Addressing psychiatric and psychosocial issues related to children and adolescents Youth in Mind

Teena M. f^cCuinness, PhD, CRNP, FAAN, Section Editor

Update on Autism and Vaccines

ABSTRACT retracted a paper that errone-
ously associated vaccines with
As the rate of autism spectrum disorders rises, parents are search-
autism ("Rétraction," 2010),
ing for answers. In this article, a small study that fueled the belief the fear that autism is caused by
in an association between autism and vaccines is reviewed, and vaccines persists. The question
the scientific evidence regarding the relationship between au- remains: Is there any scientific
evidence for this association?
tism and vaccines is explored.
The rise in the incidence
of autism spectrum disorders

I
mmunizations are one of the System (2010) documentary, (ASDs) is a growing public
greatest advances in the The Vaccine War, outlined the health concern. Recent statis-
history of health care. Nev- concerns of parents and their tics from the Centers for Disease
ertheless, many parents have fear of a link between autism Control and Prevention (CDC;
questions about a possible link and vaccines. This concern is 2009) regarding autism certainly
between immunizations and especially troubling, because grab attention; One in 110 chil-
autism. A Public Broadcasting even after The Lancet recently dren is diagnosed with autism; 1

Teena M. McCuinness, PhD, CRNP, FAAN; and Shannon Lewis

JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 48, NO. 6, 2010 15

Youth in Mind

in 70 boys has an ASD. The ac- cannot be ruled out that other maternal-fetal interaction, and
curacy of these figures is of great factors might have also contrib- neuroanatomy and neural net-
debate. A strong explanation uted to that trend, (p. 591) works are just some of the con-
for this alarming increase is the cepts parents must try to grasp to
notion of diagnostic substitu- ETIOLOGY OF AUTISM help their children.
tion: Children diagnosed today SPECTRUM DISORDERS In the 1990s, as the cases of
with an ASD may have been What do we know about di- ASDs escalated and Internet
given another diagnosis in years agnosis and etiology? Three dis- blogs became commonplace,
past (Coo et al, 2008). In Brit- orders comprise ASD: Autism is parents began to look for causes.
ish Columbia, special education the most severe; the other two Some parents considered the H
codes were reviewed to test this are pervasive developmental routine vaccinations during in-
hypothesis. Coo et al. (2008) dIsorder, not otherwise speci- fancy and preschool years to be
concluded that half of the in- fied (PDD-NOS) and Asperger's excessive; perhaps there might
crease in new ASD diagnoses syndrome (National Institute be a connection with the higher
occurred as a function of switch- of Mental Health, 2010). The rate of ASDs.
ing from one category of special predominant features of ASDs
education to the autism category include disturbed patterns of be- THE 1998 LANCET STUDY
(i.e., diagnostic substitutions). havior, especially a lack of social In 1998, Dr. Andrew Wake-
Bishop, Whitehouse, Watt. reciprocity. Other ASD features field, a gastroenterologist, and
and Line (2008) used a retro- include communication prob- his colleagues reported in The
Lancet a possible association
between autistic symptoms; irri-
table bowel disease; and the vac-
cine for measles, mumps, and ru-
Children diagnosed today with bella (MMR) (Wakefieid et al.,
1998). Wakefieid and his col-
an autism spectrum^ disorder may leagues described unusual bowel
symptoms among 12 children re-
have been given another diagnosis ferred to a pédiatrie gastroenter-
ology clinic. All had behavioral
in years past. or developmental problems, and
9 had autistic diagnoses. In 6 of
these 9 cases, either parent or
pediatrician had already associ-
spective approach ni addressing lems and repetitive and stereo- ated the onset of autistic symp-
the diagnostic substitution is- typical behaviors. toms with MMR vaccinations.
sue and found that many adults The editor of BMJ described it
ASDs are serious neurodevel-
who would now be identified this way:
opmental disorders that have ge-
as having ASDs had been diag- netic underpinnings. Grigorenko At a controversial press con-
nosed with developmental lan- (2009) proposed that the "work- ference Wakefieid appeared to
guage disorders in the 1980s. ing hypothesis of ASDs today is conflate association with causa-
In addition, Fombonne (2009), that their genetic texture is re- tion, and in the eyes of the tab-
in his review of 43 studies on lated to no single common cause, loid press bis tiny, skewed sample
the epidemiology of ASDs, but to a variety of variable ge- represented children in gen-
concluded: netic causes, which might act in- eral. The immunizarion record
There is evidence that the dependently, or in combination of then Prime Minister Tony
broadening of the concept [of with each other" (p. 591). The Blair's infant son became the
aLitisni], the expansion of diag- explosion of scientific research most politically sensitive item of
nostic criteria, the development may overwhelm families and data beld in the NHS INational
of services, and the improved the public. The arcane details of Health System). Private clinics
awareness of the condition have molecular and clinical genetics, enjoyed a brief boost to business
played a major role in explain- neurotransmitters and cell sig- by offering the three vaccines
ing this increase, although it naling, growth and metabolism. as separate, spaced injections

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 Youth in Mind

as recommended by Wakefield. recognition oí autistic symp- garding autism and vaccines

Measles returned—and did con- toms between the two samples and concluded that the over-
siderable damage. (Greenhalgb, who had received the MMR whelming majority of studies
2010, r-644) vaccine (19.3 months and 19.2 showed no causal association
Despite the small sample and months) and the group diag- between the MMR vaccine and
the lack of experimental de- nosed prior to receiving the autism (Doja & Roberts, 2006).
sign, the study received a huge vaccine ( 19.5 months) (Fom- They also noted that although
amount oí media attention, and bonne &. Chakrabarti, 2001). the vaccine preservative thi-
in the United Kingdom MMR Thus, parents did not recognize merosal was suggested as the
vaccination rates dropped from regressive autistic symptoms culprit, there was no evidence
90% in 1998 to 80% in 2004 closer to the age of first vac- in the literature to support the
(The Information Centre, 2005}. cination that might have re- relationship. Doja and Roberts
In an effort to prevent a similar vealed an association between (2006) warned of the threat of
drop in vaccination rates in the ASDs and the MMR vaccine. MMR outbreaks should parents
United States, the CDC and Na- In other parts of the world, decide not to vaccinate.
tional Institutes of Health held researchers also sought answers.
a conference examining vaccine In the United States, epidemi- The Lancet Retracts
safety issues. A thorough review ologists compared the increas- In an 81-word editorial, Lan-
of the scientific literature led to ing rates of immunizations with cer editors retracted Wakefield
the conclusion that there was a
tack of scientific evidence (in-
cluding no biological models)
linking autism to the MMR vac-
cine (Halsey iSi Hyman, 2001;
Institute of Medicine, 2001).
Psychiatric nurses should have
an '^elevator speech'\,,on the life'
New Evidence
Contrary evidence to saving nature of vaccines to share
Wakefield et al.'s (1998) find-
ings emerged. Fomhonne and
with parents.
Chakrabarti (2001) studied
three groups of children in the
United Kingdom;
• A group of 98 children the rising rates of ASDs using et al.'s (1998) paper in early 2010
with autism, diagnosed prior to statistics from the California ("Retraction," 2010). Interest-
receiving the MMR vaccine. Department of Health (Dales, ingly, the reason cited for the pa-
• A group of 96 children Hammer, & Smith, 2001). per being retracted was ethical.
with PDD-NOS (recall that this Dales et al. (2001) found that The editors stated that children
diagnosis contains features simi- there was a large sustained in- were not "consecutively referred"
lar to autism) who received the crease in the numbers of autism as stated in the paper; in fact,
MMR vaccine at a mean age of cases, rising from 44 cases per the Fitness to Practise Council
13.5 months. 100,000 live births in 1980 to had found that institutional re-
• A group of 68 children 208 cases per 100,000 in 1994, view ethics rules had been vio-
diagnosed with regressive au- a 373% relative increase. The lated. Specifically, Wakefield et
tism after being vaccinated for rate of increase of vaccinations al. (1998) had not obtained ap-
MMR. was much smaller: There was proval for invasive tests (lumbar
The researchers hypothesized only a 10% rise during the same puncture and coUmoscopy) con-
that the average age when autis- period, leading the investigators ducted on the children. Indeed,
tic symptoms were noted would to conclude that no relation- the proposal had been submit-
be close to the age of vaccina- ship existed between the MMR ted under a different study; some
tion (12 months). However, no vaccine and autism. called the paper an "iconic sym-
significant difference was found In 2006, Canadian research- bol of bad science" (Greenhalgh,
in the mean age of first parental ers reviewed the literature re- 2010, p. 644).

JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 48, No. 6,2010 17

Youth in Mind

from the New Challenges in Child-

NURSING IMPLICATIONS mankind. There is no scientific
hood Immunizations Conference
Vaccines are safe. The ben- evidence supporting a causal re- convened in Oak Brook, Illinois,
efit of vaccines is "difficult to lationship between childhood June Í2-U, 2000. Pediatrics. 107(5),
exaggerate. The availability of vaccination and neurodevelop- E84.
vaccines.. .has led to billions mental disorders such as autism. The information Centre. (2005).
of lives being saved, decades of NHS immunisation statistics: Eng-
land: 2005-06. Retrieved from
life-expectancy increase.. .and REFERENCES http://www.ic.nhs.uk/webfiles/
the elimination of a huge bur- Bishop, D.V., Whitehouse, A.]., Watr, puhlications/immstats2005to2006/
den of suffering and disability H.J., ik Line, E.A. (2008). Autism I mmun isationStatistics2 80906_PDF.
around the world" (Chatterjee, and diaKnn,scic substitution; Evi- pdf
dence from a study of adults with a
2008, p. 275). Thus, psychiatric Institute of Medicine. (2001). immuni-
history of deveiopmentai language sation safety review: Measles-mumps-
nurses should have an "eleva- disorder. Developmental Medicine and rubella vaccine and aurism. Retrieved
tor speech" (prepared talking Child Neurology, 50, M\-M5. from tbe National Academies Press
points) on the life-saving na- Centers foT Disease Control and Preven- website; http://www.nap.edu/catalog.
ture of vaccines to share with tion. (2009). Prevalence of autism pbp?recordjd=l0101
parents of young children who spectrum disorders—Autism and National Institute of Mental Health.
Developmental Disabilities Monitor-
may have questions about the (2010). Autism sfjectrum iii.srírdcr5
ing Network, United States, 2006. (pervasive developmental disorders).
autism-MMR vaccine contro- MMWR Surveillance Suminaries.
versy. Here are our suggestions: Retrieved from http://www.nimh.nih.
58(10,1-20. gov/heattb/topics/autism-spectrum-
Chatterjee. A. (2008). Vaccine safety; disorders-pcrvasive-developmental-
• There is no evidence of a Genuine concern or a legacy of un- di.sorders/index.sbtml
relationship between vaccines founded skepticism? Expert Revicu' of Public Broadcasting System. (Produc-
and autism. Vaccines. 7, 27S-277. er). (2010). Frontiine: The vaccine
• Although rhe number of Cod, H., Ouellette-Kunt:, H., LInyd, war IDVDJ. Available from http://
cases of autism has risen, it is J.E., Kasmara, L., Holden, J.J., & www.shoppbs.org/product/index.
Lewis, M.E. (2008). Trends in autism jsp;produccld=4091660
probably due to greater aware- prevalence: Diagnostic substitution
ness, more treatment options, Retraction—I leal-lympho id-nodular
revisited. ]oumal of Autism and Devel- bypoplasia, non-specific cotiris, and
and reclassification of disor- opmenial Disorders, Í8, 1036-1046. pervasive developmental disorder,
ders. Dales, L., Hammer, S.J., & Smith, N.J. (2010), Lancet, 375, 445.
• Vaccines save millions (2001). Time trends in autism and Wakefield, A.J,, Murch, S.H., Anthony,
in MMR immunization coverage in A., Linnell, J., Casson, D.M., Malik,
of lives and prevent long-term
California. Jounial of the American M-, er a!. (1998). Ileal-Iymphoid-
complications from measles (en- Medico/Association, 285, 1183-1185. nodular hyperplasia, non-specific
cephalitis and seizures), mumps Doidge, N. (2007). The brain that changes colitis, and pervasive devetopmenral
(testicular problems that cause itself. New York; Viking Penguin. disorder in children, Ltincei, 351,
infertility later), and rubella (if Doja, A., & Roberts, W. (2006). Immu- 637-641-
a pregnant woman becomes in- nizations and autism: A review of the
literature. Canadian ]uur<\ai of Neuro-
fected, her fetus may experience logical Sciences, 33, 341-346.
Dr. McCuinness is Professor, and
birth defects, including mental Ms. Lewis is an Honors undergradu-
Fombonne, E. (2009). Epidemiology oí
retardation). ate nursing student. School of Nursing,
pervasive developmental disorders.
University of Alabama at Birmingham,
• Offer hope to parents: The Pédiatrie Research, 65. 591-598.
Birmingham, Alabama.
Fombonne. E-, &. Chakrabarti, S. (2001}.
concept ot neuroplasticity is be- The authors disclose that they have
No evidence for a new variant of
coming a new focus of research, no significant financial interests in any
measles-mumps-rubella-induced au-
and Doidge (2007) documents product or class of products discussed
tism. Petiiamcs. 108(4), E58.
directly or indirectly in this activity,
some hopeful findings regarding Greenhaigh, T. (2010). CMC Waketield
including research support.
the improvement of cognitive verdict: Why did tbe Lancet take so
Address correspondence to Teena
skills for children with autism longiB.MJ, 340,644.
M. McCuinness, PhD, CRNP, FAAN,
Grigorenko, E,L. (2009). Parbogenesis
via computer-based educational of autism: A patchwork of genetic
Professor, School of Nursing, University
software. of Alabama at Birmingham, NB 320,
causes. Future Neurolo^\ 4. 591-
1530 3rd Avenue South, Birmingham, AL
599.
35294-1210; e-mail: tmcg@uab.edu.
CONCLUSION Halsey, N.A., ik Hymm, S.L (2001).
Posted: May 21, 2010
Measles-mumps-rubella vaccine and
Make no mistake, vaccines autistic spectrum disorder: Report
doi:10.3928/02793695-20100506-02
have been a great boon to hu-

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