MakingtheCASEforVaccines:
Anewmodelfortalkingtoparentsaboutvaccines
Itcanbefrustratingtostillbetalkingaboutautismandvaccineswhenasmedicalandpublichealth
professionalsweknowallthesepointsaretrue…
1. Therearedozensofstudieslookingattherelationshipbetweenautism
andvaccines,andnoneindicatealink.Youcanreadthestudiesfor
yourselfhere:
http://www.autismsciencefoundation.org/autismandvaccines.html
2. Thearticlethatoriginallypositedarelationshipbetweenautismand
theMMRvaccine,conductedbyAndrewWakefield,wasretractedin
early20101.AndrewWakefieldwasstrippedofhismedicallicense2and
hisreportwasdeemed“anelaboratefraud.”3
• TheVaccineCourthasdeniedallclaimsintheAutismOmnibus
Hearings4,writing,“thiscaseisnotaclosecase.Theoverall
weightoftheevidenceisoverwhelminglycontrarytothe
petitioners’causationtheories.”
3. Moreandmorechildrenaregettingsickfromvaccinepreventable
diseaseslikemeasles5andpertussis.6
Evenwithallthesefacts,someparentsmaystillquestionthesafetyandefficacyofvaccines.Physicians
areseeingtheeffects,accordingtoaJournalofPreventativeMedicinestudypublishedinMay20117:
• Nearly8outof10physiciansreportatleastonevaccinerefusalfromaparent.
1
ABCNews.“LancetRetractsControversialAutismPaper.”http://abcnews.go.com/Health/AutismNews/autismvaccines-lancet-retracts-controversial-autism-paper/story?id=9730805
2
TheNewYorkTimes.“BritishMedicalCouncilBarsDoctorWhoLinkedVaccinewithAutism.”
http://www.nytimes.com/2010/05/25/health/policy/25autism.html
3
CNN.“Retractedautismstudyan'elaboratefraud,'Britishjournalfinds.”
http://www.cnn.com/2011/HEALTH/01/05/autism.vaccines/index.html
4
“AbouttheOmnibusAutismProceeding.”http://www.hrsa.gov/vaccinecompensation/omnibusproceeding.htm
5
CDC.“Measles---UnitedStates,January--May23,2014.”
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6322a4.htm
6
CDC.“PertussisEpidemic–WashingtonOutbreaks2012.”
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6128a1.htm
7
“Prevalenceofparentalconcernsaboutchildhoodvaccines:theexperienceofprimarycarephysicians.”
http://www.ncbi.nlm.nih.gov/pubmed/21496754
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•
8%reportrefusalsformorethan10%ofchildrenintheir
practice.
Parentsarealsostillunsureoftheconnectionbetweenautismand
vaccines.AccordingtoaHarrisInteractive/HealthDaypollpublishedin
January20118:
• 18%ofAmericanssayvaccinescauseautism.
• 30%ofAmericansaren’tsure.
Familieswithonechildwithautismarealsolesslikelytovaccinateyounger
siblings,basedalmostentirelyontheirbeliefoftheautism–vaccineconnection9.However,astudy
disprovedthisfear,showingthatautismdiagnosisdidnotchangebyputtingchildrenonanalternate
MMRschedule.10Otherfactorswhichmayinfluencethedecisiontovaccinatearemandatesand
allowableexemptions.Whileoverallup-to-datevaccineratesarearound95%,almosthalfofUSstates
dippedbelowthat,endangeringthosewhocannotreceivevaccinesduetoageorpreexistingmedical
issueslikeleukemia.11
Thescienceonautismandvaccinesisclear,butstillsomeparentsarenotgettingthemessage.Better
communicationwithparentsaboutvaccinesisnecessary.Ourtraditionalframeworksfor
communicatingsciencearenolongeradequate.Weneedanewwayoftalkingtoparents.
New4-StepFrameworkforCommunicatingVaccineScience:TheCASEModel
Itisimportanttolistencarefullytotheconcernsparentsraiseregardingvaccinesandautism.Theymay
haveheardscarythingsonTVorfromfriends,andtheirfearsareveryreal.It’sourjobasmedicaland
publichealthprofessionalstoexplainthescienceinanewway.TheCASEMethodcombinesemotional
8
“Vaccine-AutismLink:SoundScienceorFraud?”
http://www.harrisinteractive.com/newsroom/pressreleases/tabid/446/mid/1506/articleid/674/ctl/readcustom%2
0default/default.aspx
9
“Surveyofvaccinebeliefsandpracticesamongfamiliesaffectedbyautismspectrumdisorders.”
https://www.ncbi.nlm.nih.gov/pubmed/22387922
10
AutismOccurrencebyMMRVaccineStatusAmongUSChildrenWithOlderSiblingsWithandWithoutAutism.
http://jamanetwork.com/journals/jama/fullarticle/2275444
11
VaccinationCoverageAmongChildreninKindergarten—UnitedStates,2013–14SchoolYear.
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6341a1.htm
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andscientifictalkingpointstoswayparent’semotionalresponseandhelpthemfacetheissuemore
logically.
Keepinmindthatparentswillevaluatethemessageandthemessenger.Itisimportanttomaintaina
professionalandcompassionatetonewhendiscussingvaccineswithaparent.Theyarescaredand
lookingformoreinformation.
Nexttimeyouhaveaconcernedparent,trytheCASEMethod:
•
Corroborate:Acknowledgetheparents’concernandfindsome
pointsonwhichyoucanagree.Setthetoneforarespectful,
successfultalk.
•
AboutMe:Describewhatyouhavedonetobuildyourknowledge
baseandexpertiseonthisissue.
•
•
Science:Describewhatthesciencesays.
Explain/Advise:Giveyouradvicetopatient,basedonthescience.
ExamplesofhowtousetheCASEMethodwithcommonvaccine
concerns:
“IheardonTVthatvaccinescauseautism”
• Corroborate:There’scertainlybeenalotofcoverageontelevisionaboutvaccinesandautismso
Icanunderstandwhyyouhavequestions.
• AboutMe:IalwayswanttomakesureI’muptodateonthelatestinformationsothatIcando
what’sbestformypatients,soI’veresearchedthisthoroughly.Infact,Ijustreturnedfroma
professionalconferencewherewereviewedthedataatlength.
• Science:Thescientificevidencedoesnotsupportacausallink.TheCDC,the
AAP,theNIH,theIOM(etc.)allreviewedthedataandallreachedthesame
conclusion.Dozensofstudieshavebeendone.Here’swhatwedoknowabout
whatcausesautism….
• Explain/Advise:Vaccinesarecriticaltomaintaininghealthandwellbeing.They
preventdiseasesthatcauserealharm.Choosingnottovaccinatedoesnot
protectchildrenforautism,butdoesleavethemopentodiseases.Kidsneed
thesevaccines.
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“Measlesisn’tsobad.IhadchickenpoxandIwasfine.”
• Corroborate:Icanunderstandwhyyoumightfeelthatway.Ihadchickenpoxmyself.
• AboutMe:Untillastyear,IhadneverseenacaseofHIBormeasles,butnow,asvaccinerates
decline,thesediseasesaremakingacomeback.MycolleagueinSanDiegowastellingmeabout
what’sgoingoninCAregardingthewhoopingcoughepidemic.
• Science:Thesediseaseshavecomebackinareaswherevaccinationratesarelow.Lastyear,six
childrendiedofHIBandthisyearinCalifornianinebabieshavediedofpertussis.
• Explain:Wecareaboutourpatientsanddon’twanttopracticesubstandardcare.Allour
patientsneedtobevaccinated.Myownchildrenarefullyvaccinated.
“Iwanttospreadouttheshotssotheywon’toverwhelmmychild’simmunesystem.”
• Corroborate:Kidstodaycertainlygetmoreshotsthankidsdidyearsago.
• AboutMe:OurpracticefollowstheCDCschedulebecauseitiscarefully
designedtoprotectchildrenatthetimetheyaremostvulnerabletodisease.I
participateonacommitteethatreviewstheschedule(describeyourinvolvement).
• Science:Althoughkidsgetmoreshotstoday,theyactuallyreceivefewer
antigensthanwhentheygotfewershots,becausetechnologyhasenabledusto
makevaccinesthathaveonlythepartofthecellthatinducesimmuneresponse.
• Explain:Wewantallthekidsinourpracticetobeimmunizedsothatthey
havethegreatestchanceforalong,healthylife.Myownchildrenarefully
vaccinated.Sciencehasshownthatautismriskisnodifferentifthevaccinesare
spacedoutvs.giventogether.
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WelcometoAutism101
Formanyyears,wethoughtoncethestudiesexoneratingvaccinesasacauseofautismwerepublished
thatparents’concernswouldbeallayed.Butthishasnotbeenthecase.Thegoodnewsisthatin
additiontolearningthatvaccinesdon’tcauseautism,therearenewstudieshelpingusstartto
understandwhatdoescauseautism.Bysharingsomeofthisinformationwithparentswemayfurther
beabletoallaytheirfearsregardingvaccines.
TheTypesofAutism
Autismisactuallyagroupofbrain-baseddisordersthataffectaperson’sbehavioraswellassocialand
communicationskills.Thesedisordersincludeclassicautism,PervasiveDevelopmentalDisorder–Not
OtherwiseSpecified(PDD-NOS),AspergerSyndrome,RettSyndromeand
ChildhoodDisintegrativeDisorder.TogetherthesearereferredtoasAutism
SpectrumDisorders.12Typicallywhenwetalkaboutautism,wearetalking
aboutclassicautism,PDD-NOS,andAspergerSyndrome.
WhatisAutism?
Regardlessoftheclassificationofautism,everypersondiagnosedwith
autismhassomelevelofimpairmentinthreeareas:
– Social-interestinpeople,jointattention,imaginativeplay
– Communication-language,speech
– Behavior-repetitivebehaviors,tantrums,aggression
Theconnectionofsocial,language,andbehavior
isaverysimplifiedviewofwhatautismmeansfor
afamily.Whenachildhasautismfamiliesare
mostoftendealingwithawide-rangeofmedical
conditionsandbehaviors.Therearemanymore
associatedsymptomsandsyndromes,like
anxiety,depressionandagression,andcomorbiditieslikesleepissuesandepilepsy.
12
CDC.“FactsaboutASDs.”http://www.cdc.gov/ncbddd/autism/facts.html
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WhatCausesAutism?
Scientistshavebeenhardatworklookingforthecausesofautismandalsodevelopingnewtreatments
forautism.Weknowthat15%ofautismisattributabletospecificgeneticcauses,meaningin15%of
childrenwithautismwecanidentifyageneticabnormalitythatexplainstheirautism,andthatnumber
risesasbettergenetictechnologiesaredeveloped.Wearediscoveringthatthegenesinvolvedin
autismareinvolvedintheformationandfunctionofneuralsynpases.Synapsesarethespacesbetween
neuronsthatenablecommunicationsignalstobetransmittedthroughthebrain.Bycreatingmouse
modelsthatmimicthegeneticanomaliesfoundinautism,weareabletotestnewdrugsandseeifthey
helptocorrecttheproblemswesee.Severalstudieshaveshownthatspecificdrugsaresuccessfulin
reversingthedeficitsassociatedwithautism,atleastinmice.FDAclinicaltrialsofthesedrugsinhumans
arecurrentlyunderway.
However,geneticsarenottheonlycontributortoautismrisk.Researchhasshownanincreasedriskto
certainprenatal,butnotpostnatal,environmentalexposures.Forexample,prenatalexposuretohigh
levelsofairpollutionhasbeenconsistentlylinkedtoautism13.Drugstakenduringpregnancy,like
valproicacid,ananti-epilepticmedication,isassociatedwithincreasedrisk14.Importantly,gettingthe
fluorotherseriousinfectionwithafeverdoublestheriskofhavingachildwithautism.15Most
scientistsagreethatitistheinteractionofgenesandenvironmentthatleadstoanautismdiagnosis.
Manyoftheneuralpathwaysthattheseenvironmentalchemicalstargetarethesameasthose
controlledbythegenesassociatedwithautism,leadingtoacombinationofthingsthatinfluencerisk.
Vaccines,however,havenotbeenshowntotargetthesignallingfromcelltocell,andthewaythe
neuronsshapeandconnectduringdevelopment.
HowisAutismDiagnosed?
Weareabletodiagnosischildrenyoungerandyounger.Insomestudies,childrenasyoungas6-12
monthsoldshowsignsandsymptomsofautismandlaterreceiveadiagnosis(thisiswellbeforethe
infanthasreceivedmostvaccines).16Thereisalsoanew,simplescreeningtoolforpediatricianstouse
13
A Systematic Review and Meta-Analysis of Multiple Airborne Pollutants and Autism Spectrum Disorder.
https://www.ncbi.nlm.nih.gov/pubmed/27653281
14
“Prenatal valproate exposure and risk of autism spectrum disorders and childhood autism.”
https://www.ncbi.nlm.nih.gov/pubmed/23613074
15
“Autismafterinfection,febrileepisodes,andantibioticuseduringpregnancy:anexploratorystudy”.
https://www.ncbi.nlm.nih.gov/pubmed/23147969
16
“EarlyIdentificationofAutismSpectrumDisorder:RecommendationsforPracticeandResearch.
https://www.ncbi.nlm.nih.gov/pubmed/26430168
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onall12montholdbabies17.TheAAPrecommendsroutinescreeningforautismat18and24monthsof
age.
TheCDChaslistedtheseRedFlagsforAutism18
• Doesnotbabbleorcooby12months
• Doesnotgesture(point,wave,grasp)by12months
• Doesnotrespondtonameby12months
• Doesnotsaysinglewordsby16months
• Doesnotsaytwo-wordphasesonhisorherownby24months
(notrepeating)
• Hasanylossofanylanguageorsocialskillatanyage
WhyisEarlyDiagnosisImportant?
EarlyInterventionworks.Childrenwithautisminagoodearlyinterventionprogramcanmake
meaningfulgainsinskills.Infact,withearlytreatment,30-50%makeenoughgainstobemainstreamed
bykindergarten.Thesegainscanbesustainedformanyyearsaftertheinitialinterventionisdelivered.19
It’simportanttonotethatEarlyInterventionprogramsvarybystatesocheckwithyourlocal
organizations.
AutismTreatments
Therehavebeenmajoradvancesinevidence-basedtreatments20.Thesearejustsomethathavebeen
testedtobeeffective.Usuallypeoplewithautismneedacombinationofthesetherapiestosucceed:
• AppliedBehaviorAnalysis(ABA)Therapy.BesidesthetypicalABA
procedures,severalnewmodelsbasedonthetheoriesofABAhave
showntobeeffective.Theseincluderelationshipdevelopment
intervention,pivotalresponsetraining,naturalisticbehavioral
interventionsincluding“EarlyStartDenverModel”21and“JASPER.”22
17
“Detecting,Studying,andTreatingAutismEarly:TheOne-YearWell-BabyCheck-UpApproach.”
http://www.jpeds.com/article/S0022-3476%2811%2900240-X/abstract
18
CDC.“ActEarly.”http://www.cdc.gov/ncbddd/actearly/index.html
19
Parent-mediatedsocialcommunicationtherapyforyoungchildrenwithautism(PACT):long-termfollow-upofa
randomisedcontrolledtrial.https://www.ncbi.nlm.nih.gov/pubmed/27793431
20
Evidence-BasedPracticesforChildren,Youth,andYoungAdultswithAutismSpectrumDisorder:A
ComprehensiveReviewhttps://www.ncbi.nlm.nih.gov/pubmed/25578338
21
UCDavis.EarlyStartDenverModel.http://www.ucdmc.ucdavis.edu/mindinstitute/research/esdm/
22
“PreschoolDeploymentofEvidence-BasedSocialCommunicationIntervention:JASPERintheClassroom.”
https://www.ncbi.nlm.nih.gov/pubmed/26936161
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•
•
•
•
•
•
SpeechTherapy
OccupationalTherapy
PhysicalTherapy
SocialSkillsTraining
VideoPrompting
Pharmacologicalinterventions.TheFDAhasapprovedRisperdal23andAbilify24forsymptoms
associatedwithautism,butnotthecoresymptoms.
Unfortunately,parentsofchildrenwithautismareoftenluredwithpromisesofimprovementby
charlatansorquackslookingtomakeaquickbuck.Herearesometreatmentsforwhichthereislittleor
noevidenceofefficacy:
• Camelmilk
• SpecialDiet(GlutenandCaseinFree)
• VitaminSupplements
• SecretinInjections
• Anti-fungalagents
• Chelation
• Giantelectromagnets
• HyberbaricOxygenTherapy
• HoldingTherapy
• NicotinePatch
• Marijuana(andnotfortheparent)
• SnakeOil(yes,actualsnakeoil)
Sometimesparentsorthemediawillreportanecdotalevidencethatthesetreatmentswork.Webelieve
thisphenomenonisduetothehighplaceboeffectweseeinautismtrials.Parentsaresoeagerfora
treatmenttoworkthattheyoftenreporttremendousimprovementsevenforchildrenonplacebo.
23
PubMedHealth.http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000944/
PubMedHealth.http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000221/
24
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AdditionalResources:
Everyyear,thefederalInteragencyAutismCoordinatingCommittee(IACC)writesastrategicplanto
guidefederalandprivatespendingonautismresearch.25Thisdocumentisablueprintforthemost
pressingissuesinautismscienceandisagreatresourceforthepublichealthcommunity.TheIACCalso
publishesanannualSummaryofAdvancesinAutismSpectrumDisorderResearch,26whichreportson
newfindingsthathavemadethemostimpactonthefield.
Thefollowingwebsitesarehelpfulresources.
NationalInstitutesofHealth:
• https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd/index.shtml
• https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/AutismSpectrum-Disorder-Fact-Sheet
CenterforDiseaseControlandPrevention:
• https://www.cdc.gov/ncbddd/autism/index.html
HealthResourcesandServicesAdministration:
• https://mchb.hrsa.gov/maternal-child-health-initiatives/autism
AutismScienceFoundation
TheAutismScienceFoundationisanonprofitorganzationdedicatedtoscienceandevidence.ASFfunds
autismresearchdirectly,andalsosupportfamiliesbyreinforcingthemessagethatnosciencecurrently
existstoindicatethatvaccinescauseautism.
Website:www.autismsciencefoundation.org
Blog:www.autismsciencefoundation.wordpress.com
@autismsciencefd
@autismsciencefd
@autismsciencefd
@autismsciencefd
25
IACCStrategicPlanforAutismResearch–2013(currentlybeingupdated).
https://iacc.hhs.gov/publications/strategic-plan/2013/
26
IACC.“SummaryofAdvancesinAutismSpectrumDisorderResearch.”
https://iacc.hhs.gov/publications/summary-of-advances/2015/
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