When every appearance by Donald Trump becomes a spectacle of a man in clear cognitive decline voicing untruths in rambling, fragmented half-sentences (see his address to the UN on September 23), it seems no longer meaningful to speak of watershed moments. At the press briefing the previous day, with health secretary Robert F Kennedy at his side, he tried to persuade the world that the common painkiller paracetamol, also known as acetaminophen and marketed in the US as Tylenol, is a “very big factor” in causing autism.
Tylenol is widely recommended for pain relief and fever during pregnancy, and Trump and Kennedy are convinced it has led to a big rise in autism. While a few studies have proposed a possible link between acetaminophen use and behavioural problems such as ADHD in children, there is broad scientific agreement that current evidence doesn’t support that idea. Such studies are challenging, not least because the painkiller can be bought over the counter and so surveys must rely on notoriously unreliable self-reporting. Any proposed correlations have been very weak, and the most careful and reliable studies find none at all.
The comments of Monique Botha, a specialist in social and developmental psychology at Durham University, are typical of most expert opinion: “There is no robust evidence or convincing study to suggest there is any causal relationship [between the drug and autism]”.
Botha adds that: “Pain relief for pregnant women is woefully lacking. Paracetamol is a much safer pain-relief option during pregnancy than basically any other alternative.” Trump seemed unconcerned by this, saying repeatedly in the press briefing that pregnant women in pain should just “tough it out a little bit”.
Diagnoses of autism have risen over recent decades in high-income countries. Kennedy has become convinced that some agent in the environment is the cause, and has seized on the few studies that have posited a possible link with acetaminophen. The truth is that the causes of autism are surely complex and not well understood. Many public-health experts think the rise is at least partly due to the condition being diagnosed more often, for example because of better tools for detecting it, changes in diagnostic criteria, and the decline in stigmatisation and increased awareness of autism-spectrum conditions so that parents are more likely to seek a diagnosis in the first place.
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James Cusack, chief executive of the autism research charity Autistica, told Nature that “trying to find causal mechanisms for autism is… much harder than people thought it was going to be 20 years ago.” It seems to be strongly heritable, implying a significant genetic basis, but it has been hard to pinpoint the associated genes.
Trump and Kennedy want a simple answer to this very complex problem. And it must be an answer that fits their scepticism of much mainstream medicine. Kennedy has long supported the discredited notion that autism is also linked to the MMR vaccine, a keystone of his opposition to vaccinations in general. Trump took the opportunity to tell the press that, “I think I can say that there are some groups of people that don’t take vaccines and don’t take any pills that have no autism. Does that tell you something?”
Kennedy backed him up by saying some (unidentified) studies have suggested the Amish have “very little” autism, to which Trump, unwilling to leave any room for doubt, insisted: “I heard none”. He exhorted people to “break up” their MMR vaccination into separate jabs, although there is no evidence of any benefit to that. But who needs evidence? “This is based on what I feel,” said Trump.
All this was awful enough. And it has been painfully obvious that the two men have no understanding of autism (which Kennedy has persistently demonised as a condition that leaves people a mere burden on family and society) nor any real desire to support sound research into it or offer assistance or empathy to people with autism or their families. But the debacle was made all the more grotesque by Trump’s toe-curling performance, punctuated by incoherent anecdotes and random outbursts of “Don’t take Tylenol!” whenever he seemed to lose his thread.
The sham of Trump’s insistence on “gold-standard science” has never been more naked than when he responded to one reporter’s question why his advice conflicted with the statement of the American College of Obstetricians and Gynecologists that “Acetaminophen remains a safe, trusted option for pain relief during pregnancy.” “Maybe they’re right”, he shrugged. “I don’t think they are.”
