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AUTISM FIRST STEPS
AUTISM DAILY NEWSLETTER
Monday December 17, 2001
INDEX:
* Report Of Medical Research Council Autism Review
Now Published
* Child Development in Pediatrics
* "Imperfect" vaccines may encourage more potent
pathogens, model
suggests
* Iron deficiency and impaired child development
* Autism Infant and
Pregnancy Private Research Will BE Expanded in 2002
* Autism "no longer a rare condition"
******************************
Report Of Medical
Research Council Autism Review Now Published
MRC Review of Autism
Research
http://www.mrc.ac.uk/PDFs/autism_report.pdf
and Executive Summary of
the review
http://www.mrc.ac.uk/PDFs/autism_report.pdf
******************************
Child Development in Pediatrics
Beyond
Rhetoric
Barry
Zuckerman, MD; Marilyn Augustyn, MD; Steven Parker, MD
THE
EXTENSIVE recent focus on the importance of early childhood development by
multiple sources is unprecedented and indicates that it has become a national
priority. Most important for pediatricians, parents are listening! To ensure a
scientific base for programs and policy, the National Academy of Sciences
(Washington, DC), as published in its book From Neurons to Neighborhoods,1 has rigorously reviewed
the evidence on what is known about early child development and how to improve
outcomes. Among other findings, it reports that early childhood experiences
influence brain development and shape long-term behavioral outcomes and that
parental mental health problems, particularly maternal depression and family
violence, pose heavy developmental burdens on young children. The provocative
and influential book Developmental Health and the Wealth of Nations,2 produced by
a multidisciplinary group of scientists, synthesizes relevant research and
promotes the proposition that the social context during infancy contributes not
only to brain development but also to later adult health disorders. The Surgeon
General has recently touted the importance of early preventive mental health
measures for children.3 The first
national educational goal emphasizes that all children should start school
ready to learn.4
Popular magazines such as Newsweek and Time have devoted whole
issues to early child development. Three White House conferences spanning 2
administrations in the past 5 years have specifically focused on early
childhood issues. Such information challenges pediatricians and parents to
apply new insights to their patients and families.Studies show that parents may
not have accurate information about the developmental needs of children at
specific ages.5
Another study indicates that parents want more advice from pediatricians on how
to promote learning and reduce problematic behaviors.6 A parent
group for children with autism has started a national organization called First
Signs to call for regular systemic screening by pediatricians with validated
instruments, emphasizing the social and emotional aspects of development, to
identify autism spectrum disorder.7 Among its
many initiatives is a statewide pediatric effort in New Jersey. Systematic
screening by pediatricians has also been recommended by the American Academy of
Neurology (St Paul, Minn) and other professional organizations in response to
research showing an approximately 10-fold increase in the prevalence of autism
spectrum disorder.8 Because
parent groups have a long and special tradition of improving care for children,
it is likely that they, rather than professional organizations, will be more
effective in changing practice.How then should pediatricians respond to these
new and exciting challenges? Regalado and Halfon9 have
provided an important service by assessing evidence of the efficacy of selected
pediatric interventions to promote the behavior and development of young
children. Perhaps the most striking finding in their analysis is the small
number of methodologically sound studies performed during the past 20 years.
Why the paucity of good studies? First, the field is new. Second, funding is
minimal. Third, such studies are difficult to perform. Randomized prospective
controlled trials are essential, and the interventions may be hard to deliver
in a standardized way. Finding an appropriate control group (especially in a
primary care practice) is challenging, and it is not always clear which outcome
measures to examine, both in the short term and the long term.Some of the
authors' strongest data concern the efficacy of pediatric developmental
surveillance. Studies suggest that children with developmental and/or
behavioral problems can be better identified by questioning parents about their
concerns. Surprisingly, interventions for specific common and troublesome
problems, such as crying and sleep disturbances, have rarely been evaluated.
What data exist suggest potential effective interventions, although these are
rarely used. On a positive note, new evidence supporting the effectiveness of
pediatricians promoting early literacy as part of the Reach Out and Read
Program has been published since the review period ended. Two new studies10, 11 show that
this intervention, which includes giving parents developmentally appropriate
information on book sharing and giving children a developmentally appropriate
book at each pediatric visit from age 6 months to 5 years, improves language
scores among low-income children. This intervention is now practiced in more than
1000 pediatric sites nationally and to the best of our knowledge is the only
evidence-based pediatric strategy to promote learning and development (at least
in the language area) among low-income children.Whereas additional
evidence-based data must still be generated, important efforts catalyzed by a
national interest are under way to promote early childhood development in
pediatric practice. Child development training with a special emphasis on
primary care practice has been mandated by the Residency Review Committee for
pediatrics. Behavioral and developmental pediatrics has been awarded a
subspecialty board certification, which should lead to the expansion of
research and training. Programs are being systematically evaluated and
implemented nationally to change practice by promoting early childhood
development. A recent report describes multiple innovative strategies used by
pediatric sites for enhancing early childhood development services as a part of
health care for children from birth to 3 years of age.12 One type
of approach is to facilitate a seamless system by linking pediatric care with
other relevant community-based services such as prenatal classes at the
delivery hospital, family support, home visits, early intervention, and social
service agencies. These large-scale systems are being developed with little
involvement from pediatricians as part of statewide efforts in California,
North Carolina, Vermont, Minnesota, and other states.Another approach focused
on pediatric practices enhances early childhood development capacity within the
practice. The most completely developed effort in this regard is the Healthy
Steps for Young Children Program.13 This
initiative addresses not only early childhood development but also parental
health, especially maternal depression and safety in the home, as part of
pediatric care. A critical aspect of Healthy Steps is the addition of new
professionals to the pediatric practice: Healthy Steps specialists. Typically
these people are early childhood educators, nurses, or social workers. It is
their role to collaborate with the pediatric physician in providing a range of
services; some are evidence-based and many are not, but all are consistent with
the best practices.14 The old
model of the physician toiling alone, valiantly trying to address the
burgeoning agenda of medical and psychosocial issues, is transformed into a
team model. Imagine that your 20-minute pediatric health supervision visit is
followed by an early childhood educator spending approximately 30 minutes
developing strategies with parents to address concerns or problems that you
and/or they have identified, such as crying, night waking, appropriate
discipline, limit setting, dealing with a difficult temperament, marital
problems, aggression, and the promotion of learning. This specialist also makes
home visits, provides written materials and other resources, and is available
by telephone (and is able to spend more than 5 minutes) to address
developmental or behavioral issues. This approach provides a quality of
pediatric care difficult to achieve in a traditional practice because of time
and reimbursement constraints. In early analyses, participating parents and
pediatricians were very enthusiastic.15 Although
the data on the early effects are encouraging, the complete evaluation of this
program will not be available for another few years and will have important
implications toward both what and how we practice.We hope that when the
practice-based literature is reviewed in 20 years, data from methodologically
sound studies will serve as the base for effective and innovative pediatric
practices to better promote the development of young children. Pediatric
practice buttressed by sound efficacy studies should contribute to the
solutions offered in the national discussion of early childhood development. We
must not forget that medicine is both an art and a science. We cannot sacrifice
clinical knowledge and skill while waiting for science to catch up. Now is the
time to step up to the plate and go beyond rhetoric.
Author/Article
Information
Barry
Zuckerman, MD
Marilyn Augustyn, MD
Steven Parker, MD
Department of Pediatrics
Boston University School of Medicine
One Boston Medical Center Pl
Dowling 3 South, Suite 300
Boston, MA 02118-2393
(e-mail: Barry.Zuckerman@bmc.org)
This work was supported in part by the Commonwealth Fund, New York, NY; the
Harris Foundation, Chicago, Ill; and the Maternal Child Health Bureau,
Washington, DC.Barry Zuckerman is president of Reach Out and Read National
Center, Inc. The Commonwealth Fund is the largest funder for the development,
implementation, and evaluation of Healthy Steps.
REFERENCES
1.
Shonkoff K, ed, Phillips D, ed.
From Neurons to Neighborhoods: The Science of Early Child
Development.
Washington, DC: National Academy Press; 2000.
2.
Keating D, ed, Hertzman C, ed.
Developmental Health and the Wealth of Nations: Social,
Biological and Educational Dynamics.
New York, NY: Guilford Press; 1999.
3.
US Department of Health and Human Services.
Mental Health: A Report of the Surgeon General: Executive Summary.
Rockville, Md: US Dept of Health and Human Services, Substance Abuse and Mental
Health Services Administration, Center for Mental Health Services, National
Institutes of Health, National Institute of Mental Health; 1999.
4.
National Educational Goals Panel.
Available at: http://www.negp.gov. Accessed
October 1, 2001.
5.
What grown-ups understand about child development: a National Benchmark Survey.
Available at: http://www.zerotothree.org/parent_poll.html.
Accessed October 1, 2001.
6.
Young KT, Davis K, Schoen C, Parker S.
Listening to parents: a national survey of parents with young children.
Arch Pediatr Adolesc Med.
1998;152:255-262.
ABSTRACT
| FULL TEXT
| PDF
| MEDLINE
7.
First Signs Web site.
Available at: http://www.firstsigns.org/pages/delays_disorders/asd.html.
Accessed October 1, 2001.
8.
Filipek PA, Accardo PJ, Baranek GT, et al.
The screening and diagnosis of autistic spectrum disorders.
J Autism Dev Disord.
1999;29:439-484.
MEDLINE
9.
Regalado M, Halfon N.
Primary care services promoting optimal child development from birth to age 3
years: review of the literature.
Arch Pediatr Adolesc Med.
2001;155:1311-1322.
ABSTRACT
| FULL
TEXT | PDF
10.
High P, Hopmann M, LaGasse L, Linn H.
Evaluation of a clinic-based program to promote book sharing and bedtime
routines among low-income urban families with young children.
Arch Pediatr Adolesc Med.
1998;152:459-465.
ABSTRACT
| FULL TEXT
| PDF
| MEDLINE
11.
Mendelsohn A, Mogilner L, Dreyer B, et al.
The impact of a clinic based literacy intervention on language development in
inner city preschool children.
Pediatrics.
2001;107:130-134.
MEDLINE
12.
Right place, right time: managed care and early childhood development.
Children NOW Web site. Available at: http://www.childrennow.org/.
Accessed October 1, 2001.
13.
Zuckerman B, Kaplan-Sanoff M, Parker S, Taaffe-Young K.
The Healthy Steps for Young Children Program.
Zero to Three.
1997;17:20-25.
14.
Zuckerman B, Parker S.
Teachable moments: assessment as intervention.
Contemp Pediatr.
1997;14:41-53.
15.
Minkowitz C, Strobino D, Hughart N, Scharstein D, Guyer B.
Early effects of the Healthy Steps for Young Children Program.
Arch Pediatr Adolesc Med.
2001;155:470-479.
ABSTRACT
| FULL TEXT
| PDF
| MEDLINE
http://archpedi.ama-assn.org/issues/v155n12/ffull/ped10016.html
******************************
"Imperfect"
vaccines may encourage more potent pathogens, model suggests
A model that uses evolutionary theory to investigate the potential effect of
vaccines on public health suggests that vaccines designed to reduce pathogen
growth rate or toxicity might lead to more severe disease in unvaccinated
individuals. "Vaccines rarely provide full protection from disease, but
imperfect vaccines are used to protect individuals and whole populations. If a
vaccine selects for pathogens of higher virulence, this may lead to an increase
in mortality overall", explains lead researcher Andrew Read (Institute of
Cell, Animal and Population Biology, University of Edinburgh, UK). "The
impact of vaccines that are not expected to provide full immunity, such as
candidate vaccines for malaria, is of particular concern", he adds. Read
and colleagues applied their model to assess the potential effects of various
malaria vaccines currently in development. These include vaccines that
stimulate immunity to the three stages of the life cycle of Plasmodium
species, and also antitoxin vaccines. The model was set up with values typical
of year-round endemic P falciparum malaria in a high transmission area.
"The malaria model predicts that antigrowth rate and antitoxin vaccines
select for higher virulence, while anti-infection vaccines select for lower
parasite virulence", explains Read. In the right combination, however, the
beneficial effect of anti-infection vaccines can be used to reduce the
evolutionary risk of blood stage or antitoxin vaccines. The investigators also
estimated how long virulence evolution in a parasite might take after a
vaccination programme starts. "When we used malaria as an example to track
the spread of a virulence mutant through time, a 90% vaccine coverage with an
antigrowth rate vaccine of 80% efficacy caused the evolution of a mutant
parasite with twice the virulence", says Read. "In 38 years, the
higher-virulence mutant would have increased to 50% of the parasite population,
after which it would have very rapidly become the dominant form." Although
this time-scale is relevant to public health, it is outside the scope of
clinical trials (Nature 2001; 414: 751-56). Read warns that
antigrowth rate and antitoxin malaria vaccines that are widely used for their
short-term beneficial effect at the individual level could increase the risk of
mortality for unvaccinated people, such as young children and travellers.
Anthony Stowers (National Institute for Allergy and Infectious Diseases,
Bethesda, MD, USA) welcomes the principle of using models to assess the effect
of vaccines, but asks whether this model fits what we know about malaria.
"There has been widespread use of antimalarial drugs at suboptimal doses
since at least the early 1980s in areas like Papua New Guinea and resistant
parasites have emerged. This is analogous to the partial coverage of a partially
effective antigrowth vaccine but has not resulted in a noticeable increase in
deaths from malaria in these high endemic areas as far as I am aware", he
says. Kathryn Senior
http://www.thelancet.com/journal/journal.isa
******************************
Iron deficiency and impaired child development
The relation may be causal, but it
may not be a priority for interventionPapers p 1389
Iron deficiency affects 20% to 50% of the world's
population, making it the most common nutritional deficiency.1 In developing
countries about half of all cases of anaemia in women and children result from
iron deficiency, but other important and often coexisting contributors include
malaria, hookworm infestation, HIV, and deficiencies in other nutrients such as
vitamin A and folates. 2
3 Conversely,
anaemia is just one manifestation of iron deficiency, and there are forms of
mild to moderate iron deficiency in which anaemia is absent but tissue function
is impaired. In children iron deficiency develops slowly and produces few acute
symptoms. As the deficiency worsens children become pale and weak, eat less,
and tire easily. They gain weight poorly, have frequent respiratory and
intestinal infections, and may develop pica. The most worrying association is
that between iron deficiency and impaired development in behaviour, cognition,
and psychomotor skills. Over the past three decades many studies have
confirmed this relation, but whether iron
deficiency is the sole cause of these deficits remains unclear. Last year a
panel of experts concluded that a "sigevidence exists linking iron
deficiency anaemia and child development."4 A definitive link was
excluded, because anaemia is associated with many other disadvantages such as
poverty, low birth weight, malnutrition, poor education among mothers, and lack
of stimulation in the homnificant body of causal e
all of which also affect child development.
A consistent finding in different countries is that severe, chronic iron
deficiency in infancy identifies children with poorer cognitive function and
lower scores in school achievement tests, suggesting that irreversible
abnormalities result from a deficiency at a critical period of growth and
differentiation of the brain.5 Poorer function,
however, may also result from psychosocial and economic disadvantage. How
reversible, then, are these effects? A Cochrane review concluded that cognitive
or psychomotor skills in anaemic children aged less than 3 years failed to
improve within 5-11 days of giving iron. Trials with longer periods of
supplementation have mostly lacked randomised placebo groups and failed to show
benefits, but one of two small randomised studies found a clear benefit.6 In anaemic children 3 years or older the advantages of iron
supplementation are more convincing: six of eight double blind trials showed
benefits in measures such as achievement at school, concentration, efficiency,
discriminant learning, short term memory, and IQ.7 The paper by
Stoltzfus et al in this week's issue (p 1389)
is an important contribution.3 Their finding of
significant improvements in motor and language development after 12 months of
supplemental iron is strong evidence that replenishing iron can positively influence
development even in children with severe anaemia and iron deficiency. The
study's large sample size and double blind design allow stronger causal
inference. The paper also helps to clarify the contribution of anaemia and iron
deficiency to developmental delay, indicating that although iron's effect on
motor development is mediated through improved
haemoglobin concentrations and oxygenation, development of language is promoted
through other independent mechanisms. What is the appropriate public health
response to the high burden of anaemia and iron deficiency in preschool
children in poor countries? Preventing iron deficiency
is the obvious response. Promoting exclusive breast feeding for the first six
months of life and providing appropriately fortified weaning diets is the best
way forward; but, at best, 10% of mothers breast feed exclusively for six
months in many poor countries, and diets can improve only if poverty is reduced.8 Fortification of food has been successful in developed countries
but less so in the developing worldmost poor families cannot afford infant foods fortified with iron. Currently, targeting pregnant women and young children for iron
supplementation is the prefer Supplementation, however, is costly, distribution
mechanisms are often ineffective, and compliance is low. Furthermore, the World
Health Organization has said that, for maximum effectiveness inred strategy. controlling anaemia, "integration should be sought with
malaria prophylaxis, hookworm control, immunisation and environmental health
programmes as well as programmes for prevention of micronutrient malnutrition
and community based primary health care."9 Unfortunately,
implementation strategies have not kept pace with better scientific
understanding of the disorder, and the gap between the necessary and the practical
remains unbridged. There is no real prospect of a new generation of smarter and
stronger children, replete with iron. Is preventing iron deficiency in children
a priority in areas with few resources? It has recently been proposed, somewhat
idealistically, that as a minimum goal no child under two years should be
allowed to become anaemic.10 Fortification of
staple foods (cereals, flour, sugar, salt) to deliver micronutrients to children
on a large scale is probably the most sustainable and affordable option, even
though commitment from governments and the food industry is needed.
Supplementation is a much less attractive alternative, and scarce resources may
be better spent on increasing coverage of vaccination against measles and
hepatitis B, supplying bed nets impregnated with insecticide in malarious
areas, or improving access to nevirapine to prevent mother to child
transmission of HIV. These are tough but unavoidable choices.
Haroon Saloojee, senior lecturer. (092sal@chiron.wits.ac.za)
John M Pettifor, professor. Department of Paediatrics and Child
Health, University of the Witwatersrand, PO Wits, 2050, Johannesburg, South
Africa
1. Iron deficiency anemia: reexamining the nature and
magnitude of the public health problem. Proceedings of a conference. May 21-24,
2000. Belmont, MD, USA. J Nutr 2001; 131(suppl): 563S. 2. Micronutrients
Initiative/UNICEF. Proceedings of the eastern and southern African regional
consultation on anaemia, Ottawa , 1997. 3. Stoltzfus RJ, Kvalsvig JD,
Chwaya HM, Montresor A, Albonico M, Tielsch JM, et al. Effects of iron
supplementation and antihelminthic treatment on motor and language development
of preschool children in Zanzibar: double blind, placebo controlled study. BMJ
2001; 323: 1389-1393. 4. Stoltzfus RJ. Iron-deficiency anemia: reexamining the
nature and magnitude of the public health problem. Summary: implications for
research and programs. J Nutr 2001; 131(suppl): 697-700S[Medline].
5. Lozoff B, Jimenez E, Hagen J, Mollen E, Wolf AW. Poorer behavioral and
developmental outcome more than 10 years after treatment for iron deficiency in
infancy. Pediatrics 2000; 105: e51[Medline]. www.pediatrics.org/cgi/content/full/105/4/e51
(accessed 7 Sep 2001). 6. Logan S, Martins S, Gilbert R. Iron therapy for
improving psychomotor development and cognitive function in children under the
age of three with iron deficiency anaemia. Cochrane Database Sys Rev
2001;(3):CD0001444. 7. Grantham-McGregor S, Ani C. A review of studies on the
effect of iron deficiency on cognitive development in children. J Nutr
2001; 131(suppl): 649-66S. 8. United States Agency for International
Development. Population, health and nutrition: breastfeeding and child
survival. www.usaid.gov/pop_health/cs/csbfeeding.htm (accessed 23 Aug 2001). 9. WHO. Iron deficiency: indicators for
assessment and strategies for prevention. Geneva: WHO, 1997 (WHO/
NUT/96.12.) 10. Scrimshaw NS. Prevalence, consequences and prevention of iron
deficiency and iron deficiency anemia. International Micronutrient Conference;
2000 Jun 5-7; Quebec, Canada. www.micronutrient.org/framesets/resources/res_usi.htm
(accessed 23 Aug 2001).
http://bmj.com/cgi/content/full/323/7326/1377
******************************
Autism
Infant and Pregnancy Private Research Will BE Expanded in 2002
Through
our private research since early 2000 we are finding we may have found some of
the earliest detections for autism spectrum disorders in infancy adn pregancy.
We are finding many simular test results in children with autism in the newborn
hospital medical records as well as toddler to current testing records and
parent information. In the future we may be able to detect autism as early as
at pregancy and birth for children at risk for autism. We have also been
utilizing pictues of newborns and toddlers in a seperate research study. As
soon as the questionaire becomes available, Please take a few minutes to fill
out the questionaire form on the next page, so future children with autism may
benifit from your answers, Questionaire and more information coming soon in the
Autism FIrst Steps Newsletter.
******************************
Autism "no longer a rare condition"
10:24 13 December 01
Emma Young
A massive and co-ordinated research effort to identify the causes of autism is
urgently needed, say the authors of a major UK Medical Research Council review
of autism research. The review concludes that autism and related disorders are
far more common than previously thought - and that there is no firm evidence to
date linking any environmental trigger with the disease.Autism and related
disorders affect six in every 1000 children aged under eight, the team found.
The previous figure accepted by the MRC was between one and two per 1000. The
increase is down to altered ideas about what constitutes an "autism
spectrum disorder", as well as increased awareness of the condition, the
group says.Their review of previous research revealed no evidence of a link
between the controversial MMR vaccine and autism. The group also found no firm
evidence linking immunological or bowel problems with the disorder - links that
have been suggested by some researchers. "There have been some recent very
high quality epidemiological studies in the UK, but individually, these studies
are quite small. We need future research that is interdisciplinary and has the
strength of being population-based, so we're not studying biased samples of
children," says Carol Dezateux, a consultant paediatrician at the Great
Ormond Street Hospital in London, and a member of the review group.
Nature vs nurture
Judith Barnard of the UK's National Autistic Society, who took part in the
review, says: "We're very pleased with this report, which has been long
overdue. It's an area that has been woefully under-researched in the UK in the
past. Most importantly for me, the report formally recognises that autism can
no longer be considered to be a rare condition."The group says it is
increasingly clear that there is a genetic component to autism. But long-term
prospective studies of large numbers of children, including genetic, as well as
detailed health and lifestyle data, will be needed to help tease apart the
genetic and environmental components of the disorder, says Dezateux. Much more
basic biological work, to investigate differences between autistic and healthy
brains, for example, is also necessary, she says.
Dedicated funding
How that research will be co-ordinated is another matter. The MRC can boost
"robust" inter-disciplinary autism research proposals by targeting
funds at these projects, Dezateux says.But, says Barnard: "Two years ago,
the MRC issued a report on autism and bowel disorders and called for specific
research. Nothing on that list has yet been done, because they are waiting for
'robust' proposals.""We are asking the Department of Health for a
dedicated funding stream for autism research," she says, "and raising
the issue of a need for a pro-active body to implement the findings of these review."The
review is published on the MRC's website.
http://www.newscientist.com/news/news.jsp?id=ns99991687
******************************
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