Interview Contents:

• Rising Rate of Diagnoses
• Potential Causes: Environment and Heredity
• Diagnosis and Treatment
• Impact on Families
• The Spectrum of Autistic Disorders
• Research Directions

This interview with Mitzi Waltz, author of Autistic Spectrum Disorders, looks at questions most often in the news. After working in the US as an advocate for people with brain disorders for a number of years, Waltz has decided to pursue a doctorate in order to teach and conduct academic research. She is currently with the Autism Research Unit at the University of Sunderland in England. The ARU is well-known internationally for its work on the relationship between autism and metabolic disorders. Waltz's doctoral research is focused on the medical history of autism, and she has presented to audiences in the UK and Europe on this topic and others related to autism.

Rising Rate of Diagnoses

Lamb:

There has been a lot of media coverage about the rise in rates of autism in children. Some have said that the rise in autism rates is really only the result of better screening or more refined diagnostic criteria. Is that true?

Waltz:

In short, no.

The diagnostic criteria used in the US to diagnose autism are actually tighter now than they were ten years ago, and yet the number of children with autism continues to rise. And that's not taking into account the even larger rise in the number of children with related conditions, such as pervasive developmental disorder, not otherwise specified (PDD-NOS), or Asperger's syndrome.

Doctors are doing a better job of diagnosing, and they deserve credit for that. But diagnosis is still delayed by three to six years from the first symptoms, in most cases, so there's still more improvement needed.

However, severely autistic children did not escape medical notice in the past, just as they do not now. Some were mistakenly diagnosed as simply "mentally retarded," but as the rate of mental retardation has not fallen during the period that the autism rate has risen, better diagnosis doesn't seem to tell the whole story.

If you talk to doctors who began working in this field 20 or 30 years ago, they will tell you that there's been a large and noticeable increase. So will teachers and social workers. The figures from state education departments all show an increase, as do treatment figures.

Potential Causes: Environment and Heredity

Lamb:

Is there currently research looking into the claims of some parents that autism is the result of childhood immunizations?

Waltz:

Unfortunately, the level of research is still cursory at best. There's no question in my mind that vaccination for deadly childhood illnesses has saved many lives, but some experts question whether we have traded these acute, deadly diseases for chronic and often severe conditions.

It's apparent from immunological research that children with autism have an off-kilter immune response system, and a high propensity toward autoimmune conditions. This means that children who have inherited genes linked to autism may be especially vulnerable to unusual vaccine reactions, particularly when multiple live vaccines are used. Past research indicates that they also have unusual patterns of response to measles and mumps when these conditions are caught in the usual way, especially when more than one viral illness is caught in rapid succession. Researchers need to follow up on these clues: while vaccines are important for public health, exceptions or changes to the vaccines and/or the vaccine schedule may be necessary to protect some vulnerable children. This is already done for children with HIV/AIDS and for children with infantile epilepsy.

It's important for parents to understand that MMR and other vaccines probably do not cause autism--not in the way that exposure to the measles virus causes measles, for example. But for a vulnerable child, it's possible that certain forms of vaccination, as well as certain types of infection, could be the trigger that starts a cascade of symptoms. I have spoken with too many parents whose children deteriorated markedly and obviously in connection with vaccination to discount the possibility. That said, I have also spoken with parents whose child lost skills and became autistic following infection. In my medical history research, infectious disease appears to have played an important role in autisic symptoms, even before autism had been fully described or named.

Lamb:

We assume medical experts are continuing to recommend immunizations. Are there any cautions for parents?

Waltz:

It depends on which experts you speak with, to be honest. Public health experts must be concerned with the overall picture, not individual children, so they tend to stress continued vaccination using the currently recommended doses and vaccination schedules for all children. There are many doctors who do not agree, however--indeed, a recent survey of British doctors and nurses found that many were privately worried about giving the combined MMR vaccine to their own children.

Doctors who specialize in treating children with autism are faced with this issue daily, usually when parents try to decide whether or not to vaccinate subsequent children. Some have recommended that for vulnerable children--those with autism or epilepsy in immediate family members, for example--vaccination might be beneficially delayed, and vaccines might be given separately and with long intervals between shots. Certainly, parents and doctors should use common sense: children should not be vaccinated when they are already ill, and vaccines containing the known neurotoxin thimerosol (mercury) should be avoided.

For parents faced with this dilemma, whether and how to vaccinate is an issue to explore with a specialist.

Lamb:

Is there evidence of other environmental factors being linked to the increase of autism?

Waltz:

Yes. Our research group at the University of Sunderland is particularly concerned about organophosphate pesticides. As with viral infections, some people are particularly sensitive to organophosphate (OP) compounds, while others exposed to the same amounts suffer no ill effects. These chemicals have become common in the environment. Even compounds that have been outlawed remain in the environment, and may be used illegally or be present in foods grown in countries where they are not regulated. The ARU's director, Paul Shattock, has spoken with several families whose children developed autistic symptoms that appear to have been connected with organophosphate exposure (these compounds can also cause neurological damage to adults).

The M.I.N.D. Institute at the University of California, Davis, ( http://mindinstitute.ucdmc.ucdavis.edu/) plans to investigate this organophosphate angle.

Mercury, and possibly other heavy metals, be also be an issue for at least some children with autism. Again, they may have a genetic susceptibility. Researchers in Italy found that most people with autism in their genetic study had an altered form of the gene that creates the neurodevelopmental protein reelin. One of the things that reelin normally does is assist in the metabolism of heavy metals. Someone with abnormal reelin production would likely have problems processing and eliminating dangerous neurotoxins like mercury and lead.

Metabolic problems have been an issue throughout the history of autism. Even the earliest case studies written note a high rate of bowel disturbance, unusual eating and drinking patterns, and sometimes signs of vitamin deficiency. Quite a few children with autism appear to benefit from a gluten-free and/or casein-free diet. The ARU's research has been focused on this issue for over a decade, looking at abnormal peptide activity in the gut.

Lamb:

Why do some geographical areas, such as Silicon Valley in California, have such high rates of autism in children?

Waltz:

A number of factors have been suggested. There could be environmental factors at work--something affecting people in discrete areas, such as high background levels of mercury, or exposure to pesticides.

In Silicon Valley, it's been suggested that quite a few people with Asperger's syndrome or autistic traits were drawn to the area by the lure of high-tech jobs, met partners with the same sort of traits, and passed on a "double dose" of the genes--the result being more autistic children, with more severe forms of the condition. It's an interesting theory, and bears looking at.

However, Silicon Valley's rates are similar to those of Brick Township, New Jersey, which is a working-class industrial area rather than a high-tech mecca. The island of Jersey in the UK is also reporting extremely high rates, and it has very little in-migration and almost no industry.

Lamb:

Has a genetic predisposition to autism been proved?

Waltz:

Yes, as much as such a thing can be "proved." Twin studies have shown that if one twin is autistic, the other is also likely to be autistic, or to have autistic traits. Non-twin siblings and other close relatives of people with autism are also more likely to be autistic.

However, it's not as straightforward as early researchers had hoped--there's no "autism gene," although the genes responsible for causing several conditions that include autistic traits have been identified (Rett syndrome, Prader-Willi syndrome, and Angelman syndrome, to name just three.) The genetics of autism appear to be very complex. Several genes have been identified, but it looks like it takes a combination of genes, and that more than one combination can have similar effects.

It also appears that it's not purely genetic. Your genes may give you a high susceptibility to autism, but they may not be expressed until certain environmental factors kick in.

Diagnosis and Treatment

Lamb:

Are there currently tests that can show whether the genetic predisposition exists?

Waltz:

The only commercially available tests are for conditions like Rett syndrome, where a single gene or a small number of genes have been identified. Many doctors do test for Fragile X syndrome, a chromosomal difference that is a common cause of mental retardation and is also associated with autistic symptoms.

There's no genetic testing available for autism itself, although there is a lot of genetic research going on. Three generations of my own family have given blood samples for chromosome screening to a research group, and we hope others will do this as well.

Genetic research will not lead to a cure, but if we can identify the genes involved and learn what they do, we may be able to understand what environmental factors are involved and make a difference that way. My earlier references to the reelin gene and heavy metal metabolism is a good example of what I mean--if you knew your child had a gene that kept him from metabolising heavy metals, you could do some things to be especially protective of him or her.

Lamb:

Are there other ways to "measure" autism, like physical differences in the brain?

Waltz:

In a research setting, doctors might use tools like CAT scans. They aren't used in regular diagnosis too often, although this may change in time. Researchers would love to find some kind of physical marker, something that would turn up on a blood test, for example. The M.I.N.D. Institute has identified some possible blood markers, and this kind of research is continuing.

Lamb:

How is autism currently diagnosed?

Waltz:

It's diagnosed through observation and conversation. There are several test instruments that doctors use with young children, including basic tests of neurological function and questions or tasks that are specific to the impairments seen in autism. Doctors also interview parents. If diagnosis is being done by a school district, the teacher will be involved, too. In a best-case scenario, professionals from several different disciplines will work together.

Lamb:

With physical differences now able to measured--by sophisticated brain imagery and blood assays--does it make sense to still label autism as a "mental health" issue?

Waltz:

Yes and no. It's a developmental disability, really, and should be thought of and treated as such. It's important to note that people with autism do experience a high rate of mental health problems, though, such as severe anxiety and depression. Sometimes if a person is only viewed as having developmental problems, any mental health issues that are present don't get adequate attention.

Lamb:

Does a "mental health" label work against people seeking treatment or getting support?

Waltz:

It can, although it shouldn't. In the US, developmental disability programs sometimes use IQ to determine whether a person is eligible for services. For example, unless a child has an IQ under 70, he is not eligible. But if the family then goes to the mental health system for help, the professionals there may not understand how to work with someone whose basic problems lie in developmental delay or unusual patterns of development. What's needed is treatment that's geared to the person, not the label.

Lamb:

How is autism treated?

Waltz:

In the US, the most common "treatment" is special education, followed by medication. I should note that as of yet, no medication has FDA approval as a treatment for autism, although evidence suggests that some are helpful for those secondary mental health issues.

Intervention needs to be early and intensive for the best result. There are a lot of programs available, with applied behavior analysis ("Lovaas") being the one that's been researched the best. It's great for many kids, especially those with the most severe forms of autism. Other children may benefit from a different sort of intervention. Speech therapy, occupational therapy, and physical therapy can be very useful. A type of occupational therapy called sensory integration targets the sensory differences of people with autism.

Medical treatment is still in its infancy. Many families try diet, vitamin supplements, and other complementary therapies. These can be very helpful for some (not all).

Impact on Families

Lamb:

What is the impact on parents, of a child having an autistic spectrum disorder?

Waltz:

Having an autistic child will change everything about your life, from whether you get enough sleep at night to how likely you are to get divorced.

It's hugely stressful, and that's not helped by the lack of help from medical professionals, schools, and social services agencies. Indeed, the situation for many families is horrendous, especially in areas where there are no services or where services have been completely swamped by the rising number of cases.

Divorce rates are very high in affected families, and siblings of children with autism are also affected in ways that aren't always obvious. It's essential to get help and support from others right away, or it can just be overwhelming.

Lamb:

Politicians increasingly call for "full parity" for mental health conditions. Are these treatments covered by insurance?

Waltz:

Only in those states that have specifically mandated coverage for autism, such as California. And there's still much argument as to what "coverage" means, because the treatments that have been well-researched (such as ABA) aren't seen as healthcare, per se. There's not a set protocol for evidence-based treatment, although that is taking shape in some places.

Lamb:

Are there any national support organizations for parents?

Waltz:

The best place to start is still the Autism Society of America ( www.autism-society.org), which has lots of local and regional chapters.

There may also be a local support group near you that's not part of the ASA. Make a few calls, and see what you think about the people involved. There are some groups that are great for parents of young, newly diagnosed children, others that caters to families with teens or adults. Getting online is a good way to meet other families, too.

The Spectrum of Autistic Disorders

Lamb:

What does the description of autism as a "spectrum disorder" mean?

Waltz:

It means there's a range of expression, from very severe to relatively mild.

Lamb:

What would be the range of functioning, with someone who has an autistic spectrum disorder?

Waltz:

At the low-functioning end, a person might be completely non-verbal, unconnected to all other people, self-injurious or aggressive.

There are probably many people who have Asperger's syndrome, a very high-functioning form of autism, who don't even know they have it. These people might be described as eccentric, odd, or fixated, but you wouldn't think of them as having a "developmental disorder" because they look "normal" in most respects. An adult with Asperger's syndrome might seek help for anxiety, depression, or obsessive-compulsive behaviors but cope fairly well with his or her autistic traits. I met many people who fit this description in my previous life as journalist covering high-tech topics--lots of programmers and even a few famous computer moguls.

I do know that many people with Asperger's syndrome suffer a great deal, even though they may seem to be coping. They've often had brusing childhoods, with a lot of teasing and ostracism. This takes a terrible toll. We need to pay closer attention to identifying milder forms of autism in kids and helping them learn good coping skills--and protecting them from bullies, too.

Lamb:

Are there any "good sides" of autism?

Waltz:

You bet! The ability to see the world through a different lens, to think in unique ways, and to make others question their assumptions.

One of the things I really enjoy about the adults with autistic spectrum disorders that I know is their honesty. It can be brutal, but it can also be funny and refreshing.

For high-functioning individuals, and for those low-functioning folks who have "savant skills," there's a great deal of talent amount people with autism. They often have an ability to focus very intently on a single topic. Channeled well, this can lead to being very good at math, music, art, crafts, or inventing things. I've met adults with high-functioning autism who are university professors, engineers, artists, parents; I've also met others who are stuck in dead-end jobs and very unhappy.

Lamb:

What is it like to have autism?

Waltz:

I don't know, even though I have read many "inside accounts." I think that the most difficult aspect might be the sensory disturbances many people with autism have, like having an abnormally high pain threshold that can lead to injury, or being very sensitive to light touch or noise. Temple Grandin's accounts are really interesting, although it has to be said that Temple is quite unique, even amount people with autism!

Lamb:

Are children with autism likely to have any other conditions?

Waltz:

Yes, autoimmune disorders such as allergies, asthma, eczema appear to be higher in this group. About 25 percent have epilepsy, and I suspect the real number is higher, since partial seizures are often missed. Depression, bipolar disorder, ADHD/ADD, and other conditions are also more common in people with autism.

One question that hasn't been answered yet is the medical status of adults with autism. Current research indicates that their life span is shorter than that of people without autism. We don't know why yet. There seems to be an increased susceptibility to Parkinson's disease, athough that's not certain. There's definitely an increased rate of accidental death (some of these "accidents" may be suicide or institutional abuse, however.)

All people with autism need good, regular health care and dental care.

Lamb:

Is autism related to ADD/ADHD?

Waltz:

ADD/ADHD is more common in people with autism than in the general population, it's also seen more often in their families. Perhaps there's an overlap in the genetics--it's not known at this time.

Research Directions

Lamb:

Will there be a cure for autism?

Waltz:

No, but there may be preventative measures that will limit the number of children who become autistic, and lessen the severity of their symptoms. There will definitely be improved treatments. Some treatments are already giving some children the opportunity to progress well enough to be indistinguishable from their peers. Personally, I hope that we will come to value people with autism more, and accomodate ourselves to them instead of always forcing them to conform to the ways of "normal" people.

Lamb:

Some politicians and governmental agencies also now regularly calling for more research dollars. Do you see interest and funding increasing?

Waltz:

Research funding is definitely increasing--and thank goodness for that! Sadly, much too much of that funding is going into genetic research and "rat science." Basic research is absolutely vital, but considering the number of affected children and adults who are here now and in need to help, I think we should turn the majority of funding toward finding out what works.

Lamb:

What is the most exciting research into autism today?

Waltz:

Of the genetics work, I'm most intrigued by the finding on reelin. This neurodevelopmental protein is expressed throughout life, not just before birth. Perhaps a way could be found to turn production back on if it has been turned off. This is a kind of genetic research that could benefit people with autism directly.

There are several research groups looking at various environmental factors. However, most of them are small and underfunded, and some face much opposition. Dr. Andy Wakefield is a good example--he's a lovely fellow and a terrific gastroenterologist, but since his research into vaccination and severe gastrointestinal problems in a subset of children with autism could be seen as threatening universal vaccination, he lost his job here in England. Happily, he's now working in the US. I keep a close eye on his work and that of his colleagues in Japan and Ireland.

I also stay on top of new medication studies. Medication has been a useful part of my own son's treatment program, and if there's anything new and promising on the horizon I definitely want to know.

One complementary therapy that looks especially promising is essential fatty acids. There are studies underway at McLean Hospital (Harvard) and at the University of Durham in the UK on EFAs, which have already shown promise for people with bipolar disorders. Diet is also very effective for may people with autism. It didn't turn out to be the key for my son, but I think everyone should give it a try for six months. When it works, the results can be great--decreased physical discomfort and more "connectedness" are the results I hear most often when talking to parents.

One thing I've learned from studying the history of autism is that advances have almost always come from people with a direct personal interest. You wouldn't believe how may of the major researchers in this field have an autistic child or an autistic relative. These individuals understand the challenge in ways that others don't, and their passion and perseverance makes a huge difference.

This Article has been submitted by the Jeremy's Prophecy Dot Com team for informational and educational purposes. Jeremy's Prophecy Dot Com is a website dedicated to telling the story of Jeremy Jacobs, a character in the novel, Jeremy's Prophecy Dot Com.