Pediatric Neurology Waiting Room

We’re in the big waiting room of the neurology outpatient center.

Welcome to Neurology and Neurosurgery

I imagine high school interns made the bulletin boards for a service project. No amount of glitter letters from the Oriental Trading Company is going to cheer this place up.

It’s only 9:30 but the place is already packed. I forgot my breast pump in the car. Shit. Jim has already driven away with the other kids. Just realizing I am without it, I feel engorged. One more thing. One more thing.

No time for that now, I have to check in. Last night while half-watching 60 Minutes I suspiciously printed out the QR code receipt for pre-check-in. “Simply present this at the kiosk to confirm your arrival.” How did I know that wouldn’t work the way it was supposed to?  The desk staff, as usual, are sweet and courteous, but don’t know a damn thing about the kiosk, and I can tell that their morale is low because of it. I don’t blame them for being resentful of how these machines were installed without warning, so now they are forced to train customers on their mechanical replacements.

Charlie starts to squawk. I am afraid he is going to make a scene. I say quietly, to myself, what kind of genius came up with this kiosk thing?

I text Channell where we are, what to say to the guard to let her up, what to say to the desk in case we are in an exam room when she arrives.

Charlie’s neurosurgeon walks by in scrubs, but he doesn’t see us. A wave of anxiety washes over me. Again.

PTSD.

We are called back for vitals.

Ten minutes later, Channell arrives. I catch myself sending a split-second prayer of gratitude out to the universe for giving me the good fortune of finding a behavioral support person, and friend, like Channell. She is radiant as always, looking like a cross between Mary J Blige and Michelle Obama, her skin glowing like an airbrushed magazine cover, her clothes comfortable, trendy, stylish, and confident. Without saying a word, she pulls out her phone, loads up Rocket Speller, and hands it to the screaming Charlie. He is angry that the guest Wi-Fi at the hospital is slow, and he can’t get the show he wants on his Kindle. Channell and I know this without being told, because Charlie doesn’t remember how to tell us… He greedily grabs the phone and stops screaming.

I look up, and three little girls are sitting in the kid chairs in front of the TV, taking a break from chatting to stare at Charlie with prissy, sour expressions on their faces and cold eyes. The stares come so frequently I rarely even notice them anymore, and don’t care. I wonder what’s wrong with them, or if they are here with a sibling. Is this a follow-up for a one-time-only febrile seizure?  Is mom concerned about “staring spells?”

People wonder how I can be so comfortable sharing my life in my speeches, blog and social media. Every day, I am forced to share my most intimate, private, and often humiliating moments in front of the whole world. I submit my tax returns to case workers when I apply for medical assistance, I let a steady stream of Charlie’s therapists, case managers, home health aides and nurse supervisors into my messy home each week. My genetic testing results are blasted all over the world for research studies. I am usually covered in one or more of Charlie’s body fluids, managing a sudden deluge of urine or nosebleed with a good-natured smile. I have lost all sense of privacy. When you have a child with profound and obvious special needs, there is no grieving in private. Everyone can see exactly what you are grieving about, and how you are handling it, everywhere you go. Like being followed by the paparazzi of personal tragedy.

Another little girl, about two years old and impeccably dressed, sits down at the tiny and colorfully painted table and chairs. I look up to her mother and can see that this child is her pride and joy. Rightfully so. The girl’s eyes squint and she is a little unsteady on her feet. She has the unmistakable signs of a child whose morning meds just kicked in. I know that look all too well.

I realize that I’m staring at her, and I wonder if her mother is still at that phase where the stares bother her.  I am making it worse.  Channell and I both comment on how much we love the little girl’s sparkly shoes. I project all the kindness, softness, and humanity I possibly can to her mother through my smile and gaze.

“You missed vital signs,” I say to Channell, widening my eyes, trying to force levity in my voice, but I am stretching it, and she knows it.

“Oh boy, how did that go?”

“He ripped the head circumference tape measure in half, wouldn’t do height, and waved bye-bye to the blood pressure cuff. But she did get his weight. Not bad.”

She goes along with my decision to pretend I have accepted this as my life, that I am impossibly strong, that I am “giving it to God,” or some other optimistic philosophy that I really want to believe but we both know is complete bullshit on days like today. She smiles wearily and looks down at Charlie, the love all over her face. “Oh Charles, my Charles.”

We look around absentmindedly, grateful for a break in caregiving, however brief.

A father is walking his son “around the block” of the waiting room. If I had to guess I’d say the son is about nine. His gait is off, he seems frail and he has that thing, that aura that’s always so obvious but difficult to put my finger on…he seems to have some sort of cognitive impairment.

I am no better than the other nosy spectators.

They decide to take a break and sit down by his mother. He has a blue Convaid transport chair just like Charlie’s, only newer. I want to commiserate, to ask his mom if she had to go through the rigmarole with the Seating Clinic trying to get that thing approved. The Seating Clinic pretends to be about customized equipment and individualized service, but everybody gets one of the same three chairs, no baskets or other frills unless you need to carry something like oxygen, because insurance won’t pay unless you can prove there’s a medical reason to need a basket. But we are all grateful to tears when we finally receive it. Or maybe just relieved that the tedious process of procuring it is over.

I wonder if the boy, like Charlie, was always this way, or if something catastrophic happened to him as a normally-developing child. I wonder if he has epilepsy like Charlie or something else, like a neuromuscular disease. I wonder if it is degenerative, and if it is, if his parents are also getting the, “You never know, don’t lose hope, one step at a time, we just don’t know, he’s looking really great” line from the doctors.

His parents are also looking around at the other parents, at me and at each other. It’s obvious to me that we are all wondering how we got here. We have a vague look of shock, like we just stepped out of the rubble of a building bombed in a terrorist attack. One minute we were normal moms, shopping at King of Prussia mall and doing Zumba in the church basement. The next…we were in a Facebook group typing words like ‘prognosis’ and ‘epileptologist’ to other parents whose kids have the same catastrophic illness.

The stress of that morning, that year, that decade is written across our weary faces. This morning alone: packing the diaper bag, the feeding supplies, the special cups, the emergency meds, the insurance cards, pre-registering, loading equipment, rehearsing  our questions, communicating our schedule with the home health staff, taking off of work, getting them in and out of the car…

My eyes settle on a  teenage girl in a wheelchair, talking to her mother, but not in complete sentences. I feel a pang of jealously that they can communicate at all, then realize how wrong it is to compare when clearly our lives, at least today, suck equally.

For some reason, my mind drifts to the time a few years ago that I worked at this very hospital. I was behind the scenes in the offices in the back, and there were doctors and nurses there who didn’t know my personal connection to this world. It was clinic day, and the clinicians were discussing the patients that they were about to see.

“…he was here through the ER six months ago, had an MRI, some inflammation but not enough to cause—“

–“Yup, yup. All negative, but he is very fair-skinned, fair eyes, fair hair and he is a FLK, so he has something”

“What’s a FLK?” I ask, innocently.

“Funny looking kid.”

I would be forced to quit working there because I didn’t have enough vacation days saved up to cover Charlie’s second brain surgery, which took place at that hospital. The irony. Probably just as well.

I watch the doctors and nurses walk by, trying not to make eye contact, glancing at us on occasion, then quickly back down at their clipboards and phones.

I wonder if Charlie is an FLK.

I absorb the energy of sleepless nights and unspeakable choices, broken marriages and ruined careers, a laser beam of doom pointed directly at our lives. A piano over our heads.

The nurse calls us back. I recognize her from when she took care of Charlie in the hospital. I am awash in gratitude and memories.

After the appointment, I check my phone. Jim is in parking level A1. He has both my breast pump and the baby. Redundant, I am thinking.

He has talk radio playing in the car.

They are talking about Trumpcare.

Genetic Testing, Precision Medicine, and Research: Advice From Veteran Caregivers

I received this note from Charlie’s genetic counselor just last week.

“Hi Danielle,

Results did just come back, and there was no definitive diagnosis- a copy of the report is attached for your records.  Therefore, we will move forward with getting Charlie’s information enrolled in EGI.  There was one variant identified in a gene called MTOR- changes in this gene have been identified in some children with autism spectrum disorders, epilepsy, and differences in brain formation, however these are typically de novo (only in the child), whereas Charlie’s variant was inherited from his father.  This makes it much less likely that this is the cause of Charlie’s differences.”

And with that, the mystery of why my Charlie had infantile spasms, a rare and devastating form of pediatric-onset epilepsy, deepened.

How did I feel at that moment?

Heartbroken: I knew in my head that the odds of getting an answer were slim, but my heart hoped we would find out anyway.

Discouraged: I put a lot of work into getting this test approved by insurance and scheduled, only to have my hopes dashed.

Relieved: At least they didn’t find anything, well, more awful than I already know he has.

Angry: I am so, so, so sick of all of this. Sick, sick, sick, sick of epilepsy.

Self-pity: Why is this happening to me and my child? Why can’t we get SOMETHING to go right for us?

Denial: is it possible they just don’t know everything? Could they be wrong? Could it be this MTOR, or perhaps, GABRG2, the mutation that they found on the last test that he inherited from me? How could it NOT be inherited, since my uncle died in childhood from epilepsy?

Curious: Why is Charlie like this? Is it genetic? There must be an answer.

HOPEFUL: thanks to the Epilepsy Genetics Initiative , Global Genetic Variants Registry, and other research opportunities happening for kids with epilepsy right now.

When we first embarked on our journey with infantile spasms, I turned to online caregiver support groups for advice. The known causes of infantile spasms are numerous and range from genetic mutations to stroke to brain malformation. Some parents know the cause at the time of diagnosis, but many of us do not. Every parent’s first question is, “Why?” What did I do to cause my child to be so sick? Is it something I did when I was pregnant? Some environmental exposure or medication that I took? Could it be the glass of wine I had before I found out that I was pregnant, or all the diet soda that I drank?”

We are almost relieved to find out that very often, a completely random and unpreventable genetic mutation is the culprit, but then we start to worry about what genetic testing might discover. “If I have other children, will I pass it on to them? Does the genetic mutation cause problems in other organs? How long do children with this mutation usually live?“

Again and again, the subject of genetic testing came up in the discussion forums, but I didn’t understand any of it. Up to that point, I had limited academic coursework in genetics required of my Master’s in Public Health program. Indeed, many of the current hot topics in genetics were in their infancy fifteen years ago when I started graduate school. In my professional life as a clinical research data analyst, I often work on research projects involving patients with rare diseases that have genetic causes, but always AFTER their mutations were identified, not before.

I knew nothing about genetics or mystery diseases. I was just like many of you reading this right now.

My fellow “cryptogenic” (mystery cause) parents repeatedly discussed the different genetic “panels” to request from our neurologist. At that time, there was one that looked at 53 genes commonly linked to infantile spasms. Since those days more than six years ago, the “epilepsy gene panel” has expanded. Back then, most of the parents I know who received positive results from genetic testing then went on to one of a few wonderful, large patient support communities. A terrific group that comes to mind is the Tuberous Sclerosis Alliance (for people with TSC1 or TSC2 mutations).

These smaller, narrow panels leave many of us with no idea why our child is having seizures, and therefore, what other medical conditions they are at risk to develop, which medicines to avoid, and no support group to help us care for our children throughout their lifespan.

Take heart.

There is hope.

The whole exome looks at a lot more than the smaller epilepsy panels.  However, when scientists analyze your child’s whole exome, they are looking for KNOWN mutations. New mutations are constantly being discovered and added to the list that they check for during testing. Mutations become known when people with epilepsy get their whole exome analyzed and sent to researchers who can dig deeper and identify new mutations.

That’s why it’s really, really important for all of us “unknowns” to get our kids’ whole exomes into the big genetic data pipeline, so scientists can have more people to look at, compare, and discover what’s wrong with our kids.

Some other caregivers, and even people in my own life, have asked me, “Why do you want to know? Isn’t it best to leave well enough alone? He’s already experienced years of brain damage from thousands of seizures, and has lost a big part of his brain to brain surgery. Knowing his mutation won’t change Charlie’s outcome, so why put yourself through this pain?”

Here are my own personal reasons for pursuing a genetic cause for Charlie’s epilepsy:

Precision medicine: knowing the exact mutation(s) can lead to targeted therapies for Charlie, therapies that could significantly improve his health, quality of life, and development. It is inaccurate to state that knowing his mutation now, after years of brain-damaging seizures and two brain surgeries, will not change his outcome. We just don’t know what a targeted therapy might do for Charlie.

Currently, most epilepsy treatment protocols for mystery kids like Charlie involve throwing medication after medication at them, in random order or at the preference of the physician, and hoping something works. In fact, most parents are told early on that if three medications are tried and fail, the odds of any pharmaceutical working at that point are slim. Something that works for one kid doesn’t work for the other, and nobody knows why, because we don’t understand the underlying issue that made our kids sick in the first place. It’s like not knowing that there’s a connection between glucose and diabetes. How would they ever have come up with insulin as a treatment without that basic understanding of the functions of the body that regulate glucose? It’s pretty much a crap shoot, and it’s always hard to say which med is helping or hurting, especially when the child is on two, three, four, or even more anti-epileptic treatments at a time. All of the medications have side effects, some worse than others, and the medications themselves can trigger seizures when they are withdrawn.

Knowing a mutation would allow scientists to target the specific problem, kid by kid, so that we can avoid trial-and-error crap shoot mystery diagnosis epilepsy care. This is madness, and we, as parents, have the power to make a HUGE contribution to the solution by participating in genetic studies like the Epilepsy Genetics Initiative.

Research: knowing his mutation(s) puts Charlie first in line for any study of those mutation(s), including clinical trials of new drugs that could lead to a targeted therapy for him. I don’t want a study to pass us by because, as a mystery kid, we don’t meet the inclusion criteria of a specific mutation.  For example, as soon as I find out his mutation, I can enroll in the Global Genetic Variants Registry, and receive notification whenever we are eligible to participate in a study.

Support: If there are other kids out their like Charlie, with the same combination of symptoms, I want to meet them. Maybe it won’t be until our kids’ data are roommates in the same research database that it is discovered that there is more than one Charlie out there.

Imagine if your kid had diabetes, but you didn’t know it was called diabetes. How would you meet other parents online who also had kids with the same symptoms, if you couldn’t Google ‘diabetes?’ The diagnosis makes all the difference in finding support. This is especially true for those kids who were never diagnosed with a syndrome or condition like infantile spasms (IS) or Lennox-Gastaut Syndrome (LGS). While the associated organizations do not represent specific genetic causes, there is strong support in the general IS and LGS communities that is not available to mystery kids without these diagnoses.

Access to services: Understanding and documenting the severity of his mutation(s) will help me to justify therapy and education services.

Medication safety: knowing his mutation(s) would also tell us which medications he SHOULD NOT HAVE, as some medications can make seizures worse in kids with certain mutations.

Overall health: Certain mutations that cause epilepsy also cause problems in the eyes, heart, kidneys, and/or skeletal systems, just to name a few. These problems might not become clinically apparent until long after the epilepsy presents itself. Knowing Charlie’s mutation(s) can help me to be proactive and start relationships with specialists who can follow Charlie and prevent complications that may arise.

Another “bonus” that often comes with genetic testing for epilepsy is the opportunity to learn about additional genetic mutations that you or your child might have that could cause diseases.  For example, sometimes the tests will also reveal if you have the most common mutations that are implicated in breast cancer.

Family history: Knowing his mutation(s) allows me to make other family members aware, especially if this is an inherited condition. And if it’s not an inherited condition, this information will give us all a sense of relief.

Closure: because I’m his mother, and I deserve to know.

So how do we go about getting the whole exome done and sent to researchers? I will give it to you straight:  most of the time, the burden is on you, the caregiver, to initiate this process, and the system does not make it easy for us.  It is a battle worth fighting, for so many reasons.

You will almost certainly hit roadblocks early on, most likely with the insurance company. In addition, it might be difficult to schedule the tests, especially if both parents need to have blood drawn on the same day.  Sometimes, you can arrange in advance to have the tests scheduled with clinical blood draws at your next visit, but this can be a challenge to arrange, or when you get to the lab, they might not know what you are talking about, your husband’s name isn’t in the system so he has to wait for his blood draw, your kid is hungry, you still have to drive an hour to get home and pick up your other kid at school…I know, I know, believe me!

By the time you hit your first genetics testing obstacle,  you have put so much time and effort into it that you will feel overwhelmed, frustrated, and very sick of pushing for something that will not provide immediate seizure relief for your child.  You will want to throw in the towel and say to heck with the whole thing. You may feel like you don’t have it in you to fight for this on top of everything else. I hear you. I have been there. PLEASE don’t give up, for all the reasons I listed above. Luckily, you have me and many other experienced parents who are ready and able to help you through it.

The first step is to ask your child’s neurologist if a gene panel or whole exome testing is right for you.

I will be blunt. Insurance companies can be total jerks about covering genetic testing, and it can be cost prohibitive to pay for the whole thing out of pocket. Parents often complain to me that they feel “priced out“ of genetic testing. That is absolutely shameful. I hate to hear that. Have no fear, I have found some ways around insurance rejections.

After our first brain surgery but before our whole exome testing, our brilliant neurogenetics doctor wanted to see if Charlie had a certain mutation because the next drug on our list was contraindicated for that particular mutation. In other words, if he had the mutation, that drug could make his seizures a lot worse. The insurance company rejected our request for coverage of the test, citing that it wasn’t “medically necessary.”

That particular rejection really got to me.  I had lost all faith in humanity.

Fortunately, the doctor and dedicated genetic counselor at our hospital spent a lot of time and effort educating the health insurance company and, eventually, getting the decision overturned. If you get rejected, ask your genetics counselor to get involved and advocate for a reversal.

Something else parents need to know is that many genetic testing companies offer patient assistance programs to people whose insurance won’t cover genetic testing, usually limiting your out-of-pocket expense to $100 or less. Check with the company and your genetics department about this option if your genetic testing is rejected by insurance.  If you need some advice on this, send me an e-mail:  danielle@neurologyparent.org.

Once your genetic testing is completed, you should explore research studies. Usually, it’s just a matter of consenting to let your doctor or lab send the test results, medical history, and/or blood sample to the study team.  Start by asking your neurologist about studies. If your mutation has a support group or nonprofit organization associated with it, reach out to them. Look up any clinical trial through clinicaltrials.gov. As I mentioned before, for epilepsy, I highly recommend the Epilepsy Genetics Initiative (EGI). Note that you don’t need to have a known mutation to participate. In fact, one of the goals of EGI is to make those discoveries!

For those of you with KNOWN mutations, you can join up with researchers around the world. Our friends at the Global Genetic Variants Registry have just launched their website here. The purpose of their site is to link families with genetic epilepsies with researchers, possibly on the other side of the world, to understand the genes of epilepsy and find new treatments.

Finally, I reached out to my own network, Neurology Parent Professionals, for advice for families who are facing the prospect — or aftermath — of genetic testing.  Here is some of their advice:

“Make an in-person appointment with a genetic counselor and make sure they explain the mutation in a way that you can understand.  Ask a few key questions at the appointment, such as:

  • Is this definitely a pathogenic mutation?
  • How does it affect or potentially affect the child? This way you get set up with the right specialists right away such as cardiologist, ophthalmologist, physical medicine, etc.
  • Is gene therapy an option for this specific mutation, either now or in the future?

Research away, education is power, learn as much as you can- read it even if it doesn’t make sense right now, it will eventually as you continue to learn. Google it often, as there’s constant updates in genetic research right now

I know everyone is in a different place in their journey and some may not be able to jump right into advocacy but as soon as you are ready, get involved!”

–Leah

“Starting the process to access services if applicable is necessary to learn and initiate even though it is a stressful time. Every State has different case loads, waiting lists, evaluations etc.  Become proficient on the ins and outs of your insurance. Do you need referrals? What quality and quantity of services are provided by the plan? Does your State bill for services or do they bill your insurance? Know that pharma offers services to absorb medical costs. Last, try not to become overwhelmed. It’s a lot that has to be accomplished but just stay calm. It’s a marathon, not a sprint (most of the time but not always).”

–Andrea

“Just because they find other kids with that same mutation doesn’t mean they are “Apple to Apple.” They may have other mutations that play into it, a larger mutation, and other factors play in. So, just because you find like families you may not find like kids.”

–Holly

I hope that you find this post useful as you navigate your own genetic testing odyssey. The goal of my blog is always to write posts that I wish were available to me when Charlie and I were just starting out. As always, please don’t hesitate to contact me or comment below, with any questions or suggestions.

Helpful resources

How to Research Your Child’s Medical Condition Like A Pro

Genetic and Rare Disease Information Center: Support for Patients and Families

Epilepsy Genetics Initiative

YouTube Course:  Useful Genetics from University of British Columbia

Global Genetic Variants Registry

Rare Epilepsy Network

Clinicaltrials.gov  Look up clinical research studies in the US

How to create Google news alerts (put your mutation name or syndrome in and get an alert every time it is mentioned online)

NIH Precision Medicine Initiative Cohort Program  This is a very educational website for people interested in learning more about precision medicine.

Special Sounds

I’m sure your water didn’t really break.  You must be imagining that.

In this day and age, 34 week preemie is nothing.

He’s meeting his milestones.  Stop worrying.

It’s too early to say there’s anything wrong with him,  let alone autism.

It’s just teething.

It’s just a growth spurt.

It’s probably nothing.

Try to catch it on video.

Sometimes moms get nervous.

Have you been checked for postpartum anxiety?

We think it’s infantile spasms, but we can’t tell you for sure until tomorrow.

The price of that drug is so high that we don’t offer it here for ethical reasons.

He’s one  of the lucky ones.

I knew if we prayed enough he would be cured.

He won’t need early intervention.

We didn’t properly review the first MRI.

One hundred seizures per day is your new normal.  Unless he has more than that for ten days straight, I don’t want to hear it.

That kind of surgery is not for kids like him.

There is nothing more we can do.

He is not sick enough for nursing services.

He’s too sick for day care.

God only gives special children to special parents.

He doesn’t qualify for speech therapy because he can’t talk.

I call the spasm seizures “Superman seizures” because their arms go up.  It’s a cuter way for my patients’ parents to look at it.

I think a three-piece puzzle is an unrealistic goal.

Wraparound isn’t for kids with infantile spasms.

I wish I was that flexible.

I wouldn’t worry about getting him glasses.  He doesn’t do anything besides play with his iPad.

Did you know when you were pregnant that something was wrong with him?

I know exactly how you feel.  My dog had seizures.

Will he grow out of it?

He will grow out of it.

He has plenty of time to catch up.

 

Your claim has been rejected.

Your claim has been rejected.

Your claim has been rejected.

 

Your request has been denied.

Your request has been denied.

Your request has been denied.

 

He is no longer seeing new patients.

Fill out this form.

Call this number.

We need more documentation.

He has been dropped from…

We no longer cover…

Will he ever…

She is on sabbatical.

That ketogenic diet cannot possibly be good for him.

If he is hungry enough, he will eat.

How long do you think he will live?

He sure seems happy!

Call the Neurology Fellow On Call.

What are those toxic medications doing to his body?

I only feed my child organic.  I hate to give my child Tylenol.

Is Charlie excited about Santa?

Did he even notice you were gone?

Why don’t you just leave him at home?

Are you going to put him in a home?

If you have insurance, why do you need a fundraiser?

Was it a complicated pregnancy?

Did you take any medications during your pregnancy?

Do you think your age when you had him had anything to do with it?

There is a six-year wait for that benefit in this State.

If you fail three medications, the odds of anything working are almost nil.

We don’t think he really has autism, but it’s the only way to get services.

Can he talk?
Can he walk?
Can he feed himself?

 

You don’t qualify for the study.

We can’t watch him by ourselves.

That drug isn’t legal in this State.

Just Google a list of approved private schools and visit all of them.

I can’t tell you that without an evaluation.

We can discuss that at the IEP meeting.

I wouldn’t go without an advocate.

It’s time to renew…

We can always go back in again and take out more of his brain.

We have never tried…

Why does he drool so much?

 

Is he retarded?

 

Would you like to participate in a study?

The results of this study will not benefit you or your child directly but..

Have you gone to Dr. Rockstar?

We no longer accept your insurance.

Please send in diapers and wipes.

Technically, it’s a wheelchair.

He looks so normal.

There’s a waiting list for

…but we don’t have one at this school.

…but we don’t have one in this County.

He isn’t making progress.

He’s doing great…for him.

Are you going to wear purple today?

Are you going to the epilepsy walk?

Do you know a good neurologist in…

Does that really work?

Do you think it’s helping?

She’s not officially trained to do that but it’s pretty common sense.

Even if we do find a mutation, there’s a good chance we won’t know what it means.

…but they are not allowed to change diapers.

Most kids with infantile spasms don’t do half as well as him.

He seems so happy.

I don’t know how you do it.

You have to be at home to sign for it.

He’s too old for…

He’s too young for…

The attending will stop by and then we will try to discharge you sometime today or tomorrow.

He doesn’t have the right diagnosis for…

Too bad you don’t live there.

Have you ever read Flowers for Algernon?

Please help.  My child was diagnosed with infantile spasms today.

 

Please hold.

Please hold.

Please hold.

How to research your kid’s medical condition like a pro

Tips from a mom who happens to be a professional researcher.

I am often asked if having a background in medical research helped me in navigating my son’s complex, mysterious, and rare medical condition.

The answer is:  yes and no.

Before I became a full-time epilepsy activist/blogger/goddess/mom/public speaker/all-around glamorous diva extraordinaire, I worked in clinical research.  For nine years, I was a research data analyst and database manager for adult pulmonary research at Johns Hopkins.  I did statistics for presentations, conference posters, and peer-reviewed manuscripts, and helped to plan and implement large-scale clinical research studies on subjects like pulmonary hypertension, asthma, and cystic fibrosis.  Before that, I worked for several years in women’s health.  What that means is, when my son was diagnosed with infantile spasms, I knew absolutely nothing about pediatric neurology.

In many ways, I was a total beginner just like many of you.

On the other hand, my degrees in political science and public health combined with my experience in the health care field taught me a whole lot about where to find the good information about my son’s condition.   I also know a lot about research “systems,”  how papers get published, how research is funded, and how to read a paper.

I would like to share with you my “essentials,” or the sites that I check first when I am looking up research or general information about my son’s condition, or helping another family look for information.

Using a few of my tricks, you can be good at this, too.

FINDING AND OBTAINING ARTICLES

UpToDate is hands-down my favorite resource for finding the latest, evidence-based information about any condition, written by doctors who really know their stuff.  These articles summarize the state of the research on a particular topic, synthesizing all of the latest studies, in an easy-to-read format.  The patient articles are free, but you can fairly inexpensively subscribe to the whole site with short-term access.  The articles that you get with the subscription tend to be much more detailed and are at a higher reading level than the articles written for a patient or caregiver audience.  Best of all, the articles provide lots of references to journal articles if you want to read about anything that was summarized in greater detail.  Oh, how I love UpToDate.

How can you find these journal articles?  Start with PubMed.   Click on the link and put my name (Boyce Danielle) into the box at the top.  It will send you to a list of a bunch of articles I co-authored.  Once you stop yawning, you can try searching for something that actually interests you.  Try putting in the name of a top researcher that you may have heard of, your child’s condition, or a combination of search terms like “epilepsy” “brain surgery” (although you might want to get more specific on those search terms, as it will give you way too many results to be helpful).  PubMed is where I start when someone asks me, “Hey, Danielle, I read a news article that came out yesterday that says they found a genetic mutation that causes cortical dysplasia.  Do you know what that is?”  I will play around with those words and between Google and PubMed (Googling [study epilepsy “cortical dysplasia” genetic] might lead to the authors’ names, which is then entered into PubMed), I will get enough information to answer the question.  There are a lot of different tools in PubMed that can help you search like a pro.  Just poke around that site for a while to get the help that you need.  Once you have your list of results, click on the article title to get the abstract, or a quick overview of the paper.  Many of the abstracts link to free full-text articles. Sometimes you have to dig around a bit to find the free links.  If the article you want is not free, sometimes your doctor or social worker will print out a copy using their institution’s access privileges– just don’t ask too often, because this takes up a bit of their time.  The organization called Partners in Information Access for the Public Health Workforce has published an essential list of other strategies for accessing medical literature.  It never hurts to have a good relationship with your local librarian.  Librarians love to help with research projects, and often have contacts at local medical libraries.

Side note: It also never hurts to try the Institute of Medicine (IOM).  The IOM convenes expert panels and sometimes publishes really great documents jam-packed with good information and references.   This includes recommendations for changes that should be made to improve care.   I mention the recommendations because I often cite the recent IOM report on epilepsy in my advocacy efforts (“but, the IOM thinks we should do this, too!”)

INTERPRETING THE ARTICLES

Now that you have your articles, you may be thinking, “Holy cow, I don’t understand a word of this!  What does this all mean for my child?”  Have no fear!  I can help you.  The BMJ’s “How to read a paper” series will help to demystify what you are reading.  Note:  it is very important to choose papers based on well-designed research studies, because the interpretation of results is much more straighforward and relevant if you do.  Reputable sources mentioned above and your physician’s recommendation are the best place to start.

That’s it!  That’s all there is to it.  Once you have mastered these basics, read on for some special topics.

SYSTEMATIC REVIEWS

Cochrane Reviews take all of the published evidence on a topic and synthesize it using a fancy and totally legitimate methodology called a systematic review, and then draw conclusions for level of evidence for a particular intervention.  Clear as mud, right?  OK, let’s try an example.  I am interested in learning about the evidence based on the published literature on brain surgery for epilepsy.  I put “epilepsy brain surgery” into the search and obtained these results.  The review explains how many studies were selected, how the analysis was performed, the limitations of the analysis, and the authors’ conclusions.  If you link out to the Cochrane Library, you can find a lot more details, including author information.  Pretty awesome, huh?  I guarantee that if you mention a relevant Cochrane Review to your child’s doctor, she or he will be very impressed and will also possibly fall off her or his chair.  The only limitation for some of these reviews is the fact that rare conditions or interventions (like brain surgery for children with infantile spasms) occur too infrequently to be studied on a large scale, so there might not be many studies, and therefore there might not be enough evidence to give them a thorough summary.

Online courses

Now that you have a taste for this, how about taking some FREE online courses to expand your knowledge base a little?  You know, in your spare time! 🙂

While this CDC course focuses on population-level (public health) studies, I think it is a great way to get you thinking analytically.

Khan Academy is one of my favorite sites ever.  You can learn almost anything for free.  I can get lost on this site for hours the way I imagine other women get lost in the lip gloss aisle of Sephora.  Conclusion:  I may need to get out more.  I just can’t help myself.  This is a great site for getting caught up on basic science and biology, like organs and how they work.  Sign up for free and then start with the Health and Science section of the site.  For parents of kids with neurological issues, check out Biological Basis of Behavior:  Early Methods of Studying the Brain.

MIT Opencourseware is one of those projects that restores my faith in humanity.  Hundreds of courses on almost every subject imaginable available to anyone to review, FREE!  Like Khan Academy, this site is more for big picture topics related to the human body rather than individual diseases.  If you search for broad terms like, “brain” you will be blown away.

These are just a few of the millions of resources online waiting to be discovered.  There’s nothing stopping you from being the most educated person in the room about your child’s condition.  After all, you are already the expert, and you always were.  Now you have the research to prove it.

I am so happy to be able to share this information with you, my most fabulous readers.  Please comment if this post helps you or if you have any questions!