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Autism on the rise, but MMR vaccine is not the cause

Early intervention practitioners, special educators, and developmental pediatricians have suspected for some time that autistic disorders are increasingly prevalent. In California, for example, the Department of Developmental Services has reported an increase in the number of children in the state diagnosed with "full spectrum" autism (not the milder forms, such as Asperger syndrome) from 2,778 in 1987 to 18,460 as of July 2002. To find out the reason—or reasons—for this increase, the California legislature commissioned the Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, an autism research center at the University of California at Davis, to perform a study in which MIND researchers sent questionnaires to the parents of 684 children who had been given a diagnosis of full-spectrum autism. Half the children in the study were teenagers, born between 1983 and 1985; the rest were children 7 to 9 years of age, born a decade later. Comparisons of the two age groups showed that one popular explanation for the autism epidemic—that standards of diagnosis were becoming less rigorous— did not hold water: Diagnostic criteria were the same for both age groups. Nor could the increase be blamed on financial incentives; the regional centers making the diagnosis do not get more funding for identifying more children with disabilities. Nor were families with autistic children moving to California to get better services; most of the children in both groups were born in the state. The increase, researchers concluded, is not an artifact: It is a reality. And the problem isn't confined to California: The Centers for Disease Control and Prevention is looking into apparent increases in the autism rate in 13 states.

No one has an answer for what is happening. Autism is believed to be a disorder with a large genetic component, but an increase of the magnitude seen in California and other parts of the country cannot be explained by genetics alone. Some parents of autistic children, however, think they have identified the culprit: The measles-mumps-rubella (MMR) vaccine, given to children at about the same age that signs of autism tend to become apparent. This purported association between autism and MMR has not been corroborated by any scientific studies, but the allegation continues to be widely accepted.

A recent study from Denmark, however, seems definitive. Denmark maintains complete records of, among other health parameters, immunizations and psychiatric diagnoses for the entire population. Researchers conducting a retrospective cohort study of all 537,303 children born in Denmark between January 1991 and December 1998 found no evidence of causality between MMR vaccination and autism. The risk of autism was similar among vaccinated and unvaccinated children, and no temporal clustering of cases of autism was observed at any time after immunization. (For full study results see: Madsen KM, Anders H, Vertergaard M, et al: N Engl J Med 2002;347:1477.) Like California, Danish records show a sharp rise in the incidence of autism during the 1990s.

A boom in drugs prescribed for children (and other reasons for concern)

According to a new study by Medco Health Solutions, spending on prescription medications for children increased 85% over the last five years. Although this finding doesn't mean that kids take more medicine than adults do (children account for only 5% of prescription drug expenditures), it does mean that more children under the age of 19 are taking medication, and for a longer period, than was the case five years ago. Medco researchers offered two explanations:

• Conditions such as asthma, allergies, and attention deficit disorder are being diagnosed more often in children and being treated more aggressively.

• The price of medicines is going up; 30% of the increase the study uncovered is attributable to an increase in price.

It is encouraging to note that the study also found that antibiotic prescribing for pediatric patients is not increasing but holding steady at about 34% of children per year. Still, as long as so many medications given to youngsters are untested in children, these figures should give child health experts pause.

Prescription drugs are not the only cause for concern in children. According to a report from the General Accounting Office requested by a group of senators and representatives, persistent vaccine shortages have led a number of states to ration vaccines on the recommended immunization schedule and, in 30 states, to alter immunization requirements for school entry.

Last, over-the-counter medications that children use may also pose a danger to them. Last month, an advisory panel voted 21 to one to recommend that the FDA adopt stronger warnings of the danger of liver damage from an overdose of formulations that contain acetaminophen. The recommendation was followed almost immediately by a similar suggestion to warn users of aspirin and nonsteroidal anti-inflammatory agents of possible stomach bleeding and kidney failure associated with overdose.

Eye on Washington

Midterm elections are over, and results leave the Republican Party in control of both houses of Congress. There is little reason to suppose that the lame-duck Congress that returned to Washington after the elections will get far with the administration's legislative agenda, however. Speaking at a press conference the day after the election, President Bush put top priority on passage of legislation to establish the new Department of Homeland Security and to make the $1.35 trillion tax cut, set to expire in 2010, permanent. Presumably, the lame ducks will also provide authorization for departmental funding to keep the federal government in operation, if only by continuing resolution. Real work will resume when the new Congress takes office in January.

In the meantime, these government activities are worth noting:

• A "while-you-wait" test for human immunodeficiency virus (HIV) infection was approved by the Food and Drug Administration (FDA). The new test can be read in 20 minutes from a fingerstick specimen of blood. It should be particularly helpful in reducing mother-to-infant transmission of HIV, enabling health workers to test while a woman is in labor and then, if necessary, treat the newborn.

• The administration's nominee to head the Reproductive Health Drugs Advisory Committee at the Food and Drug Administration is W. David Hager, MD. Dr. Hager is the author of a book, As Jesus Cared for Women: Restoring Women Then and Now. In his private practice of obstetrics and gynecology, Dr. Hager will not prescribe contraceptives for unmarried women. He is a signer of a petition from the Christian Medical Association urging the FDA to rescind its approval of the abortifacient RU-486.

• A federal judge struck down FDA regulations requiring pharmaceutical manufacturers to test their products on children—the so-called pediatric rule. According to the court, the FDA overreached statutory authority. A bill to write the regulation into statute law is awaiting further congressional action.

• On October 1st, the states lost $1.2 billion that had been appropriated by Congress, but left unclaimed, for State Children's Health Insurance Programs (SCHIP). The money can now be used by the government for other purposes. The states will lose an estimated $1.6 billion more next year if Congress takes no action to extend a Sept. 30, 2003 deadline for using those additional funds.

• In testimony before a congressional committee considering proposals to expand the SCHIP program, Richard Bucciarelli, MD, presented the American Academy of Pediatrics's commitment to universal access to quality health care for children from birth through age 21, and for all pregnant women, regardless of age. In support of that goal, Dr. Bucciarelli testified, the AAP favors the Mothers and Newborns Health Insurance Act of 2001 (S 724), which gives states the option of covering pregnant women in the SCHIP program. The AAP opposes the new administrative rule that expands SCHIP to cover unborn children because it fails to recognize the important impact of the mother's health on the fetus.

Judith Asch-Goodkin
Contributing Editor

CALENDAR

January 15–20, 2003 Masters of Pediatrics, Bal Harbour, Fla. To register, call 800-622-4453 or visit www.mastersofpediatrics.com

February 3–7 San Diego Conference on Child and Family Maltreatment,San Diego, Calif. For information, contact cdconference@chsd.org

February 22–March 1 Pediatrics 2003: Winter Ski Conference, Breckenridge, Colo. For information, contact info@symposiamedicus.org

March 5–7 Second Annual Forum for Improving Children's Health Care, Lake Buena Vista, Fla. For information, visit the Web site of the National Initiative for Children's Health Care Quality ( www.nichq.org/events )

March 13–16 Association of SIDS and Infant Mortality Programs, 16th Annual Conference, Washington, D.C. For information, visit the Web site of Boston University School of Medicine ( www.bumc.bu.edu/pediatrics )

March 31–April 2 The Spectrum of Developmental Disabilities XXV, Baltimore, Md. For information, call Johns Hopkins University School of Medicine's Office of CME at 410-955-2959 or contact cmenet@jhmi.edu

April 7–12 31st Annual Pediatric Trends, Baltimore, Md. For information, contact cmenet@jhmi.edu or visit www.hopkinsmedicine.org/cme

April 10–11 4th European Convention on Safety Promotion and Injury Control, Paris, France. For information, visit the European Consumer Safety Association Web site, www.ecosa.org/csi/ecosa.nsf/news

April 23–-26 National Pediatric Infectious Disease Seminar, New Orleans, La. For information, visit www.npids.org

May 11–14 Child and Youth Health 2003, 3rd World Congress and Exposition, Vancouver, B.C. For information, contact congress@venuewest.com

 

Updates. Contemporary Pediatrics 2002;12:11.