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Evaluating the Results
Underlying problems seen with almost all of these children include chronic yeast (candida) and bacterial overgrowth. Most concerning is clostridia bacteria, which can be identified on the OAT. In fact, the Great Plains Laboratory OAT is often exceptionally helpful in identifying clostridia, because it checks for various toxins produced by the bacteria. These toxins can greatly influence brain chemistry and lead to behavioral problems, sometimes manifesting as self-injurious and aggressive behavior. The diagnosis of undetected clostridia is one of the reasons I always recommend that families do the OAT instead of automatically electing antifungal therapy as their primary approach. If the child has an underlying problem with clostridia as well as yeast, both conditions need to be addressed simultaneously.
The choice of treatment depends on the severity of these conditions and the underlying biological factors that are driving the child's behavior problems. From a traditional medical standpoint, if clostridia is present, you can treat it with Flagyl (metronidazole) or vancomycin as an antibiotic option. Concurrently, nystatin or Diflucan (fluconazole) can be given, with probiotics as supportive therapy following the antibiotics. For a child who is physically and emotionally sensitive to medication, regimens with other supplements may be implemented, such as grapefruit seed extract, oil of oregano, uva ursi, etc. Various antiparasitic herbs have been used in treating both yeast and bacteria as well. Certain probiotics, such as Culturelle (Lactobacillus GG), have a specific affinity to clostridia bacteria. VSL#3 is another effective probiotic manufactured at very high potency that has an affinity for clostridia bacteria and is frequently used in treating inflammatory bowel disease. It's important to note that sometimes kids who are really sensitive to antibiotics are also highly sensitive to the herbs, so it is not as though the herbs are always 100% effective or less potent.
Additional Workups
PANDAS. If you suspect that a child has PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections), then it is important to run a strep panel, checking for ASO (antistreptolysin O titer) and the anti-DNaseB titers. Great Plains has a streptococcal panel for these two markers, which are specific for the group A beta-hemolytic strep known to trigger PANDAS.
Immune deficiencies. Children with immune deficiencies often have a history of chronic, repeated ear, throat, or sinus infections over the course of months and years. If they have been on multiple antibiotics or tend to have repeated outbreaks of herpes lesions, this merits an in-depth immune assessment. I begin with total immunoglobulin tests for IgA, IgG, and IgM from GPL or a conventional lab. I also commonly perform a T- and B-cell analysis, and a natural killer (NK) cell analysis. LabCorp and Quest can do the majority of these tests: the ASO, anti-DNaseB, total immunoglobulins, and the T- and B-cell and NK cell analysis. Great Plains has an immune deficiency panel, which includes these immunoglobulin markers, plus subclasses of IgG for a more in-depth evaluation.
Viral titers. Approximately 60% to 70% of these children have high viral titers. Unfortunately, we are not able to test for all of them. When I suspect that the herpes viruses are primary in a case of autism, I do a viral panel to check IgG and IgM for herpes 1 and 2, HHV 6, Epstein-Barr, and cytomegalovirus. In all my years in practice, I have never seen an elevated IgM level when testing for cytomegalovirus (CMV). However, I have seen many tests that show elevated IgG levels for CMV, which typically indicates an exposure history, and research cases in the past have shown a link between CMV and autism. A herpes viral panel is available from LabCorp and Quest, which makes sense if you strongly suspect that you have a patient with a number of immune problems.
Food allergies. In my experience, 99% of the time, food reactions are IgG-related. These sensitivities tend to create problems because they stress the child's immune system, which can compromise digestion, resulting in inflammation and even behavioral issues. If the child has a history of eczema, dermatitis, or allergic reactions that suggest food reactivity beyond IgG sensitivities, I would also order an IgE food panel.
Environmental allergens. Great Plains offers an inhalant panel. I do not order that panel in an initial workup for most kids, because it is usually not necessary, but if you have a child with a history of allergies, it can be worthwhile.
Lyme disease. In my own practice, I do not see much Lyme disease, and I have done a fair amount of testing. For a more advanced assessment of a child who is not progressing, with a known Lyme exposure or risk, testing could include Lyme biotoxin analysis. This is most relevant to the child who is not getting better, despite all of the common therapies. When I do Lyme testing, I use IGeneX. A positive Lyme test warrants evaluation for coinfections as well. Treatment for Lyme in autism is an entire discussion beyond the scope of this article.
Kryptopyrrole testing. This urine test is worthwhile if you have a child who is very erratic emotionally, with significant psychiatric involvement, including aggressive volatility and/or impulsivity. The test is relevant if you have done other evaluations, yet the child continues to have underlying behavioral problems, and you have ruled out yeast, bacterial overgrowth, and food sensitivity issues.
Pyrroles are a chemical within the hemoglobin that is created in excess in this disorder. The pyrroles sequester B6 and zinc, contributing to imbalances of these nutrients, which can skew neurochemistry significantly. This is a likely reason why so many autistic children have done well with B6 supplementation.
Gut disorders. From a physical standpoint, one of the most problematic issues in autism is constipation and/or diarrhea. Upward of 80% of the children in my practice initially present with one of these issues – and sometimes both. These problems are major roadblocks to healing. If the child has a history of constipation, it is imperative to do the organic acids test to rule out yeast or bacteria. You also want to do a comprehensive stool test to rule out bacterial and parasitic infections, and opt for the food sensitivity profile to rule out food reactions. These three tests will help in the assessment of both constipation and diarrhea. At some level, at least 60% of these young patients tend to have aggressive or self-injurious behavior, though not all of the same intensity, often attributed to clostridia bacterial overgrowth.
Clostridium difficile
Children on the autistic spectrum are exquisitely sensitive to the toxins of yeast. Many of these kids also have an underlying problem with respect to clostridia bacteria. There is an entire group of clostridia that produce a chemical called HPHPA (3-(3-hydroxyphenyl)-3-hydroxypropionic acid), which disrupts dopamine metabolism by interfering with an enzyme called dopamine beta-hydroxylase. This metabolic glitch can lead to moodiness, tantrums, extreme anxiety, aggression, and/or self-injurious behavior. Researchers have also linked HPHPA to schizophrenia in certain individuals. The HPHPA chemical is a serious toxin with profound neurological effects in autism.
If you treat only for yeast, in some cases that can make the clostridia worse. I learned this long ago, working with a young boy who had autism but no symptoms of aggression or self-injurious behavior. He typically displayed giddy, goofy, silly behavior with a lot of inappropriate laughter, almost as if he were drunk, which is often associated with yeast overgrowth in children on the spectrum. When we did the organic acids test, the marker for clostridia (the HPHPA) was normal, but high normal, so we decided to treat him solely for yeast. Within two days, this giddy child became uncontrollably aggressive and self-injurious. I realized that this was behavior associated with a clostridia reaction and that suppressing the yeast had allowed the clostridia to proliferate, likely by reducing biological competition with the yeast. He and his family were in so much distress that rather than wait several weeks for new test results, we decided to treat him right then for the clostridia. I implemented an antibiotic (Flagyl) for clostridia, and within seventy-two hours his aggressive behavior was gone. What we saw over the coming months was that periodically this child would slip back into aggressive behavior, and subsequently we were able to correlate his behavior with positive test results for clostridia. In each case, his high clostridia markers coincided with aggressive and self-injurious behavior. I realized that this was a pattern that was occurring in other children as well. Consequently, I caution people to avoid treating only for yeast (unless lab testing confirms absolutely no problems with clostridia), because some kids get better on the antifungals and other kids become much worse.
Heavy metal exposure. I do hair and porphyrin tests as a way to open a discussion regarding heavy metal detox. The hair analysis provides an indication of exposure over time. The porphyrin test gives an indication of the cellular toxic effects of heavy metals, because porphyrins are produced in the mitochondria of the cell. However, I have seen many hair analyses that show high levels of metals but no porphyrin imbalance. That means the patient has been exposed and the exposure level is fairly high, but he or she is not manifesting with a significant level of cellular toxicity per se. In those cases, we can defer heavy metal detox to a later time, because there does not appear to be a strong toxic effect occurring at the cellular level.
If the porphyrin test is positive, that is an indication that there is some kind of cellular toxic effect due to the presence of heavy metals. That finding provides the basis for a discussion about detox. In either case, this combination of tests enables me to raise the issue and suggest that at some point in the future, we will need to consider heavy metal detox therapy. However, typically on the first visit I avoid the word chelation, which carries negative connotations for some parents. Initially, I simply use the test results as the basis for identifying the next steps.
Triage. Much of this testing supports triage. What do we do first, second, and third? Many of these children have similar issues, i.e., gluten sensitivity, digestive problems with yeast and bacteria, nutritional imbalances, etc. Work on these first. There are some therapies that can be clinically beneficial but, because they are less familiar to families, must be discussed at the right time, from the standpoint of practice and compliance. The lab testing I have discussed provides the information a practitioner will need to get a comprehensive viewpoint of the major medical issues afflicting a particular child. These labs also provide talking points so parents can begin researching various treatments to increase their comfort level.
Specific Issues
Behavior problems. With aggressive or self-injurious behavior, I order the organic acids test and the CDSA to rule out overgrowth or infections. The food sensitivity test and the urinary peptides panel are important because food reactions can lead to behavior problems, too. Blood testing is important, particularly for total cholesterol. The lower the child's cholesterol level, the greater the tendency for mood disorders. In reality, all of the testing is important, but those three domains are critical to evaluate.
Expressive language disorders. GI pathogens can have an impact on expressive and receptive language. For these issues, start with stool testing and organic acids testing. Language can also be affected by food reactions. Tests that tend to be the most important for assessing biomedical factors in expressive language are the peptides test, IgG testing for food sensitivities, and the organic acids test. Heavy metals can have an impact on language, so doing heavy metals assessment is important. Hair analysis and porphyrin testing are useful initial screening assessments.
The reality for most physicians is that 80% to 85% of the underlying issues in autism are covered by the testing and scenarios described here.
Engaging the Family
Today, thousands of parents are turning to biomedicine, seeking help for a newly diagnosed child or one who has not responded to other interventions and continues to struggle. Many families are overwhelmed by the wide range of biomedical interventions (the gluten-free, casein-free diet being just one example). Typically, I do not raise the question of Lyme testing or chelation in these initial evaluations. The primary goal is to help them get started in this process, so they do not become overwhelmed or frustrated. People need to feel empowered, and there is definitely a learning curve involved.
There is also a certain group of parents who have been at it for a while, have researched these biomedical issues, and are looking to move to the next level. Much of what I do is in response to the parents and where they are in the treatment process. I have found that if I introduce a concept they are not familiar with too early, they may defer treatment. This is why it is so critically important for parents to research and educate themselves about the testing and treatment options, so they can be informed partners in the decision-making process. Biomedical interventions do not work if parents are not educated about these therapies. A phased approach is absolutely essential, given the expense, the learning curve, and the needs of these complex, highly sensitive children.
Kurt N. Woeller, DO, earned his degree in osteopathic medicine at the University of New England, a health sciences university on the coast of Maine, founded in 1831. He has served as a complementary medicine physician since 1998, guiding testing and treatment for individuals with complex medical conditions that include autism, autoimmune diseases, mental health disorders, and neurological conditions such as multiple sclerosis and Parkinson's disease. With respect to autism, he has worked with thousands of families, implementing biomedical interventions for their children. An experienced lecturer, he has participated in numerous integrative medicine conferences in the United States and abroad. Dr. Woeller serves as clinical consultant to Great Plains Laboratory, presenting free monthly webinars on various topics related to integrative medicine and to BioHealth Laboratory, providing trainings on the intricacies of biomedical and functional diagnostic laboratory testing.
Resources
Books. Dr. Woeller has written two books that are based on his experience in the treatment of autism. Autism: The Road to Recovery is available at www.AutismRecoveryBook.com and Methyl-B12 Therapy for Autism can be obtained at MethylB12ForAutism.com. Both books explore approaches to the treatment of autism that he has used successfully in clinical practice.
Free videos and other information. Interested individuals can access free videos and information on autism intervention at www.AutismRecoveryTreatment.com. A multitude of educational videos by Dr. Woeller are also available on YouTube and Vimeo.
Patient membership site. Dr. Woeller maintains an extensive online educational resource for parents and clinicians regarding the benefits of biomedical therapies for autism. His membership site, Autism Action Plan, can be accessed at www.AutismActionPlan.com. Members have direct access to Dr. Woeller through an interactive forum for Q & A. There is also an extensive library of videos, recorded webinars, clinical protocols, and case studies on the site.
Physician training. Currently under development is a comprehensive physician training program, with an emphasis on functional diagnostic medicine and biomedical intervention for autism,autoimmune diseases, mental health disorders, and neurological conditions. This will be an online program that includes options for group and one-on-one training with Dr. Woeller. Launch date is expected to be mid-2014.
Patient comanagement and physician preceptorships. Dr. Woeller is available for the comanagement of autism patients and to work one-on-one with clinicians for a broader understanding of autism biomedical intervention. For more information, please contact his office at 951-461-4800 or info@MySunriseCenter.com. Information on Dr. Woeller's work, specifics regarding upcoming conferences, and links to his websites can be accessed at www.DrWoeller.com.
Editorial
Nancy Faass, MSW, MPH, is a writer in San Francisco who has worked on more than 40 books; she also provides articles, white papers, and writing for the Web via HealthWritersGroup.com.
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