Action For Autism

Placebo effect in autism

PLACEBO EFFECT

By happy coincidence I have just read a very interesting article on the placebo effect in New Scientist and listened to  two radio broadcasts on the same subject from Ben Goldacre. There are also discussions of both broadcasts here and here on Ben’s Badscience blog.

Placebo effect is often used disparagingly with reference to the anecdotal evidence for alternative and complementary therapies. There is a common misconception that the placebo effect is not real. Patients are deluding themselves. What they really need is a dose of allopathic medicine with those expensive molecules created by big pharma preciely targeting the locus of the disease in the body and eliminating it.

Both the article and the broadcasts challenge that idea. As Ben says in one of the broadcasts, if we support evidence based medicine we have to admit that according to the evidence the placebo effect is real. He gives some striking examples:

• Patients improving with their pacemakers switched off.
• Branded painkillers proving more effective than unbranded ones.
• Placebo proving as effective as some medications for irritable bowel syndrome.
• People who knew they were on placebo reporting benefits.
• Some people even managed to experience negative side effects of a drug while on placebo.

Ben makes the point that it is not the pink pill (though pink placebo pills do work differently to blue placebo pills) or the faux acupuncture or the placebo pain control cream that is working. Within the total context - the white coat, stethoscope, diplomas on the wall, intangibles like bedside manner etc - the pill may seem to be effective. But the placebo effect is more to do with the total doctor/patient relationship. The placebo effect works with real medicines as well as placebos. Patients who knew they were receiving morphine reported less pain than patients receiving the same dose without being told.

The challenge now is to fully understand the complexities of the placebo effect and use it effectively and ethically to improve patient care and patient outcomes. We may have something to learn from the alternative therapists. The ones who truly believe in what they are doing are probably very good at making full use of the placebo effect even if they do not fully understand it.

OUR EXPERIENCE

We experienced this with a homeopath and a practitioner of the Bowen Technique, a light touch massage. At the time we were having a hard time. Our son was getting nothing from health or education services and was severely stressed, as were we all. The benefits we got from our sessions were simple. They listened. They were sympathetic. They were gentle with us. They were such nice people. They really wanted to help us. They really believed they could help us and we wanted to believe. I tried some of the therapy myself but there was something not quite right about the guy doing the massage. We developed a sense of unease and the placebo effect diminished.

When I discussed the apparent benefits with our son’s paediatric psychiatrist he dismissed it airily as the power of suggestion. When my son had a meltdown in his office on his first visit and had to be physically restrained I could not help wishing that this psychiatrist could calm somebody with the power of suggestion.

AUTISM AND PLACEBO 

The placebo effect does not mean that alternative therapies work in the sense that their theoretical underpinnings are correct. But it is such a powerful effect that it may be working through the therapy in some cases even if the therapy per se does not work.  If we accept that one of the major causes of challenging behaviour in autistic children is the mismatch between their social understanding and the expectations of family, friends or school then an obvious way to help them is to revise our expectations. Electing for any type of therapy effectively does that.

BEHAVIOURAL EXAMPLE

This has happened many times in my career. A pupil is acting inappropriately. Attempts to control the behaviour are not working. We stop and carry out a functional behavioural analysis. We think we have stopped intervening while we collect baseline data. But from the child’s point of view we have changed our intervention. And so his behaviour changes. And we have changed ourselves as well. If I am charting incidents I feel in control. I am no longer challenged by the situation.  I no longer feel challenged by the child. I no longer provoke the behaviour I am seeking to control.

BIOMEDICAL EXAMPLE

I go to my alternative practitioner who tells me my child has gut problems that are causing his behaviour. We need a special diet and some supplements. It is not his fault. It is my fault for feeding him the wrong stuff. So I stop blaming him for his behaviour. I cut the kid some slack while waiting for the diet to kick in. I change and my child responds. I credit the diet and the doctor who prescribed it.

I am not sure if those two examples are strictly speaking the placebo effect. But they fit the general pattern of a total context having the power to explain what is happening more fully than the obvious recourse to the pink pill, the chart or the change of diet.

Ben’s second programme concludes with a doctor arguing that the power of placebo works best in those conditions were there is not a specific disease pathway amenable to a pharmaceutical magic bullet. Autism is very much like that. Yet the alternative therapists who infest our community claim precisely the opposite. They believe they know the precise biomedical pathways that lead to autistic behaviour and claim to have targeted interventions for each one. Mainstream medicine cannot claim much in the way of moral high ground in relation to autism. But its acknowledged ignorance and impotence in the face of this enigmatic condition is surely preferable to such hubris?

August 26th, 2008 Posted by Mike | Quackery, biomedical interventions, science | 6 comments