Doc Discussions with Dr. Jason Edwards
THIS is the podcast you have been looking for! "Doc Discussions" are just what the title says they are: physicians from a wide range of specialties, talking about relevant, up-to-date medical topics, not to mention tips on habits to help you live your best life. Your host, Jason Edwards, MD, is a board-certified radiation oncologist with a PhD in cellular and integrative physiology at St. Luke's Hospital in St. Louis, Missouri. Dr. Edwards explores not only diseases but also suggests techniques to optimize mental and physical health for a long and good life. Real people. Real advice. Real good. This is Doc Discussions, with Dr. Jason Edwards!
Doc Discussions with Dr. Jason Edwards
Trust, Science, and Parental Fears: Part 1 of Navigating Childhood Vaccination Decisions
The fears parents face when making healthcare decisions for their children can be overwhelming, especially when it comes to vaccines. In part one of this candid conversation with pediatrician Dr. Lisa Ryan, we dig into the complex world of vaccine hesitancy and why it continues to grow despite decades of scientific evidence supporting vaccine safety.
Dr. Ryan shares her frontline experience with parents' most common concerns, particularly the fear that multiple vaccines might "overwhelm" a baby's immune system. She offers a fascinating perspective that puts this worry into context: a baby's first breath exposes them to more antigens than all vaccines combined. Parents often make decisions based on emotional, gut reactions rather than data—a very human response when it comes to protecting our children.
Perhaps most compelling is Dr. Ryan's observation that "vaccines are victims of their own success." Today's parents haven't witnessed the devastating effects of diseases like polio, measles, or severe rotavirus. Our grandparents' generation vividly remembered summers when neighbors suddenly found themselves in iron lungs from polio—creating an urgency for vaccination that modern parents simply don't feel. This absence of visible threat makes the theoretical risks of vaccines loom larger than the now-rare diseases they prevent.
We also explore the infamous MMR-autism controversy, tracing its origins to Andrew Wakefield's discredited 1998 study and examining why autism diagnoses have increased (hint: it's not vaccines but broader diagnostic criteria and better screening). The conversation takes a surprising turn when discussing how pediatric practices handle vaccine refusal, with Dr. Ryan explaining why many doctors cannot maintain effective relationships with families who fundamentally distrust their medical guidance.
Whether you're a parent with questions about vaccines, a healthcare professional navigating difficult conversations, or simply curious about this contentious topic, this episode offers thoughtful, nuanced perspectives that acknowledge both the science and the very real emotions driving healthcare decisions.
Hello, welcome to Doc Discussions. This is Jason Edwards and I'm here again with Dr Lisa Ryan, a pediatrician at Woods Mill Pediatrics. Phone number is 314-453-9666. Lisa, welcome, how are you doing?
Speaker 2:Hi, good, I'm glad to be back.
Speaker 1:Yeah good, you were great last time. I thought you were really great on the mic, and so I thought we could get into kind of a maybe a somewhat controversial topic of vaccine hesitancy.
Speaker 2:Okay, yes, that's a big one, an important one.
Speaker 1:Yeah. So you know, my assumption is is that this is something that pediatricians have kind of dealt with more and more as the years have gone on. Is that accurate, or has it kind of been more popular and less popular?
Speaker 2:No, I think that's fair to say that things kind of ebb and flow Recently. We're really in a spot where we're seeing more and more vaccine hesitancy. People are asking more and more questions and we're seeing more and more vaccine refusals and sadly we're seeing some of the consequences of that too.
Speaker 1:So what are some of the common misconceptions patients or patients family members have about vaccines?
Speaker 2:You know. First of all, it's really hard to say because typically you know if a family comes in, it's hard to kind of pinpoint exactly what they're concerned about. I'd say probably the biggest one, though, is they're worried about too much at once. Okay, so they see us giving, you know, a couple of shots at one time and get very concerned that I have this brand new tiny baby and we hear often that you're going to overwhelm the immune system. So I'd say that's probably the biggest concern.
Speaker 2:Sometimes people will come in with arguments that the vaccines are actually harmful I don't think we hear that one quite as often or that they're not studied well. Again, I don't think we hear that one quite as often. Or that they're not studied well Again, I don't think we hear that one quite as often. But, truthfully, I almost feel like it's sort of this gut feeling that it's something that I don't think my baby really needs, and in my mind there is some negative outcome that weighs any possible benefits, and sometimes I don't think they're even able to really verbalize what they're worried about or what they think might happen.
Speaker 1:Yeah, you know, there it reminds me of a book by Daniel Kahneman called thinking fast and slow, and like most books, I read like half of it and then you know most books they like give you get the gist of it and then they just pound the same point home for another couple 100 pages. But there's this like emotional knee jerk thinking, which is good, you know, sometimes you don't have all day to think about something. And then, and then the slow thinking is this logical, methodical thinking. If you can break it down into math or physics, you would do that and try to figure out like what the best answer is. And I think you know the idea of seeing a newborn baby getting needles stuck in it, whether it's one needle or 10 needles or 15, it's not a good feeling. And so it seems like it's kind of that fast knee jerk feeling that like hey, this doesn't seem right, even though we've been doing it for a really long time.
Speaker 2:Right, right, seen hesitancy similar to what you were saying, that the idea of actively doing something is a harder thing to take on than the idea of just kind of sitting back and seeing what happens.
Speaker 1:Yeah.
Speaker 2:Like the parent would feel more guilt if I made this decision and something happened, rather than let me take my chances.
Speaker 1:Yeah, yeah, okay, I get that, and so that's like a type of cognitive dissonance. And so, yeah, get that. And so that's like a type of cognitive dissonance and so, yeah, the the, it feels unnatural. Sometimes it's better to, you know you're, you want to just sit back and kind of let things play out and and and then you would have kind of less guilt on your heart, despite whatever the outcome may be.
Speaker 2:Sure, sure. And the other part of that too is we'll say often that vaccines are a victim of their own success. You know, a lot of these vaccine preventable illnesses we just don't see anymore. A parent doesn't even know. I mean you say, hey, your baby might get measles, they're like okay. So you know, my grandparents had measles, my parents had measles, nothing terrible happened to them. Or you know, we vaccinate against chickenpox. I had chickenpox when I was small. I had a mild case. I seem fine. So you know, I think a lot of it is just very far removed. Polio has been a lot in the news recently and you know our I guess it's our grandparents at this point remember the springs or the summers where you know your neighbor could be in the iron lung tomorrow because they had polio and how scary and how fearful that was. And that's just. Parents just don't see that. It's just that fear is not there. They think it's so far removed that again they're willing to take the chance.
Speaker 1:That makes a lot of sense. That's a good point. You know, when I think of polio, I think of FDR, of course but, you know that's.
Speaker 1:you know we don't see people with polio and I can't. I think I think maybe I've seen one patient ever with it, but it's just not something that's present. If it's in your face, then that. You know. Fear drives a lot of decision making and so you know, you read something online and it's scary, despite not really having the context of it, and that can really be your anchoring bias. It's the first thing you see, the first thing you think of, and it's just hard to move off that position.
Speaker 2:That's true or you just don't fully understand, fully comprehend how it works and I've had, you know, patients talk to me about that too, and the best analogy I've come up with there is you know what I don't enjoy flying. I'm a nervous flyer. It does not make sense to me at all how this giant plane is going to get off of the ground and get me safely to my destination. However, at some point I have to trust that you know the engineers built this plane, that all the people have checked the plane out, that the pilot knows what he's doing and I have to sort of give that over to him that he's going to get me safely to my destination. So at some point too, I say you know you got to trust the experts. People have been doing this for a long time. They know more than we do and we have to trust what they're telling us. And there's a lot of distrust now per mile.
Speaker 1:It's obviously safer than driving in a car Right Um the um, but it's just. It's just that thing in your head that you know it gets stuck there. It just doesn't see. It's scary.
Speaker 2:It's a little bit out of your control.
Speaker 1:Yeah, yeah, for sure, for sure, um and so um. How have the number of um shots that children get changed over the years?
Speaker 2:Um, so that's a really good question. Um just generically. Yeah, so basically, at most visits, babies are now getting um two injections and a little syrup that they drink. Okay, and because we have combined vaccines, so one of those vaccines is going to give you a DTAP, a Hib and a polio uh, vaccination all in one shot.
Speaker 1:Yeah.
Speaker 2:And you know your. Dtap, that is, you know already three different vaccines, Um, and then you know your, your Hib and your polio. So now that's what one, two, three, four, five, kind of all in one, and then your um, Prevnar vaccine in another, and then your rotavirus is the drink. So that was what like six, seven things were vaccinating against, kind of all in once. Okay, but it's two shots and a drink, correct, correct. So you know, sometimes you'll just see all those, depending how you look at it. You know, if you see all of that sort of laid out in front of you, it does seem overwhelming, it does seem like a lot of stuff. But what we've been able to do over time is actually, the exposures from all of those is much less than when your baby is born and takes his first breath. The antigens in there, there's just much fewer, got you. So we're able to sort of refine things that way. So even though it seems like a lot and it seems like it's more, it's actually technically a little less.
Speaker 1:Gotcha, it's less of a load, less of a challenge to the system. So if I was kind of playing the role of a skeptic and said you know, this seems like it's too much, playing the role of a skeptic and said you know, this seems like it's too much, it seems like it's overwhelming the system, which, I get you know, a very rational person could say that Then you would think that children would be. If the immune system was kind of biased in this way because of the recent vaccination, meaning that it's making these antibodies towards the antigens that you just gave it, that if it was overwhelming the immune system, then they would be prone to other illnesses.
Speaker 2:Sure, If your immune system is busy doing one thing you're saying then it wouldn't be able to do the other stuff Right.
Speaker 1:And so you would expect that the rates of like not only influenza but all sorts of things would increase, and I don't think there's any data to support that, that children get sick more often. You know from like the normal culprits.
Speaker 2:Sure, no, definitely not. I mean most of those. I mean obviously ebbs and flows with the season. Sure, sure, and COVID kind of threw stuff out of whack so it's become a little harder to predict, but we're certainly not seeing kids sicker than we ever had before. I mean truthfully, the sick season is much calmer than it's ever been. I mean, I used to, we used to bring in like 18 kids with like RSV, but now we have an RSV vaccine and you know, we I haven't seen, I've seen maybe like four this year.
Speaker 1:When did that come out the RSV?
Speaker 2:This I want to say is the second season.
Speaker 1:Really. Yeah, you know I had to do a pediatric oncology rotation and you know that was like and it was in the wintertime and that was like, it was like a big deal. These kids were really sick and some of them had chemotherapy, some not. But I mean the RSV was to me, you know, very scary.
Speaker 2:Well, as a resident, that was a big deal.
Speaker 2:That was kind of like what you were there to learn because, we would admit these kids overnight and usually most of them were able to go home the next day. Some of them might stay a little longer, but that was what part of pediatric residency was being able to admit all these kids, being able to recognize which kid was sick and would need more help and being able to figure out which ones were good to go, you know, the next day and when they were ready to go home. But we used to. I mean during the busy time we'd have like 20 admins at night and I know that children's Hospital is like overflowing now and I think all the hospitals really are with various other viruses and stuff. But I mean I haven't had a hospitalized RSV kid this year.
Speaker 1:Yeah, so yeah, that's great. I mean, for me being a non-pediatrician, I mean kids are much more resilient than adults. You know, I remember seeing a patient with leukemia who had like a hemoglobin of like two. You know, you're not surviving that as an adult. A kid you know two weeks later is like running around. It's the best part of pediatrics. I mean they are resilient, for sure, and so are each, or is each, vaccine tested in randomized, controlled trials before they use it.
Speaker 1:Yeah, yeah, yeah, and they're large, randomized controlled trials, right, right, right. And that's kind of the gold standard for any drug or vaccine is to, you know, use it on a lot of people and then follow those people and see what happens.
Speaker 2:I mean there's some caveats there, because obviously we don't want to leave kids prone to getting these infections if we've realized that the vaccine is going to help them. So the randomized controlled trial might be slightly different than it would be for some kind of drug or something like that. And I think we saw that to some extent with the COVID vaccine. We had controls and we had people who were on it and once we realized it was going well, they were able to kind of stop and just start vaccinating everyone.
Speaker 1:OK, and so what you're saying is, if there's obvious evidence or strong evidence or a strong suggestion that it's working, there's not this group, that doesn't get it Right, because you would be kind of doing a disservice to that group. But you could at least compare them to historical controls that did not have that Sure yeah, which is, you know, pretty good.
Speaker 2:Yeah, yeah, and of course we're kind of following along and we're looking to see if there's any negative side effects. The rotavirus vaccine actually there used to be two versions of the rotavirus vaccine and one of them they started to see an increase in intussusceptions, which is kind of where the intestine telescopes in on itself.
Speaker 1:Yeah.
Speaker 2:And you know, I don't know that they were necessarily able to say that it was causing or that sort of thing, but there was enough of a signal there for them to actually that one got pulled from the market and now we only have this other one.
Speaker 1:So I read that drugs, just all drugs, not pediatric drugs not vaccines but just drugs. About 25% of them will end up having like a black box warning and about 2% will get pulled from the market. Has that happened with vaccines at all?
Speaker 2:I mean the, the road tech is the one that really stands out. Some of them have been refined like it was the, the DTaP vaccine. The pertussis component of it used to be sort of a bigger antigen. I have to admit I don't remember the specifics.
Speaker 1:But they made it better.
Speaker 2:Yeah, but they changed it because there was more side effects to that particular part. So they were able to go back and kind of rework it, and that's why we now have the DTaP as opposed to the DTP.
Speaker 1:And that's been around forever.
Speaker 2:Yeah, it's been quite some time, but I mean, I haven't been doing this all that long and I can still remember, you know, when I started practice, the HPV vaccine was coming out and the rotavirus vaccine was coming out. And just even in the short time I've been in practice, you know when I was a resident we would admit tons of kids with rotavirus. And I haven't seen rotavirus in ages.
Speaker 1:And that's a virus that causes a lot of diarrhea and things like that.
Speaker 2:Yeah, kids would get admitted for dehydration, like all March. Like that was how we spent our March and I haven't seen rotavirus in a really long time.
Speaker 1:And so I mean, in a way you could say well, that's kind of scary, this vaccine, this rotavirus vaccine, you know vaccine, this rotavirus vaccine, you know the initial one got pulled. But also, I mean, it should also give you some comfort that they're monitoring these things closely and if there is an issue they will pull it quickly.
Speaker 2:Right, right, I mean there's, and a lot of the vaccine skeptics kind of point to this, to this database where people can submit their what they believe is a vaccine side effect.
Speaker 1:Yeah.
Speaker 2:And a lot of skeptics will say that you know, we submit all of these and these are all very real side effects and because they're all there, we need to be looking at these vaccines more closely and stopping use of them. But what actually happens is, once those side effects are in there, there's someone who's going through and really, you know, analyzing is this actually due to the vaccine? And looking at the science behind it before they make any sort of decisions about it.
Speaker 1:Yeah, so OK, so this is. Sir Bradford Hill talked about this a long time ago. It's causation versus association, and so you're going to have, if you have a group of people vaccinated whether it's the COVID vaccine or a flu vaccine or you know your childhood immunizations things will happen to people in both groups, whether you're vaccinated or not. Right, and actually this is a good example. So patients who have had hormone replacement therapy estrogen have a higher risk of breast cancer and according to the old data, your relative risk would double. And so if you're a woman in the United States, your likelihood of getting a breast cancer is about 16%, 17%, let's say 16% If you take hormone therapy. They used to think that your risk was double, so it would be 32%. But 100% of women who took estrogen replacement and got breast cancer thought that it was from the estrogen. But even though it was only half the time, half the time you would have gotten it anyway.
Speaker 1:And so there's all these errors and judgment that people have, and I think it's fascinating to study that, and I have them, and you have them, and everybody has them. But if you actually know they exist, your likelihood of making mistakes starts to go down, and I think that's where errors and judgment can occur. You take the like everybody who takes the flu vaccine every year. There's going to be people who die the next day, but there's also going to be people who didn't take the flu vaccine who die the next day too. Now if you're the person who takes the flu vaccine and dies the next day, good luck trying to convince that person that it's a coincidence. I mean, when a coincidence happens to you, it does not feel like a coincidence. You see direct cause and effect, and that's what's hard for you know. You hear these anecdotal stories and that's what's hard for people to separate.
Speaker 2:I mean, you're just not going to be able to convince that individual that it's unrelated. Yeah, no, you're exactly right, because that's sort of the last big thing. You remember? I've talked to patients too in terms of I'll be like, okay, let's pretend that you know your baby is all ready to get his vaccine and he's on the table and I've got his leg and I've got the vaccine ready to go, and I'm about to put it in his leg, but I get distracted and I turn around and I don't do it yet and then all of a sudden your baby starts having a seizure. If I hadn't turned around and I had done the vaccine right, then your baby was going to have the seizure either way. But now you're convinced it's caused by the vaccine and goes back to to some of these ideas we haven't touched on yet about the MMR and autism, and a lot of that has to do with the same time you're giving the MMR vaccine is around the time that we're diagnosing autism.
Speaker 1:And what? What age is that? 12 months 12 months.
Speaker 2:So at 12 months everybody's getting the MMR vaccine.
Speaker 1:So this really came in the late 90s, when Andrew Wakefield I think he was an English physician came out with a study showing that vaccines were associated with autism. Later, I think that it was found that the data was manipulated.
Speaker 2:Yeah, it was flawed. So I think it was like 1998 or so.
Speaker 1:He had two studies.
Speaker 2:So the first one came out and if I remember correctly it was published in the Lancet and it was basically making an associate, or his hypothesis was that when you give the MMR vaccine you cause proteins to enter through the digestive tract. We cause inflammation in the digestive tract which allows proteins to enter which then later cause autism. So that was kind of what he set up, but it was flawed in a lot of ways. I think the sample size was super small. I think he had used like friends from his kid's birthday party or something Like.
Speaker 2:There was something really weird there and as you know, science has to be replicated, and no one was ever able to see these same results.
Speaker 1:Yeah, yeah, for sure. I mean, especially in the social sciences. They have a very difficult time replicating studies which you know should make us somewhat suspicious. You know about that kind of stuff, but in the that doesn't happen very often with medical trials. Usually if a large sample size, it's reproducible Not always, but so other people tried to do the same trial and were not able to replicate it.
Speaker 2:Right right. So it wasn't. They couldn't replicate it, and when they went back, it's just the whole study design was flawed. And so like the Lancet actually removed it, so it's as if it never existed. But of course the damage was already out there and I believe he published a second paper it was like three or four years later with kind of similar findings. Again, I don't remember the specifics, but it was something about seeing measles virus in cells in the intestine.
Speaker 2:And so, again, he was associating that with the vaccine, but without. That's a pretty big jump, yeah, yeah, so, so, yeah, the damage was done and I think that was around the time that people started questioning these things. I mean, you know my oldest, she was born in 2003. And I remember, you know, being a little like, okay, I've sort of heard these things.
Speaker 1:You know and asking her doctor.
Speaker 2:But we're doing this. You know like this is safe to do and him being like yeah.
Speaker 1:And so like, yeah, you have, like you would say, you had some a little bit of skepticism, yeah, and and like I, I would say like it's, it's okay to be, you know, to ask questions, right, it's okay to not, you know, you know to be like this. This feels weird. Um the um, I think um it's, and we you and I talked about this earlier um, practices, sometimes don't you know, if the patients say I do not want to get vaccinated, a lot of practices I would say the majority of pediatric practices actually say you know, then we can't be your doctor.
Speaker 2:Yeah, we're just not the right fit, we're just not the doctor for you and our practice is one that's like that, and it wasn't a decision we came to easily, but it's one that I feel pretty strongly about. I mean, first of all, I want to be able to protect all my patients in the waiting room. If I have a baby in the waiting room who isn't old enough to be vaccinated or can't be vaccinated due to a medical issue, I want them to feel that they're not going to come into my office and catch a vaccine preventable illness. So that's a big part of it. But the other part of it too is I think it's just really hard for me to form the doctor-patient relationship that that patient needs.
Speaker 2:I guess in my mind, you know, I think one of the very best and most important things I can do for your child is ensure that he's vaccinated. And if I'm trying to do that and you don't think that that's the best thing for him, if you think that if I vaccinate him I'm poisoning him or, you know, inhibiting his health in one way or another, I don't think you would trust me with any other medical decision, and I think there's already a distrust there. So you know, like if you come in for a ear infection I say, hey, amoxicillin is the best med for you. Are you necessarily going to trust that either, like it seems like for everybody, you should be going somewhere where you trust what your doctor is telling you.
Speaker 1:Okay and feel comfortable with that. So it's not like coercion or punitive, it's just a bad fit. I think so, and it's just kind of like say hey, like I wish you the best, but you know we got to kind of part ways here.
Speaker 2:Right, right. Well, and the other thing is, you know, sometimes parents will come in and be like I only want the most important vaccines, and I'll be like well, how do we decide what is the most important? You know, and I'm not saying it flippantly, but it's like- it's not a ranking right, yeah, is the most important one, the one you're most likely to get? Is it the one you're most likely to die from? Is it the one that has the most painful death? Like, how are we going to decide?
Speaker 1:that I don't feel comfortable making that decision.
Speaker 2:Yeah, we have people who reviewed the vaccine schedule. They figured out what order it should be given in order to make sure that we're protecting you from the earliest stage possible. There's just no reason to stray from that.
Speaker 1:Yeah, yeah, and so I'm going to go. We talked about autism. I'm going to go just a little bit off topic for a second. Okay, why do you think that there's an increased incidence of autism?
Speaker 2:We screen for it more.
Speaker 1:Yeah, that's, that's, that's what I thought.
Speaker 2:Yeah, and even that, I think, has been over the course of my career too, like when I came out of residency, it was something that you know, it was kind of in the back of your mind and you would sort of you know, we obviously always talk about development, but at some point I don't remember when I mean we do very specific screens at 18 and 24 months you know, so not only are we talking about development at every visit, but they've now created a questionnaire that parents will fill out and it can basically signal as someone who's at risk.
Speaker 2:So I think we're just picking it up more. We've also kind of extended the definition. I think it used to be a very narrow definition and now we've made it much wider, realizing that people benefit even if they don't meet the narrow definition of autism. They may still benefit from the therapies if we widen that definition.
Speaker 1:So you don't think that there's been some sort of evolution of human beings where, like, the trait is just more abundant than it used to be in our population? I know, I know, that's a tough question to answer, but I mean, I do I think there's a genetic component?
Speaker 2:Probably yes, but I just think it's. I don't think it's more prevalent for those sorts of reasons. I really think it's just more changing the definition and just more awareness. You're more likely to see the things you're aware of and looking for.
Speaker 1:Yeah, it's kind of my presumption that the more experts you have in autism in a population, probably the higher the incidence will be.
Speaker 2:If you're a hammer, you see a nail. What was that? I'm sorry. If you're a hammer, you see a nail.
Speaker 1:Yeah, I mean a little bit of that. You know, If you're a hammer, you see a nail. I mean a little bit of that. You know, I think back growing up and I mean there are kids that now I'm not an expert on autism, but there are kids that I, you know, we all do this and I kind of sometimes I'm like that's OK, and sometimes I don't, when you're like, oh yeah, he's on the spectrum, like something feels a little off. You know it's kind of been come socially okay to do that Right, and I don't know I don't feel 100% about that. But but we all know people who are like, okay, like I could. Maybe that guy was autistic that I grew up with and like, you know, still, everything was fine, we still live a good life. We're all different right.
Speaker 1:Every way but.
Speaker 2:but you know now like that person would probably have a diagnosis, right yeah, and you know now, like that person would probably have a diagnosis, Right yeah, and you know, and for what's that worth? It can get you services, it can get you help at school, it can make things a little bit easier for you. So I think in some ways and.
Speaker 2:I'm not saying this necessarily happens in some ways. I think if you're on the edge, it might be worth just doing it so that you can get that help. Yeah, so maybe that alone accounts for you know a little bit, a little bit more. I mean, I I've certainly sent kids for evaluations where I'm pretty sure they don't have it, and they definitely come back with the diagnosis.
Speaker 1:So do you think I mean on something like that, that it's not like a blood test you get, and you have this like result yes or no? Um, it's, you know, kind of a judgment call based off a multitude of things. Do you think there's an overdiagnosis of it? I mean, there's got to be to some degree, but do you think, like, that degree is large or small?
Speaker 2:I mean, I think it's hard to reuse the word overdiagnosis. I mean, I think I'm thinking of patients who, where I'll be like I don't know that this is really autism. This seems more about like a developmental delay or, you know, maybe an isolated speech delay, but they end up getting the diagnosis of autism. They end up getting the ABA therapies as well as other intensive therapies and within a couple of years, they're actually, you know, back in a realm where you wouldn't see any deficits.
Speaker 1:Yeah.
Speaker 2:So was that really a diagnosis or did they get better because of the help? You know I'm not really sure. Either way, I'm happy they got better and you know we don't have to worry about it and I don't think the diagnosis necessarily like follows them or anything like that. But I think because of cases like that too, like I said, I think we are maybe a little quicker to call this autism, so that they can get help, which we know will be helpful.
Speaker 1:So the thought is to err on the side of giving it to the diagnosis to them than not.