Functional Communication Training for Children with Autism Spectrum Disorders

Children with autism struggle with communication issues.  While these children often evidence social skills deficits and repetitive/stereotypical behaviors, many of these problem areas can be remediated if the child is taught how to use language functionally.

A functional use of language is something that is difficult to teach in the classroom, but it can be managed through appropriate procedures and strategies. We often “measure” language by asking parents and staff to identify how many words a particular child may speak; programs are then developed to increase the number of words which children on the spectrum speak.

However, this measure of assessing language in children on the spectrum (i.e., a total amount of vocabulary) gives an incomplete picture of the nature of the child’s strengths and weaknesses – it is a good start to teach vocabulary, but we need to go beyond that.

Our studies of evolutionary psychology indicate that humans are a species that uses tools; it is this tool use that sets us apart from other mammals and other species.  Language is another tool that we use to obtain what we want from the environment.

While some children speak too little and others too much, what all these children on the spectrum share is the inability to use language effectively as a tool to actualize their goals.  Some children do not have enough words to express themselves – these students need to be taught more words and when these words should be used.  Others have so many words that they do not know which ones to choose to express themselves – these students need assistance in choosing their words and using them at appropriate times.

In the absence of efficient methods of communication, many children on the spectrum resort to other means to actualize their goals.  These means are often interpreted by many of us in the schools to be destructive, rude or disrespectful.  But, using words as tools to actualize their goals is a concept that is difficult for them to understand.  So, they often perform other actions to obtain their goals.  In the most severe cases, they will injure themselves in horrific ways.  In other cases, they may yell, scream, throw things or perform any other set of actions that would be considered a “meltdown” or “tantrum”.

Fortunately there are many guides out there that are easily written and can help the practicing school psychologist.  Mark Durand’s Severe Behavior Problems: A Functional Communication Training Approach is an excellent book that has helped me tremendously when implementing Functional communication training (FCT).

FCT is a set of procedures that teach communication skills to the child as a replacement to the inappropriate actions with which he is engaging.  Central to FCT is the idea that child perform challenging responses to the environment when they: 1) lack the communication skills to convey their intent or 2) do not know which specific communication patterns should be used to convey their intent.

For example, one of the children with which our team is currently working had a goal of using the word “no” to stop activities which he did not enjoy.  While this goal may appear to be counter-intuitive, we wanted the word “no” to replace what his current response at the time was: biting staff members until their skin broke.  Conceptually, it was important for us to understand that while his reaction was extreme, his biting was the tool he used to stop activities .  Our goal was to teach him how to use another tool, which would actualize the same goal (stopping activities) better and more efficiently.

Typically, when this student was presented with a task that he usually avoided (i.e., math), he often bit staff.  What we had done initially is as he would lean in to bite, we gave him the command “Say no”.
At first any sound was rewarded with a cessation of the activity and a loud proclamation from the staff member indicating “OK, all done!”.  We walked away quickly and gave him a break for 2 – 3 minutes.  After he learned to just make a sound and not bite, we required that he approximate the sound “n”.  Soon after we ratcheted up the demands and required he say “no”, which lead to “no more” and then “no more, please”.

Our next step was to identify what aspects of the activity (math, in this instance) was so aversive, and we worked to teach him the component skills that he lacked so that he may perform the activity in the future.

Visual strategies can be used in addition to FCT or instead of FCT.  For example,  with another child, our team has developed a visual strip of common phrases that one particular child can use (e.g., “No thank you”, “Yes, please”, etc.).  When the targeted child is asked a question, he is pointed to the particular menu of phrases that he can use.  The student then can scan the phrases and can select the one he can use.  Our team does require that he use the words; failure to do so would have him too dependent on the strip.  Two very useful resources for these sets of procedures are A Picture's Worth: PECS and Other Visual Communication Strategies in Autism by Andy Bondy and Lori Frost and Visual Strategies for Improving Communication: Practical Supports for School & Home by Linda A. Hodgdon.

Overall, teaching children with autism better alternatives for communication can greatly enhance their social skills, advocacy and overall life satisfaction.

Don't be Afraid of the New Autism Diagnosis

Cathy Lord, in a piece that she wrote for the Huffington Post, said:

In the DSM-5, we propose a new way of looking at these disorders, merging them into a single diagnosis of autism spectrum disorder. We believe this will create more accurate diagnoses and improved access to services. It should also improve research into ASD, because there will be less diagnostic confusion

And I agree.  I feel that there has be undue anxiety regarding a variety of issues.  There are a host of reasons why these changes are being implemented.  For example:

1. Research suggested that there was considerable confusion among researchers, doctors, psychologists and psychiatrists regarding the criteria of PDD-NOS, Autistic Disorder, and Asperger Disorder.  Often we saw "graduations" of one disorder into the other, which tended to be problematic, often leaving people with the complex task of attempting to identify a label instead of looking to begin interventions and help the children and adults in need.
2. Emergent research suggests that Asperger Disorder and Autistic Disorder, as currently defined in the DSM-IV differ only in levels of language and/or IQ (one may argue that IQ as a construct is heavily influences by language, but that is a debate that I would leave for some of my other colleagues).  The Neurodevelopmental group of the DSM-5 argued that they did not want  diagnostic decisions to be based on IQ or language. One can argue that there is a paucity of studies that have looked at this difference (Relying on memory, I can recall roughly 15 articles in the period from 1994 - 2012), and I would argue that the reason more research is not being published in peer-review publications is that these studies are finding no difference except in language and IQ.  
3. Others have bemoaned the fact that there the DSM is dropping Childhood Disintegrative Disorder (CDD).  While there isn't a good base of experimental data to support this difference, we see that emergent case study research suggests that CDD is probably the norm.  That is to say, the group hypothesized that autism is an auto-immune disorder which kicks in within the first few months of a child's life, similar to MS which kicks in in the fourth decade of someone's life.  This might explain parents' descriptions of the disorder.  A fascinating hypothesis, which may be the key to explaining such parental reports.

I agree with Cathy Lord and the work that her Neurodevelopmental group has engaged in.

Autism Caught On Tape -- Computer Scientists Use Technology To Help Children With Autism

ScienceDaily -- Computer scientists have devised two tools to help people interact with autistic children. Videotaping interactions allows teachers or parents to replay situations and evaluate the cause of particularly good or bad behavior. Cataloging actual data, rather relying on memory or interpretation, proves to be a more accurate measure of a situation.

Further Work on Abnormal Face Processing in Children with Autism

Katarzyna Chawarska, Frederick Shic, Ami Klin and Fred Volkmar are due to present a paper at the International Meeting for Autism Research May 3-5 in Seattle, Washington. Their paper will focus on previous findings regarding face recongition in children with autism as well as new research as well.

• Toddlers with autism spectrum disorders (ASD) often have difficulty focusing on people's faces and making eye contact, but these researchers found that these same toddlers do not have difficulty looking at photographs of faces.
• They also found that toddlers with ASD spend most of the time examining the eyes. This is a surprising finding, given that avoiding eye contact is one of the classic hallmarks of autism.
• The results suggest that pictures of faces and eyes are, by themselves, neither inherently unattractive nor inherently aversive to toddlers with ASD. Therefore, the limited attention to faces and eyes observed in natural settings may be due to the fact that faces don't stand out to them as much as other objects in the environment.
• There also may be heightened arousal related to the complex social and perceptual context in which faces usually occur.
• The study examined visual scanning patterns and recognition of faces and abstract patterns in toddlers. The data were collected through an eye-tracking system.
• When given time to familiarize with a picture of a face, both groups spent more time looking at the outside features of the face, such as the hair, ears and the neck compared to the their typically developing peers.
• The researchers postulated that toddlers with disabilities were having a harder time encoding information regarding facial identity because they were simply looking less at facial features, which are of greatest help in extracting this type of information.
• Those toddlers with ASD who adopted a pattern of looking at faces which closely resembled the pattern of typical toddlers, were less socially impaired and were also better at face recognition
• While typical and developmentally delayed toddlers move quickly between various inner elements of the face, scanning rapidly between the left and right eye, toddlers with ASD tend to look longer at specific facial features than other children, which might signify an idiosyncratic approach to face processing specific to ASD in early development.

Review of "Strange Son" by Portia Iverson

Mr. and Mrs. Iverson have set up a foundation to deal with autism in their and many other individuals' chidlren. Mrs. Iverson wrote this book about her experiences with Soma Mukhopadhyay from Bangalore, India. Soma had managed to teach her severely autistic son, Tito to communicate, write poetry on a laptop, and articulate his thoughts and feelings.

Mrs. Iverson persuaded her foundation to bring Soma and 14-year-old Tito to Southern California for what proved to be an exhausting and exhaustive monthslong effort by a network of neuroscientists and well-wishers to anatomize the miracle that was Tito. But few miracles withstand minute dissection, and this one was no exception.

For one thing, the young poet was still an immensely dysfunctional adolescent who could not remain still for most neurological testing, who was besieged by erratic impulses (like trying to jump out of a minivan speeding down a California freeway) and who became unhinged whenever he was separated from his mother.

His mother was a loner and a bit of an oddball, whose method of cajoling intelligent communication from Tito depended on an alphabet board and a frenetic combination of shouts, gestures and taps on the knee.

But, when Soma finally sat down with Mrs. Iversen’s Dov and begins to prod and cajole him just as she does Tito, their frighteningly inaccessible and uncontrollable child began to use an alphabet board to tap out logical human thoughts.

He wanted a Barbie doll and a blue blazer. He identified that he had known how to read English for three years. His favorite color is red. He thinks his little brother is spoiled rotten. After a few weeks he drops Barbie like a shot when he learns that dolls are for girls.

We learn that Soma’s method works better for some autistic children than others, and is nowhere near being a panacea.

I havent read the book, but it may be interesting. Those of you who have, please drop me a line

Mirror Neurons and ASD

The discovery of premotor and parietal cells known as mirror neurons in the macaque brain that fire not only when the animal is in action, but also when it observes others carrying out the same actions provides a plausible neurophysiological mechanism for a variety of important social behaviors, from imitation to empathy.

Recent data also show that dysfunction of the mirror neuron system in humans might be a core deficit in autism, a socially isolating condition. Here, we review the neurophysiology of the mirror neuron system and its role in social cognition and discuss the clinical implications of mirror neuron dysfunction.

Suicides in New Orleans

This is a reprinting of a posting to a blog that I used to manage.

I worked for about 10 years in Nassau county, which is a suburb of New York. The last three years I coordinated a program for high functioning middle school students diagnosed with autism (I'm long since gone).

One of the things that focused on teaching was Theory of Mind, a complex skill that requires individuals to put themselves in other people's shoes, to think their thoughts - in essence, to feel their emotions, to be happy when they are happy and to cry when they are sad. I was rarely successful. Jack was not a success story for me. Sure he had develops some friendships while I was there, but he had not fully mastered the idea of Theory of Mind. But I enjoyed him immensely, despite his resistance to schoolwork and his chronic narcolepsy.

When I went back to visit him in 2005 and the others, he asked me to play chess, his favorite game. We sat there, enjoying each other's silence as the cool September breeze blew over us through the corner window.

"So, did you watch CNN at all?", he broke the silence.

"Yep"

"That's really a shame about those people in New Orleans."

My interest was piqued. "Yes it is-"

"I mean, when the waters are drained those people are gonna go back to destroyed houses, and wow - they might get depression or something bad- or even worse they might kill themselves"

"Why would they kill themselves?"

"WHY?! WHY?! - you're the psychologist - you tell me - they're gonna go home and nothing is there - if that happened to me - I have no idea how I would cope with it. Just no idea. Those poor people."
______________________________________________________

So if a child with autism could predict massive depression and suicides, why can't the Federal government, FEMA, the President, the governor of Louisiana or the mayor of New Orleanse predict it? Why couldn't they preliminarily deal with it?

The New York Times reported about a month ago that the suicide rate in New Orleans has risen to at least two times more than the average national rate. Many people who live though natural or wartime disasters tend to develop a disorder named Post Traumatic Stress Disorder or PTSD.

Common characteristics of the disorder include reliving the traumatic event through frightening memories, or nightmares that provoke the same feelings of horror, helplessness, and fear that you felt at the time of the event. These memories can be triggered by exposure to reminders of the event. Of course, the people who returned to their devastated, destroyed, demolished homes were forced to confront and relive the disaster over and over again.

PTSD is a type of anxiety disorder. Researchers from the University of Winnipeg in Manitoba, Canada found that the presence of an anxiety disorder as well as intense levels of hopelessness and despair increased the probability that an individual would commit suicide. It doesn't take a Ph.D. in psychology to know that hopelessness and continued exposure to a stressful event could lead to suicide. It also doesn't take an advanced to degree or a heightened level of civic-mindedness that something can be done to deal with this situation.

The science of prevention is a burgeoning field in psychology, which is guided by a principle borrowed from medicine. Prevention science has led to mandatory inoculations of children to fluoride in water. People who exercise more are less likely to get sick; some managed health care companies now fully or partially subsidize gym memberships. The same goes for psychology as well. Instead of attempting to heal once the damage has been done, we can either:

• prevent the problem altogether
• innoculate the individual so that the problem is not that bad.

Of course, if you have seen the examples I listed above, many of the prevention programs need to come from governmental agencies or need to be instituted by various corporate organizations. It would do no good if two or three socially conscious doctors began to dump fluoride into our reservoirs - we need the federal government to enact this into legislation.

While the entire population of New Orleans required some form of "inoculation" before re-entering the city (as well as ongoing interventions after entering the city), there are certain people who are more at risk for developing PTSD and then evidencing suicidality. Women are more likely to develop PTSD than men; minorities who come from a lower socioeconomic level are also more likely to develop PTSD. Then again, males tend to complete suicides more frequently than females, due to access to more lethal and more severe methods (e.g., guns).

While many people were ready to blame FEMA for the debacle in initial assistance to the residents of New Orleans, they were really not to blame. FEMA is an agency that deals with more long term, protracted issues. FEMA is responsible for initiating and maintaining rescue operations as well as clean-up and rebuilding. FEMA should also be responsible for initiating a suicide and PTSD prevention program for the city; this is FEMA's and the Federal government's most flagrant abuse in this whole matter so far.

NJ Assembly Speaker Joseph Roberts Jr. seeks action on autism

As has been documented in many CDC studies, the rate of autism is highest in New Jersey (and here in New York, in Staten Island). The most recent CDC study found the rate of autism to be 1 in 152 nation-wide, but in NJ, the rate was 1 in 94 children. Researchers are puzzled as to why the rate is so high.

Speaker Roberts put together a package of seven legislative bills to support autism treatment measures. They include:

• The establishing a statewide autism registry.
• The training of teachers in autism awareness.
• The creation of a task force on adult autism.
• Requiring autism awareness training for emergency personnel.
• The provision more money for the Governor's Council on Autism, which spend $4 million per year.
• The instruction of doctors in early detection.
• The revision of the seven-person Governor's Council on Autism to add two more members and diversify membership.

I applaud Speaker Roberts' initiatives, however, I'd like to hold off judgement in order to review the bills. Specifically, I would like to see evidence based interventions as the basis for training teachers and emergency personnel; I'd also like to see where this money will be going. For instance, there should be some money earmarked to examine why the rate is so high in NJ, as well as money provided for the intensive treatment of autism.

Furthermore, I would be interested to see how this bill would affect school psychologists who are practicing in New Jersey.

Autism May Be More Prevelant Than Previous Estimates, CDC Report says

The Centers for Disease Control and Prevention (CDC) reported findings today from the first and largest summary of prevalence data from multiple U.S. communities participating in an autism spectrum disorder (ASD) surveillance project. The results showed an average of 6.7 children out of 1,000 had an ASD in the six communities assessed in 2000, and an average of 6.6 children out of 1,000 having an ASD in the 14 communities included in the 2002 study. All children in the studies were eight years old because previous research has shown that most children with an ASD have been identified by this age for services.

For decades, the best estimate for the prevalence of autism was four to five per 10,000 children. More recent studies from multiple countries using current diagnostic criteria conducted with different methods have indicated that there is a range of ASD prevalence between 1 in 500 children and 1 in 166 children. The CDC studies provide information on the occurrence of ASDs in fourteen communities in the United States.

"Our estimates are becoming better and more consistent, though we can't yet tell if there is a true increase in ASDs or if the changes are the result of our better studies," said CDC Director Dr. Julie Gerberding. "We do know, however, that these disorders are affecting too many children."

Overall, the 2000 study found ASD rates ranged from one in 222 children to one in 101 eight-year old children in the six communities studied.

The 2002 study found ASD rates ranging from one in 303 to one in 94 among eight-year old children. The average finding of 6.6 and 6.7 per 1,000 eight-year-olds translates to approximately one in 150 children in these communities. This is consistent with the upper end of prevalence estimates from previously published studies, with some of the communities having an estimate higher than those previously reported in U.S. studies.

ASDs are developmental disabilities and are defined by considerable impairments in social interaction and communication and the presence of unusual behaviors and interests. They can be diagnosed as early as 18 months and last throughout a person's life. ASDs include autistic disorder, pervasive developmental disorder - not otherwise specified (PDD-NOS, including atypical autism), and Asperger syndrome.

The 2000 study included approximately 4.5 percent of U.S. eight-year-old children born in 1992 from six states - Arizona, Georgia, Maryland, New Jersey, South Carolina and West Virginia. A total of 1,252 eight-year olds were identified as having an ASD.

The 2002 study included approximately 10 percent of U.S. eight-year-old children born in 1994 from 14 states - Alabama, Arizona, Arkansas, Colorado, Georgia, Maryland, Missouri, New Jersey, North Carolina, Pennsylvania, South Carolina, Utah, West Virginia and Wisconsin. A total of 2,685 eight-year-olds were identified as having an ASD.

"It is extremely difficult to accurately estimate the number of children who have an ASD," said Dr. Marshalyn Yeargin-Allsopp, chief of CDC's autism program. "Medical records often do not provide such information, and identification is often made by schools or education specialists.

The data reported today by the Autism and Development Disabilities Monitoring (ADDM) Network was designed to provide more consistent and reliable estimates."

"It's important to note that these studies don't provide a national estimate, but that they do confirm that ASDs in the areas surveyed are more common in these communities studied than previously thought," said Yeargin-Allsopp. "We need to continue efforts to monitor the prevalence of ASDs and to improve our understanding of these disorders. Good estimates of how many children in a community may have an ASD will also help school and health officials in their planning and intervention efforts."

The purpose of CDC's ADDM project was to develop a system for better understanding the size and characteristics of the population of children with an ASD.

In addition to trying to measure the number of children with an ASD, the studies also looked at when parents and others first noted signs of developmental concerns in their children. The 2000 and 2002 studies found 51 percent to 88 percent of children with ASDs had documented developmental concerns before the age of three. Half of the children were diagnosed with an ASD when they were between four and one half and five and one half years old. The most commonly documented concerns were in language development, followed by social development.

"We don't know the causes of ASDs, but we do know that if we can identify autism and other developmental problems in children early, they can begin receiving appropriate interventions sooner," said Yeargin-Allsopp. "It is important for parents, health care professionals and childcare providers to recognize developmental milestones such as smiling, pointing and waving bye-bye. It's also important that health care professionals give children routine developmental and autism-specific screenings."

While these studies did not investigate the causes of ASDs, CDC's Centers for Autism and Development Disabilities Research and Epidemiology (CADDRE) Network is doing a multi-state study to help identify factors that may put children at risk for ASDs and other developmental disabilities.

This project is being conducted by CDC, University of Alabama at Birmingham, University of Arizona at Tucson, University of Arkansas, Colorado Department of Public Health and Environment, Johns Hopkins University, Washington University in St. Louis, University of North Carolina at Chapel Hill, University of Medicine and Dentistry of New Jersey in Newark, University of Pennsylvania School of Nursing, Medical University of South Carolina, University of Utah, Marshall University and the University of Wisconsin-Madison. Six sites participated in the 2000 project, and an additional eight were added for the 2002 project.

CDC also has a public awareness campaign titled, "Learn the Signs. Act Early" designed to increase the awareness of child development by educating parents, health care professionals and childcare providers on the importance of tracking a child's social and emotional development, including the potential early warning signs of autism and other developmental disabilities.

Asperger's disorder ruled to be a disability by a federal judge

One of the issues that has plagued many school officials working working with children with Asperger's disorder is whether or not this disorder actually meets the criteria for a legal disability as per IDEIA.

In Maine, a federal judge has provided some guidance:

• A York County girl who suffers from Asperger's syndrome is entitled to special education services even though she completes her homework, behaves well in class and scores well on tests
• The judge in the case said that the girl's parents demonstrated that the disability adversely affects her educational performance "and is thus eligible for special education under (federal law) due to her Asperger syndrome and her depressive disorder." (note: the article does not indicate under which classification disability category Asperger's syndrome is subsumed).
• The ruling described Asperger's as a "clinically recognized pervasive developmental disability" with symptoms that include "limited interests or an unusual preoccupation with a particular subject to the exclusion of other activities."
• The girl in this case, who attended public schools in Hiram and Cornish through 5th grade, performed well academically but in the fourth grade her teachers noticed that she looked sad, anxious and had a difficult time making friends.
• The decision recognizes that social development is an important part of education

Of course, the ruling should have broad impact in many areas, specifically in the fact that case law is recognizing and shaping the fact that Asperger's Disorder has educational impacts that go far beyond reading, writing and math.











Technorati tags: autism asperger special education IDEA IDEIA

Vaccinations do not cause autism

I've taken a lot of information from the CDC site which discussed the same topic. For more information, go to: http://www.cdc.gov/nip/vacsafe/concerns/autism/autism-mmr.htm



Does the measles-mumps-rubella (MMR) vaccine cause autism?
Current scientific evidence does not support the hypothesis that measles-mumps-rubella (MMR) vaccine, or any combination of vaccines, causes or contributes to the development of autism.


Several panels and reviews have investigated this topic see: (National Academy of Sciences, Institute of Medicine). These reviews have concluded that the available epidemiologic evidence does not support a causal link between MMR vaccine and autism.

What have studies found regarding MMR vaccine and autism?
Below is a review of several studies that highlight the lack of a causal or correlational link between the MMR vaccine and autism.

• In 1997, the National Childhood Encephalopathy Study (NCES) was examined to see if there was any link between measles vaccine and neurological events. The researchers found no indication that measles vaccine contributes to the development of long-term neurological damage, including educational and behavioral deficits (Miller et al., 1997).

• A study by Gillberg and Heijbel (1998) examined the prevalence of autism in children born in Sweden from 1975-1984. There was no difference in the prevalence of autism among children born before the introduction of the MMR vaccine in Sweden and those born after the vaccine was introduced.

• In 1999, the British Committee on Safety of Medicines convened a "Working Party on MMR Vaccine" to conduct a systematic review of reports of autism, gastrointestinal disease, and similar disorders after receipt of MMR or measles/rubella vaccine. It was concluded that the available information did not support the posited associations between MMR and autism and other disorders.

• Taylor and colleagues (1999) studied 498 children with autism in the UK and found the age at which they were diagnosed was the same regardless of whether they received the MMR vaccine before or after 18 months of age or whether they were never vaccinated. Importantly, the first signs or diagnoses of autism were not more likely to occur within time periods following MMR vaccination than during other time periods. Also, there was no sudden increase in cases of autism after the introduction of MMR vaccine in the UK. Such a jump would have been expected if MMR vaccine was causing a substantial increase in autism.

• Kaye and colleagues (2001) assessed the relationship between the risk of autism among children in the UK and MMR vaccine. Among a subgroup of boys aged 2-5 years, the risk of autism increased almost 4 fold from 1988 to 1993, while MMR vaccination coverage remained constant at approximately 95% over these same years.

• Researchers in the U.S. found that among children born between 1980 and 1994 and enrolled in California kindergartens, there was a 373% relative increase in autism cases, though the relative increase in MMR vaccine coverage by the age of 24 months was only 14% (Dales et al., 2001). For more on this study, see California Data on Theory of Autism and MMR Immunization.

• Researchers in the UK (Frombonne & Chakrabarti, 2001) conducted a study to test the idea that a new form, or "new variant," of Inflammatory Bowel Disease (IBD) exists. This new variant IBD has been described as a combination of developmental regression and gastrointestinal symptoms occurring shortly after MMR immunization. Information on 96 children (95 immunized with MMR) who were born between 1992 and 1995 and were diagnosed with pervasive developmental disorder were compared with data from 2 groups of autistic patients (one group of 98 born before MMR was ever used and one group of 68 who were likely to have received MMR vaccine). No evidence was found to support a new syndrome of MMR-induced IBD/autism. For instance, the researchers found that there were no differences between vaccinated and unvaccinated groups with regard to when their parents first became concerned about their child’s development. Similarly, the rate of developmental regression reported in the vaccinated and unvaccinated groups was not different; therefore, there was no suggestion that developmental regression had increased in frequency since MMR was introduced. Of the 96 children in the first group, no inflammatory bowel disorder was reported. Furthermore, there was no association found between developmental regression and gastrointestinal symptoms.

• Another group of researchers in the UK (Taylor et al., 2002) also examined whether MMR vaccination is associated with bowel problems and developmental regression in children with autism, looking for evidence of a "new variant" form of IBD/autism. The study included 278 cases of children with autism and 195 with atypical autism (cases with many of the features of childhood autism but not quite meeting the required criteria for that diagnosis, or with atypical features such as onset of symptoms after the age of 3 years). The cases included in this study were born between 1979 and 1998. The proportion of children with developmental regression or bowel symptoms did not change significantly from 1979 to 1988, a period which included the introduction of MMR vaccination in the UK in 1988. No significant difference was found in rates of bowel problems or regression in children who received the MMR vaccine before their parents became concerned about their development, compared with those who received it only after such concern and those who had not received the MMR vaccine. The findings provide no support for an MMR associated "new variant" form of autism and further evidence against involvement of MMR vaccine in autism.

• Madsen et al. (2002) conducted a study of all children born in Denmark from January 1991 through December 1998. There were a total of 537,303 children in the study; 440,655 of the children were vaccinated with MMR and 96,648 were not. The researchers did not find a higher risk of autism in the vaccinated than in the unvaccinated group of children. Furthermore, there was no association between the age at time of vaccination, the amount of time that had passed since vaccination, or the date of vaccination and the development of any autistic disorder. Though there were many more vaccinated than unvaccinated children in the study group, the sample was large enough to contain more statistical power than other MMR and autism studies. Therefore, this study provides strong evidence against the hypothesis that MMR vaccination causes autism.
  DeStefano et al. (2004) conducted a study to see if there was a difference in the age at which children with autism and without autism received their first MMR vaccination. The study's findings showed that children with autism received their first MMR vaccination at similar ages as children without autism. More information about this study can be found on the

CDC's research on vaccines and autism web page.

Are there studies that suggest there might be a connection between autism and MMR vaccine?
The existing studies that suggest a causal relationship between MMR vaccine and autism have significant weaknesses. he MMR-autism theory is based on the idea that intestinal problems, like Crohn’s disease, are the result of viral infections nd can contribute to the development of autism. The theory has its origins in research by Wakefield and colleagues (1989; 1990) which suggested that inflammatory bowel disease (IBD) is linked to persistent viral infection. The following lines of logic are followed to prove this idea.

1. In 1993, Wakefield and colleagues reported isolating measles virus in the intestinal tissue of persons with IBD. However, the validity of this finding was later called into question when it could not be reproduced by other researchers (Afzal, 1998; Iizuka et al., 2000).
2. Thompson and colleagues (1995) suggested in a retrospective cohort study that MMR vaccine might be a risk factor for Crohn's disease. However, the selection and recall biases and the differences in data collection in this study were so substantial as to cast doubt on the validity of the findings.
3. Two studies out of Sweden linked measles infection in utero to the development of IBD (Ekbom et al., 1994; Ekbom et al., 1996). However, these studies involved a very small number of cases and when researchers identified the persons to be included in the 1996 study, they had prior knowledge that cases of Crohn’s disease had occurred in the offspring of two women who were infected with measles during pregnancy. This is called "selection bias" and limits the strength of the study.
4. The MMR-autism theory came to the forefront when, in 1998, Wakefield and colleagues reviewed reports of children with bowel disease and regressive developmental disorders, mostly autism. The researchers suggested that MMR vaccination led to intestinal abnormalities, resulting in impaired intestinal function and developmental regression within 24 hours to a few weeks of vaccination. This hypothesis was based on 12 children. In 9 of the cases, the child's parents or pediatrician speculated that the MMR vaccine had contributed to the behavioral problems of the children in the study.

There are a number of limitations in the Wakefield et al. (1998) study that must be reviewed as well.

1. The study used too few cases to make any generalizations about the causes of autism; only 12 children were included in the study. Further, the cases were referred to the researchers and may not be a representative sample of cases of autism.

2. There were no healthy control children for comparison. As a result, it is difficult to determine whether the bowel changes seen in the 12 children included in the study were similar to changes in normal children, or to determine if the rate of vaccination in autistic children was higher than in the general population.

3. The study did not identify the time period during which the cases were identified.

4. In at least 4 of the 12 cases, behavioral problems appeared before the onset of symptoms of bowel disease; that is, the effect preceded the proposed cause. It is unlikely, therefore, that bowel disease or the MMR vaccine triggered the autism.

5. In 2004, 10 of the 13 authors of the study retracted the paper's interpretation, stating that the data were insufficient to establish a causal link between MMR vaccine and autism (Murch et al., 2004)

6. In another study that generated media attention and raised public concern in the UK (Uhlmann et al, 2002), researchers found measles virus fragments in the intestines of children with "new variant" IBD (children with both IBD and developmental disorder). Scientists looked for the presence of measles virus in the intestinal tissue of 91 children with new variant IBD and 70 "controls" (children without this type of IBD). The researchers found measles virus fragments in 75 out of the 91 children with "new variant" IBD, and in only 5 of the 70 controls. While this provides evidence for an association between the presence of measles virus and IBD in children with developmental disorder, it does not mean that the measles component of the MMR vaccine causes IBD or developmental disorder. As a commentary published with the article asserts, the data could just as easily be interpreted as indicating that the IBD or the developmental disorder cause the persistence of measles in the intestines (Morris & Aldulaimi, 2002). In addition, the researchers did not compare the virus found in the intestines of patients with the virus used in the MMR vaccine; nor did they provide information regarding whether or not the children in the study had been previously vaccinated with MMR or had previously contracted measles disease. The limitations of this study are further discussed in a letter written by the Director of CDC’s National Immunization Program to the UK’s Chief Medical Officer.


What about the claim that the number of children with autism has been increasing ever since the MMR vaccine has been in use?
Data from California (Department. of Developmental Services, 1999) have been used to illustrate an increase in cases of autism since the introduction of MMR vaccine. However, the data have been presented inaccurately (Fombonne, 2001). Fombonne (2001) lists several reasons why the data are misrepresented, for instance:

• the figures presented are based on numbers, not rates and do not account for population growth and changes in the composition of the population,
  changes in diagnostic definitions were not controlled in the report, and
  as in other areas of the country, children with autism are currently being diagnosed at earlier ages meaning that there will be an increase in the number of reported cases.
• A

2001 study (Dales et al.) used the autism case numbers provided by the California Department of Developmental Services and compared them with early childhood MMR immunization level estimates for California children. Results showed that for children born from 1980 through 1987, there was no major change in MMR immunization levels with the exception of a small increase in children born in 1988. This small increase was followed again by steady levels in children born through 1994. On the other hand, the cases of autism increased markedly, from 44 cases per 100,000 live births in 1980 to 208 cases per 100,000 live births in 1994. Even if one allows that a true increase in autism has occurred and the increase is not due to changes in diagnostic methods, diagnostic categorization, and improved identification of individuals with autism because of the level of services offered (Fombonne, 2001), this analysis shows that receipt of the MMR vaccine is not a factor. If it were a factor, one would expect the shape of the MMR level of immunization curve to be very similar to the autism case numbers. This is not the case, thus the analysis in this study argues against a link between MMR vaccination and autism.

Would it be safer to separate the MMR vaccine into its individual components--in other words, give children three separate shots, at different times (e.g., six months or one year apart), instead of one combined shot?
There is no confirmed scientific research or data to indicate that there is any benefit to separating the MMR vaccine into its individual components.

A publication by Wakefield and Montgomery (2001) suggests that there is an increased risk of immune-mediated disease when the MMR vaccine is administered as one vaccine versus when the 3 vaccines are administered separately. The specific issue of the safety of multiple vaccines given as one vaccine was addressed by the Institute of Medicine (IOM) (1994, p.63). They stated that the number of separate antigens in a vaccine would not likely result in a significant burden on the immune system that would result in immunosuppression.

The issue of multiple vaccines and immune dysfunction was addressed again by the IOM in 2002. An IOM Immunization Safety Review Committee concluded that a review of the available scientific evidence does not support the suggestion that the infant immune system is inherently incapable of handling the number of antigens that children are exposed to during routine immunizations. The IOM committee also did not suggest any need to change the current US vaccination schedule for MMR.

Splitting the MMR vaccine into three separate doses given at three different times would cause more discomfort from additional injections and would leave children exposed to potentially serious diseases. For instance, if rubella vaccine were delayed, 4 million children would be susceptible to rubella for an additional 6 to 12 months. This would potentially allow otherwise preventable cases of congenital rubella syndrome (CRS) to occur through transmission of rubella from infected children to pregnant women. Ironically, infection of pregnant woman with "wild" rubella virus is one of the few known causes of autism. Thus, by preventing rubella infection of pregnant women, MMR vaccine also prevents autism. See the following studies

Chess,S. Autism in children with congenital rubella. J Autism Child
Schizophr. 1, 33-47 (1971).
Chess,S. Follow-up report on autism in congenital rubella. J Autism
Child Schizophr. 7, 69-81 (1977).

Should a younger sibling of an autistic child, or a child of someone who has autism be vaccinated with MMR or other vaccines?
Yes. Current scientific evidence does not show that MMR vaccine, or any combination of vaccines, causes the development of autism, including regressive forms of autism.

A younger sibling or the child of someone who suffered a vaccine side effect usually can, and should, safely receive the same vaccine. This is especially true since the large majority of side effects after vaccination are local reactions and fever, which do not represent a contraindication.



Should we delay vaccination until we know more about the negative effects of vaccines?
No. There is no convincing evidence that vaccines such as MMR cause long term health effects. On the other hand, we do know that people will become ill and some will die from the diseases this vaccine prevents. Measles outbreaks have recently occurred in the UK and Germany following an increase in the number of parents who chose not to have their children vaccinated with the MMR vaccine. Discontinuing a vaccine program based on unproven theories would not be in anyone's best interest.

Isolated reports about these vaccines causing long term health problems may sound alarming at first. However, careful review of the science reveals that these reports are isolated and not confirmed by scientifically sound research.

Detailed medical reviews of health effects reported after receipt of vaccines have often proven to be unrelated to vaccines, but rather have been related to other health factors. Because these vaccines are recommended widely to protect the health of the public, research on any serious hypotheses about their safety are important to pursue. Several studies are underway to investigate still unproven theories about vaccinations and severe side effects.