Autism and the Environment Challenges and Opportunities for Research: Workshop Proceedings (2008) / Chapter Skim
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Day 2--April 19, 2007
Day 2--April 19, 2007
Pages 165-282
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From page 165... ...
That is both good news and bad news. The bad news is that I believe that we are way behind where we ought to be, that there is a tremendous need to have a focused research agenda, but also from my perspective the resources necessary to implement that research agenda as well.
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From page 166... ...
Then at the end of the day, we have reserved a substantial amount of time for discussion by everybody in the room. Let me now introduce Henry Falk, who is the chair of this first session on environmental epidemiology, using population-based studies to isolate the environmental causes of autism.
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From page 167... ...
Her research interests are in environmental exposures, pregnancy outcomes, and epidemiological methods. She is on the editorial boards of the American Journal of Epidemiology, Environmental Health Perspectives, and Epidemiology, and was on the scientific advisory board for the U.S.
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From page 168... ...
From these administrative database studies, we have learned about patterns: We have learned about the age effect of the parents, obstetric complications as risk factors, and aspects of the time trends in autism. Moving along to the genetic studies, these again, like the clinical studies, are volunteer samples.
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From page 169... ...
Each pie represents a set of sufficient causes that will cause autism in at least one individual out there. It might be that A is a genetic factor, that B is another gene, that C is an environmental factor in the prenatal period, and D might be something happening at birth or postnatally, just hypothetically.
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From page 170... ...
If you go back to get medical records from these individuals, you are collecting essen-tially prospective data, data that were originally written down in a prospective manner. These studies also have been collecting specimens with linkage to laboratory scientists.
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From page 171... ...
We ask about fish consumption and other household product use for metals. Another example, data on infections can be abstracted from the medical records and is collected by interview from the medical history.
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From page 172... ...
Several baby sib studies to date have been focused on the early behavioral, but not biological, indicators, and have started postnatally. Our aim is to determine what are the critical time windows for environmental exposures, and what are the biomarkers that we might use to identify pregnancies and children at high risk.
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From page 173... ...
As I said, the medical records do provide us with early information. We have been looking at even preconception, looking at things like in vitro fertilization, medications that the mother took during pregnancy, what kind of induction or augmentation of labor happened.
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From page 174... ...
Newschaffer: Thank you. I have been tasked to talk a little bit about the promise and potential of international studies and international epidemiologic studies that shed some light on environmental exposures and autism.
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From page 175... ...
We need to make sure that variation in measures of disease frequency in one country and another country reflect underlying risk and aren't related to other factors.
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From page 176... ...
In general, if we see a lot of variation across countries and the variation is of great magnitude, we feel that that suggests a probable role for an environmental cost. It is theoretically possible that genetic variation could bring about large differences or multiple differences across countries, but typically when you see these patterns, they are associated with environmental risk factors.
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From page 177... ...
Here is an example of the problems we get when we try to use nation to proxy specific exposure. These are plots of breast cancer incidence on the y axis, and on the x axis the countries are ordered by an estimate on how much dietary fat intake there is in the country.
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From page 178... ...
So if we go into a population that has higher prevalence of susceptibility genotypes, we may be able to find the environmental exposure easier. The same logic applies for gene finding.
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From page 179... ...
We have limited data so far in developing countries. In part through the efforts of CDC and Autism Speaks, investigators who are doing autism research internationally have been brought together in a series of symposia.
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From page 180... ...
In my last 24 seconds, I want to acknowledge the folks who have arranged the international epidemiology symposia, Autism Speaks and the CDC and the participating investigators there, and my colleagues on our China pilot, because I wouldn't have gotten into the international studies business if it weren't for all them. Thank you.
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From page 181... ...
The next speaker is Diana Schendel, who will be talking about the CADDRE study in environmental epidemiology. Diana is a lead health scientist in epidemiology, team lead in developmental disabilities branch of the National Center on Birth Defects and Developmental Disabilities at CDC, and serves as science liaison for CDC Center for Autism and Developmental Disabilities Research in Epidemiology, the CADDRE project, and is principal investigator for the department in metropolitan Atlanta.
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From page 182... ...
This may seem like a far cry from what is needed in an environmental epidemiology framework, but in fact, the ADDM Network provides a very fundamental role by providing us with a much better understanding of the patterns of occurrence of autism as well as the patterns of occurrence associated with some very broad environmental factors, such as variation in geography or community and by sociodemographic factors. The ADDM data can also provide some very important understanding of the impact of certain methodologic factors on the variation in the observed prevalence that we see.
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From page 183... ...
The data in the ADDM Network can also inform public health policy by providing numbers to quantify the public health burden of autism in a given community, as well as identifying vulnerable, at-risk, or perhaps underserved populations, all of which are important reference points for developing a framework for environmental epidemiology. Finally, the ADDM data can provide clues, as Craig Newschaffer has already described, regarding potential broad environmental factors.
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From page 184... ...
Stepping into this enormous analytic need that we have in environmental epidemiology is the CADDRE program, contributing a small part to helping us disentangle this complex mixture. The CADDRE program in its first funding cycle was charged with developing a collaborative epidemiologic study that was conceived at the time to be offsetting a deficit in federal programs with an explicit population-based epidemiologic focus.
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From page 185... ...
Children who fall above or who achieve a score above our cutoff for the autism screen will be designated a possible case, and those who fall below the cutoff will be randomly selected to serve as our NIC group participants. I might also add that the target age range for children in this study is children ages 24 to 60 months.
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From page 186... ...
Our data collection includes a variety of interviews and selfadministered questionnaires, including a 7-day stool diary and 3-day diet history. We will be doing extensive medical abstraction, similar to what was described for the CHARGE study, including preconceptional records for certain providers of the mothers, if they had psychiatric or immune dysfunction or hormonal dysfunction, and we have 3-year postnatal medical record examinations of the children.
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From page 187... ...
Finally, with multiple research domains, we can look at multiple causal pathways or look at multiple points within a single pathway, and with some overlap of other studies that have been described, we can replicate analyses from prior studies. So we think the primary role of the SEED study for an environmental epidemiology perspective is that it simply gives us a much better understanding of the role of a variety of broadly environmental and genetic factors in ASD which can serve as a referent for studies that might be focused on more specific toxicological factors.
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From page 188... ...
Schendel, there is a lot of confusion about rates and trends and comparability of various statistics. Why would you make the choice to lump all of the autism spectrum disorders together in a single measure, as opposed to distinguishing between the different subclassifications?
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From page 189... ...
Dr. Schendel: The data are there yes, to the extent that these data are recorded in the medical records of these children.
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From page 190... ...
Wilcox: Thank you for the invitation to be here. I am not an autism researcher.
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From page 191... ...
This type of birth defect comes in what might seem at first to be a bewildering variety of manifestations: it can be only a cleft lip, it can be only a cleft palate, and it can be various combinations of both of those things. What we have come to understand is that these are actually two different birth defects.
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From page 192... ...
Some of these things are very familiar to you all, and have already been touched on by various speakers. We know the fetal nervous system is particularly susceptible to toxins at a low level of exposure that would not affect adults.
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From page 193... ...
The retrospective reconstruction of exposures, as a number of the previous speakers have commented on, is always difficult. This is one reason prospective studies are particularly useful -- they can gather exposure information in more detail, and we can then try to associate those exposures with the emergence of the disease later.
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From page 194... ...
My conversation with Per Magnus went along these lines: You have great opportunities to measure pregnancies and pregnancy outcomes, but you're not paying much attention to environmental exposures. Environmental research was not the Norwegians' expertise, not something that they had much experience with.
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From page 195... ...
So we made plans on the spot to combine our biological samples with their quite complicated and complete study of autism in Norway, all within the framework of this cohort study. So my pitch here is that these cohort studies provide a structure that can be useful in ways that we don't even anticipate when they are started.
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From page 196... ...
Ms. Bono: Right, it is of huge importance in time trends.
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From page 197... ...
Although the medical records are supposed to record lot and batch numbers, we have not always found that in the medical records, for one thing. The other problem is that people who now get these flu vaccines at their local mall, there may be no record that we can determine.
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From page 198... ...
When we planned the SEED study, it was at the same time that CHARGE was being planned, and there were other activities investigating vaccine safety at CDC. So we chose not to focus on that particular etiology, rather go at the main etiologies I described.
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From page 199... ...
As a nonepidemiologist, I am learning a lot about these epidemiologic studies that are ongoing, and some that have been completed in this area. But it is a little bit unclear to me exactly what the strengths and the weaknesses are, what the complementary and overlapping areas of goals are for each one of these studies, and what the gaps might be that need to be filled by studies that have not yet been funded or solicited.
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From page 200... ...
Now, when it comes to environmental exposures, as you know, the problem is how do you reconstruct exposures that happened in the past. And questionnaires are one of the tools we have.
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From page 201... ...
I think since these studies were designed perhaps 6, 7, 8, 10 years ago, maybe it is worthwhile, as David Schwartz is suggesting to think about what is covered by the current group of studies and what is perhaps missing, and some suggestions to that. That might be worth maybe coming out of this afternoon's discussion with some suggestions about that.
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From page 203... ...
Needham: Today I will emphasize exposure to stressors, particularly environmental chemicals that may have the potential to lead to autism spectrum disorders. In 1989, the National Research Council first set forth the concept of the exposure–effect continuum, which traces an environmental chemical or some other stressor from its source into the environment, then to human exposure, and finally to a possible effect.
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From page 204... ...
The individual stressors that we have discussed include genetics and personal characteristics such as age, nutritional status, health status, and sex, and many others. In addition to the environmental stressors and individual stressors, we have talked about autism spectrum disorders occurring in a population mostly from the confluence of environmental stressors and individual stressors that affect the fetus through the mother or affect the infant directly.
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From page 205... ...
So where do we start in assessing human exposure to chemicals that may be linked to autism spectrum disorders? At CDC we are interested in biomonitoring, but we also recognize that biomonitoring is not a stand-alone tool, so we also use questionnaire data and historical information.
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From page 206... ...
On the left-hand side, we listed the different biological matrixes that might be available to us. Then we looked at various life stages, for example, at adult preconception, each trimester during the fetal period, age zero to 1 year, 2 to 3 years, 4 to 11 years, and so forth, and then ranked the potential for monitoring persistent organic chemicals in these various matrixes at these various life stages.
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From page 207... ...
have structures similar to chemicals that have been linked to autism spectrum disorder. In listing some of the chemicals that have been linked by various groups to autism spectrum disorders, there is no obvious relation among their chemical structures.
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From page 208... ...
There are some modeling efforts that are going on now to help ascertain some of the body burden measurements for nonpersistent chemicals, but going from a urine concentration to the total amount of a chemical in the body is difficult. In conclusion, biomonitoring techniques are available for assessing human exposure to environmental chemicals; however, we need your help in determining the chemicals or classes of chemicals to measure.
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From page 209... ...
Also, you had a great slide on where to start, and you had the list of chemicals that cause oxidative stress and several things. I think it is important to add to that list what chemicals are injected, because we have a problem right now with the mercury, aluminum, and other additives in vaccines.
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From page 210... ...
Dr. Needham: We do collaborate with other investigators with federal agencies, like NIEHS, David Schwartz and his folks, and EPA and others as well, academia.
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From page 211... ...
We have the possibility of using personal sensors or dosimeters for measuring drug doses as well as dosimeters for environmental exposure. During this talk, as we transition toward the future of measurement technologies, we will see a trend toward the molecular level, looking at single molecular lesions, developing nanodosimeters that can circulate in the bloodstream for identifying body burden, and we will also see how we can use molecular methods for presymptomatic and early diagnosis.
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From page 212... ...
If we are interested in environmental exposure and we want to know what is being released, some of these systems are going to have to be implemented in both urban and rural environments to get a handle on what is there, what is their temporal variation, and what the concentrations are in a variety of urban and rural settings. Large, complicated, power-hungry instruments may be one way to get to these answers in the near term and should be considered.
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From page 213... ...
These devices are called total sensing systems. This next slide shows a technology that I think will genuinely enable the field of autism research, and that is new sequencing methods.
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From page 214... ...
This platform measures thousands of things in nearly a hundred samples at once. Each of these little sensors is able to mate with a well in a 96-well microtiter plate with a different sample in each well, so you can measure lots of samples and measure thousands of things simultaneously.
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From page 215... ...
Each of these little red dots is a single enzyme molecule. We measured the kinetics of each of these enzyme molecules.
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From page 216... ...
We are getting better and better at being able to measure things, and because of this ability, it will enable lots of fields, including the field of autism research. I'd be happy to answer any questions.
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From page 217... ...
If we believe that autism is on the individual level, can you gain important information by not going out and getting 2,000 individuals into the study, but maybe 5 individuals in the study?
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From page 218... ...
He just gave a seminar at Tufts the other day, and he presented data that showed that he can get to somewhere on the order of about 10 to 12 molecules of sensitivity for small organic molecules.
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From page 219... ...
Francis Collins at the Genome Institute is leading the genetics program within the genes and environment initiative, and NIEHS is leading the exposure biology program, but it is really a trans-NIH program to develop sensors, both personalized environmental sensors and biological responses to environmental forms of stress, that allow us to then take those measurements and move them quickly into studies of populations and individuals that are at risk of being exposed. So NIH is investing in this.
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From page 220... ...
But we are in the market of trying to support investigators to use those tools as much as possible to apply to the research. As part of the genes and environment initiative, there is a component in 2009 and 2010 to use these assays in genetic studies, so that we are looking at gene and environment as opposed to just environmental exposures or genetic susceptibility factors.
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From page 221... ...
How do we entice companies that have these technologies to now spend their time looking at environmental exposure for autism and other diseases? Again, it is a tough question.
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From page 222... ...
Dr. Falk: We have a few more minutes before the break, but this maybe goes to Gary Goldstein as well as to David Schwartz, but in terms of training needs for people working with the instrumentation, but going back to Alan's opening comment, maybe also training needs for people using all the data and informatics and so on.
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From page 223... ...
So I think we are probably in the same framework here. The question that Gary Goldstein asked was the question that I had after looking at the NIEHS website describing the exposure biology program.
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From page 224... ...
That ties into what Tom Insel was just saying, which is banking. I was really curious, listening to both of your ends, what are the efforts to coordinate those and make sure that the samples are collected in a somewhat analogous fashion, so that when these tools are ready to go, we can make use of them?
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From page 225... ...
PROCEEDINGS 225 Dr. Falk: We must now end this session, but first Alan Leshner has a few words.
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From page 227... ...
So this necessarily involves epidemiologists, which need to identify a priori assessment tools, what sorts of medical record abstractions are needed, what sorts of questionnaires might be needed to get the most information that might in fact lead to an understanding of environmental exposures, even though questionnaires have their own limitations. Then most importantly, to define a rational and doable strategy for biological sampling.
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From page 228... ...
One way to look at it is with the development of international studies in autism, to try to identify populations who have different traits, while surveying with the same methods. I gave a preliminary communication last year.
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From page 229... ...
What we know from environmental exposure, like valproic acid, thalidomide exposure, were all in the first weeks of gestation, when it all led to autism. So I think there is a critical task for epidemiologists, to try to sample the possible exposure during the first weeks of gestation.
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From page 230... ...
Are the mental health folks comfortable with the way the phenotyping is being done in the environmentally driven studies, and are the environmental folks comfortable with the way the environmental phenotyping is being done in the mental health-driven studies?
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From page 231... ...
My first thought that I had before we got into this last issue of what is missing in the phenotyping fortified what Craig Newschaffer was saying and others. What we can do with these different types of study designs for either ongoing or existing studies, is augment the data collection for particular environmental characteristics and add to the data collection.
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From page 232... ...
If I understood what Eric Fombonne was saying, in those rare cases where you have an environmental exposure that appears to be causative, as we sometimes say about certain genetic mutations that are so predominant that the environment doesn't count, and there are certain environmental exposures where the genetics don't count. So if we had a couple of those, just as we do in genetics, you would want to use those as your beachhead, to start off with.
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From page 233... ...
PROCEEDINGS 233 Dr. Pessah: I'd like to speak to this as a toxicologist, because those models certainly are interesting models of autism, but they don't really portray the full spectrum of autism.
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From page 234... ...
I am telling you my experience in asthma. We have done this in our work in longitudinal studies, and the best way is for those who are experts in the field -- this is something that David Schwartz was asking for -- to define a minimal set of ascertainments that need to be done in a very large number of potential cases.
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From page 235... ...
Are you doing a medical history? You talked about the treatments, but in terms of thinking about environment, are you doing an exposures questionnaire, that kind of thing?
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From page 236... ...
We wanted to at least be able to do that very well, create a very efficient matching system where researchers can identify subjects in the areas. We can e-mail them, and we can try to illuminate this thing that is slowing down autism research.
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From page 237... ...
That is the gap which deals with the cost of extracting quality information from medical records. We need to put more money into that.
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From page 238... ...
There was a huge, huge issue about what we measure, what is our sensitivity, and how do we integrate large datasets on exposure assessment. This would involve exposure experts, analytical chemists, engineers who are developing new technologies, and of course through the new NIH genome environment initiative.
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From page 239... ...
They are not done provocatively. Trying to get the chelation study off the ground, as we are all hoping to, but pulling the data samples without a provocative agent may not produce any information.
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From page 240... ...
If you take every child with autism and enroll them in a chelation study without first identifying the children that have body burdens of metals, then the ones who do respond, it is not going to be significant because the other ones that didn't have a body burden of metals to begin with.
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From page 241... ...
Dr. Schendel: Just real quick about the exposure assessment.
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From page 242... ...
Here I have given you some examples, where one could immune profile from primary cells. I think that cell lines, Epstein-Barr transformed B lymphocytes are very useful, but they have their limitations.
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From page 243... ...
Chelation is one that has been discussed quite a bit here, but also what about antioxidants, vitamin supplementation, what about DHA, some of the biological markers that are oxidative stress involve lipid metabolism. How can we bring these into innovative clinical trials?
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From page 244... ...
I am a stem cell biologist. In spinal cord injury, I know what I am supposed to repair.
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From page 245... ...
has been doing over the last 10 years, by building a database with the genetic information, it is all open access; it is all forced sharing. The problem is integrating it on a larger level, which is supposed to be attempted by NDAR, with respect to the medical records.
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From page 246... ...
But first I want to endorse what Tom Insel said, which is this notion of the integration. The communities are not well integrated, and I think that is a problem.
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From page 247... ...
I think you all are doing more of that, which I think is great. The other gap that is a different category is, I hear the enthusiasm among the professional epidemiologists for prospective studies.
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From page 248... ...
We continue to change the definition of autism spectrum disorders. We need to get back to more continuous variables, because our discrete categories are not working very well.
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From page 249... ...
I think we need to look at that. In addition in terms of gaps, for the epidemiology I think it is very important that we get a handle on subtypes, and that we don't just report rates of autism spectrum disorder as 1 in 150, or 1 in 100 for New Jersey, but that we actually determine whether that is Asperger's or PDD-NOS.
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From page 250... ...
Ms. Bono: I agree with that about the time trend data.
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From page 251... ...
I think, Sallie Bernard, you raised that point as well.
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From page 252... ...
Everybody has said the importance of bioinformatics, but also it would be important to know animal models, are they relevant, which animal models, which are you interested in? Mark was talking about mechanisms.
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From page 253... ...
The topic of public–private partnerships tracks with that, and is a part of it. So with that little bit of context, Sallie Bernard, you're on.
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From page 254... ...
I think that the organization I represent here, which is SafeMinds, we have certainly tried to historically have a role in those types of activities, and bringing the environmental side of the gene–environment equation to the forefront of autism research. The second area in public–private is what projects are you actually funding in the research arena?
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From page 255... ...
If you are looking at the data and the data say that there is a gene– environment interaction that is involved in autism, and you look at what has happened with autism research, all of the money except for maybe a little tiny proportion has gone to the gene side. So we need to rebalance that.
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From page 256... ...
One is, hit it with everything you've got. When we talk about things like the National Children's Study, we use multiple endpoints and multiple risk factors, we get everything we can into that study to be as efficient as possible, and as broad as possible, and we hope that as David Schwartz says, you look at as much as you can, and you hope that you catch all the right clues.
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From page 257... ...
I am a founding and volunteer board member of Autism Speaks, which is now about 2 years old. I thought I would take my time to tell you a little bit about what we are doing.
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From page 258... ...
The Autism Treatment Network is under discussion right now. This is benchmarked to the successes of the Cystic Fibrosis Network.
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From page 259... ...
Are they appropriate gaps to work on right now? That is what Autism Speaks is about.
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From page 260... ...
At Congress's request, in 2003 we developed an autism research matrix which was a set of short-term and long-term goals, both high and low risk, over a 10-year period. In 2006 we reviewed the matrix, including fairly broad input in our analysis.
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From page 261... ...
As Dr. Gary Goldstein was mentioning, there may be an opportunity here for particular areas, which might struggle in peer review, to be picked up, at least for the pilot phase, by Autism Speaks or the Simons Foundation or by some other group before they maybe get taken to a larger scale and get funded by NIH.
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From page 262... ...
An article appearing in this month's issue of the Archives of Pediatrics and Adolescent Medicine documents the important role of parents in autism research. Parents have organized research funding, they have constructed clinical research networks, they have popularized empirical-based treatments, they have suggested new avenues for research, and they have anticipated shifts in the understanding of autism.
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From page 263... ...
The Autism Research Institute reports that over a thousand parents have completed questionnaires regarding their child's recovery from autism. In addition, several large clinical practices that utilize a biomedical approach to treating autism have offered to open up their practices for data mining to identify historical, physical, and clinical information which could provide clues to autism's etiology, heterogeneity, and effective treatments.
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From page 264... ...
DR. DAVID SCHWARTZ National Institute of Environmental Health Sciences My view is pretty simple.
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From page 265... ...
AIDS patients were leaders in the AIDS clinical trials network and I think the same could be done with families with autistic children. The third infrastructure need that I think is important to consider is training in this area.
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From page 266... ...
266 AUTISM AND THE ENVIRONMENT workshop to have serious sitdowns among the various funders about how to do a better job coordinating and parsing out who does what, because we are talking serious money. They are not trivial amounts of money coming out of the private sector, whereas in some other domains there really is trivial money coming out.
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From page 267... ...
I want to talk a little bit more about the time trends data that Mark Blaxill brought up before, and say that this continues to be a dark cloud that distracts us from the real issues that we have to solve. To Tom Insel's point earlier about what will we be sorry about when we look back 5 years, we need to do the retrospective studies, and we also need to start to gather the data now in the ADDM studies, looking at the subtypes, what percentage of the kids are Asperger's, what percentage are autism, and what percentage of the kids are PDD-NOS, so that we can use that to inform the science and also use that for planning purposes so that we can plan for treatment for all of the kids.
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From page 268... ...
So we need to talk to each other about how to take and store those samples. Also, we need to look at other stressors, certainly environmental chemicals come to mind, but we also need to look at such stressors as infectious agents and also the effects of the psychosocial.
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From page 269... ...
As we have heard, the private sources are matching the public sources now, and may very well exceed the public's resources in terms of autism research. So we need to coordinate those efforts so there is not duplication in the areas that Gary has mentioned that have been underfunded in the past.
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From page 270... ...
I want to go to a couple of areas. First, in relation to the topic I was asked to speak upon, which is the international studies, especially in developing countries, I think we need to work on culturally robust, easy-to-implement screeners.
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From page 271... ...
I agree with Alison Singer and several others that time trends are very important, what changed in the environment and when. The phenotype is very important, biomarkers that Sophia Colamarino mentioned, the clinical data mining Lyn Redwood mentioned, recovery studies that Sallie Bernard has talked about.
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From page 272... ...
On the immune system, I think Gary Goldstein is right. I think one can make the prediction that these individuals are in TH-2 imbalance.
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From page 273... ...
Mr. Blaxill: I want to talk a little bit about the burden of proof on time trends.
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From page 274... ...
Dr. Susser: I agree that we should really tackle the time trends problem, and that we should trace the course of autism over an individual's life span, not just over the first few years.
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From page 275... ...
Finally, with regard to interesting existing scientists and companies in studying autism, which is not a huge population, there are a variety of conditions which have overlapping biochemistry and pathophysiology with regard to inflammation and oxidative stress, various neurodegenerative diseases across the life span, obesity, diabetes, and work has been done in those domains. People who have been working in those domains, that could be recruited to this effort so that it wouldn't have to start from scratch in autism.
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From page 276... ...
I know that Paul Law and the folks at Autism Speaks are working on ways that those individuals who can't currently participate in research rapidly could. I will finish by echoing Gary Goldstein's plea that we move very quickly to a cystic fibrosis or cancer-line treatment network.
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From page 277... ...
So I think that is a powerful model for the private sector to stimulate pharmaceutical companies to be engaged in this process. It is not the usual big players, but it is the small innovator companies that will come out of the young people who get recruited to be researchers in autism research and other areas.
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From page 278... ...
I think we should probably look at environmental exposure which might increase the rate of mutations in germ cell lines of fathers in particular. That would be something which would also be to follow up.
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From page 279... ...
There is a meeting at the same time as we are meeting here of the think tank from DAN and the Autism Research Institute. I want to bring greetings from them, because there has been some back and forth and there will continue to be back and forth.
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From page 280... ...
They have several different programs that have been long, positive, and successful in getting the consumer advocates involved in speaking with the director about the research agenda as well as the peer review process, and just keeping open lines of communication between the two groups. Participant: I didn't know she was going to talk, but this falls perfectly with what I was going to mention.
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From page 281... ...
So one thing that would I think help would be if this panel of distinguished scientists could urge upon national government the same kind of commitment that has called forth the sense of national urgency at the political level, and that begins at the presidential level, to declare a national emergency, to marshal all of the resources that we can bring to bear on this crisis. At the present rate of increase, which I think Mark Blaxill said was 10-fold since 1990, in two or three generations every child will be born with autism or related neurological deficit or some sort.
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From page 282... ...
It is sometimes hard to find the right information or people. So I just wanted to offer myself as a contact, if I can help, in the spirit of partnerships, data sharing, and so on.
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