptoms were displayed.

    The median age at diagnosis (the age at which half the children were diagnosed) was 8.2 years for children with seven symptoms and 3.8 years for those with all 12 symptoms….”

    Possibly not the worst autism study I’ve seen published in recent years…but close to it.

    1. qetzal says:

      Excellent point! In fact, that CDC study that found the 1 in 50 prevalence (2.00%) was for children aged 6-17! In contrast, Mumper’s cohort was aged 2 year 2 months to 7 years 10 months. The CDC study also says if you look at the same cohort of kids, but ask how many had been diagnosed with autism in 2007 (when they were 2-13 years old), the prevalence was only 1.37%! (Note that Mumper’s ref list doesn’t include the CDC study, but you can find it here: http://www.cdc.gov/nchs/data/nhsr/nhsr065.pdf.)

      But even worse, Mumper’s own data belies the value of her “interventions.” She herself claims that there have been no new ASD diagnoses among her patients since 2000. Meanwhile, her strategies “were phased in over time as the evidence emerged, without prospective tracking measures.” So she claims to have gone from a 0% ASD prevalence in 2000, to a 0% prevalence in 2013, and that’s supposed to be evidence that the strategies she’s implemented over time were beneficial?

  3. Lawrence says:

    Excellent point – why rely on hundreds of actual studies from a variety of institutions (both government & independent) worldwide, when you can take one or two quack studies to prove your point….morons…..

  4. Don says:

    “In any case, I don’t know any scientist or pediatrician who would argue that breastfeeding is in general good for babies…”

    I doubt that you intend to state that pediatricians are not in favor of breastfeeding, but some nitpicker will.

  5. Since we’re relying on anecdotal evidence… When I was a kid (born 1965) our pediatrician handed out antibiotics like they were candy. The kids used to run behind the city trucks spraying DTT (cause the mist was refreshing, I guess). My dad used to fog the fruit trees with pesticides (insecticide, fungicide) while we played under them*, there was lead in the gas and folks generally didn’t worried about smoking while pregnant or in the house around kids.

    I suspect that is a higher level of exposure to harmful toxic substances than most kids recieve today with a conventionally grown diet and a good pediatrician. If Dr Mumper is correct, seems like we should have had a higher incidence of autism then than now. Of course, then no one I knew was autistic, there was just a lot of other words used to describe kids that were very similar to the kids who are diagnosed with autism now.

    *I try to stay away from pesticides in the garden now, but I still get a sense of nostalgia when I smell them.

    By the way, for a satisfying experience, read the “testimony dismantled” link.

  6. lilady says:

    I will be offline for a few hours. When I return I’ll post more of opinions about this “study”…which is so wrong on so many levels….it is overripe for picking it apart.

  7. cphickie says:

    Excellent analysis of a deeply flawed “paper”.

    There’s also a “Figure 3″ in this paper that is orphaned and not cited anywhere as to why it is there. Also, Mumper cites 21 patients referred for endoscopy from her practice but only gives the results for 20 in her Table 1. Yet more examples of how pathetically peer-reviewed this paper was.

    Mumper also doesn’t tell us what happened to the pediatric patients lost to follow up (which she admits happened). Without knowing if any of them were later diagnosed as having autism, how can she claim her n = 294 as valid? Given that she clearly thinks she is “preventing autism” (and probably claims as much in her clinic), it’s possible that a patient of hers showing developmental delays consistent with autism left the practice because either: 1)that child’s parents were p*ssed that all this “prevention” wasn’t working or 2)the parents didn’t want to disappoint Dr. Mumper.

    Mumper claims no new cases of autism for her practice since 2000, but says, due to several changes in her electronic health record (EHR) computer program that looking at the data before 2005 would be “difficult to ensure adequate data capture”. Well, apparently you could check back to 2000 for ASD diagnosis codes, so why can’t you check back for all your other criteria to make the n a little bigger on your “study”, Dr. Mumper? In the days before EHRs (which you well remember, Dr. Mumper) it was called chart review.

    As David mentions, 37 newborns a years is ridiculously small for a pediatrician running a solo practice. Since I’m a pediatrician, I used my EHR to look at the number of newborns that came to me that would likely meet the inclusion criteria in her study (minus the bogus “alternate” vaccine schedule, of course) and estimate that in my first 3 years (2005-2007) of practice (when I was solo), there were 450 newborns that I could have used. Double that for her ~ 6 year period and (if I’d stayed solo) that would be 900 newborns–a lot more than her 294.

    Thanks, lilady for finding a recent age of autism diagnosis paper. Here is the actual journal title and location: “Frequency and Pattern of Documented Diagnostic Features and the Age of Autism Identification” (http://www.jaacap.com/article/S0890-8567(13)00076-2/abstract)

    This paper shows nothing other than the lengths to which a clearly biased pediatrician who understands little about true research will go to advance a false cause.

    1. David Gorski says:

      There’s also a “Figure 3″ in this paper that is orphaned and not cited anywhere as to why it is there.

      Heh. Good catch. I was too busy looking at the references over and over and over again, not believing that such an obvious mistake would be made and thinking that I must be missing something. :-)

    2. lilady says:

      Dr. Chris: I’m chuckling about your statement thanking me for finding “a recent age of autism diagnosis paper”.

      The study I provided was partially funded by The Autism Science Foundation…never, ever to be confused with the Autism Research Institute. :-)

      http://autismsciencefoundation.wordpress.com/2013/04/09/identifying-asd-in-community-settings/

      Mumper’s “Schedule” has a notation to “discuss hepatitis B with physician” at age two, yet there are no hepatitis B vaccines administered before school. Three doses of Hepatitis B vaccine are required for school entry in Virginia. Mumpers also provides 1 dose of Varicella vaccine at age 5, yet Virginia requires two doses of the vaccine for school entry (effective March 3, 2010):

      http://www.vdh.virginia.gov/epidemiology/immunization/requirements.htm

      My best guess is that Dr. Mumper does, in fact, administer the # 1 Hepatitis B vaccine at age 5 and her patients’ parents receive written notification from the school district to make an appointment with Dr. Mumper to administer the #2 Hepatitis B dose (of the 3 dose series), and to administer the #2 varicella vaccine, 28 days after the child received the first doses of those vaccines.

  8. rork says:

    Unbiased and long-term followup are the death of many new treatments.
    Power(1-(1/77),294)=.021 for the nerdy types out there. That’s one-sided ofcourse.

  9. Calli Arcale says:

    Wait a minute . . . so not only is this a rather small cohort followed for an inadequate length of time, but she’s studying her own patients. She has significant leverage in what diagnoses they may receive. Seems it would be rather easy to ensure that no children in her practice got an ASD diagnosis. I mean, I’ve seen unblinded studies, but that’s just plain ridiculous.

  10. Carl says:

    Dangit, I wanted to be the first one to point out the big gaping difference in years between Mumper’s minimum observation period and reality. But I can dump the quote I found on the CDC website related to it:

    most children are not diagnosed until after they reach age 4. Diagnosis is a bit earlier for children with autistic disorder (4 years) than for children with the more broadly-defined autism spectrum diagnoses (4 years, 5 months), and diagnosis is much later for children with Asperger Disorder (6 years, 3 months).
    http://www.cdc.gov/ncbddd/autism/data.html

  11. David Weinberg says:

    “One notices that there are only 52 references listed, even though citations number up to 70 in the text. ”

    I’ll see your 70 citations and raise you 31. In the “Discussion” section there are citations up to 101 (see page 142). So half of her citations aren’t supported by references. They must run quite a tight peer review process over at North American Journal of Medicine and Science.

  12. David Weinberg says:

    There is no mention of IRB approval in this paper. This could have been an oversight by the author, but some of the language of the paper makes me suspect that this wasn’t done under IRB supervision. In the Methods section, it is stated:

    “Inclusion criteria were: 1) all general pediatric patients born in 2005 or later; 2) presented for well child care prior to 2 months of birth and 3) followed until at least the age of 2 years and 2 months.”

    It is very unlikely that an IRB would allow an open ended time period like that. Retrospective studies have to have a opening and closing date for when data are allowed to be collected. The closing date has to precede the date that the protocol is accepted by the IRB, otherwise it is not a retrospective study.

    1. Carl says:

      This could have been an oversight by the author,

      It could have been an error, but with somewhere between 31 and 101 references either not existing or being misused, complete nonsense being included, and bad study design being used, it starts to get easier to just say that the entire wrong paper was submitted. “Oops, this was just a work of satire we were passing around the anti-vax office, and everyone was throwing in random rants until the whole thing ballooned and someone accidentally emailed it to the journal!”

      1. Chris Hickie says:

        Sadly, if the entirely wrong paper was submitted, it was also revised and accepted 2 weeks later still as the wrong paper. Either way, there is a whole lotla stupid going around here between author and journal.

  13. stuastro says:

    Do these AoA people STILL not realise that that there is no mercury in vaccines?

  14. Stephen H says:

    Wait, I hadn’t realised that 1975 was a cut-off year. I was born in 1968 and diagnosed with Asperger’s in 20xx. Does that make me one in five thousand? Or one in fifty?

  15. DW says:

    It would also appear this journal doesn’t copy edit anything. Even a half-comatose copy editor would catch such a massive FUBAR reference list.

  16. Why does the vaccine hypothesis hang on so tenaciously in the minds many people? I think it is because no good alternative idea has emerged to take its place. Many people feel something during the 1st year of life has changed for today’s infants. Vaccines are given during this critical period for social development. And they are relatively new as is this epidemic of ASD. So the timing is right or and convincing for this group of people.

    But I believe something else is blocking social development during this same time period. I believe it is something simple almost obvious but barely studied at all. It is tv and video. Infants are more and more exposed to them in the last 50 years or so. They present to the infant the same social cues (faces, eyes, voices, motion, music etc.) infants have used for eons to find social partners to interact with. But no interaction is possible with a video screen. It is a social dead end. Some infants will prefer not to socialize with the people around him when they have the choice of video screens. Sadly enough many of those children will develop ASD.

    1. Woo Fighter says:

      Dr. Oestreicher,

      Are you really trying to tell us you honestly believe that TV, iPads and videogames cause autism? Do you tell that to your patients? Sheesh. (Eyes roll.)

      From a comment the good doctor posted on another skeptic blog:

      “The cause of this epidemic is not vaccines or a sudden change in our genetic makeup. It is the massive onslaught of video devices and distracting toys into the life of infants. The babies are drawn to and amused by these objects and thereby entranced away from the two-way communication they need in infancy to acquire the skills and interest for normal social development.

      Leonard Oestreicher MD
      Author: The Pied Piper’s of Autism
      How Television, Video and Toys in Infancy Cause ASD
      http://www.toystvautism.com

  17. Scott says:

    My son was born in 1990 and diagnosed with autism 4 years later. I don’t believe that vaccines caused his condition. Rather, the umbilical cord being around his neck twice at birth (oxygen starvation) led to brain injury and autism.

  18. WilliamLawrenceUtridge says:

    Dr. Oestreicher:

    As said by Dr. Gorski in the article – it’s more likely that the increase in autism rates are due to diagnostic substitution, changes in the diagnostic criteria and broadening of the categories. The idea that there is a genuine rise in real autism rates is a questionable hypothesis. I think you are confusing correlation and causation. For instance, autistic children may not be reinforced by social interaction so they may attend more to TV and other noninteractive stimuli rather than these stimuli causing autism. Or, the two are completely unrelated. In addition, your assumption that something environmental is blocking social development is an assumption. First off, having worked with autistic children, some do respond to social cues and stimulation, some are even reinforced by it. Secondly, for those who are not interested in social cues and stimulation, it may be, and is more likely, to be related to a genetic cause than environmental causes.

    Keep in mind that the certainty you seem to hold regarding this relationship, this projection of cause onto toys and TV, is the same certainty held by parents who believe that vaccination causes autism. Without evidence, what you have is speculation – not explanation.

    It’s also quite parent-blaming, a hail backwards to the refrigerator mother hypothesis – if only you had loved and played with your children more, they might not have autism. Again, having worked with autistic children, I found their parents to be highly involved in their children’s lives, not indifferent. Admittedly selection bias might be an issue since I worked with the parents who sought interventions. But I am hard-pressed to describe your theory in non-emotive terms since I find it rather offensive.

  19. elburto says:

    +1

    These theories that blame mothers* are beyond offensive.

    Parents of children with ASDs (or any other significant developmental issues, illnesses or disabilities) have enough to contend with, without being made to feel guilty about allowing TV into their houses.

    I don’t think I can recall speaking with a single parent who didn’t feel guilty, and somehow responsible for their child’s condition, no matter what the condition and what the cause. Seeing someone break down, because they’re convinced that they are solely to blame for the difficulties their child is having, is gut-wrenching. I’ve spoken with mothers who felt that they should’ve somehow known about a certain gene, or insisted that if they’d stayed awake and watched over their baby 24/7 then she might not have had that seizure, or if only they’d waited to go into labour until morning (as if controlling that was a possibility) then maybe a different shift on the maternity ward could have spotted the foetal distress earlier, and prevented their child being born with cerebral palsy.

    I’m also wondering how you explain the prevalence of ASDs in children who never see a screen of any sort? I lived on the edge of one of the UK’s significant populations of Hasidic Jews. This particular sect adhered to an incredibly strict brand of Haredism that didn’t even allow English language or secular books in the house, never mind television, computers, games consoles or portable media devices. The community had a not-insignificant number of children** with ASDs, and had schooling facilities and a therapy centre dedicated to those kids, and to the handful of children with Down’s Syndrome.

    The same can be said for similar communities all over the world, and for Amish and Mennonite settlements, FLDS enclaves, and in other populations who do not have access to television or computers. How do we blame mothers account for ASDs in those cases?

    The Dr Ostreichers of the world seem determine to isolate the One True Cause of ASDs, something environmental that can be blamed, it’s a cop out and it’s lazy thinking. Fortunately there are plenty of dedicated teams of scientists and researchers who are willing to investigate other avenues.

    *Let’s face it – when these people theorise that parents are to blame, that’s usually referring to the primary caregiver which, statistically speaking, is the mother.

    **Women have often had more than ten children by the time they reach menopause, but the largest number I was aware of (at that time, in that community) in one family was eighteen. Childbearing starts young ( usually 18/19) and contraception is only allowed if the community rabbi has given that particular couple a ‘heter’ (an individual ruling) that the woman may use it to prevent pregnancy. Otherwise, a birth every 18-20 months is pretty much expected in healthy, fertile women. The number of children with chromosomal abnormalities like DS seemed slightly higher than average, although that’s influenced by a number of factors.

  20. WilliamLawrenceUtridge says:

    The Dr Ostreichers of the world seem determine to isolate the One True Cause of ASDs, something environmental that can be blamed, it’s a cop out and it’s lazy thinking. Fortunately there are plenty of dedicated teams of scientists and researchers who are willing to investigate other avenues.

    The self-aggrandizing nature of their proclamations is also irksome. “I have identified the cause of autism! I have the only truth on the matter! I am certain that I have identified what goes wrong, when everyone else missed it!”

    I have trouble believing this.

  21. autismepi says:

    As stated very clearly by the author, this study has significant methodologic problems that makes any causal inference impossible. However, other well done genetic and epidemiologic studies do support a large role for environmental factors:
    http://www.ncbi.nlm.nih.gov/pubmed/21727249 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3174192/

    Many potential environmental factors have not been rigorously investigated. One standout is acetaminophen. It is frequently given to pregnant women and infants, it can affect the immune system, it is known to reduce glutathione, the bodie’s detoxifier, and it causes atrophy of purkinje cells in the cerebellum (in male mice). These are all consistent findings in autism:
    http://www.ehjournal.net/content/pdf/1476-069X-12-41.pdf
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3534986/pdf/nihms428627.pdf

    Sale of acetaminophen has increased with the reported autism prevalence rates, perhaps what we are seeing is not all better diagnosis.

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