New Autism Data

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facetguy

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Interesting article on some new CDC autism data:
http://www.huffingtonpost.com/david-kirby/rising-autism-numbers_b_397978.html

It discusses an interview with a top government autism researcher.

Key points:
*Autism cases are increasing at a frightening pace

*They cannot all be explained away by better reporting and expanded diagnostic criteria (which is the usual excuse given for the increased cases of autism)

*To say that it is simply all genetic is no longer viable

*Environmental exposures play a key role; epigenetics science will hopefully continue to expand our understanding of the interplay between our DNA and our environment (both pre-natally and post-)

*There may even be a viral connection; research is ongoing

*Autistic kids CAN and DO recover; it's not just that they were misdiagnosed or that their parents are imagining things or that their charlatan physician is tricking them

*Autism isn't a simple homogeneous group; there are subgroups with different issues (GI, autoimmune, etc.) and likely different therapeutic targets

*Regarding vaccinations, some of these subgroups may be particularly susceptible

*Prevention may be possible
 
I guess you take the head-in-the-sand view. Too bad.
 
I guess you take the head-in-the-sand view. Too bad.

I'm sorry, but I have to agree with rxnman. Quoting an article from the Huffington Post is bad enough, but you quoted an article by David Kirby, author of Evidence of Harm - Mercury in Vaccines and the Autism Epidemic: A Medical Controversy.

facetguy said:
*Regarding vaccinations, some of these subgroups may be particularly susceptible

An interesting conclusion to draw from what Dr. Insel actually said.

Finally, I asked if the IACC would reconsider its decision to reject vaccine research, given these new data, and in particular, Hepatitis B coverage -- which increased from about 27 percent to more than 90 percent between 1994 and 1998.

"I think what you are going to see with this update is that there is a recognition that we need to look at subgroups who might be particularly responsive to environmental factors," Dr. Insel said. And with that tantalizing statement, he unfortunately had to go to a meeting.
As you can see, he did not state that "some of these subgroups may be particularly susceptible" to vaccination-caused autism. Nor did he state that more research into vaccination-autism links is warranted or would be funded. No legitimate study has shown any linkage between vaccination and autism. In fact, many studies, including a thorough review of the evidence by the Institute of Medicine, the conclusions of which the CDC supports, have found NO LINK between rising autism incidence and vaccination trends.
 
I'm sorry, but I have to agree with rxnman. Quoting an article from the Huffington Post is bad enough, but you quoted an article by David Kirby, author of Evidence of Harm - Mercury in Vaccines and the Autism Epidemic: A Medical Controversy.

Like it or not, sometimes information exists outside of medical texts or journals. Attacking Kirby in this instance is meaningless and whiffs of dogmatic thinking.

An interesting conclusion to draw from what Dr. Insel actually said.

As you can see, he did not state that "some of these subgroups may be particularly susceptible" to vaccination-caused autism. Nor did he state that more research into vaccination-autism links is warranted or would be funded. No legitimate study has shown any linkage between vaccination and autism. In fact, many studies, including a thorough review of the evidence by the Institute of Medicine, the conclusions of which the CDC supports, have found NO LINK between rising autism incidence and vaccination trends.

He states, admittedly somewhat cryptically, that certain subgroups of autistic kids may be susceptible to environmental inputs, and he said this in response to a vaccine-related question. How am I so far off base in your view? Of course, that is not saying that, population-wide, vaccines cause autism. It does suggest, however, that for certain individuals, certain environmental stimuli can be problematic. Are there never adverse reactions to vaccines? (For the record, both of my kids are fully vaccinated.)

By the way, the Interagency Autism Coordinating Committee, the government's top autism panel and headed by Dr. Insel, stated in November:

"The committee agreed that it was important to determine whether subpopulations exist that are more susceptible to environmental exposures and proposed an objective:
"Support studies to determine if there are subpopulations that are more susceptible to environmental exposures (e.g., immune challenges related to infections, vaccinations, or underlying immune problems)."
The language for this new objective was unanimously accepted."

Does that mean that vaccines are the only, or even a significant autism-triggering environmental input? No. But it does mean that it remains on the list of areas of ongoing study.
 
I sometimes wonder what level of evidence would be sufficient to convince people that vaccines and autism are not related. You already have exhaustive, overwhelming lines of evidence which have been unable to find a link between the two. If the amount of money and resources that have been poured into disproving that theory (multiple times over) had been applied to helping those with the condition or looking for the actual cause, we might be getting somewhere by now.
 
I sometimes wonder what level of evidence would be sufficient to convince people that vaccines and autism are not related. You already have exhaustive, overwhelming lines of evidence which have been unable to find a link between the two. If the amount of money and resources that have been poured into disproving that theory (multiple times over) had been applied to helping those with the condition or looking for the actual cause, we might be getting somewhere by now.

Vaccines aside, do you have any theories as to the increasing cases of autism, and where would you like to see more research dollars go?
 
I think that the studies thus far have helped us determine what isn't causing autism. At this point the vaccine thing is kind of like beating a dead horse. I can't really offer any novel theories of my own, but don't you think that at this point the money would be better put to use on studies that focus on treatment and rehabilitation for the disorder (improving communication/sociability)? There definitely needs to be more inquiry as to the genetic and environmental factors associated with the disease, and at this point further vaccine research (at least re: autism) is taking away from that.
 
I would agree that no research dollars should be wasted. Although I'm certainly no expert in the area of autism research or vaccines, it's my understanding that much of the research cited has looked at either MMR or thimerosal. To extrapolate to all vaccines may not be valid. And there appears to now be more emphasis being placed on the subgroups of kids that seem to be particularly susceptible to environmental triggers, whatever those may end up being. Surely, most kids do fine with vaccines. But there are those well-versed in the literature that are not convinced that vaccines are definitely not playing some role, and that's why we continue to see additional research efforts. I don't think these research dollars would be appropriated by those in charge of them if the case were completely closed. Research into treatment is warranted, too, but until the cause of this rise in autism is nailed down, more is needed there.
 
I sometimes wonder what level of evidence would be sufficient to convince people that vaccines and autism are not related. You already have exhaustive, overwhelming lines of evidence which have been unable to find a link between the two. If the amount of money and resources that have been poured into disproving that theory (multiple times over) had been applied to helping those with the condition or looking for the actual cause, we might be getting somewhere by now.

Something I've been saying for years 👍

So it's frequently been said these days that the rise in autism is not due to increased diagnosis. Has this statement been validated? Here's what I mean: before 1996, Asperger's did not exist as a diagnosis; since then, it's an autism spectrum disorder. Some adults are being diagnosed later in life with Asperger's after being told their children have it (a friend of mine is one of these).

Are they taking into account all the people being diagnosed at an older age, who are then added to the children also being diagnosed?

And the diagnosis can be pretty vague - who's to say "Developmental disorder not otherwise specified" is really an autism spectrum disorder.
 
I sometimes wonder what level of evidence would be sufficient to convince people that vaccines and autism are not related. You already have exhaustive, overwhelming lines of evidence which have been unable to find a link between the two. If the amount of money and resources that have been poured into disproving that theory (multiple times over) had been applied to helping those with the condition or looking for the actual cause, we might be getting somewhere by now.

No amount of evidence will convince the Jenny McCarthys and idiots of the world. Just look at how many people think Obama wasn't born in the US, despite no shred of evidence to suggest it. Ignorant people will just think what they want to believe.
 
Something I've been saying for years 👍

So it's frequently been said these days that the rise in autism is not due to increased diagnosis. Has this statement been validated? Here's what I mean: before 1996, Asperger's did not exist as a diagnosis; since then, it's an autism spectrum disorder. Some adults are being diagnosed later in life with Asperger's after being told their children have it (a friend of mine is one of these).

Are they taking into account all the people being diagnosed at an older age, who are then added to the children also being diagnosed?

And the diagnosis can be pretty vague - who's to say "Developmental disorder not otherwise specified" is really an autism spectrum disorder.

A study published by CDC a couple weeks ago says it has. And Dr. Insel (who as noted earlier in the thread heads the Interagency Autism Coordinating Committee for the U.S., and who also is the Director of the National Institute of Mental Health) agrees with the CDC. That's a little different than a mob of crazed parents of autistic kids.

Dr. Insel, as quoted in the article in the OP, has stated "As far as I can tell, the burden of proof is upon anybody who feels that there is NOT a real increase here in the number of kids affected" (that would be you Pharmavixen). Also from the article: "He (Dr. Insel) said factors such as better ascertainment "don't really explain away this huge increase" and that "you really have to take this (increase) very seriously -- from everything they are looking at, this is not something that can be explained away by methodology, by diagnosis.""

From the CDC study:
"Although community identification of children with ASDs increased during the study period, this factor alone does not explain fully the increase in ADDM-identified prevalence." [note: ADDM = Autism and Developmental Disabilities Monitoring (ADDM) Network]

"a clear pattern did not emerge that would permit attributing the majority of the increase in ASD prevalence to the use of the broader ASD spectrum."

"For children identified with an ASD by age 8 years, the reduction of age of identification does not appear to be a substantial factor influencing prevalence estimates."

"Although some of these increases can be accounted for by improved identification and awareness, the steady increase in ASD symptoms in the population possibly reflects increased risk, particularly among males."

"Although improved ascertainment accounts for some of the prevalence increases documented in the ADDM sites, a true increase in the risk for children to develop ASD symptoms cannot be ruled out."
 
I'm sorry, but it's just irresponsible to imply that vaccines have anything to do with autism, or even that they should remain a topic of serious study. Why do I say that? Because it is talk like that which has already caused the unnecessary deaths of hundreds (maybe thousands by now) of children from things like mumps and measles. When the first flawed research came out the government didn't wait for proof. They required withdrawal of mercury compounds from childhood vaccines, just to be safe. They launched a fund to compensate families of children injured by vaccines. These actions legitimized a whole generation of conspiracy theorists like Kirby and have convinced tens of thousands that vaccines are unsafe. By the way, it's not just the children of vaccine-fearing parents who are dying, it's also the children with contraindications to vaccination who were previously protected by herd immunity. When an intervention as important as vaccination is in question, it's unacceptable to imply that the jury is still out. Time and time again the link has been disproven by quality studies. BTW, facet, while it is true that most of the studies focused on MMR and thimerosol, mercury free vaccines and non-vaccination or placebo vaccination were often the comparison groups. In other words, there is data out there on all types of vaccines and abstinence.

Nothing is impossible, and you may be right that there will be a subgroup of ASD patients who are hypersensitive to vaccines. HOWEVER, vaccination trends can in no way explain the population level rise in incidence and should not be a serious avenue of investigation.
 
I'm sorry, but it's just irresponsible to imply that vaccines have anything to do with autism, or even that they should remain a topic of serious study. Why do I say that? Because it is talk like that which has already caused the unnecessary deaths of hundreds (maybe thousands by now) of children from things like mumps and measles. When the first flawed research came out the government didn't wait for proof. They required withdrawal of mercury compounds from childhood vaccines, just to be safe. They launched a fund to compensate families of children injured by vaccines. These actions legitimized a whole generation of conspiracy theorists like Kirby and have convinced tens of thousands that vaccines are unsafe. By the way, it's not just the children of vaccine-fearing parents who are dying, it's also the children with contraindications to vaccination who were previously protected by herd immunity. When an intervention as important as vaccination is in question, it's unacceptable to imply that the jury is still out. Time and time again the link has been disproven by quality studies. BTW, facet, while it is true that most of the studies focused on MMR and thimerosol, mercury free vaccines and non-vaccination or placebo vaccination were often the comparison groups. In other words, there is data out there on all types of vaccines and abstinence.

Nothing is impossible, and you may be right that there will be a subgroup of ASD patients who are hypersensitive to vaccines. HOWEVER, vaccination trends can in no way explain the population level rise in incidence and should not be a serious avenue of investigation.

I don't think very many people are calling for the eradication of our vaccination program; that would be a bit hyperbolous. As I said, my kids are vaccinated. What is concerning, though, is the notion on the part of some that vaccines are nothing but miracles and that's that, and to dare suggest any inquiry into them is scandalous. But where would we be if science stopped asking questions?

We don't know everything there is to know about autism, that much is clear. And we know that some kids react adversely to vaccines. And there is thought that some kids that have issues (e.g., mitochondrial dysfunction) may be particularly susceptible to certain environmental inputs, which includes vaccines. Sure, the numbers of kids in this category cannot explain the rapid increases in autism cases. But the point is that we are far from knowing everything and to simply wave off future research efforts is foolhardy.

I think ideally in the future we would have a way to somehow pre-screen kids to try to predict who may be at risk for adverse effect of vaccination. Perhaps this won't be feasible economically, I don't know. But it would be nice.

As to your conpiracy theorists, others might call them parents looking for answers but getting nothing but stonewalled. And why do you continue to denigrate David Kirby? He wrote a book about the history of the various grassroots autism groups and reported on their efforts to gain some answers. His book certainly touched a nerve and did make public some information that shines a light on what had always been behind-closed-door kind of stuff. But I felt his book, and his ongoing reporting, is quite even-handed.

To the current research, some have called for well designed study of vaccinated vs. unvaccinated kids; these studies never get approved though. As to placebo vaccination studies, I would think that such a placeo arm would never get approved. Do such studies exist? I know they don't exist for flu vaccines, despite being called for by international vaccine experts.
 
A study published by CDC a couple weeks ago says it has.
nope.
And Dr. Insel (who as noted earlier in the thread heads the Interagency Autism Coordinating Committee for the U.S., and who also is the Director of the National Institute of Mental Health) agrees with the CDC.
But not with your misrepresentation.
Dr. Insel, as quoted in the article in the OP, has stated "As far as I can tell, the burden of proof is upon anybody who feels that there is NOT a real increase here in the number of kids affected"
Cop-out. Anti-science. IF you're a future medical provider and so disdain actual science, then you need to be kicked the hell out of the profession before you kill someone.
Also from the article: "He (Dr. Insel) said factors such as better ascertainment "don't really explain away this huge increase"
he claims. he's a quack with a political agenda. So in science, he is utterly irrelevant.
and that "you really have to take this (increase) very seriously -- from everything they are looking at, this is not something that can be explained away by methodology, by diagnosis.""
Sure it is. You claiming otherwise, you better prove it.
From the CDC study:
"Although community identification of children with ASDs increased during the study period, this factor alone does not explain fully the increase in ADDM-identified prevalence." [note: ADDM = Autism and Developmental Disabilities Monitoring (ADDM) Network]
Yeah "community identification" Think about that for awhile. It in no way expresses what you misrepresent it to mean. Dishonesty is an unappealing quality in a medical provider. please take up law instead.
.."a clear pattern did not emerge that would permit attributing the majority of the increase in ASD prevalence to the use of the broader ASD spectrum."
or the other way around.
"For children identified with an ASD by age 8 years, the reduction of age of identification does not appear to be a substantial factor influencing prevalence estimates."
But adding diagnoses under the spectrum certainly does.
"Although some of these increases can be accounted for by improved identification and awareness, the steady increase in ASD symptoms in the population possibly reflects increased risk, particularly among males."
or possibly not.
"Although improved ascertainment accounts for some of the prevalence increases documented in the ADDM sites, a true increase in the risk for children to develop ASD symptoms cannot be ruled out."
Or ruled in.
 
...But where would we be if science stopped asking questions?
But not the same subject over and over again. You're like the creationists, denying what already has solid evidence.
As to your conpiracy theorists, others might call them parents looking for answers but getting nothing but stonewalled.
baloney. they seek specific answers already proven false, so they misrepresent and lie to make their message sound valid even though it already is proven false. It turned into their religion.
And why do you continue to denigrate David Kirby?
he's a liar, that should be enough.
To the current research, some have called for well designed study of vaccinated vs. unvaccinated kids; these studies never get approved though. As to placebo vaccination studies, I would think that such a placeo arm would never get approved. Do such studies exist? I know they don't exist for flu vaccines, despite being called for by international vaccine experts.
How many subjects are sufficient for you to accept data? 2 mill? 10 mill? You really haven't actually looked at the data, have you? You're coming across as just as dishonest as kirby now.
 
Regnvejr, just so I understand, you disagree with just about everything I quoted from the CDC study. And you also disagree with the Interagency Autism Coordinating Committe and feel that Dr. Insel is a quack who is utterly irrelevant in science, even though he oversees the committe that decides where research science relating to autism will focus. Hmmm, maybe the problem lies with you? And I think you misunderstood. The statements I quoted weren't my own; they were direct quotes from the study. What the study attempted to do was to list many of the possible reasons why the rate of autism is increasing, then examine the available data (not facetguy's or David Kirby's data, but CDC data) to figure out whether all the typical reasons (expanded diagnostic criteria, etc.) are valid or not. I quoted from the study to show what they conclude. Again, you can claim it's a cop-out or anti-science or whatever, but I didn't publish the study. Why the defensive posture? I get the feeling you are one of these autism deniers who is now uncomfortable with the thought that you may have been wrong.

Clearly this is not a settled area of science, and research should continue. And you, a man of science as you proudly are, should be all for these investigations instead of continuing to wish the problem away. It ain't goin' away.
 
...I get the feeling you are one of these autism deniers who is now uncomfortable with the thought that you may have been wrong.
Then you're a *****. I treat it daily, and what you quoted was crap. THAT is my point.
Clearly this is not a settled area of science,
Like creationism is not "settled"?

There is a difference between exploratory science and quackery. Wasting resources and energy on quackery takes away from treatment and REAL medicine.

So before you get enamored with slick talk, just because it confirms your agenda, paranoia or politics, it behooves you to check out its reliability.
 
Regnvejr, just so I understand, you disagree with just about everything I quoted from the CDC study. And you also disagree with the Interagency Autism Coordinating Committe and feel that Dr. Insel is a quack who is utterly irrelevant in science, even though he oversees the committe that decides where research science relating to autism will focus. Hmmm, maybe the problem lies with you? And I think you misunderstood. The statements I quoted weren't my own; they were direct quotes from the study. What the study attempted to do was to list many of the possible reasons why the rate of autism is increasing, then examine the available data (not facetguy's or David Kirby's data, but CDC data) to figure out whether all the typical reasons (expanded diagnostic criteria, etc.) are valid or not. I quoted from the study to show what they conclude. Again, you can claim it's a cop-out or anti-science or whatever, but I didn't publish the study. Why the defensive posture? I get the feeling you are one of these autism deniers who is now uncomfortable with the thought that you may have been wrong.

Clearly this is not a settled area of science, and research should continue. And you, a man of science as you proudly are, should be all for these investigations instead of continuing to wish the problem away. It ain't goin' away.

Published studies don't necessarily make it the truth or accurate. The only way you can confirm if a research result is legit is if there are repeatable, independent studies to confirm the hypothesis. So far the anti-vaccination campaign has yet to show enough independent studies to back up their supposed link between autism and vaccination. Haven't you looked at their methodology and data closely? Don't look just at the conclusion and claim it to be fact. CDC data might be accurate but that doesn't mean people who take those data would use it properly. It's not hard to omit a few criteria in the data just so the data would fit your hypothesis. Until I can see more testable and reproducible studies on the vaccine and autism link, I'll stick with the 99.9% of the studies that show that vaccines are safe. Remember a big rule in epidemiology, Correlation does NOT equate causation! Take a uni lvl class in epidemiology to learn how to read and analyze research data more appropriately. The epidemiology class at my med school sure opened up my eyes on how much data manipulation and suspicious data gathering methods that occur in research papers.

BTW the CDC's data isn't 100% accurate. I've had the ire of using CDC's data as the answer on one of my exams only to find out it's out of date and wrong. ugg...
 
Published studies don't necessarily make it the truth or accurate. The only way you can confirm if a research result is legit is if there are repeatable, independent studies to confirm the hypothesis.

No doubt. I'm with you there.

So far the anti-vaccination campaign has yet to show enough independent studies to back up their supposed link between autism and vaccination.

Are we talking about anti-vaccine advocates? I thought we were talking about figuring out why autism rates are increasing at a frightening pace. Why does this discussion always get derailed by talk of anti-vaccine advocates?

Haven't you looked at their methodology and data closely? Don't look just at the conclusion and claim it to be fact. CDC data might be accurate but that doesn't mean people who take those data would use it properly. It's not hard to omit a few criteria in the data just so the data would fit your hypothesis. Until I can see more testable and reproducible studies on the vaccine and autism link, I'll stick with the 99.9% of the studies that show that vaccines are safe.

What is my hypothesis?? And to the bolded, that IS what's being called for: more study. Folks like regnvejr claim the issue is settled; there is no increase in rates and it all comes down to diagnostic criteria etc. I tend to side with this CDC study and other evidence that says that regnvejr's claims may not explain it all and that more investigation is needed. Why is that unreasonable?? And, just to be clear, this wasn't intended to be some vaccine-bashing post. There is increasing interest in environmental factors as they relate to autism, and for a small subset of kids vaccines may be the trigger. But that doesn't explain it all. There may be additional environmental triggers that need to be explored. I'll say for the hundredth time: I'm not calling for the scrapping of the vaccine program. Please don't misunderstand or misrepresent my position.

Remember a big rule in epidemiology, Correlation does NOT equate causation! Take a uni lvl class in epidemiology to learn how to read and analyze research data more appropriately. The epidemiology class at my med school sure opened up my eyes on how much data manipulation and suspicious data gathering methods that occur in research papers.

This is an unfortunate truth. And sometimes this data is used to create policy, or at least greatly influences prescribing habits.


BTW the CDC's data isn't 100% accurate. I've had the ire of using CDC's data as the answer on one of my exams only to find out it's out of date and wrong. ugg...

I'm sure they aren't perfect. But it is worth taking into consideration and, as previously stated, following up on instead of pretending (*coughRegnvejrcough*) it doesn't exist.

And, just as an aside, why does anyone who calls for more autism research suddenly have some diabolical agenda?
 
...Are we talking about anti-vaccine advocates? I thought we were talking about figuring out why autism rates are increasing at a frightening pace. Why does this discussion always get derailed by talk of anti-vaccine advocates?...
Because the current version of the anti-vaccination movement believes the increase in autism is due to vaccines, even though that idea that has been thoroughly disproven. Because you quoted an article by a guy who is an anti-vaccine advocate and blames vaccines for the increase in autism. Because you overstated the importance of the linked interview when you named the thread "New Autism Data," when it is really just opinions.

These are all things you should avoid if you don't want to give the impression that you are an anti-vaccine advocate who blames vaccines for the increase in autism. Just sayin'.
...What is my hypothesis?? And to the bolded, that IS what's being called for: more study...
Antivaccinationist also call for more research, but only if it supports their argument. If you're asking for more study into autism and it's causes, you're going to get all of the support in world. We don't know what causes it and we'd like better treatments for it. But if you or anyone suggests that vaccines are the cause and should be studied further, that's ridiculous.

...I'll say for the hundredth time: I'm not calling for the scrapping of the vaccine program. Please don't misunderstand or misrepresent my position...
That's also not uncommon rhetoric. Jenny MacCarthy says that we shouldn't scrap the entire vaccination program either, but then she says we should "green our vaccines," and "too many, too soon."
...A study published by CDC a couple weeks ago says it has...
Do you mean this study?
What is causing the increase in children identified with ASDs?

No single factor can explain changes in the ADDM Network-identified ASD prevalence over time, and although some of the increases can be accounted for by improved identification, it also is possible that the symptoms associated with ASDs have increased steadily among the population. The question of how much of this increase in ASD prevalence is due to a genuine increase in risk is impossible to answer fully. It also is clear that there is not a single reason for the increase. Instead, many different factors have been at play. While we are reaching a better understanding of ASD prevalence among children in the United States, we are still in the midst of a changing landscape with changes in identification, awareness, and improved understanding of the complex causes of ASDs. As more studies indicate that ASD prevalence is approaching 1% or greater, it will be essential to know if the estimated prevalence will level out or continue to change over time. Continuing to evaluate the prevalence of ASDs among children born in this millennium is very important.

Don't misinterpret the scientific uncertainty described above as some sort of proof that there is a cause of autism beyond expanded diagnostic criteria. Every single scientific study will point out its own limitations, emphasize it's own importance, state how it could be improved, and give several different possible explanations of the data. This is on the order of discussing with your neighbor whether it will rain this afternoon or not based on the fact that it is overcast this morning. That's it.
 
Because the current version of the anti-vaccination movement believes the increase in autism is due to vaccines, even though that idea that has been thoroughly disproven. Because you quoted an article by a guy who is an anti-vaccine advocate and blames vaccines for the increase in autism. Because you overstated the importance of the linked interview when you named the thread "New Autism Data," when it is really just opinions.

These are all things you should avoid if you don't want to give the impression that you are an anti-vaccine advocate who blames vaccines for the increase in autism. Just sayin'.

Who cares what the anti-vax movement thinks? Are they the only people on the planet who have an interest in why there are more autism cases than ever? As to David Kirby, I don't know the guy from Adam. Clearly the book he wrote is a sensitive subject. But why are we to assume that the guy is completely one-dimensional and is incapable of any other thoughts on the matter of autism (or anything else, for that matter; he did just write a new book which has nothing to do with autism)? Regarding the article, the interview and the opinions, the point was that the CDC had just released new DATA. This has little to do with opinions, although I think Dr. Insel's take on the matter should count for something, given his position in the autism research community. Just sayin'.

(More later. Wife calling.)

Antivaccinationist also call for more research, but only if it supports their argument. If you're asking for more study into autism and it's causes, you're going to get all of the support in world. We don't know what causes it and we'd like better treatments for it. But if you or anyone suggests that vaccines are the cause and should be studied further, that's ridiculous.

That's also not uncommon rhetoric. Jenny MacCarthy says that we shouldn't scrap the entire vaccination program either, but then she says we should "green our vaccines," and "too many, too soon."
Do you mean this study?


Don't misinterpret the scientific uncertainty described above as some sort of proof that there is a cause of autism beyond expanded diagnostic criteria. Every single scientific study will point out its own limitations, emphasize it's own importance, state how it could be improved, and give several different possible explanations of the data. This is on the order of discussing with your neighbor whether it will rain this afternoon or not based on the fact that it is overcast this morning. That's it.
 
Who cares what the anti-vax movement thinks?...
I do, because their efforts harm us and kids.

...Are they the only people on the planet who have an interest in why there are more autism cases than ever?..
Straw man and patently false, as show in the paper you quoted.

...As to David Kirby, I don't know the guy from Adam...he did just write a new book which has nothing to do with autism)?...
Clearly you do know him in some way because you know he released a new book.

...Regarding the article, the interview and the opinions, the point was that the CDC had just released new DATA...
Then you should have quoted the CDC data, not some interview written by a very biased source.
 
While this debate has remained relatively civil so far, please keep in mind that personal attacks and insults should be kept out of it.
 
Antivaccinationist also call for more research, but only if it supports their argument. If you're asking for more study into autism and it's causes, you're going to get all of the support in world. We don't know what causes it and we'd like better treatments for it. But if you or anyone suggests that vaccines are the cause and should be studied further, that's ridiculous.

I can't argue with that. But others might, others who believe the increases in autism are all just some statistical manipulation and don't need to be further investigated.

That's also not uncommon rhetoric. Jenny MacCarthy says that we shouldn't scrap the entire vaccination program either, but then she says we should "green our vaccines," and "too many, too soon."

I'm surely not going to speak for Jenny McCarthy.


This is the study:
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5810a1.htm


Don't misinterpret the scientific uncertainty described above as some sort of proof that there is a cause of autism beyond expanded diagnostic criteria. Every single scientific study will point out its own limitations, emphasize it's own importance, state how it could be improved, and give several different possible explanations of the data. This is on the order of discussing with your neighbor whether it will rain this afternoon or not based on the fact that it is overcast this morning. That's it.

I guess we'll see what the future research shows. That's the way this should work.
 
I do, because their efforts harm us and kids. Straw man and patently false, as show in the paper you quoted.

OK. I was being facetious there. I just wanted to reel you back from going off the anti-vax deep end.

Clearly you do know him in some way because you know he released a new book.

There was a blurb to that effect in his bio appearing with the article. I would call that paying attention, not idolizing David Kirby.

Then you should have quoted the CDC data, not some interview written by a very biased source.

I did. But I also quoted Dr. Insel from Kirby's article, yes.
 
http://discovermagazine.com/2009/jun/06-why-does-vaccine-autism-controversy-live-on

A quick read on why the vaccine controversy lives on. Mentions Kirby, Huffington Post and discusses the evidence.

Now that we've all read the Discover article, go back and read the Kirby article I posted at the top of this thread. Don't you see WHY I posted it? The Discover article goes through all the vaccine-related stuff from the past years and also discusses the issue of whether autism rates are real or a diagnostic/statistical anomaly. This new CDC study, on the other hand, reports data that suggests the autism rate increase cannot simply be waved off as a function of increased diagnostic criteria, etc. And the article I posted doesn't even get into the vaccine issue (well, maybe a little at the end, with some suggestion that there may be a subpopulation of particularly susceptible kids).

That is why I thought Kirby's article was worthwhile. Because it presents new data and avoids the typical anti-vax static. But sure enough, most of the comments in this thread so far have been to blast Kirby, blast the Huffington Post, blast the anti-vax movement, blast me as having some paranoid agenda, and ignore the newly presented CDC data. So who's the crazy one here?

The Discover article does mention the Huffington Post not because it has been some kind of spearhead in the anti-vax movement but because that is where an article by RFK Jr. appeared some years ago. And it mentions Kirby, who when you read the Discover article comes out sounding pretty reasoned.
 
I am still not convinced that it's a matter of altered definitions and changed reporting and the CDC study does not address that because it does not stratify according to what sort of ASD the patients had, but lumps them all together. Like I said in my previous post, Asperger's didn't exist as a diagnosis before 1996. A close friend was diagnosed at the age of 40; his daughter, was diagnosed at age 3. So there's 2 cases of ASD where, fifteen years ago, there would have been none.

As it says in the CDC study,
Before the 1980s, the term "autism" was used primarily to refer to autistic disorder and was thought to be rare, affecting approximately one in every 2,000 (0.5%) children (2,3). Autism now is considered to be one of three disorders classified together as ASDs (4). Using diagnostic criteria established in the early 1990s, which encompass a broad spectrum of disorders (15,16), the best estimate of ASD prevalence is that approximately six or seven of every 1,000 (0.6%--0.7%) children have an ASD. These estimates are approximately 10 times higher than estimates using earlier criteria (2--4,12).

So you see my problem - they are saying that there's a definite rise in a set of pathological conditions, but in the 1990s they changed the rules around diagnostic criteria of how you define these conditions in the 1st place. Above, the CDC comes right out and says that changing the diagnostic criteria changes the prevalence of ASD at least 10-fold.

I know that there are autism experts saying there are more children with an actual neurological problem. I'm sure these experts know more about autism than I do. But I don't take anybody at their word - show me the data!
 
...Are we talking about anti-vaccine advocates? I thought we were talking about figuring out why autism rates are increasing at a frightening pace. Why does this discussion always get derailed by talk of anti-vaccine advocates?
they are also the group who makes the claims about increased autism rates, the ones whose agenda is that there must be some environmental connection that makes it preventable.

When the genetic links and predispositions are clear, insisting that there are curable causes that will eventually make these kids absolutely and completely normal is a pipe dream. It is parents refusing to accept reality and pushing for what we already know is false. Pushing more in that direction will merely take resources away from real issue research into autism, all because some parent can't accept that these kids never will be able to say "I love you" to their parents.

Yeah, I really feel for parents of children with autism. I deal with them and their kids every day, I see their difficulties, the disappointments the daily victories and losses. But the parents who hurt the research and the Science through their denial, be it "facilitated communication," Vitamin E overdosing or whatnot, they are a setback to treatment.

We still have no treatment worth crap for actually treating Autism. We can cover the mod swings and behaviors a little bit so they don't beat up to much on people around them, and that makes everybody happier. But actual treatment for autism is in short supply.

Or didn't you know that's the crowd behind your newfound cause? before you decide to advocate for something, it is a very good idea to know the details behind them.
What is my hypothesis?? And to the bolded, that IS what's being called for: more study. Folks like regnvejr claim the issue is settled; there is no increase in rates and it all comes down to diagnostic criteria etc.
Nope. Your misrepresentation of my point doesn't help you here. At some point I will have to accuse you of outright lying unless you reign in your wild claims here.
I tend to side with this CDC study and other evidence that says that regnvejr's claims may not explain it all and that more investigation is needed. Why is that unreasonable??
(1) I am not saying I have all the answers, your misrepresentation none withstanding. it is time for you to drop the Ad Hominems. (2) redirecting research funds just prolongs the time until we have anything real to offer people with autism.
And, just to be clear, this wasn't intended to be some vaccine-bashing post. There is increasing interest in environmental factors as they relate to autism, and for a small subset of kids vaccines may be the trigger. But that doesn't explain it all. There may be additional environmental triggers that need to be explored.
There has been environmental claims for many decades now. They ALL have turned into dead ends. Yes, people oh so much WANT there to be an environmental factor so it can be easily treated. Wishful thinking is not science and does not produce results. No, Vitamin E didn't fix it. It wasn't the "refrigerator mom." It wasn't vaccine preservatives. There is no small subset of kids with vaccine sensitivities. these studies **HAVE** been done and redoing them over and over again is a waste of resources that takes away fro other sources. Refusing to accept the conclusive result of many studies all saying the same thing is baloney, it is quackery.
I'll say for the hundredth time: I'm not calling for the scrapping of the vaccine program. Please don't misunderstand or misrepresent my position.
But you want MORE vaccine studies, even though they have already been done in detail. How many are enough? How many subjects? Obviously, 2-4 mill subjects are not enough for you. Are 10 mill. enough? When will you agree to direct research toward what actually helps?
I'm sure they aren't perfect. But it is worth taking into consideration and, as previously stated, following up on instead of pretending (*coughRegnvejrcough*) it doesn't exist.
That's enough from you. I recommend you drop that crap really fast.

And putting my name in that nice parenthesis merely makes you look like you can't stand by openly express your view. Not good either.
And, just as an aside, why does anyone who calls for more autism research suddenly have some diabolical agenda?
But you are not. You are calling for removing funds from legitimate research into some stupid political agenda of a subject that already have been studied. You are like a creationist wanting to put biology research into whether Evolution actually happens.
 
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Who cares what the anti-vax movement thinks?
Because they have caused kids to not be vaccinated, and therefore some are dying. Because they take resources away from legitimate research. These people are despicable liars.
Are they the only people on the planet who have an interest in why there are more autism cases than ever?
They're the ones who insist that some fixable environmental cause is right under our noses, just because they want there to be. They're the ones who push quackery.
As to David Kirby, I don't know the guy from Adam.
Some of us do. When you get yourself a new hero, I suggest you know what he is all about first.
Clearly the book he wrote is a sensitive subject. But why are we to assume that the guy is completely one-dimensional and is incapable of any other thoughts on the matter of autism
because that's his past behavior. Best predictor of future behavior is past behavior. That's well-established.
 
... This new CDC study, on the other hand, reports data that suggests the autism rate increase cannot simply be waved off as a function of increased diagnostic criteria, etc.
And, of course, people with autism actually being diagnosed with it instead of Schizophrenia and so on.
That is why I thought Kirby's article was worthwhile. Because it presents new data
There is nothing new in his article. He has pushed the same stuff for a long time.
 
I blame BPA (an estrogenic compound) in our plastics for autism. See? I can make up BS without any evidence too.
 
they are also the group who makes the claims about increased autism rates,

(Pretends to tap microphone) Hello, is this thing on?? The CDC study referred to in this thread says the rates are increasing.

From the study: (note: not from facetguy, David Kirby, or Huffington Post)
"The average prevalence of ASDs identified among children aged 8 years increased 57% in 10 sites from the 2002 to the 2006 ADDM surveillance year."

Also from the study:
"These results indicate an increased prevalence of identified ASDs among U.S. children aged 8 years and underscore the need to regard ASDs as an urgent public health concern."

Your repeated inability to listen to anything other than your own opinion on this matter is scaring me bro.

(to be continued later...)

the ones whose agenda is that there must be some environmental connection that makes it preventable.

When the genetic links and predispositions are clear, insisting that there are curable causes that will eventually make these kids absolutely and completely normal is a pipe dream. It is parents refusing to accept reality and pushing for what we already know is false. Pushing more in that direction will merely take resources away from real issue research into autism, all because some parent can't accept that these kids never will be able to say "I love you" to their parents.

Yeah, I really feel for parents of children with autism. I deal with them and their kids every day, I see their difficulties, the disappointments the daily victories and losses. But the parents who hurt the research and the Science through their denial, be it "facilitated communication," Vitamin E overdosing or whatnot, they are a setback to treatment.

We still have no treatment worth crap for actually treating Autism. We can cover the mod swings and behaviors a little bit so they don't beat up to much on people around them, and that makes everybody happier. But actual treatment for autism is in short supply.

Or didn't you know that's the crowd behind your newfound cause? before you decide to advocate for something, it is a very good idea to know the details behind them.
Nope. Your misrepresentation of my point doesn't help you here. At some point I will have to accuse you of outright lying unless you reign in your wild claims here.
(1) I am not saying I have all the answers, your misrepresentation none withstanding. it is time for you to drop the Ad Hominems. (2) redirecting research funds just prolongs the time until we have anything real to offer people with autism.
There has been environmental claims for many decades now. They ALL have turned into dead ends. Yes, people oh so much WANT there to be an environmental factor so it can be easily treated. Wishful thinking is not science and does not produce results. No, Vitamin E didn't fix it. It wasn't the "refrigerator mom." It wasn't vaccine preservatives. There is no small subset of kids with vaccine sensitivities. these studies **HAVE** been done and redoing them over and over again is a waste of resources that takes away fro other sources. Refusing to accept the conclusive result of many studies all saying the same thing is baloney, it is quackery.
But you want MORE vaccine studies, even though they have already been done in detail. How many are enough? How many subjects? Obviously, 2-4 mill subjects are not enough for you. Are 10 mill. enough? When will you agree to direct research toward what actually helps?
That's enough from you. I recommend you drop that crap really fast.

And putting my name in that nice parenthesis merely makes you look like you can't stand by openly express your view. Not good either.
But you are not. You are calling for removing funds from legitimate research into some stupid political agenda of a subject that already have been studied. You are like a creationist wanting to put biology research into whether Evolution actually happens.
 
Facet. There are two separate issues here which are being treated as one. I agree, and I think most others will also, that the new CDC data shows that the increase in autism cannot be explained solely by diagnostic factors. I will agree that we need to research causes which explain this increased incidence including environmental factors. HOWEVER, I disagree that this new data justifies further research into vaccines as a cause for autism, a topic which has been thoroughly explored.
 
Facet. There are two separate issues here which are being treated as one. I agree, and I think most others will also, that the new CDC data shows that the increase in autism cannot be explained solely by diagnostic factors. I will agree that we need to research causes which explain this increased incidence including environmental factors. HOWEVER, I disagree that this new data justifies further research into vaccines as a cause for autism, a topic which has been thoroughly explored.

I'm in agreement. We will, however, likely see some further illumination over the years on the subpopulations we've mentioned before. These additional details will come as we learn more overall about the causes of autism and how certain predispositions may exist. I agree though that vaccines don't explain everything about autism.
 
... the ones whose agenda is that there must be some environmental connection that makes it preventable.

There's that agenda thing again.

When the genetic links and predispositions are clear, insisting that there are curable causes that will eventually make these kids absolutely and completely normal is a pipe dream.

I know you realize that environmental triggers can lead to the expression of genetics in one way vs. another. The old expression "Genetics loads the gun, environment pulls the trigger" comes to mind. The continually emerging science of epigenetics, among other things, is allowing us to understand this. So to say 'It's a genetic thing, end of story' is missing a big piece of the puzzle. Future research will attempt to unravel these mysteries, particularly regarding environmental triggers. No agenda. No paranoia. Just science.

It is parents refusing to accept reality and pushing for what we already know is false. Pushing more in that direction will merely take resources away from real issue research into autism, all because some parent can't accept that these kids never will be able to say "I love you" to their parents.

Yeah, I really feel for parents of children with autism. I deal with them and their kids every day, I see their difficulties, the disappointments the daily victories and losses. But the parents who hurt the research and the Science through their denial, be it "facilitated communication," Vitamin E overdosing or whatnot, they are a setback to treatment.

We still have no treatment worth crap for actually treating Autism. We can cover the mod swings and behaviors a little bit so they don't beat up to much on people around them, and that makes everybody happier. But actual treatment for autism is in short supply.

Or didn't you know that's the crowd behind your newfound cause? before you decide to advocate for something, it is a very good idea to know the details behind them.

See above.

Nope. Your misrepresentation of my point doesn't help you here. At some point I will have to accuse you of outright lying unless you reign in your wild claims here.

I understood your position as one which denies that there is an increase in autism rates. Is this not your position?


(1) I am not saying I have all the answers, your misrepresentation none withstanding. it is time for you to drop the Ad Hominems.

No one has all the answers. Thus the need for additional investigation.

As to ad hominems, you have so far called me dishonest, a *****, a liar, paranoid, and someone with a political agenda, at least.


(2) redirecting research funds just prolongs the time until we have anything real to offer people with autism.

By "anything real" you mean anything that you already understand and/or deem important.

There has been environmental claims for many decades now. They ALL have turned into dead ends. Yes, people oh so much WANT there to be an environmental factor so it can be easily treated. Wishful thinking is not science and does not produce results. No, Vitamin E didn't fix it. It wasn't the "refrigerator mom." It wasn't vaccine preservatives. There is no small subset of kids with vaccine sensitivities. these studies **HAVE** been done and redoing them over and over again is a waste of resources that takes away fro other sources. Refusing to accept the conclusive result of many studies all saying the same thing is baloney, it is quackery.
But you want MORE vaccine studies, even though they have already been done in detail. How many are enough? How many subjects? Obviously, 2-4 mill subjects are not enough for you. Are 10 mill. enough? When will you agree to direct research toward what actually helps?
That's enough from you. I recommend you drop that crap really fast.

And putting my name in that nice parenthesis merely makes you look like you can't stand by openly express your view. Not good either.

No, it was just kind of humorous.

But you are not. You are calling for removing funds from legitimate research into some stupid political agenda of a subject that already have been studied. You are like a creationist wanting to put biology research into whether Evolution actually happens.

Ugh.
 
[re: David Kirby]Some of us do. When you get yourself a new hero, I suggest you know what he is all about first.

Just curious: did you read Kirby's book?

because that's his past behavior. Best predictor of future behavior is past behavior. That's well-established.

The science of autism is evolving, and from what I can tell so is Kirby's reporting.
 
I blame BPA (an estrogenic compound) in our plastics for autism. See? I can make up BS without any evidence too.

Even the FDA has changed it's position on BPA from one of "Move along, there's nothing to see here" to "OK, we initially overlooked a bunch of data and now we have some concerns about BPA". BPA should and will continue to be investigated as it relates to human health, as the information so far has been concerning.
 
I'm in agreement. We will, however, likely see some further illumination over the years on the subpopulations we've mentioned before. These additional details will come as we learn more overall about the causes of autism and how certain predispositions may exist. I agree though that vaccines don't explain everything about autism.

Vaccines don't explain anything about autism.
 
facetguy, if you had posted only the data from the CDC I would expect everyone here to agree with you. The issue arises when you start quoting anti-vax groups on how they interpret these data to support their cause.

Here let me do what this original post was supposed to do.

This is the data that the CDC has on autism http://www.cdc.gov/ncbddd/autism/data.html

Here is the quote you stated in full:
"CDC considers ASDs to be an urgent public health concern. Increased concern in the communities, continued demand for services, and reports estimating a prevalence of about 1 percent underscore the need for a coordinated and serious response to improve the lives of people with ASDs."

Here is the page you quote it from in the CDC:
http://www.cdc.gov/ncbddd/autism/addm.html

Kindly note that no where does the CDC data said anything about vaccination causing this increase nor the increase in vaccination is correlated with the increase in autism. Strangely enough with the strong anti-vaccination that's been going on in recent years, there should be less autism occurring not more. So either the anti-vaccination campaign utterly failed and actually made more people vaccinate their kid or there is no correlation between autism and vaccination.

If you do wish to look into vaccination and autism correlation I suggest you look at children vaccination before age 8. The CDC data on autism mostly focus on children at the age of 8.
 
May I propose a new hypothesis? Actually I'll do it anyway.

My hypothesis is autism is caused by an environmental trigger in genetically susceptible children that is not vaccine related. Since autism has to do with the brain, the trigger would most likely cause a change in the brain (lost or gain of function), probably brain damage of some sort. So we look at vaccines as a possible cause, however vaccines protect children from potentially devastating illnesses that may cause neurological harm. After the anti-vaccination campaign's hard work in the last several years, more and more parents are refusing to vaccinate their children and thus exposing their children and the children who are too young to be vaccinated to more potential harm. We don't know what this environmental trigger is, but instead of combating the trigger, we are removing the protective barriers to brain infection by eliminating vaccinations to children. If this is true, we would see in the coming decades a great increase in autism incidence as the anti-vaccination campaign take on more followings than they have now.

Unfortunately for this hypothesis to hold any water, we need to wait at least 10 more years. Currently anti-vaccination campaigners are comparing data from well established vaccination surveillance programs in the present with out of dated surveillance and outdated autism classification criteria decades ago. If we can hold the criteria of autism to be constant for the next decade or more, we might get enough data to either support or refute my hypothesis.

The unfortunate situation is that unvaccinated children can become infected and be carriers. The children's parents might be willing to take that risk, however what about the parents of children who are too young to be vaccinated? Those families will have to be wary of unvaccinated children, else their own child may get infected by diseases that should have been wiped out long ago. Unlike the older children, the infants do not have well developed immune system and any infection may lead to horrible defects and even death.

Such is the dilemma of medicine...
 
facetguy, if you had posted only the data from the CDC I would expect everyone here to agree with you. The issue arises when you start quoting anti-vax groups on how they interpret these data to support their cause.

Here let me do what this original post was supposed to do.

This is the data that the CDC has on autism http://www.cdc.gov/ncbddd/autism/data.html

Here is the quote you stated in full:
"CDC considers ASDs to be an urgent public health concern. Increased concern in the communities, continued demand for services, and reports estimating a prevalence of about 1 percent underscore the need for a coordinated and serious response to improve the lives of people with ASDs."

Here is the page you quote it from in the CDC:
http://www.cdc.gov/ncbddd/autism/addm.html

Kindly note that no where does the CDC data said anything about vaccination causing this increase nor the increase in vaccination is correlated with the increase in autism. Strangely enough with the strong anti-vaccination that's been going on in recent years, there should be less autism occurring not more. So either the anti-vaccination campaign utterly failed and actually made more people vaccinate their kid or there is no correlation between autism and vaccination.

If you do wish to look into vaccination and autism correlation I suggest you look at children vaccination before age 8. The CDC data on autism mostly focus on children at the age of 8.

Read cpants' post #35 to help clear up confusion.

I didn't quote any anti-vax groups that I know of.

Too much emphasis has moved toward vaccination in this thread. That was not my intention or focus. I think some minds reflexively drift into 'Beware: Anti-Vax' mode when the topic of autism is even mentioned. We are talking about the reasons behind the increasing rates of autism. Stay focused.
 
While we are on the topic, here's more from everyone's favorite sources:
http://www.huffingtonpost.com/david-kirby/the-emlancetem-retraction_b_446749.html

Just take a slow, deep breath and read it.

This post deconstructs the article far better than I ever could. I suggest you read it.

http://scienceblogs.com/insolence/2010/02/the_martyrdom_of_st_andy_part_2_david_ki.php#more

Seriously, stop quoting the Huffington Post. They are not a legitimate source of scientific information.

Also, do you realize how rare it is for a scientific journal to retract an article? This is an embarrassment to both the editors of the journals and the authors associated with the study. For Kirby to shrug it off as it it is no big deal without discussing the merits of the decision is ridiculous.
 
This post deconstructs the article far better than I ever could. I suggest you read it.

http://scienceblogs.com/insolence/2010/02/the_martyrdom_of_st_andy_part_2_david_ki.php#more

Seriously, stop quoting the Huffington Post. They are not a legitimate source of scientific information.

Also, do you realize how rare it is for a scientific journal to retract an article? This is an embarrassment to both the editors of the journals and the authors associated with the study. For Kirby to shrug it off as it it is no big deal without discussing the merits of the decision is ridiculous.

Meat, I don't quote the HuffPost because I confuse it for NEJM. It's news, not a medical journal. And like him or not, Kirby stays in tune with the news of the autism research community. Tell me you didn't learn anything about the ongoing and upcoming research projects he mentioned? Even the scienceblog guy skipped over the fact that there are more studies forthcoming on the environmental contributions to autism. Lighten up.
 
+1 for quoting HuffingtonPost and not some stupid quacky pseudoscience site like ScienceBasedMedicine.org.
 
Vaccines have been given since the times of Jenner, Thimerosal has been in vaccines for decades. http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/VaccineSafety/UCM096228 The increases in autism and autistic spectrum disorders (ASD) are recent. With other heavy metals i.e. Copper, Arsenic and Lead there has not even been a proposed link in children with exposure to these. In fact the hallmarks of toxicity to these are very different than ASD or autism. If thimerosal, an organomercury caused autism, it should be seen in groups with exposure to heavy metals. Also the amount of thimerosal given in all vaccines is within CDC limits. Since no one has conclusively proved a link between autism and vaccines and vaccination has been widespread for several decades and there is increased surveillance for these disorders as well as a wider definition of autism when considering ASD, there are other possibilities.
 
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