Gilles de la Tourette's syndrome

I have read enough to know that there are still many parents, and, yes, professionals, too, who believe that "once autistic, always autistic." This dictum has meant sad and sorry lives for many children diagnosed, as I was in early life, as autistic. To these people, it is incomprehensible that the characteristics of autism can be modified and controlled. However, I feel strongly that I am living proof that they can.

Temple Grandin, PhD1

Even chough he received frequent medical care from his pediatrician, Tyler Kelly was a sickly baby. "From the day we brought him home from the hospital as a newborn," said Marcy Kelly, Tyler's mother, "he suffered from severe gastroesophageal reflux and all the discomfort it causes. He underwent an upper GI [gastrointestinal] series when he was just a week old, and the results revealed moderate reflux and slow gastric emptying." It was not until 2-month-old Tyler received the vaccines recommended for children his age, however, that his health problems really began.

"A couple of days after he was vaccinated, Tyler developed an ear infection that became chronic," said Kelly, "and he began to show signs of seasonal allergies. Soon, he was covered with severe eczema. Within days, he was also diagnosed as having RSV [respiratory syncytial virus] and a reactive airway disorder that required a steroid administered with a nebulizer. Most solid foods disagreed with him; after almost every meal, his face and ears would become hot to the touch and fiery red. Eventually, we discovered that he was reactive to 30 of 40 food-related allergens."

Kelly and her husband were diligent in seeking medical treatment for their son. They carefully followed the conventional allopathic therapy recommended by his pediatrician, who prescribed cisapride, ranitidine, albuterol, analgesic medication, and a variety of antibiotics and steroids for their baby's multiple disorders. None of those treatments was effective. "Then, when he was a year old," said Kelly, "he received an MMR [measles-mumps-rubella] vaccine and a flu shot from his pediatrician during a single office visit. We were concerned because Tyler had a severe respiratory infection, but we were assured that vaccination at that time would not be a problem. A few days later, he experienced some GI problems that really concerned us: he began to vomit every night after he'd been put to bed, and he developed severe, persistent diarrhea. Then, in addition to his other physical problems, he stopped growing." Tyler's pediatrician diagnosed asthma as the cause of those symptoms and prescribed additional nebulized steroids. The newly prescribed steroids produced no improvement.

Kelly and her husband were distraught about their son's physical decline, but as Tyler grew older, an equally distressing change in his cognitive abilities began to occur. "When he was 18 months old, he had a 25-word vocabulary," said Kelly. "He sang songs, exhibited joint attention, responded to affection, and interacted normally with us and with others. Six months later, he'd lost all of his language except for two or three words and had become completely nonfocused. He'd stopped interacting with us and even stopped reacting to his name. He had drifted away."

When Kelly expressed her concerns about Tyler's health and cognitive decline to his pediatrician, she was reassured that his development was within normal parameters for some boys his age. "Although autism occurs four times more often in boys than in girls," she said, "that diagnosis was never considered. We were encouraged not to worry, but we were not satisfied with that."

Driven by desperation, the Kellys sought state-sponsored evaluation for their son, whom they enrolled in an early intervention assessment program for physically or developmentally disabled children. Tyler's regressive autism was diagnosed when he was two-and-a-half years old. "As soon as we received the diagnosis, I began to intensively research autism," said Kelly, "and I discovered anecdotal information from the physicians and the parents of autistic children about special diets and several safe and effective complementary medical treatments. Over the next several years, multiple specialists in integrative medicine tested Tyler for heavy-metal toxicity; allergies; yeast in his stool; exposure to pesticides; vitamin, mineral, and nutritional deficiencies; liver-function abnormalities; and bloodchemistry disorders. Before he was 5 years old, we had spent well over $100,000 on our son's medical care."

Tyler's laboratory test results continued to reveal myriad abnormal values: an elevated white blood cell count, anemia, a toxic level of ammonia, high levels of heavy metals and pesticides, yeast overgrowth, and multiple allergies. Marcy Kelly diligently treated her son with the alternative therapies prescribed, which included a gluten-free, casein-free diet; high-dose vitamin and mineral therapy; homeopathic remedies; and compounded medications (antifungals; chelation therapy with alpha-lipoic acid and dimercaptosuccinic acid [DMSA]; transdermal forms of thiamine tetrahydrofurfuryl disulfide, zinc, and magnesium; and methyl-B^sub 12^ injections). Tyler also received educational therapy 40 hours per week.

Eventually, this intensive treatment and the Kellys' unflagging commitment to their son paid off. "We began to notice a gradual improvement in Tyler's physical health during his early treatment with complementary therapies, most of which were compounded," said Marcy Kelly, "and his asthma went away soon after we eliminated gluten and casein from his diet. His eczema slowly resolved, his diarrhea and vomiting disappeared, and he began to grow again. The results of his blood chemistry panel eventually normalized. His physical development accelerated as he became healthier, and when he was between the age of 4 and 5 years, we noticed a tremendous improvement in his language and social skills." Key to that success, said Kelly, was the expertise of Tyler's medical specialists and the benefits of treatment with compounded medications designed and adjusted for his changing needs.

To his parents' immense and joyous relief, as Tyler's therapy continued, so did his physical and intellectual improvement. Today, he is a happy, active, outgoing six-and-a-half-year-old boy. "Many mainstream physicians say that it's not possible to recover from autism," said Marcy Kelly. "We beg to differ. During a 4-year period of treatment with complementary therapies, Tyler went from being sick all the time to never being sick. His IQ [intelligence quotient] is normal, and our neurologist is amazed at his progress. He no longer follows a restricted diet of any kind, and his only treatments are fatty-acid supplements and educational intervention. In short, he's doing great."

At the time of this writing, Tyler had just graduated from his first year in mainstream kindergarten, where he required no assistance from a one-to-one aide. "He's learning to read, and he's very good at math and any skill that involves patterns," said Kelly. "Although he has some slight language delays, he expresses himself very well, and he has an audiographic memory. He often engages in imaginative and creative play. He reads music very well, plays piano, and enjoys soccer. He's learned to swim, attends a mainstream summer camp, and is very affectionate and very related to the people in his life. He even teases his little sister, like any other 6-year-old. I believe that the combination of alternative medical treatment, customized medications, intensive educational intervention, and Tyler's own determination has helped him to overcome the tremendous challenges that autism imposes. He's the light of my life."

Autism Defined

The term "infantile autism" was coined in 1943 by Kanner, who applied it to a group of 11 children with common characteristics: the inability to develop interpersonal relationships, extreme aloofness, delayed speech, "autistic" aloneness, repeated simple patterns of play activities, noncommunicative use of speech, an obsessive insistence on sameness, and specific remarkable aptitudes.2,3 Over the last 50 years, that definition has been revised and expanded. "Autism" now refers to a lifelong neurobiologic spectrum disorder with several subtypes2 that can occur in the same individual in a wide variety of combinations and severities.4 The overall incidence of autism is consistent worldwide and does not differ according to race, ethnicity, social or economic level, lifestyle, or educational level. It is, however, diagnosed four times more frequently in boys than in girls.4 In 2005, some form of autism afflicted an estimated 1.5 million children and adults in the US.4

Clinical Features

People with autism exhibit distinctive clinical features that include impaired verbal and nonverbal communication, difficulty with social interactions, and restricted or repetitive behaviors.2 Frequent comorbid conditions include GI diseases,5,6 autoimmune disorders,5,7 and mental retardation.5,8 Research reveals specific information about the burden borne by autistic individuals: about 60% exhibit poor attention and concentration; 40%, hyperactivity; 43% to 88%, morbid or unusual preoccupations; 37%, obsessive behaviors; 16% to 86%, compulsive or ritualistic behaviors; 50% to 89%, stereotyped utterances; 70%, stereotyped mannerisms; 17% to 74%, anxiety or fears; 9% to 44%, depression, irritability, agitation, and/or inappropriate affect; 11%, sleep disorders; 24% to 43%, a history of self-injury; and 8%, tics.2,9 Some investigators consider those characteristics to be features of a concomitant neuropsychiatric condition, such as attention deficit/hyperactivity disorder (ADHD), an affective disorder, obsessive-compulsive disorder, or Gilles de la Tourette's syndrome.2,10

Diagnosis and Treatment

Testing for Autism

Although our understanding of the neurobiologic features of autism is increasing, a definitive cause of the disorder has never been established.2 The diagnosis of an autism spectrum disorder is based solely on the patient's behavior." Behavioral testing for autism includes several accepted modalities: the Childhood Autism Rating Scale (CARS), which evaluates a child's body use, adaptation to change, listening, verbal communication, and relationship to people; the Checklist for Autism in Toddlers (CHAT), which is used to identify social communication disorders in children as young as 18 months; the Autism Screening Questionnaire, a scale used to evaluate communication skills and social functioning in children aged 4 years and older; and the Screening Test for Autism in TwoYear-Olds, which evaluates play, motor imitation, and joint attention in children of that age.4 No medical tests are definitive for the disorder, but physiologic testing is often used to rule out comorbid diseases that elicit signs and symptoms similar to those produced by autism.4

Therapy

Treatment for autism has been the subject of controversy for decades. Evidence indicates that comprehensive intervention (parental counseling, behavior modification, special education in a highly structured setting, sensory integration training, speech therapy, social skill training, medication) significantly benefits many autistic individuals. Dietary restrictions, such as the elimination ot gluten, casein, sugar, chocolate, preservatives, and food coloring, have proven beneficial in some patients.'-' Research shows that the detoxification of mercury and other heavy metals by DMSA/2,3-dimercapto-1-propanesulfonic acid (DMPS) chelation also produces a marked benefit.12 Alternative or complementary medical therapies are often prescribed according to their suggested mechanism of action: immune system modulation, GI support, improved neurotransmitter function, or nonbiologic intervention.13

Pharmacologic Treatment

The role of neurochemical factors in autism suggests the benefits of psychopharmacotherapy for autistic individuals.2 Serotonin reuptake inhibitors are often effective in treating depression, obsessive-compulsive behaviors, and anxiety.4 Amitriptyline hydrochloride, bupropion hydrochloride, diazepam, lorazepam, or alprazolam may be helpful in treating behavior problems. Some autistic patients exhibit a decrease in hyperactivity, stereotypic behaviors, withdrawal, and aggression as a result of treatment with antipsychotic medications such as clozapine, risperidone, olanzapine, or quetiapine, which were developed for the treatment of schizophrenia.4 Stimulants such as methylphenidate hydrochloride, amphetamine mixed salts, or dextroamphetamine sulfate may increase focus and decrease hyperactivity and impulsivity, particularly in higher functioning autistic children.4 Patients treated with any of the aforementioned drugs, however, must be closely monitored for the development of adverse effects.4

Vitamins, Minerals, and Supplements

Evidence suggests that treatment with vitamins, minerals, or supplements, including vitamin B6 and magnesium, vitamin B12 and folic acid, and (for sleep disorders) melatonin, benefits autistic individuals, although such therapy remains controversial. According to a review by Pfeiffer and colleagues, "The majority of studies report a favorable response to vitamin treatment. However, interpretation of these positive findings needs to be tempered because of methodological shortcomings inherent in many of the studies."14

Future Therapies, Novel Approaches

Genetic and molecular biologic studies may eventually identify the genes that dictate certain manifestations of autism, which would enable the very early identification of those at risk.15 According to some experts, future research should emphasize multicenter investigative collaboration in which the efficacies of pharmacologic treatment, nonmedication interventions such as behavioral therapy", and combinations of those modalities are the focus of study.2 Imaging techniques, including positron emission tomography and magneticresonance imaging, might also prove useful by enhancing the understanding of the action between drugs and neurotransmission receptors in autistic individuals.2,15 Treatment with long-chain omega-3 fatty acids is also very promising.12

Unlocking Autism: Interviews with the Experts

If the manifestations of autism are various, so are the approaches to its treatment. Among the clinicians whose therapeutic regimens have provided the most effective outcomes for children with autism are Jeff Bradstreet, MD; James Neubrander, MD; and Kenneth Bock, MD. Each has developed a highly refined medical strategy that has proven effective for hundreds of autistic children. Supporting those strategies is the skill of the compounding pharmacist. Patsy Angelle, RPh, includes the challenges of compounding for patients with autism among her areas of specialization.

Clinical Management of Autism

Jeff Bradstreet, MD

Dr. Jeff Bradstreet is one of two clinicians at the Good News Doctor Foundation and International Child Development Resource Center (ICDRC) in Melbourne, Florida, who specialize in the treatment of pediatric neurodevelopmental disorders. About 95% of Dr. Bradstreet's patients, who range in age from 1 to 45 years, are autistic. "By definition, autism is a severe developmental disorder," said Bradstreet. "Autistic individuals have definable abnormalities in certain biological mechanisms such as sulfation, methylation, and immune system function. Many also exhibit inflammatory bowel disease. A substantial proportion of their biochemical functioning, metabolism, and systemic detoxification becomes dysfunctional. They often demonstrate low levels of the reduced forms of glutathione and methionine, elevated levels of the markers of oxidative stress, and elevated levels of heavy metals.

"Because sulfation neutralizes a variety of toxins and manages oxidative stress as it occurs, the symptoms of abnormal sulfation are protean and include difficulty with concentration, attention, and cognition. Abnormalities in methylation are expressed as hyperactivity and poor concentration. Disorders of methylation and sulfation are associated with significant immune system abnormalities such as allergies and intestinal tract inflammation. Expressions of oxidative stress in autistic children include immune dysregulation and problems with the central nervous system."

The detoxification of patients with autism is one of Bradstreet's many areas of expertise. "Our goal is to restore the body's natural processes of methylation and sulfation, as well as the management of oxidative stress," he said, "which is where the compounding of pharmaceuticals and nutritionals is essential. A compounding pharmacist is a great ally in treating complex neurobehavioral disorders. A customized preparation can be made in a hypoallergenic format or a special dosage form that the patient can tolerate. Certain dosage forms such as transdermals bypass the digestive tract, which in autistic patients is often dysfunctional. For all those reasons, compounded medications improve compliance.

"Compounds also can be prepared to correct specific deficiencies in, for example, methionine, cysteine, or glutathione. Custom-designed medications are very valuable for highly allergic individuals who cannot tolerate the dyes, fillers, or additives contained in the standard manufactured prescriptive medications they require. A compounding pharmacist can prepare those medications to order so that they are very clean and allergen free."

Among the compounds that Bradstreet prescribes most often is transdermal reduced glutathione, which fights oxidative stress and abnormal sulfation. "Patients treated with that compound exhibit improved mentation, focus, eye contact, and presence," he said. "I also prescribe the injectable methylated form of vitamin B12, which combines with homocysteine to regenerate methionine. When autistic children receive twice-weekly injections of methyl-B12 or transdermal glutathione supplementation, we observe a significant improvement in the three signs considered diagnostic of autism: social withdrawal and isolation, the lack of or inappropriate use of language, and stereotypic repetitive behaviors. As we provide improved energetics to the cells, oxidative stress resolves and heavy metals are eliminated, and all the basic symptoms of autism abate."

James A. Neubrander, MD

Dr. James Neubrander, a specialist in the use of subcutaneously injected methyl-B12 to treat autism, is the owner and director of the Autism Clinical Research Center of New Jersey in Edison, New Jersey, and coauthor of a recently published article on oxidative stress and impaired methylation in autistic children.' "Without a doubt, autism is a treatable disorder," said Neubrander, who is also trained in pathology and environmental medicine. "Most autistic children benefit from biomedical treatments such as methyl-B12, dietary restrictions, supplementation, compounded antifungals, and transdermal forms of chelating agents. I also refer many patients to a gastroenterologist who prescribes treatment such as sulfasalazine to heal the gut. But starting treatment with methyl-B12 often obviates the need for additional therapies."

Although the best response to methyl-B12 therapy occurs after long-term treatment, autistic symptoms improve in 94% of Neubrander's patients with the therapy that he has designed. His research and treatment plan are described on his website (www.drneubrander.com). In that regimen, the concentration of the compound administered (a 25-mg/mL methyl-B12 stock solution), the site of injection (the buttocks), the dosage (64.5 pg/kg administered subcutaneously at a 10- to 30-degree angle once every 3 days for most patients), and the length of therapy are important in conferring maximum benefit. Children who require a higher dosage usually do not seem to exhibit an increase in intolerable adverse effects.

Neubrander's website also features videos of the therapeutic response of autistic patients treated with his regimen as well as testimonials from grateful parents, who attest to their child's dramatic improvement in cognition, language skills, and social interactions (see the sidebar titled "Emerging from Autism: Caitlin's Story" in this article). Many of Neubrander's patients have advanced from a relatively nonfunctional status to a clinical assessment of "totally normal with no residual effects of autism," an effect that he attributes primarily to methyl-B12 therapy.

Customized medications have an essential role in Neubrander's therapeutic plan. "I use compounding pharmacies almost exclusively," he said. "My compounder and I work with the patient's parents as a team. All the methyl-B12 prescriptions that I write are compounded, as are all antifungals and the chelators DMPS, DMSA, and EDTA [ethylenediamine tetraacetic acid]. I love compounding pharmacists because only they can prepare what I want to prescribe: pure formulations without dyes, fillers, and additives at whichever dose and concentration the patient needs and in whichever form the patient will best accept."

Kenneth Bock, MD

Dr. Kenneth Bock, FAAFP, FACN, CNS, is the author of The Road to Immunity: How To Survive and Thrive in a Toxic World,16 a board-certified family physician, president-elect of the American College for Advancement in Medicine, and a specialist in the treatment of autism at the Rhinebeck Health Center and the Center for Progressive Medicine in Rhinebeck, New York. Since 1983, he has maintained a comprehensive integrative medicine practice with a special interest in nutritional medicine. "Over the years," he said, "my practice has evolved, and I now treat patients from all over the world with complex chronic illnesses that are difficult to diagnose or manage, such as autism spectrum disorders, chronic recurrent infections, ADHD, chronic fatigue syndrome, fibromyalgia, cancer, chronic Lyme disease and other tick-borne illnesses, and various autoimmune disorders." More than 50% of Bock's practice is devoted to the treatment of autistic patients, who range in age from 2 to about 40 years.

Dr. Bock has applied his special interest in immune modulation and detoxification to the management of autism with great success. "Autistic children are unable to detoxify heavy metals, and they exhibit abnormalities in methylation and sulfation," he said. "When those processes are deranged, serious health problems develop. The incidence of autism skyrocketed in the 1990s in the United States when many vaccines were formulated with higher levels of heavy metals (not as a result of better diagnostics).

"Behavioral and educational therapies are essential for autistic children, but it's important to remember that autism is not a psychiatric disorder; it is a complex syndrome with neurometabolic features, neuroimmune components, and gastrointestinal characteristics. With proper treatment, more and more children recover and lose the diagnosis of autism. They rejoin society and are placed in mainstream classes without a one-to-one aide. Their life and the lives of their family members are turned completely around for the-better. Enabling that change to take place is extremely rewarding. Without a doubt, the treatment of autism is the most gratifying work that I've ever done."

Bock's approach to treating autism consists of a thorough evaluation, including a detailed medical history and a review of overt and occult causes for the patient's signs and symptoms. "It's a very rigorous assessment that involves in-depth laboratory testing for metabolic imbalances, allergies and food sensitivities, nutritional deficiencies, and autoimmunity. We explore extensive physiologic, metabolic, and biochemical aspects of the patient's function. Then, for each patient, we develop a highly individualized treatment program consisting of dietary modifications; nutritional supplementation that includes amino acids, essential fatty acids, minerals, and vitamins (every autistic child deserves a trial of methyl-B12); antimicrobials (if necessary); and detoxification modalities. Compounded medications are especially useful because many autistic patients can't swallow capsules or tablets. A compounding pharmacist can prepare a liquid formulation free of all possible allergens; for example, a prescription of nystatin can be prepared as a liquid that, unlike the manufactured form of that medication, is free of sugar and dye. I prescribe compounded forms of almost all the medications (antifungals, antibacterials, nutritional supplements, chelators) that I use to treat my autistic patients, and I've found that compounding pharmacists are great allies in the treatment triad. They are very good at communicating with my patients and, like me, they are always interested in problem solving, in doing what works. They do what it takes to ensure that treatment is successful."

The Compounder's Perspective

Patsy Angelle, RPh, is a pharmacist at Prescription Compounds in Baton Rouge, Louisiana, who specializes in compounding preparations for individuals with autism. "Our autistic patients come to us with at-risk situations from a variety of populations," said Angelle. "Some have been born prematurely, and others have experienced adverse reactions after vaccination. Many suffer from recurrent infections or gastrointestinal problems. Every formulation that we prepare must be designed for a specific patient, and those with autism have myriad sensitivities, allergies, intolerances, and dosageform preferences. They are highly sensitive to texture. Most autistic children have trouble swallowing capsules, so medications often must be prepared in a liquid form that contains no detectable grit. We supply special dosing devices for those children to ensure that the correct dose is received in an efficient manner. Even topicals must be very smooth and creamy to be acceptable.

"Flavor is also extremely important, as is the stability of flavored products. When adding a flavor, we always check the pH of a preparation to be sure that the active ingredient will maintain its integrity. To ensure compliance, we often prepare a formulation to completion minus the flavoring agent and will then supply a fewsamples to determine the patient's preference before the compound is finalized. Some autistic children have a type of food addiction and will eat only one or two foods, so we'll have to flavor a prescription to resemble that specific taste. To some patients, both flavor and texture are very important. If, for example, a creamy consistency in a certain flavor is preferred and the compound that we prepare is sticky, it will be refused. Fine-tuning the physician's formula to accommodate the dosage form and the patient's taste and texture preferences is a delicate but essential balance that we must achieve."

After Angelle receives a new patient's medical history, the results of recent laboratory testing, and the order from the prescribing physician, she meets with the parent or caregiver to inquire about the child's favorite colors, flavors, food preferences, and textures. "That personal demographic information is very important," she said. "Then we build a formula that will meet the needs of the patient and his or her doctor." Among the formulations that Angelle compounds for autistic children are antifungals, chelation agents, antibiotics, and nutritional supplements in topical, oral, or injectable form. Before releasing each prescription, Angelle counsels the parent or caregiver about its use and the effects and results of treatment. She communicates frequently with the patient's caregiver and physician, and compounds are constantly modified to accommodate changing medical needs. "I truly respect all those who provide care for autistic children," she said. "Effective treatment for autism is not an easy regimen; it takes a lot of special effort. I hope that all compounding pharmacists are able to give their time to this special patient population. Autistic patients really need us. If we all work together, we can immeasurably improve their quality of life."

Conclusion

Autism, then, is a lifelong neurobiologic disorder that profoundly affects quality of life. The early diagnosis of autism is elusive, and its imprint on those afflicted is so unique that the course of the disorder is hard to predict in individual patients. Symptoms provoked by idiosyncratic sensitivities to diet and environment are often difficult to treat and recur with alarming frequency. In spite of those therapeutic challenges, new treatments and regimens offer hope to autistic patients and to their family members, whose lives are shaped by the constant demands of care. In that effort, pharmaceutical compounding has an essential role.

References

1. Grandin T. Emergence: Labeled Autistic. [Temple Grandin's Website.] Available at: www.templegrandin.com. Accessed August 17, 2005.

2. Tsai LY. Psychopharmacology in autism. Psychosom Med 1999; 61(5): 651-665.

3. Kanner L. Autistic disturbances of affective contact. J Nerv Child 1943; 2: 217-250.

4. [No author listed]. Autism Society of America. Understanding Autism: What is autism? [Autism Society of America Website.] Available at: www.autismsociety.org. Accessed July 26, 2005.

5. James SJ, Cutler P, Melnyk S et al. Metabolic biomarkers of increased oxidative stress and impaired methylation capacity in children with autism. Am J Clin Nutr 2004; 80(6): 1611-1617.

6. White JF. Intestinal pathophysiology in autism. Exp Biol Med (Maywood) 2003; 228(6): 639-649.

7. Sweeten TL, Bowyer SL, Posey DJ et al. Increased prevalence of familial autoimmunity in probands with pervasive developmental disorders. Pediatrics 2003;112(5):420.

8. Bolte S, Poustka F. The relation between general cognitive level and adaptive behavior domains in individuals with autism with and without co-morbid mental retardation. Child Psychiatry Hum Dev 2002; 33(2): 165-172.

9. Tsai LY, Ghaziuddin M. Autistic disorder. In: Weiner J, ed. The Comprehensive Textbook of Child and Adolescent Psychiatry. 2nd ed. Washington, DC: American Psychiatric Press; 1996: 219-254.

10. Tsai LY. Brief report: Comorbid psychiatric disorders of autistic disorder. J Autism Dev Disord 1996; 26(2): 159-163.

11. Baron-Cohen S, Belmonte MK. AUTISM: A window onto the development of the social and the analytic brain. Annu Rev Neurosci 2005; 28:109-126.

12. Kidd PM. Autism, an extreme challenge to integrative medicine. Part 2: Medical management. Altern Med Rev 2002; 7(6): 472-499.

13. Levy SE, Hyman SL. Novel treatments for autistic spectrum disorders. Ment Retard Dev Disabil Res Rev 2005; 11(2): 131-142.

14. Pfeiffer SI, Norton J, Nelson L et al. Efficacy of vitamin B6 and magnesium in the treatment of autism: A methodology review and summary of outcomes. J Autism Dev Disord 1995; 25(5): 481-493.

15. Tanguay PE. Pervasive developmental disorders: A 10-year review. J Am Acad Child Adolesc Psychiatry 2000; 39(9): 1079-1095.

16. Bock K. The Road to Immunity: How To Survive and Thrive in a Toxic World. New York, NY: Pocket Books; 1997.

Jane Vail

St. Louis, Missouri

Correspondence may be addressed to:

Patsy Angelle, RPh, Prescription Compounds, 7414 Picardy Ave, Suite C, Eaton Rouge, LA 70808. E-mail: compounds@eatel.net

Kenneth Bock, MD, FAAFP, FACN, CNS, Rhinebeck Health Center, 108 Montgomery St, Rhinebeck, NY 72572. E-mail: kbock@rhinebeck bealth.com

Jeff Bradstreet, MD, ICDRC, 1688 West Hibiscus Blvd, Melbourne, FL 32901. E-mail: drbradstreet@aol.com

* Marcy Kelly, Wedge-wood Pharmacy, 373-K Egg Harbor Rd., Sewell, NJ 08080. E-mail: mkelly@wedgewoodpharmacy.com

* James A. Neubrander, MD, Autism Clinical Research Center of New Jersey, 15 South Main St, Edison, NJ 08837. E-mail: drneubrander@ drneubrander.com

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