Vaccine-Autism Federal Test Case
In June 2007, a US Court of Federal Claims tribunal began hearing the first of nine test cases that will examine whether certain vaccines and/or thimerosal can cause autism. The results of these test cases will determine whether autism will be added to the list of vaccine injuries, recognized by the Vaccine Injury Compensation Program (VICP). VICP, which is financed by a 75-cent surcharge on each vaccine, was established to protect vaccine manufacturers from lawsuits and thereby make sure that vaccine production continues. The program dispenses money for medical expenses, lost future income, and up to $250,000 for pain and suffering. Claimants are required to appeal to VICP before engaging in a lawsuit against the manufacturer. Unlike a product liability lawsuit, VICP claimants need only show a causal relationship. "If medical records show," Stephen D. Sugarman, JD, explains in a New England Journal of Medicine Perspective article, "that a child had one of several listed adverse effects within a short period after vaccination, the VICP presumes that it was caused by the vaccine (although the government can seek to prove otherwise)." Autism, however, is not on the list of covered adverse effects. About 300 autism-related claims have been rejected, and another 4800 autism claims are pending. Expert witness testimony from the nine test cases and their outcomes should provide guidance for settling other autism claims.

The first test case, Cedillo vs. Secretary of Health and Human Services, involves 12-year-old Michelle Cedillo, who developed symptoms seven days after receiving the measles, mumps, and rubella (MMR) vaccine. In addition to autistic symptoms, Michelle has inflammatory bowel disease, glaucoma, and epilepsy. She is confined to a wheelchair and uses a feeding tube. A ruling is expected in 2008.

People who do not receive compensation from VICP are permitted to file a regular lawsuit. Few do. They would have to convince a jury that the vaccine in question has a defective design or that it lacks necessary warnings about its use. Families of autistic children, however, have the power of large support groups, organized lawyers, and even federal senators and congressmen behind them. While a VICP ruling to include autism on its list of vaccine injury will not directly affect vaccine manufacturers, it could further erode public trust in vaccinations.

Bridges A. Children with autism get day in court. USA Today. June 11, 2007. Available at: www.usatoday.com/news/health/2007-06-11-3419893127_x.htm. Accessed January 18, 2008.
Mauro T. Test case linking vaccines and autism reaches federal court. Legal Times. June 5, 2007. Available at: www.law.com/jsp/law/LawArticleFriendly.jsp?id=1180947929140. Accessed January 3, 2008.
Sugarman SD. Cases in vaccine court – legal battles over vaccines and autism. N Engl J Med, September 27, 2007: 357(13): 1275-1277. Available at: www.NEJM.org. Accessed January 3, 2007.

DMG and Autism
Supplementation with N,N-Dimethylglycine (DMG) has been credited with bringing noticeable improvement in some children with autism. About 42% of 5367 children who took DMG in Autism Research Institute's survey "Parent Ratings of Behavioral Effects of Biomedical Interventions" (Feb 2006) got better; 51% showed no effect; eight percent reported worse behavior. In children who respond to DMG, parents and teachers report better verbal communication, better social interaction, better eye contact, improved affection, reduction in seizures, and improved sleep, according to Roger V. Kendall, PhD. In his book Building Wellness with DMG, Dr. Kendall explains that DMG benefits the neurological system and helps modulate the immune system. The compound provides glycine to make phosphocreatine, an energy source for the central nervous system and muscles. It also acts as a methyl donor. Methylation activates catecholaminergic pathways, which produce neurologic chemicals that affect behavior (e.g., dopamine).

Dr. Kendall recommends one to four 125 mg tablets per day for an autistic child and two to eight 125 mg tablets per day for an adult. He says to start by taking one tablet for two or three days, then gradually increasing the dosage to the desired amount by adding another tablet every few days. "If agitation or hyperactivity is seen," he writes, "it is recommended that folic acid should be given in the amount of two 800 microgram tablets for each 125 mg of DMG taken. Some professionals suggest that DMG should always be supplemented with folic acid."

DMG. Available at: www.dmgdoctor.com/dmg.php. Accessed January 3, 2008.
Kendall RV. DMG and autism. In: Building Wellness with DMG. California: Freedom Press; 2003: 96-118.

Agricultural Pesticide and Autism
A California study, published in Environmental Health Perspectives (October 2007), looks at the incidence of autism spectrum disorders (ASD) among children whose mothers were exposed to agricultural pesticide applications during pregnancy. Pesticides are known neurotoxins, and many can travel across the placenta to the fetus. Few studies, however, have looked at the neurological consequences of pesticide exposure in children. The population for this California study consists of 269,746 infants born between January 1, 1996 and December 31, 1998 to women living in the 19 counties that make up the California Central Valley (a highly agricultural area). Infant deaths, multiple births, and preterm infants were excluded. The researchers used California Department of Developmental Services files to identify children with ASD. The California Department of Pesticide Regulation provided agricultural pesticide application records during the four years after January 1, 1995. A reported 6,710,727 applications occurred during that period.

The researchers looked at pesticide application dates and gestation stage. They found that organochlorine pesticides were associated with ASD incidence. The association becomes smaller the farther the distance from the application site, becoming nonsignificant at 1,750 meters (1.085 miles). The most pesticide-sensitive stage of gestation appears to be in the eight weeks after neural tube closure. Organochlorine pesticides are used on cotton, fruits, vegetables, beans, and nuts. These halobenzene derivatives are generally metabolized by the cytochrome P450 system.

The California researchers say that their "results require replication in further studies and should be treated with caution." Some of the limitations of this study include the possibility of exposure misclassification since as many as one-in-three women changes her home address during pregnancy. Also, the researchers were unable to adjust for confounders such as prenatal vitamin use and the possibility that some mothers may have been employed in agriculture and not exposed simply through drift. This study is not trying to discount the role of mercury in ASD. Rather, it looks at other possible "environmental insults" that can lead to neurological problems. "ASD as currently defined," they write, "may well include multiple disorders that have not yet been successfully differentiated."

At least 200 scientists from a variety of fields have voiced concern about prenatal exposure to environmental chemicals. The International Scientific Committee at the International Conference on Fetal Programming and Developmental Toxicity (Faroe Islands, May 2007) stated in a position paper: "The old paradigm, developed over four centuries ago by Paracelsus, was that ‘the dose makes the poison.' However, for exposures sustained during early development, the most important issue is that ‘the timing makes the poison.' This extended paradigm deserves wide attention to protect the fetus and child against preventable hazards."

Early exposure to chemicals can affect long-term brain development, scientists warn. CRIME Times. 2007;13(3): 3.
Roberts EM, English PB, Grether JK, Windham GC, Somberg L, Wolff C. Maternal residence near agricultural pesticide applications and autism spectrum disorders among children in the California central valley. Environmental Health Perspectives. October 2007; 115(20); 1482-1489. Available at: www.ehponline. Accessed January 2, 2008.

Assistance for Developmentally Disabled
About 75% of the 4.6 million developmentally disabled people in the US receive in-home care from family members without public-funded aid. But families are now seeking help in growing numbers. Aging parents, in particular, are finding that their own decline in physical stamina and health as well as the financial strain makes caretaking increasingly difficult. Many families with disabled children live with financial challenges, partly due to the child's medical and therapeutic costs and partly due to home demands that take time and energy from focusing on a career. "The poverty rate among families whose children have developmental disabilities is nearly twice the national average, according to a 1998 study by Glenn Fujiura, an associate professor at the University of Illinois," Clare Ansberry wrote in The Wall Street Journal (September 20, 2005).

In 2005, an estimated 80,000 developmentally disabled people in the US were waiting for in-home help or an opening in a group home. Their wait can last years. Part-time, in-home help (while parents work) costs an average of $19,000/year. Group home care costs an average of $68,000 per year, about half the cost of state institution care. Half of public funding for developmentally disabled persons comes from the federal government (mostly Medicaid); 46% comes from the state; and local governments pay about four percent. Most states give priority to those who live on their own, need 24-hour care, or are homeless. Increased demand for services, rising costs, and a lack of home care workers have propelled states to raise eligibility requirements and limit the number served.

Ansberry C. Needing assistance, parents of disabled resort to extremes. The Wall Street Journal. September 20, 2005; A1, A5.

ADHD Treatment Study Update
A three-year follow-up to the 1999 Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (MTA) reports that "children continue to experience improvement in their symptoms regardless of which treatment they use"(my emphasis). In the original 1999 randomized study, 579 children, aged seven to ten years, received stimulant medication (e.g., Ritalin), intensive behavior therapy, a combination of medication and behavior therapy, or community care ("whatever the parents could find"). The researchers evaluated attention deficit hyperactivity disorder (ADHD) symptoms, Oppositional Defiant Disorder symptoms, reading achievement scores, functional impairment, and social skills, using parent, teacher, and clinical evaluations. Children in the stimulant group and in the stimulant-plus behavioral therapy group had significantly better evaluations than those receiving community care or behavioral therapy alone. At the end of the 14-month study period, families were free to use whatever treatment they wished or to stop treatment altogether.

At 36 months, 485 children from the initial study (now ten to 13 years) were re-evaluated (Jensen PS, et al. Three-year follow-up of the NIMH MTA study. J Am Acad Child Adolesc Psychiatry. 2007;46:988-1001). In this follow-up, 71% of children who took stimulants in the original study were still taking ADHD medication at a "high level." Also, 62% of those in the community care group and 45% of the behavioral therapy-alone group were on high levels of medication. Overall, however, the advantage of taking ADHD medication for an extended period had disappeared. The researchers even looked at the number of days the children were on medication and found "no significant difference in ADHD symptoms." The researchers were reportedly "struck by the remarkable degree of improvement found in all of the subjects over time." Even though the children, on average, had some symptoms, the symptoms were no longer severe. "The benefit for patients may be related to the extra attention brought by participation in the study or may reflect ‘a natural waning of symptoms,'" the researchers say. Without a control group of children who received no treatment, these researchers could not be sure if ADHD symptoms decline without treatment as a child matures.

Doheny K. After 3 years on Ritalin, kids are shorter, lighter than peers. WebMD Medical News. July 20, 2007. Available at: www.medicinenet.com/script/main/art.asp?articlekey=82704&pf=3&page=1. Accessed January 9, 2008.
Elias M. Kids treated for attention deficit get better in a few years. USA Today. July 19, 2007. Available at: http://www.usatoday.com/news/health/2007-07-19-adhd_n.htm. Accessed December 27, 2007.
Phend C. ADHD therapies hold roughly uniform benefit in the long run. Medpage Today. July 20, 2007. Available at: www.medpagetoday.com/Pediatrics/ADHD-ADD/tb/6205. Accessed January 9, 2008.

EEG Neurobiofeedback and ADHD
EEG neurobiofeedback can teach children with ADHD how to focus their attention, according to recent studies. The therapy usually involves a screen display (often in the form of a video game) that responds to a child's brain waves. When children produce brain waves that indicate focused attention, they win. When the brain waves slip into daydream mode, they lose. Thom Hartmann explains in his book The Edison Gene (reviewed in this issue) that, in the process, children learn what it feels like to be in a focused state and how to return to that state when the mind wanders.

Researchers are using double-blind controlled studies to verify neurobiofeedback's effect on children with ADHD. In an editorial, Laurence M. Hirshberg of The Neuro-Development Center (Providence, Rhode Island), refers to a study by R. DeBeus, presented at The Annual Meeting of the American Psychiatric Association, Toronto, Canada, in May 2006. The study involved 42 children with ADHD, randomly assigned to an active neurobiofeedback group or to a sham-treatment group. Demographic, diagnostic, intelligence quotient, and achievement score variables were very similar in the two groups. Three behavior measures and a quantitative EEG indicated "highly significant improvements" in the active treatment group. Four other controlled group studies indicate that the response rate to neurobiofeedback is similar to medication response rate (about 75%), according to Richard Sogn, MD. In addition to improving attention, neurobiofeedback often reduces a child's anxiety and increases emotional regulation. "Parents will say something like, ‘I'm not sure his attention is better yet, but he sure is easier to live with,'" Hirschberg writes. "In parallel with this, we often see improved parent-child relationships and reduced parent and familial stress."

Neurofeedback works best when the child is motivated and at an age that finds "winning the game" interesting. Older children can find the game boring. Also, the older the client, the more difficult it becomes to make EEG changes. Neurobiofeedback treatment for ADHD takes at least 40 sessions, costing up to $100 per session. Benefits may not be noticeable until midway through the treatment. Neurobiofeedback, like medication, works best when used in conjunction with other therapies such as nutritional counseling, improving parenting skills, individual educational plans, social skills training, and medication.

Hirshberg LM. Place of electroencephalographic biofeedback for attention-deficit/hyperactivity disorder. Expert Rev. Neurotherapeutics. 2007;7(4): 315-319. Available at: http://neurodevelopmentcenter.com/fileadmin/uploads/Hirshberg_Editorial.pdf. Accessed January 9, 2008.
Kane A. The role of neurofeedback in ADHD treatment. (September 19, 2004). Available at: http://addadhdadvances.com/neurofeedback.html. Accessed January 9, 2008.
Sogn R. ADHD and neurofeedback. (April 26, 2006) Available at: http://blogs.webmd.com/adhd-medications-and-treatments/2006/04/adhd-and-neurofeedback.html. Accessed January 9, 2008.

Gluten-Free-Casein-Free Diet and Autism
Actress Jenny McCarthy promoted the importance of diet, specifically a gluten-free-casein-free diet (GFCF), for children with autism when she talked about her son Evan on The Oprah Winfrey Show (September 18, 2007). Casein is a phosphoprotein found in milk products. Gluten is a protein that gives dough made from wheat, rye, barley, or oat flours its elasticity. Autism Research Institute reports that 65% of the 1818 children whose parents kept them on a GFCF diet reported improved behavior.

Jenny McCarthy removed wheat and dairy from Evan's diet even though he did not test positive for gluten allergy. The improvements she saw encouraged her to remove artificial colorings (which contain heavy metals), sugar, and yeast from his diet. In Evan's case, yeast overgrowth apparently played a significant role. "Evan started to come out of autism completely after I killed CANDIDA (sic)," McCarthy writes. "Evan is still on the GFCG diet, and if I take him off or feed him sugars, his candida comes back and so do old autism characteristics."

Keeping a child on a restrictive diet can seem overwhelming. Several parent support groups on the Internet, including www.gfcfdiet.com, provide guidance. McCarthy also recommends Talk About Curing Autism (www.TACAnow.org). Both McCarthy and gfcfdiet.com emphasize that "there is NO cheating!" Reading ingredients listed on food labels is essential for this program to work. "You can't give a little here and there [even unintentionally] and still expect to see a change," say writers at www.gfcfdiet.com. A lactose-free product may still contain casein (caseinate), and once-acceptable products may have an ingredient change that triggers symptoms. At www.gfcfdiet.com, writers recommend keeping a food, behavior, and symptom (rashes, diarrhea, etc.) journal to see what is or is not working. It usually takes about two to three months for results.

That first month can be hard, though, if the child rebels and refuses to eat acceptable foods. For the diet to work, parents must keep their resolve. "Because [Evan] could only eat the foods that I put in front of him," Jenny McCarthy writes, "I knew sooner or later he would eat. It was a struggle at first, but let's face it, sooner or later they get REALLY hungry, and they're gonna eat what you give them. You just need to be strong. Eventually he adjusted and now only prefers GFCG." While diet is not a cure-all for autistic syndrome disorders, it has been credited with improving speech, readiness/ability to learn, better bowel function, less cranky behaviors, and more affectionate and less self-stimulatory behaviors in many children.

Autism Research Institute. Parent Ratings of Behavioral Effects of Biomedical Interventions. ARI Publ. 34/Feb. 2006.
GFCFDIET. About us. Available at: www.gfcfdiet.com/NewPage2.htm. Accessed December 27, 2007.
Lindgren, DC. Artificial food and cosmetic coloring: A hidden source of toxic metals. Available at: www.townsendletter.com. Accessed January 22, 2008.
McCarthy J. Things I didn't get to on the show that I'd like say…[sic]. Available at: http://gfcfdiet.com/Jenny.htm. Accessed December 27, 2007.
Talk about Curing Autism (TACA). Gluten free/ casein-free (GF CF) dietary intervention. Available at: www.talkaboutcuringautism.org/gfcf-diet/gfcfdietintro.htm. Accessed December 27, 2007.

Methyl-B12
Methylcobalamin (methyl-B12), given as a subcutaneous injection or as a nasal spray, can have a significant effect on language and speech, eye contact, and socialization in children with autism. Dr. James Neubrander initiated the use of methylcobalamin injections in 2002. He based the treatment on oxidative stress and methionine synthase research by Richard Deth, PhD, and Jill James, PhD. According to Defeat Autism Now! doctor Jaquelyn McCandless, MD, 25 mg/ml injections at 64.5 mcg/kg of body weight every three days is the optimal volume and dose. The subcutaneous injections are given with a BD 3/10 cc insulin syringe with an 8 mm, 31-gauge needle.

Stan Kurtz, an independent researcher and father of an autistic child, developed the MB12 nasal spray idea. His research indicates that MB12 nasal spray may be helpful to some people with memory problems, anxiety, chronic fatigue, sleep regulation, chemical sensitivity, asthma, irritable bowel syndrome, inflammatory conditions, migraines, ADHD, and autism. MB12 nasal spray begins to work within minutes. In a March 2006 trial, it apparently normalized brain waves in a 23-year-old with DSM-IV Attention Deficit Disorder. Three post-tests, including one immediately after using the nasal spray, "showed a dramatic lessening of theta wave activity (3.5-7.5 Hz)" from baseline. Theta wave activity occurs when people are daydreaming and not focused or attentive. The subject also began more relaxed and attentive.

MB12 nasal spray requires a prescription in the US and is available from compounding pharmacies that are familiar with Defeat Autism Now! protocols. The dosage for the nasal spray is less exact than for the injection. "We suggest you use as little as you need to get the desired results," Stan Kurtz writes. "Using more does not mean better results. Taking a break from time to time or trying to space out your administration is a good practice to make sure you are not administering too much."

A person's response to the vitamin depends on individual biochemistry and physiology and on environmental factors. Mode of administration is a factor. Some people experience a beneficial effect with the nasal spray but no effect with the injections and vice versa. A few people experience side effects after receiving a dose of MB12 nasal spray, including temporary hyperactivity, headaches, crankiness, and/or sleepiness (especially if taken on an empty stomach). If such symptoms occur, Stan Kurtz's website (www.childrenscornerschool.com) suggests trying other types of detoxification before using methyl B12 again.

Kurtz S. MB12 Nasal spray summary (draft document) March 16, 2007. Available at: www.childrenscornerschool.com/mb12nasalspray.htm. Accessed January 1, 2008.
McCandless J. Clinical use of methyl-B12 in autism. Autism Research Institute Newsletter. 2005;19(4). Available at: www.autism.com/ari/editorials/ed_b12.htm. Accessed January 1, 2008.

PhosphatidylSerine, Omega-3, and ADHD
"PS [PhosphatidylSerine] has a unique molecular structure that makes it a building block for all the cells of the body," Parris M. Kidd, PhD, says in his book PS (PhosphatidylSerine) Nature's Brain Booster for Memory, Mood, and Stress. "When added to the daily diet as a supplemental nutrient concentrate, PS can have great benefits for the human brain." Even though every cell membrane in the body contains this compound, nerve cells need it the most. Without phosphatidylSerine (PS) in their membranes, nerve cells can neither produce nor conduct electrical impulses. The PS molecule is designed to carry two fatty acids, one of which is the omega-3 fatty acid docosahexaenoic acid (DHA). DHA is essential for healthy brain and nerve function. Studies indicate that omega-3 fatty acids can also reduce ADHD symptoms. PS supplementation increases energy production in the brain and can improve memory, learning, comprehension, and word recall, according to research.

Preliminary evidence suggests that PS can help children with behavioral and attention problems. Carol Ann Ryser, MD, a physician who treats children with ADHD, and Dr. Kidd performed a pilot study involving 27 children, ages three to 19 years. Dr. Ryser added 200 or 300 mg of PS per day (depending on body size) to her usual "best [treatment] program" for each child. "PS produced marked, clinically meaningful benefit for 25 of the 27 children," Dr. Kidd reports. Attention, concentration, learning, and behavior improved with PS use. No adverse effects or drug interactions were reported.

Kidd Parris M, PhD. PS (PhosphatidylSerine) Nature's Brain Booster. St. George, Utah; Total Health Communications, Inc.; 2005.
New research supports value of omega-3 supplements in reducing ADHD symptoms. CRIME Times 2007;13(3):4,5.

Early Thimerosal Exposure and Neuropsychological Outcomes
In September 2007, New England Journal of Medicine (NEJM) published a widely publicized study called "Early Thimerosal Exposure and Neuropsychological Outcomes at 7 to 10 Years." William W. Thompson, PhD, from the Influenza Division and Immunization Safety Office, Centers for Disease Control and Prevention (Atlanta, GA) led the study, which involved 1047 children. The children and their mothers received their health care through one of four HMOs since the child's birth. Children whose birth weight was less than 2500 grams or who had encephalitis, meningitis, hydrocephalus, or other conditions that "could bias neuropsychological testing" were excluded. HMO records provided the data used to assess the children's exposure to mercury in thimerosal-containing vaccines during the prenatal period, the neonatal period (birth to 28 days), and the first seven months of life. The children, ages seven to ten years, completed standardized tests to assess 42 neuropsychological outcomes. The conclusion reads: "Our study does not support a causal association between early exposure to mercury from thimerosal-containing vaccines and immune globulins and deficits in neuro-psychological functioning at the age of 7 to 10 years."

The January 3, 2008 issue of NEJM contains two critical letters. Sallie Bernard, executive director of SafeMinds and a member of the panel of external consultants for this study, writes, "The sample was skewed toward higher socioeconomic status and maternal education" and "[excluded] children in higher-mobility families, who tend to have lower academic and behavioral function." Also, "only 30% of families selected for recruitment participated, a low rate for scientific research." In their response, the authors say they "controlled for socioeconomic factors, maternal education, and maternal IQ in the statistical analyses."

In the second letter, James P.K. Rooney raises questions about nutritional and genetic factors that may influence results. The authors respond: "Although nutrition and genetics play an important role in neurodevelopmental outcomes, we believe (my emphasis) that the factors pointed out by Mr. Rooney were unlikely to confound the results of our study because they are unlikely to be correlated with thimerosal exposure."

In the study's discussion section, the authors admit that prenatal exposure to methyl mercury, found in fish, has "significant negative effects" on neuropsychological performance (e.g., speech and verbal abilities, dexterity, attention, and visuospatial abilities). "However, the appropriateness of methyl mercury as a referent for assessment of exposure to ethyl mercury from thimerosal is questionable," they assert, "since the half-life of ethyl mercury in blood (<10 days) is much shorter than the half-life of methyl mercury (> 20 days)." The reference for this statement is a 2005 National Institute of Environmental Health Sciences study by Thomas M. Burbacher and colleagues, "Comparison of Blood and Brain Mercury Levels in Infant Monkeys Exposed to Methylmercury or Vaccines Containing Thimerosal." In this study, infant monkeys were given methyl mercury (via oral gavage) or IM injections of thimerosal-containing vaccines at birth and one, two, and three weeks of age. The researchers measured blood mercury (Hg) levels two, four, and seven days after each exposure and total and inorganic brain mercury levels at intervals after the final exposure. Although the half-life of ingested methyl mercury is longer than injected ethyl-mercury, the authors of this study do not make the leap that one mercury compound is less or more toxic than the other. "The current study indicates that MeHg," they conclude, "is not a suitable reference for risk assessment from exposure to thimerosal-derived Hg. Knowledge of the toxicokinetics and developmental toxicity of thimerosal is needed to afford a meaningful assessment of the developmental effects of thimerosal-containing vaccines." Have toxicokinetics and/or developmental toxicity studies been performed?

This study includes five pages of outcome statistics. It looks impressive, even daunting. But I wonder what the researchers used as a control. Have these neuro-psychological tests ever been given to a cohort of mercury-free kids? Is that even possible?

Bernard S. Early thimerosal exposure and neuropsychological outcomes (letter). N Engl J Med. January 3, 2008: 358(1):93-94. Available at: www.nejm.org. Accessed January 3, 2008.
Burbacher TM, Shen DD, Liberato N, Grant KS, Cernichiari E, Clarkson T. Comparison of blood and brain mercury levels in infant monkeys exposed to methylmercury or vaccines containing thimerosal (abstract). Environmental Health Perspectives. April 21, 2005. Available at: www.ehponline.org/docs/2005/7712/abstract.pdf. (519KB .pdf) Accessed January 3, 2008.
Rooney JPK. Early thimerosal exposure and neuropsychological outcomes (letter). N Engl J Med. January 3, 2008: 358(1):93-94. Available at: www.nejm.org. Accessed January 3, 2008.
Thompson WW, Price C, Goodson B, et al. Early thimerosal exposure and neuropsychological outcomes at 7 to 10 years. The New England Journal of Medicine. September 27, 2007; 357(13): 1281-1292. Available at: www.nejm.org. Accessed January 1, 2008.