On the Couch

I'm glad to have a weekend going on here. Taking it very easy today, after a full and intense week.

At one point this morning, I plopped down onto the couch and flopped over onto the pillows, with a tired sigh.

JoyDad flopped next to me and hug-tackled me.

Joy, who'd been watching the TV at the other side of the room, circled around in our direction and twinkled at us. Much as if to say, "Gimme some of that hug-action!"

We laughed and called her to join us. She came right over, and scrambled up between us.

There we sat, a Joy-sandwich of a hug, and watched TV together for a while.

Just call it hug-therapy.

Conference Report, Part 1: Paula Kluth

I almost feel like I should say "Didja miss me?" yet again. It's been a very full week since returning from the Autism Society of Wisconsin (ASW) conference a week ago Friday. Many spinning plates, and per usual many are Joy-related, from conversations about inclusion at church to the fact that we've got her IEP meeting this afternoon to plan for kindergarten in the fall.

But I promised some conference-reportage!

One lovely piece of convergence at the conference was that Joy's itinerant special-educator, who leads Joy's school district team and has been coordinating the IEP prep, attended the first few days of the conference as well. I'm loving the fact that the person with whom we're writing Joy's first ever official behavior plan... also attended the conference day-long workshop with Paula Kluth, a session called The Problem with "Behavior Problems:" Supporting Students with Autism & Other Disabilities. [Note - I'll be calling her by her first name, as I did with Temple Grandin and Eric Courchesne, though in each case the more formal choice would be the title "Dr."]

Paula put "Behavior Problems" in quotes in her title on purpose. It seems that throughout her career around these issues, she's been wanting to write and speak about the "supporting" emphasis while publishers (and conference producers?) bring the pressure to use language that explicitly references "behavior." Which makes sense with the generally-used language -- Joy's going to have a "behavior" plan and all that -- but I love the move to change the conversation.

One way in which the workshop enabled that conversational change was to challenge the attendees to do some self-reflection. For example, one set of questions that we discussed in small groups was "When do you behave badly? What helps you "recover" from your own bad behavior? What is one effective and positive behavior strategy that you have used?" I bet that nobody had trouble coming up with personal examples; I know I didn't. Attendees reported behaving badly when they're hungry, tired, offended, stressed, overwhelmed, when people won't listen, when they're having a hot flash!

Then Paula asked these questions around effective strategies: Did anybody say, "I can't calm down until...

• someone drags me away?
  
• someone enforces an immediate negative consequence?
  
• someone yells at me enough?

So why is this the kind of strategy that so often comes into play for students with disabilities? when what really helps the conference attendees in their own "behavior problems" is more along the lines of: have a snack; change of venue; exercise; walk away; etc?

Really, who among us wants someone to come along and try to "change our behavior" anyway??

But we can all use a little helpfulness and support along the way. The reframed question, as the presentation put it, becomes "How can we effectively and sensitively support individuals with disabilities?" or more broadly, "How can we be helpful to people?"

So, what does seem to help? In very broad strokes:

• Being surrounded by people who care
  
• having meaningful social relationships
  
• being in a comfortable setting
  
• having an engaging curriculum (driven by novelty and joy, as opposed to "death by sight-words")

Another nugget from the day that I found very thought-provoking was reflection on "shepherds," i.e. how very much adult-presence and "proximal support" students with autism often have. How much of the hovering and correction -- y'know, those things we do because it's good for them, right? -- is necessary and how much not? Do we expect students with disabilities to be "on task" for more of the time than students without disabilities?

Well. The workshop was chock-full of anecdotes and suggestions and excellent ideas for providing appropriate support through environment and materials and relationship-building. It was actually so much as to be an overload, and if I try to reflect much of that back in bloggy format, I'll just be transferring that overload. It struck me as the kind of thing where, once you've got the right framework in your consciousness, there were almost enough ideas to be presented in a "strategy of the day" daily calendar format!

For me, what was truly important about the workshop was the framing -- the commonalities -- the sense that it's really all about being human and how we all react.

Here's a quote that didn't come from the presentation, but rather from a favorite album of mine when I was a kid, Free to Be You and Me:

Some kind of help is the kind of help
That helping's all about
And some kind of help is the kind of help
We all can do without!

For more information:
http://www.paulakluth.com/
including one particularly helpful page on being calm in crisis
The article is adapted from her book You're Going to Love This Kid: Teaching Students with Autism in Inclusive Classrooms.

Back from a Conference

Didja miss me?

I guess I didn't tell you where I was going, or even that I was going! I just spent the past three days in Green Bay, Wisconsin at the Autism Society of Wisconsin (ASW) annual conference.

JoyDad got to have single-dad duty for those three days. He did great. Rose was weepy the day before I left, but once I was gone she carried on in fine form. I understand that Joy was a little bit of a handful, which I like to think may have had something to do with missing me. Maybe?

When I got home last night, though, she was in a cheerful and chatty mood. We sang Old MacDonald, and she gave me some gorgeous "oink, oink" (you know, the snorty-thing with the cute wrinkled up nose) and a "neigh" or two, and some nice tiger roars.

What, you don't have a tiger on your farm? Well, our farm has a nice noisy one!

The conference was rich and full. I think there are three blog-posts coming here, one for each of the keynoters, 'cause they hit a trifecta of excellence:

• Paula Kluth, who gave a daylong workshop called The Problem With Behavior Problems
  
• Temple Grandin (I felt like such a fan-girl... I got to meet her! She autographed a book for me! Swoon!)
  
• Eric Courchesne, neurological researcher, on the state of the art in autism brain research and implications for what does (and does not) cause autism

Stay tuned!

But Wait, There's More...

More emergings, that is.

Joy has become much more attuned to greetings and goodbyes. The high-five came about in the fall, I believe, and has been a lovely hook upon which to hang interaction at Sunday school and kindergarten practice. What's new, though, is a level of engagement and interaction, plus new signals. Joy has re-learned the bye-bye wave! And she also does a fun new greeting, where she gives a huge grin and stretches out a pointer finger. Sort of like in the movie E.T., if I'm not dating myself too badly here!

Another re-emergence is the "Clap, clap, uh-oh!" game. I don't remember when we first invented this -- I think it was a couple of years ago. It's a two-person game, facing each other, Person 1 is set to clap their hands and Person 2's hands are on the outside. Person 2 "makes" Person 1 clap hands, several times in a row. The soundtrack is "Clap... clap... clap..." and then Person 2 makes Person 1's hands miss and cross instead of clapping, and the vocalization is a big giggly "UH-OH!" Joy is not only willing to play the game again, she can be either Person 1 or 2. And she is willing to supply the "uh-oh" herself more often than not. AND, on Sunday when I was on nursery duty at church with her, I caught her in a quiet moment playing the game with herself. And she did the motions and said "cah, cah, uh-oh!" All on her own.

She's getting good at opening the car door from the outside and getting all the way in, with our Honda Fit at least.

She's mastering the "flip trick" for putting on her coat.

This morning she was playing in the kiddie area at the carshop while we were getting an oil change, and her shoe came off. This is a girl who, when her boot pulls off in the snow, can walk for several steps before anyone notices that the boot has gone... she not only noticed the shoe right away, but picked it up, then on voice-prompt brought it over to me. And as we were putting in on, she said "ahhhhn" (a nasal-sounding, French-like pronunciation that had an implied "n" rather than an American "n" but still!)

And just so as not to ignore Miss Rose, who is doing some pretty amazing things herself: she drew a picture last October for a contest at Ask magazine, where they were supposed to submit ideas to scare monsters away. Her submission was selected and published in the March issue!

Her caption: "This monster has electric snakes coming out of his head. He will scare ghouls out of their pants!"

Boo!

Emerging

It feels like spring. The snow is mostly melted off the garden, and soon we'll take the mulch off our strawberry plants. Snowdrops are blooming on the south side of the house; tulip leaves are poking through in the front flowerbed.

And for the past two weeks, new/renewed vocalizations have been sprouting for Joy like shoots from subterranean bulbs. There've been so many, it's hard to keep track. Some of them are Elvis Sightings: she said "buh-buh" for bye-bye, just once! She said "muh" together with her "more" sign at just one snack time, two requests in succession! She said "bay" for her bagel, just once! Others are more durable: a big explosive "pah!" that might mean "play". A lovely "chew" noise that is associated with her chewy toy (and also with a tickle game).

Rose and I have been attuned for noticing signs of spring. We saw the first robin of the season on Friday morning near Joy's daycare. We saw an animal in the backyard that first looked like a rabbit, but then turned out to be a squirrel with a white tuft on the end of its tail.

I remember one of the concerns I had when I first meet with the Birth-to-Three case manager who came to our house for an intake interview. I told him about how, when I would be on for childcare with Rose and Joy and Joy's daycare buddy, I'd point to a squirrel out the front window. Rose and Buddy would be fascinated. I could not get Joy to look. "Maybe it doesn't mean anything," I said self-deprecatingly. The case manager wouldn't commit to what meant what, but told me to keep paying attention.

This morning Joy was looking out the front window, watching a squirrel. Later in the morning we went for a run, with her in the stroller. She tracked a bird that flew over. She giggled at an airplane. And every time a car went past, she'd turn her head around to follow it, with a great big giggle.

Did I mention we went for a run? I am picking myself back up after falling off the wagon with running during the long dark iciness of January and February. It feels so good to re-emerge onto ice-free sidewalks and sunshine pouring down.

Rose is making great strides on piano these days. The material in her class is getting more and more challenging, and she's keeping right up. She's got the ear... when she makes a mistake, she hears and works to correct it. And it helps a lot to have me play through a song just once when the rhythms get too difficult.

Joy's speech therapist was all set to write up a present-level for Joy's upcoming IEP that said something to the effect that imitation was not something that has moved very far forward this year. All of a sudden, the occasional imitations are popping forth all over, from animal noises to word-approximations. At school during her kindergarten practice the other day, she was playing Row Your Boat on one of those wooden rocking-boat kinds of toys, with a couple of other kids. "If you see a lion, don't forget to roar!" went the music. The kids roared, Joy roared. And then she roared again, to get more roars going. Not just imitation, but initiation too!

There are other things -- more occasional potty successes, getting her coat on and off by herself, making attempts to blow bubbles. The list is getting too long to remember. I've been a little bit hesitant to even write about it, for fear of jinxing the whole thing. But I think it's time to start celebrating, at least just a little.

Happy spring!

Oil of the Snake

The deliberately-deceptive "quack" doctor is a well-recognized figure both in history and in fiction, particularly western movies and novels. I have a cousin who wrote a book on three such charismatic con men of the 20th century, including one John Brinkley who promoted transplants of goat glands as a cure for infertility or lost virility (and also ran for governor of Kansas!) One slang term for such characters is "snake oil salesmen."

Ah, but nothing is as simple as it seems. Turns out that the term "snake oil" comes from a particular Chinese medication, a product of the Chinese water snake, that is still used for relief from arthritis and joint pain. The jump from traditional Chinese medicine to association with American quackery may have come about when Chinese immigrant laborers on the Transcontinental Railroad shared their joint pain remedy with laborers of European descent. Funny thing is... for the specific joint pain application, the oil of the Chinese water snake might possibly have certain beneficial properties...

The presenters in the first LEND session on alternative therapies were all students in professions who will be working with children with disabilities some day. They were exceedingly careful about keeping their own language respectful, even when they were obviously skeptical and quoted other organizations who used strong language (such as the National Council Against Health Fraud, on record that "chelation therapy of autistic children should be considered child abuse."

The term "snake oil" didn't pop up until the second set of presentations, which had family-member trainees sprinkled among the presenters -- I think that somehow the family members were a trifle less shy about bringing quack-doctor-history and anecdotes into the mix. Somehow the second session carried more history, more of a sense of the ebb and flow of popularity of alternative treatments and how a single treatment may be sold for a variety of ailments over time.

In fact, that's one of the hallmarks of potentially fraudulent, non-evidence-based treatment: a long laundry-list of what it claims to cure. Good for what ails you!

Among the treatments that were discussed in the second session (hyperbaric oxygen therapy [HBOT], auditory integration therapy/training [AIT], hippotherapy, vitamin therapy for Down syndrome), the laundry-list history came up in relation to HBOT.

Hyperbaric oxygen therapy involves breathing oxygen in a pressurized chamber to increase the blood-oxygen level. It's been around since the 17th century, and is an established treatment for decompression sickness, a potentially-fatal condition that can come about when someone goes too quickly from a pressurized situation (like deep-sea diving or working far underground) back to ordinary air-pressure. Over the years there have been various efforts to link HBOT to other ailments as well. One of the more flamboyant historical HBOT figures was a Dr. Cunningham, who in 1921 built a hyperbaric chamber 20 meters in diameter, in which patients could actually reside. He claimed that anaerobic bacteria were responsible for a whole range of ills from cancer to high blood pressure, and that an oxygen-rich hyperbaric environment would discourage/treat the bacteria. (This was the point in the presentation at which the term "snake oil" was used -- the idea of treating infections caused by anaerobic bacteria in this way may have merit, but that's different from cancer!) Dr. Cunningham was eventually denounced and his massive steel chamber was demolished for scrap metal.

More recently, HBOT has received publicity as an alternative treatment for cerebral palsy and autism. Neither of these applications of HBOT has yet been the subject of a Cochrane Review (a major go-to source for evidence-based medicine). There have been two studies of HBOT for autism led by Dan Rossignol, most recently a double-blind, multi-center trial in 2009 that found significant improvements. The presenters did point out, however, that the improvements were based on parental observation (and as I mentioned about the Elder 2006 study on the GFCF diet, parental reports can be much more enthusiastic than researcher observations.) HBOT is a relatively expensive treatment, $300-400 per session -- and the protocol in the Rossignol study involved 40 sessions.

Another therapy where a family member on the presentation team came down a little harder due to personal experience was vitamin therapy for Down syndrome -- I think the three presenters were all students of genetic counselling. The idea is that the manifestations of Down syndrome, from intellectual disability to facial differences, can be ameliorated by treating the syndrome as a metabolic condition. Some of the substances involved include thyroid supplementation, flaxseed oil, and dimethylglycine (DMG), but the list is long and varied. One of the presenters had family experience with a prominent practitioner of this approach, a Dr. Forrest Warner, known for his travelling clinics that set up in a given city for a day. Parents lined up with their children for a short expensive evaluation in which expensive supplements were recommended, to be taken indefinitely in the absence of any follow-up. Granted that this is a single anecdote, but it obviously had an impact on how the presenter viewed the therapy.

The research on vitamin therapy for Down syndrome is mostly negative, to the point that the National Down Syndrome Society has stated:

The administration of the vitamin related therapies -- e.g. the vitamin/mineral/amino acid/hormone/enzyme combination, has not been shown to be of benefit in a controlled trial, that the rationale advanced for these therapies is unproven, and that the previous use of these therapies has not produced any scientifically validated significant results. Moreover, the long term effects of chronic administration of many of the ingredients in these preparations are unknown. Despite the large sums of money which concerned parents have spent for such treatments in the hope that the conditions of their child with Down syndrome would be bettered, there is no evidence that any such benefit has been produced.

Just at the end of the presentation, someone (presenter or faculty member in the audience, I can't remember?) mentioned that flaxseed oil and DMG have some proponents when it comes to autism as well. [Good for what ails you?]

Next up, auditory integration therapy (AIT), presented by audiology students. Given the alternative status of AIT, I suppose it's not surprising that this was not something the presenters had been exposed to in their studies to this point. In fact, they were having a hard time trying to understand and explain what exactly was involved. The claims for the therapy for autism spectrum disorders involve increased attention span and eye contact, and improvement in abnormal sound sensitivity. The therapy itself involves listening via headphones to specially modulated music 2x/day for 10 days (I believe this was the Berard method.) Cost can be in the neighborhood of $2000.

There's been a bit more research regarding AIT for autism; a 2004 Cochrane Review found 6 studies worth addressing, which ended up measuring a variety of outcomes and reported mixed results. One potential risk may be that the sounds could be damagingly loud, but I don't have a citation for that. The group concluded by citing a technical report from the American Speech-language Hearing Association (ASHA) stating that AIT has not met scientific standards for efficacy and safety and should be considered experimental.

The only presentation I haven't discussed yet was the one on hippotherapy, which (contrary to the word's appearance) does not involve hippopotamuses! "Hippo" is the Latin root word for "horse," and hippotherapy is a strategy that uses horseback riding as part of an integrated intervention program in cases of neuromusculoskeletal dysfunction, a program that may include physical therapy, occupational therapy, or speech-language. The movement of the horse is said to mimic the human pelvic movement of walking. Hippotherapy has a full-blown association (founded in 1992) and a certification board (since 1999) and the presenters' handout listed a whole slew of practitioners in our state. Risks are not extensive -- allergies, and the fact that a horse is a large and potentially unpredictable animal -- and proponents claim gains in patient self-confidence along with the therapeutic gains.

However, hippotherapy is one of the explicit exclusions in our state's recent autism insurance mandate -- along with HBOT, AIT, chelation and special diets, come to think of it. Barbara at TherExtras had some reflections on hippotherapy (to some extent in conversation with me!) a month ago, exploring the ramifications of pushing to get hippotherapy recognized as medical treatment. One of the LEND faculty brought up a related note when she compared the self-confidence gains from hippotherapy to what might result from participation in organized sporting activities.

Thus endeth the roundup of our LEND explorations into alternative therapies. Just to reiterate, every one of these alternative therapies has its enthusiastic proponents and its skeptics. Some have been quite thoroughly discredited, others are squarely in the "need more research" category and that research could tip either way.

One piece of advice that I'd offer for folks gathering information on an alternative therapy. I would suggest searching the following sources for a pull-no-punches skeptical take:

• Respectful Insolence
  
• Quackwatch

Even if they speak of any given therapy in harsh or off-putting terms, it's a useful counterweight to potentially overly-enthusiastic claims. And not all of the therapies listed in these past few posts are evaluated there. (For example, hippotherapy is not mentioned on either site.)

One final note. Back when Barbara (TherExtras) and I first met, we had a conversation about craniosacral therapy. She included in her post the following Bible verse, which had been in the readings at her church that week:

Why spend your money for what is not bread; your wages for what fails to satisfy? -- Isaiah 55:2

That verse was among the scriptures read at my church this past week.

No coincidences!

Diapers and Care Coordination

Sometimes the little stuff just annoys all out of proportion.

One recent annoyance is actually probably a nice little step forward in Medical Assistance cost-cutting for the state... We learned toward the end of the year that Wisconsin had chosen a single supplier for home-delivery diapers through MA, so we were going to have to change suppliers. So I dutifully called our old supplier, Home Delivery Incontinence Supplies, and discussed how the change was to happen. We settled on a date for one final shipment (Jan. 28) to give me time to get things underway with the new supplier, J&B Medical.

To get set up with the new supplier took something like four calls, with some phone tag thrown in, some forms to fill out and mail back, a batch of diaper-samples for us to test and choose (because of course they had different brands than HDIS).

Then we got a week into February and hadn't received our final shipment from HDIS. The first customer service rep I spoke to confirmed that no shipment had gone out, but couldn't tell me why. Her supervisor was to call me back at work. No call came. I had to call again to discover that our "prior authorization" had run out Jan. 23, so they cancelled our shipment. Without informing us. No, they couldn't get a new prior-auth, because gee, they're not our supplier any more. Meanwhile, it turned out they had called my home number instead of work, and JoyDad spent 20 minutes on hold returning that call, not aware of all my phoning.

We had no leverage. What could we do, fire them? (Well, I guess I can tell the story on my blog... heh.)

But do we have any leverage with the new supplier? Well, no. We can't fire them either, they've been given the monopoly.

Fortunately the new supplier was nicely responsive. Diapers arrived promptly, and they're even brand-name (Luvs).

And... the annoying leakage problems that I wrote about a while back have been dramatically reduced! So there was a happy ending to the story. This time.

I sometimes feel that I'm not exactly grateful enough for the publicly-funded diapers, especially since we wouldn't qualify if it were an income-based deal.

But sometimes, it's the little things that take so much time and effort and tracking, and knowing that you're at the mercy of bureaucratic forces over which you have no leverage. Plus we learned recently at LEND that nearly 10% of families of children with special health care needs reported in 2006 spending over 11 hours a week coordinating or providing health care for their child.

I'm wondering if people were even counting this kind of stuff. Bleah.

Hope, Without a Prescription

My previous "Hope" post made its way to a friend of the family from the neighborhood where I grew up.

Her lovely off-blog response included a poem from Emily Dickinson:

Hope is the thing with feathers
That perches in the soul
And sings the tune without the words
And never stops at all.

So amazingly appropriate for my Joy, my sweet wordless perpetual motion darling.

Hope. Together we learn to sing the tune without the words.

Hope

In my last post, I quoted several times from an article in this week's Time, in which author Karl Taro Greenfield profiles Jenny McCarthy, prominent celebrity-mother proponent of alt-med recovery for autism.

I guess I'm not quite done with the article yet.

Greenfield sums up McCarthy's campaign with these words:

Of course, McCarthy is not a doctor. She really has only the one prescription: hope.

The article also quotes Age of Autism blogger Kim Stagliano criticizing her children's doctor for failing to offer that hope.

'I have three children on the spectrum,' says Stagliano. 'I have yet to really get one actionable piece of assistance from my pediatrician. They offer nothing. Nothing... These treatments are filling a vacuum.'

Joy and I have had our moments of this too.

It was just about two years ago, February 2008. And Joy hit a stretch of misery. She was having frequent seizures at that point, several a day, one-minute-long events that each carried an hour of inexorable unhappiness in its wake. But it was more than that. She was waking in the night to cry. She was inconsolable for hours at a stretch. She'd grab us by the hand and lead us to the front door -- but once we took her outside (into the frozen wasteland of February in Wisconsin), it was clear that she really didn't want to be there either. We came to believe that what she was asking when she led us to the door was "Take me away from here, to somewhere that will make me feel better!" And we had no means of doing that. We were helpless. I took her to Urgent Care, certain that there must be an obvious physical cause. Ear infection? Strep throat? But no.

Several days later found us in our pediatrician's office -- a capable woman, who'd done a good job with Joy's care to that point. I like her very much -- she brings a good combination of empathy and no-nonsense, plus an undercurrent of shared Christian faith. But that day, as Joy raged around the exam room taking divots out of the exam table with her teeth, the pediatrician had nothing to offer, beyond a weak suggestion that I should really seek out some respite help.

Nothing to offer. No hope.

That wasn't an answer I was prepared to accept. I began working my local network.

What kept me going through the next days were two conversations. One was a phone conversation with an expert from Agency 2, who also has a child on the spectrum. What stood out from my conversation with her was the sympathy, the "been-there-myself," and a suggestion of craniosacral therapy as something that had been helpful in their situation. The other conversation was with a friend from church with spectrum experience. She had several suggestions for pediatrician-switching.

Those conversations gave me the hope I needed, plus something to do. And during the days as I explored the possibilities of craniosacral, and the options for a new pediatrician, Joy's misery began to gradually ebb. On its own. And spring was coming. We were going to make it after all.

I'm grateful that the incident led us to a new doctor for Joy, even if he's across town. He specializes in special needs, and has parental experience on that score as well. We see him every 3 months as a matter of course. I don't expect to hit that "nothing we can do" wall with him. (Rose still sees Joy's former pediatrician, and I'm pleased that by "firing" her for Joy, we didn't lose our connection. In fact, her office got the H1N1 vaccine before Joy's new clinic did, and she called us to let us know and offer it to Joy!)

As for the craniosacral therapy, it became less urgent once we were out of the immediate crisis. We did eventually make the attempt later that summer, to no discernable effect, and blogged about the process in detail.

Interestingly, Joy's initial pediatrician was actually "right," in a way. Joy made it through the crisis without medical intervention -- we needed to do... nothing. And respite was a sound idea! But the lack of other ideas, and the lack of hope, was just not tolerable at the time.

So far, I'm sounding like I'm resonating pretty strongly with Kim & Jenny. And up to a point, I guess I am.

Here's where it differs, though. The hope I was seeking was not cure/recovery from autism. The hope I needed was for a livable life. For me, those two ideas are not the same. Our new pediatrician isn't offering recovery/cure. But he does offer expert medical guidance as we seek a path for a meaningful, joyful, potential-fulfilling life. We're grateful for that.

I'm wondering a couple of things, as I remember that sequence of two years ago.

One: would it have been helpful for Joy's former pediatrician to offer some form of placebo? Even if she didn't believe in it herself? After all, hope is what was needed...

Two: do parents of children with known genetic conditions (Down syndrome leaps to mind) blame their pediatricians in the same way that some parents in the autism community do for not being able to offer a cure?

I'd have answered "no" to the second question, but after having heard the LEND presentation on vitamin therapy for Down syndrome (to be blogged about soon), I'm no longer so sure. Though if that level of blame & conspiracy-thinking is happening, we're not hearing about it in the popular press in the same way.

What do you all think about placebos, and about what level of blame is fair to heap upon pediatricians, or upon Western medicine in general?