april 2016

April 2016

Volume 5Issue 4

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S a n M a t e o C o u n t yIN

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E Autism Spectrum Disorder: the biggest challenge

of our generation

Successful outcomes for children with ASD

No MMR-autism link in large study of vaccinated vs.

unvaccinated kids

Physician

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Editorial Committee

Russ Granich, MD, Chair; Judy Chang, MD; Uli Chettipally, MD; Sharon Clark, MD; Carri Allen Jones, MD; Edward Morhauser, MD; Gurpreet Padam, MD

Sue U. Malone, Executive Director Shannon Goecke, Managing Editor

SMCMA Leadership

Michael Norris, MD, President; Russ Granich, MD, President-Elect; Alexander Ding, MD, Secretary- Treasurer; Vincent Mason, MD, Immediate Past President

Alex Lakowsky, MD; Richard Moore, MD; Michael O’Holleran, MD; Joshua Parker, MD; Suzanne Pertsch, MD; Xiushui (Mike) Ren, MD; Sara Whitehead, MD; Douglas Zuckermann, MD; Dirk Baumann, MD, AMA Alternate Delegate; Scott A. Morrow, MD, Health Officer, County of San Mateo;

Editorial/Advertising Inquiries

San Mateo County Physician is published ten times per year by the San Mateo County Medical Association. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted.

Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised.

For more information, contact the managing editor at (650) 312-1663 or smcma@smcma.org.

Visit our website at smcma.org, like us at facebook.com/smcma, and follow us at twitter.com/SMCMedAssoc.

© 2016 San Mateo County Medical Association

April 2016 - Volume 5, Issue 4

Columns

S a n M a t e o C o u n t y

Physician

Feature Articles

Autism Spectrum Disorder: The biggest challenge of our generation ............................................... 8Uli Chettipally, MD, MPH

Successful outcomes for children diagnosed with ASD ....................... 10Kylie Billingsly, PhD

No MMR-Autism link in large study of vaccinated vs. unvaccinated kids .......................................................... 12Autism Speaks

SMCMA membership updates...............................................................13

Classified ads, index of advertisers ......................................................14

Of Interest

President’s Message: Strength in numbers ............................................... 5Michael Norris, MD

On the cover: St. Mary’s Pre School City Quay, by Flickr user William Murphy. Reprinted with permission under Flickr Creative Commons license. (https://www.flickr.com/photos/infomatique/6851747542)

4 SAN MATEO COUNTY PHYSICIAN | APRIL 2016

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The passing of the torch...

President’s Message

Michael Norris, MDPresident

Strength in numbers

Pre-game show for the Warriors’ first playoff game with Houston. Camera shows MVP Steph Curry warming up, wearing a sweatshirt with the team’s playoff slogan “Strength in Numbers.”

Hmm…what a concept—so basic, yet so awkward to attain. Throughout this recent NBA season, the Warriors have been celebrated for their team approach to the game. For many years the style of play in the league has centered about one or two stars, who would control every possession, turning the game into a “one on one” contest, while the other four teammates stood and watched. The Warriors have embraced the unselfish style of multiple passes, with each player on the floor participating, and sharing the scoring. The Warriors have the strongest bench in the league, with each member expected to be ready to perform at top level when called upon. Of course, Mr. Curry has set many personal scoring records this season, but he is just as ready to pass to a teammate who may have a better shot at that moment. There are 15 players on the team, and each night 10 or 11 will play important minutes and contribute to the success as seen this season. The record would not be as record-shattering if not for the “Bench.”

I recently participated in a team activity in Sacramento, as the CMA held its annual Legislature Advocacy Day, an opportunity for physicians to engage their representatives and discuss mat-ters important to all doctors. SMCMA was represented by doctors Alex Ding, Russ Granich, Vincent Mason, Barbara Weissman; Executive Director Sue Malone and me. One night we were joined for dinner by Senator Jerry Hill and Assemblymember Rich Gordon. We talked at length about prospective legislation, and our representatives were quite open to a frank back-and-forth

What is organized medicine? Is it campaign donations, ballot measures, lobbying? Yes...and more. The individual physician is an important member of the team. Analogous to the Golden State Warriors, each member of the team, whether the MVP or the bench player, needs to be able to step up and perform when needed.

Continued on next page

6 SAN MATEO COUNTY PHYSICIAN | APRIL 2016

President’s Message (continued)

discussion. That evening Senator Mark Leno also stopped by. The next day, Mr. Gordon gave us a tour of the Assembly cham-ber, and Kevin Mullin joined us for a photo in front of the speak-er dias. I felt like a middle school kid on a field trip as we toured the State Capital.

Watching the system in action demonstrates to me that out people in Sacramento are very busy with committee meetings, presentations and government business. For them to take time to meet with us showed how important physicians and their is-sues are on a state and national level. “Organized” medicine is not a bad thing, and can accomplish a great deal for the lives of doctors and their patients. But what is organized medicine? Is it campaign donations, ballot measures, lobbying? Yes…and more. The individual physician is an important member in the “Team.” Analogous to the Warriors, each member of the team, whether the MVP or the bench player, needs to be able to step up and perform when needed.

So how does one doc participate in the big show? Too often I hear “The medical society does nothing for me.” How can one come to that belief, when they have never asked questions about the organization, never engaged a board member, never joined a committee? If you have an issue, let someone know. You can be an important member of the team, or be the guy on the end of the bench, overlooked when it comes to playing time.

A great way for members to get engaged is to participate in our activities and programs.

The SMCMA has a separately incorporated Community Service Foundation that administers a free community health program, Walk-With a Doc. Now in its sixth year, our 2016 program will feature 26 Saturday morning walks at preserves and trails all over San Mateo County, from East Palo Alto to South San Francisco, and Pacifica to Redwood Shores. We kicked off in early April and will continue until October.

I’m participating almost every week and encourage you to join us. SMCMA staff does all the work of selecting the sites and publicizing the walks—all the physican volunteers need to do is show up. You can get details and sign up at www.smcma.org/walkwithadoc. Get outside and get some ex-ercise, meet new people, extol the virtues of healthy habits—it’s all good!

We also have two exciting social events coming up. Our annual meeting will take place on the evening of Thursday, June 23 at the Hiller Aviation Museum in San Carlos. See the planes, engage your colleagues, and get to know the SMCMA and its leadership.

Later this summer, on Sunday, August 28, we will have a family picnic at beautiful Huddart County Park in Woodside, Bring the spouse, bring the kids, and bring your appetite. I expect to see you out there, teammates!

And the Warriors? Steph Curry twisted his ankle in the second quarter, and sat out all but three minutes of the second half of Game 1, forcing extra minutes and expanded duties on the bench. Final score: Warriors 104, Rockets 78. Game 2: Curry sits at courtside in street clothes—Warriors 115, Rockets 106. ■

APRIL 2016 | SAN MATEO COUNTY PHYSICIAN 7

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AUTISM SPECTRUM DISORDER: The biggest challenge of our generation

This was in the early 90s, when it was still a rare diagnosis. Not many pediatricians were familiar with the problem. There was not much available as treatment. Applied Behavior Analysis (ABA) was just beginning to take root as the mainstay of treatment.

Fast forward 20 years, things have not changed much, but Autism Spectrum Disorder (ASD), as it is now called, has become more prevalent.

Here is how the U.S. Preventive Services Task Force (USPSTF) recently described ASD:

“Autism spectrum disorder is a disorder of brain development in children. It affects a child’s behavior and his or her ability to inter-act with others. Children with ASD have trouble communicating with and relating to others and may have different interests than children without ASD. Some signs and symptoms of ASD include avoiding eye contact, not playing with other children, repetitive behaviors, language difficulties, and showing an intense focus on certain objects while having no interest in other things. Autism spectrum disorder can range from mild to severe. Symptoms of ASD are usually first seen in the second year of life but can start earlier or later.”

There is no clear and predictable cause for ASD, nor a marker or lab test to diagnose it. There are no definitive treatments available; most treatments show limited success. There is no known cure for

ASD, nor are there medications specifically targeted toward its symptoms. These individuals are expected to have a normal lifes-pan. Although the literature and professional societies describe it as a disease of the childhood, children with ASD do grow up to become adults with ASD! Suddenly the problem becomes much bigger, as these adults with ASD have to now live, work and thrive as individuals in the society. It takes a huge toll on the parents. It can be physically, emotionally, socially and financially burden-some for the family of these individuals. Our society is not pre-pared to be able to take care of their lifelong needs.

Clinically, ASD is a complex condition. The range of symptoms spans social, emotional, physical and functional realms. And each individual may present with different symptoms and pose a unique clinical challenge. Over the last 15 to 20 years, the preva-lence of ASD has been increasing. The Centers for Disease Con-trol and Prevention estimates that one in 68 children born in the United States has ASD. There have been many reasons cited for this increase, but none of them holds up to rigorous scientific scrutiny. Although diagnosing children early may have benefits, the USPSTF did not find enough evidence to recommend univer-sal screening. It has left it to the discretion of the parents and the professionals dealing with the child. Although over-diagnosis has been raised as an issue, CDC found that 18% of the children with ASD symptoms were undiagnosed.

by Uli Chettipally, MD, MPH

I do not remember studying much about Autism in medical school, other than hearing the term and that it is a rare disorder of the childhood. Then our first child was diagnosed with Autism. We could tell she was “different” even when she was a few weeks old, but did not know what it was, until the professionals diagnosed her when she turned three.

APRIL 2016 | SAN MATEO COUNTY PHYSICIAN 9

The ASD definitions for the purposes of services in California vary widely. All persons diagnosed with ASD are not eligible for Special Education services. Out of these, only some qual-ify for services under Department of Developmental Services’ definition. In the meantime, the school districts and regional centers have been swamped with rising numbers and the need to provide services. Their resources are not growing with the expected increase in the numbers of their service population.

These rising numbers can challenge our society at many levels. As medical professionals, we have a large role to play, especially in the research arena. A lot of work needs to be done to take on the biggest challenge of our generation. ■

About the author

Uli Chettipally, MD, MPH, is an emergency physician, researcher and innovator at Kaiser Permanente Medical Center, South San Fran-cisco. He is also co-founder of the Bay Area Chapter of the Society of Physician Entrepre-neurs (SoPE), a nonprofit, global biomedical and healthcare innovation and entrepre-neurship network.

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

14,039

17,508

21,066

24,943

29,370

34,668

39,711

46,196

53,183

59,690

65,908

71,825

78,629

84,718

90,794

California autistic public school students, 2001-2015

Source: California Department of Education

10 SAN MATEO COUNTY PHYSICIAN | APRIL 2016

No matter what age a diagnosis is given, it helps when fami-lies take advantage of any and all resources available to them through the school district, insurance, regional center and the community. While taking advantage of services earlier than later is helpful, I have seen successful outcomes with children who receive the diagnoses later on (after 10 years of age) and closely follow recommendations by their treatment team.

After receiving the diagnosis, it is natural for parents to go through a grieving period. It helps when they can begin to see that their child is no different than before the diagnosis and to understand that it is an avenue for their child to get better support and services to grow into the best individual that they can be. While each child on the spectrum is unique, they all have the ability to maximize their potential and learn new skills throughout their lifetime. The diagnosis does not define them or their capabilities, but is a lens through which others can understand and provide them with more support.

The first step toward helping a child is recognizing their strengths and weaknesses and setting reasonable expectations. Often individuals on the spectrum have an uneven spread of abilities. There are many children on the spectrum who have normal or above average intellect, but are behind socially and emotionally. Given their normal intellectual ability, influ-encers in their lives (such as parents, teachers, coaches and

others working with the child), may expect them to have the same emotional and social maturity as their peers, which can lead to anxiety and even depression as they advance in age. Having loving and understanding parents who know when to push their child and when to be more understanding can con-tribute to better emotional outcomes.

It also helps for those working with the child to always be thinking about their future and the next stage of life. For ex-ample, how am I going to support my child with skills to navi-gate middle school if they are currently in elementary school? Or, how will I help equip them to live independently while simultaneously helping support them with the current chal-lenges of high school? Each stage of life will present a new set of goals to navigate. Parents or providers who are able to see ways to teach new skills for each of these stages will have a child who is better prepared for the transition.

Due to a lack of social judgment, many children on the spec-trum end up making careless mistakes or poor decisions. I of-ten speak to parents about the importance of reviewing social scenarios and prepping them about potential dangers more than anything else. A child on the spectrum will likely require more conversations about crossing the street, being aware of strangers, understanding internet safety, bicycle safety, know-ing when not to follow the crowd, knowing how to respond to bullying, and so on. Kid Power (www.kidpower.org) offers

by Kylie Billingsly, PhD

SUCCESSFUL OUTCOMES FOR CHILDREN DIAGNOSED WITH ASD

For the last six years, I have had the pleasure to work with hundreds of families of children

with Autism Spectrum Disorders (ASD) as the Autism Specialist in the department of Psy-

chiatry at Kaiser Permanente, Redwood City. When parents first learn their child has been

diagnosed with ASD, they often feel devastated—but with autism on the rise, more social

awareness and an increase in services available, the prognosis is often much better today

than it has been historically.

APRIL 2016 | SAN MATEO COUNTY PHYSICIAN 11

resources and parent and child workshops on bullying and personal safety for typical and special needs children. This can be a great resource for starting conversations on topics such as personal safety.

Helping the child with ASD understand their own strengths and weaknesses early on can be instrumental as they begin to become more aware of their struggle with making friends or not fitting in socially. Parents know their child better than anyone else and can recognize the right time to let their child know about their diagnosis, but should also be careful not to inform their child too late. I find teens that are aware of their diagnosis and willing to take steps toward personal improvement, usually have a better outcome than teens who have not been informed. The parenting series at Stanford can be a great resource to support parents talking to their child about ASD.

Lastly, it can be challenging to have a child with special needs. Parents often need their own support in navigating different hurdles throughout the journey. In the Bay Area

parents can seek support through parenting groups offered through Community Gatepath (www.gatepath.org), Parents Helping Parents (www.php.com) or Stanford’s Autism Par-ent Support Group (http://www.stanfordchildrens.org/en/service/autism/parent-support-activities). It can be helpful to know that you are not alone as well as to get information on services and supports that have helped other families. ■

About the author

Kylie Billingsly, PhD, is a child and adolescent psychiatrist and the Autism Specialist at Kaiser Permanente Medical Center, Redwood City. Her experience with children on the autism spec-trum ranges from conducting diagnostic as-sessments, to educating parents, running social skills groups, performing 1:1 direct Applied Be-havioral Analysis (ABA) service, developing and supervising ABA programs, research, and con-

ducting trainings and consultation for other mental health professionals.

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It is never too late to expand the mind of a person on the autism spectrum. — Dr. Temple Grandin

Mary Temple Grandin (born August 29, 1947) is an American professor of animal science at Colorado State University and world-renowned autism spokesperson. She is widely celebrated as one of the first individuals on the autism spectrum to publicly share insights from her personal experience of autism. She is also the inventor of the “hug box,” a device to calm those on the spectrum. In the 2010 Time 100, she was named in the “Heroes” category.

12 SAN MATEO COUNTY PHYSICIAN | APRIL 2016

No MMR-autism link in large study of vaccinated vs. unvaccinated kidsIn the largest-ever study of its kind, re-searchers again found that the measles-mumps-rubella (MMR) vaccine did not increase risk for autism spectrum disor-der (ASD). This proved true even among children already considered at high risk for the disorder.

In all, the researchers analyzed the health records of 95,727 children, in-cluding more than 15,000 children un-vaccinated at age 2 and more than 8,000 still unvaccinated at age 5. Nearly 2,000 of these children were considered at risk for autism because they were born into families that already had a child with the disorder.

The report appeared in JAMA, the Jour-nal of the American Medical Association, in April 2015.

“Consistent with studies in other popu-lations, we observed no association be-tween MMR vaccination and increased ASD risk,” the authors write. “We also found no evidence that receipt of either one or two doses of MMR vaccination was associated with an increased risk of ASD among children who had older sib-lings with ASD.”

The analysis looked at autism rates and MMR vaccination at ages 2, 3, 4 and 5 years. It showed no increased risk of autism with immunization at any age. In fact, autism rates were lower in the vaccinated groups. However, this might be because parents who see early signs of autism were more likely to delay or avoid vaccination, the authors speculate.

Lower vaccination rates among families affected by autism

Some 15 year ago, a small, now-discred-ited study sparked concerns about a link between the MMR vaccine and autism. Since then, a large and growing body of research has continued to find no asso-ciation. Still, the continuing uncertainty around what does cause autism has left some people worried. Such concerns

likely explain why vaccination rates have dropped in families that have an older child with the disorder.

In the new study, MMR vaccination rates for children without an affected older siblings were 84 percent at 2 years and 92 percent by age 5 years. Vacci-nation rates for children with an older sibling affected by autism were signifi-cantly lower: 73 percent at 2 years and 86 percent at age 5 years.

In an accompanying editorial, Dr. Bryan King, director of the Seattle Children’s Autism Center, writes:

“Taken together, some dozen studies have now shown that the age of onset of ASD does not differ between vac-cinated and unvaccinated children, the severity or course of ASD does not differ between vaccinated and unvaccinated children, and now the risk of ASD recur-rence in families does not differ between vaccinated and unvaccinated children.”

Study made possible by large databaseThe investigators performed their analy-sis using the claims records from a large US health plan database (the Optum Re-search Database). Participants included children continuously enrolled in an associated health plan from birth to at least 5 years of age between 2001 and 2012. All had an older sibling.

Of the 95,727 children in the study, around 1 percent (994) were diagnosed with autism during the study’s follow-up period. Among those who had an older sibling with autism (1,929), ap-proximately 7 percent (134) developed the disorder. This difference in autism prevalence—between children with or without an older sibling affected by au-tism—is consistent with earlier studies. ■

Source: Autismspeaks.org https://www.autismspeaks.org/science/science-news/no-mmr-autism-link-large-study-vacci-nated-vs-unvaccinated-kids.

The MMR Vaccine Controversy

In 1998 Andrew Wakefield et al. published a fraudulent paper about twelve children who supposedly had bowel symptoms along with autism or other disorders soon after admin-istration of MMR vaccine. In 2010, Wakefield’s research was found by the General Medical Council to have been “dishonest”; the research was declared fraudulent in 2011 by the British Medical Journal.

Wakefield was struck off the UK medi-cal register, with a statement identi-fying deliberate falsification in the research and was barred from prac-tising medicine in the UK. Several subsequent peer-reviewed studies have failed to show any association between the vaccine and autism.

The Centers for Disease Control and Prevention, the Institute of Medicine of the National Academy of Sciences, the UK National Health Servic, and the Cochrane Library review have all concluded that there is no evidence of a link between the MMR vaccine and autism.

Health experts have criticized media reporting of the MMR-autism contro-versy for triggering a decline in vac-cination rates. Before publication of Wakefield’s findings, the inoculation rate for MMR in the UK was 92%; after publication, the rate dropped to be-low 80%. In 1998, there were 56 mea-sles cases in the UK; by 2008, there were 1348 cases, with two confirmed deaths.

Source: Wikipedia.org

APRIL 2016 | SAN MATEO COUNTY PHYSICIAN 13

SMCMA welcomes new members

Amy Bagatto, MD*Internal Medicine

Emergency MedicineRedwood City

David Pusateri, MD*Internal Medicine

Emergency MedicineRedwood City

Michael Grazier, MD*Emergency Medicine

Daly City

Scott Sherr, MD*Internal Medicine

Emergency MedicineRedwood City

Daniel Houseman, MD*Emergency Medicine

San Mateo

Mark Notash, MD*Emergency Medicine

Moss Beach

Eric Weintz, MD* Emergency Medicine

Redwood City

Surinder Yadav, MD*Internal Medicine

Emergency MedicineRedwood City

In MemoriamRobert Turner, MD

January 18, 2016

RETIREMENTSThe following members have recently retired from practice:

Charles Szabo, MD David Weinberg, MD

San Mateo

San Mateo

MEDICALc o u n t y

a S S o c i at i o n

Why PHYSICIANS PRACTICING IN SAN MATEO COUNTY need to be SMCMA/CMA members:1. By speaking with a unified voice, physicians exert a powerful influence in the political

process. Organized medicine in the “one voice” that legislators want to hear from on health care issues.

2. SMCMA and CMA worked tirelessly to protect MICRA (the Medical Injury Compensation Reform Act), spearheading a successful campaign to defeat legislation in the 2014 that would have gutted MICRA and sent malpractice insurance rates skyrocketing.

3. SMCMA is involved in several intitiaves to improve community health, including access to care for the uninsured, vaccination, end-of-life issues, and much more.

I am a member of the SMCMA because protecting MICRA and ending SGR couldn’t have happened without the help of organized medicine. “

RUSS GRANICH, MDHospice & Palliative Medicine, SSF

SMCMA President-Elect

Join SMCMA/CMA Today! ■ 650-312-1663 ■ www.smcma.org/join

Value of Membership

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