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Treating Children with Autism
Using Hyperbaric Oxygen Therapy
Summary:
In more than 7,000 facilities worldwide, hyperbaric oxygen therapy (HBOT) has been used for decades to heal serious infections, non-healing wounds, and to treat divers with thebends. An increasing number of these hyperbaric medical centers are also successfully treatingneurological injuries and disease such as autism. Recent studies have suggested that a commonlink among children with autism is chronic inflammation of areas of the brain and gut, and thatthe anti-inflammatory effects of HBOT may make it one of the safest and most effective ways tohelp resolve the debilitating effects of autism.
In Hawaii, according to the most recent Department of Education statistics, nearly 1 in every 74 children with special needs1 enrolled in public schools in Hawaii are children who fallwithin the autism spectrum, and direct DOE services for these children are estimated to cost over$30 million per year. Since 1992, statistics show the prevalence of children in Hawaii diagnosedwith autism has increased by over 2700%.2 Geneticists researching autism have suggested thatthis may be related to a genetic pre-disposition among Pacific Islanders and Asians. Accordingto a 2004 US Dept of Education report3, Asian American and Pacific Islander students (whoethnically make up more than 65% of all children enrolled in public school in Hawaii) were also1.24 times more likely to receive special education and related services for autism than all otherracial/ethnic groups combined. Resources for the evaluation and treatment of autistic children in Hawaii are very limited. For example, there are currently only two registered DAN! doctors (trained specialists in autism)in the entire state, and functional imaging SPECT scans commonly used to understand theongoing neuropathology are virtually unavailable for children in Hawaii. As the onlyhyperbaric treatment facility in the state commonly providing therapy to children with autism,we have documented consistently positive reports of improvement in autistic patients followingHBOT. In order to provide a more objective basis for the use of HBOT to treat these children,however, a study using less subjective reporting methodology was needed.
This study evaluated the effects of 20 hours of hyperbaric oxygen therapy on the functional outcomes of twenty children (4 females and 16 males) ranging in ages from three toseven years, each with a clinically proven diagnosis of autism, and living in Hawaii. Pre-HBOTbaseline and post-HBOT follow up evaluations were performed by experienced autism testingclinicians in the community, independent of the treating facility. Testing outcomes provedstatistically significant clinical improvements in 100% of the children in one or more of thefollowing areas: Communications, Social Interaction, Imagination/ Creativity, StereotypedBehaviors and Global Assessment of Functioning (GAF) scores.
Background:
More than 50 years ago, Dr. Leo Kanner, a psychiatrist at Johns Hopkins University, wrote the first paper using the term 'autism' to describe a group of children who had severesocial, behavioral and communication problems. In a review of his original case descriptions, itappears that he was especially interested in these children because their constellation ofsymptoms was so unusual. Today, those same symptoms are more commonplace than many other childhood diseases, and are being recognized at an earlier and earlier age by enlightened physicians andwell-informed parents who are unassailable advocates on behalf of their children. To put this inperspective, a recent Hawaii Autism Prevalence Report makes the comparison of rates of autismto rates of cancer. This telling comparison, which is based upon figures from the Centers forDisease Control, shows that autism is now more prevalent in the United States than all forms ofcancer combined. Autism is probably most accurately characterized as a neurodevelopmental disorder with a complex etiology. In the science of epidemiology, environmental factors are thosedeterminants of disease that are not transmitted genetically. Environmental factors also maydetermine the development of disease in those genetically predisposed to a particular condition. Stress, diet, exposure to chemicals, toxins, pathogens, and radiation are common environmentalfactors that determine a large segment of non-hereditary disease. If a disease process is found tobe the result of a combination of genetic and environmental influences, it is considered to be multifactorial. Autism is a classic example of a disease with a multifactorial etiology, in that itis believed to manifest itself only in children who have both a genetic predisposition and also anexposure to some kind of environmental trigger.
Although there is great debate among experts about the actual causes of autism, it is accepted among health statisticians that a consistently rising prevalence trend (as we have seenin Hawaii) implicates environmental factors in the causality of autism. A steady prevalencetrend over time (which we have not seen) would be more likely to implicate genetic factors inthe causality of autism.
The fact that genes, alone, are not a deciding factor in the development of autism was show in a recent multi-million-dollar genetics study which gathered and studied data on over athousand families with at least two children diagnosed with autistic spectrum disorder.4 Comprehensive genetic screening was used to evaluate each family’s genetic makeup, but in thefinal report, the researchers reported that “None of our linkage results can be interpreted as‘statistically significant’.” In another recently published study, a percentage of the group studied showed an increased sensitivity to mercury than the general population, thus supporting the hypothesis that
autistic children may carry a genetically increased susceptibility to certain environmental toxins,
including mercury.5 ON a note important to Hawaii, a large 2006 published study found that
Pacific Islanders, Asian, Native Americans, and multiracial subjects studied had a higher
prevalence of elevated blood mercury than all other racial/ethnic participants.6 A five-year
study of over 100,000 people found that Asians and Pacific Islanders also have the highest levels
of iron in their bloods of all the racial/ethnic groups screened.7 Researchers involved in the
study have suggested that Asians and Pacific Islanders may carry a genetic mutation which
allows their bodies to process heavy metals differently than other races. This is significant in
the world of autism research since heavy metal exposure is one of the most often discussed
factors as a possible environmental trigger for the disease.8
In a remarkable related study just released by researchers from the Harvard Medical School9, heavy metal toxicity as a cause of oxidative stress and its effect on children with autism
was discussed in detail. This research focused on specific biological “markers” of oxidative
stress in the brain. These markers were found to be elevated by 68.2% in patients with autism
when compared to tissues from those without autism. The study notes that “Mercury strongly
associates with oxidative stress.(Mercury) induced oxidative stress results in oxidative
modification of DNA, protein and lipids, as well as inhibition of the enzymes crucial for the
brain development. Thus elevated levels of mercury in brain potentially interfere with normal
brain development.” Oxidative stress is caused when oxygen-based processes in the body are
not adequately supported or balanced (oxidants vs. antioxidants). Multiple studies since 2001
have demonstrated the effectiveness of hyperbaric oxygen therapy to decrease oxidative stress
overall, and improve the function of proteins (HSB70) in the body which naturally protect
against oxidative stress. 10
As the incidence of autism has increased over the past 20 years, many other important clinical studies have contributed to an increased understanding of how the disease manifestsitself and how to define and recognize the symptoms. This has led to earlier identification andassessment in affected children, thereby affording parents and physicians the opportunities toprovide earlier interventions. Unfortunately, many of those effective interventions were poorlyunderstood and not readily available until just a few years ago.
Finally, in 2004 a paradigm-changing study in the world of autism research encouraged researchers to focus less on finding the cause or etiology of autism, and instead to find more
effective ways to treat the resulting biological effects of the disease itself. Drs. Vargas, et al.
found that although autism manifests itself in a wide variety of symptoms, the common factors
among autistic patients studied of all ages was a chronic inflammatory process which affected
both the brain and immune system functioning.11
Shortly thereafter, Dr. Andrew Wakefield, and his colleagues in Texas, published a study of gastrointestinal symptoms in148 young children with a primary diagnosis of autistic spectrumdisorder (ASD). Much like the Johns Hopkins University researchers, they found that chronicinflammation (this time in the gut, manifesting itself as acute and chronic gastrointestinalsymptoms) was a “characteristic pathological finding in children with ASD.”12 A number ofrelated studies with similar findings have since been published supporting this finding.
The Johns Hopkins University researchers were clear in their recommendation that “(b)ecause this neuroinflammatory process appears to be associated with an ongoing and chronic
mechanism of CNS dysfunction, potential therapeutic interventions should focus on the control
of its detrimental effects (while preserving reparative benefits) and thereby eventually modify
the clinical course of autism.”
As autism researchers around the globe studied these findings, they began to evaluate available treatments to resolve the chronic inflamation which acts as the basis of so many of thechallenges faced by affected children.13 , 14 The use of corticosteroids ( Prednisone), Minocycline (an antibiotic with antiinflammatory properties), and nonsteroidal anti-inflammatory drugs have all been studied inthe treatment of autism 15, 16, 17, but all have significant negative side effects and some are even contraindicated for use in children because of the potential for serious complications (e.g., Reye'ssyndrome). Further review of available treatments in search of a safer way to address chronic neuroinflammation in autistic children led to evaluations of decades of neuro recovery researchin the field of hyperbaric medicine 18, 19, 20 Hyperbaric oxygen therapy (HBOT) has a well-known anti-inflammatory effect21, and has been shown to measurably improve immune function22. This is important because studieshave suggested that there is a genetic relationship between autism and immune systemdysregulation.23 Multiple studies have shown that oxidative stress can be significantly reducedwith HBOT through the upregulation of antioxident enzymes. HBOT increases blood flow inthe brain in areas where blood flow is depressed, improves the function of existing mitochondriacells, and increases the production of new cells, as well as improving neurotransmitterabnormalities.24 All of these results are crucial in the comprehensive treatment of a child withautism.
Clearly one of the most important factors to consider when treating these fragile young patients is that hyperbaric oxygen therapy is one of the safest and lowest risk medical treatmentsavailable today. One of the best proofs of this fact may be Dr. James Neubrander’s clinic inEdison, New Jersey, through which over 25,000 hours of hyperbaric therapy have been safelyand effectively provided to children with autism. The safety factor is widely recognized by thosewho assign and evaluate medical risk. As Paul Harch, MD notes in his book, The Oxygen Revolution, “Possibly one measure of the (safety of hyperbaric oxygen therapy) is the minimalrate ascribed by malpractice insurance companies to HBOT, which falls into one of their lowestranking (risk) categories.”25 Perhaps the most comprehensive review of the medical science supporting the use of HBOT to treat autism was performed at the University of Virginia by Daniel Rossignol, MD,26
and was published in 2006. In it, Dr. Rossignol reviewed the effects of hyperbaric oxygen
therapy on the most common pathophysiology found in autism, including neuro inflammation,
gastrointestinal inflammation, cerebral perfusion, detoxification enzyme function, immune
system dysregulation, and six other commonly affected areas. In all of these areas of
pathophysiology critical to the resolution of autism in children, HBOT was found to have a
clinically important positive effect.
Study Objectives:
Examine the effects of hyperbaric oxygen therapy on fifteen key behaviors commonly evaluated in children with autism and autistic spectrum disorder. Participant Selection:
The study included 20 children with DSM-IV diagnosis of Autistic Disorder, confirmed with Autism Diagnostic Observation Schedule (ADOS) and Autism Diagnostic Interview-Revised (ADI-R) testing. Pre-HBOT and post-HBOT testing was performed by experiencedautism testing clinicians in the community, independent of the treating facility.
The children included 4 girls and 16 boys ranging in age from 3-7 years of age, with a median age of 5 years 7 months at the start of treatment. Two of the participating boys wereidentical twins, and one of the boys had an unaffected fraternal twin brother at home. Fifteen ofthe children came from either an Asian or Pacific Islander ethnic background. All of thechildren had been diagnosed for at least a year or longer prior to participation in our study.
The mean age of the biological mothers at the time of birth was 34.6 years, with four of the mothers aged 40 or over. The mean age of the biological fathers at the time of birth was 37years, with eight of the fathers age 40 or older when their child was born. Although exact individual childhood immunization schedule information was unavailable for each of these children, the state of Hawaii follows the CDC recommended protocols forchildhood vaccinations, and it is believed that each child received immunizations consistent withthat protocol, beginning with the Hepatitis B vaccine within 48 hours of birth. Unlike statessuch as California, Delaware and Iowa, the state of Hawaii does not regulate or restrict theamount of the mercury-based preservative thimerosal used in immunizations.
Two of the children were born as the result of in-vitro fertilization. Eighteen of the children had lived the majority of their lives in Hawaii, with 17 residing on Oahu and one onMaui. Six of the children were from military families, reflecting the high percentage of U.S.
military personnel residing on the island of Oahu in Hawaii. There was no placebo or controlgroup.
Eligibility Criteria:
Participants were at least 3 years old at the start of the study, and did not reach their 8thbirthday by completion of treatment.
Both genders were eligible, and we did not seek to balance the number of boys and girls.
It was just by chance that our numbers accurately reflect the reported 1:4 ratio of incidence between girls and boys with autism. Participants had a DSM-IV diagnosis of Autistic Disorder, confirmed with a completeschedule of testing including Autism Diagnostic Observation Schedule (ADOS) andAutism Diagnostic Interview - Revised (ADI-R). All pre-study testing was completedwithin 30 days of each child’s first hyperbaric treatment.
All participants were HBOT naive prior to treatment.
All participants completed 20 hours of HBOT within 6 weeks of their start.
Post-study testing was completed within 30 days of the final HBOT session. Parents chose the independent testing clinicians from a list of recognized and experiencedresources available in the community, and made their own testing appointments. None ofthe clinicians had any prior experience working with children who had completed acourse of HBOT. Although the HBOT sessions were provided without charge, the costsof pre-study testing (ADOS and ADI-R) and post-study testing (same tests plus TheChildhood Autism Rating Scale or CARS) were paid for by the participants’ families. Exclusion Criteria:
Our exclusion criteria followed a model suggested by autism research Daniel Rossignol, M.D.: DSM-IV diagnosis of Pervasive Developmental Disorder other than Autistic Disorder,including PDD-NOS (Pervasive Developmental Disorder, not otherwise specified) andAsperger’s Syndrome Chronic ear infections, with last incidence less than 3 months ago Uncontrolled asthma, especially anxiety-induced asthma Methodology:
For this study, all participants received comprehensive ADOS and ADI-R testing no more than 30 days prior to beginning HBOT. Of the 20 children participating in our study, 60% (12) were on concurrent diet (primarily gluten- and casein-free) therapy, and 55% (11) were taking various forms of supplements. Although several of the children had undergone previous chelation therapy, none wereparticipating in concurrent chelation therapy throughout the course of treatments.
Each child was treated at the Hyperbaric Medicine Center, in Honolulu, Hawaii. Protocols used included 20 hours HBOT at 1.5 ATA of pressure using only 100% oxygen. Eachchild was treated in the same Fortius 420 hard sided monoplace chamber. Although thischamber is customarily used with hyperbaric hoods, we used tight-fitting pediatric aerosol masksinstead because compliance was much greater when compared with the hoods. These maskswere sealed (no open holes in the face portion), and had a colorful dinosaur face molded into themask. Each child chose their own mask at the beginning of their treatment sessions, and usedthat same mask each time they were treated.
All children were accompanied during treatment sessions by a parent or adult caregiver.
In one case where there were identical twin boys participating in the study, they were actuallytreated at the same time throughout the majority of their sessions. This was made possiblebecause the Fortius 420 has two output connectors for oxygen flow within the same chamber,making it possible to connect two separate masks at the same time. It should be noted here that we chose to use the hard-sided chamber because the protocols required that we use 100% oxygen and 1.5 ATA of pressure - neither of which areavailable in the soft inflatable chambers. Soft chambers have been used successfully in bothresearch (Dr. Daniel Rossignol’s study) and therapy programs (Dr. James Neubrander’s Centerin Edison, New Jersey, uses a prescribed combination of both hard-sided chambers and inflatablechamber protocols for each child). However, soft sided chambers generally cannot be used atpressures above 1.3 ATA, and require the use of oxygen concentrators which produce a lowerpercentage of therapeutic oxygen than the 100% we needed for this study. Furthermore, our pastexperience treating children with autism has been most successful using the 100% O2 and 1.5ATA protocols recommended by many experts in the field. Therefore, only the hard sidedmonoplace chamber was used.
Each participant was required to complete their 20 hours of therapy within a six week period. 55% (11) of the children completed at least a portion of their treatments using longerperiods of time in chamber per session - 90 to 120 minutes. Of these children, more than half(6) showed a statistically greater improvement than the average, with total ADOS scoresimproving at least 7 points overall. Of interesting note, the child who showed the mostsignificant improvements in all areas of evaluation completed nearly all of his treatments in 90-minute increments over the course of only 14 days.
Six of our participants completed their therapy in 15 days or less after the first treatment. Of these 6 children, 50% (3) showed a statistically better scoring level of improvements overallthan the mean. Based on these results, we would recommend that additional studies investigatewhether more significant improvements can be achieved overall if the HBO treatments arecompleted on accelerated schedules. After completion of therapy, the children were retested using the same testing criteria, with the addition of a CARS profile with comments. Results were measured solely based uponthose noted in the independent testing reports. No subjective data or clinical observationsrecorded during the course of treatment by the treating facility’s medical staff was included oravailable to the testing clinicians.
Although the independent testing clinicians knew that the children were receiving hyperbaric therapy, they were purposely given no direct information or instructions as to whatspecific autism symptoms to evaluate or discuss in their reports, other than to follow traditionalADOS and ADI-R testing criteria and guidelines.
Sixteen common areas of autism symptomology were evaluated and compared using standardized autism testing tools in each of the 20 children before and after HBOT. The 16specific symptom categories included those found in the areas of communication, socialinteraction, imagination and creativity, and stereotyped behaviors. Each child was alsoevaluated using a Global Assessment of Functioning (GAF) scores.
Results:
Results of the study are illustrated on the graph below.
Autistic Behaviors Exhibited Before and After Hyperbaric Therapy
1. Verbal Skills: 70% (14) of the children exhibited impaired to no verbal skills in the pre-
treatment testing and/or demonstrated moderate to frequent repetition of words and phrases.
100% (14) of the children exhibiting these symptoms showed significant measurable
improvements. 40% (8) of all of the children in our study moved from a strictly “Autistic” rating
(the most severe) into the less severe “Autistic Spectrum” category. 20% (4) of all of the
children in our study actually improved to a point that where they were no longer on the
autistic spectrum in the area of communications and verbal skills.
2. Insistence on sameness; resistence to change: 60% of the children (12) showed insistence
on sameness and a resistence to change in the pre-treatment testing. 83% (10) of those children
showed measurable improvements in this common autism symptom area.
3. Emotional outbursts (laughing, crying, etc.) for no apparent reason: 20% (4) of the
children exhibited notable challenges with repeated emotional outbursts in the pre-treatment
phase. 50% (2) of these children improved as rated in post-therapy testing.
4. Aloof; prefers to be alone; difficulty mixing with others - This was one of the most
common symptoms noted among our study group in the pre-therapy testing 75% (15) of the
children exhibited these symptoms to a degree that it was specifically notable in the pre-therapy
testing phase. 93% (14) of these children showed significant measurable improvements after
HBOT. Post-therapy testing noted that improvement in this symptom area affected the
childrens’ ability to interact with peers in school, relate to siblings better and feel more
comfortable in situations where they are exposed to a large number of strangers, such as in
recreational and team sport activities.
5. Frequent tantrums: This was an important findings in 45% (9) of the study children prior
to their treatments. 77% (7) of these children experienced measurable improvements in this area
according to the post-therapy testing. Not unexpectedly, this was one of the most often cited
improvements resulting from the therapy by the parents, themselves.
6. No desire to be cuddled or to comfort others: 30% (6)of the children in our study
regularly exhibited these symptoms according to the pre-therapy testing reports. 66% (4) of
these children exhibited measurable improvements in this area. The development of empathy
for others around them and concern for the feelings of others is an area that can fail to develop in
children with autism even much later in life, and can result in difficulty functioning in a
workplace or in interpersonal relationships. Therefore, improvement in this area can be of vital
importance.
7. Little or no eye contact: 40% (8) of the children routinely made little or no eye contact in
the pre-therapy testing phase. 87% (7) of these children improved enough after therapy to
change their original findings in this area. For the facility staff, this is often one of the earliest
subjective symptoms of improvement in the children we treat with autism.
8. Unresponsive to usual teaching methods: 30% (6) of the children exhibited measurable
challenges in this area of the pre-treatment evaluations. 83% (5) showed measurable clinical
improvement in the post-testing evaluations. This finding is important as improvement often
means that the child can be integrated into a more common classroom setting.
9. Sustained odd play; spins objects or self; unusual attachment to objects: 40% (8) of the
children exhibited this behavior for scoring purposes in the pre-therapy testing period. 62.5%
(5) improved enough to change their scoring related to this common symptom.
10 Apparent over-sensitivity or under-sensitivity to sounds, tastes, textures, smells, fear or
pain: 75% (15) of the children in our study exhibited one or more of these areas of increased or
decreased sensitivities prior to HBOT. 60% (9) of these children experienced significant
measurable improvements as noted in the post-treatment testing evaluations.
11. Physical hyperactivity or extreme hypoactivity: 40% (8) of our study participants
exhibited significant measurable symptoms in these areas prior to treatment. 75% (6) of those
children showed substantial improvements in the post-therapy testing following their hyperbaric
therapy. It is important to note here that anecdotally, we have sometimes seen a temporary
increase in hyperactivity between the 15th and 20th hour of therapy in the children we have
treated for a full 40 hour course of therapy outside of this study. In the study children,
however, only 10% (2) of the children showed any increase in hyperactivity and that increase
was characterized as moderate. In addition, one of the children actually showed a measurable
improvement in this area as compared to her pre-therapy evaluation.
12. Acts as if hearing impaired; often unresponsive to verbal cues: 45% (9) of our study
children were shown to have measurable challenges in these areas prior to taking part in the
hyperbaric therapy protocol. 88% (8) of these children tested at improved levels after treatment,
with better responses overall.
13. Aggressive/self-injurious behavior: 40% (8) of our participants had either a demonstrated
habit or significant history of aggressive or self-injurious behaviors in the pre-therapy testing
period. This included skin scratching and scraping, biting, hitting, kicking with the intent to
harm another, and similar destructive or injurious behaviors. 50% (4) of these children showed
significant improvements or a complete cessation of these behaviors after completing their
therapy.
14. Imitative behaviors: 35% (7) of the children participating in our study exhibited “frequent
imitative behaviors” in their pre-therapy testing evaluations. 85% (6) of these children showed
significant, measurable reduction in their most common imitative behaviors following hyperbaric
therapy.
15. Repetitive behaviors: As one of the most recognizable symptoms of autism, it wasn’t
surprising that 55% (11) of the children participating in the study revealed typical repetitive
behaviors in their pre-therapy testing evaluations. 81% (9) showed a marked reduction in these
behaviors after therapy.
16. GAF: The Global Assessment of Functioning scale is a common psychological
evaluation tool which measures the patient’s overall social, psychological and (when
appropriate) occupational functioning and coping skills against that of society at large. Fully
70% (14) of the children participating in our study showed increases in their GAF scores
between the pre- and post-therapy testing. The remaining 6 children were all noted to have
shown improvements, but not enough to change their overall Global Assessment of Functioning
score.
Conclusions:
This study was conducted at the Hyperbaric Medicine Center located in Honolulu, Hawaii. Our interest in working with children with autism is long-standing, beginning with aplay therapy and respite program which began nearly ten years ago. When hyperbaric therapywas added to the rehabilitative programs in 1992, one of the program’s earliest patients was achild with autism. To date, we have provided HBOT to more than 60 children with a primary diagnosis of autism or autistic spectrum disorder. Based upon very positive clinical experiences, we havecome to expect generally good recovery results in children with symptoms similar to those whoparticipated in our study. The detailed clinical testing performed before and after the course oftreatment, however, provided significantly greater evaluation data than we have ever been ableto observe previously, and the results have been deeply encouraging.
Communication: Of the children in our study, 70% (14) of the children exhibited
improved scoring in the area of communication skills as tested with the Autism DiagnosticObservation Scale (ADOS). Of the remaining six children, five showed improvements duringtesting, but not enough to change their overall score. Although one child did not specificallyshow improvements which could be verified with testing, it was noted that the child was alreadyhigh functioning with good verbal skills prior to treatment. Perhaps most importantly, 4 of the20 children in our study scored well enough to move out of the autistic spectrum in the area ofcommunication after HBOT, and 8 of the children improved enough to move from strictlyautistic (as scored in the ADOS) to autistic spectrum. Social Interaction: 80% (16) of the children showed improved scoring in the area of
social interaction. 30% (6) of these children showed remarkably significant improvements of 4or more ADOS scoring points. Of the remaining four children, two showed positive changes,but not enough to change their overall score. One of the children showed a negative scoringchange in the area of reciprocal social interactions, but the testing clinician also noted that thischild had recently lost two Skills Trainers with whom he had an emotional attachment, and thatthis may have affected his social interactions. A second child also tested slightly lower in this one category, but the evaluating physician attributed this to the fact that the child did not want to engage in the ADOS activitieswhen he was being observed rather than an actual negative change in symptoms. The physiciannotes that although the scoring did not reflect an overall improvement in the child’s reciprocalsocial interaction skills, measurable improvements were noted in other important areas including interest in other children, interest in group play, sharing enjoyment, pointing and gesturing.
Overall in the area of reciprocal social interaction,10% ( 2) of our study children improved enough to move out of the autism spectrum in this area altogether; and 25% (5) of thechildren moved from autistic into the autistic spectrum scoring realm. Imagination & Creativity: In the area of imagination and creativity, 30% (6) of the
children showed obvious improvements in scoring. 70% (14) of the children’s overall scores
remained unchanged in this area. Anecdotally, it has been our experience outside of this study
that when children go on to complete the usually recommended protocol of 40 hours of
HBOT, we see the greatest improvements in imagination and creativity occurring somewhere
after their 30th hour of treatment .
Stereotyped Behaviors: In the area of stereotyped behaviors, 55% (11) of the children
show measurable clinical improvements which was reflected in their scoring. 30% (6) of thechildren were reported to have shown improvements, but not enough to change their score in thisarea. 15% (3) of the children showed a slight (1 point) increase in stereotypical behaviors afterHBOT. Two of the three children, however, improved to the point overall that they moved to thenext lower level of impairment in all other categories. One of the three remaining childrenexhibited improvements in all other areas of evaluation except stereotyped behaviors, but notenough to change his overall scoring.
In summary, 100% (20) of the children involved in this study exhibited statistically significant measurable improvements in one or more of the ADOS scoring areas noted aboveand/or their Global Assessment of Functioning scale. The testing clinicians noted again andagain that these areas of improved symptoms all represent important day-to-day, quality of lifechanges including: (1) better ability to cope with and participate in classroom settings, (2) bettercontrol of, or even in some cases, a complete cessation of tantrums, (3) less sensory challengeswhich resulted in, for example, a willingness to eat a wider variety of foods, less sensitivity tounexpected noises, (4) greater ability to focus (for example, one of the children sat through anentire school assembly for the very first time after treatment), (5) more interest in being cuddled,and in comforting others, (6) improvements in sleep habits, (7) accelerated learning andretainment of skills, and (8) improved levels of anxiety overall.
Discussion:
Hyperbaric oxygen is not a new treatment for children with neuro dysfunction. A review of the scientific literature shows that as early as the 1960s, studies have been published (Lancet,1964)27 demonstrating the positive effects of hyperbaric oxygenation on oxygen-deprivedinfants. More recently there have been very large research projects evaluating the use of HBOTto treat children with cerebral palsy. One of the largest (nearly 100 children) has been funded bythe U.S. military, is a multi-year, randomized double blind study that is currently underway inDayton, Ohio.28 .
In simple terms, hyperbaric oxygen therapy is a medical treatment that helps the body heal itself by making oxygen available to tissues which are not receiving an adequate supply. Inthe case of children with autism, this appears to be due to a chronic inflammatory process whichinterferes with many complex brain functions that would normally occur without theinflammation. An analogy would be to imagine trying to focus and make decisions when onehas a severe headache or upset stomach. It is difficult for most of us to function under theseconditions. In children with the symptoms of autism, the frequent inability of their brain anddigestive system to function properly causes a wide constellation of interrelated challengeswhich are difficult to overcome without intervention at the root level - improving the underlyinginflammatory process.
Hyperbaric oxygen has a multilevel effect on the central nervous system: it reduces swelling of the inflamed tissues; it repairs the blood-brain barrier and stabilizes cell membranes. It also increases the ability of white blood cells to stabilize or “clean up” damaged areas and -perhaps most importantly - creates new blood vessels in areas where they are needed. This is aprocess called angiogenesis, and is vitally important to the resolution of the neurologicalsymptoms manifested in children with autism. This is also important to maintain the long-termimprovements gained though HBOT, because once the new blood vessels have grown into thedamaged tissue areas of the brain, they are believed to become a permanent improvement. It isprimarily why the resolution of symptoms seen during treatment tend to consistently remain afterHBOT is completed.
The potential for permanent improvements is also a key factor in figuring the overall cost effectiveness of HBOT. According to Fighting Autism (www.fightingautism.org) a group thattracks autism prevalence and costs statistics, the annual cost of education, medical care andrelated services for a child with autism ranges from $30,000 to $65,000 a year, and these costsare generally bourne by parents, health insurers, school systems, as well as state and federalgovernment stake holders. The one time cost of 40 hours of HBOT in Hawaii is between$6,000 and $9,000, and since the effects are thought to be permanent, lasting throughout thechild’s lifetime, it is expected that the one-time cost of therapy may be far offset by the savingsin costs of current and future care. Hyperbaric oxygen therapy is also important in the treatment of children with autism because it is effective in helping the body rid itself of excess heavy metals such as mercury. Itis theorized that children with autism may have a genetic abnormality that causes a reduction inthe normal levels of glutathione which is an important mercury-detoxifying agent in the body.29 This makes it more difficult for their bodies to get rid of excess mercury such as that found invaccines containing thimerosal.30 Thimerosal is a preservative which contains nearly 50% ethyl mercury by weight. The FDA estimates that throughout the 1990s it was used in more than thirty licensed vaccines andother medications marketed in the US. During this time the vaccine schedule for infantsincluded as much as 187 mcg of mercury in the first six months of life--far exceeding levelsaccepted as safe. Scientists have often noted that many symptoms of autism closely resemblethose of mercury poisoning. Reportedly, thimerosal is no longer being added to most vaccines,and states which have taken the added step to ban its use (e.g., California) are, interestinglyenough, beginning to see a drop in their state’s autism rate.31 Although our study included only children in the 3-8 year age range, studies have shown that biomedical interventions (including HBOT) may be helpful even in older autistic
individuals.32 Harvard’s Martha Herbert, MD, PhD writes that “. the awareness that the brain
as well as medical conditions of children with autism may be conditioned by chronic biomedical
abnormalities such as inflammation opens the possibility that meaningful biomedical
interventions may be possible well past the window of maximal neuroplasticity in early
childhood because the basis for assuming that all deficits can be attributed to fixed early
developmental alterations in neural architecture has now been undermined.” [emphasis added]
In simple terms, this means that even older children or autistic adults may be improved with
treatment.
In Hyperbaric therapy, the baseline recommended protocols for treating an autistic child is 40 hours of treatment at 1.5 ATA of pressure using 100% medical grade oxygen. Eventhough our study was only able to treat each child for half (20 hours) of the protocolrecommended number of treatments, the resulting improvements in symptoms were clearlyapparent in all levels of testing. It should be noted that the protocol pressure used in the study -1.5 ATA - was chosen because studies tracking glucose utilization and metabolic activity haveshown it to be a pressure which is optimal for most brain support and repair.
Based upon prior experience treating children with autism, we expected that children who were most severely affected by their symptoms would see the most significantimprovements. Instead, we found that the distribution of improved scores were fairly consistentamong all of the children.
We also expected that our younger study patients (5.5 yrs and younger) would respond faster and show more significant improvements in their evaluation scores overall than our older(5.6 years and older) children. Although the testing results showed this to be true in most casesin the area of communication skills, our scores showed improvements consistently throughout allage ranges in the areas of social interaction, imagination & creativity. In the area of stereotyped behaviors, two of the youngest children exhibited a slight increase in stereotypical behaviors, but in both cases the increase in minor stereotypicalbehaviors also accompanied an increased interest in a variety of important areas. The testingclinician noted that this increase interest “.provides the motivation for further development,and therefore the overall prognosis is greatly improved.” Early Diagnosis
Experts agree that early diagnosis is still the key to best recoveries overall for these children. 33, 34, 35, 36, 37 Unfortunately, there are many practical obstacles to recognizing autismin a child at a very early age. It is important to understand that traditionally, the threebehavioral domains of autism are not considered a medical problem (such as an infection or awound would be), and may easily be overlooked for months or years. For example, socialinteraction problems can appear to be related to hearing impairments, and delays in languagedevelopment can be written off as just a “late-talker.” Several of the children in our study camefrom multi-lingual families, so initially there was a concern that this slowed their recognition ofwords. Consequently, the slow development of language skills may not have been reported asearly as it otherwise might have been.
Paradoxically, the “insistence on sameness” of autistic children can also make them appear to be “easy” children, since they may make few demands. Further delays can occur onceconcerned parents have recognized that their child has serious developmental issues because theprocess of scheduling a formal clinical assessment can take months.38 Over the years, many key definitions of autism specified the time for the onset of symptoms as 30 - 36 months.39. Several of the children in our study were exhibiting alarmingsymptoms as young as 12 months of age. Of the 20 children participating in our study, all wereclearly exhibiting classic autistic symptoms by age 27 months, with a median age of clearlyrecognized symptoms by 15.5 months. Hyperbaric oxygen therapy is not a cure for autism. It may be, however, a way of ensuring the most complete recovery possible. Hyperbaric oxygen takes the “stress” off all thecells in the body by providing oxygen, a necessary component of every chemical and healingprocess, and allows the body to recover. Although the brain makes up less than 2% of the body’sphysical mass, about 20-30% of the body's consumption of oxygen occurs within the brain and spinal cord. These areas are extremely sensitive and responsive to oxygen increases andsupport.40 HBOT is generally considered the simplest, safest and most effective way known inthe field of medicine to provide substantial extra oxygen support when needed.
The use of HBOT to treat children with autism has been somewhat hampered by a medical community perception that there is a lack of studies available to show how hyperbarictherapy works. In fact, over the years there have been over 30,000 studies worldwide relating tohyperbaric therapy, and many of them - especially in recent years - have been related to thetreatment of neurological disorders.
Unfortunately, it is difficult to find the funding for large scale efficacy studies. Oxygen is considered a drug, and most drug studies in the United States are funded by majorpharmaceutical companies. Since oxygen cannot be patented (thereby achieving some basis forfuture payments or reimbursement for costs), there is no financial incentive for these companiesto invest in continuing hyperbaric research. This fact has made it difficult for parents andphysicians to find the detailed study information they need. Fortunately, this is beginning tochange as evidenced by Dr. Daniel Rossignol’s studies and those of Dr. Paul Harch, Dr. PierreMarois in Canada, Dr. Daniel Lacey’s Dayton Study, Dr. Richard Neubauer, and many, manynotable others.
One important result of these recent studies is a reminder that substantial improvements can be achieved most easily (1) by children within the autism spectrum when the children are
young and (2) the behavioral and bio-medical issues are addressed through a comprehensive
intervention program. This study - as well as practical clinical experience from other
hyperbaric facilities around the world who treat children with autism - suggests that HBOT is
an important component to a comprehensive intervention program in order to achieve fullest
and most expeditious recovery for children with autism.
This study would not have been possible without the support of the owners and staff of the Hyperbaric Medicine Center, donations of oxygen from AirGas in Honolulu, and a generousprivate donation of a special monoplace chamber specifically used to treat our children.
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