Archive for the ‘>ALL<’ Category

Video Games FOR ADHD – Are You Kidding?

Monday, June 22nd, 2020

Appearing recently in the well-respected British medical journal, The Lancet, was this parent-shattering oxymoron, “A novel digital intervention for actively reducing severity of paediatric ADHD (STARS-ADHD): a randomised controlled trial.

I have to speak up here! If your child attacks you with this study (and the requisite social media exaggerations), and threatens a lawsuit if you do not allow video gaming – here are the facts:

This is the only video game in question, designated in the research as AKL-T01, now named Endeavor. It was first researched as an “… investigational digital therapeutic designed to target attention and cognitive control delivered through a video game-like interface via at-home play for 25 min per day, 5 days per week for 4 weeks.” The program utilizes “… a proprietary algorithm designed to improve attention and related cognitive control processes, by training interference management at an adaptive and personalised high degree of difficulty… As the user proceeds through the intervention and the different environments, periodic recalibration occurs to maintain an optimal difficulty level.”

Strengths – Given the wide-sweeping scope, this research was quite thorough, as to group size, selection criteria, testing, and the clever use of a control group with similar interactions and expectations (but utilizing a mundane program), and statistical significance was achieved.

“The primary outcome measure for this trial is the ‘Test of Variables of Attention‘ scale (TOVA API), an FDA approved biomedical device that measures” “… attention and inhibitory control as part of an ADHD diagnosis or for monitoring intervention outcomes and has been widely used in both clinical practice and research studies.”

There is ample literature to support efficacy of other specific cyber-protocols that address Speech and Language, behaviors, academic pursuits, and various unique issues that appear under the vast Attention Deficit – Hyperactivity umbrella. Plus, there are many programmers who continue to search for digital cures for all sorts of activities to address people with focus and attention issues.

Weaknesses – Even according to the authors, “The primary outcome measure for this trial – findings on the followup TOVA testing – differs from most pharmacological efficacy trials for ADHD, which typically use parent-rated or clinician-rated symptom measures.” This is obviously a controversial sticking point.

Secondary outcome measures of parent and clinician reporting of ADHD symptoms and functional impairment did not meet statistical significance versus the ‘placebo’ program.

Other drawbacks, such as comparison to medications, other recognized treatments, and applicability to the real world ADHD issues are addressed in the paper’s discussion section, supported by a convincing volume of research and statistical data.

Lastly, however the reader wants to value such information, there is a huge conflict of interest concerning the researchers and their relationship to Akili, the company that is producing the product.

At this time, the company is offering Endeavor to a small group of those who request it – apparently as a trial. Direct consumer costs were not published at this writing, including questions about hardware/software requirements and expenditures for upkeep, evaluations, etc. The average cost of testing and follow-up, for the TOVA device analysis, can be expected to exceed one thousand dollars, based on other media reports.

Discussion
The volume of medical research that warns about the dangers of digital media, and the personal observation by so many parents that Screen Addiction Disorder has taken over their children’s souls, makes it difficult to digest headlines, such as, Can a Video Game Help Kids With ADHD? I told the Mom of a child with preferred behaviors, lack of focus, distractibility, and over-activity about this video game and her response was “Every moment past 40 seconds on a screen and we will pay for it in hours of sensory and general anxiety.”

Endeavor App From Akili

Conclusion
This was a single report about a single program designed to address specific testable signs and symptoms of ADHD, with solid pre- and post-test data. Personally, the more objective the investigation, the more I can get my head around a diagnosis as ephemeral as Attention Deficit-Hyperactivity disorder. In this arena, it has succeeded.

If you are thinking of ‘getting’ this invention, parents should first ask, “Can my child sit for 1/2 hour per day, 5/7 days, for a month, without medication?” Plus, lingering questions include, “Will additional medication make it better or worse? How long will a 1-month session last afterward? How will this treatment pertain to my child’s school performance, socialization, and conversation?

When the application is available, The Child Development Center is ready to prescribe it – to the correctly diagnosed patient who is a proper candidate to achieve the success outlined in this research.

To be perfectly clear, then, this study does not mean that Junior gets to spend all day watching you-tubers jabber away at a fake competition!

Notes on an Epidemic 2 – Not COVID-19

Monday, May 25th, 2020

Quarantine has led our practice down the road of virtual visits, in order to continue to assist the ever-growing population of developmentally different patients. At each interview, I have asked the parents and children what they liked best?, and what was the most challenging? during this bizarre period in human history.

The Good
No doubt, more time spent together as a family was the #1 response. Parents ‘forced’ to work from home, avoid travel, furloughed (or worse), closed businesses, first responders whose partner must remain with the kid(s), and… well… no one else to rely on! The nuclear family alone, together.
So, what did parents learn?
Renewed kudos for teachers, and appreciation for the multitude of difficult tasks they perform daily.
Renewed appreciation for the caretaker who has been at home, previous to this catastrophe.
Keener awareness about the child’s strengths, weaknesses and unfulfilled abilities.
First-hand observation of how the child responds to educational demands. Often, parents get to observe the reasons why teachers, and other professionals complain of poor focus, attention, easy distractibility and overactivity.
One-on-one interactions, when possible, may often result in more effective education.
Healthier meals for all, and those who require specialized diets are more likely to be in compliance.
Reduced stress and anxiety for the child, and often the entire family.
Fewer distractions when afforded appropriate space.
More exercise as permitted by outdoor exposure.

The Bad
Being cooped up in a relatively small space with only the ones that we love, highlights how much we must love them.
One child replied to the commonly asked, “How am I as a teacher?” question with, “Mom, you really suck!” Parents signed up for parenthood, and the skillset of teachers and therapists is just that – a learned and practiced art. You can’t just hand the job over to a Mac.
Consistency is a hallmark in successful treatment of behaviors. Every learned skill requires practice and repetition until the child understands the concepts. Quarantine has disrupted this process, so return to a ‘real’ schedule with professionals, feels like a MUST.
Acquisition of medications and supplements, and other necessary doctor visits have had to be postponed, adding to concern and frustration.
In such closed quarters, many ASD patients get to practice manipulation on their parents.
Online courses fail to grab many children’s attention – especially if focus is a basic concern. Parents’ constant need to redirect may become another learned behavior – by the parent!
Certainly not parents, but even siblings, do not represent the true exposure to socialization the patients must practice.
Schedules, with are such an important ingredient to assist children’s development, become relaxed or absent. Often, sleep can become disturbed, as well.

The Ugly
Behaviors in confined spaces can become extremely violent, disruptive, and may even require potent medications.
Resources have become stretched and so therapies, medications and supplements have sometimes had to take a back seat to more basic needs.
On-line special needs learning can be especially frustrating and become counter-productive if behaviors deteriorate.
Back-to-school, whenever that happens, is gonna be a bitch for many families.

Conclusion
Perhaps surprisingly, some parents have decided to stay home post Quarantine. That given this time, a more complete understanding about what the child can do- and can’t, what the educational system can do- and can’t, and how this new-found information can lead to optimal outcome for every child.

Others have said, “No, this kid needs to get the willies out, needs to get with other children, has to learn to follow a schedule, and get back to the therapies that were getting Junior on the right track.” Okay, that’s helpful to know, as well, especially if families were wondering, “Was any progress being made?”

Given that there is no next ‘normal’, perhaps parents will discover a more fitting new ‘normal’ experience for special needs children.

Notes on an Epidemic – Not COVID-19

Tuesday, May 5th, 2020

What is the best way for medical experts to get ahead of this modern pandemic? This very website, TheAutismDoctor.com, has provided my most fruitful research since opening The Child Development Center of America over a decade ago.

As in previous epidemics, such as ‘Cocaine Babies’ or ‘HIV Babies’, conventional medicine is slow to recognize, slower to study and, therefore, even slower to treat. So, how is a curious pediatric fellow with a particular interest in an emerging medical event supposed to learn how to help affected patients?

Modern allopathic medicine does not provide a Pediatric Residency or Fellowship to address functional and holistic medicine for any malady, let alone ASD. Psychiatric, neurologic and pediatric specialists consider their role in autism as diagnostic, not therapeutic.

Although medical journals have been the traditional method for accruing necessary information, the choice is no longer the obvious Pediatrics, Neurology, or even Child Development publications. Such ad-supported literature seems to underrecognize, underreport and mischaracterize the ever-increasing number of affected patients (see CDC graph). The current issue of PEDIATRICS features 13 new scientific articles. Two studies report about weaknesses in vaccinations programs, two cover the dangers of e-cigarettes, and no mention of ASD in the cover sheet. In Utero Antidepressants and Neurodevelopmental Outcomes in Kindergarteners and Rates and Stability of Mental Health Disorders in Children Born Very Preterm at 7 and 13 Years ARE about autism, but you wouldn’t necessarily recognize it from the title.
The conventional approach appears to be overly concerned about proving that alternative methods are useless at best, harmful at worst; and safety first – at all costs – when it comes to diagnosis and treatments for autism. Sidestepping the “A” word impedes the rise of important studies when Googling “research in autism spectrum disorder.”

Valuable information can be researched in peer-reviewed publications such as Autism Research, Molecular Autism, Autism, Journal of Autism and Developmental Disorders, Developmental Medicine & Child Neurology, plus the all-too-few papers that appear in trusted periodicals, such as The New England Journal of Medicine, or the Journal of The American Medical Association, for example. Google Scholar and National Center for Biotechnology Information, are reliable resources when seeking specific information about a specific topic.

Presently, The Medical Academy of Pediatric Special Needs (MedMaps.org), whose goal is excellence through dissemination of scientific information and collegial interaction, represents both a useful starting point as well a valuable venue for the most seasoned practitioners from all over the world to learn and discuss our unique problems and practices. Our canceled semiannual March meeting was another notch in Coronavirus’ take-no-prisoners belt.

In the meantime, an offshoot, highly non-official group has coalesced. Our small band of pediatric specialists has dubbed ourselves as the ‘Havana Group’, because of our initial conversations at a similarly named restaurant in Costa Mesa, CA (remember the days when we met at restaurants?). New problems continue to arise, and complicated medical issues are discussed via video chats. So far, viri (of any type) have not interfered with our monthly meetings.

Experience being the best teacher, our families’ journeys and the children’s response to various protocols have become the most valuable resource for outcome success. Professional Fellowship enables members to gain knowledge exponentially, especially given the ever-increasing number of patients. In the face of sparse useful scientific research, many practitioners have developed our own database as another valuable tool to track progress.

Discussion
The Corona Virus Epidemic has forced everyone into a state of profound reflection and redirection. Certainly, parents who are at home have become de facto school administrators, nurses, teachers, and therapists, in additional to all the other parental and (hopefully) work duties.

This near-apocalyptic viral event has prompted a renewed journalistic inclination to spread the word about another medical catastrophe. COVID-19 represents complex, serious and vexing medical problem. However, it appears a great deal more solvable – with a lot more resources – than the epidemic that is affecting nearly 2 percent of our children.

Conclusion
Preparing stories for TheAutismDoctor.com, has proven an invaluable tool by forcing an organized approach to the successful treatment of a disparate but somehow related variety of signs and symptoms presently classified as ‘Autism’. Quarantine has afforded my practice the increased time to read and write about the most important childhood epidemic of the 21st century.

Autism Literature Review 2019

Tuesday, December 31st, 2019

January
Prenatal Exposure to Air Pollutants Linked With Increased Incidence of Autism
Nitrogen oxide pollution is emitted from vehicle exhaust, and the burning of coal, oil, diesel fuel, and natural gas, especially from electric power plants. They are also emitted by cigarettes, gas stoves, kerosene heaters, wood burning, and silos that contain silage.
Of 132,256 children born in the Vancouver metropolitan area between 2004 and 2009…An increased risk for ASD was associated with prenatal exposure to NO (nitric oxide). These data corroborate similar findings from other studies conducted worldwide and suggest that decreasing NO exposure among pregnant women may reduce the incidence of ASD in metropolitan areas.

Sibling Recurrence Risk and Cross-aggregation of Attention-Deficit/Hyperactivity Disorder and Autism Spectrum Disorder.
Later-born siblings of children with ASD or ADHD appear to be at elevated risk for the same disorder, but also of being diagnosed with the other disorder.

Why genetic tests matter for autistic people
Three-part series with much better answers than the old-fashioned, typical view espoused by most ‘modern’ medical practitioners.

Real life Experience of Medical Cannabis Treatment in Autism: Analysis of Safety and Efficacy
Prospectively analyzed data was collected as part of the treatment program of 188 ASD patients aged 18 years treated with medical cannabis between 2015 and 2017. It was found that that medical cannabis is a good, safe and effective option in relieving the symptoms of autism, including seizures, tics, depression, restlessness and tantrums. Overall, more than 80% of their parents reported a significant or moderate improvement in their children.

February
A Multisite Randomized Controlled Two-Phase Trial of the Early Start Denver Model Compared to Treatment as Usual
Early intervention works! This single-blind, randomized, multisite, intent-to-treat study was designed to replicate and extend Dawson et al.’s (Pediatrics. 2010;125: e17-e23) randomized controlled trial testing the effects of the Early Start Denver Model (ESDM), an intensive play- and routines-based intervention delivered in natural settings.

Association of Maternal Prenatal Vitamin Use With Risk for Autism Spectrum Disorder Recurrence in Young Siblings
Maternal daily intake of prenatal vitamins during the first month of pregnancy appears to be associated with reductions in recurrence of autism in high-risk families…

March
Altered Connectivity Between Cerebellum, Visual, and Sensory-Motor Networks in Autism Spectrum Disorder: Results from the EU-AIMS Longitudinal European Autism Project
Researchers demonstrated alterations in network connectivity. “The between-network alterations broadly affect connectivity between cerebellum, visual, and sensory-motor networks, potentially underlying impairments in multisensory and visual-motor integration frequently observed in ASD.”

Long-term Risk of Neuropsychiatric Disease After Exposure to Infection In Utero
Maternal infection during pregnancy may be responsible for some portion of autism and depression in childhood and adulthood among the exposed offspring.
Or… it could be the antibiotics! Maternal infections have been around for years. But, the new antibiotics? Only since the start of the autism epidemic.

April
Measles, Mumps, Rubella Vaccination and Autism: A Nationwide Cohort Study
To be clear, this retrospective paper demonstrated the following: In a group of Danish children in the first decade of this century, during which time the incidence of ASD was 1/1000 (vs. ~1/59 presently in US), in a schedule with fewer additional vaccines (compared to US) and different timing of the MMR, there was no increase in the incidence of autism in the vaccinated group.
It did not prove that MMR was safe for all.

Long-term benefit of Microbiota Transfer Therapy on autism symptoms and gut microbiota
“Our observations demonstrate the long-term safety and efficacy of MTT as a potential therapy to treat children with ASD who have GI problems, and warrant a double-blind, placebo-controlled trial in the future.”
I asked Dr. Adams, directly, should I recommend this intervention for my patients. His answer was, “Well, not at this time.” “What is the expected improvement?” I asked, since one of our apraxic patients underwent the fecal transplant, but had no change in communication months later.

Evaluation of the Diagnostic Stability of the Early Autism Spectrum Disorder Phenotype in the General Population Starting at 12 Months
“The findings suggest that an ASD diagnosis becomes stable starting at 14 months of age and overall is more stable than other diagnostic categories, including language or developmental delay. After a toddler is identified as having ASD, there may be a low chance that he or she will test within typical levels at 3 years of age. This finding opens the opportunity to test the impact of very early-age treatment of ASD.”
Yay… earlier diagnosis and earlier treatment leading to optimal outcomes!

May
Whole-genome deep-learning analysis identifies contribution of noncoding mutations to autism risk.
Really dense research, but 2 important points for our ASD community:
1. Confirms that all children with developmental challenges should have genetic testing (copy number variation, exome analysis, Fragile X or Rett’s if indicated) and
2. Those who have had previous testing that was determined to be ‘negative” by their physician, might want to have another look.

Clustering of Co-Occurring Conditions in Autism Spectrum Disorder During Early Childhood: A Retrospective Analysis of Medical Claims Data
Lays a groundwork for creating a sub-classification system within ASD. There isn’t just one ‘kind’ of autism, and treatments that are aimed at ‘co-morbidities’ are often successful in ameliorating certain behavioral challenges.

A phase 2 clinical trial of a vasopressin V1a receptor antagonist shows improved adaptive behaviors in men with autism spectrum disorder
Balovaptan was well tolerated across all doses, and no drug-related safety concerns were identified. These results support further study of balovaptan as a potential treatment for the socialization and communication deficits in ASD.
“It is too early to discuss (balovaptan’s) availability on the market,” said Bob Purcell, a spokesman for Roche subsidiary Genentech… In the meantime, nasal oxytocin has been quite helpful for a selected group of our patients, in whom eye contact is particularly challenging.

June
The misnomer of ‘high functioning autism’: Intelligence is an imprecise predictor of functional abilities at diagnosis
Research indicates that “estimates from intelligence quotient alone are an imprecise proxy for functional abilities when diagnosing autism spectrum disorder, particularly for those without intellectual disability… ‘high functioning autism’ is an inaccurate clinical descriptor when based solely on intelligence quotient demarcations and this term should be abandoned in research and clinical practice.”
As I have previously noted, there are plenty of ‘low-functioning’ neurotypical people out there.

Propionic Acid Induces Gliosis and Neuro-inflammation through Modulation of PTEN/AKT Pathway in Autism Spectrum Disorder
Propionic acid (PPA), a short-chain fatty acid (SCFA) and a product of dys-biotic ASD gut, on human neural stem cells (hNSCs) proliferation, differentiation and inflammation was studied. “Clearly, the data supports a significant role for PPA in modulating hNSC patterning leading to gliosis, disturbed neuro-circuitry, and inflammatory response as seen in ASD.”
An in-vitro study (test tube), to be sure, but additional evidence of environmental effects on the nervous system.

Improvement of Language in Children with Autism with Combined Donepezil and Choline Treatment
“Combined treatment of donepezil hydrochloride with choline supplement demonstrates a sustainable effect on receptive language skills in children with ASD for 6 months after treatment, with a more significant effect in those under the age of 10 years.”
Donepezil is for Alzheimer’s, lots of side effects, and is not indicated in pediatrics. The choline is OK.

July
Maternal Diabetes and the Risk of Autism in Offspring: ADA
“Results summed that children born to mothers with an HbA1c greater than 6.5% were nearly twice as likely to be diagnosed with autism during follow-up (HR= 1.70; 95% CI 1.06-3).”
Another risk factor – not cause and effect. But glucose control during pregnancy could be one important preventative strategy.

August
Atypical eating behaviors in children and adolescents with autism, ADHD, other disorders, and typical development
“Atypical eating behaviors were significantly more common in autism (70.4%) than in children with other disorders (13.1%) and typical children (4.8%).”

Inherited and De Novo Genetic Risk for Autism Impacts Shared Networks
“We implicate 69 genes in ASD risk, including 24 passing genome-wide Bonferroni correction and 16 new ASD risk genes, most supported by rare inherited variants, a substantial extension of previous findings.”

THIS WEARABLE DEVICE CAN PREDICT AGGRESSIVE OUTBURSTS IN PEOPLE WITH AUTISM A MINUTE IN ADVANCE
1. You have advanced warning of 1 minute – I have seen outbursts come out of nowhere. And, what is a caretaker to do during that minute??
2. You have to put the wristband on the child.
3. The child has to keep the wristband on.
Hmmm…

Implication of hypocholesterolemia in autism spectrum disorder and its associated comorbidities: A retrospective case–control study
Autistic people are four times as likely as controls to have low cholesterol, and those with the lowest cholesterol levels have high rates of intellectual disability, anxiety and depression, according to a new study.
Which is why doctors should test LIPID levels in affected patients – there is effective treatment, and we have found that eye contact is the first sign to return.

September
Genetic registry reaps bounty of new autism genes
Is it genetic or is it the environment?
It’s the interaction of toxins, bacteria, etc. on susceptible individuals.

A Pivotal Response Treatment Package for Children With Autism Spectrum Disorder: An RCT
24-week randomized controlled trial in which community treatment was compared with the combination of parent training and clinician-delivered PRT. PRT-P was effective for improving child social communication skills and for teaching parents to implement PRT.

October
Current state of evidence of cannabis utilization for treatment of autism spectrum disorders
“Studies revealed mixed and inconclusive findings of cannabis effects for all conditions, except epilepsy. Adverse outcomes were also reported, which included severe psychosis, increased agitation, somnolence, decreased appetite, and irritability. In addition, a wide range of cannabis compositions and dosage were identified within the studies, which impact generalizability.”

Accuracy of Autism Screening in a Large Pediatric Network.
The popular M-CHAT/F test for ASD in toddlers was found to be less accurate than shown in previous studies, and revealed significant disparities in detecting early autism symptoms in minority, urban and low-income children.
Maybe this is why pediatricians are so confused about an accurate diagnosis.

Association of Cord Plasma Biomarkers of In Utero Acetaminophen Exposure With Risk of Attention-Deficit/Hyperactivity Disorder and Autism Spectrum Disorder in Childhood
“… findings support previous studies regarding the association between prenatal and perinatal acetaminophen exposure and childhood neurodevelopmental risk…”

Gluten-Free Diet in Children with Autism Spectrum Disorders: A Randomized, Controlled, Single-Blinded Trial
“There were no differences between groups in autistic symptoms, maladaptive behaviors, or intellectual abilities after the intervention. A GFD compared with a GD did not affect functioning of children with ASD.”
No testing, no specific elimination based on findings. So, are families supposed to believe this “science”, or their lying eyes when signs of ASD improve with diet?

November
Dietary Interventions for Autism Spectrum Disorder: A Meta-analysis
Dietary supplementation (including omega-3, vitamin supplementation, and/or other supplementation), omega-3 supplementation, and vitamin supplementation were more efficacious than the placebo at improving several symptoms, functions, and clinical domains.
Since the effect sizes were small, official commentary ran the gamut from “may improve symptoms of autism” to “not helpful”.

ASD Symptoms in Toddlers and Preschoolers: An Examination of Sex Differences
Since there are fewer females, understanding subtle differences may make diagnosis more accurate.

December
Executive Summary: Identification, Evaluation, and Management of Children With Autism Spectrum Disorder
The American Academy of Pediatrics is finally catching up to the epidemic. It’s about time.

Predictive impact of rare genomic copy number variations in siblings of individuals with autism spectrum disorders
Earlier analysis, earlier detection, earlier intervention… basic genetic testing (21st Century) is a must for children with developmental concerns, and possibly their siblings, as well.

Quadrant Biosciences Launches First Ever Epigenetic Saliva Test for Autism
A test ordered by the doctor, designed to provide a probability of an autism diagnosis based on epigenetic biomarkers in the saliva.
The company found that its test “accurately picks up 82 percent of autistic children and identifies 88 percent of children who do not have the condition.”
The Child Development Center is now in the process of obtaining the necessary kits in order to assist our families who may wish to have further information about their children with developmental concerns.


Autism Research Year-End Review 2018

Tuesday, January 1st, 2019

As the number of children who demonstrate developmental delays continues to increase, scientific knowledge remains sorely lacking. These are my top picks for this year’s most useful human research and events that address our understanding about the cause(s) and treatment(s) of these conditions.

January
LabCorp patents autism diagnosis method
There has been some controversy and squabbling over ownership of this method, and the test remains unavailable. It would be nice to utilize such patient information, if it helps achieve earlier diagnosis and intervention.

A Biomarker Characterizing Neurodevelopment with applications in Autism
Speaking of biomarkers, here is one based on noting small changes in movement.

Autism risk factor search aided by epigenetics study
The more we understand how the environment interacts with our genetic makeup, the more we comprehend how this epidemic is unfolding.

February
Association of Maternal Use of Folic Acid and Multivitamin Supplements in the Periods Before and During Pregnancy With the Risk of Autism Spectrum Disorder in Offspring
This is some good news for Moms seeking a prevention strategy. “Maternal exposure to folic acid and multivitamin supplements before and during pregnancy is associated with a reduced risk of ASD in the offspring compared with the offspring of mothers without such exposure.” A word to the wise: Take the recommended amounts, more is not necessarily better, and could be worse.

Damaging de novo mutations diminish motor skills in children on the autism spectrum
Minor genetic variations are no longer “of no consequence for your child’s condition.” In April, similar research, involving paternal genes, is linked  here.

March
Developmental and behavioral alterations in zebrafish embryonically exposed to valproic acid (VPA): An aquatic model for autism.
When Zebrafish (or monkeys, or mice) talk, I’ll become more interested in this line of research. As long as we don’t understand why humans talk, we are missing the bigger picture.

Alterations of White Matter Connectivity in Preschool Children with Autism Spectrum Disorder
The communication difficulties feellike a connectivity issue in the brain network. Utilizing MRI data, researchers reported that, “The identification of altered structural connectivity in basal ganglia and paralimbic-limbic networks may point toward potential imaging biomarkers for preschool-age patients with ASD.”

April – Autism Awareness month
Preliminary Evaluation of a Brief Autism Screener for Young Children
By utilizing a 2-minute parent questionnaire, “the PDQ-1 may be a useful supplement to developmental surveillance of autism.” The questions can be found in the article.

Association of Prenatal Ultrasonography and Autism Spectrum Disorder
Increasing ultrasonic energy (to visualize the fetus) increased autism risk. LOTS of controversy followed this one!

Prenatal mercury exposure and features of autism: a prospective population study
The authors concluded, “… our study identifies no adverse effect of prenatal total blood Hg on autism or autistic traits provided the mother ate fish. Although these results should be confirmed in other populations, accumulating evidence substantiates the recommendation to eat fish during pregnancy.” So, let’s ignore the evidence that certain fish contain a lot of toxins, and that elevated mercury levels are associated with developmental delay.

May
Differential immune responses and microbiota profiles in children with autism spectrum disorders and co-morbid gastrointestinal symptoms
A powerful paper describing the gut-immune-brain connection in autism.

EEG Analytics for Early Detection of Autism Spectrum Disorder: A data-driven approach
EEG measurements were collected from 99 infants with an older sibling diagnosed with ASD, and 89 low risk controls, beginning at 3 months of age and continuing until 36 months of age… Prediction of the clinical diagnostic outcome of ASD or not ASD was highly accurate when using EEG measurements from as early as 3 months of age. Specificity, sensitivity and PPV were high, exceeding 95% at some ages. Prediction of ADOS calibrated severity scores for all infants in the study using only EEG data taken as early as 3 months of age was strongly correlated with the actual measured scores.” This could be a good reason to check the EEG even in the absence of possible seizure activity.

Multivariate techniques enable a biochemical classification of children with autism spectrum disorder versus typically‐developing peers: A comparison and validation study
This is a follow-up study that verifies the accuracy of experimental autism blood test that was originally documented last year. This is very important if it holds up, to assess level of involvement and improvement.

June
Clinical Features of Children With Autism Who Passed 18-Month Screening
“This is the first study to reveal that children who pass M-CHAT screening at 18 months and are later diagnosed with ASD exhibit delays in core social and communication areas as well as fine motor skills at 18 months. Differences appeared to be more pronounced in girls. With these findings, we underscore the need to enhance the understanding of early markers of ASD in boys and girls, as well as factors affecting parental report on early delays and abnormalities, to improve the sensitivity of screening instruments.” A thorough history and physical, plus appropriate labs can often do the trick.

Association of Food Allergy and Other Allergic Conditions With Autism Spectrum Disorder in Children
Autism rates nearly tripled in children with food allergies. Immune function related to ASD again.

July
Maternal Type 1 Diabetes and Risk of Autism in Offspring
“These results suggest that the severity of maternal diabetes and the timing of exposure (early vs late in pregnancy) may be associated with the risk of ASD in offspring of diabetic mothers.” Other factors were discussed. That means good prenatal caret diagnose and treat, if Mom has the condition.

The Treatment of Autism Spectrum Disorder With Auditory Neurofeedback: A Randomized Placebo Controlled Trial Using the Mente Autism Device
“Our results show that a short 12 week course of NFB using the Mente Autism devicecan lead to significant changes in brain activity (qEEG), sensorimotor behavior, and behavior (standardized questionnaires) in ASD children.” Costs are about $2000, and 40 minute workout per day. That is, if you can the child to wear it. Less than half of the 5-15 year-olds completed the treatment.

August
Prenatal Exposure to Acetaminophen and Risk for Attention Deficit Hyperactivity Disorder and Autistic Spectrum Disorder: A Systematic Review, Meta-Analysis, and Meta-Regression Analysis of Cohort Studies
The conclusion, “Acetaminophen use during pregnancy is associated with an increased risk for ADHD, ASD, and hyperactivity symptoms,” is followed by a plethora of disclaimers.

Prenatal, perinatal, and neonatal risk factors of autism spectrum disorder
Infant seizures and maternal meds top list of risk factors for autism. This is in contradistinction to a recent study that diminishes the effects of maternal medication. More conditions that demand good prenatal care.

Association of Maternal Insecticide Levels With Autism in Offspring From a National Birth Cohort
Researchers found that exposure to DDE, which forms after the now-banned pesticide DDT breaks down, can as much as double the chance that a woman gives birth to an autistic child. Although banned over 45 years ago, it can be found in food, soil and groundwater.

Drug approval could boost research on marijuana treatment for autism
Cannabidiol, the primary ingredient Epidiolex,”…has been approved to alleviate seizures in two epilepsy syndromes… this is the first federal approval of a product derived from the marijuana plant…” It’s quite expensive – $32,500 a year, $2,708 a month, $677 a week, and ~ $96 a day.

September
Prenatal Tetanus, Diphtheria, Acellular Pertussis Vaccination and Autism Spectrum Disorder
Somehow, the new concern is that children under 2 months are going to step on a rusty nail or become exposed to really sick individuals. Tdap is safe in pregnancy, this research concludes, and even helps to protect the newborn. Here’s the rub: In Southern California, from the years studied, “ASD was diagnosed in 1341 (1.6%) children, and the incidence rate was 3.78 per 1000 person years in the Tdap exposed and 4.05 per 1000 person years in the unexposed group…” The CDC reported the overall prevalence of children with either ASD or other DD…” approximately 5.2%. That is not per thousand, so something seems incorrect about patient selection?

Genetic influences on eight psychiatric disorders based on family data of 4,408,646 full and half-siblings, and genetic data of 333,748 cases and controls.
More information about autism and other psychiatric conditions that incriminate familial susceptibility.

October
Fetal and Infancy Growth Pattern, Cord and Early Childhood Plasma Leptin, and Development of Autism Spectrum Disorder in the Boston Birth Cohort
“Is early life growth and a biomarker leptin related to ASD risk? To answer this question, we followed 822 children from birth and found that those who gained weight very quickly in infancy, had higher leptin levels in early childhood, had a greater chance of later ASD diagnosis.”

Restricted and Repetitive Behavior and Brain Functional Connectivity in Infants at Risk for Developing Autism Spectrum Disorder
Regarding ‘stims’… “Children who have repetitive behaviors, a core autism trait, show particular patterns of brain activity as early as 1 year of age…”

Relationship of Weight Outcomes, Co-Occurring Conditions, and Severity of Autism Spectrum Disorder in the Study to Explore Early Development
The risk of obesity tracked with the severity of autism traits. The authors concluded, “Prevention of excess weight gain in children with ASD, especially those with severe symptoms, and in children with developmental delays/disorders represents an important target for intervention.”

November
Attention Deficit–Hyperactivity Disorder and Month of School Enrollment
One of my favorites… let’s let kids be kids just a bit longer, without labelling them. Calling young children who are over-active ‘hyperactive’ is not appropriate and can lead to medications or incorrect preschool placement.

Brain responses to language in toddlers with Autism linked to altered gene expression
Finally, some research on the challenging sign of speech apraxia in ASD.

Association of Prenatal Exposure to Air Pollution With Autism Spectrum Disorder
Epidemic = Susceptible individuals (genetic) + environmental event. This large study on prenatal exposures to air pollutants and Autism Spectrum Disorder (ASD) found an increased incidence of ASD in the children of more heavily exposed women.

Validation of a Salivary RNA Test for Childhood Autism Spectrum Disorder
“Salivary poly-omic RNA measurement represents a novel, non-invasive approach that can accurately identify children with ASD. This technology could improve the specificity of referrals for ASD evaluation or provide objective support for ASD diagnoses.” Three of the authors are co-inventors of the process – an obvious conflict of interest.

December
Maternal metabolic profile predicts high or low risk of an autism pregnancy outcome
The authors concluded, “…it is not possible to determine during a pregnancy if a child will be diagnosed with ASD by age 3. However, differences in the folate-dependent transmethylation and transsulfuration metabolites are indicative of the risk level (High Risk of 18.7% vs. Low Risk of 1.7%) of the mother for having a child with ASD.” Identifying susceptible individuals is a great first step, especially for subsequent pregnancies.

Long-Term Efficacy and Safety of Pediatric Prolonged-Release Melatonin for Insomnia in Children with Autism Spectrum Disorder
This should assuage those families who continue to be concerned about this useful and relatively innocuous sleep supplement.

Conclusions
Prevalence and Treatment Patterns of Autism Spectrum Disorder in the United States, 2016
An estimated 2.8 percent of children ages 3 to 17 have ever been diagnosed with autism and 2.5 percent — or 1 in 40 — currently have the developmental disorder. There are very few practitioners who care for children with the disorder.

Regardless of whether ASD is a new epidemic, or ‘just a re-classification’ of previous developmental conditions, there are too many patients, with little understanding and a paucity of useful treatments. We must continue to hope that progress will accelerate in response to the reality of a condition that affects so many of our population.

Fecal Transplant as an Autism Treatment

Sunday, June 3rd, 2018

The prestigious New England Journal of Medicine recently published an article entitled, Fecal Microbiota Transplantation for Primary Clostridium Difficile Infection. It is likely that parents of children with ASD, who exhibit gastrointestinal difficulties, will ask, “Can we use this to help Junior recover?”

The answer is a complicated, “Maybe. But, more research is needed.”

The study looked specifically at ‘C. diff’ – one strain of bacteria, not to be confused with parasites, fungi, viri, or other nasty cooties. The follow up was a mere 70 days. In children with yeast or other such distress, recurrence may appear weeks, months, or even years later.

Recent Literature
According to the Fecal Transplant Foundation, the treatment, “was first documented in 4th century China, known as “yellow soup”… there has never been a single, serious side effect reported…”

2010
Pyrosequencing study of fecal microflora of autistic and control children
Dr. Feingold, “examined the fecal microbial flora of 33 subjects with various severities of autism with gastrointestinal symptoms, 7 siblings not showing autistic symptoms and eight non-sibling control subjects… The results provide… a compelling picture of unique fecal microflora of children with autism with gastrointestinal symptomatology.”

2012
This review concluded that FMT, “is now arguably the most effective form of Clostridium difficile eradication… potential value in ulcerative colitis… as well as previous unexpected applications, such as obesity, diabetes and several neurologic disorders.”

2013
Fecal Microbiota Transplantation: Indications, Methods, Evidence, and Future Directions
“Most institutions utilize fresh feces, have adopted an approach of using highly filtered human microbiota mixed with a cryoprotectant and then frozen… with dramatic shifts in recipient gut microbial communities noted after transplantation… The route of administration … can be naso-duodenal, transcolonoscopic, or enema based…”

2014
A research paper that summarizes, “FMT is a highly effective cure for RCDI (recurrent Clostridium difficile infection), but increased knowledge of the intestinal microbiota in health maintenance, as well as controlled trials of FMT in a wide range of disorders are needed before FMT can be accepted and applied clinically.”

2015
Fecal microbiota transplantation broadening its application beyond intestinal disorders
The authors covered earlier works and noted, “FMT is a promising approach in the manipulation of the intestinal microbiota and has potential applications in a variety of extra-intestinal conditions associated with intestinal dysbiosis.”

2017
Microbiota Transfer Therapy alters gut ecosystem and improves gastrointestinal and autism symptoms: an open-label study
A rather complicated 2-1/2 month protocol resulted in, “an approximately 80% reduction of GI symptoms at the end of treatment, including significant improvements in symptoms of constipation, diarrhea, indigestion, and abdominal pain. Improvements persisted 8 weeks after treatment… behavioral ASD symptoms improved significantly and remained improved 8 weeks after treatment ended. “

Discussion
Signs and symptoms of gastro-intestinal distress ought to be present when seeking such treatment. This may appear obvious, but oft-times the gut has already been addressed and healed. Or, the primary cause(s) of the autism may originate from elsewhere, such as metabolic, genetic, toxins, etc. This complicated intervention may be superfluous.

One potential harm of fecal transplantation is The Unknown. What might the tiny viri, of which we know little – other than their ability to transform cells (cancer, cell death, immunity) – do to the recipient as regards potential long term danger?

Another risk is The Known. Can transferring bacteria from one person to another cause harm (immediate or delayed), due to allergy or other incompatibility?

Prior to his untimely demise a few years ago, in a personal communication with the intrepid Dr. Jeffrey Bradstreet, he lamented that the process was extremely resource intensive (to assure safety) and subject to recurrences, after as little as 3 months.

Conclusion
Earlier, Dr. Feingold noted, “If the unique microbial flora is found to be a causative or consequent factor in this type of autism, it may have implications with regard to a specific diagnostic test, its epidemiology, and for treatment and prevention.” FMT research helps enforce the gut-brain connection that has been noted in autism since Dr. Leo Kanner described the condition 80 years ago (although his Freudian underpinnings seem to have obfuscated his patients’ GI issues).

Autism consists of a variety of mysterious signs and symptoms. In all of the studies performed to date, there is a relatively short followup period, not necessarily reflective of an affected child’s time frame. It is difficult to ascertain whether regression, aggression, poor sleep, diarrhea, constipation, sensory overload, etc. are due to a specific organism or a different mechanism. Accurate knowledge the intestinal microbiota is paramount to assess efficacy and prevention of recurrence.

As costs, resources and safety become established with other disease entities, and practitioners learn how to effectively administer the protocol, this type of treatment may take a more prominent role in treatment of Autism Spectrum Disorder.

* My previous article on this subject appears here.

Mother’s Day Wish – UPDATE

Sunday, May 13th, 2018

Six years ago, I dedicated this post to all of the incredible Mothers who deal with Autism Spectrum Disorder, and the associated symptoms, every day. Thousands of patients later, my feelings are even more heartfelt.
You are not alone.

We are not alone.
We’re not seeking miracle cures, just little miracles.

I wish that I had more time for
My affected child, the other kid(s), my husband, myself.

Something is just not right with my child, I wish we could figure it out.
She doesn’t speak at all. If she would just say “yes” once in a while.

There used to be some words, but now there’s not even eye contact.
When do you think she will say “mama” and mean it?

If he would only get ready in the morning, Such a battle.
If he could only remember what he just read.

Kids should have friends.
When do you think he will be able to play with his sister?

The family doesn’t’ seem to understand our problems.
We haven’t taken a vacation since…

I wish she wasn’t so disruptive in school.
If we could just figure out how to get him to focus.

He keeps saying the same thing over and over.
Those ‘stims’ are driving us crazy.

If we could all only get a good night’s sleep.
He has had diarrhea ever since I can remember.

He eats so little, I’m afraid he’s not getting enough.
She seems to be sick all of the time.

I wish she would stop biting her arms.
I wish he would stop hitting his mom.

If the doctors would only figure out what is wrong. If they would only listen.
How is my child going to make it in: preK, K, first grade, middle school, high school, life?

We’re not looking for miracle cures, just little miracles.

The numbers of affected children continue to go up, not down. By combining traditional therapeutic interventions, modern scientific techniques, and a holistic approach to patient care, we have addressed many of these concerns for a multitude of families. The staff at The Child Development Center will continue to assist children affected with this modern epidemic, seek answers, and provide relief whenever possible.

Thank you to our Warrior Moms who continue to fight through such difficult times.

©TheAutismDoctor.com

Autism & MTHFR Explained

Sunday, April 1st, 2018

I have attempted to write this explanation – about the MTHFR gene – for more than a year now, often surrendering because it just gets so complicated (see diagram on right – and that is a simplified version)!

However, almost daily now, I need to explain the testing and interventions that revolve around the MuthrF#$Ker gene, which produces an enzyme that can assist in the brain’s ability to process (among many other important body reactions) in patients with ASD.

So, here is my simplified version, which covers the important steps for our understanding about testing and treatment for autism:

1. Folate (natural), folic acid (synthetic), Folinic acid (active) and 5-methyl folate (active) are not exactly the same a form of Vitamin B9.

2. There are several reasons why the levels of the B9 might be reduced:
Reduced intake. Picky eaters and kids don’t usually savor green leafy vegetables or lentils.
Problems with internal state of health will affect availability. Synthetic folic acid must go through the liver, natural folate is metabolized through the intestines.
Antibodies that bind to, or block the active compound. This is why doctors check the Folate Receptor Antibody Test (FRAT). The presence of such inappropriate barriers implicates reduced activity, so administration of additional vitamin should help alleviate difficulties.
Any ‘weakness’ in the body’s inability to convert the vitamin – that includes the MTHFR gene that regulates the enzyme called methylene tetrahydrofolate reductase.

3. The most studied and concerning genetic variations are often designated as C677>T, A1298>C. Hieroglyphics aside, we  inherit a ‘C‘ and an ‘A’ from each parent, and each deviation yields a less potent enzyme, so the implication is that giving the active forms of the vitamin can be beneficial. (Dr. Google, and many labs will report variations as pertains to the risk of hyperhomocysteinemia, a medical condition observed in approximately 5% of the general population, associated with an increased risk for many disorders.) For ASD, improved communication is the goal of treatment.

4. The supplements include L-methyl folate, available as a prescription under Deplin®. A web search of this product will often result in a call from parents, “My child doesn’t have schizophrenia or depression!” Marketing. Improved outlook is just one of the treatment outcomes. As noted previously, in ASD the aim is more efficient neural processing.

5. Another intervention is available as folinic acid (<1 mg dosages) and as the prescription, Leucovorin. An Internet inquiry may stimulate a call, such as, “My child doesn’t have cancer or get chemotherapy.” Different market. At a recent MedMaps.org conference, I asked two top researchers whether they prefer one or the other active form. Each doctor replied with the opposite answer. Availability and cost help determine choice, and sometimes we try both.

Conclusion
The various forms of folate appear to be safe, effective interventions that can address weaknesses in the area of oral-motor functioning in individuals with ASD. In practice, agitation is the principle side effect, and too much ‘stimming’ or aggression is reason for discontinuance.

The gene controlling MTHFR production is important, but not the only one affecting multiple enzymatic pathways that lead to successful data processing. We are already discovering other critical genetic steps (SOD, COMT, etc.) and there are thousands of other genetic crossroads that will improve our understanding and lead to successful interventions.

For our more advanced readers – please feel free to submit any corrections, etc. that you feel might be necessary.

Medical Academy of Pediatric Special Needs Conference – Spring 2018

Sunday, March 18th, 2018

The Fall 2017 conference was ‘hurricaned’ out, so it’s been a year since I reported on the semi-annual 3-day scientific meeting of the Medical Academy of Pediatric Special Needs. This post will focus on the two most controversial topics – one, a treatment, and the other involving a popular new diagnosis.

Medical marijuana.
The less psychoactive, and legal part of pot – CBD (cannabidiol) – has been available for a couple of years now. Our experience at The Child Development Center, and the consensus of the group, was that it may be helpful for seizures, but perhaps less so for aggression, stimming and sleep. With no serious side effects, however, except for price (for high quality, measurable concentrations), it could be worth a try.

Much more effective, according to Dr. Michael Elice, are products that contain a measurable amount of THC (tetrahydrocannabinol). The presentation covered his experience with CBD+THC = medical marijuana. Utilizing the Autism Behavior Checklist as a measuring tool, he noted significant reductions in irritability, ‘lethargy’, stereotypy (stimming) inappropriate speech, and hyperactivity for a small number of children. To be fair, he also presented a child whose symptoms worsened with treatment. Overall, Dr. Elice told the audience that this intervention can be quite helpful for aggression and negative behaviors, though not for the ‘verbal diarrhea’ that many recovering children exhibit.

I inquired about the paucity of literature supporting medical marijuana, and studies that describe abnormal brain development when administered to youngsters. Dr. Elice responded that 1) The affected children’s brains are already demonstrating problems in development, and 2) Compared to the conventional meds, cannabis seems more efficacious with fewer side effects

No protocol was offered… the correct form, concentrations of THC/CBD, timing, and best mode of administration have yet to be elucidated. For physicians in states where pot is not legal, this treatment is not a realistic option. Even where there are medical exemptions, the process is resource intensive and tedious.

PANDAS/PANS 
Auto-immunity that affects a young child’s brain in an acute fashion, has been a popular diagnosis of late. Participants were treated to a full day of discussion by the most famous clinicians and researchers in the field. The room was packed.

The first speaker of the day was Dr. Aristo Vojdani, an Israeli researcher who practically invented food allergy testing. In fact, he began his presentation by declaring that he has learned the weaknesses of his earlier work, and the misconceptions about those tests. His take home messages were 1) Group A streptococcus is only one of many environmental trigger that contribute to symptoms, 2) Many pathogens and food components cross react with brain cells to cause problems, and 3) Accurately defining such antibodies and which receptors are affected is necessary to remove the environmental triggers.

Dr. Madeline Cunningham presented her modern view of molecular mimicry – “the sharing of antigenic determinants between the host and invading organisms.” The heart, brain, and other tissues can become the targets of the body’s response to environmental pathogens or toxins. Identifying the reactivity of brain proteins – the Cunningham Panel – may not be specific to strep, and helps explain disparate results. Tics, OCD and other neurologic difficulties are the result of a weakened blood-brain barrier and cross-reactivity.

Dr. Tanya Murphy presented, Antibiotic Treatment in PANS, Panacea or not? The specific signs and symptoms of PANS and PANDAS were elucidated. The role of Group A strep as a precipitating agent was emphasized. Specifically the rise of ASO (antistreptolysin O) often precedes the rise AntiDNAse B, but a positive culture for the organism is the best evidence. The successful role of antibiotics in general, and which ones seemed to work best was covered in detail.

A panel discussion involving these esteemed experts completed this incredibly interesting day.

Conclusions
Practicing functional and integrative medicine nowadays, with insurance stipulations and conventional dogma, presents unique challenges. The pediatric version faces even more obstacles, due to uncertainty of diagnosis, non-conventional treatments, and the vaccination issues. Without this Pediatric Fellowship, such work would be even more frustrating. The sharing of our collective experience regarding the epidemic of children with ASD and ADHD has taken diagnosis and treatment to newer and more modern levels of understanding.

As in previous years, the most valuable part of these conferences is the esprit du corps and networking of experience and ideas.

A Successful Autism Doctor Visit

Sunday, February 18th, 2018

This story is a total rip-off. The New York Times recently featured a worthwhile piece entitled, A Doctor’s Guide to a Good Appointment. In that vein, I couldn’t help but add my two cents worth of advice about how to make the best of a family’s first visit to a developmental specialist.

Finding a functional medicine specialist.
The opinion of a pediatric neurologist is a good start. But, time is of the essence and evaluations that involve months of waiting serve the patient poorly, because they represent needless delay. A trusted pediatrician can be a great help. Therapists’ views are important because they are independent observers who know the child more intimately.

However, if you still can’t put your finger on what’s wrong, and if you find that you have been going to a variety of specialists (e.g. GI, allergy, dermatologist. pulmonologist), maybe it is time to seek a modern medical viewpoint. When possible, ask other parents about their research and experience, but don’t forget that every child is unique, so this merely represents one piece of the puzzle. The most reliable web advice is to be found at the Medical Academy of Pediatric Special Needs clinician directory.

Before your visit:
Labs, X-rays, MRI’s, EEG’s, IEP’s, psychological reports, hospital records, and evaluations of all types are extremely helpful. It is understandable, however, that some parents may prefer a completely fresh, unbiased opinion, perhaps saving that data for a future visit.

At The Child Development Center, we find videos extremely valuable. Taking the time to produce a written history with your specific concerns often yields the most satisfying consultation.

On the day of:
It may be difficult to appreciate the anxiety that all family members experience in this situation, including the child. Another stranger. More tests. Overcoming fear may require social stories, bribery, a favorite food, electronic devices, or some other tested method.

Either a picture, list, or a bag of the present medications and supplements, streamlines the visit. Plus, any archive of past meds – what worked and what didn’t – can similarly improve the efficiency of the interview.

Perhaps it goes without saying, but be sure to bring along any familiar toys, blankets, etc., so that the doctor is able to observe the children and the parents can focus on the conversation. Whenever possible, a close family member or therapist will be a valuable addition to the team.

An open discussion with the practitioner is imperative. Even the tension caused by a family’s disagreement about whether there really is a problem, is important in making an accurate assessment and creating a useful treatment plan.

Back at Home:
Perhaps this is the most difficult part. Who should you believe? Have any of the previous treatments been particularly successful? Has the child reached some plateau where he/she seems stuck? What are the alternatives? Listen to your heart.

Having reached some degree of non-conventional intervention, there may be a desire to further micromanage. Can 2 functional medicine doctors perform better than one? Although parents who attempt this course may be correct, a mixture of protocols could delay improvement. Get started with one intervention at a time, and become comfortable that nothing is causing harm. Be clear about what skills you are targeting and document progress.

Not infrequently, the treatment can involve periods of increased aggression or even regression, due to the ‘die-off’ of harmful organisms, food restriction, arduous therapy sessions, even new-found skills and sensory overload. Close contact with the practitioner (via email, phone, follow-up visits) is a must at this juncture, if the treatment plan is to be followed and successfully implemented.

Conclusion
All of the points in the ‘real’ Times article are well-taken and valuable in this instance, as well. Hopefully, this advice will serve to make the experience of taking the next step in your child’s journey even more productive.

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Brian D. Udell MD
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