Autism--an overview! With Dr Taryn Liu, pediatric neurologist.

Episode 99 of Ask Dr Jessica with Dr Taryn Liu, discussing autism.  Dr Liu is a dedicated pediatric neurologist who specializes neuro developmental disabilities in children, and she primarily treats children with autism.   In this podcast, you will hear Dr Liu share her compassion and insights into autism spectrum disorder.  She demystifies common misconceptions, and also explains the social and emotional challenges.  Additionally, she highlights early signs in children, like joint attention and non-verbal communication.  Her insights provide valuable information for both parents and professionals who would like a deeper understanding of autism spectrum disorder.  If you would like to see Dr Liu as a physician, she currently works at Children's Hospital of Los Angeles.

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

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The information presented in Ask Dr Jessica is for general educational purposes only. She does not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your child's health care provider.

Transcript

Unknown: 0:00

Hi everybody welcome to the Ask Dr. Jessica podcast. I'm your host and paediatrician Dr. Jessica Hochman. On this podcast, you'll hear me talk about various issues surrounding children's health and their well being. And my goal is to help you feel more confident, knowledgeable, and worry less as you move through your parenting journey. On today's episode, I talked to Dr. Taryn Liu about autism. Dr. Lu is a dedicated paediatric neurologist and she works at Children's Hospital of Los Angeles. She primarily treats children with developmental disabilities, including children with autism. I feel grateful to have had the chance to talk to Dr. Liu. She's insightful, knowledgeable and passionate about her work. And I think this is a great conversation for anyone who would like a deeper understanding of autism spectrum disorder. I'm so excited to have you on the podcast. Thank you so much for the work you do as a doctor. Oh, I'm so happy to be here. Thanks so much for inviting me actually love my job. That is so good to hear. Speaking of your job, can you tell everybody what is it that you do? What do you do for work? Yeah, so I'm a paediatric neurologist. I specialise in neurodevelopmental disabilities, and I mostly work with early diagnosis, evaluation and management of children with neurodevelopmental disabilities and coexisting conditions. So mostly children with autism, intellectual disability, ADHD, learning disability, making the diagnosis, helping families sort of through the process of getting appropriate services, and then also helping to identify aetiology. So why a child might have their difficulties. That's amazing. I'm so happy to know that a doctor like you is out there. There's a lot. There's a lot of doctors out there. And I'm curious, how did you become interested in paediatric neurology? Yeah, that's a really good question. So after my undergraduate work, I got a public health degree. And around the time of my public health education is when that was around the time that the debunking of the study that sort of implicated MMR vaccines as the cause of autism was was being refuted. And, and sort of, like debunked, essentially. And I was pregnant with my first boy. And and I, you know, have a science background, but there's a part of me as a mom, I was like, do I need to be afraid? Should I be afraid? You know, what is autism? What is this? Is it something that you catch? Is it something that goes away? And I spend a lot of questions, and then I worked with a lot of individuals and their families on the spectrum. And that kind of just got me very interested in autism spectrum disorder. And so when I went into medical school, I knew that I wanted to work with children with disabilities. And then when I was applying to residency, I was like, wait a minute, there's developmental paediatrics. There's child neurology, which one should I choose. And then I decided the child neurology route, because I felt like I would be able to do more in terms of not only helping to diagnose but manage these complex neurodevelopmental disabilities. And that's kind of what led me here. I say that what I do for a living is i Doctor, but really, I'm a human. I'm a mom, I am a neighbour, I'm a community member, a daughter, a sister, niece, a wife, you know, all these things. And so that's kind of how I approached my, my daily clinic work is because we're all just humans looking for the same answers. And we all want the best for our family and our children. So I want to talk more about autism spectrum disorder, because a lot of people think about autism, it makes the news all the time, how the numbers are going up. And I want to sort of set the record straight about what it is, what causes it, what we know about it, but we don't know about it. And so first, I want to ask you Can Can you explain what exactly is autism spectrum disorder? Yes, I think that's a very good question. I think it's a very complex question. And I think that the majority of people and even healthcare professionals don't quite understand what autism is. I think most of the time individuals think that autism is a speech disorder, and it's an intellectual disorder. And actually, it's neither of those, although you can have speech and language difficulties and intellectual disabilities with autism spectrum disorder. So when we think about autism spectrum disorder, we we should think about the two main components of the diagnosis, and that is difficulties with social and emotional communication. So that's one sort of large domain. And then the second domain is having restricted repetitive behaviours or restricted interests. And there are different different subcategories within those two domains that help someone who is assessing a child be able to parse out of these are social communications due to autism versus speech and language delay versus cognitive delays. Because I think it's really important to pick apart that first domain of autism and it's really good because autism is a difficulty with back and forth communication, but not only in verbal language, but also with nonverbal communication. So being able to understand gestures, being able to understand facial expressions, being able to produce facial expressions that are appropriate for the social setting. But then we also have reciprocity, not only interpersonally, but also with us and our environment. So for instance, knowing how to act at home versus at the grocery store versus at school versus a place of worship, we adjust our behaviour and we adjust our language based on those different social settings and individuals with autism. don't perceive and, and receive those same social cues because of differences in their brain and how it works. And so they don't act differently in those in those settings. That's really sort of why they struggle with communication. So it is a communication, disability, but it's not necessarily a speech disability. And then coming with that is the need for repetition, sometimes a typical play sensory difficulties, etc. So it's a complex diagnosis that I think, take some time to fully understand. And I'm thinking about as you're talking, I have a first cousin whose daughter has autism, and she's made market improvements, as the years have gone on. And he tells me where you can really see it still, you know, as much improvement as she's made. He remember she has autism, when he hurts himself, for example, it will hurt himself and he has two other daughters, I will ask them, they'll look really concerned. How are you doing? Daddy? Are you okay? You hurt yourself. And his daughter who has autism, she sort of forgets to ask him until she sees her sister's asking, then she's clued in Oh, I'm supposed to ask how he's feeling. But it's not an innate response from her. That's right. That's right. And that's often very true even in play and the use of language, so often the prosody of language, how and why they're using their language and how they have learned to use their language. So some children will be very verbose, but they'll have very scripted sentences, because they have learned through watching somebody else, or even watching, you know, a character on television that when somebody gets hurt, and when somebody is crying, I need to ask them, Are they feeling okay? But individuals with autism do not do not, you know, innately have those same abilities in the ways that we would socially expect them to, for their age. And I'm curious for parents listening, who might be concerned that maybe their child is on the spectrum? Are there any characteristics or attributes that you notice from children to reassure parents that their kids don't have autism? So So one of the very first signs of a child who you know, is at risk, or may have a higher susceptibility of autism, is their ability to have joint attention and to communicate without verbal language? So one of the things in the question that we ask a lot is, Does your child point, so we communicate and children learn to communicate without the use of language even before they turn one. And they do that by making eye contact either with you, or making joint attention with something that you're pointing to, or will even point to something to get your attention. And so when those things like pointing, eye contact and joint attention are missing in the first year of life, or are not present by 12 months of age, that's a big clue. And so I would say those are the most important things, children that are able to communicate their needs with pointing, gesturing, shrugging their shoulders crossing their arms nodding yes, shaking No, but don't have language are more likely to have an expressive or receptive language disorder than autism spectrum disorder. So I would say joint attention, the use of gestures and pointing early on are very important. Interesting. So so if a parent sees their children demonstrate joint attention, can they be reassured that their child will not develop autism? Is it? Is it that easy? Oh, my child's pointing at one and they're showing me things can they can they take a deep breath that that won't be their child's diagnosis? I would say no, not wholly, because we're very aware of, you know, the component of developmental plateau or even loss of social communication difficulties in individuals with autism spectrum disorder. And as opposed to in the past, we would think of, you know, what was described as autistic regression as a minority, I would say in a majority of patients with autism. There is some sort of developmental plateau, or even a subtle regression in social cues and communication abilities, at some point during the first two years of their life. So you'll often hear parents saying they were developing normally until they weren't. Usually there are some cues and clues that were there early on. But definitely they have become more obvious, as we expect children to use language more frequently, in typical development, that same timeframe is when children with autism really sort of stand out from their peers. You know, and I always wonder, because the MMR vaccines given between a year 15 months, if that's why parents or attribute their children's regression to the vaccine, because it's timed at the same time when we notice those signs of autism. And unfortunately, the notorious study by Wakefield that was later debunked, claiming a relationship with the MMR vaccine and autism had already made the headlines. I think that is a huge, you know, confounding factor, aside from the fact that that study had an n of 12, and was, you know, completely falsified in so many different ways. There's actually a couple of those parents who later came out and said, I read that study, and he actually falsified the information that I gave him. So he's, he's, he was a GI specialist, studying children with GI issues. And then also had, you know, we know that children with autism have allergy issues, GI issues, and so it's kind of like this very handy patient population that he had, but then subsequently, retrospectively made these associations about the MMR vaccine children with this new syndrome, he called with essentially leaky gut, so severe GI symptoms and autism regression. And he said it was related to the MMR vaccine. We know that autism was described in the 60s, long time ago, before the MMR vaccine was even, you know, available, so we can do debunk it on many different levels, I think. But yes, it was an NF 12. And yes, I do think that the timing of that is, is very convenient to be able to match those two things up. Dr. Wakefield actually lost his medical licence in the subsequent decade after that, and that that whole study was actually withdrawn from the journal it was published in. And ever since then, the medical community has been working really hard to debunk this myth that autism is a result from the MMR vaccine. As a mom, I get it right. Even as a mom, before I went to medical school, I had fears, right, I had an eye and I was a scientific mind. But you know, you sort of get into this, and I'm sure you, as a physician, sometimes have to separate your your mom, self and your doctor self. And it gets very complicated, right. So as a mother, I understand those fears. 100%. But then when the evidence is in front of you, it's so hard to deny the obvious evidence that it's not related vaccines are not related to autism spectrum disorder. And I agree that when when theories are posed, it's important to really look into and make sure that we're doing is, is safe and not harmful to kids. But what what struck me is there's been subsequent studies, like there's a Danish study that looked at hundreds of 1000s of kids. And they did not find an association with MMR and autism. In fact, they found that getting the MMR vaccine almost had a protective effect. There were fewer kids that had autism in that cohort, you know, and it was retrospective, so they were looking at a database of kids and then looking backwards at who, who had autism, and if they had had the vaccine, but I think that's interesting to see such a large group of kids without, without any association, that and you know, there are some families actually, we talked about, you know, increase propensity for developing or having a child with autism, there are families who have several children with autism, and, you know, their first one or two children at the vaccine have autism. So their subsequent children, they refrain from having the vaccine, but they still have autism. So it's hard to, you know, look at those families and say, well, it was the vaccine that caused the autism, right, because clearly it wasn't, and it's not there are other risk factors that do increase the likelihood of having a child with autism or that child having autism. But not but not nothing. You've noticed from what you've read from the vaccine itself? No, no question about the second part of diagnosing autism when you talked about the repetitive behaviours. I wanted to clear this up a little bit because I'll have parents where their children do stimulatory behaviours they'll they'll spin in circles or you'll hit their head on the wall or they'll google it and they'll find the word autism. Are there any clues for parents to distinguish between what is normal and when to consider a diagnosis of autism? spectrum disorder. Sure, I think that context is really important. So if we think about communication in general, children who have difficulty communicating, become frustrated, kind of like we do when we're talking to our partner, or we're talking to a family member, right, like communication, or lack thereof can be frustrating. So any child who has difficulty communicating, who is frustrated may throw themselves on their ground may, you know throw for lack of a better word, a tantrum. But does that actually equate to autism? The answer is no. When we're thinking about stereotyped or repetitive behaviours, we should think about those that are not necessarily in context of being frustrated, although they may occur when someone is frustrated or when someone's excited. But oftentimes, these you know, stereotyped behaviours provide some sort of sensory input. So sort of like doing these behaviours in repetitive ways, without a clear reason why. So why is the Child you know, repetitively spinning in circles, at times that seem inappropriate, for instance, like in the middle of the night, or when they're at the grocery store, versus like they're at a dance party, or they're at a birthday party, and they're spinning in circles? I think that context is really important frequency and quality. And so I think it's okay to bring that information up to a physician, but not all of those behaviours necessarily equate to autism spectrum disorder. Nor is that a diagnostic criteria, it just a feature we see. But you don't have to have stereotype behaviours to have a diagnosis of autism spectrum disorder. No, that's helpful because that question comes up all the time. Kids do funny things when they're little. Yeah, they do. And actually, a lot of children with ADHD also have sensory difficulties and stereotyped behaviours that may, you know, especially if they have ADHD, and expressive language delay may look like autism very early on to an unskilled eye. So it's, it's important to be able to clarify those things. There are factors that we know may influence a diagnosis, but vaccines are not one of them. What are the factors that we know of that that may that may lead to a diagnosis of autism? Okay, so we do have some some clear answers. But I would say that, in general, it's mostly multifactorial. So we know that there's a genetic component, we know there's a genetic component, when we look at data from, you know, genome wide association studies or siblings studies. So a mother or a father that has a child with autism, the second child, or a subsequent child is at higher risk or an increased likelihood of having autism spectrum disorder, then a family whose first or second child doesn't have autism spectrum disorder. And we know that that's true as well in identical twin studies. So the risk is higher in the Twin than in a subsequent, you know, biological sibling who is not an identical twin. There are other risk factors as well, including increased parental age. So that's increase, you know, or higher maternal age, but also paternal age, particularly men over the age of 40. There's some evidence to suggest that wide gaps between maternal and paternal age is also an increased risk. Like what does that mean, like a 10 year difference or greater than 10 year difference? I think this is interesting, too, because a lot of men think they can have kids at any age they want. But there are some risks involved. Yeah, just like, you know, in what they now term is geriatric pregnancy for women, which boggles my mind, but women over the age of 35. Right. We've also found that there's some evidence of, you know, women who have difficulty getting pregnant, so that the need for reproductive assistance, including IVF. Now, it's unclear if it is the difficulty of becoming pregnant secondary to age, or genetic factors within a couple or a pair, who are having a child or if it's specifically the IVF process itself. That is that is unclear, but it is a risk factor. And we also know that individuals who who do IVF tend to be older anyways. So you know, is there some combination of those things together? It's kind of hard to know, there are auto immune factors as well. So as much as we think about autism spectrum disorder and coexisting conditions, we also think about, you know, they tend to have increased eczema, increased GI symptoms, and that is directly related to the auto immune system. When we look at mothers with autoimmune disease, including things like asthma, psoriasis, lupus, they are more likely to have children with autism spectrum disorder as our mothers who have February illness in the second trimester are more likely to have children with autism spectrum disorder. So there is definitely an immune logic component that we're not fully understanding yet. Have you heard people talk about the Amish and how Amish population do not have many children with eczema nor autism? Is that real? And do you think if it is real, why why might that be? That's a really good question. I've actually not heard that. And so if that data exists, that would be really interesting to look at. Yeah, it makes me think that there must be an environmental component. Sure. I think that there, there's always that environmental component. When we look at rates of autism, it's really hard to compare at times, because not all countries, not all states even have long term prospective surveillance data on autism spectrum disorder. In general, though, when we're comparing between countries who do have similar surveillance systems, the rates really don't change greatly from country to country, we haven't found any ethnicity difference. Although in the United States over the last 20 years, as we've been monitoring the data, something I hear a lot is how the numbers of kids getting diagnosed with autism has drastically increased in recent years. Can you tell me the numbers like what what numbers are we talking about? And how have the rates increased? Yeah, so the autism and Developmental Disabilities Network. In 2000, they, the CDC started to surveil autism spectrum disorder, and the diagnoses to help clarify which populations might be at risk. There are, for a long time, there were 11 sites and those sites are at large academic institutions, and several, obviously 11 different sites in the country, but not even 11 Different states, for instance. And so the populations that are surveilled are those in and around large academic centres. So for instance, the diagnosis of autism spectrum disorder, the rates are now one in 36 children in California is actually one and 24. Whereas in Missouri, and I don't want to misquote, but I think it's more of like one and 60. And that's because of the availability, for a child to be able to receive an evaluation and receive a diagnosis is different in these states. It's also different among different, you know, racial groups, which actually has nothing to do with science. Right, right. Race is a is not a science based idea. It's just based on skin colour, purely interesting. And so it's a box to check, right doesn't actually mean anything about genetics, necessarily, whereas ethnicity might. And then in California, for instance, the data comes out of San Diego County, so it doesn't actually even include Los Angeles County. And it doesn't include any part of Northern California. And so the data itself is skewed, I think. So as the numbers increase, it basically is saying that we're doing a better job in certain parts of the country, at identifying children with autism earlier, which is awesome. But it's not necessarily truly reflective of incidence, it's just purely prevalence. So it's a snapshot in time, how many children have a diagnosis of autism spectrum disorder in this county when we're collecting the data. And they use eight years of age because we hope that by eight years of age, if your child has autism, they have been diagnosed, and it sort of boggles my mind the the increase in numbers, and I'm always trying to think of an explanation because I remember I think, just a few years ago, it was something like one in 54 boys with autism. Yeah. And not that long before that. It was like one in 86. Yeah. And I'm wondering, you know, is it just that we're better at diagnosing autism? Is that what's going on here? Yes, for the most part, yes, it is because we are doing a much better job at diagnosing and diagnosing earlier. And we have found that in general. So now the term that we use is intellectual disability. So an IQ less than 70. A child or a person has a diagnosis of intellectual disability. This historically was called mental retardation. So as an intellectual disability is parsed out from Autism Spectrum Disorder, we have general rates of intellectual disability decreasing as Autism Spectrum Disorder rates are increasing because we're doing a better job at identifying the difference between there are individuals with autism spectrum disorder, who might seem like they have intellectual disability when in fact they don't. But their ability to communicate and use their language and their cognitive abilities is affected because of their ability to sort If perceive and process the world, and use their knowledge in social settings, I think of a lot of adults who I was friends with in childhood. And I wonder if it was a different era, if they were, you know, a child in today's world, there's a good chance they would have been diagnosed with autism spectrum disorder, maybe socially awkward, not that great with emotional cues. And I wonder if 30 years ago, we were really saving that diagnosis for the severe cases. And the numbers I think, would definitely have been higher. If the criteria were different back then. Yes. And I always explain to parents too, you can have autism spectrum disorder and be a genius and also be very verbose. But you can also have autism spectrum disorder and have severe speech and language disorders such that some times parents or other individuals will say they're nonverbal, and they can also have severe intellectual disability. So when we talk about a spectrum, that's I think, what sort of encompasses the heterogeneity and how an individual with autism spectrum disorder presents, whether or not there is intellectual disability, and whether or not there is speech and language disorder, because those are individual diagnoses that can coexist. You can also have autism and ADHD, 40% of individuals with autism have ADHD. And so those children's symptoms may be a lot more intense because of the ADHD and parsing out the difference. Is this inattention because of their ADHD? Or is this inattention because of, you know, their intense fascination with this idea or, you know, object and their lack of doing attention? Right. So it's kind of it's interesting, that's, that's really interesting. 40% of children with autism also have ADHD. Wow. Yes. I think it's also really important to appropriately identify Autism Spectrum Disorder, especially in children when they're young, so that we can really understand and conceptualise why they have their challenges, because children with autism spectrum disorder without intellectual disability and without severe speech and language disorder are at higher risk for anxiety and depression in later school age and adolescents. And they're also at higher risk for suicidality. And so being able to, you know, have children with autism spectrum disorder receive appropriate mental health services is really important, so that we can avoid, avert and appropriately treat their anxiety. So for parents listening, who may have a child who's on the spectrum, and they want to do the best they can to give them support. Do you have any recommendations as to where they should go? To help support their child? Yeah. So I think it depends on the child and on the family. So just as autism is different, and every child I think every family understands and deals with autism spectrum disorder differently. So Autism Spectrum Disorder is not something that can be cured. It is something that is a part of the the person and will be a part of the person through their life. Although at different times, there might be different struggles that come along with it. I think that building a really good relationship with your primary care doctor is number one, because the primary care doctor no matter how many specialists you see oftentimes is the person who's going to be putting in the orders for you know referrals to a psychologist referrals to ABA therapy, speech therapy, occupational therapy, physical therapy, and all the rest. So developing a good relationship with your paediatrician is one being evaluated by a developmental paediatrician, a psychologist or a neurologist to at least, you know, get a sense of what is necessary. I think sometimes it's confusing for parents to know, you know, what does my child need? And what does my child not need? Not all children do benefit from ABA therapy, but there are a good number of children that will hugely benefit from ABA therapy, you know, but I also think that it's very important to remember that there is a large portion of individuals and families who really struggle on a daily basis with children with severe symptoms. And so I would say it really depends on the family and the child. But having a good paediatrician and a good sub specialist, whether that be a developmental behavioural paediatrician or a neurologist I think is key. And if if the child is impaired, cognitive cognitively or has significant behavioural challenges getting services through the government. So in California, that would be the regional centre, that will be important as well and working with the school system. So having an IEP in place and at some point when the child is in high school, making sure to have a plan going forward for transition into adulthood. Whether that means vocational school whether that means an after care centre Whether that whether that means University. So working on that and thinking about that in high school, just like as you would for a child without autism spectrum disorder, that's a great point. I think a lot of times we focus on the early years and services, what a great reminder to think about how to prepare them for the real world. Yeah, I always, you know, think it's important for parents to remember that their child with or without autism is going to grow and learn and develop and will be a part of our community and our society. And so not we cannot always predict the future. And that's true for any child, it's just helping them and supporting them with their current needs, and then trying to anticipate without worrying terribly about what is going to come in the next year. And the next five years, I'll say that working with families and patients with autism spectrum disorder is probably my, my, one of my favourite patient populations, because I think individuals with autism teach us so much about life. There's a quote, and I don't even know who said it, but this individual has autism. And he said, I see things that most people don't, but I don't see the things that the majority of people do. And that sort of speaks to the autistic brain, right? They sort of are fascinated and interested with things that most people may not even pay attention to. But the obvious things like the social cues and things they make just sort of, you know, wash over my first cousin's daughter with autism, she goes to a school designed for kids with autism, which my cousin feels so fortunate because after the end of the day, he doesn't have to take her to special locations for speech therapy, physical therapy, occupational therapy, ABA therapy, it's all in that one school. I wonder if that will become more popular available for families? I hope so at this point, unfortunately, it's it's mostly private institutions. I mean, that would be amazing. If that. If that could be the case for every child, like your job have that in Ireland, actually. Oh, really? Yeah, there's a there's a really great documentary. It's called Autism and ni, it's available on Amazon Prime. And they do such a great job in their school setting. That's good to know. Yeah, I will definitely check out that documentary. So I'm just curious, like an all the time you spent working with families who have autism, with children with autism, is there anything that you want people to know that you feel like they don't quite get about autism that you would love for them to understand better? Yeah, I think this is another great quote that I actually recently heard. And it had nothing to do with individuals autism, but he's a writer, and he was giving advice if, if humans were to be extinct, what is like a one sentence probe that you might give the next life form. And he said, that we know, much more than we can say. And I thought, oh, my gosh, that's literally what I am trying to express on a daily basis to my children with autism spectrum disorder is that there's so much more aware, and they know so much more than they can often express. And so they do pick up on emotions, and they do understand when people are frustrated, they may not respond in the ways that we expect, but it's really important to remember that they are human, just like the rest of us and, and we should, we should treat them we should talk to them, call them by their name and, and look at them in the eye but not expect that they're going to look us back right but but to respect them and treat them as as you would want to be treated. I think that's really important. The other thing that I I like to sort of relate to in general, the the population is that you can have autism spectrum disorder and be very, very, very sweet and very, very social. We have this idea that it's the child who doesn't want to be around other children doesn't want to talk or doesn't want to interact. Those are the individuals with autism spectrum disorder. But a lot of children with autism are so sweet, they love to cuddle, they love to give kisses, they love to chat with people, and sometimes often will just insert themselves and not understand you know, boundaries, and will almost be like overly affectionate and overly social in ways in which makes people uncomfortable. So kind of getting away from you know, autism is a deficit in the wanting to be social. It's more of just being social in ways that are not acceptable to the majority of people. You shared such a beautiful quote and I think that really gives some good food for thought. So I appreciate you explaining how you think about children with autism and definitely I think it helps to stay And in their shoes. Yeah. And and I really think that, in general, we as humans have way more in common than we do different. And I would say that's true for every human on this planet, is that we have more in common than than we think. And if we really, like conceptualise that, I think we'd all just be much happier together. I actually 100% agree with you. Right? We all, we all have very much relatable lives. Yeah. Similar lives. Yeah. Yes. You're so lovely. And for parents that are listening that have a child with autism, and they're listening to you and they want to see you. Can they see you and how can they schedule a visit with you? Yeah, they can see me so I work at Children's Hospital Los Angeles. I work at the neurologic institute that I also work at the behavioural Health Centre. And if you feel like your child needs an evaluation, or you just need some better understanding, you can come and see me just have your paediatrician refer you to Children's Hospital Los Angeles to behavioural health or neurology. Thank you so much. Yeah, thank you. I really appreciate it. Thank you for listening, and I hope you enjoyed this week's episode of Ask Dr. Jessica. Also, if you could take a moment and leave a five star review wherever it is you listen to podcasts, I would greatly appreciate it. It really makes a difference to help this podcast grow. You can also follow me on Instagram at ask Dr. Jessica