Dr. Fombonne isn’t a “Monkey Person”, but he Does Play One in Court – The Omnibus Autism Proceeding – Second Set of Hearings (Thimerosal & Autism) – Day Twelve – May 28, 2008
By Kent Heckenlively, Esq.
In the testimony of Drs. Catherine Lord and Eric Fombonne the government comes up against what I believe is the Achilles heel of the government’s assertion that vaccines have no connection to the autism epidemic.
Parents report changes in the children following a vaccination. Animal and biological studies provide indications that mercury can have devastating effects on living organisms. Medical professionals using vaccine-damage as a starting point to recover children make startling progress in some cases. The government says all this is smoke without a fire. Indeed, the government doesn’t even seem to think the ground is warm.
Personally, I think all of this evasion is starting to wear on the Special Masters.
Direct Examination of Dr. Catherine Lord (Expert Witness for the Government)
Dr. Lord is a clinical psychologist with numerous publications and has worked with about 4,000 children and adults with autism in her career. She is an expert in behavior and development and regression in autism. Part of her work has involved developing the DSM-IV to diagnose autism.
Parents come to her every day with questions about vaccines and autism. She does not believe vaccines have anything to do with autism.
She believes regression occurs in autism. It used to be thought the main loss was words, but what appears to be even more common is the loss of social skills. The lost skills generally recognized by parents include loss of speech, loss of social routine, smiling, and understanding humor.
She can’t define the regression as gradual or precipitous, but says it’s variable. She also states that most children who lose words eventually regain them. She believes all children with autism improve, but the amount is highly variable.
Curiously, she doesn’t believe autism is associated with one gender more than any other.
While she believes pediatrician’s records are the best available information, she thinks they are very problematic.
She was one of the principal authors of the Richler study which tried to determine if a clear, regressive phenotype could be found in autism in relation to the MMR vaccine. She found a minor correlation with autism and gastro-intestinal issues, but couldn’t find any relationship between MMR and autistic regression.
Dr. Lord is not aware of any evidence that the etiology of children with regressive autism is different than the general population of people with autism.
She does not believe Dr. Kinsbourne’s over-arousal model of autism accurately describes autistic behavior.
Cross-Examination of Dr. Lord (Expert Witness for the Government)
While Dr. Lord believes autistic regression can be a striking phenomenon she doesn’t believe there is a distinct phenotype for regressive autism. She agrees that autism itself is a symptomatic diagnosis, without any clear bio-markers.
Dr. Lord agrees that the diagnosis of autism usually involves some abnormalities in communication, social reciprocity, and play skills. Her study didn’t really look at play skills, although among the children with autism there was an increasing amount of non-functional play. She wasn’t able to give a sense of what percentage of the children she studied had normal development prior to regression.
Dr. Lord does believe genetics are a significant factor in autism. In the past she has stated that autistic regression does not appear to run in families, but now she’s saying she doesn’t know.
She doesn’t know if individual genetic combinations might combine with environmental exposures to cause autism. However, her recently formed National Institute of Health committee is considering looking at potential environmental factors.
She did not participate in the 2007 Institute of Medicine Environmental Factors and Autism workshop. Besides her study on the MMR, she’s not aware of any other published studies looking at a link between thimerosal-containing-vaccines and autism.
The Richler study referred to in her direct testimony has not yet been peer-reviewed and is not yet published. Some of her funding for the study came from the National Institute of Health.
Redirect Examination of Dr. Lord (Expert Witness for the Government)
Dr. Lord is not a geneticist.
The NIH committee on which she sits will be looking at environmental factors in autism.
She does not think looking at the loss of play skills is helpful in diagnosing autism because of what may be observed in a 45 minute session in a doctor’s office.
The Richler study which was previously discussed looked not just at MMR, but also if they could determine some common pattern to autistic regression.
Recross Examination of Dr. Lord (Expert Witness for the Government)
Dr. Lord could not give a number on the children in her study who experienced regression across all three domains normally observed in autism; communication, social reciprocity, and play skills.
She did not review the medical records of William Meade or Jordan King.
Direct Examination of Dr. Eric Fombonne (Expert Witness for the Government)
Dr. Fombonne is a professor of psychiatry at McGill University and specializes in the epidemiology of autism. He’s director of child psychiatry at McGill, serves on editorial boards, and publishes in peer-reviewed journals. Last year he diagnosed somewhere between 250 to 300 new cases of autism.
He spent a good deal of time explaining epidemiology and many of its relevant terms.
Dr. Fombonne said that the current rate of autism in the United States is 66 per 10,000 children or approximately 1 in 166 children. Curiously, there is a significant difference between the states with New Jersey being three times higher than in Alabama. He attributes that to better ascertainment in New Jersey than in Alabama.
Dr. Fombonne spent a good deal of time discussing various epidemiological studies; the Vidd study from Denmark, the Verstraeten study from the United States, the Green study looking at Scandanavia, the Madsen study, Dick and Hay, Heron, his own in Pediatrics, the Schecter study, and Thompson. None of these studies showed any association between thimerosal and autism.
According to Dr. Fombonne, the only study which showed any association was the one done by Mark and David Geier. He has problems with their methodology.
Depending on how you define regression, it appears to be present in 15% to 41% of the cases.
He does not have any disagreement with the criticism of Dr. Greenland that none of the studies to date have looked for a uniquely susceptible subpopulation. However, epidemiology never tests for any particular subgroup unless they have some preliminary evidence that such a subgroup exists.
Dr. Fombonne is critical of Dr. Greenland’s assertion that because in the Richler study (the previous government Dr. London was one of the chief authors) they found that 72% of autistic children displayed pre-regressive abnormalities, that the remaining 28% of the children were normal.
Fombonne reviewed the medical records of Jordan King and William Mead and agrees with their diagnosis of autism. However, he doesn’t believe their thimerosal-containing vaccines had anything to do with their autism.
He does not believe that any conclusion can be drawn Jordan’s significant improvements since he was simultaneously doing speech therapy, ABA, as well as diet, supplements, and bio-medical treatments.
Special Master Questions
The Special Master tried to get Dr. Fombonne to provide more information on why nothing could be concluded from the improvement of William Mead and Jordan King. Dr. Fombonne’s testimony was that so many different things were tried that it was difficult to disentangle the effect of one from the other.
While it was nice to hear about William’s progress in language, he is unaware of any research which supports chelation, and as far as secretin, randomized clinical trials have not shown it to be effective in restoring neural development.
Cross-Examination of Dr. Fombonne (Expert Witness for the Government)
Dr. Fombonne believes autism rates are roughly similar around the world, but evidence shows they are increasing. On the question of whether rates were lower in the past, he says it’s difficult to answer that question.
Despite the fact that primates have most of our other diseases, he’s not aware of there being any studies looking at autism in primates.
Dr. Fombonne says there is no good evidence of an increase in autism. He admits that exposure to the rubella virus in the womb can increase the risk of autism, as can exposure to the drugs thalidomide and tributalene. He believes the question of whether there has been a true increase in autism is unanswered.
He admits that his slide for autism prevalence in California in 1995 is 6 of every 10,000 children, less than 10% of the current rate of autism. He believes that the 1995 rate is because of an approximately 10-fold underestimation of the true rate of autism. However, he still believes the numbers can be used to show thimerosal had nothing to do with autism.
The Madsen numbers from Denmark show an incidence rate of .2 or .3 per 10,000, while in later years it was around 67 to 70 per 10,000. Fombonne still believes that despite a 99% underestimation rate that these numbers can be used to show no connection between vaccines and autism.
Fombonne was unaware that the Young-Geier study was published in the official journal of the World Federation of Neurologists associated with the World Health Organization, a fully peer-reviewed publication. He does not have an opinion on about the fact that the CDC approved the Youg-Geier protocol and that it passed the Institutional Review Board of Kaiser Northwest and Kaiser Northern California.
Fombonne was unaware that Young and Geier were not allowed to compare total vaccines for any one child, or to access any data beyond the year 2000.
He did not know that the data sets used by Young and Geier are fully available to the government. He did not look at them in preparing his report.
Fombonne admits that his use of the term “definite regression” is not used in any standard text. There is also no accepted definition of “regressive autism.”
He agreed that the Leinhart study which he cited said that environmental events may act in an additive or second hit fashion to individuals with a genetic vulnerability to autism.
Dr. Fombonne does not believe there is any good evidence upon which to base a study comparing mercury exposure and autism. In his opinion, studies should not be undertaken unless there was a convincing starting point.
He has looked at the studies of mercury exposure and the effects on primates, but says he’s not a monkey person.
Fombonne agreed that detailed parental accounts are the most reliable historical information on a child, but that there are other ways this could be measured in the future.
The family attorney then went over various parts of the parental testimony about the reaction of their children to the vaccines. He agrees that there is nothing in the medical records to indicate Jordan King or William Mead had any autistic behaviors before the age of 18 months.
Redirect Examination of Dr. Fombonne (Expert Witness for the Government)
Fombonne went over again that there is no generally accepted distinct phenotype of regressive autism.
Questions from the Special Masters
There was some further clarification that there are difficulties in rating the types of skill loss seen in children with autism.
The changes seen in William Mead and Jordan King after 18 months were similar to what he has seen in children in his practice.
Closing Thoughts on this Day of Testimony
I keep trying to figure out how the government thinks they’re going to win this case.
Dr. Lord, the government’s expert witness on regression in autism can’t find any specific phenotype for regressive autism. She believes genes are involved, but not the environment. However, her NIH committee is considering the gene-environment interaction in relation to autism. It’s a little like O.J. vowing to find the “real killers” of his wife and Ron Goldman.
Dr. Fombonne, the government’s expert witness in the epidemiology is comfortable saying that previous studies must have underestimated the prevalence of autism by a 99-fold factor, but can’t provide any support for his own belief that autism rates have remained stable over time. I guess we’re supposed to believe all of those other epidemiologists couldn’t count.
He doesn’t believe there is any evidence to even examine the possibility of mercury and its relation to autism, although when confronted by primate studies showing neurological damage as a result of mercury exposure he backs off by claiming he’s “not a monkey person.”
I’ll bet the Special Masters have their own opinions about who the monkeys are in this case.
Kent Heckenlively is Legal Editor for Age of Autism.