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Autism Spectrum Disorder and Pervasive Developmental Disorders in Children
By Stephen Cowan, MD, FAAP
from “Integrative Medicine for Children” edited by Dr. May Loo, 2008 Saunders
Terminology
1. Clinical Consideration in Autism
2. Etiology :
a. Genetic Influences
b. Prenatal Influences
c. Post-natal Influences
d. Gastrointestinal Inflammation in autism
3. Conventional diagnosis of Autism
4. Differential Diagnosis
5. Conventional management of Autism
6. CAM management considerations:
a.
b.
c.
d.
e.
f.
The "leaky gut" syndrome and autism
Treating Dysbiosis
Healing the Gut
Strengthening Immunity and Detoxification
Chelation of Toxic Elements
Neuro-metabolic Fine-Tuning
7. Holistic Management Considerations (author's experience)
8. Summary
9. References
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Autism Spectrum Disorder and Pervasive Developmental Disorders in Children
By Stephen Cowan, MD, FAAP
Over the past 10 years there has been a significant rise in the diagnosis of Autism
Spectrum disorder (ASD) in North America and Europe. What was previously felt to be a
rare genetic disorder with a prevalence of 1:2000 now is estimated to be as high as 1:165
children.1,2 Initial denial by the medical community of a significant rise in prevalence
has been refuted by studies that have shown this not to be due to improved diagnostics or
shifts in the criteria for diagnosis.3 4 The acknowledgement that genetic syndromes do
not rise epidemically has led researchers to search for possible alternative explanations
for this devastating syndrome.
Terminology
The term "Autism" was originally coined by Leo Kanner in 1943 and further described
by Hans Asperger in 1944. They described a somewhat heterogeneous group of children
with an unusual "social-communication syndrome" who appeared to be languageimpaired, detached and had a number of odd behaviors. In 1967 Dr. Bernard Rimland
established the Autism Research Institute (ARI), a non-profit organization, devoted to
conducting research on possible causes and treatment of autism. In 1994, the Diagnostic
and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV), began referring
to Autism as a "spectrum" in order to stress the wide variation in signs and symptoms.
This has been further refined to include other neuro-behavioral disorders under the
category of Pervasive Developmental Disorder (PDD). (See DSM IV-R Table 1) The
3
term "PDD- Not Otherwise Specified" (PDD-NOS) has been used to refer to children
who do not meet the specific criteria for Autism presented in the DSM IV-Revised but
nevertheless have some social-communication dysfunction. Recently the term "Autism
Spectrum Disorder" has been coined to describe this group of children.
Table 1. DSM-IV-R Diagnostic Criteria for Diagnosis of ASD5
A.
A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from
(2) and (3):
1.
qualitative impairment in social interaction, as manifested by at least two of the
following:
a.
marked impairment in the use of multiple nonverbal behaviors such as eye-toeye gaze, facial expression, body postures, and gestures to regulate social
interaction
b.
failure to develop peer relationships appropriate to developmental level
c.
a lack of spontaneous seeking to share enjoyment, interests, or achievements
with other people (e.g., by a lack of showing, bringing, or pointing out objects of
interest)
d.
a lack of spontaneous seeking to share enjoyment, interests, or achievements
with other people (e.g., by a lack of showing, bringing, or pointing out objects of
interest)
2.
qualitative impairments in communication as manifested by at least one of the following:
a.
delay in, or total lack of, the development of spoken language (not accompanied
by an attempt to compensate through alternative modes of communication such
as gesture or mime)
b.
in individuals with adequate speech, marked impairment in the ability to initiate
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or sustain a conversation with others
c.
stereotyped and repetitive use of language or idiosyncratic language
d.
lack of varied, spontaneous make-believe play or social imitative play
appropriate to developmental level
3.
restricted repetitive and stereotyped patterns of behavior, interests, and activities, as
manifested by at least one of the following:
a.
encompassing preoccupation with one or more stereotyped and restricted
patterns of interest that is abnormal either in intensity or focus
b.
apparently inflexible adherence to specific, nonfunctional routines or rituals
c.
stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or
twisting, or complex whole-body movements)
d.
persistent preoccupation with parts of objects
B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3
years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or
imaginative play.
C. The disturbance is not better accounted for by Rett's Disorder or "Childhood Disintegrative
Disorder".
Clinical Considerations:
Children on the Autistic spectrum share a common dysfunction in "relatedness". This is a
core feature that accounts for many of their odd behaviors. Though often subtle and
frequently missed by parents and clinicians in very young children, the incapacity to
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"socially connect" may carry more predictive weight than delays in verbal expression.
Problems with relatedness are linked to receptive language dysfunction. Parent and
clinicians often concentrate more on the number of words a child can say rather than
what he/she can understand. To new parents or inexperienced clinicians, it may not be
obvious that a child does not comprehend. Asking a child to use a finger to point at a
specific object in response to a command is a simple exercise that can elicit receptive
language problems . An extreme form of receptive language dysfunction involves the
inability to recognize facial expressions. It is important to recognize that a child who
confuses a smile for anger may appear to respond quite bizarrely. Receptive language
dysfunction impacts on a child's ability to "read social cues". This may be the only clue
that there is a problem in high-functioning children such as Aspergers Syndrome.
Relatedness also manifests as the inability to "reciprocally interact". Typically, autistic
children will have great difficulty "taking turns". A simple exercise to assess this skill is
to ask a parent to roll a ball to the child and observe if and how many times the child will
"get the game", rolling it back and forth. Limited ability to "pretend play" also reflects
this restricted social-communication ability in autism. These children are often unable to
"symbolically" represent the world with language. This greatly limits the capacity to
mentally transform an object or mimic adult behavior. The spontaneous development of
imagination, imagining a pencil as a rocket-ship or feeding a bowel of pretend soup to a
doll (pretend person) does not occur unless relatedness and receptive language develop.
The clinician must additionally be keenly aware of the quality of a child's sense of
humor. "Getting the joke" implies sophistication of social-language abilities that is often
lacking in the autistic child.
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Lastly the clinician needs to observe the degree to which the child's repertoire of
activity is restricted. Due to the inability to understand the unpredictable world of human
language and behavior, many children develop a rigid set of routines as self-defense.
They often show intense resistance to change that can harden into obsessive compulsive
behaviors. Many self-stimulatory behaviors develop as a way of "blocking out" the chaos
of the world. An autistic child may choose sensory input that "feels" good and withdraw
into it when they are being overwhelmed. Some children with autism seem to get caught
in the details of things, spinning shiny objects, studying the electrical circuitry of a room,
etc. They appear to be hyper-focused, studying the basic mechanisms of their
environment. Self-stimulation, (hand-flapping, spinning etc.) may also be the result of an
apparent heightened sensory awareness. Many children with autism will demonstrate
extraordinary sensory abilities. These may result from a compensatory reaction to the
limitations on the "social senses". One observes analogous abilities in the heightened
visual acuity of the hearing impaired child and the heightened sense of smell or touch
seen in the visually-impaired child.
Etiology
The etiology of autism at present is unknown. This may be largely due to the fact that
Autism is a "symptom complex" and not a single entity. No single cause has as yet
been identified but recent research is beginning to reveal pieces to the puzzle.
1. Genetic and Metabolic Factors: Chromosomal abnormalities account for less than
1% of children with autistic features6,7. These involve aberrations in chromosome
15q (15q11-q13)8,9 Conventional texts report that less than 5% of autistic children
show evidence of in-born metabolic disorders.10 Family studies in children with
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autism have noted an increased prevalence of autoimmune disease, inflammatory
bowel disease, depression, obsessive–compulsive disorder, anxiety disorder, bipolar
disorder, social phobia and language disorders.11 12 13 14 There is some evidence that
relatives of autistic children show mild social, communicative or repetitive behaviors
that may place them on the "normal end" of the autistic spectrum. There is a 3:1
predilection for males over females in autism, which may indicate some genetic
influence or may be related to the relative strength of social/empathy skills generally
demonstrated by girls. Twin studies of autistic children show a 60-90% incidence of
autism in monozygotic twins.
Recent research has shown important evidence that multiple gene-loci may be
involved in the expression of autistic characteristics.15 Studies have shown an
increased number of genetic variants (polymorphisms) associated with the enzyme
activity of Methylenetetrahydrofolate Reductase (MTHFR) in children with Autism.16
This enzyme is essential in the Methionine Synthase reaction, a major biochemical
component of the detoxification process associated with production of glutathione,
methylB12 , folate/follinic acid activation and dopamine formation. This may have
great importance in understanding the etiology of Autism as a spectrum related to
potential neuro-toxic exposures. Current thinking in genetics understands the
complexity of human neuro-social development to result form the "organic" nature of
genes which are turned on and off by various environmental stressors.
2. Prenatal Influences: Over the past 5 years, the term "Regressive Autism" has begun to
be used to differentiate a subtype of children who are developmentally normal until 1-2
years of age and then begin to lose milestones or plateau in developmental progress.17 18
8
19 20 21
. Retrospective studies have found a number of associations with the development
of Autism. These include: exposure to epidural anesthesia, the older age of parents at the
time of conception, elective or emergency caesarian section, use of pitocin for labor
induction, and threatened abortion, 22 23
3. Post-natal Influences: In order to explain the apparent exponential rise in prevalence of
autism in recent years, researchers have been looking at a number of potential
environmental causative factors. Over the past decade, many articles have suggested a
possible role of mercury exposure in autistic-like neurologic disorders. Remarkable
similarities between mercury toxicity and autism have been noted. 24 25 26 Mercury has
been shown to compromise the detoxification mechanism mediated by glutathione and
methionine synthase. 27 28 29 It has also been noted that mercury toxicity causes
impairment of the immune system and increased risk of autoimmunity.30 31 A significant
source of methyl-mercury has been found in Thimerisol-containing vaccines and there is
some evidence that cumulative exposures have the potential for neurologic sequelae.32 33
34
Based on the VAERS and US Department of Education data, Geier demonstrated a
linear statistical relationship between the incidence rate of neurodevelopment disorders
after childhood immunization and increasing thimerisol in vaccines. 35 36 37. In light of
the literature acknowledging the potential risks to the infant exposed to mercury during
infancy in the context of the increasing prevalence of autism spectrum disorder,
pharmaceutical companies have begun removing thimerisol from vaccines. 38 39 40
4. Gastrointestinal Inflammation in Autism: In 1999, Horvath published evidence of an
apparent inflammation of the gut in children with Autism.41 The following year
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Wakefield demonstrated biopsy evidence of chronic enterocolitis in autistic children.42
Recent studies have shown abnormal gut mucosal immune infiltration and impaired
intestinal permeability in autistic children. 43 44 45 46 Emerging research ofver the past
twenty years has generated a new field of study linking brain and gut function. Much of
this has concentrated on the immune effects of stress on the gut.47 48 49 The reverse
relationship, where inflammation of the gut affects brain dysfunction has also been found
in children with autism and the term "Autistic Entero-colonic Encephalopathy" has begun
to be used. 50
51 52 53 54
Evidence of impaired gut immunity associated with Candida
overgrowth in children with autism has been demonstrated with increased excretion of
urinary arabinose and analogs of Krebs cycle metabolites.55 56 57 58
In 1998, Wakefield published the highly controversial findings of a possible link
between Measles virus and the gut-inflammation found in children with Autism. This
was based on biopsy identification of genomic measles RNA in lymphoid follicles of gut
mucosal in children with regressive autism. 59 Based on previous studies that have
demonstrated a known relationship between measles infection and Crohns disease and
other inflammatory bowel diseases60 61 62 , he proposed that live measles virus vaccines
such as the MMR may play a role in the immunologic etiology of autism. Other studies
have failed to confirm this association.63 64 65. Singh et al have recently published a
number of articles showing evidence, however, of an abnormal hyper-immune response
to measles in children with autism which may represent a mercury-induced autoimmune
response to live virus exposure.66 67 68 There is mounting evidence of increased
autoimmunity in Autism. 69 70 71 72 73 Clearly further studies are needed to clarify the
relationship between viral immunity and autism.
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The Conventional Diagnosis of Autism
There is no doubt that the earlier a child is evaluated for possible Autism Spectrum
Disorder, the better the prognosis. The American Academy of Pediatrics has recently
highlighted the need for early diagnosis with the A.L.A.R.M. policy which encourages
early evaluation, diagnosis, referral and parent education. 74 The diagnosis of autism
spectrum disorder is typically based on the criteria described by the DMS-IV-R. (see
table1). With the recent increase in the prevalence of Autism, the American Academy of
Pediatrics has adopted recommendations made by the American Academy of Neurology
and the Child Neurology Society which developed practice guidelines to help the
clinician.75 (This information has been endorsed by the American Academy of
Audiology, the American Occupational Therapy association, The American speechLanguage-Hearing association, the Autism National Committee, Cure Autism Now, the
National Alliance of Autism Research and the Society of Developmental Pediatrics).
The initial assessment of a child suspected of having Autism begins in the
clinician's office where routine developmental screening should be a part of general
health supervision. There are a number of developmental screening tools available that
have some sensitivity in picking up children with developmental problems. These
include: The Ages and Stages Questionnaire, the BRIGANCE screens, the Child
Development Inventories and the Parents' Evaluations of Developmental Status.76 Of
note, the Denver-II (DDST-II), which is widely used by pediatricians as a screening tool
has been shown to detect only 30% of children with language impairments and 50% of
children with mental retardation.77 78. The importance of listening to parents' concerns
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about developmental issues cannot be overstressed and there have been studies
demonstrating the high sensitivity and specificity this carries in detecting global
developmental deficits.79 80 Optimum screening combines attention to parents' concerns
and observations coupled with appropriate screening tools.
Important signs that raise suspicion of a autism and require immediate evaluations
include:
1. No babbling, pointing or gesturing by 12 months of age
2. No single words by 16 months of age
3. No two-word spontaneous phrases (not echolalia) by 24 months
4. Any loss of any language or social skills at ANY age
Following the identification of a child "at risk" for a developmental disorder like
autism, it is recommended that the child be referred for formal audiologic evaluation and
lead testing if pica is present. Because there are no biologic markers for autism, a
number of screening tools have been developed to look "specifically" for signs of Autism
Spectrum Disorders. These include: "The Checklist for Autism in Toddlers" (CHAT),
and the "Autism Screening Questionnaire (ASQ)". Newer screening tools are currently
being developed to increase specificity such as the PDDST-II-stage 1 and the Australian
Scale for Aspergers syndrome. It is recommended that a clinician experienced in the
diagnosis and treatment of autism be consulted for an accurate diagnosis. The formal
evaluation of a child for autism should include:
1. A family history
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2. A Parent interview (Gilliam Autism Rating scale, the Parent Interview for
Autism, the PDDST-Stage 3, The Autism diagnostic interview, Revised, The
Childhood Autism Rating Scale, the Screening Tool for Autism)
3. Past medical history (birth history, milestones, regressions, seizures, pica)
4. Physical/neurologic evaluation: head circumference (there is an increased
prevalence of macrocephapy in autism), presence of dysmorphic features, gait
disturbance, hypotonia, and presence of focal neurologic signs.
5. Genetic evaluation for Fragile X syndrome and Tuberous sclerosis (children with
these syndromes may exhibit autistic characteristics)
6. Verbal and Non-verbal communication assessment
7. Cognitive Assessment of adaptive skills
8. Sensory-motor and occupational therapy evaluation
9. Neuropsychological and behavioral assessment
10. Selective metabolic testing: (inborn errors of metabolism may be associated with
autistic behaviors though the prevalence is less than 5%)81
11. EEG studies: the prevalence of seizures in autism is estimated at 7-14%.82
Electrophysiologic studies should be reserved for children who demonstrate
clinical or subclinical seizures and have a history of regression in development.
12. CT and MRI studies: inconsistent findings in neuro-imaging studies of children
with autism make these studies unwarranted as routine unless there are specific
neurologic concerns83
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Differential Diagnosis:
AS a child develops, the nervous system is constantly being remodeled by environmental
stimulae through a process known as Apotosis or "neurologic pruning". This permits the
most efficient neural pathways to be fortified while those that are inefficient are
destroyed.84 The constantly changing nervous system may present the clinician with a
confusing picture when diagnosing a child with autism. Early on, many developmental
problems may present with similar characteristics of autism but as the nervous system
matures characteristics may change or subside. This is in no way a reason to delay
evaluation and treatment but it is wise to remember that a diagnosis of autism can only be
taken as a "snapshot" of a moment in the constantly adapting child's life. Odd behaviors
such as "self-stimulation" and "echolalia" may not be specific to children with autism but
may be non-specific signs of other developmental language disorders. Careful evaluation
and tracking is essential to determine the accuracy and prognosis for each child. See
Table 2 for examples of related syndromes to consider.
Table 2: Differential Diagnosis
Rett's Disorder;
Childhood Disintegrative Disorder
Asperger's Disorder
Schizophrenia
Selective Mutism
Expressive Language Disorder
Mixed Receptive-Expressive Language Disorder
Semantic Pragmatic Language Disorder
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Verbal Apraxia
Non-Verbal Learning Disability
Mental Retardation
Stereotypic Movement Habit Disorder
The Conventional Management of Autism :
Early diagnosis is imperative in order to start treatment as early as possible. As
with other developmental disorders, prognosis is improved with early detection and
treatment. 85 86 The first-line of management is referral to early intervention services for
neuro-development support. Controversy over treatment has changed through the years.
10 years ago, conventional neurology/psychiatry considered treatments such as Applied
Behavioral Analysis (ABA) and Sensory Integration Therapy (SI) to be "alternative
therapies" but these have now become standards of care in many areas. Early
intervention services for autism typically include: Special education, Speech therapy,
Occupational therapy, Physical therapy and Social skills therapy. Based on evaluation of
a child's particular deficits and sensitivities, additional therapies may include: Auditory
Integration Therapy, Sensory Integration Therapy, Visual Training Therapy, Music
Therapy, Cranio-Sacral therapy.
At present there are no specific indications for the pharmacologic treatment in
autism. Conventional medicine has relied on the pharmacological management primarily
for the management of aggressive or compulsive behaviors in autism. Medications such
as Risperidone, Abilify, Prozac, Paxil, Adderall, Depakote, Propranolol and other
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psychotropic medication are currently being used on an experimental basis by the
psychiatric/neurology specialists.
Complimentary and Alternative Management Considerations:
Because of the unknown nature of autism, parents and practitioners have explored
a wide range of CAM practices over the years. Since 1967, The Autism Research
Institute has been supporting research in alternative treatments in autism. The ARI
recognized that many parents may feel significant desperation in their search for a "cure"
which puts them at particular risk for trying many treatments simultaneously which can
lead to exorbitant expense as well as confusion as to what is actually working. In the past
ten years, a number of clinicians and researchers have developed the "D.A.N. protocol"
(Defeat Autism Now!) in an attempt to assess the efficacy of various alternative and
nutritional therapies in autism.87 Parents should be advised to seek qualified, informed
professionals such as clinicians who have been trained in the D.A.N. protocol and are
listed on the ARI website. http://www.autismwebsite.com/ari/index.htm
Based on the accumulating etiologic evidence in the scientific literature, the
D.A.N. protocol has proposed that autism results from the cumulative effects of repeated
toxic exposures in genetically predisposed children.88 Recent evidence of impaired gut
immunity and function in autism has led CAM practitioners to treat this disorder as a
toxic inflammation of the neuro-digestive system. Understanding the etiologic sequence
(see table 3) that leads up to the full blown expression of Autism is essential to
developing a treatment strategy for each child: (see table 4). The sequence and dosages
of supplements listed below are meant only as a general guide to practitioners and are by
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no means specific for one particular patient. Variations in clinical presentation,
laboratory data and responses to interventions must always be taken into consideration by
the CAM practitioner when choosing an intervention.
Table 3. Etiologic Sequence of Autism
Genetic Predisposition
↓
Perinatal Factors
↓
Impaired Detoxification
↓
Gut Inflammation
↓
Yeast overgrowth
↓
"Autistic Enterocolitis, Encephalitis Syndrome"
Table 4. Treatment Sequence in Autism
1. Treat Dysbiosis
2. Heal the Gut
3. Strengthen Immunity and Detoxification
4. Chelation of Toxic Elements
5. Neuro-metabolic Fine-Tuning.
1. "The Leaky Gut Syndrome" and autism: A major component of the immuneregulatory system in the infant is located in the digestive tract. In genetically-predisposed
children, repeated exposures to toxins results in a chronic inflammation of the intestinal
wall with subsequent "hyper-permeability" that allows increased absorption, ("leaking
in"), of macromolecules, diasaccharides, antigens and toxins resulting in neuro-immune
dysfunction.89 90 91 A viscous cycle of gut mucosal damage is set up by repeated
mercury exposure or antibiotic use which leads to abnormal gut-flora overgrowth
"dysbiosis" (yeast, pathogenic bacteria like clostridia etc.). This further damages the gut
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mucosa leading to absorption of the toxic by-products of abnormal gut flora (lactic acid,
organic acids, arabinose, biologically active peptides etc.) which aggravate brain function
leading to progressive neurologic damage.92 93 94 95 96 A host of non-specific symptoms
may be early signs of "leaky gut". These include eczema, bloating, colic, hives, reflux,
wheezing, diarrhea, and constipation. Treatment of "leaky gut" syndrome is an essential
component of the CAM management of autism although its presence is not specific to
autism.
2. Treating Dysbiosis: One of the first steps in the CAM management of a child with
Autism is to treat abnormal gut flora (dysbiosis) if present.97 Organic acid tests are
available to determine the presence and degree of dysbiosis98. An IgG Food Sensitivity
test will give indirect evidence of "leaky gut syndrome" and serve as a guide to what
foods to avoid. Often simply "lightening the load" of foods that are "toxic" to a leaky gut
will have a beneficial effect on behavior. 99 Placing a child on a Gluten-free, Casein-free
diet reduces the burden on the digestive system.100 In some cases, the reduction of
casomorphin absorption is enough to improve developmental progress.101 102 The
treatment of Candida yeast overgrowth may require pharmaceutical antifungals such as
Nystatin or Diflucan. Although this will often have a significant effect on developmental
progress, antifungal drugs can have a compromising effects on liver function and must be
used with great care. Natural antifungals include Garlic, Grapefruit seed extract and
Saccharomyces Boulardii. Parents should be counseled to watch for symptoms of "die
off" (the effects of absorption of toxins from killed yeast). These may include behavioral
regressions, loose stools, increased self-stimulation, abdominal pain, and rashes. The
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addition of probiotics is essential to gut health, replacing pathogenic organisms with
"good bacteria".103 A trial of Elaine Gottshalts's Specific Carbohydrate Diet (SCD) has
proven to be beneficial in treating dysbiosis. The basic premise of the SCD is to limit the
availability of carbohydrates that pathogenic intestinal microbes require for energy. By
depriving their food source, the bacteria will gradually decrease in number. As the
number of microbes decreases so do the toxic by-products they create.104
3. Healing the Gut: In addition to probiotics, the gut lining can be strengthened with some
basic nutritional supplements that include: (Approximate dosages based on DAN
protocol, individual considerations are required)105 106
Zinc: picolinate form is most absorbably 10-50mg/day
Calcium: 250-1000mg/day
Magnesium: glycinate form is most absorbable, 100-300mg/day)
Vitamin B6: in activated P5P form 50mg < 5 years old
Vitamin C: up to 1000 mg /day
Vitamin A: as cod liver oil or as supplement 1000-5000 iu/day
Selenium: 50-150mcg high doses may be toxic
Supplements that reduce inflammation of the gut include:
L-Glutamine: up to 3500 mg/day
Licorice root: in deglycyrrhized form up to 500 mg/day
Aloe barbadensis: up to 50mg/day
Omega 3 Essential Fatty Acids (EFA): 750-1200mg/day
Coenzyme Q 10: 30-60mg/day,
Grape seed extract,
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Vit B12 as methylcobalamin 750-2500mcg as subcutaneous injection
DMG (Dimethylglycine): 125-250mg/day
Digestive enzymes improve absorption and should be given with meals.
Authors note: It is this author's experience that it is wise to start autistic children at
lower doses for all supplements because of heightened sensitivities. Often in fact, lower
doses may give paradoxically better responses than higher doses.
4. Strengthening Immunity and Detoxification Support : Reducing the oxidative stress on
the body has been shown to improve both gut and neurologic function.107 Reduced
Glutathione (oral 150 mg BID, topical 125 mg BID or IV 300-600 mg)108 has both antiinflammatory functions as well as being supportive in the detoxification mechanism. It is
available in both oral form and as a topical gel which may be better tolerated and better
absorbed. In addition, high dose Vitamin C, Carnosine, Vitamin B6, Magnesium, Zinc,
Selenium, and Folinic acid support biochemical pathways involved in the protection
against oxidative damage.
5. Chelation of Toxic Elements: The removal of heavy metals has been utilized in the
treatment of lead poisoning for many years. Based on evidence that children with autism
may have faulty immune function, it has been hypothesized that they cannot handle the
increased exposure to heavy metals known to have neurologic effects such as mercury
found in vaccines and environmental pollutants. With this in mind, provoking an
excretion of these metals with a chelating substance such as DMSA would determine the
need for removal by chelation.109 Since chelation is a potentially dangerous procedure,
support of both the digestive and immune systems is essential before trying to remove
potentially toxic elements. Careful monitoring for adverse reactions from both the
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chelating agents and the mobilization of toxic elements is required. Hematologic and
liver function monitoring is recommended and the procedure often requires mineral
supplementation. Bone marrow suppression and impaired hepatic function although rare
have been reported during the chelation process.110 Allergic reactions and seizures have
also been reported. 111 A single-dose challenge of a chelator like DMSA (10mg/kg)
followed by measurement of urinary metal excretion will determine the need for
chelation. (Authors note: It has been this author's experience that many parents seek
quick treatment solutions and rushing into chelation should be avoided because it can
result in making a child sicker if the child is not adequately prepared and monitored by
an experienced clinician.) Natural detoxing agents such as Garlic, Cilantro, Chlorella,
Chitosan and Hyaluronic acid have been used in the treatment of heavy metal toxicity.
Allithiamine (a synthetic form as thiamine tetrahydrofurfuryl disulfide: TTFD) is a garlic
derivative that may potentiate removal of heavy metals and has been recommended as a
topical application.112
6. Neuro-Metabolic Fine-Tuning: Impaired function of methionine synthase impacts on
the bio-activity of SAMe, B12 and glutathione, all of which play a role in the chemical
mediators of brain function. Supplementation with DMG (dimethylglycine), TMG
(betaine), Methyl B12, Amino Acids, DMAE, L-theanine, Acetyl-L-Carnitine, Coenzyme
Q10, and specific neurotransmitter precursors like tyrosine and 5 HTP and Tryptophan
can support proper brain function. Tests are available to indirectly assess relative
imbalances in neuro-transmitters113.
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Other Holistic Management Considerations:
It has been this author's experience that the challenges facing a clinician in the
treatment of children with autism require a holistic perspective that takes into
consideration the complex interactions of both internal and external environments.
Chinese medicine offers a complete system of medicine that provides a novel model for
understanding autism in the framework of disharmonies and imbalances. Although there
are no published studies on the use of Chinese medicine in autism, the author has found
practical applications in conceptualizing etiology and designing treatment options
through TCM.
In traditional Chinese Medical texts, children with mental disorders that bear
similarities to Autism are described as resulting from "phlegm misting the mind".114 The
origin of this phlegm is thought to be internal trauma, excessive wetness, inappropriate
diet, and food stagnation. Stagnation in the spleen network is a common source of
phlegm in children due to intense activity during the formative years of growth. The
Spleen's importance in transforming food into qi and differentiating "clear" and "dirty"
fluids in the digestive processes cannot be overstated in children.115 Spleen dysfunction
corresponds well with the "leaky gut" model described above. Furthermore, the spleen is
considered to be the residence of thought, influencing introspection, and focus, factors
that are impaired in autism.
In the Five Phase Model (see diagram) described in Chinese medical texts116, 117
118
there is a regulatory (ke) relationship between the Spleen and Kidney (Jing which is
responsible for the inherited capacity to develop and thrive). This is well-illustrated by
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the etiologic relationship between causative environmental agents and genetic
predisposing factors found in autism.
When the spleen network is weakened or stagnant, phlegm begins to "mist the
mind". Consequently it cannot support the Lung/Large Intestine system (sheng cycle)
with resultant signs of constipation, diarrhea and eczema. With further toxic exposures
and damage, the kidney network decompensates, leading to an "ungrounding" of
developmental drive with apparent plateaus and regressions in development. As the fivephase system uncouples, the Liver network show signs of dysfunction resulting in motorplanning problems, balance issues and agitated "fight or flight" behaviors. Ultimately,
with "rebellion of the Liver", the Heart network, the so-called "Emperor" loses rule over
the governing of physical, emotional, and spiritual aspects of the being. Speech, which is
governed by the Heart is blocked and shen is unstable. Thus autism can be understood as
a multi-system failure, resulting in the unpredictable and disconnected nature of the child.
Treatment is aimed at first re-establishing harmony between the Spleen qi and
Kidney/jing, (dietary management, treating dysbiosis, supporting the immune system),
strengthening the Lung/Large Intestine (re-establishing membrane boundaries, healing
the gut) followed by strengthening the Liver/hun (detoxification and chelation) and
ultimately comforting the Heart/shen (support of neuro-metabolic fine-tuning). A
treatment plan which incorporates this model allows the practitioner to integrate chinese
dietary principles, herbs and acupuncture/acupressure into the D.A.N. protocol.
Having treated a large number of children with autism over the past 10 years, this
author has found this method very effective. It is important to note, however, the dangers
of doing "too much too fast". "Too much" acupuncture may be overstimulating to the
23
overly sensitive autistic child and making changes too fast can have a destabilizing effect
on the delicate balance of development. It is the author's experience that Laser
acupuncture also tends to provide excess stimulation while tuning fork stimulation of
particular acupuncture points and the use of gold-plated magnets has a beneficial effect.
In particular, the treatment of "Shen Men" ear points with magnets, foot massage (tui na)
of K1 and LV3 and gentle acupuncture at K3, SP6, St 36, LI11, TB5 have beneficial
regulatory effects and appears to work synergistically with some of the other treatments
outline above. Herbs that promote harmony between Spleen and Liver (such as
Bluperium root, cyperus, licorice root, unripe citrus peel etc.) and Kidney and Heart
(such as rehmannia root, sciszandra, salvia root, and lotus seed) have been particularly
helpful. 119
Summary
CAM treatments can be of great benefit in the management of Autism. In light of the
rising prevalence of this disorder and the limited treatment options offered by
conventional medicine, practitioners should be encouraged to explore alternative
treatment options that have proved successful. Developing a holistic treatment plan
requires an understanding of autism as a cumulative series of insults to the neuroimmunologic system. The complex relationship between genetic predispositions and
toxic exposures may account for the wide variations in symptoms encountered in this
syndrome. This may have great importance in preventive management when counseling
siblings of children with autism. Early non-specific symptoms such as eczema and
chronic loose stools associated with language delays may be subtle signs of impending
24
developmental dysfunction. Since no single cause of autism has been found, research
must be aimed at considering multiple variables together. A careful history and tracking
of symptoms is essential for diagnosis, management and prognosis. An approach to
management that respects the highly sensitive nature of children with autism can result in
profound improvements in behavior and development.
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