Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
Physician Co-editor Lee H. Beecher, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Gregory A. Plotnikoff, M.D., MTS Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Katie R. Snow TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reect the ofďŹ cial position of TCMS.
September/October Index to Advertisers TCMS OfďŹ cers
President: Edwin N. Bogonko, M.D. President-elect: Lisa R. Mattson, M.D. Secretary: Carolyn McClain, M.D. Treasurer: Kenneth N. Kephart, M.D. Past President: Peter J. Dehnel, M.D. TCMS Executive Staff
Sue A. Schettle, Chief Executive OfďŹ cer (612) 362-3799 sschettle@metrodoctors.com Jennifer J. Anderson, Project Director (612) 362-3752 janderson@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Andrea Farina, Communications and IT Coordinator (612) 623-2885 afarina@metrodoctors.com Barbara Greene, MPH, Community Engagement Director, Honoring Choices Minnesota (612) 623-2899 bgreene@metrodoctors.com Katie R. Snow, Project Coordinator (612) 362-3704 ksnow@metrodoctors.com Terri Traudt, Project Director, Honoring Choices MN (612) 362-3706 ttraudt@metrodoctors.com For a complete list of TCMS Board of Directors go to www.metrodoctors.com.
Autism Advocacy and Law Center LLC ....14 Billing Buddies MN .........................................12 CrutchďŹ eld Dermatology.................................. 2 Dermatology Consultants...............................22 DMG Financial Group .....Inside Back Cover Fairview Health Services .................................31 Fraser ..................................................................11 Geriatric Services of Minnesota ....................31 Greenwald Wealth Management ..................18 HCMC .................................................................27 Healthcare Billing Resources, Inc. ...............10 Healthcare Billing Resources, Inc. ...............29 Holland Center ..................................................17 Lockridge Grindal Nauen P.L.L.P. ...............28 Minnesota Autism Center ................................ 1 Minnesota Epilepsy Group, PA ....................12 MMIC ................................ Outside Back Cover Multicare Associates .........................................27 Saint Therese.......................................................29 The Davis Group .............. Inside Front Cover Transform 2013 (Mayo Clinic)....................... 4 Uptown Dermatology & SkinSpa................28 Whitesell Medical Locums, Ltd. ..................31 Winona Health ..................................................30
&UXWFKÀ HOG 'HUPDWRORJ\ ´5HPDUNDEOH SDWLHQW VDWLVIDFWLRQ IURP TXDOLW\ VHUYLFH FRQYHQLHQFH DQG H[FHOOHQW UHVXOWV¾
Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.
Exceptional Care for All Skin Problems
'LEVPIW ) 'VYXGL½ IPH --- 1 (
For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (763) 295-5420 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Katie Snow at (612) 362-3704.
2
September/October 2013
&SEVH 'IVXM½ IH (IVQEXSPSKMWX
4WSVMEWMW
%GRI 7TIGMEPMWX 8S[R 'IRXVI (VMZI 7YMXI )EKER 12
Your Patients will Look Good & Feel Great with Beautiful Skin.
%TTSMRXQIRXW
ZZZ &UXWFKĂ€ HOG'HUPDWRORJ\ FRP
MetroDoctors
%X ]SYV VIUYIWX [I LEZI WEQI HE] ETTSMRXQIRXW EZEMPEFPI JSV ]SYV TEXMIRXW [MXL EGYXI WOMR GEVI RIIHW
The Journal of the Twin Cities Medical Society
CONTENTS VOLUME 15, NO. 5
2
Index to Advertisers
5
IN THIS ISSUE
SEPTEMBER/OCTOBER 2013
Our Spectrum of the Autism Spectrum By Lee Beecher, M.D., and Marvin Segal, M.D.
6
PRESIDENT’S MESSAGE
A Letter to the Membership By Edwin N. Bogonko, M.D. Page 15
7
TCMS IN ACTION
By Sue Schettle, CEO AUTISM SPECTRUM DISORDERS
8
s
Colleague Interview: A Conversation With Travis Thompson, Ph.D.
13
s
Mandated Coverage for Autism Spectrum Disorder By Dominic Sposeto
15
s
Autism: From How it Works to How We Can Help More Effectively By Martha R. Herbert, Ph.D., M.D.
19
s
The Lovaas Model of Early Intensive Behavioral Intervention By Eric Larsson, Ph.D., L.P., B.C.B.A.-D.
Page 32
21
s
A Wide Variety of Autism Services Available at Fraser By Pat Pulice
23
s
Autism Training in the University of Minnesota Pediatric Residency Program By Emily Borman-Shoap, M.D., and Tom Scott, M.D.
25
s
Autism and the Environment: Challenges and Opportunities for Minnesota’s Public Health System By Anne Kelly, M.D., MPH, FAAP, and Kathleen Schuler, MPH
Page 7
28
New Members
29
In Memoriam
30
MCC Helps Alleviate Provider Frustration with Credentialing Career Opportunities
32
LUMINARY OF TWIN CITIES MEDICINE
Abraham Bert Baker, M.D.
Page 8
MetroDoctors
The Journal of the Twin Cities Medical Society
On the Cover: This issue tackles the mystery of Autism Spectrum Disorder and provides resources for physicians. Articles begin on page 8.
September/October 2013
3
It’s time to make a difference. September 8–10, 2013 http://www.mayo.edu/transform/
IN THIS ISSUE...
Our Spectrum of the Autism Spectrum AUTISM SPECTRUM DISORDERS (ASD) occupy a growing segment of the professional concern of primary care physicians, mental health professionals, third party payers and yes, even politicians. The increasing incidence of this constellation of disease processes, classically characterized by social deficits, communication difficulties, and stereotypical/repetitive behaviors, is confounded by a number of factors: not knowing its specific causations, not agreeing on a variety of existing treatment modalities, not settling upon an efficient payment schema and not having a handle on our society’s responsibility in dealing with this complex condition. The articles in this issue of MetroDoctors attempt to unravel and add light to this conundrum. Initially, Dr. Travis Thompson, a U of M psychologist with a long and eminent career largely devoted to ASD, effectively answers queries submitted by our panel of editorial clinicians covering the gamut of this disorder. Dominic Sposeto follows that by familiarizing us with new Minnesota mandated legislation dealing with insurance payment coverage — paralleling and possibly complementing the institution of the Affordable Care Act, which in itself contains no specific provision for ASD. The Minnesota government health care insurance mandate for autism treatment poses daunting challenges to both health care insurers and the treatment community: How and by whom will medical necessity for individual autism spectrum care be determined? How much of this is social support vs. medical care? And, how much will this cost Minnesotans in direct government payments and added insurance premiums? Stay tuned. Dr. Martha Herbert, a Harvard University clinician, in scholarly fashion, addresses the causes and care of ASD, leading to exciting current implications that may be utilized in dealing with challenges encountered in this field now and in the future.
By Lee Beecher, M.D., and Marvin Segal, M.D., Members, MetroDoctors Editorial Board
MetroDoctors
The Journal of the Twin Cities Medical Society
Lee Beecher Beecher, M M.D. D
Marvin Segal, Segal M M.D. D
Dr. Eric Larsson then relates to us the classical Lovaas Applied Behavioral Analysis (ABA) treatment, the positive results of this early intervention approach, and — for the sake of completeness — includes discussion of objections to this demanding treatment methodology. The Fraser Autism Center’s Director, Pat Pulice, takes us through the dynamic development of that facility’s highly individualized principles of care, and includes an important discussion regarding the need for support of ASD patients as they transition to adulthood. Drs. Borman-Shoap and Scott, of the U of M, then provide us with an insight into the current training of pediatricians as they prepare for increasing encounters with ASD. Dr. Ann Kelly and Kathleen Schuler relate some current theories of contributing factors to the development of ASD, in addition to the well-recognized genetic component, which have the potential to be incorporated in the search for effective management. Lastly, neurologist, Dr. A.B. Baker is featured as this issue’s Luminary of Twin Cities Medicine. If he were still with us today, he’d surely be intrigued by the unsettling complexity of the many variables associated with ASD — and he’d probably search along with us for their solutions. Enjoy this issue. It’s a good read. September/October 2013
5
President’s Message
A Letter to the Membership EDWIN N. BOGONKO, M.D.
Dear members, A few years ago, the MMA Board of Trustees (BOT) participated in a strategic planning process and a book by Harrison Coerver and Mary Byers called Race For Relevance became the centerpiece that informed their collective in deciding the future of the MMA. Central to embracing this new way of managing the MMA and its fading membership involved setting in motion a process that will eventually overhaul MMA governance by reducing the size of the board, empowering the CEO and staff of the MMA as the de facto leaders of MMA with a narrow focus on a few strategic priorities. In their new world, the MMA takes back control from physician volunteers and empowers the staff to run the organization like a business. The volunteers have been deemed to have failed the MMA and now a new model of staff-guided operations and policy formulation is the silver lining. Oversight by the members is not well articulated and for a lot of our members who have opposed all or some of the proposed changes, there is danger in the radical changes being proposed. Doing away with the House Of Delegates (HOD) for example takes away a key democratic privilege of the membership in exchange for an experiment that has yet to be validated. The TCMS board has engaged the MMA in a process of dialogue for the better part of 2013 asserting the need for consensus on ideas from their proposal that make sense to our membership and around which there is overall agreement. While it is clear the MMA has already received approval to downsize their board to ease decision making, what has yet to be articulated well is the role of individual physician members and what say they will have in the new governance dispensation. We know that our members have high expectations on getting value for their membership — how do we provide that value? How do we keep them engaged? With increased competition for dollars and membership as well as old technology, current systems may seem impractical. We cannot operate in 2020 the same way we function now. We need to realign our resources to assist our members by providing meaningful services and programs that they value and new opportunities to lead in today’s fast-paced environment. We must continue to provide efficient services and offer rapid and quality responses to specific member issues. We need to continue to build on that value proposition. This is one race we cannot afford to lose. At the TCMS, we recognized all the above and made recommendations to the MMA that supported the vast majority of the governance changes…one sticking point revolved around the democratic privilege for members to provide check/balance — currently the HOD. In its place, the MMA has proposed listening sessions, policy forums and a small competency based board to provide oversight. We contended that the best decisions are made when diversity of ideas and perspectives are encouraged and heard. A concept of “deep democracy” where all voices are valued before decisions are made is vital to successful organizational results. With this and member representations in mind, we suggested consideration for a phased process of evaluating the relevance and effectiveness of the alternative to the HOD: one that ensures there remains a credible way for a single member to bring forward issues and allows members to vote on the stance MMA should take on important issues; that board selection and appointment be determined in part by members — a key democratic principle; and finally a process that has clear lines of board membership — preferably nominated by the component medical societies following agreed upon guidelines. Until that process is seen to be a credible and practical alternative, the HOD should stay. In fact, listening sessions and policy forums are the right thing to do in spite of the HOD. Interestingly, the past two chairs of the MMA governance task force have both been on record as preferring a stronger HOD in addition to the new changes. The MMA leadership has opted instead to pursue the singular goal of eliminating the HOD and at times some have made it sound like TCMS opposes all of the governance changes. As a fraternity of volunteers, we must remember that those who do not agree with us are just as important as those who do. To radically change (Continued on page 7)
6
September/October 2013
MetroDoctors
The Journal of the Twin Cities Medical Society
TCMS IN ACTION SUE A. SCHETTLE, CEO
The TCMS Legislative and Policy committee members were honored to have Dr. Kathryn Duevel as our guest speaker at the July 2013 committee meeting. Dr. Duevel is an ob/ gyn physician serving on the MNsure board of directors and has agreed to participate in the upcoming TCMS educational forum, “MNsure: What you need to know,” to be held Thursday, September 26, 5:30 p.m. at the Ramada Plaza. RSVP’s required: $25 for
members/$40 non-members. Register at www.metrodoctors.com.
Dr. Kathryn Duevel
Dr. Edwin Bogonko, TCMS president, Nancy Bauer, associate director
of TCMS and I attended the University of Minnesota Medical Student White Coat Ceremony on Friday, August 9 at the Ted Mann Theatre on the University of Minnesota campus. Dr. Edwin Bogonko was given the opportunity to address the 1st year medical students and their guests. TCMS provides each medical student with an ADC Buck Neurological Hammer with our name embossed on it. The 4th annual Honoring Choices Minnesota Sharing the Experience Conference was held on Thursday, July 18. Nearly 100 participants attended the meeting from three states. Penny Wheeler, M.D., chief medical officer from Allina Health, was the keynote speaker. This event is a MetroDoctors
positive reinforcement for the work we are all doing with Honoring Choices Minnesota. The East Metro Medical Society Foundation and the West Metro Medical Foundation boards of directors each appointed three representatives to a merger exploratory committee. The group has met twice to discuss the pros and cons of merging the foundations. Recommendations about merging the foundations are forthcoming.
10, 2013, 11:30 a.m. at the Town & Country Club. Guest speaker Commissioner Lucinda Jesson will discuss MNsure. Register online at www. metrodoctors.com or call Andrea Farina at (612) 623-2885.
The Twin Cities Medical Society Board of Directors revisited the TCMS strategic plan at their July meeting. Staff provided a report card of where we stand on the various key elements of the strategic plan put forward in 2010. I am happy to report that we are clearly on track with our five key areas of focus which include: Public Policy Advocacy, Public and Community Health, Supporting the Practice of Medicine, Effective Management of the Society and Increasing the Visibility and Awareness of TCMS to our members. The board agreed that we would revisit our Strategic Plan at the five-year mark.
Lisa Mattson, M.D., TCMS president-elect, Edwin Bogonko, M.D., TCMS president, and Madelyn Lenhard, MS3 addressed 120 incoming
The Senior Physicians Association Annual Event is Tuesday, September
first year medical students at a Lunch and Learn on Thursday, August 8, extending the invitation for their involvement in the profession of medicine.
Several medical students learn about opportunities for TCMS, MMA and AMA involvement with Drs. Bogonko and Mattson.
President’s Message (Continued from page 6)
how we operate and paint those against as out of touch and in the minority misses the point. We all serve our fellow physicians and our profession in so many different ways, often with diligence and great sacrifice. We cannot afford to create discord and fracture our membership on the only area that more consensus needs to be built on. That would be bad leadership. At the upcoming annual meeting, the vote to do away with the HOD will be the most consequential one yet in its 160 years of history. Precedence and sheer sacrifice on the part of those who over the years have preserved our right to associate and chart our own destiny is on the line. We currently hold that baton in trust for our membership. I would ask the question if the U.S. Congress determined not enough people come to vote, would it be fair to have non-elected officers be the de facto leaders of the country? Unimaginable. Out of sheer principle, the resolution as it stands — to do away with the HOD — is premature.
The Journal of the Twin Cities Medical Society
September/October 2013
7
MedicalSpectrum Telemedicine Autism Care Organizations Disorders
Colleague Interview: A Conversation with Travis Thompson, Ph.D.
T
ravis Thompson, Ph.D., LP currently serves as professor and graduate faculty member, Special Education, Dept. Ed Psychology, University of Minnesota and a consulting scientist, KennedyKrieger Institute, Baltimore, MD. He previously served as director John F. Kennedy Center for Research on Human Development and professor, Department of Psychiatry and Psychology, University of Minnesota from 1969-1991 and professor, Vanderbilt University, Departments of Psychology and Human Development from 19912000. He then went to the University of Kansas Medical Center and served as director, Institute of Child Development and Smith Professor of Psychiatry from 2000-2003. Dr. Thompson earned his BA and MA degrees and his Ph.D. Psychology (Neuroscience) and Child Development at the University of Minnesota. He served as a USPHS Predoctoral Research Fellow; NIMH Postdoctoral Fellow (Psychopharmacology) at the University of Maryland; and Special Post-Doctoral Fellow at the University of Cambridge, UK. Dr. Thompson is currently an ad hoc member of the AMA Task Force on CPT Codes for autism ABA services, and has been an invited speaker in 47 states within the U.S. and 16 countries outside the U.S. He has been an author or editor of 30 books and 243 professional journal articles and chapters.
In your familiarity with the scientific literature, are there hard data on the causes of autism? Are there myths or urban legends surrounding Autism that need to be dispelled? This is one of the larger misconceptions about autism. Progress in discovering causes of autism has actually been more rapid than other common diseases such as various cancers and heart disease that were well known for centuries but only relatively recently yielded concrete information about causes leading to effective treatments. Like cancer, autism is a very heterogeneous disorder with multiple contributing components to different subtypes. Many of the components are genetically caused or at least predisposed. One often hears in the media that there is little hope of understanding autism because it is so complex genetically. Reality check: Of the hundred or so genes linked to autism in at least some studies, 8-10 are reliably associated with autism across numerous studies that account for a significant proportion of cases. Most of those genes contribute to components of brain synapse formation in one way or another. Most people with autism appear to have dysfunction in a relatively small number of brain areas in the temporal lobe, especially the amygdala, pre-frontal and cingulate cortex. In some individuals, other areas appear to be dysfunctional as well, such as language and mirror neuron areas. Anything that 8
September/October 2013
could cause damage to those areas pre- or postnatally could, in principle, cause some symptoms of autism. While most causes appear to be specific genetic errors (e.g. inherited, age-related translocations, spontaneous mutations), it is also possible those brain structures can be damaged by neurotoxins such as alcohol or because of other infections or genetic disorders, such as Congenital Rubella or Fragile X syndrome.
A diagnostic category called “autism spectrum disorders” has been created. Field trials show that clinicians have trouble distinguishing “Autistic Disorder, Rett’s Disorder, Childhood Disintegrative Disorder, Asperger’s Disorder, and Pervasive Development Disorder.” Viewing autism spectrum disorders as a continuum of functional impairment referencing severity of clinical signs and symptoms, what is your advice on tests or evaluation protocols which are useful to clinicians? In working with young children, I would encourage physicians and their staff members to become familiar with the Academy of Pediatrics First Signs protocol which can be obtained on their website or on the Autism Speaks website http://www.autismspeaks. org/what-autism/diagnosis/screen-your-child. Simple screening can be done by most trained professionals. Once it is determined a MetroDoctors
The Journal of the Twin Cities Medical Society
child screens positive for putative autism, s/he should be evaluated by a psychologist, pediatrician, psychiatrist or pediatric neurologist who specializes in the disorder. At this time, the Autism Diagnostic Observation Schedule-R is the gold standard test. Most evidence points to forms of familial autism as existing on a continuum. For example, some studies have shown that within an extended family, Autism, PDD-NOS and Asperger syndrome are found with increased prevalence, which shouldn’t be the case if they are qualitatively unrelated. On the other hand, it is likely some forms of autism will eventually be found to be relatively autonomous and requiring specialized services, such as some types of Asperger disorder. For the time being we have to live with DSM5. However, a child can score in the autism range on this test and not necessarily have autism. Training in differential diagnosis is essential. Children with a specific communication disorder, anxiety difficulties and mild intellectual delay can score in the autism range on the ADOS and not necessarily have autism. Those children do not need Early Intensive Behavioral Intervention, they usually need speech therapy, assistance with their anxiety and quality special education services. So, to determine a child has autism and not some other condition, usually a battery of tests is administered. Testing in older children and young adults is much more difficult because comparable protocols have not been developed, though the ADOS has some norms for older individuals as well.
Many studies show an escalating rise in the incidence and prevalence of autism spectrum disorders. What is your take on this? Most of the reported increase in prevalence appears to be due to increased ascertainment. The first widely accepted diagnostic test, the ADOS, was first released in 1989 and the following year reported autism prevalence sky-rocketed. It’s a little like the appearance of Snellen’s eye test. Once the test was generally available, it was discovered many more people had eye problems than previously realized. The alarming CDC prevalence figures have to be viewed with caution because they are based on reports from school district records that are confounded by the levels of staff training and the availability of autism services in school districts. More affluent school districts with a great deal of services generally report higher prevalence levels. Adjacent school districts in poor minority areas may report half the prevalence. Most of the foremost experts in the field believe the prevalence has always been higher than recognized — especially the milder forms of autism. Are their clinical entities that masquerade as Autism? And/or the reverse?
Most clinics specializing in autism receive a large number of referrals of cases that have tentatively been diagnosed with autism elsewhere, that do not have autism. Children with ADHD who have behavior problems (most of them), who have communication disorders (such as Specific Language Impairment) and are MetroDoctors
The Journal of the Twin Cities Medical Society
anxious (such as due to school failure, family problems or genetic predisposition), are readily misidentified or misdiagnosed by personnel who have not been well trained in autism differential diagnosis. High school or college age individuals with high functioning autism often disappear under the radar of most clinicians. They are usually seen as quirky, anxious, rigid and a bit socially inept, but not necessarily identified as having a known disability. When they have problems with their families or are experiencing significant depression or OCD symptoms, they may be referred for clinical evaluation. Such individuals often profit from Cognitive Behavioral Therapies alone or combined with anti-anxiety antidepressant medications.
Patients with extraordinary abilities to calculate or remember minute details (savants) continue to fascinate us. Special skills are also frequently associated with anxiety or social ineptness. How can we recognize patient skill and strength while addressing disability and dysfunction? Provide an example. Savants are rare among individuals with autism spectrum disorders, but focal skills and interests are common in autism. I always ask families or other caregivers what a patient does especially well, or whether there is anything s/he finds especially interesting. Initially, they may perceive their child’s interest in constantly drawing geometric figures as a problem rather than as a talent. However, with assistance from a trained professional, some parents realize that those talents can be transformed into useful skills. With probing, it is often possible to find either talents or special interests that can provide clues to promoting positive skills in daily life. The best examples are in highly repetitive activities requiring a high degree of precision, such as computer programming and book-keeping. Individuals with autism traits are common among people who are especially good at statistical and computer-related jobs. In a clinic with which I was associated, of 30 families with whom we worked over several years, in 24 one or both parents had mathematics or technology-related jobs. In lower functioning non-verbal individuals with autism, such focused interests are usually in non-functional motor routines or collecting and/ organizing non-functional materials (string, bottle caps). In the latter cases, those interests or activities are seldom the basis for useful activities to enrich the person’s life.
What advances in diagnostic and/or treatment do you envision, both short term and long term? In the long term it is likely genetic screening for some forms of autism will be possible. While these genetic subtypes will account for a minority of cases, they will positively identify autism and permit parents and professionals to pursue intervention with knowledge of what they are dealing with. They will also suggest clues for developing treatments and possibly other genetic forms or autism. In the short term, a limited screening battery available (Continued on page 10)
September/October 2013
9
MedicalSpectrum Telemedicine Autism Care Organizations Disorders Colleague Interview (Continued from page 9)
in doctors’ or psychologists’ offices is likely to emerge using a combination of specific behavioral and biomedical indices, such as simple communication and social behavioral measures, facial dysmorphology, eye tracking of faces vs non-faces or presence of the Broad Autism Phenotype in first degree relatives. A strategy similar to that developed by the National Cancer Institute SEER Program (Surveillance Epidemiology and End Results) is being explored by a collaborative group of researchers lead by the Kennedy Krieger Institute, is likely to make it possible to identify subtypes of cases, and to retrospectively match successful treatments to autism subtypes.
Are there valid significant preventive measures? There is a great deal of interest in starting early social, communication and behavioral intervention in high-risk children, such as siblings of children with autism. Some researchers are interested in extending this same strategy to more extended family members who exhibit the Broad Autism Phenotype but do not meet the diagnostic criteria for autism. Several studies are currently underway to determine whether that reduces the later prevalence of autism in those children. There are no specific biomedical procedures that successfully prevent autism at this time. There is no compelling evidence that vaccines are related to autism, or
that special diets reduce autism risk. It is possible that evidence of specific neurotoxin exposure may be more clearly linked causally to autism in the future, which could lead to public health measures.
The price tag for the care of patients with ASD is huge and among the most costly of any medical or behavioral condition. Yet, agreement on the effectiveness of various treatment modalities and meaningful outcome data seem to be lacking and quite controversial. How do you explain/reconcile this disparity? Most of the apparent discrepancy about efficacy of autism treatments has been created by private and public funders who do not want to pay for autism services. For those interested in historical comparisons, nearly the identical strategies were used by private and governmental payers to avoid paying for mammography and other breast cancer testing and treatment methods. The payers’ goals were to create the misimpression that those tests were inaccurate, and treatments were much too expensive and did little practical good. Only when women advocates in Congress brought enabling legislation to a vote, did the funders begin to reluctantly change their tune and, as they say, the rest is history. The best longitudinal study done with children with autism who receive no treatment was by DeMyer, MK, Barton, S, DeMyer, WE, Norton, JA, Allen J. and Steele R. (1973) Prognosis in autism: A follow-up study. Journal of Autism Child Schizophrenia. 1973;3:199–246 showed that 2-4 percent of children with autism function in the typical range without treatment by adolescence. A video showing what happened to young people with autism without treatment is available on the Minnesota Developmental Disabilities website which illustrates our first efforts to develop meaningful treatments in the late 1960s. http://mn.gov/mnddc/parallels2/one/video/changes.html. Approximately 30 studies, some RCTs and other less well controlled, all show basically the same outcome of intensive early behavioral treatment in autism. For about half of children who receive Early Intensive Behavioral Intervention (EIBI) for 15-30 hours per week for 18 months to three years, between two and seven years of age, most of their more limiting autism symptoms disappear or are greatly diminished by the time they enter school. While they continue to have some autism signs (social awkwardness, anxiety proneness) they usually function reasonably well in school. Longitudinal studies remain to be done into adulthood, but thus far, it appears most of those youngsters do (Continued on page 12)
10
September/October 2013
MetroDoctors
The Journal of the Twin Cities Medical Society
You Ask. Fraser Answers.
Quick answers for physicians and providers.
612-767-7222
Select 1 for English, then 3 for contact.
Dedicated contact for Physicians and Professionals. $# " ( # # ( $! "' ' #! ! ' ( % $ # " ( ! # # ( ! '
$ # ! " # ! ! "" "
Fraser Autism Center of ExcellenceTM is Minnesota’s largest and most experienced provider of autism services. Fraser also provides services for over 60 different disabilities for children and adults with special needs through healthcare, education, and housing.
MedicalSpectrum Telemedicine Autism Care Organizations Disorders Colleague Interview (Continued from page 10)
reasonably well, but some will require limited ongoing support. So the best evidence is that about half of children with autism function in the typical range with effective treatment compared with 2-4 percent without. Within the next year it is very like CPT codes will become available to reimburse such services in recognition of these basic clinical facts.
Are pediatricians and family physicians adequately trained in the early recognition, treatment and referral patterns for ASD patients? All pediatricians and most family physicians who include a substantial number of children in the practice, should learn to screen for autism and refer those cases that clearly fail to pass the screen. Currently few family physicians and pediatricians have received this training. It is very easy to learn to do; nurses or nursing assistants in physician offices could very easily perform this screen during intakes. The consequences of not detecting autism within the early years of life are very serious indeed, greatly delaying obtaining essential services. The Academy of Pediatrics launched a national training effort several years ago, but that needs to be repeated throughout the country.
12
September/October 2013
Are the current ASD advocacy groups (mainly parental) helpful to the research and treatment activities of professionals in this field? Several national autism advocacy organizations have been absolutely instrumental in supporting important autism research, such as Autism Speaks and Association for Science in Autism Treatment and Dr. Paul Offit’s Autism Science Foundation. These are largely parent organized and run groups which involve trained scientists in their advisory and planning infrastructure. Other organizations are largely influenced by advocates of untested and sometimes potentially harmful treatments, who view professionals who insist on scientific evidence as their enemies. Physicians and other professionals are always best to try to work with local Autism Society of America chapters if feasible. Often a physician or psychologist working in a medical practice is welcomed with open arms to speak at ASA chapter meetings or to be available as a resource to families. Even if parents don’t always agree with you, most families appreciate hearing from someone they know is a straight shooter and telling them the facts as best they understand them, while also compassionately understanding the parents’ dilemma. Developing a long-term relationship of trust with advocacy organizations is important in garnering the support necessary to improve the lives of our patients with autism.
MetroDoctors
The Journal of the Twin Cities Medical Society
Mandated Coverage for Autism Spectrum Disorder
A
new state law will require large employers (50 or more employees) to provide health insurance coverage for autism spectrum disorders for children less than 18 years of age. This legislation resulted from an ongoing debate within the Minnesota state legislature about the coverage for diagnosis and treatment of autism. Autism is considered a spectrum disorder due to the variability of individual symptoms and the range and impact on individuals from mild to severe. ASD is estimated to now occur in one in 88 children in the United States. Its scope and impact has created a considerable grassroots lobby for the coverage of this disorder under both government and private insurance programs. For the last three years, autism has been a very controversial topic at the legislature with treatment advocates supporting broader mandated ASD coverage while health plans and employers groups have questioned the expense and timing of such a mandate. Over 17,000 individuals with an ASD diagnosis were enrolled in Minnesota state health care programs in 2010. Three-fifths were children under the age of 18. The Department of Human Services currently covers a range of services for people with ASD. These services include speech, occupational and physical therapies, early intensive behavioral and developmental interventions as well as a full range of pharmaceutical interventions in common use to treat ASD symptoms. While coverage under MinnesotaCare and Medical Assistance was not an issue By Dominic Sposeto
MetroDoctors
of contention, a private insurance mandate was a very hot topic. The numerous benefit changes required under the Affordable Care Act, including the new essential benefit set for individual and group health insurance sold through health insurance exchanges, complicated the debate. ASD is not a mandated benefit under the ACA. The argument was made that it would be very problematic for the state to add a mandated benefit before our state insurance exchange and the products offered to both individuals and small employers hit the marketplace. After considerable debate, the legislature crafted what some called a compromise. The ASD mandate would apply only to large employers and not to individuals or small employers who will be able to buy insurance through the state’s health insurance exchange. The impact of this mandate may not be as great as advocates had hoped since most large employers opt or can opt for self-insured plans which are exempted from state mandates under ERISA law. Autism spectrum disorder is defined in Minnesota law as “conditions as determined by criteria set forth in the most recent edition of the Diagnostic and Statistical Manual or Mental Disorders of the American Psychiatric Association.” Covered treatment would include early intensive behavioral and development therapies, neurodevelopmental and behavioral health treatments and management, speech therapy, occupational therapy, physical therapy, and medications. All covered treatment must be medically necessary and consistent with generally accepted practice parameters as
The Journal of the Twin Cities Medical Society
determined by physicians and licensed psychologists who typically manage patients with autism spectrum disorders. Treatment must be in accordance with an individualized treatment plan prescribed by the child’s treating physician or mental health professional. Health plans may request an updated treatment plan once every six months. The new large employer mandate will take effect January 1, 2014. Dominic is the president of Dominic Sposeto and Associates, a consulting and lobbying firm he created. The firm provides a broad range of government relations and public affairs services, which include, lobbying, public relations, governmental rule-making advocacy, political action and grassroots legislative strategies. The firm also assists clients in the development and management of their communication, public relations, and political action programs.
September/October 2013
13
Guardianship and special needs planning for the future. '3&& 0/-*/& 8&#*/"3 UP GBNJMJFT BลขFDUFE CZ EJTBCJMJUZ When a child who has a developmental disability turns 18, parents can no longer make decisions for that child unless they go to court and obtain guardianship. This Webinar explains the process of establishing guardianship, and also covers issues that should be considered to plan for the future - such as supplemental needs trusts and special needs trusts.
%BUF /PW QN OPPO 3471 JOGP!BVUJTNMBXDFOUFS DPN
tel. ล JOGP!BVUJTNMBXDFOUFS DPN ล BVUJTNMBXDFOUFS DPN OE 4U 4& 4UF .JOOFBQPMJT ./
Autism: From How it Works to How We Can Help More Effectively
A
t present there is a vast gap between looking for what causes autism and figuring out how we can help. Lurking behind this gap are unanswered questions and unquestioned assumptions about how autism works. Emerging approaches in neuroscience and systems biology are bridging this gap, and offering us practical ways to improve the lives of people affected by autism right now. While finding genetic causes have long been the “Holy Grail,” considering environmental factors is gaining momentum. The GUIDE framework for summarizing the set of factors that may contribute to Autism Spectrum Disorders (ASD) — Genetics, Undiagnosed infections, immune or autoimmune disorders, Increased incidence and diagnosis, Diet and nutrient deficiencies, Environmental effects and epigenetics — has been ably reviewed in this issue by Anne Kelly and Kathleen Schuler. How do such risk factors turn into autism? What happens in the brain and body to transform a child who experiences an autistic regression? How might these diverse risk factors pile up and interact to drive the emergence of autism? Regression into autism is clearly documented by retrospective studies of videos, showing that many children had a period of virtual normalcy before becoming autistic.1,2 Certainly the brain would have to change the way it performs in order for the features of autism to emerge. Remarkably we know very little about this transformation, but clues from different domains are starting to piece themselves together into a coherent picture — and one that By Martha R. Herbert, Ph.D., M.D.
MetroDoctors
offers us avenues for both treatment and prevention. My own interest in this question was sparked over the last decade by reflecting on the physiological requirements of brain activity and the emerging documentation of physiological problems in autism that might interfere with optimal brain function.3 Here are two separate sets of observations that I started to think were connected: s 4HE BRAIN IS THE ORGAN IN THE BODY with the highest energy demands. Synaptic firing requires a huge amount of energy. Yet mitochondrial dysfunction is common in ASD: About 5 percent of people with autism appear to have genetically based mitochondrial disease (much higher than the rate in the general population),4 and a much larger proportion with no evidence of mitochondrial mutations have laboratory evidence of mitochondrial dysfunction such as
The Journal of the Twin Cities Medical Society
we see in other chronic diseases like obesity, cancer and diabetes.5,6 s 4HE PRODUCTION OF COMPLEX THINKING and perceptual organization requires highly organized, finely tuned and exquisitely timed brain coordination. The behavioral domains defined as core autism — impaired communication, social interaction, recognition of emotion and flexible adaptation to change — all require complex information processing. Yet functional MRI and EEG studies are showing a strong tendency toward reduced coordination across different parts of the brain in people with ASD.7,8,9 Could it be that the behavioral manifestations we label as autism are not hardwired? Perhaps the brain was not genetically wired differently from the start — but instead lost its ability to keep up with complex, rapidly changing demands. Could this “falling behind” emerge at least in part from impaired bioenergetics metabolism? Perhaps the brain is sending less signals because it doesn’t have the energy. As I looked at my patients and tracked the emerging research, several other seemingly separate features of autism also started to seem linked. s .EUROINmAMMATION .EUROPATHOLogy and gene expression studies are showing activation of neuroglial cells consistent with innate immune activation, and upregulation of neuroimmune gene expression rather than changes in “neurodevelopmental genes” as the most prominent alteration in gene expression in autism.10,11 (Continued on page 16)
September/October 2013
15
MedicalSpectrum Telemedicine Autism Care Organizations Disorders How it Works (Continued from page 15)
When glial cells get activated, they neglect their normal housekeeping functions. They provide less metabolic support for neurons and they fail to remove the excitatory neurotransmitter glutamate from the gap between neurons at the synapse, so it keeps stimulating the cells longer than it should. They also produce a lot of excitatory chemicals and immune substances.12 As a result, the nervous system enters a state of “excitotoxity,” producing noise, rather than signal, because the stimulation comes from chemical dysfunction inside the brain, not information relayed to the brain by the sense organs. With the mitochondria’s weakened ability to contribute to signal, and the neuroinflammation’s abnormal production of noise, we have what in engineering is called a “reduced signal-to-noise ratio” which degrades the quality of information the brain can produce. s .ERVOUS SYSTEM DYSREGULATION SLEEP and sensory dysfunction are nearly universal in ASDs and autonomic nervous system dysfunction and anxiety are highly prevalent as well. Putting neuroinflammation and nervous system dysregulation problems side by side raises significant chicken-and-egg problems: which comes first? We know that sleep deprivation and stress can generate pro-inflammatory cytokines,13 increase anxiety, and impairs attention and learning. All of these can be hugely vexing issues for people with ASDs. At the same time we don’t know whether the inflammation causes the nervous system dysregulation, or vice-versa, or whether both are driven by other triggers — or whether the whole thing is a vicious circle that can get ever harder to overcome over time. With these considerations in mind I started to look at my patients and the research to see how much these problems were intrinsic, irretrievably built-in and fixed, and how many things we could find in their lives that could be modified to reduce the severity of these problems. Various individuals with autism have: s 'ENETIC VULNERABILITIES NOT JUST IN “brain genes” but also increased presence of physiology that is vulnerable 16
September/October 2013
s
s
s
s
(either because of genetic reasons or prior environmental hits) to disturbance or degradation — this includes presence of multiple single nucleotide polymorphisms (SNPs) in one-carbon metabolism pathways, oxidative stress, impaired methylation, certain genetic biases toward immune dysfunction, SNPs increasing vulnerability to harm from toxicants such as lead and PCBs, and mutations increasing vulnerability to the above mentioned mitochondrial dysfunction.14-18 %NVIRONMENTAL EXPOSURES 3EVERAL studies, including a recent large one,19 report an association between exposure to air pollution and vulnerability to autism. Interestingly air pollution is associated with the development of brain inflammation.20 Exposure to pesticides also increases risk for autism and can interfere with various biochemical pathways.21 3ELF RESTRICTED DIETS NUTRIENT MALABsorption and low levels of nutrients important for biochemical metabolism and nervous system function: Many children with autism restrict their diets to beige colored foods like milk and cheese, to certain textures, and/or to sugary foods, giving them poor intake of vitamins and minerals; and the impact of this on nutrient status can be worsened by chronic diarrhea, fat malabsorption and other digestive system disturbances.22,23 This poor nutritional status can increase physiological and brain vulnerability.24,25 ,ACK OF EXERCISE DYSREGULATED BOWEL regimens and poor sleep hygiene. All of these problems can exacerbate inflammation and poor health and feed health-degrading vicious cycles. !BNORMAL INTESTINAL MICROBIOME with missing varieties of healthy organisms and presence of potentially harmful organisms.26-29 This can be further worsened by a diet high in sugar or other high glycemic index starches, failure to include probiotics or fermented foods in the diet and repeated courses of antibiotics for recurrent ear or strep infections common in the medical history of
infants prior to regression into autism, which can deplete important species in the microbiome. Research into the impact of gut microbiome on brain function is rapidly emerging. s %XPOSURE TO HIGH GLYCEMIC INDEX LOW nutrient density junk food as reinforcers in behavioral therapy, leading to satiation of the child on these substances and reducing their appetite for healthier higher nutrient density whole foods. s 3IDE EFFECTS FROM POTENT MEDICATIONS such as atypical antipsychotics utilized for severe behavioral dyscontrol that can promote weight gain and hormonal dysregulation and make it harder for a child to exercise. It thus appears that while there may be certain built in biases toward dysfunction, there are many additional contributors where modifications could be made to reduce risk and improve health and resilience. Finally, both published evidence and clinical observation has been accumulating to undermine the idea that ASDs are intrinsically irreversible. s ! GROWING NUMBER OF PAPERS ARE SHOWing reversal of autism-like features in mouse models of genetic syndromes like Fragile X, Rett syndrome and tuberous sclerosis commonly associated with autism.30-33 s 3TUDIES ARE DOCUMENTING LOSS OF DIagnosis in a significant minority of children previously rigorously diagnosed with autism.34 s 0UBLISHED EVIDENCE THAT SIGNIlCANT numbers of children show transient amelioration of core features of autism in the setting of fever (a phenomenon also being investigated in other neuropsychiatric disorders such as schizophrenia).35,36 s 0UBLISHED REPORTS OF TRANSIENT AMElioration of autism symptoms during antibiotic treatment, as well as many anecdotal reports of transient improvements in communication, social interaction and calmness during clear fluids only diet in preparation for procedures, during steroid therapy, and after anesthesia.37
MetroDoctors
(Continued on page 18)
The Journal of the Twin Cities Medical Society
MedicalSpectrum Telemedicine Autism Care Organizations Disorders How it Works (Continued from page 16)
We need to look at lifestyle modiďŹ cations and how they may impact the severity of autism. Given the severity of physiological and developmental disruption, more aggressive lifestyle modiďŹ cation is likely to be more successful. This would include high nutrient density diet, avoidance of toxins in household and personal products, removal of allergens and immune triggers from the diet, aggressive sleep hygiene, vigorous exercise and stress reduction.40 I am currently part of a team of researchers developing a research program to document this approach in the largest residential facility in the state of New York, the Center for Discovery, which is based on a biodynamic organic farm and sees dramatic reductions in adverse behaviors and increases in function when this program to reduce allostatic load is applied in a consistent and coordinated fashion. Lifestyle modiďŹ cation is surprisingly difďŹ cult to implement in today’s health economic milieu. But just as we know that a large portion of the $750 billion a year we spend on type II diabetes is preventable,41 the same may be true of autism
Put together, all of these pieces seem to suggest that the “autismâ€? may be more like a state than a ďŹ xed trait — more like a chronic dynamic encephalopathy than a ďŹ xed static encephalopathy. This combination of factors starts to suggest that autism spectrum disorders may not emerge simply from a genetically “brokenâ€? brain wiring diagram, but may in fact emerge from and/ or be worsened by struggling physiology. 38,39 If struggling physiology can make things worse, improving physiology may improve the brain’s signal-to-noise ratio, by improving the ability of the brain to have the energy to coordinate information more effectively, and reducing the endogenous noise generated by neuroinammation. Given the alarming and expensive rise in the number of reported cases of autism, this approach of using lifestyle modiďŹ cations to improve the signal-to-noise ratio in the brain in autism offers approaches worth investigating that are practical and inexpensive, and could potentially help large numbers of people.
spectrum disorders. Moreover, alongside the rises in reported cases of autism are rises in ADHD, asthma, obesity, diabetes, and neuropsychiatric and learning disabilities where similar considerations apply. In conclusion, since a plausible argument can be made for taking lifestyle considerations more seriously in autism spectrum disorders, physicians should look at poor lifestyle choices and low-grade chronic medical problems as things that could be improved and ramiďŹ ed through the person’s whole system rather than as things that would not impact the autism. Dr. Martha Herbert is a neurologist and neuroscientist at the Massachusetts General Hospital/Harvard Medical School, and author of many publications and blogs available at www.marthaherbert.org, www.AutismRevolution.org, www.autismWHYandHOW.org and www.transcendresearch.org. She can be reached at marthaherbertmd@gmail.com. References are available at: www.metrodoctors.com. Click on Publications Tab, MetroDoctors online, References and Resources.
YOU KNOW EVERY BONE
INLĂ•ĂŒĂŠV>Â˜ĂŠÂ˜>“iĂŠÂœÂ˜Â?ĂžĂŠÂœÂ˜iĂŠÂ“Ă•ĂŒĂ•>Â?ĂŠ THE HUMAN HAND, “iĂŠÂœ œ˜Â?Ăž ĂžĂŠÂœ œ˜iʓ “ vĂ•Â˜`° Nobody expects you to be a full-time doctor and a part-time investor. As a CERTIFIED FINANCIAL PLANNER™ and MD,, I work exclusively with physicians who
know kno no there’s a more effective way to invest. Call today for a free consultation and see personalized wealth managethe difference d ment can make to your life.
ÂœiÂ?ĂŠ Ă€iiÂ˜Ăœ>Â?`]ĂŠ
C ,/ ĂŠF ĂŠ* Â?ÂœiÂ?JÂ?ÂœiÂ?}Ă€iiÂ˜Ăœ>Â?`°Vœ“
,™
™xĂ“Â‡Ăˆ{£‡Çx™xĂŠĂŠUĂŠĂŠÂŁĂˆĂˆĂ¤ĂŠ-ÂœĂ•ĂŒÂ…ĂŠ ˆ}Â…Ăœ>ÞÊ£ää]ĂŠ-Ă•ÂˆĂŒiÊÓÇä]ĂŠ-ĂŒÂ°ĂŠ ÂœĂ•ÂˆĂƒĂŠ*>ÀŽ]ĂŠ ĂŠxx{ÂŁĂˆĂŠĂŠUĂŠĂŠĂœĂœĂœÂ°Â?ÂœiÂ?}Ă€iiÂ˜Ăœ>Â?`°Vœ“ Securities and advisory services offered through Commonwealth Financial NetworkÂŽ, member FINRA/SPIC, a Registered Investment Adviser. Fixed Insurance products and services offered by Greenwald Wealth Management are separate and unrelated to Commonwealth.
18
September/October 2013
MetroDoctors
The Journal of the Twin Cities Medical Society
The Lovaas Model of Early Intensive Behavioral Intervention
A
pplied Behavior Analysis and intensive behavior therapy has been continuously refined since its inception in the early 1960s. The mission of the Lovaas Institute is to develop and evaluate the most effective, evidence-based behavior therapy for children with autism spectrum disorders. It therefore continues to incorporate new clinical and assessment methods when they become objectively proven effective. And yet, the Lovaas model is not just the culmination of all research in ABA. Instead it is a particular strain of ABA, in which the recovery-oriented goals of the parents drive the mission of treatment. What is Recovery-Oriented Treatment?
An evaluation of intake goals presented by parents has found the following common goals: to develop a child who shares the parents’ affections in natural and mutual ways; who will make and keep normal friendships with other children; who will independently succeed in typical classes in school; who will be flexible and responsive in social situations; who will comply with the natural expectations of the community; and who will participate readily and easily in all the enjoyments of life — birthday parties, holidays, trips, sleep-overs, sports, and family outings. When recovery-oriented treatment is effective, then the child’s behavior will not keep them from enjoying a normal life with their family, and there will be no more need for specialized treatment. This is the best possible outcome for a child. Several
By Eric Larsson, Ph.D., L.P., B.C.B.A.-D.
MetroDoctors
aspects of behavior therapy have proven to increase the likelihood of recovery from autistic symptoms. These are: intensity, early intervention, behavior therapy, parent training, dynamic programming, frequent behavioral assessment, and frequent expert supervision. How Could this be Accomplished?
Behavior Analysts conduct a weekly clinical review with the parents to evaluate the child’s current maladaptive behavior patterns through direct observation in the home, and customize the effective treatment package. It is critical to directly evaluate and revise the program each week, because autism is so heterogeneous. No two children are alike, and no two family systems are alike. The effective early intervention program may consist of a series of 800 different behavioral objectives and treatment procedures, which are customized for the child over a period of three years. There are no set approaches: repetition may be best or variation may be best, correction vs. shaping, visual vs. auditory cueing, etc. at any one point in a child’s therapy. For accountability, to determine medical necessity, a thorough prognostic assessment of the child’s responsiveness to treatment is conducted every six months to ensure that the child is accomplishing more than they would from typically available services. In this way, each parent can trust that their treatment program is worth the significant sacrifices that they are making in order to obtain the best possible outcomes for their child. As well, the Lovaas Institute takes steps to ensure that each child receives a full complement of
The Journal of the Twin Cities Medical Society
experienced staff, and that all staff receive weekly supervision and training. What is the Treatment Like?
Each week, a Behavior Analyst observes how the social environment affects the child’s behavior. The most powerful social effect upon behavior is reinforcement. Reinforcement is a process in which a social consequence of a child’s behavior is rewarding enough that the child begins to engage in the behavior more frequently, as a result. Where the typical child will naturally show an interest in normal social play and affection, and learn their language and social skills from these interactions, the child who suffers from autism will show an increasing tendency to persistently seek out unusual reinforcers. Their preoccupation with the unusual behaviors begins to crowd out normal daily learning and socialization to the point that the child fails to develop normal language and social skills. (Continued on page 20)
September/October 2013
19
MedicalSpectrum Telemedicine Autism Care Organizations Disorders The Lovaas Model (Continued from page 19)
Without treatment, normal, loving parents and caring teachers respond to these behaviors by supporting them, rather than confronting them. Not only do they understandably attempt to connect with the child by sharing in their preoccupations (“ohhhh, more sticks? Let’s line them up again!”), but they also begin to act to avoid the excessive tantrums that the child will exhibit when their desires are not indulged in (“OK, I turned the lights back off, you can play in here while we eat in the other room”). Many children are so demanding that their parents no longer sleep together, because one parent is sleeping with their 8-year-old, with the lights on. In treatment, new social, play, and language skills are developed in intensive 1:1 treatment sessions. For a child who had been gradually falling behind over a period of two years, it takes just as many more years of intensive therapy to make up for their lost time, so the child receives 40 hours a week of 1:1 focused therapy for several years. During that time, the parents receive substantial clinical support to resist the temptation to indulge the child’s tantrums, and to generalize the child’s skills 24-7. What are the Results of this Approach?
Not every child will accomplish complete and natural independence, but because the treatment incorporates objective measures of responsiveness to treatment, the parents and funders have the kind of data needed to make efficient care determinations. Over the years, various writers have advanced philosophical objections to this approach — that the approach is too demanding, too costly, or not really effective. But these objections are not data-based. ABA is a scientific pursuit rather than a philosophical one. Behavior Analysts have taken great care to conduct objective research to prove the effectiveness of the most appropriate individualized approach for each child, in line with their parents’ goals. What follows is a brief review of some of the highlights of over 500 studies conducted at University centers over the past 50 years. 20
September/October 2013
In 1972, Lovaas published the first long-range outcome study of early intervention with children with autism. For the first time, this study showed the children’s potential to make clinically important gains. These children had all been placed into a state hospital, with no hope of acquiring basic language and play skills, much less symptom amelioration. Despite these prospects, the 16 children did learn language and play skills. But what is less well known is that the study was the first of its kind to identify prognostic indicators of responsiveness to treatment. Lovaas found a matrix of outcomes where the children who responded best were the younger children who also had high parental involvement. He then initiated a 10-year study of how best to serve that highest performing segment of the population.1 Other behavioral researchers from his lab began to focus on the other children who had not benefitted from parent training. These children were not to be “thrown away,” as society had already done, but instead they were to be referred to other valuable treatment modalities such as center-based treatment, medical management, respite, and functional community programming.2 In 1987, the outcomes of the early intensive behavioral intervention program found that, when evaluating a group of children who met strict intake criteria and received intensive treatment for three years, 90 percent gained social language and play skills, and lost autistic behaviors. Half of those reached the best outcomes — normal IQ, independent success in school, and loss of diagnosis. This study again suggested a matrix of prognostic indicators. Only 5 percent of children who received less intensive treatment achieved those same outcomes.3 In 1993, a subsequent follow-up study of the same children proved the lasting effects of the approach. This series of studies, which included component clinical studies of methods and assessment, extended the methodology to include periodic measures of responsiveness to treatment. The periodic measures proved to further enhance the cost-effectiveness of the approach.4 By the time that several independent replications of the approach had been
published in 2007, it became clear that the intensive behavior therapy model could maximize the value of limited health care dollars by focusing on prognostic and periodic objective measures of responsiveness to treatment.5, 6, 7 Today in Minneapolis, the Lovaas Institute Midwest has replicated the same results with a larger sample of children. For the purpose of accountability, the Lovaas Institute conducts a comprehensive multimodal assessment every six months that includes objective behavioral measures of both rate of progress and clinical improvement, norm-referenced measures, social validity measures, and independent standardized assessment. In essence, while each child’s presentation and access to services will vary, a comprehensive analysis of the child’s response to treatment will dictate the most cost-effective services. The average cost of the intensive treatment at the Lovaas Institute is the same as the less effective traditional services — $65,000 per year for only three years.8 In 2013, the Minnesota legislature passed a series of laws to guarantee coverage of intensive behavioral treatment of autism. It will now be crucial to establish a sound set of funding regulations that will ensure the accessibility of services for families. Dr. Eric Larsson is currently the Executive Director of Clinical Services at the Lovaas Institute Midwest, a Licensed Psychologist and Board Certified Behavior Analyst-Doctoral. He consults internationally on early intervention for autism, and on cost-effective service delivery. He teaches classes and supervises undergraduate and graduate students at the University of Minnesota and the University of Kansas. He currently serves on the Behavior Analyst Certification Board. For information about intakes, contact the Lovaas Institute Midwest, at (612) 9258365, laraderksen@lovaas.com. Dr. Larsson can be reached at elarsson@lovaas.com. References are available at: www.metrodoctors.com. Click on Publications Tab, MetroDoctors online, References and Resources.
MetroDoctors
The Journal of the Twin Cities Medical Society
A Wide Variety of Autism Services Available at Fraser
F
raser is Minnesota’s largest and most experienced autism provider serving children and adults with more than 60 types of mental and physical disabilities. Their programs are nationally recognized for high quality, innovation, and individualized, family-centered approach. As a Children’s Therapeutic Treatment Service (CTTS) provider, the Fraser Autism Center of Excellence combines therapy, skills, and behavioral services. The treatment plan and level of intensity is determined by medical necessity through an extensive evaluation process. Children receive the intervention at the intensity, frequency and duration needed to progress to a less restrictive environment. Frequency of services range from as little as one hour a week or to more than 40, depending upon the individual’s treatment plan. Most major health plans provide coverage for Fraser’s services. What Does Intervention Look Like at Fraser?
Over the past three decades, the Fraser Autism Center of Excellence has developed a unique treatment model that integrates Applied Behavioral Analysis (ABA), developmental, and relationshipbased approaches. Fraser’s autism model is characterized as creating highly individualized treatment programs that help children develop a broad range of communication, social, cognitive, coping, and safety skills. The Fraser model also incorporates mental health best practices like building multidisciplinary teams around the child’s needs, By Pat Pulice
MetroDoctors
supporting parents and coordinating with community providers. Fraser’s broad range of services offers multiple possibilities to match the needs of each child and family. Fraser staff routinely seeks feedback from family physicians, neurologists, psychiatrists and pediatricians like, Dr. Jim Moore, who participates on Fraser’s Autism Advisory Committee and Advisory Board. “Among the many things I value about Fraser is its openness to advances in our scientific understanding of autism, its innovative methods and willingness to adapt treatment plans to fit the needs of individual clients and families.” Dr. Moore has been referring pediatric patients to Fraser for over 25 years. Children with autism spectrum disorders often have complex needs. Patients receive a thorough evaluation of developmental and adaptive skills. Parent interviews and standardized testing are part of the process. Parents and caregivers receive education on effective interventions that can be embedded into their routine. The evaluation process and parent education works well for patients of pediatrician Dr.
The Journal of the Twin Cities Medical Society
Peter Loewenson, Site Medical Director of HealthEast Woodbury Clinic and Fraser Board Member. “I appreciate Fraser’s approach, especially for the more challenging to diagnose patients. They are able to tailor the assessments and treatment plans accordingly.” In 2009, a survey of Minnesota families identified the majority of children with an autism diagnosis had three additional conditions or diagnoses. Fraser clinicians have expertise in dual diagnoses and can provide comprehensive services. At Fraser, families can expect a “one-stop” for services that include intensive autism treatments, speech and occupational therapies, music therapy, personal care services, feeding consultations, childcare and more. Collaboration between therapist and child is essential. Research confirms successful intervention requires trust and accurate delivery, making staff training and supervision essential. Fraser’s staff are experienced and credentialed in evidenced-based practices including Treatment and Education of Autistic and related Communication Handicapped Children (TEACCH), Roger’s Early Start Denver Model, Social Communication Emotional Regulations Transactional Supports (SCERTS), and ABA. Additionally, Fraser psychiatrists, neurologists, pediatric therapists, and other experts in other childhood disorders provide a well-rounded perspective on each child. Transiting to Adulthood
While Fraser is known for specializing with young children, hundreds of school-aged (Continued on page 22)
September/October 2013
21
MedicalSpectrum Telemedicine Autism Care Organizations Disorders Fraser (Continued from page 21)
children and adolescents are served at Fraser. The transition to school-aged services is supported by Fraser case managers, helping families access services in their community. Behavioral aide services also support success as students take the skills they learn into the school setting. School-aged
children often utilize intermittent services of individual and group skills training to build social and coping skills. Skills groups become a venue for meeting friends and families who share common experiences. Clients who were once managing well in high school can begin to struggle in young adulthood. Behaviors which might result in a trip to the principal’s ofďŹ ce in high school were now posing safety and
We’re pleased to welcome... Margaret A. Collins, M.D. and Matthew J. Larson, M.D. to Dermatology Consultants beginning August 1, 2013. Dr. Larson will be practicing Medical Dermatology, Pediatric Dermatology and Skin Cancer Screening. Dr. Larson comes to us with several years experience as a Dermatologist in the Twin Cities area. He is the current President of the Minnesota &GTOCVQNQIKECN 5QEKGV[ CPF C $QCTF EGTVKƂGF &GTOCVQNQIKUV Dr. Larson attended the University of Iowa College of Medicine and completed his residency at the University of Texas Southwestern in Dallas. Dr. Larson will see patients at QWT 'CICP QHƂEG Dr. Collins will practice Medical Dermatology and Skin %CPEGT 5ETGGPKPI 5JG KU C $QCTF EGTVKƂGF &GTOCVQNQIKUV CPF KU CNUQ $QCTF EGTVKƂGF KP (COKN[ /GFKEKPG &T %QNNKPU attended the Medical College of Wisconsin and completed JGT (COKN[ /GFKEKPG TGUKFGPE[ CV VJG 7PKXGTUKV[ QH Washington Valley Medical Center. She completed her residency in Dermatology at the University of Wisconsin, Madison. Dr. Collins will see patients at our Vadnais *GKIJVU QHƂEG We look forward to Dr. Larson and Dr. Collins continuing our tradition of excellent care for skin diseases. Please call 651-209-1600 for an appointment. Visit dermatologyconsultants.com for more information.
skin. care. experts.
legal risks in adulthood. Parents began to seek guidance for their adult children. Fraser responded by increasing our adult evaluation teams, specializing in differential diagnosis and transition referrals. Recently accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF), Fraser Career and Employment Planning assists adults with autism ďŹ nd and maintain employment. Devin, at age 23, attended classes to learn about the social aspects of job interviewing and placement. Learning how to dress, create a portfolio, and answer interview questions landed him an internship at a CPA ďŹ rm. Independent living is also an important skill for our clients with autism. Fraser Residential Living has been a part of the Fraser history of serving clients with developmental disabilities. Fraser has 26 group homes, ďŹ ve apartment buildings and four supportive living homes that serve many people with autism. Fraser continues to think outside the box to help clients maintain daily routines, engage in recreation and social events. As clients age, Fraser continues to support them with life events; such as death, cancer and failing health. This journey is consistent with the mission Mrs. Fraser created: partnering with families, professionals, and the community to help each individual achieve their highest potential. Pat Pulice has more than 25 years of experience working with children with autism spectrum disorders. Under her direction, Fraser received the Autism Program of the Year Award (2000) from the Autism Society of America. Today, she serves as Director of Fraser Autism Center of Excellence, and is highly regarded as one of the nation’s leading autism experts. A list of Fraser Autism Services is available at: www.metrodoctors.com. Click on Publications Tab, MetroDoctors online, References and Resources.
dermatologyconsultants.com
22
September/October 2013
Fraser General inquiries: (612) 861-1688 Fraser Physician/Professional Line (612) 767-7222 Option 3. MetroDoctors
The Journal of the Twin Cities Medical Society
Autism Training in the University of Minnesota Pediatric Residency Program
T
he goal of the University of Minnesota pediatric residency training program is to provide robust and comprehensive training in pediatrics. This includes broad exposure and experience in subspecialty care as well as general pediatrics. One key area of this training is Developmental-Behavioral pediatrics. The care of children with Autism Spectrum Disorders (ASD) represents a significant component of the day-to-day practice of the general pediatrician. The prevalence of ASD is approaching one in 50 children. A typical general pediatrician in practice will likely have at least 20 children with autism whom they are actively caring for. The residency curriculum provides a comprehensive framework of training in ASD. This includes normal child development, autism screening, diagnosis, management, and care coordination. The context of this training occurs in several settings, including primary care fundamentals seminars, continuity clinics, and the Developmental-Behavioral pediatrics (DBP) rotation. Normal Child Development: Residents gain experience with the expected patterns for normal child development in a variety of ways. They participate in focused seminars on normal child development during the first two years of residency. Special attention is paid to the key domains of child development, including language, motor, social/emotional, and cognitive skills. These seminars are facilitated by Developmental-Behavioral Pediatrics faculty members. Residents also By Emily Borman-Shoap, M.D., and Tom Scott, M.D.
MetroDoctors
Emily Borman-Shoap Borman-Shoap, M.D. MD
Tom Scott, M.D.
have the opportunity to observe typically developing children in action during visits to the University of Minnesota Child Development Center. Finally, residents work closely with their continuity clinic preceptors to gain skills in discussing common developmental and behavioral concerns with families.
for ASD at age 18 months and 24 months. This screening should occur in addition to paying close attention to parent concerns and ongoing developmental surveillance at all clinic visits. Residents gain an understanding of the importance of implementing autism screening using the Modified Checklist for Autism in Toddlers (M-CHAT) during their DevelopmentalBehavioral Pediatrics rotation. The importance of prompt action in the face of parental concerns is also highlighted in the video “First Signs” which residents view during their DBP rotation.
Developmental and Social/Emotional Screening: Residents are introduced to screening tools early in their training in the context of their continuity clinic setting. During their DBP rotation, residents have the opportunity to further explore a variety of screening tools with focused study on the parameters that should be used when selecting an appropriate instrument. Developmental screening tools that are often used in the community include the Child Development Inventories (Ireton) and the Ages and Stages Questionnaires (ASQ-3). Residents are also being introduced to the importance of social/emotional screening with the ASQ-SE. Autism Screening: Early identification is fundamental to the care of children with autism. The American Academy of Pediatrics and the CDC recommend screening
The Journal of the Twin Cities Medical Society
ASD Diagnosis: The DBP rotation utilizes the CDC teaching modules, “Autism Case Training: A Developmental Behavioral Pediatrics Curriculum.” This freely available online curriculum provides a comprehensive guide to the care of children with autism spectrum disorders. This curriculum includes a component “Making an Autism Diagnosis” which highlights the four key steps that should be taken when an autism spectrum disorder is suspected: 1) Schedule audiologic evaluation, 2) Refer for comprehensive ASD (Continued on page 24)
September/October 2013
23
MedicalSpectrum Telemedicine Autism Care Organizations Disorders Autism Training (Continued from page 23)
evaluation, 3) Refer for early intervention/early education services, 4) Schedule follow-up visit. A comprehensive evaluation for ASD should occur in the context of an interprofessional team including psychologists, speech/language pathologists, and physicians. The CDC teaching modules highlight the components of a comprehensive ASD evaluation including: s $ETAILED HISTORY FROM CAREGIVER s 0HYSICAL %XAMINATION s /BSERVATION OF CHILD s $EVELOPMENTAL PSYCHOMETRIC TESTING s 3PEECH LANGUAGE TESTING s $ETERMINATION OF CATEGORICAL !3$ diagnosis using DSM criteria and a standardized tool s !SSESSMENT OF FAMILY S KNOWLEDGE regarding ASDs, coping skills, resources, and supports s -EDICAL GENETIC WORK UP AS INDICATED by clinical picture During their DBP rotation, pediatric residents are able to work side-by-side with experts in Developmental Behavioral Pediatrics and stay up-to-date on the latest information regarding autism. For example, the new DSM V criteria for Autism Spectrum Disorders have been updated. All Autism Spectrum Disorders are now classiďŹ ed under one broad category (ASD), with key features noted in two domains: 1) deďŹ cits in social communication and social interaction and 2) restricted repetitive behaviors, interests, and activities. Symptoms of ASD must be present in early childhood and must together limit and impair everyday functioning. Autism Treatment: Residents gain knowledge of the comprehensive treatment approaches to autism that include educational, community-based, and medical interventions. Key educational components of autism treatment include: s )NTENSIVE "EHAVIORAL )NTERVENTION (Applied Behavioral Analysis-ABA, Early Start Denver) s %ARLY CHILDHOOD SPECIAL EDUCATION s 3PEECH THERAPY AND OCCUPATIONAL therapy s )NDIVIDUALIZED %DUCATION 0LANS
24
September/October 2013
The AAP recommendations for the treatment of autism include entry into intervention as early as possible (as soon as ASD diagnosis is seriously considered) and provision of intensive interventions with active engagement for at least 25 hours per week for 12 months per year. Medical treatments offered for children with ASD may include medications for sleep issues, seizure disorders, attention disorders, or reactive behaviors. Residents learn about the role of the primary care provider in initial evaluation, referral to an autism specialist in other disciplines (including DBP, psychology and psychiatry, speech/language therapy, occupational therapy) and ongoing support for families. Residents also learn to maximize available resources by coordinating simultaneous evaluation and treatment by medical and educational systems. Residents are taught the central role of the primary care provider in providing ongoing coordination of care in the context of the medical home for patients with autism spectrum disorders. Residents are also guided in the critical importance of community resources such as the Autism Society of Minnesota for family education and support. Key Community Partners: During their DBP rotation, residents gain skills in caring for children with ASD in diagnostic centers and DBP clinics. The following sites are teaching locations during the DBP experience: s !LEXANDER #ENTER FOR #HILD $EVELOPment and Behavior s 5NIVERSITY OF -INNESOTA #LINICS s &RASER s (EALTH0ARTNERS 2IVERSIDE s 5NIVERSITY OF -INNESOTA #HILD $Evelopment Center s #HILDREN S (OSPITALS AND #LINICS OF Minnesota s 'ILLETTE #HILDREN S (OSPITAL Dr. Jim Moore, a developmental-behavioral pediatrician is the lead teacher for autism training during the DBP rotation. Residents also learn about ASD from the following core faculty in developmental behavioral pediatrics: Drs. Andy Barnes, Brooks Donald, John Garcia, Anjali Goel, Pam Kaplan (PNP), Carrie Kippes, Anna
Kostanecka, Jenni Lessin, Dan McClellan, Kim McConnell, Betsy Murray, Michael Reiff, Jerry Rosen, Tom Scott, Sylvia Sekhon, and Laurel Wills. Residents also utilize their skills in ASD screening, assessment, ongoing treatment and family support, into practice in the continuity clinic setting in a variety of locations including: s (ENNEPIN #OUNTY -EDICAL #ENTER s #HILDREN S (OSPITAL AND #LINICS OF Minnesota s &AIRVIEW 5NIVERSITY #HILDREN S #LINIC s 0ARK .ICOLLET s (EALTH0ARTNERS s 0RIVATE PRACTICES INCLUDING !SPEN Metro Pediatrics, Mendakota Pediatrics, Partners in Pediatrics, Pediatric and Young Adult Medicine, Southdale Pediatrics, South Lake Pediatrics, Stillwater Pediatrics References utilized by residents and also useful for primary care clinicians in practice are available at: www.metrodoctors.com. Click on Publications Tab, MetroDoctors online, References and Resources. Tom Scott, M.D. is interim director of the Developmental-Behavioral Pediatrics residency program in the Division of General Pediatrics and Adolescent Health at the University of Minnesota. He is a member of the Governor’s Task Force on the Prevention of School Bullying and is on the policy committee of the Minnesota Chapter of the American Academy of Pediatrics. Dr. Scott has been a consultant in Developmental-Behavioral Pediatrics at the Alexander Center of Park Nicollet and at HealthPartners. He can be reached at scott051@umn.edu, or (952) 237-4312. Emily Borman-Shoap, M.D. is the pediatric residency program director at the University of Minnesota. She is a general pediatrician and her practice is at the Fairview University Childeren’s Clinic. Dr. BormanShoap serves as a faculty advisor for medical students at the University of Minnesota. Her professional interests are medical education and primary care for children with complex health care needs. She is also an active board member of the Minnesota AAP Chapter. She can be reached at: borm0029@umn.edu, or (612) 624-4477.
MetroDoctors
The Journal of the Twin Cities Medical Society
Autism and the Environment: Challenges and Opportunities for Minnesota’s Public Health System
I
n the past two decades the diagnosis of autism spectrum disorder (ASD) has increased at least fourfold in the United States. Nationally, one in 88 children are diagnosed with ASD, and some have estimated even higher rates in Minnesota. Costs to society and to families are staggering — an estimated $35 billion is spent each year in the U.S. for persons with ASD.(1) Research on Medicaid-reimbursed health care expenditures correlates the exponential rise in ASD-associated costs with an increase in the number of children receiving services.(2) Despite these alarming trends, to date extensive research has been unable to explain the etiology of ASD or reduce the incidence of new cases through prevention strategies. Not Only Genetics
ASD is a developmental disorder that impairs communication and social interaction but is also known to affect both behavioral and physical health. Common issues include; gastrointestinal disorders, peculiar dietary habits, sleep disorders, and seizures. The complex nature of ASD, the lack of reliable genetic or biologic diagnostic markers, and the variability in how ASD is diagnosed, make it challenging to evaluate the prevalence of ASD and the response to treatments. Current research is shifting the view of a solely genetic disorder to ASD as a genetic disorder which may be triggered by environmental factors with neurodevelopmental, health
By Anne Kelly M.D., MPH, FAAP, and Kathleen Schuler, MPH
MetroDoctors
Anne Kelly M.D., MPH, FAAP
and behavioral consequences.(3) More and more, scientists are suggesting a link between environmental toxins and ASD. In particular, the risk from prenatal and early life exposures to toxic chemicals is increasingly recognized.(4,5) Emerging Research
New theories of causation are based on the interplay of multiple factors, summarized as “GUIDE,” in Figure 1 on page 26. The body of science linking environmental toxins and autism is growing, as illustrated by results of a large scale study linking prenatal exposure to hazardous air pollutants with increased risk of autism.(6) Nutrition is critical to optimal child development and good nutrition early in life has positive effects on gut function, bone health, immunity, longevity learning, behavior, and it reduces risk for cardiovascular disease.(7) Studies suggest children with ASD have lower levels of critical nutrients and higher levels of various toxicants compared to controls.(8,9) Nutrients such as vitamin D, zinc and
The Journal of the Twin Cities Medical Society
Kathleen Schuler, MPH
selenium are known to counter the effects of some toxins, and antioxidants from fruits and vegetables have multiple benefits including neuroprotection. Emerging research suggests children with ASD have various genetic weaknesses, particularly associated with metabolic detoxification, perhaps making them more vulnerable to toxicants at lower doses. The triad of genetic vulnerabilities, nutrient deficiencies and cumulative toxin exposures may be the magnifying factors that “tip” a child into ASD. More Is Needed in Minnesota
Growing public concern, the alarming increase in the number of children diagnosed with ASD, and the significant growth in private and publicly funded health care expenditures for ASD highlight the need for a comprehensive public health plan. Public health resources are needed to systematically investigate a broader range of health-related factors (Continued on page 26)
September/October 2013
25
MedicalSpectrum Telemedicine Autism Care Organizations Disorders Autism and the Environment (Continued from page 25)
Figure 1
and potential environmental triggers. In addition to documenting ASD prevalence by race/ethnicity, sex, and cognitive functioning, there is an urgent need to collect data on other risk factors including timing and extent of environmental exposures to toxins, nutritional deficiencies, perinatal complications and dietary patterns. Case specific comprehensive data will contribute to a better understanding of how genetic vulnerabilities and complex environmental factors interact to result in the varied symptoms that make up ASD. The Centers for Disease Control’s (CDC) Autism and Developmental Disabilities Monitoring (ADDM) Network helps provide a better understanding of the prevalence, population characteristics, and impact of ASDs and other developmental disabilities in the United States. The ADDM Network employs a multisite, records-based surveillance methodology to retrospectively review data from education and health facilities. Four National Institute of Environmental Health Sciences long-term studies are looking at prenatal, neonatal and early life environmental exposures, as well as development of new research tools to better understand environmental contributors to ASD. While these efforts contribute to
our understanding of ASD prevalence and the role of environmental factors, there is much more that local public health and clinical systems can do to address the growing problem of ASD. Human biomonitoring — the measurement of chemicals and their metabolites in biological specimens/body fluids — is an important tool for integrating environment and health. The CDC’s National Health and Nutrition Examination Survey (NHANES) is an excellent model to assess exposure to environmental
At a recent National Institute of Environmental Health Sciences symposium on ASD, scientists identified a list of substances in our everyday environments that have the potential to affect learning and development. This list includes organochlorine pesticides, automotive exhaust, brominated flame retardants, mercury and lead.(3)
26
September/October 2013
chemicals and possible links to ASD risk. The Minnesota Department of Health’s biomonitoring program since 2007 has developed an excellent track record through several biomonitoring studies, both completed and underway. Enhanced bio-monitoring programs at the state level could contribute valuable information on children’s exposure to environmental toxins and provide additional state-specific data which could be used in epidemiological and clinical research on autism. Direct in-person evaluation of each child and possible environmental risk factors are not part of the ADDM assessment, but could add much needed data. New models of clinical care are being tested in Minnesota that could be used to collect data efficiently without duplicating services. A Minnesota medical home model designed to meet the needs of children with ASD was evaluated and families reported greater satisfaction with services and fewer unmet needs,(10) and the University of Minnesota, School of Nursing is evaluating clinical models that utilize advanced practice nursing and telehealth/ videoconferencing to coordinate care and remotely manage health problems for children with medical complexity.(11)
MetroDoctors
The Journal of the Twin Cities Medical Society
We don’t yet fully understand exactly how the genetic, dietary and environmental pieces of the autism puzzle fit together or which physiological mechanisms trigger autism and why. Although some of the increases in ASD incidence can be accounted for by improved identification and awareness, the steady increase in ASD diagnoses suggests that other factors may be playing a role. No single factor explains the changes identified in ASD prevalence over time, and much needs to be done to understand the relative contribution of the multiple factors involved. There is an urgent need for a coordinated and integrated approach to ASD within Minnesota. More children are receiving services for ASDs and data regarding their symptoms and responses to treatments are documented in disparate health care records throughout the state. Even without fully understanding the complex causes of ASD, integrating baseline and treatment data could provide valuable information and lead to more effective interventions. Prevalence estimates can be used to plan policy, educational, and health care services for ASD, but a concerted effort to enhance the public health response to the autism “tsunami” is called for. As a state, we can build on the excellent work our clinicians, researchers and the Minnesota State Health Department to develop a public health agenda and seek resources to help solve the autism puzzle. Anne Kelly M.D., MPH, FAAP, founder and past medical director, U Special Kids – University of Minnesota, and founder and president, Nutrition Ignition Learning Lab. She can be reached at: anne@nutritionignition. com. Kathleen Schuler, MPH, senior policy analyst, Institute for Agriculture and Trade Policy Co-Director, Healthy Legacy. References and a suggested reading list are available at: www.metrodoctors.com. Click on Publications Tab, MetroDoctors online, References and Resources.
MetroDoctors
The Journal of the Twin Cities Medical Society
Our new PICU
has pediatric trauma specialists at the ready and offers seriously ill or injured children the best chance at getting better.
We are proud to announce an even higher level of critical care with the grand opening of our new and improved Pediatric Intensive Care Unit. The modern family centered design features private rooms with private baths and enough space for families to gather and sleep in as they attend to a seriously sick or injured child. To speak to a physician, make a referral or admit a patient, call: HENNEPIN CONNECT at 800-424-4262 • hcmc.org/pediatrics
September/October 2013
27
New Members Eric P. Carls, M.D. Allina Medical Group Family Medicine Lian S. Chang, M.D. Lian S. Chang, M.D., LLC Psychiatry Kara V. Cundy, M.D. HealthPartners Internal Medicine Kambiz Farbakhsh, M.D. Life Clinic Medical Internal Medicine/Nephrology Brad A. Feltis, M.D. Pediatric Surgical Associates Pediatric Surgery Howard J. Haines, M.D. Emergency Physicians Professional Assn. Emergency Medicine David C. Homans, M.D. Park Nicollet Heart & Vascular Center Cardiology, Cardiovascular Diseases Joseph K. Hwang, M.D. University of Minnesota Department of OB/ GYN and Women’s Health Obstetrics and Gynecology Elizabeth L. Kennedy, D.O. Ridgeview Excelsior Clinic Family Medicine Alexander C. Lai, M.D. Minneapolis Radiology Neurology, Diagnostic Radiology, Neuroradiology James S. Mallery, M.D. Hennepin Healthcare System, Inc. Internal Medicine, Gastroenterology Jeffrey D. Meyer, M.D., MPH Fairview Clinics Internal Medicine, Occupational Medicine Joseph Rinowski, M.D. Park Nicollet Clinic Family Medicine Fredericus J. Van Kuijk, M.D. U of M, Dept. of Ophthalmology Ophthalmology Brian C. Weitz, M.D. Fairview Cedar Ridge Clinic Family Medicine Dayna L. Wolfe, M.D. Global Rehabilitation, LLC Pediatrics, Physical Medicine & Rehab
28
September/October 2013
MetroDoctors
The Journal of the Twin Cities Medical Society
In Memoriam
Cardiac Care at Saint Therese Strengthening the Heart for a Healthier Life Blending specialized skilled nursing with supervised exercise and education, Cardiac Care at Saint Therese gives your patients the confidence and tools to be successful at home.
LEONARD GREENE, M.D., passed away on May 27, 2013 at the age of 82. Dr. Greene was a pediatrician in Minneapolis for 40 years. Dr. Greene became a member in 1960. ERHARD L.A. HAUS, M.D., passed away in June 2013. Dr. Haus was a pathologist with Regions hospital since 1966. He became a member in 1971. MANUEL O. JAFFE, M.D., passed away at the age of 82 on June 18, 2013. Dr. Jaffe was board certiďŹ ed in dermatology and laser surgery. Dr. Jaffe became a member in 1986. ROBERT C. B. KNUTSON, M.D., age 91, passed away on June 26, 2013. Dr. Knutson graduated from the University of Minnesota Medical School in 1947 then trained as a fellow in anesthesiology at the Mayo Clinic. Dr. Knutson was a founding partner of Associated Anesthesiologists. He became a member in 1949.
Cardiac Care at Saint Therese offers... ‡ ,QWHJUDWHG SURJUDPPLQJ FRQQHFWLQJ GRFWRUV QXUVHV UHKDE VSHFLDOLVWV clinical nutritionist and on-site pharmacists ‡ 6SHFLDOO\ WUDLQHG VWDII VNLOOHG LQ FDUGLDF UHKDE ‡ 2Q VLWH (.* ‡ &DUGLRORJLVW FRRUGLQDWLRQ ‡ 3RVW GLVFKDUJH FRRUGLQDWLRQ WR KHOS SUHYHQW KRVSLWDO UHDGPLVVLRQV SA I N T TH E R E S E of N E W H O P E
To learn more call 763.531.5028 or visit sttheresemn.org/cardiaccare %DVV /DNH 5RDG ‡ 1HZ +RSH 01
ANATOL LYSYJ, M.D., passed away on June 5, 2013 at the age of 87. Dr. Lysyj was an OB/GYN practicing at Oakdale Obstetrics & Gynecology as well as Fairview Hospital and North Memorial Medical Center. He became a member in 1954. PAUL A. STAHLER, M.D., age 90, passed away on June 28, 2013. Dr. Stahler attended Marquette University in Milwaukee completing an internship at Jersey City Medical Center and a surgical residency in Wisconsin. Dr. Stahler became a member in 1950. THEODORE R. THOMPSON, M.D., age 70, passed away on Sunday, July 28, 2013. Dr. Thompson was a neonatologist and professor in the department of pediatrics at the University of Minnesota for 42 years. Dr. Thompson became a member in 1985.
MetroDoctors
The Journal of the Twin Cities Medical Society
September/October 2013
29
MCC Helps Alleviate Provider Frustration with Credentialing
W
hen physicians identiďŹ ed credentialing as one of their top three administrative burdens, MMA listened and set out to address the problem. The Minnesota Credentialing Collaborative (MCC) brought physicians (and other health care providers), hospitals and health plans together to simplify the credentialing process and eliminate paper applications. Over the past four years, the MCC’s Community Partners have made continuous improvements to the credentialing process. Two recent improvements ensure that the hospitals and health plans obtain all information needed to process the application, and simplify the physician’s role in signing and sending the application. The MN health plans reached agreement on the core set of data that must be submitted for credentialing, and the MCC ApplySmart tool ensures that these data elements are complete before allowing the application to be submitted. Deb Luck, Credentialing Supervisor at BlueCross BlueShield indicates “Applications submitted through the MCC help us be more efďŹ cient and process applications more quickly. It reduces the need to go back to providers for missing or incomplete information. And the digital signature process ensures the date is legible — a key stumbling block for credentialing compliance.â€? In July, the MCC simpliďŹ ed the physician’s role in signing and sending the application. Clinic administrators can now queue up applications for the physician. The physician reviews the application, enters his or her digital signature, and the application is sent electronically to all the hospitals/health plans selected. Susan Gibson, Minnesota Oncology Hematology, PA states she is a big fan of the MCC, “the new processes eliminate the need to courier documents to physicians and wait for returned applications — which may/may not be complete.â€?
30
September/October 2013
With the advent of electronic medical records, physicians are familiar with the technology and digital signature process. When the next hospital or health plan
Already, over 30,000 applications have been submitted through MCC. credentialing packet is due, the majority of the work is already complete. You simply update the information, apply the digital signature, and electronically submit the
application. Health plans record the receipt of the application and many will update the status of the application throughout the credentialing process, reducing the need for follow-up phone calls to check on the application’s status. Gayle Peterson, Minnesota Gastroenterology, PA ďŹ nds that “the time to process an application has been cut in half as a result of a more efďŹ cient process. The software is user friendly with tools that allow you to review the required ďŹ elds by payer. Once the application is submitted, you feel secure it was submitted accurately.â€? (Continued on page 31)
CAREER OPPORTUNITIES
W
Boating, Beethoven, Bluffs and more! www.winonahealth.org
Join our progressive healthcare team, full-time opportunities available in these areas: Dermatology Emergency Medicine Family Medicine
Hospital Medicine Internal Medicine Orthopedics
Pediatrics Psychiatry
Winona, a sophisticated community nestled between beautiful bluffs and the mighty Mississippi— kayak the rivers, fish the streams, watch the eagles, take in world-class performances during the Beethoven and Shakespeare festivals and stand inches away from a Van Gogh at the MN Marine Art Museum. Learn more at visitwinona.com.
Contact Cathy Fangman ) cfangman@winonahealth.org
# % ) Winona, MN 55987 ) 800.944.3960, ext. 4301 ) winonahealth.org MetroDoctors
The Journal of the Twin Cities Medical Society
CAREER OPPORTUNITIES
Please also visit www.metrodoctors.com
Fairview Health Services Opportunities to fit your life
Fairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Shape your practice to fit your life as a part of our nationally recognized, patient-centered, evidence-based care team. Whether your focus is work-life balance or participating in clinical quality initiatives, we have an opportunity that is right for you: 3 3 3 3 3
Dermatology Emergency Medicine Family Medicine General Surgery Geriatric Medicine
3 3 3 3 3
Hospitalist Internal Medicine Med/Peds Ob/Gyn Palliative
3 Pediatrics 3 Psychiatry 3 Urgent Care
Visit fairview.org/physicians to explore our current opportunities, then apply online, call 800-842-6469 or e-mail recruit1@fairview.org.
Sorry, no J1 opportunities. fairview.org/physicians TTY 612-672-7300 EEO/AA Employer
MCC (Continued from page 30)
Dolly Schmidt, MCC Executive Director is enthused about product expansions being released this fall. ApplySmart Plus will allow physicians to submit applications electronically to CAQH (clearinghouse for national health plans), without needing to complete the cumbersome CAQH forms and re-attestation process. In addition, physicians can use the system to track CME and quality. The second ApplySmart Plus product release due out later this fall, will provide sophisticated reporting and data management tools at a cost that may be significantly less than competitors’ solutions — and utilizes the data already stored in the providers application. If you are interested in learning more about the MCC and its new product releases — please contact us at supportmcc@ credentialsmart.net or dschmidt@mncred. org. MetroDoctors
The Journal of the Twin Cities Medical Society
September/October 2013
31
LUMINARY of Twin Cities Medicine By Marvin S. Segal, M.D.
ABRAHAM BERT BAKER, M.D. It is unlikely that he topped 5’5” in his stocking feet, but in many other ways he was larger than life — a true Giant of Minnesota and Twin Cities medicine. Dr. A.B. Baker’s brilliance was evident from the time of his early education in the Minneapolis Public Schools through the U of M where he earned B.A., B.S., M.S., M.D. and Ph.D. degrees — being honored along the way with election to Phi Beta Kappa, AOA and Sigma Xi. His initial research and teaching staff career at the U led to him being named Professor and Chief of Neurology at age 38 — a position he held until his academic retirement over 30 years later. Dr. Baker’s research interests were diverse though profound. The subject of his Ph.D. thesis was hemorrhagic encephalitis and he was the first to isolate its causative virus. Among his 200+ paper contributions to the medical literature were monumental additions regarding poliomyelitis — its pathology and clinical characteristics. His work on bulbar polio led to the true localization of the respiratory center in man and his utilization of tracheostomy in these patients resulted in a remarkable 80 percent decrease in the mortality of that dreaded disease. Later in his career his research and writing focused upon neurovascular disease, and he applied his superb clinical skills at Mount Sinai Hospital after retiring from the U. It is ironic that the cause of his death was Alzheimer’s Disease, a condition that he dealt with significantly during his professional career. A.B. Baker was named, in an informal survey, by a majority of former students as the most memorable of their clinical faculty contacts. The reasons mentioned for choosing him dealt little with his remarkable accomplishments (founder of the American Academy of Neurology; instrumental in the creation of the National Institute of Neurologic Disorders; primary mentor of hundreds of neurologists — many occupying academic posts and heading their own departments; author/ editor of “Clinical Neurology,” the leading neurology text; world-wide honors of recognition as arguably the leading neurologist of his time; and a coveted Regents 32
September/October 2013
Professorship from his alma mater). Rather, they were led to this choice by his superbly organized and crisply delivered lectures, his teaching of a diagnostic pathologic profile methodology that had far reaching applications well beyond the field of neurology, by figuratively traveling with him through the nervous system and meticulously localizing the site of a pathologic lesion, and especially by thinking back to his total treatment sessions — where scientific objectivity took a back seat to the compassion and understanding required to carefully observe and care for the total patient. The humanistic instincts of Abe Baker, relayed to his students in a firm though empathetic fashion would, for example, emphasize that how a new stroke patient was being supported in activities of daily living or how they would fit into a family constellation were every bit as important as pin-pointing the site of a lesion or determining specific medication requirements. The ability to list all cranial nerves in order may eventually fade from the memory of a young physician, but the expectation of Dr. Baker for that doctor to care for the gamut of requirements of an ill person would hopefully linger indefinitely. Dr. A.B. Baker — a scholar, a dedicated family man, an energetic clinician and patient advocate, and a supremely gifted teacher. Yes, a true Giant of Minnesota and Twin Cities medicine. This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com.
MetroDoctors
The Journal of the Twin Cities Medical Society
MetroDoctors
The Journal of the Twin Cities Medical Society
July/August 2013
33
Relax.
Discover solutions that put you at ease.
At MMIC, we believe patients get the best care when their doctors feel calm and conďŹ dent. So we put our energy into creating risk solutions designed to eliminate worry. Solutions such as medical liability insurance, physician well-being, health IT support and patient safety consulting. It’s our own quiet way of revolutionizing health care. To join the Peace of Mind Movement, give us a call at 1.800.328.5532 or visit MMICgroup.com.