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Autism is the fastest-growing developmental disability in the United States – more children are now diagnosed with Autism Spectrum Disorders (ASD) than with cancer, diabetes, and AIDS combined. The rate of ASD has increased from 1 in 100,000 births to 1 in 54 male births, as reported by the Centers for Disease Control in 2012.
A comprehensive biomedical workup for autism encompasses much of what we already do in complementary medicine, but also involves a different perspective, due to the needs of this unique population. Many of these children have sensitivities that affect them in ways well beyond what most physicians typically see in family practice, in terms of cognition, behavior, social functioning, and language development.
The treatment of ASD is relevant to the clinical experience of physicians in integrative medicine because many of these kids have the same underlying medical issues we usually see in adult patients suffering chronic ill health, such as gut disorders, persistent bacterial or yeast overgrowth, immune dysfunction, multiple food sensitivities, nutritional imbalances, and undiagnosed viral infections. However, these health issues affect them in unusual ways that tend to be underappreciated.
When young patients present with these symptoms, how do we triage their issues? How can we prioritize lab testing and treatment, given the range of causal factors and symptoms and the tremendous expense that may be incurred by the family?
Although each of these children tends to be highly unique as an individual, as a group they have many issues in common, reflected in unusual developmental and behavioral patterns. As a doctor involved in complementary medicine for decades, when I began working with autism, I quickly realized that the autistic spectrum encompasses every aspect of the conditions typically treated in integrative practice. Autism does not necessarily manifest as inflammatory joint conditions or chronic fatigue, but the underlying biochemical imbalances are often the same.
Children with ASD frequently have extensive gastrointestinal issues, resulting in chronic inflammation that can affect them neurologically. Many of them have extreme reactions to foods. They may have yeast or bacterial overgrowth and/or parasitic infections. These common underlying dynamics can manifest as behavioral problems, learning disabilities, or cognitive imbalances.
What is it about the autistic child that is unique?
When we look at children on the autism spectrum, I believe that we are seeing the impact of environmental factors on crucial brain development. One of the distinguishing features of autism is the influence of environmental exposures and insults, neurologically and biochemically, on a child's nervous system at different vulnerable developmental stages. Environmental toxins – whether due to yeast or bacterial biotoxins, a vaccine, food, or some other type of environmental insult – affect these children at a critical point in brain development when neural pathways have not completely come together, and brain centers are still being integrated. This matrix of factors manifests in the various symptoms we now call autism.
Many of these same underlying problems from infections, foods, or environmental exposures also occur in adult life, but at that point we have transitioned through these essential developmental milestones. As we age, the brain and nervous system develop, stabilize, and mature. Neural pathways are established and are no longer as vulnerable as they were when we were children.
There are also a number of different causes and determining factors in ASD. Certainly, genetic influences play out in a subgroup of kids, but these conditions do not all have the same etiology and the symptoms do not fall in a predictable pattern. That said, most of the kids have some degree of problems in four major areas: cognition, language, socialization, and behavior. Some children have receptive or expressive language issues that are much more involved than others. Some are more social and others are completely antisocial, but again there is a spectrum with different levels of severity across a range of symptoms. Many have behavioral problems that may involve aggressive or self-injurious activity or even psychotic behaviors. Some are happy-go-lucky. They like to be held and to be around their parents or other kids, whereas other children on the spectrum shy away from social contact. There is also odd, stereotypical activity that we see in almost all of these children, involving self-stimulatory or sensory-seeking behavior. They all tend to have some aspect of those behaviors.
The Intake Interview
When I see a child for the first time, I want to get feedback from the parents on the major problems affecting their child. I ask a series of open-ended questions and then begin developing a treatment program around the issues that emerge. Typical questions include: Does your child have a medical history of any concern? I always want to get an idea from the parent as to what their child's development was like. Were there any problems in the first year of life? Were they hitting their milestones? I also want to know what the child was like as he or she transitioned into the second year. The vast majority of kids on the autism spectrum usually show more pronounced problems around 15 to 18 months. That is often the point at which parents begin to notice a lack of language, poor eye contact, or strange behavior (spinning in circles, hand flapping, or not playing with their toys appropriately). The child may be having more meltdowns or perhaps they are just not connecting socially with other children or with their parents anymore. Typically, children on the spectrum are diagnosed by 2½ to 3 years of age.
Many of the kids that we see today have what is termed regressive autism. That is, the parents describe a normal pregnancy, normal delivery, and good development early on, with the child hitting milestones on time. Often around 14 to 16 months, these children begin to change, sometimes quite rapidly. This is one of the situations in which we see children lose language, lose eye contact, and develop some form of strange behavior.
In some cases, viral vaccines are a problem. The media and the traditional medical community want to deny there is a link to the MMR (measles, mumps, and rubella) vaccine. However, I have seen a fair number of kids who are still reacting to that vaccine, so I ask about vaccine history. Did the parents notice any changes in their child after vaccinations – changes involving irritability, sleep disturbance, poor eating habits for a couple of weeks, a fever, or a rash – anything that might give some indication of an adverse immune reaction?
When children react to a vaccine adversely, we see this same regressive pattern: loss of eye contact and language, and strange behaviors. Often there is also an impact on the digestive system, leading to persistent diarrhea, abdominal bloating, and increasing food intolerance, none of which was evident before the vaccine. Consequently, a history of adverse reactions to vaccines is important to determine.
Sometimes these patterns are linked to a vaccine reaction, sometimes not. I believe these issues go beyond the mercury preservative thimerosal, which was so prevalent in vaccines in years past. Some of the children on the autism spectrum have a history of heavy metal exposure, and we see this worldwide. The type of exposure seems to be dependent on the region where the child lives. Every autistic child from China that I have seen has tested high for arsenic levels. Children from the Central Valley in California, near the farming communities, also test high in arsenic. In the Middle East, South America, and Indonesia, we see high levels of lead. I can almost predict the test results based on where the child lives. Heavy metals are certainly a part of the autistic condition, but it is not all due to thimerosal.
I make it a point to ask parents about other major issues affecting their child. Do they have any allergies or reactions to medications? We talk about receptive and expressive language development. I inquire about socialization. Do they have any social interest or are they completely disinterested? Are they looking at other kids? Do they reach out to other kids? Are they playing appropriately? I want to know about behavior, including obsessive-compulsive problems, and issues such as anxiety.
Establishing a Baseline
It is helpful to get an idea of what parents have already done, so we talk about biomedical interventions and any other therapies they have tried. Many of them have already tried or are currently doing dietary intervention, such as the gluten-free, casein-free diet. Often parents have also started some basic supplements. There are numerous websites that have starter supplements for kids on the spectrum, and this is perfectly appropriate.
I encourage parents to monitor their child's response to each intervention. I want to get an idea of what they are seeing: Has the child started sleeping better? Does the child have improved eye contact? With every therapy they do, I like to get an idea of what changed. I suggest that they make one change at a time, so they can monitor the effects.
Sometimes they have seen doctors, sometimes they have not. My goal is to get an idea of what they have tried and what has worked best for their child. I ask, if you were going to redo everything you have done, what would you be sure to do the second time around? I always want to find what has helped in the past, because if something has worked, we either want to continue it or, in some cases, come back to it at a later time. Invariably, it comes down to three basic interventions:
1. Diet. The vast majority of these kids get improvement with dietary modification, often a gluten-free, casein-free diet – or some other form of dietary intervention.
2. Supplements. Usually, the family has tried some type of nutritional supplement that has helped their child, whether it is a multivitamin, cod liver oil, probiotics, or digestive enzymes.
3. Methyl-B12 injections. This injection therapy is almost always on the list of what has worked best. It improves the underlying methylation imbalances that are so common in autism. We often see great improvements in environmental awareness, language development, and cognitive skills with this therapy. Methyl-B12 is a tremendously effective treatment, which I have detailed in a book on how to clinically implement methyl-B12 in autism intervention (available at www.MethylB12ForAutism.com).
Tracking Adverse Effects
Another equally important question is, what made the situation worse? What happened? Did a particular therapy or environmental exposure cause an allergic reaction, bowel problems, or behavioral issues?
There are certain therapies to which some kids react quite strongly. That is important to know, because you want to be aware of other therapies that might have a similar effect on a child's sensitive chemistry. Highly sensitive kids, for example, may react to a B vitamin or to a probiotic of some kind.
I always ask parents where they are doing their research: what they are reading, which websites they use, and the support groups to which they belong. What other types of treatment would they like to try? What is their gut instinct about their child? As doctors, we know a lot about medicine, about the therapies and supplements we use, but parents know their child intuitively, so I want to know what they think. Many parents are quite insightful. The vast majority of parents I've worked with who have kids on the spectrum are highly motivated and highly educated. They study, they pay attention, and they are invested in the process of helping their child get well, so it behooves me as a physician to tap into that knowledge, to help them help their child.
This process does not take a great deal of time, perhaps fifteen minutes of conversation as part of an initial intake. This type of interview provides a great deal of background information and you can expand from there.
Nonblood Lab Tests
Organic Acids. To screen for the most common problems underlying autism, I believe that every child should have an organic acids test (OAT) from Great Plains Laboratory. If I could run only one test on a child, this would be the one I would order. The test is in depth with respect to cellular metabolism and various nutritional markers, as well as markers for neurotransmitters and toxins of yeast and bacteria. From that information, a great deal of therapy can be implemented, whether that involves treating for yeast or clostridia bacteria or perhaps modifying various supplements. I think every child on the autism spectrum should have this test performed, regardless of the severity of their condition.
Additional testing. Other nonblood tests that I feel are essential for these kids include the following:
· Comprehensive Digestive Stool Analysis (CDSA) – a more in-depth assessment of gut function
· Urinary peptides test – an analysis that evaluates for elevated peptides of gluten and casein
· Hair analysis – an easy-to-obtain screening for heavy metal exposure
· Urinary porphyrins test – a cellular index of heavy metal toxicity at the mitochondrial level
The CDSA is available from Great Plains Laboratory (GPL), Genova, and Doctor's Data. The porphyrin and urinary peptides are done by GPL, and the hair analysis is available through both GPL and Doctor's Data. GPL accepts numerous different types of insurance, so for many patients there is the potential for insurance reimbursement.
This preliminary testing rounds out a substantial nonblood test assessment for a child, providing a great deal of useful information. Again, if only one test can be done, do the OAT from Great Plains Laboratory.
If blood testing can be performed, then initially I recommend the following lab tests:
· Complete blood count with differential
· Liver panel
· Anemia panel
· Thyroid panel, including TSH (thyroid stimulating hormone), free T3, and free T4
· Lipid panel – make special note of total cholesterol, which is often low in autistic children
· Vitamin D3 (25-OH – 25-hydroxyvitamin D)
These blood chemistry panels can be done by almost any lab: LabCorp, Quest, and some local hospitals.
Food sensitivities. I recommend comprehensive IgG testing for food sensitivities. I do mine at Great Plains Laboratory because they also have a blood spot test (finger prick), which tends to be easier for highly sensitive children.
Nutritional deficiencies. The most common deficiencies we see are primarily vitamin D, zinc, and sometimes iron. Vitamin D is often deficient in these kids. Iron deficiency can be a contributing factor in the sleep problems associated with autism. In addition, more subtle factors may show up in the testing, such as a cholesterol deficiency.
Low cholesterol levels are a problem for many children on the spectrum, because cholesterol is essential to brain development. Healthy fats are required for the myelination of the brain and for the health and repair of cell membranes. Cholesterol supports adrenal pathways and sex hormone production and is also critically important in improving the efficiency of oxytocin receptors in the brain. The vast majority of kids on the spectrum have a problem with oxytocin function, which can result in problems with socialization and cause symptoms of anxiety.
These introductory lab tests provide a great deal of information regarding metabolic conditions, low cholesterol problems, mitochondrial imbalances, thyroid issues, anemia, yeast and bacteria overgrowth, markers for neurotransmitter level imbalances, food sensitivities, and heavy metal exposure. This initial panel of tests supports 80% of the biomedical interventions found to manage and sometimes reverse autism. With this information, the integrative medicine provider can take an evidence-based approach that goes well beyond general screening for food allergies and other common problems identified in blood work.
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