Approaching Disorders from All Angles: The NDPC at D-H
You will not find centers anywhere in the U.S. where such experts are working together from such diverse disciplines."
Autism spectrum disorder (ASD) is an equal opportunity disability; it occurs in all racial, ethnic and socioeconomic groups. ASD is almost five times more common among boys (1 in 42) than among girls (1 in 189). According to the Centers for Disease Control and Prevention (CDC), in the U.S., approximately 1 in 68 children has been identified on the autism spectrum. One in 6 children had a developmental or intellectual disability (2006-2008) ranging from mild to severe, from cerebral palsy to autism.
Beyond these statistics are children and families that the Neurodevelopmental Child Psychiatry Clinic (NDPC) at Dartmouth-Hitchcock (D-H) was created to help by providing a comprehensive plan for the care of each child.
The NDPC “is a very unique clinic,” Stephen H. Mott, MD, director of the Child Development Program at D-H explains. To listen to Dr. Mott discuss autism diagnosis and treatment on NPR see link at end of story. Mott has worked with children dealing with developmental disorders for almost three decades. “You will not find centers anywhere in the U.S. where such experts are working together from such diverse disciplines. We see kids who are absolutely the most complex.” The multidisciplinary clinic is a diagnostic and evaluative resource staffed with specialists from diverse areas. Mott, a developmental cognitive neurologist, works closely with Jennifer McLaren, MD, assistant professor of psychiatry, and Arthur C. Maerlender, Jr., PhD, neuropsychologist, both from the Geisel School of Medicine at Dartmouth.
There is also a diversity of disorders according to McLaren: “We see children with autism, which is a neurological-developmental disorder, but the clinic’s purpose is actually much broader than that. We diagnose genetic and metabolic syndromes, Down syndrome, intellectual disabilities, cerebral palsy, and traumatic brain injury. We see rare disorders like fragile x and genetic issues, but also fetal alcohol exposure, which is pretty common.”
A child with one of these conditions may have to seek help from several disciplines, says Mott, “but traditionally these patients are seen independently by care providers, however, it’s really important to put our expertise together at the same time.” This inclusive approach is also important because often a child is experiencing co-occurring disorders or conditions. McLaren agrees, “We really see the clinic as one point of care with multiple perspectives, all focused on one child. That is what allows us to do a comprehensive evaluation.”
“Families usually come to us when they have a child who is struggling in the community and home,” says McLaren, “Parents and schools are overwhelmed and no one knows how to approach the issues.” After a thorough diagnostic evaluation the clinic provides a recommended course of treatments, accommodations and resources.
The evaluation is a two-day process that includes neuropsychological and psychiatric testing, as well as a physical and neurological exam. McLaren points out, “Each child receives an evaluation based on their needs. It’s tailored to the family and school’s concerns, and what has already been done in the community. Also, we look at a child’s IQ, attention and executive functioning—their cognitive strengths and weakness, how they learn and understand information.”
Before they do anything, Mott says, “We first take a careful history of what the problems are. We do this primarily with the parents, who may bring school representatives. We review all medical, developmental and school histories. We also meet with the child to hear their concerns.”
Once all of the information has been reviewed and the testing is completed, Mott, McLaren and Maerlender along with the rest of the care team, including child psychiatry fellows, meet together and come up with a recommended course of action. Once the report is written, it is reviewed with the family and they are given a copy. The parents can also choose to have copies of the report given to others including their child’s primary care physician and school.
“We provide lots of recommendations and approaches,” says McLaren, “from therapy and behavioral recommendations, to school accommodation or psychiatric medication, follow-ups for neurologic workups looking for possible seizure disorders or possible genetic testing.” Beyond that, the clinic provides suggestions for parenting approaches in the home, and other resources and support in the community.
Families travel from all over New Hampshire, eastern Vermont, southern Maine, and northern Massachusetts to the NDPC due to the uniqueness and quality of the services offered, including working with the families to receive care with within their community. “We are really invested in the medical home [a model of comprehensive, coordinated care close to home], and sending our recommendations back into their community, connecting families with resources so they can receive therapy from their local health centers, and support from their school districts,” says McLaren. “However, if there are struggles or concerns we are still here for the families and they can contact us.”
“Children come to us primarily after being referred by their primary care physician,” says Mott, “but also by psychiatry, neurology, or by our own child development area. If a primary care physician is not involved in the process from the beginning, then within the patients’ community there is no medical home to take over care and support, which is an integral part of the process.
The medical home and close-to-home community resources are extended partners of the NDPC. “I think these children are a patient population we are all really invested in,” McLaren notes. It is this wide-reaching, multidisciplinary team care approach, and the individualized comprehensive evaluations, that are effective and unique aspects of the clinic. “I think children and families really benefit from that,” Mott adds. “Collectively, we are interested in helping families navigate and cope with the difficulties that come with these diagnoses.” Families come in looking for answers; they leave not only with a documented plan, but also with hope.
Dr. McLaren demystifies the new autism classifications in this article, Reclassifying Autism Spectrum Disorders for ParentingNH.com