Tuesday, 2 May 2017

Homeopathy and Autism - Part One

Questions about the competence of lay homeopaths are often raised even by other homeopaths. Although Codes of Ethics and Practice often state that a practitioner must practice within their limits, there seems to little understanding of what these limits might be.

This article is split into several parts as otherwise it would be very long and the longer the post is, the more difficult to complete.

Code of Ethics and Practice
The Society of Homeopaths Code is used as an example. Partly because it is the most developed Code of any of the trade associations that represent homeopaths. To quote one relevant section -
Section 3 - Professional obligations

Competence and Continuing Professional Development  
16) Registered and student clinical members must be aware of the limits of their professional competence and where appropriate, will refer to other practitioners ensuring that the practitioner to whom they refer is suitably qualified.  
17) Registered and student clinical members should regularly monitor and evaluate their clinical skills and actively extend their knowledge base and their own personal development through continuing professional development.  
18) Evidence of continuing professional development will be taken into account when hearing allegations regarding a registered or student clinical member’s professional conduct or competence.
Whilst some would argue that lay homeopaths have no professional competence or clinical skills, that is a value judgment that others would not accept. An awareness of limits would appear to be in contradiction to the beliefs of some homeopaths that homeopathy can cure almost anything as long as the correct remedies are given. 

Treating Autism with Homeopathy
To say this is controversial would be an understatement. Nor just because of the absence of evidence of efficacy for homeopathy but also because because of ideas espoused for the causes of autism and the anti-vaccination messages that often go along side. Some neurodiversity advocates also find the idea that autism is something to be cured insulting enough from the medical profession.

Whilst there are other serious conditions that homeopaths claim to treat, treating autism seems quite popular. The ethical issues involved are often more difficult than for some other conditions. They also can arouse great passions.

The fundamental question is - whether treating autism is beyond the limits of any lay homeopath?

This is a complex subject and requires much explanation.

What is Autism?
There are four conditions that could be thought to fall under the umbrella of Autistic Spectrum Disorders (ASDs).
The names under various medical coding schemas do vary and have changed through various revisions of the schemas. However, the public don't really make any distinction except, perhaps, with regards to Aspergers. Public awareness of autism is not very good though. Autism in this post will be used in the sense of ASD, except where made clear otherwise.
Individuals diagnosed with autism spectrum disorder must present two types of symptoms:
  • Deficits in social communication and social interaction
  • Restricted, repetitive patterns of behavior, interests or activities
Is one definition but the diagnosis of autism is not clear cut. That assumes that one can be referred for a diagnosis. It can be very difficult in some healthcare systems. Diagnosis is generally performed by a paediatrician who specialises in autism. Diagnosis is performed by observation and interview and scoring against one of various diagnostic tools such as Autism Diagnostic Observation Schedule (ADOS). These tools are subjective to a degree and it must always be borne in mind that the "performance" of a patient can vary over time. Indeed, the presentation of some symptoms occur as the result of "triggers". There is a potential for both under and over diagnosis.

The term "autism" did not exist until 1910 but the current diagnostic notions only date back to 1938 and it took many years for them to be seen as something different than other developmental issues. Nor was this an overnight process. It is also bound up with the history of the treatment of those with learning disabilities in the wider context - for example, in the past, people with autism would have been lumped in with others as "mentally defective" and incarcerated in an asylum, largely hidden away from the public. These issues make it impossible to determine the historical prevalence of autism. That some adults in later life are diagnosed as autistic does highlight the changes. 

It is assumed that most people are familiar with the symptoms of autism but if not, NHS Choices provides some useful informationRepetitive, ritualistic behaviours often make others uncomfortable and can be thought socially unacceptable. 

Childhood Disintegrative Disorder
CDD is very mysterious bur rare - one figure given is 1.7 cases per 100,000. It seems to be characterised the sudden loss of learned skills, a regression to a previous state. In some cases, before it happens, the child is aware that something is happening to them and can become very distressed. There can be some signs of development delay before this happens.

The stories of children with CCD often come across as one of a child developing normally up until around three years old. The child is often described as outgoing and social, then there is a crisis and the child regresses dramatically. This is not that different from some of the stories that are told by those who believe that their children's autism is due to vaccines.

Little research is being done into CCD, partly because of its rarity compared to ASD in general. It's also difficult to conduct tests on these children. It might be thought that such a sudden regression must be the result of neuro degeneration but what research there is suggests not. It also suggests that in certain ways the brain is functioning more like a neurotypical infant that a child with another form of autism.

Whether looking at CCD or ASD in general, it seems very unlikely that a lay homeopath would have the competence to diagnose autism (although to be fair, it would be extremely unlikely that they would ever be placed in the position of having to do so - very likely that they would be dealing with children with a pre-existing diagnosis).

What are the causes of Autism?
In all bar a minority of cases, the exact causes of autism are unknown beyond there being a strong genetic component. It can be difficult to untangle the causes of co-morbidities from the causes of autism. For example, epilepsy is relatively common in those with autism but the nature of the linkage is unclear. There are also some known risk factors but again, the links are unclear.
  • Genetic - There are some rare single gene mutations such as Fragile X Syndrome but in general, whilst, say twin studies suggest that there is a very strong genetic component to autism it's not known what genes are involved and this is suggestive of many genes potentially being involved. Aspergers may well be more strongly genetically linked than other forms of autism.
  • Epigenetic - which can be a difficult concept for the non-specialist. Basically, external factors can switch on/off the the expression of certain genes. In the case where different versions of a gene have been inherited from both parents, only one is expressed. 
  • Prenatal factors - Infection is one suggested cause. Congenital rubella syndrome is known to cause autism in a few cases. Cytomegalovirus is also suggested. As far teratogens go, there are theories but no firm evidence. Use of certain psychiatric drugs may be a risk factor. Maternal age as well and also gestational diabetes.
  • Birth factors - Premature birth and/or low birth weight may be risk factors as could be hypoxia during birth but again, there is no firm evidence.
  • Disease - Subacute sclerosing panencephalitis is caused by measles. It is often fatal. It can produce autism though. There are also genetic diseases that can cause autism by damaging the brain such as Tuberous sclerosis.
There are many more potential causes and risk factors but a full discussion is way beyond the scope of this blog post. Suffice to say, genetic causes would seem be to the most important.

The debunked belief that autism can be caused by vaccination would appear to be common among lay homeopaths even if it sometimes couched in terms "helping parents to make their own decisions". Some examples of homeopathic ideas about the causes of autism. Firstly from the late Tinus Smits.
In his experience autism is an accumulation of different causes and about 70% is due to vaccines, 25% to toxic medication and other toxic substances, 5% to some diseases.
And later -
Medication during and after pregnancy, especially vaccinations are very toxic to the young child's brain. Even illness, medication and vaccination in the energetic field of the father and mother before pregnancy can be transmitted to the child by energetic transfer.
A different homeopath, Alan Freestone says
  • Vaccine Damage. This is still disputed, but I have experienced the damage vaccines can cause myself! 
  • Genetics. I don’t believe that certain genes CAUSE autism, rather they may make people more susceptible to autism when exposed to certain environmental triggers
  • Toxins from the environment or from the mother (mercury and other heavy metals can pass from mother to foetus)
  • Medications that the mother was taking during the pregnancy or birth
  • Emotional stress experienced in the birthing process or in pregnancy
Neepa Sevak states
  • Genetic predisposition. 
  • Complications in pregnancy and child birth. 
  • Viral infections like Rubella during the first trimester of pregnancy. 
  • Maternal exposure to mercury (e.g., consumption of seafood high in mercury, mercury dental fillings, etc.). 
  • Exposure to certain other environmental toxins. 
  • Childhood vaccines. 
  • Digestive abnormalities or allergies to certain foods like dairy products. 
  • Lack of Glutathione (glutathione is an antioxidant and a detoxifying agent in your body). 
  • Candida Overgrowth. 
  • Foods containing Genetically Modified Organisms. 
  • A Hiatus Hernia that disrupts protein digestion. 
  • Excessive use of oral antibiotics.
The retired Luc De Schepper helpfully tells us about the maisms involved.
There are three main miasmatic states, just like there are only three major defense mechanisms in any organism, starting with the individual cell: inhibition or deprivation (loss of function) or exaggeration of excitability (which translates into irritation or acute inflammation) is the first defense. This is called PSORA in homeopathic terms. The second defense mechanism constructive defense, called SYCOSIS in homeopathy with dilatation (cysts), softening (relaxed ligaments leading to prolaps of the organs) or hardening or induration. It is the third one of these defense mechanisms that is the predisposed soil to the formation of ASD: destructive defense, called the SYPHILLITIC miasm in homeopathy. A living being has only three defense mechanisms to invasion of microorganisms: inflame, indurate or be destroyed in an attempt to maintain the well-being of the person as a whole. In other words, no trigger can cause ASD without the syphilitic miasm found in the child's family background.
The rest of the article is worth reading simply to demonstrate the mindset of certain homeopaths.

It's possible to go on. A few of the reasons given by homeopaths are correct. Some are wild extrapolation from research that suggests linkage (rather than causation) between something measurable and autism but a lot are just plain wrong. Very wrong. 

The beliefs of homeopaths about the causes of autism can be harmful in themselves. Certainly, from a public health perspective, discouraging vaccination is not a good thing. Giving advice on the benefits/risks of vaccination could be thought to beyond the competence of lay homeopaths.

More troubling is the concept that lay homeopaths can diagnose the cause of autism, the concept that autism is a symptom of something else that can be diagnosed (and treated) given that the consensus is that the causes of autism are largely unknown. Speculative, unevidenced theories are one thing but taking them as proven is quite another.

There is no cure for autism. There are some cases in which children develop to the a point where they are no longer classified as autistic by diagnostic tools but "cure" is a strong word. Especially given that the causes are largely unknown.

Better outcomes are associated with earlier acquisition of language, higher IQ and having a marketable skill. It's not unusual to find people with Aspergers in the workplace, having relationships of all kinds and having a family and children. It's more unusual to encounter those with a prior diagnosis who "pass" as neurotypical but they do exist. "High functioning" is a term that is sometimes used, although for some it has negative implications. If the causes of autism are mysterious, the reasons why some later no longer meet the diagnostic criteria are even more so. This article is interesting.

However, it would seem that for the majority of those with ASD outcomes are less good. Living independently is an impossibility for some. Some will continued to be cared for into adulthood by their family, others with end up in some sort of residential care. The quality of that residential care can vary enormously depending on where you are in the world and/or family income.

Claiming that autism can be "cured" or "reversed" by a specific treatment is highly unethical on the basis of the above.

Inaccuracies and Omissions
This post is very likely to contain them. On that basis, comments are more than welcome. If necessary, the post can be revised and re-published.