December 12, 2012

Autism Treatment Network (ATN) at Children’s Hospital of Philadelphia (CHOP)

Posted in AMT's Faves, Life's Little Moments, My Take on Autism tagged , , , , , , , , , , , at 12:31 pm by autismmommytherapist

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At the conclusion of a routine sick visit eight years ago, my son’s pediatrician told me my boy had a severe and lifelong neurological disorder by perfunctorily shoving a batch of miscopied articles into my shaking hands, all of which contained the word “autism” in the titles. He then quickly and summarily left the room.

He wished me an offhanded “good luck” before he departed, leaving me to gather the pieces of my shattered soul along with the detritus that comes with any toddler. This pseudo-diagnosis was delivered to me so thoughtlessly not by any quack, but by a renowned physician in our area, one whose practice was fifteen minutes from the nation’s capital. He was the pediatrician with a waiting list to get in; the one whom everybody loved.

Through my grief and shock, and if I’m honest, my hope now that I knew what Justin’s differences meant, I felt an intense rage at having been informed this way. I vowed someday I’d try to do something about it. Now, it seems, I’ll get to have that chance.

The knowledge that my eldest son’s development wasn’t exactly typical didn’t come as the greatest shock to me back in 2004, as I’d been concerned about some of his behaviors for the previous eleven months. Still, I would have preferred to hear his doctor’s concerns rather than read them with one hand tenuously clutching those damning articles and the other attempting to keep my seventeen-month-old from falling off the examination table. I felt terrified, hollowed out, and numb all at the same time.

The detail that kept me sane was he had written the numbers of several excellent developmental pediatricians on the front page of one of the articles, so at least I wasn’t starting from scratch. Even as I gathered up my boy and his toys I had a partial plan on how to get the official diagnosis, which I knew would lead to the appropriate therapies I had no idea in that moment I’d be mostly conducting solo for the next fifteen months.

The contacts wouldn’t change everything, but they were helpful in that terrible moment. Still, the information was delivered so cruelly, and would lead to so many different referrals both for therapeutic practices and for diagnoses, that the entire experience was exhausting, and completely less than optimal.

When we had finally settled Justin into a routine about a month later I found in my few unfettered moments I would fantasize about a one-stop-shopping experience, one in which my pediatrician would have been able to deliver the diagnosis I had to wait another four months to acquire a state away. I also dreamt of spending my time actually delivering services to my child rather than gracing the waiting rooms of the myriad specialists we were directed to see, all of whom would hopefully ameliorate the co-morbid symptoms that so plagued my son, namely gastrointestinal issues and sleep disorders.

I wished desperately that we’d had a better experience. My heart still broke for the numerous parents whose children would continue to be diagnosed, some in that exact brusque and uncaring manner, many who would have their child’s condition revealed to them in a way that might make my experience look exemplary.

My eldest is almost ten years old now, and it’s been almost a decade since that devastating day, one which continues to haunt me. In the interim I’ve relocated my family to New Jersey for the educational systems and proximity to family, and we’ve had a second child, also diagnosed on the autism spectrum. I never lost hope for the one-stop-shopping experience, so when I heard about the Autism Treatment Network (ATN) at Children’s Hospital of Philadelphia (CHOP) over a year ago, I jumped at the opportunity.

As participants in the program both of my children could be enrolled and have access (if needed) to the services of a nutritionist, a developmental pediatrician, a neurologist and a psychologist all within the same hospital system. Specialists in gastroenterological disorders, metabolic disorders, and sleep disorders are available as well.

We would be asked to make the commitment to schlep to Philadelphia four times in the next three years with each child, but we could pull them from the program at any time. The ATN is primarily funded by Autism Speaks, and has seventeen centers throughout the United States and Canada. Its mission is to provide families of children with autism with state-of-the-art, multi-disciplinary care.

Last week along with several other parents I had the honor of being invited to participate on the first autism-centered Family Partners Program, an initiative dedicated to improving the delivery of services of the ATN to families with children on the spectrum. I was fortunate to spend the evening with Amy Kelly and Amy Kratchman (family advisors for the ATN) who are spearheading the program with the hospital, as well as with two intensely dedicated developmental pediatricians (Amanda Bennett and Susan Levy).

The forum was rounded out by several other parents of children with autism spectrum disorders as well as staff from the hospital and the ATN. While there are many goals the team wishes to accomplish, the main focus of the group is to provide feedback to CHOP and the ATN about programs, initiatives, research, quality and improvement projects that involve families with children on the autism spectrum.

Once the preliminaries (and the food, a definite bonus) were dispensed with, we got down to brass tacks. I’m not certain who first proffered up the idea, but fairly soon into the meeting someone asked the parents these questions:  Would you prefer to have your pediatrician be educated and knowledgeable about your child’s co-morbid conditions?  Would you like them to be able to treat these conditions?  Finally, would you like to see the ATN in better collaboration with pediatric and adult physicians (since children with autism eventually become adults with autism) so that your child could be predominantly treated in-house?

As I reluctantly put down my Caesar salad wrap and looked around the room at moms nodding their heads in emphatic agreement, we all answered with a resounding “yes”.

Frankly, it sounds like paradise to me.

I know that some parents will read this article and be extremely skeptical that any type of collaboration will take place, much less lead to significantly improved delivery of services. The truth is, however, that we have to start somewhere. CHOP has already begun to consider a practice in which to pilot this collaboration, and the ultimate goal is to expand the collaboration to other pediatric practices in the region, with at least one provider in every practice being well-informed and educated about autism.

If you’re wondering why any double-booking appointment physician would be interested in this type of instruction, the ATN at CHOP has worked that piece out too. All pediatricians are required to carry a certain amount of MOC (Maintenance of Certification) credits to maintain their board certification, and this partnership would satisfy some of those requirements.

Given that I’m a “behaviorist” on the side, I was happy to hear that these doctors would not just be intrinsically rewarded. Time is in short supply for all of us. Physicians would not just walk away with an increased knowledge base about their patients- they’d have credits toward retaining their licensure as well.

Throw in a little chocolate, and it would be the perfect experience.

Of course, all of this is a huge undertaking, and its success ultimately resides in multiple practitioners desiring to deliver better services to beleaguered families, which is no small undertaking. I’m aware that educating one physician in every practice in the United States will take some time (perhaps the understatement of the year), but a number of other autism milestones took a great deal of hard work too.

It wasn’t so very long ago that Early Intervention was just a pipe dream, or that offering self-contained classrooms to autistic children who need that confinement was an unheard of practice. I’m certain this process will involve small and laborious steps. I’m also certain the ATN will succeed, and the moment can’t come too soon.

Somewhere out there soon, a baby will be born. In a few years his mom will approach his physician with her concerns, her worries, her fears. She may be told they’re nothing. She may be told to wait.

She may be told she’s right.

And if she is, hopefully she’ll be given the tools to help her child succeed in a compassionate, caring, and informed manner that won’t break her heart.

It all starts with a little hope.

For further information go to http://www.autismspeaks.org

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March 7, 2012

Clarity

Posted in My Take on Autism tagged , , , , , at 10:28 am by autismmommytherapist

“No Justin, not yet honey”, I say for the hundredth time in what I like to call my “faux calm but really freaking out voice”. Once again I block my eldest son, who has moderate autism, from pushing the button which will gain him entrance to the inner sanctum of Children’s Specialized Hospital. My choice to prevent his entrance is met with more tears and tantrums, and at the sound of his elevated distress, the kindly nurse who just took his blood pressure and weight statistics comes out of her office yet again to offer her assistance.

We’ve reached the end of perhaps the longest half hour I’ve experienced in quite a while. I’ve just spent thirty minutes filled with my distraught boy trying to escape the “evil confines” of the waiting area, a room with which he is completely familiar as we have been here many times before to meet with his former developmental pediatrician. The nurse has even gone so far as to slide by Justin into the back of the building and tell the new doctor to “hurry up”, an action which has made her my new best friend.

I share this life-changing information with her, and she laughs. Finally, a mere fifteen minutes after our scheduled appointment (but in reality, a lifetime for me), the secured doors slide open, and our current developmental pediatrician makes his appearance.

Justin is less than impressed.

The next hour is spent with me trying to entertain my eldest with the twelve thousand preferred toys I’ve brought, ones which usually engage him, while I simultaneously try to make it clear to our practitioner in some semi-coherent fashion why we’re actually here. I am distracted by my son’s myriad attempts both to don his coat and make me wear mine, which will signal our imminent departure, and by the loud intermittent whooshing sound of the heating vent which is preventing me from hearing half of what the doctor is saying.

I ask him if the vent can be turned off so I can hear him better. Of course, it can’t. I scrape my chair in closer to him, an action which momentarily gives Justin hope that we are leaving, and leads to a burst of greater protests when this does not become reality.

I remind myself that during most doctor’s visits Justin is compliant. Today, however, I am taking one for the team.

As our practitioner spends a few minutes conducting a physical exam on my son, I allow my mind to wander to my youngest child. He has autism too, although his is very mild. Zach is at the moment living out one of his dreams to be a paleontologist, as his entire pre-school is currently engaged in a dinosaur event of the greatest magnitude. I sit back in my chair, and am struck by the dichotomy in my sons’ days. My eldest, desperate to leave his current situation. My youngest, witnessing a volcano erupt, using tools to excavate “ancient artifacts”, and consumed with joy as he acts out his current preferred vocation.

And I fully admit as my son’s exam is concluded, and he heads once more for his coat, that I wish I were with his little brother.

The truth is, I’m tired, really, really, tired. This is our third stop in the “gathering opinion tour” as to how to help our son, who has regressed in terms of behaviors and overall demeanor since an illness struck him four months ago. I refocus my attentions on our pediatrician as he suggests a new medication plan, one completely different than the one suggested by the medical brethren at CNNH. I mentally catalogue his reasons behind the suggestion, hoping I retain them long enough to share them with my spouse. These are serious drugs both practices are offering up to us as solace to Justin’s increased aggression and malaise, and the decisions his father and I will make are soul-suckingly difficult.

At this moment, I just don’t feel like making decisions anymore. Of course, the thought chaser is, I have to.

We wrap up our visit, Justin all smiles and joy at our impending departure, and I manage to corral him within the office long enough to grab a scrip for his current prescription. We head for egress, he fairly dragging me along, his doctor asking us to wait in the foyer for some important information he will print regarding his medical suggestions. Justin and I approach the sliding doors, and there is no longer any chance of containing him. The information will have to wait.

And as we head for the car, braving gusts of cold wind which Justin seems to enjoy, I silently ask the universe for some quick solutions, and clarity.

June 8, 2011

Alphabet Soup

Posted in My Take on Autism tagged , , , , , , , at 9:01 am by autismmommytherapist

It’s Friday afternoon, and I’m trying really, really hard to suppress my irritation as I drive, and losing the battle miserably. I’m on my way to Justin’s new neurological pediatrician with husband and boy in tow, unhappy because we went to the wrong office, and now we’ll be late for our appointment. Justin had his intake at their facility in north Jersey months ago, but somehow Jeff and I both missed that this practice has two offices in the central part of our state, and now I’m cursing under my breath that I didn’t check the website more thoroughly. I look at my car clock once again, and sigh. I placate myself that getting Justin in and out of the first office, for the most part, was easy. Except for the fact that for the first time ever my eldest was scared in an elevator, which prompted him to launch his seventy-pound frame into my arms in the hopes I’d carry him out of it, we’re still okay. I’ll need a chiropractor immediately, but we will be okay.

We’ve switched clinicians in part due to that waiting room incident, but also because my husband and I have come to believe that Justin has a dual diagnosis of ASD and OCD, and we’re hoping to have fresh eyes assess the situation. The secondary diagnosis of obsessive-compulsive disorder has been largely dismissed by Justin’s practitioners in the past, all of whom have thought that his rigid adherence to ritual is simply a facet of perseveration, a central tenet of autism. His father and I think it may be something more.

Last month we were fortunate to have the BCBA from Justin’s school in our residence for a few hours to assess his “maneuvers”, the rotation of DVDs/CDs/picture frames/shoes/plush toys that consumes him, and drives us crazy. This gifted woman with decades of experience with children on the spectrum validated our concerns, agreeing with us that some of his actions were a function of the repetitive aspects of a spectrum disorder, but the duration and severity of his focus indicated something else was amiss as well. Jeff and I subsequently figured it was worth the hell of finding a new doctor, and made the calls.

We pull into the parking lot of the hospital complex a mere three minutes late, and since at our first visit this woman seemed to be the paragon of compassion, I figure she’ll let our tardiness slide. We whisk Justin into the waiting room and check him in, and my husband makes sure the receptionist has our new insurance information while I attempt to keep Justin from barging in on a surgery. Our new neuroped takes us almost immediately, which further endears her to me, and I quickly tote goody bag, boy and purse into her well-lit and child-friendly examination room. Not only is there space for the four of us to sit, but there appear to be actual “autism-interesting” toys for Justin’s perusal as well, and once again I’m grateful we put him on that long waiting list last summer. I find myself almost giddy at how simple the entire affair has gone.

As I’ve said before, it doesn’t take much these days.

At our last visit we broached our concerns about the possibility of Justin’s sporting a second disorder, so we spend a good portion of our appointment time discussing how he’s doing at school (beautifully), his behavior at home (save for the constant house reorg, wonderful), and the numerous interventions we’ve attempted. My husband and I share with her the opinion of our fabulous BCBA-for-a-day, and reiterate we’re aware of the difficulty of culling out the perseverative aspects of his behaviors from those that might be purely of a compulsive nature.

Eventually, we stop talking, and listen.

Our learned practitioner concurs with us that dual diagnosis is difficult, and perhaps at the end of the day, immaterial. She says that from what she’s heard it is probable he has both disorders, and she’s willing to state it for the record. We discuss our “plan of attack”, which begins with increasing the dosage of his current medication, then perhaps exploring others if this intervention fails to mitigate the situation. We are given time-frames and parameters for using this approach, and she throws out the names of other potential medications. Our doctor gently informs us that things might get worse for a while before they get better, if they get better. We are reminded that none of this may work because he has autism, as well as OCD. Finally, our new physician gently tells us that it may take months to see a change, if any, because finding the right SSRI for OCD is a complicated task.

Hmm. Ambiguity in a treatment plan. It seems we’ve been here before.

As Justin begins to tire of the toys he initially found so fascinating, his father and I simultaneously wrap up our little tete-a-tete with Justin’s doctor, whom I’d recommend unequivocally to anyone (and that doesn’t happen often). We gather our stuff, thank her, and as Jeff heads to the exit with our boy, I tell him I’m going to make our next appointment in person, so I don’t have to remember to place the call next week. When I finish reconfiguring the chess pieces of our summer schedule I have an appointment secured, and head rapidly back to the exit so we can attempt our return home prior to rush hour.

In the distance I see Jeff struggling a bit with Justin’s safety harness, and I heighten my pace because I know how frustrating those buckles can be, and frankly, I’m just better at it. I know I have almost an entire minute alone to process this dual designation before I’m reunited once again with my family, and, I quickly assess my emotional state (I’ve become expert at this over the years). Unbidden as I walk, the tune from the “alphabet song” enters my head. There is a slight variation on a theme this time with the words “ABCD, ASD, HIJK my son has OCD” inserting itself into my fatigue-ridden brain.

No, I’m not sure where that came from.

I continue on to the car, and realize I’ve suspected this outcome for years, am far more interested in whether or not this knowledge can help alleviate some of his more troubling symptoms than whether or not he has a second “label”. So many recent studies seem to suggest that a variety of disorders comprise one big happy family, with ASD, OCD, ADD and others perhaps fighting for purchase on one or two chromosomes. Perhaps we’ll add more letters to his “alphabet soup” along the way, perhaps not. At the end of the day, what he has is irrelevant to who he is, and how much he’s loved.

And as I leave the parking lot after a brief skirmish with my spouse over which direction to turn (he was right, I know, it’s shocking), I remind myself that on the bad days, and yes, there still are bad days, that this absolute truth is what I need to remember most.

April 10, 2011

Resurgence

Posted in My Take on Autism tagged , , , , , at 8:15 am by autismmommytherapist

SLAM!!!!!  Zach and I jump a bit as we’re sitting at his art table, and I quickly smile both to hide the fact my heart has briefly stopped, and that I am completely exasperated. It is, perhaps, the THOUSANDTH time Justin has slammed the closet door this afternoon (okay, slight exaggeration, but it FEELS like it), and my patience is frayed to its ragged, disintegrating ends. Zach asks “What is Justin doing, Mom?”, and I reply “organizing his toys, hon”, but secretly, I admit to myself I really have no idea. While the lion’s share of the playthings from the closet have been exiled to the garage recently due to Justin’s escalating OCD, he has still managed to find something in there to rearrange- namely, his plush toys. Although the positions we have discovered them in have been mildly amusing to me and his father, our overriding emotion upon witnessing this returning obsession has been dismay, and sadness.

For so long, he had been doing so well.

Over the years, as I’ve spoken to people about my eldest son and his neurological disorder, I’ve found most conversations end up centering around his lack of speech, and how difficult that must be both for him and our family. While I don’t want to minimize this deficit (believe me, there are many days I wish the child could just TELL me why he’s rivaling my PMS-state), it certainly has not been his greatest impediment to functioning in the “real world”. Even the aggressive moments that plagued us, his therapists, and his teachers over the years were scattered enough to be “livable”, until the end of his sixth year when the incidence increased so greatly we sought the assistance of medication for him.

Although the non-verbal aspect of his autism and the pinching have both been considerably daunting, the single greatest component of his disorder that affects his life the most is the OCD/ perseveration. It’s what clued me in at his six month birthday that something was amiss (when your infant chooses to spend his entire day spinning a faux fish bowl throughout the hardwood floors of your home, it’s time to contact that developmental pediatrician). His predilection for rotating objects, rearranging photos around our home, or hiding one shoe from a pair in absolute obscurity (his mother’s personal favorite) prevent him from engaging in more appropriate pursuits, effectively limiting his world to a minimum of activities.

There are mornings when I almost have to carry him out of the house to get him on the bus, and not because he doesn’t want to go to school, because he’d live there and marry his teacher if he could. It’s simply that the random pattern of paper slips, and oft-ignored Xeroxed reminders on our chaos of a kitchen table are not arranged to his liking, and he can’t leave until they are. Perhaps it is that I have erroneously placed a new photo of he and his brother in the family room, rather than mid-way upon our living room bookshelf at an angle that is just so. After all these years I still cannot discern the precise patterns he is striving for, and his penchant for order is enslaving him. There are many days his closet machinations would leave him in tears if we weren’t constantly redirecting him, in our own attempt at ritual.

There are as many days that little face, desperate in his desire to get it “right”, engenders tears in me as well.

The thing that brings me and his father most to despair, is that the OCD comes in cycles, is stealthy in its resurgence. It’s only been the last six months or so that it’s escalated to this level once more, and once again, it doesn’t seem to be precipitated by anything in particular. In the past, it seemed to be high fevers that heralded the return of the full body tics and desire for order that would consume him for a few months, then dissipate. Since he had those glorious ear tubes inserted last fall there have been no fevers, no antibiotics, no palliative measures taken to address the always-accompanying upset stomach that perhaps were the triggers to his obsessive state. Despite all the progress he’s made socially, academically, and emotionally, this bane to our existence, this barrier to his happiness, is simply back.

Of course, we’ll address it to the best of our abilities. We’ve found a new neurological pediatrician with whom we feel more comfortable (and yes, if you’re wondering, she has a waiting room). Jeff and I felt she really listened to us at our first visit, was open to the suggestion we’ve been hearing from several professionals in Justin’s life that he might have a dual diagnosis of both autism, and actual OCD. She’s willing to think out of the box a bit with medications, comprehends the limits of a therapeutic approach, and understands we have thoroughly explored the tenets of ABA to alleviate his suffering. There is even the possibility of enrolling Justin in a study someday, if we collectively feel it will be to his benefit. We’ll return to see her in a few weeks time, and I feel confident all options will be evaluated, that he is in good hands, that my boy is receiving the best care possible.

But I can’t help wondering, if despite all our attempts to quiet the sometime chaos of his beautiful mind, if this is as good as it gets.

May 21, 2010

House Call

Posted in Life's Little Moments tagged , at 8:52 am by autismmommytherapist

This past Friday afternoon I summoned the courage both to wake my youngest son early from his nap AND brave Route 34 at rush hour, and make my thrice-yearly pilgrimage to an appointment with my sons’ neurodevelopmental pediatrician. I have been making these runs to various specialists for six years now, and as I poured my growling, lethargic offspring into his carseat for the thirty minute trek I briefly recalled how these visits used to be emotional landmines for me. No matter how kind the practitioners were to us (and believe me, not all of them had any clear affinity for children), I usually concluded each visit with a take-home gift of a dozen sodden tissues, or I’d barely make it to the car until the waterworks commenced.

It wasn’t that they were nasty to me (most of the time), just that in the space of a few minutes and several pertinent questions put to my non-verbal boy that all of our progress could be whisked away, buried in what I termed his “litany of lacking”. With my second child however, one who in particular was doing so well, I just couldn’t manage to summon the appropriate dramatic reaction, was instead annoyed we’d miss the walk I’d planned to take to work off the extra Hershey’s kisses I’d had that morning.

I have my priorities after all.

As we rushed down the highway in my usual “ten minutes late” mode to every appointment, I decided to be mature, and instead of blasting Stevie on our journey I chose instead to “prep” Zachary for his encounter with our venerable pediatrician. I asked him what he’d say when he met her (I got “hi, I’m Zachy”), and queried him about his age (he’s three, and has the requisite fingers to prove it). I even got a bonus response regarding his gender, in case we weren’t certain. I wondered how much Dr. P would remember of Zach’s demeanor from our last visit six months ago, the one where he barely looked at her (although really, how compelling IS a pediatrician to a two-and-a-half-year-old), and only reluctantly and intermittently responded to her questions.

During that fall visit he had also failed at my favorite test of all, the time-honored tradition of “lay out three pictures and tell me which one is an animal, etc.” game, an endeavor in which many autistic children tend to suck. Zach was true to his peeps that day, and although he quietly identified most of the photos displayed for him, he could not for the life of him tell anyone what they did. This inability to perform did not concern my husband one bit, as he was so thrilled with Zach’s overall progress. I however personally plummeted into a shame spiral, depressed that after all our efforts he couldn’t even identify Lassie. I was pissed.

Today, however, I was hoping to knock our practitioner’s socks off. This is what now constitutes a thrill for me in my daily life.

As we unerringly made our way to her office (thanks to the witchcraft of my newly installed GPS, which I employ religiously despite the fact that I’ve been to this office literally a dozen times) we ran through the gamut of basic greetings, colors, shapes, nursery rhymes, etc., and eventually I decided to up the ante a little. Sometimes my son’s pre-school teacher gives him “homework”, and since I’m a former educator BY GOD I will support his instructor in any way possible. Zach’s latest assignment was to try to memorize his address, and since I’ve actually been blessed with a child who might not only get lost some day but could actually tell people where he resides, I was determined he would get the facts down cold.

We took this assignment very seriously, with mommy repeatedly pointing to the numbers on our home until they rolled off of his tiny tongue, and taking even more calorie-burning walks around the neighborhood to identify our street sign at every appropriate corner. We even made field trips to as many “welcome to town” signs as I could locate, and slowly Zach acquired the necessary information, eventually rattling off house number, street and village with ease. I was gratified to learn that he generalized this information to school, and was comfortable informing his teacher (and apparently anyone within earshot) of where he lived. I personally was excited not only that he’d conquered this task, but had retained the knowledge for more than a week.

One skill down, only five million more to go.

Eventually we reached our destination, and walked into the spartan offices of our neuro pediatrician. After fifteen minutes of watching Zachy show off his coloring acumen to the pretty pre-teen girls waiting for their sister to conclude her visit, we were finally called into the throne room, and the interview commenced.

He nailed it.

He responded to every question correctly, eliciting somewhat of an astonished response from our usually slightly dour physician. He replied to all of her commands with gusto, copied a circle with his broken orange crayon with ease, built a tower for her AND counted the blocks required, just to show off. If this had been the SAT’s, he’d have been destined for the Ivy League college his parents wouldn’t be able to afford to send him to.

After the weighing in and the requisite physical exam were conducted, complete with Zach’s request to look in Dr. P’s own nose with the cool flashlight, I was told he could descend from the exam table, and congratulated on his progress and my efforts on his behalf. I admit that I found this most amusing as I am certain the majority of Zach’s improvement is due to his innate ability to respond to therapy, not any magic on his mother’s part, but for once I’m in a good mood at a doctor’s office, and I take the compliment.

Of course, I can’t just let things lie. I have to push for the gold star, because God forbid a glowing report regarding my youngest son’s development should be enough for me. I am still an educator, after all.

After gathering Zachary’s twelve toys and persuading him to relinquish the blood pressure gauge for “next time”, I say goodbye to our positively beaming doctor, and go for it. I ask my youngest son to tell the nice lady where he lives, a question I’ve put to him dozens of times over the last few weeks, one in which he now always answers correctly and with great joy. He reacts by carefully handing me his sippy cup, and turns to look at the kindly older woman regarding him with amusement.

He pauses for dramatic effect, then responds enthusiastically “in a house”, and bolts for the waiting room and yet another set of adoring pre-teens.

Apparently, my son has his priorities too.