1. Treating The Whole Child SPARC 2011 Conference Largo, FL September 25, 2011 David Berger, MD, FAAP Board Certified Pediatrician Owner – Wholistic Pediatrics, Tampa , FL Assistant Professor – University of South Florida College of Nursing www.wholisticpeds.com

2. What is Wholistic Pediatrics? Wholistic Pediatrics is the name of our medical practice. It recognizes the individuality of the patient/family and takes into account the many differences in a person/family’s health philosophy and the many options that are involved in maintaining or obtaining optimal health.

3. The Medical Home Model The Medical Home is a place a family can go to provide all needs for their child. Besides providing individualized, high quality care, a medical home should be able to provide a network of specialists, therapists, counselors, and educators so that all needs of the patient/family is met. This model is what is being advocated by the American Academy of Pediatrics and the US-Department of Health and Human Services

4. Autism Medical Home tinyurl.com/autism-medical-home

5. When treating the whole child, we first need to discuss “prevention.” It is my belief that there are steps that a family takes prior to conception, during pregnancy, and infancy that can reduce the likelihood of a child having developmental, intestinal, or immunological issues This is a lecture all its own, which I gave three years ago at this conference, and I would direct interested families to the Lectures section at www.wholisticpeds.com, Power Point Presentation (slide Show): “Prevent Harm Now: How to Carry, Birth, and Raise a Healthy Child in a Toxic World” SPARC Conference, September 2008

6. About “Recovery” The goal of treatment is recovery: defined as a more rapid developmental trajectory, restoration of specific functions and, in the best case, a normal life. Recovery is NOT the same as a cure.

7. Getting Enrolled in Various Therapies Each community/county/state will have its own system for getting children enrolled in government-funded programs. We are fortunate in our community that the USF-Center for Autism and Related Disabilities has knowledge of biomedical therapies and will refer interested families to our office…..but this seems to be the exception and not the rule in other communities.

8. Various Types of Educational Therapies ABA – most widely accepted/implemented – evidence based – well documented results Pivotal Response Training Carbone method Floortime RDI ETC…

9. Positive Reinforcement Regardless of which therapy you choose, The key to increasing frequency of desired behaviors and decreasing undesired ones is positive reinforcement every day across all environments This is not intuitive or easy, it requires a lot of thought and effort and it’s full time Must be consistent across all environments – home/school/grandparent’s house/etc to be effective Data must be tracked Timeouts, consequences, etc. are used differently with ASD kids

10. Other Evidence-Based Therapies Speech Therapy Occupational Therapy/Physical Therapy Physical Therapy Sensory Integration Auditory Integration Therapy (AIT) Craniosacral therapy Vision Therapy

11. Sensory Integration Dysfunction(SID) Sensory integration dysfunction is a brain disorder affecting at least 5 percent of the population. The condition occurs most often in those with autism, attention deficit disorders, fragile X syndrome, and the intellectually gifted. Those with SID appear to experience either muted or exaggerated chemical reactions in the brain to specific sensory stimulation.

12. Unique Sensory Needs Each child has a unique set of sensory needs. Generally, a child whose nervous system seems “high wired” needs more calming input, while the child who is more “sluggish” needs more arousing input.

13. Sensory Diet A “sensory diet” (phrase coined by OT Patricia Wilbarger )is a carefully designed, personalized activity plan that provides the sensory input a person needs to stay focused and organized throughout the day. Just as you may jiggle your knee or chew gum to stay awake or soak in a hot tub to unwind, children need to engage in stabilizing, focusing activities too. Those not able to “self regulate” need to be taught how to do this. http://sensorysmarts.com/sensory_diet_activities.html

14. Audio Integration Therapies Therapeutic Listening Tomatis Berard

15. Therapeutic Listening Therapeutic Listening is a highly individualized method of auditory intervention utilizing electronically altered compact discs in protocols specifically tailored by sensory integrative professionals to match client need. This must be supervised by a qualified therapist to be successful.

16. Therapeutic Listening implemented in a variety of settings including clinic, school, and home (however was designed for use a home program) designed for children 2 years of age and older including adults Designed for individuals with sensory modulation issues except those with schizophrenia and/or sound-evoked seizures 20-30 minute sessions, two times per day, for 5-7 days per week for each CD

17. Therapeutic Listening The therapist chooses the CD’s based on the clients issues and response to other CD’s. The CD’s for each series have specific guidelines for use and specific clinical applications for which they are appropriate. Each individual’s CD selection is unique in the type of modulated music. The client also participates in movement activities to help integrate the body and nervous system. Listening With the Whole Body: Clinical Concepts and Treatment Guidelines for Therapeutic Listening, By Sheila Frick, OTR and Sally Young, PhD www.vitallinks.net has a list of providers who offer this therapy.

18. Tomatis Method Founded by Alfred Tomatis, a French ENT, in the 1950s Tomatis felt the ear is important not only for hearing but also for energizing and regulating the brains state of alertness and attention, coordinating posture and movement, and connecting our intentions and thoughts with our physical and verbal interactions with our environment. (www.tomatis.net)

19. Tomatis Method Consists of 4-6 hr sessions per week, followed by a pause for several weeks Trains the ear to make fine discriminations of sound in the desired high frequency range Helps train the ear to accommodate to and focus on those important sounds that lay the foundation for language and communication not a home program (www.tomatis.net)

20. Berard Method developed by Dr. Guy Berard, in France 40 years ago designed specifically for individuals with Hyperacusis and/or hypersensitivity to sound; These individuals can’t sift through everyday sounds to pay attention to what is important. Sounds are intensified for them, decreasing their concentration and increase their distractibility. (www.aitinstitute.org )

21. Berard Method consists of 2- ½ hr sessions per day for 2 weeks appropriate for children 3 and up and adults only devices endorsed by Berard are the Earducator and the AudioKinetron (which is being phased out, replaced with the Digital Auditory Aerobics Device.) These devices modulate the music that is played through it (no special CD’s are used for this program) not a home program (www.aitinstitute.org )

22. Vision Therapy A type of physical therapy for the eyes and brain -- is a highly effective non-surgical treatment for many common visual problems such as lazy eye, crossed eyes, double vision, convergence insufficiency and some reading and learning disabilities. In the case of learning disabilities, vision therapy is specifically directed toward resolving visual problems which interfere with reading, learning and educational instruction. Listening With the Whole Body: Clinical Concepts and Treatment Guidelines for Therapeutic Listening, By Sheila Frick, OTR and Sally Young, PhD

23. Vision Therapy-What Is It? a progressive program of vision "exercises" or procedures; performed under doctor supervision; individualized to fit the visual needs of each patient; conducted in-office, in once or twice weekly sessions of 30 minutes to one hour; sometimes supplemented with procedures done at home between office visits ("home reinforcement" or "homework"); (depending on the case) prescribed to -- help patients develop or improve fundamental visual skills and abilities; improve visual comfort, ease, and efficiency; change how a patient processes or interprets visual information. http://www.visiontherapy.org/

24. Biomedical Treatment Diet (ideally with a physician, nutritionist or dietitian who has experience with this population)– gluten/casein-free diets, and elimination of other food allergens, low sugar, etc. Individualized treatment plan with autism medical specialist (MD, ND, DO, etc.) to address: Food and environmental allergies and sensitivities Amino acid deficiencies Enzyme deficiencies Chronic rashes, diarrhea, etc.

25. Basic Strategy Give them what they need nutritionally Minimize triggers of inflammation – allergies, toxins Break the inflammatory cycle

26. Improving the Diet Consume 3-4 servings of nutritious vegetables and 1-2 servings of fruit each day. Consume at least 1-2 servings/day of protein Greatly reduce or avoid added sugar (soda, candy, etc.) Avoid “junk food” – cookies, fried chips, etc. (even if GF/CF, etc) Greatly reduce or avoid fried foods or foods containing trans-fats Avoid artificial colors, artificial flavors, and preservatives Go organic as much as possible. Read about the “Dirty Dozen” and “Clean 15”: http://tinyurl.com/CNN-DirtyDozen

27. Detecting Food Allergies Look for: Red cheeks Red ears Dark circles under eyes Changes in behavior related to food consumption Keep a diet log: Look for patterns between symptoms and foods eaten in the last 1-3 days Elimination-Reintroduction Diet (on Medical Topics section) Order IgE and IgG blood tests*: IgE related to an immediate immune response IgG relates to a delayed immune response (Please note that IgG testing is not definitive—it only provides a short list of likely suspects. The only way to be sure is to do a very methodical elimination diet. If funds are tight and you can’t get IgG testing covered by insurance, skip it.)

28. Evidence from GI Scoping This is what allergens do to a sensitive person’s GI tract; this kind of tissue should be smooth and uniformly pink.

29. Allergies or not: Gluten-/Casein-free Diet Rationale: T. Buie at Harvard Medical School found that many children with autism have defective and/or few digestive enzymes – means food doesn’t break down. This is different from a food allergy. Large proteins like gluten and casein cause problems in the bloodstream. If not fully digested, opiate like proteins can be produced and cause negative symptoms Recommendations: Requires 100% avoidance of all gluten products and all dairy products (often soy, and sometimes corn and rice as well) Giving digestive enzymes with food may further help Caution: need calcium supplement unless on excellent diet

30. Vitamin & Mineral Supplements Rationale: A double-blind, placebo-controlled study (published by Adams et al.) found that a strong, balanced multi-vitamin/mineral supplement resulted in improvements in children with autism in sleep and gut function, and possibly in other areas. Recommendation: Use an allergen-free multi-vitamin. There are many formulas specifically for ASD. It only works if it goes in – use reinforcers.

31. Vitamin D There is emerging evidence that neurological and immunological development are impacted by vitamin D deficiency. The impact likely starts during pregnancy. I would recommend that prior to conception or during pregnancy, all women have their 25 hydroxyvitamin D level checked, and by either sun exposure or supplementation get her level at least to 50ng/ml.

32. Vitamin D (continued) In my practice, which is in “sunny” Florida, we find that pregnant women average about 30 mg/ml. It takes between 1000-2000mg of vitamin D3 to raise the blood level 10mg/ml. Powdered capsules may work best. The Vitamin D Council recommends that all pregnant women take 5000IU of vitamin D3. I think it is reasonable to start this dose and then check the mother’s blood level after 3 months of daily supplementation. We also increase the mother’s vitamin D3 intake by 2000IU once the baby has delivered if she is nursing, or add 1000IU to infant formula if not breast feeding.

33. Methylcobalamin Rationale:Methyl-B12 is closely aligned with the folic acid biochemical pathway and is necessary for detoxification. Unfortunately, many autistic children have a defect in the enzyme associated with the methylationpathyway. Recommendations:MB-12 is only by prescription. For approximately 85% of children 65 -75 mcg/kg/every 3 days works well. Some children need it more frequent (ie every 1-2 days) and others can tolerate it only if given once a week. It is best if given by a small injection

35. Vitamin B6 is required for production of serotonin, dopamine, and glutathione.

36. Magnesium helps curtail hyperactivity caused by B6 alone.

38. Amino Acids Rationale: Some children with autism have digestive problems and self-limited diets that are low in protein. This can lead to amino acid deficiency, (get fasting blood panel to identify) depriving the brain of neurotransmitters, hormones, enzymes, antibodies, immunoglobulins, glutathione, etc. Recommendations: Test: Fasting plasma amino acids, and possibly 24 hr urine (NOTE: unusually high levels in urine may indicate wasting) Increase protein intake Use digestive enzymes Give a customized amino acid

39. Digestive Enzymes A Comprehensive Digestive Stool Analysis can reveal if some types of foods are not being digested well, suggesting a problem with specific digestive enzymes. But I usually treat presumptively if there is presence of undigested food particles in the stool or if stool remains abnormal after probiotics and yeast/bacteria removal Use allergen-free digestive enzymes to aid in breaking down food and facilitation better nutrient absorption Enzymes come in capsule form (but can be sprinkled on food) Give with every meal.

40. Yeast in the Gut Rationale: Many anecdotal reports of yeast overgrowth in children with autism, but limited research evidence. We suspect some yeast toxins can have major effect on behavior/aggression. Recommendations: Probiotics: 30-500 billion CFU’s Antifungals: Nystatin, Diflucan, Sporanox, Nizoral, Lamisil, or Amphotericin Low-sugar diet /Specific Carbohydrate Diet Stool analysis and Organic Acid testing for gut bacteria/yeast markers

41. Thyroid Rationale:Perhaps 10% of general population has low thyroid levels, and at least that many children with autism also may have that problem. One study found that children with autism have unusually low iodine levels Low iodine is the major cause of mental retardation worldwide (over 80 million cases) - becoming more common in US (decreased use of iodized salt). Recommendations: Testing: Measure body temperature before waking; should be above 97˚F Measure iodine levels Thyroid function and auto-antibody testing (caution re. reference ranges being too broad in some cases) Treatment: Iodine supplementation if low Thyroid supplements, preferably natural animal extracts; caution re. overdosing;

42. Sulfation Rationale:Many children with autism have excess loss of sulfate in their urine, resulting in a low level of sulfate in their body. Recommendations: Testing: Urine testing of free and total sulfate is useful to check for excessive loss of sulfate. Blood testing can be used to check for levels of free and total plasma sulfate. Treatments: Oral MSM (500-2000 mg depending on size and sulfate level) Epsom Salt (magnesium sulfate) baths – 2 cups of Epsom salts in warm/hot water, submerged up to necksoak for 20 minutes, daily Epsom salt rubs: see article on Medical Topics Section at www.wholisticpeds.com

43. Glutathione Rationale: Studies show low glutathione (critical antioxidant) in children with autism due to abnormalities in their methylationpathway. Recommendations: Testing: Measure level of glutathione (fasting plasma or RBC). Treatment: Oral glutathione is poorly absorbed (perhaps 15%). Alternatives include IV /transdermal/nebulized glutathione, or N-acetyl cysteine (precursor to glutathione, but be careful of causing yeast relapse)

44. Clean up Your Home Go to: http://autism.com/pro_webcasts.asp and watch Dr. Freedenfeld’s presentation on removing toxins from your child’s environment.

45. Immune Function Rationale: Several studies found altered immune system in autism, generally with shift to Th-2, and some evidence for increased incidence of auto-immunity. Recommendations: Treatments include: IVIG: (Gupta et al., found IVIG benefited 4 of 10 children, with 1 case of marked improvement, though improvement is sometimes short-lived. ) Immunomodulators such as Low dose Naltrexone and Spironolactone Antiviral therapies (Valtrex, acyclovir)

46. Each chapter covers developmental areas of gross motor, fine motor, cognitive, language, self-care, and emotional social skills — the building blocks to academic achievement, athletic prowess and social and emotional balance. 44

47. Red boxes provide activities and exercises that you do with your child to promote the various developmental skills for optimal overall growth and development. The manual is structured in various monthly development stages so that the parent learns as they go. This information is powerful. It is everything a parent needs to have the knowledge and skills to make the most of their time with their child. Hundreds of photos visually stimulate what you can do to help your toddler reach their full potential. Blue boxes share pertinent information of key points that help you grasp core developmental concepts. 45

48. Antibiotics Antibiotics have been associated with yeast and clostridia overgrowth conditions. It is estimated that 70-80% of antibiotics prescribed in America are not necessary. I would strongly recommend following the “first signs of illness” article on the Medical Topics section of our webpage (or the flu article during flu season), most patients significantly improve within a day if started right away.

49. Antibiotics (continued) About 75% of ear infections will clear without antibiotics, using pain medications and proper hydration. If there is not a hole in the ear drum, I will add an olive oil/garlic/goldenseal product to be placed in the ear canal. “Bronchitis” in pediatrics is a viral infection. There is no role for antibiotics in “bronchitis.” If abnormal lung sounds are heard, get a chest x-ray to confirm a bacterial pneumonia before being starting an antibiotic. “Sinusitis” is a very questionable diagnosis, I would wait until a patient was non stop for 2 weeks with significant runny nose/congestion and a trial of allergy treatment before starting an antibiotic. Pharyngitis should only be treated if proven to be Strep. Fine to wait for a culture to come back before treating.

50. Vaccines For a comprehensive discussion about the biological plausibility of a relationship between vaccines and autism, I would suggest viewing my lecture from the Dallas 2009 DAN!/ARI conference, which can be found on the “Free Online Lectures” page at www.autism.com. I also would recommend reading Stephanie Cave’s “What Your Doctor May Not Tell You About Children's Vaccinations” (revised 3/11) and Dr Bob Sears’ “The Vaccine Book”.

51. Hepatitis B Vaccination of Male Neonates and Autism Diagnosis, NHIS 1997-2002 Carolyn M. Gallagher, Melody S. Goodman (SUNY Stonybrook). J Tox and Environ Health, Nov 2010 Universal hepatitis B vaccination was recommended for U.S. newborns in 1991; however, safety findings are mixed. The association between hepatitis B vaccination of male neonates and parental report of autism diagnosis was determined. This cross-sectional study used weighted probability samples obtained from National Health Interview Survey 1997–2002 data sets. Vaccination status was determined from the vaccination record. Logistic regression was used to estimate the odds for autism diagnosis associated with neonatal hepatitis B vaccination among boys age 3–17 years, born before 1999, adjusted for race, maternal education, and two-parent household. Boys vaccinated as neonates had threefold greater odds for autism diagnosis compared to boys never vaccinated or vaccinated after the first month of life. Non-Hispanic white boys were 64% less likely to have autism diagnosis relative to nonwhite boys. Findings suggest that U.S. male neonates vaccinated with the hepatitis B vaccine prior to 1999 (from vaccination record) had a threefold higher risk for parental report of autism diagnosis compared to boys not vaccinated as neonates during that same time period. Nonwhite boys bore a greater risk.

52. Vaccines (Continued) So if you hear that there are no studies that have shown that there is an association between vaccines and autism, that is just not true. But each parent must make their own decision on how to proceed with vaccines for their child. Informed Consent implies not only that a parent consents to giving a vaccine, but that the parent has been fully educated as to the risks, benefits and alternatives. As part of Florida legislation that did not pass last year, we created “The Statement of Florida Vaccine Rights and Informed Consent”, which can be found on the VACCINES section at www.wholisticpeds.com

53. THE FLEXIBLE VACCINE SCHEDULE FAMILIES HAVE THE RIGHT TO FOLLOW THE STANDARD 2011 CDC IMMUNIZATION SCHEDULE. MINIMAL TIME INTERVALS BETWEEN VACCINES SHOULD BE ESTABLISHED BASED ON THE 2011 CDC CATCH-UP IMMUNIZATION SCHEDULE http://www.cdc.gov/vaccines/recs/schedules/downloads/child/catchup-schedule-pr.pdf STATE REQUIRED VACCINES: NAME Dose # Age to give DTaP or non-Thimerosal Diphtheria-Tetanus 1 2-36 months (minimum of 1 month in between dose 1 and 2) 2 4-39 months (minimum of 1 month in between dose 2 and 3) 3 6-42 months (minimum of 6 months in between dose 3 and 4) 4 15-72 months (minimum of 6 months in between dose 4 and 5) *5 4-6 years Tetanus-Diphtheria or Tdap (booster dose) 1 11-12 years *per the CDC, the fifth dose is not necessary if the forth dose was administered at age 4 years or older, but at least 4 doses are needed before starting Kindergarten.

54. THE FLEXIBLE VACCINE SCHEDULE STATE REQUIRED VACCINES: NAME Dose # Age to give Polio 1 2-36 months 2 4-39 months 3 6-72 months** 4* 8-10 years** Must be a minimum of 4 weeks between each dose *per the CDC, if the 3rd dose of Polio is given at 4 years or older, a 4th dose is not necessary, but at least 3 doses are needed before starting Kindergarten. ** consider getting IgG titer before giving this dose and exempting if titers indicate patient is protected ------------------------------------------------------------------------------------------------------ Varicella (Chicken Pox) 1 12-48 months 2 48-72 months** Must be a minimum of 3 months between each dose ** consider getting IgG titer before giving this dose and exempting if titers indicate patient is protected

55. THE FLEXIBLE VACCINE SCHEDULE NAME Dose # Age to give Measles/Mumps/Rubella*** 1* 12-48 months 2** 48-72 months Mumps*** 1 12- 48 months 2 48-72 months Rubella*** 1 12- 48 months 2 48-72 months Measles*** 1 12 - 48 months 2 48-72 months **only if there are negative IgG titers for one or more components and MMR Triple Vaccine is only option available. *** minimum of 1 months in between any 2 doses check IgG titers for all children in the 12 months prior to starting Kindergarten for Measles, Mumps and Rubella. If not protected for one of the viruses and only MMR available, give MMR #2 at least 1 months after Triple or any of the single components given. If single virus available, give what is lacking, 1 month between each vaccine.

56. THE FLEXIBLE VACCINE SCHEDULE NAME Dose # Age to give Hib* 1 15-18 months (only 1 dose is recommended after 15 months old) *Family can also choose to follow the more standard recommendations of giving 3 doses prior to 15 months and 1 additional after 15 months as stated by the current CDC catch up schedule ----------------------------------------------------------------------------------------- Prevnar ** 1 (24-30 months) (only 1 dose is recommended after 2 years old) ---------------------------------------------------------------------------------------- Hep B ** 1 11-13 years 2 3 months after 1st dose 3 3 months after 2nd dose **Family can also choose to follow the more standard recommendations as stated in the current CDC catch up schedule

57. My Personal Recommendations Regarding Vaccines Do not vaccinate when there is signs of over-inflammation such as active wheeze, eczema or allergy. Consider waiting until 2 years old, or not vaccinating at all, children who are high risk, or with significant family history, of auto-immune or hyper-inflammatory conditions. Give vitamin C, zinc and Echinacea/larix from 3 days before until 3 days after any vaccines, and vitamin A the day before, of, and after (dosing according to “On the first signs of illness article” on the Medical Topics section at www.wholisticpeds.com.) Get IgG titers before boosters in year prior to starting Kindergarten, only give vaccine if not immune at that time (? Tetanus “legality”).

58. My Personal Recommendations Regarding Vaccines Unless there are certain circumstances (mom Hep B+, early day-care), consider waiting until at least 6 months old before giving any vaccine. Do not give more then 1 new vaccine at a time so if there is a reaction, it may be easier to figure out what it was due to. Consider giving more than 1 vaccine at a time for 3rd and subsequent doses for a particular vaccine, if there were no negative reactions to the first 2 doses. Wait at least 3 months in between live virus vaccines (M,M,R and Varicella). Consider delaying these until 2 years old unless high incidence in community. Do not vaccinate when sick or until 2 weeks after illness resolved.