Timothy Zercher 0:00

Stephen, thank you so much for joining us. We really appreciate you taking time out of multiple, multiple roles. No problem. Happy to be here. Absolutely. So, first question I always like to ask is what drew you into the behavior health space? What is your story?

SPEAKER_00 0:11

Well, trained as a pediatrician. And while I was in training, I had the opportunity to spend what we call an elective period, one to three months. Instead of in the hospital, you get to go out of the hospital and go somewhere else for a period of time. And I spent my time at the Bank Street College of Education in New York. And it was a moment where my sense of child development from a pediatric perspective confronted the differences in the perspective of the early childhood educators around child development. And it kind of raised a flag to me that there's not that we had completely different perspectives, but we had different points of view on child development, how children develop. And I really began to get an interest in that developmental process. I went on as a result of that experience. My first job after training was not as a clinician, but it was with the New York City Health Department as the medical director for the Bureau of Daycare. And I will say it had been my experience at Bank Street that qualified me for that role. However, I was the only doctor among 35 of the most sophisticated early childhood educators I ever could have imagined. So being the minority professional, which is unusual in medicine, usually the doctors are the majority professional, everybody's in service too. I had to be respectful and deferential and really kind of come to understand the perspective that early childhood educators took on the behavior of children. And I will say that has set the tone for my entire career. Even when I began to work in autism and IDD, it was really about being the liaison, the bridge between the two or three or four different disciplines that were sharing the care of an individual, whether a child or an adult. So this has characterized the way that I've approached everything since. And I will say the recent efforts across the entire healthcare system around what's called behavioral health integration, it has really been the way that I've approached this all along. I'm not trying to toot my own horn here, but the fact of the matter is it was organic for me, and it's really natural for me to begin to focus on these kinds of systems that really focus on integrated care. That's awesome.

Timothy Zercher 2:22

And that's what you're doing now, too, which makes complete sense.

SPEAKER_00 2:24

Honestly, no, it's almost 100% of what I'm doing right now, whether I'm working in the mental health space, which is part of my role, whether I'm working in the autism care space, another part of my role, or even the work that I do in my role with the American Academy Pediatrics, it's really about how do you develop a model of care and a care plan that is truly centered on the person. One of the artifacts of the way our systems of care are organized right now is that each discipline has its own mental model for a care plan. So you have the medical care plan, the behavior analytic care plan, the social work care plan, the speech and language pathology care plan, the occupational therapy care plan. One of the things that I really learned from that original work with the early childhood community was how to keep the focus on the child and have the goals for any plan of care be child-oriented. But then the question becomes how do all of those disciplines contribute to the child-centered goal? And this is again, our systems of care are truly discipline siloed in many ways. However, just because everybody's seated at the table doesn't mean they're necessarily working together. So multidisciplinary and integrated are two different things.

Timothy Zercher 3:33

Absolutely. So, and actually, I want to ask a little bit more about that. So you talk a lot and have worked on incorporating the human factor and how sometimes that gets lost in complex care systems, especially from the leadership side. What is one behavior that you find really improves quality and safety of care that doesn't necessarily show up on a company dashboard?

SPEAKER_00 3:51

Two things. One is you have to ask the why behind any treatment goal. And the why isn't necessarily based upon identified pathology. As a matter of fact, one of the things that I learned from my college in adult medicine is sometimes there may be a compelling reason to create an intervention around pathology, but it's not necessarily the patient's desire or wish. And people are allowed to make decisions about where they want their priorities to be. And this is particularly true in the informed consent process a lot. You have to go through all of the potential consequences of what we're doing. So I look at treatment in a two-step fashion. Number one, there is a response to treatment, but a response to treatment may or may not be an outcome. And my focus in that, the one thing that you're asking about is really what is the outcome for the person in their life? And a great example of this is, and this is a true story, middle schooler with autism is in the social skills situation. I'm making this number up. They score a five on their social skills assessment. Let's just say it's an out of 10 score. They go through the social skills training and their score goes from a five to an eight. Okay. That's not an outcome. The outcome is how those social skills are used in their life to fit in school and make friends and do all those things that social skills allow us to do. Now, I will say this is my approach to this, but in my work with teams, and sometimes the teams of people who work with you aren't necessarily this model isn't really built in to them. So part of what we try to do is to get people to understand that the outcome is the benefit to the value to the individual of the thing you're doing, not necessarily the response to your intervention for the thing you're treating.

Timothy Zercher 5:42

I really like that. I think the world would be a better place. Patients would get better care if more people understood that and internalize that and then incorporate it into their actual work.

SPEAKER_00 5:51

Thank you for that. However, I will let's be realistic, it's not always easy to do because our systems of measurement are not necessarily designed to do that. So part of the challenge in these situations is how do you operationalize that? By the way, there's no rule for it now. In some cases, it's very qualitative and you do it with shared decision making, particularly with children and families. You ask the family, what do you want to get out of therapy? What's your goal? And I don't want to hear, I want my child to mand to 10 items, because by the way, no parent ever has said that. But the question then becomes, okay, what is manding going to do for your child? And now you can explain if the parent says, I'd really just love be able to go to the mall and not have to chase or worry about elotement. I'd love for go on vacation with my family. And okay, great. Let's work backwards from that and look at all of the things we can do that can ladder up to that life experience.

Timothy Zercher 6:40

Absolutely. Because that's what actually matters is actual life experience, no matter what, right? And no matter what's technically on the tracking metrics.

SPEAKER_00 6:48

And there's a difference between that and what the behavior analytic community calls socially significant behaviors, because it really becomes very individualized at some level. Although I do think ultimately there's a crosswalk that we can create because there are some models for life course outcomes for children in general. So to me, I don't wanna I don't want to talk about autism outcomes being any different than our expectations for any child.

Timothy Zercher 7:10

Absolutely. So shifting topics a little bit, you've redesigned care in public, nonprofit, and private for-profit settings. What is kind of your go-to approach for getting real buy-in from clinicians and operators when we all know change tends to be unpopular?

SPEAKER_00 7:28

Honestly, I mean, you try from day one to focus on a co-creation process. You can't come in with a model and impose it as a framework. I talk about this a lot when I talk about just working with physicians because we have a mental model for how we learn things. And I'll give it to you right now. Number one, what's the basic science behind what we're going to talk about? Number two, how does that basic science go wrong? When it does go wrong, what are the signs and symptoms? And then what are the interventions that can help us intervene into the thing that goes wrong? A simple rubric. By the way, that mimics the first four years of medical school. It's exactly like that, kind of. So what I try to do in these situations, and even though I'm a pediatrician, I actually ran a national primary care practice for the elderly, homebound elderly. We became an accountable care organization. I had 250 doctors who I had to get them to rethink their roles and responsibilities under a value-based care agreement because you take on different burdens with your patients with that. So we took a step back. And again, the question was what's the underlying framework for this? What's the basic science of what we're doing? And that again helps with, as I said before, the why. And then you say, okay, here's the delta between what we're doing today and the goal we want to achieve. What are the things we need to add or subtract? Very important, because people don't often don't think about subtracting. What are we going to not do anymore? And then how can we do that in a way that isn't overwhelming? We're just not adding layers and layers and layers of work, which unfortunately in today's systems of care, there's a lot of that. But you kind of go through this co-creation process and it doesn't have to be extended. It just shows people the respect that you're not going to impose something on them. You're going to give them a chance to express their voice. You're going to tell them where the boundaries are. There are certain things that we need to do because there are regulations for an accountable care organization. They're not debatable. My favorite story about this is I was worked at a hospital system once and we had the patient experience survey from the federal government, the CAPS survey from the federal government that was being sent out to all the patients in the hospital. And the chairman of medicine was sitting in the back of a room one day reading the letter that CMS requires you to send and proceeds to try to critique it. I mean, he's tearing it apart. And so he goes through this whole process of telling how terrible this letter is. It's poorly written, it shouldn't be used. And the CEO actually said, it doesn't really matter what you think. That's a mandated letter. Thank you. And none of that matters. Yeah, thank you. None of that matters. And in this, as you said, buy-in process or engagement process, you do have to make it clear where some of the boundaries are because people will, particularly physicians, we're really good at finding what's wrong with things. It's our job. People will look for the flaws. And again, as part of what you say is a part of avoiding that change if they can.

Timothy Zercher 10:05

Absolutely. Well, and that's always our human default, no matter what, is to avoid change because that is always painful. But looking again at talking more about change, I know you spend a lot of time in the autism space. In your mind, what is the future of autism services looking like?

SPEAKER_00 10:20

Beware what you asked for here. So I have been the chief medical officer of a national ABA provider. I also have been the founder of a smaller ABA provider. I've sat on the Autism Commission on Quality. I was the only physician on the Standards Committee for the Autism Commission on Quality. And I'm very actively involved in autism and IDD at the American Academy Pediatrics. I think that autism care is really at a critical moment in its social evolution. The last four years has seen a doubling in evidence on interventions to support young autistic children. In parallel, there is again a massive growth in our understanding of the neuroscience of autism, the genomics of autism, developmental psychology, and the whole lived experience personhood side of things. And I honestly think some of the fundamental reasons that AVA was considered a breakthrough therapy just don't exist anymore. I wrote a book, there's a chapter in my book about how important the science is. So I'm not discounting the science, and I'm not discounting the role of behavior analysis in the lives of autistic children. However, the figure-ground relationship for therapeutic interventions is shifting. And it's shifting from being condition-centered to being child-centered, along the lines of what we just discussed with behavioral health integration, from autism in a behavioral context to autism in a developmental context. And this perspective, by the way, is not just about autism. It's actually based on a broader general understanding of human development that has occurred, applied to autistic children, and the evidence is overwhelmingly good and good for children. And what this will do is allow us to really diversify the portfolio of evidence-based tools for both pediatricians and parents to meet the needs of what is an increasingly diverse autistic community. And you've got the conversations going on right now about profound autism and what that means and high need children and high need adults, because I spent two years recently supporting an organization that took care of people with IDD, both children and adults. And we know that autism does not end at age 21 just because services end. And you know how we can think about this more from a life course perspective. And I give you an example if you want. Yeah, yeah, yeah, yeah. Please. All right. So so a great example is joint attention. Joint attention is again, we know this now from neuroscience. We didn't know this before. And I want to say something right here, which is it really was the growth of ABA because parents and advocates felt like the current systems of care for autistic children weren't really meeting their needs, and they identified ABA and they brought ABA into the system. That really was the impetus for so much of this growth in the research. So they called attention in a big way to the community and resulted in all this growth of knowledge. Well, one of the things that we've learned along the way is that joint attention is fundamentally an information processing problem at the level of internal cognition. It's underlying neural activity that, by the way, may have complete absence of an observable behavioral manifestation. So an autistic child may internally recognize that another person is sharing their experience. They may internally recognize that someone is sharing the object, they may mentally track where that person's focus, but show no difference in their gaze, their pointing, or outward signals. Why is this important? Because joint attention is responsible for relational health. And relational health is responsible for emotional regulation. So if we actually are able to understand this issue of joint attention as an information processing issue and treat our interventions from that perspective, downstream, we may see less emotional dysregulation and not need the behavioral intervention. So again, like I said, critical moment, it's an evolutionary process, not answered. But again, back to the integration issue, all of us medicine, psychiatry, neurology, psychology, speech, language, OTPT, behavior analysis, we all share the care of these children. And it's in those children's best interests if we focus on the child-centered needs and then how our various disciplines contribute to goal achievement for that, as opposed to segmenting these into various treatment plans.

Timothy Zercher 14:51

Absolutely. And following strict preset rules for all children in our care. Yeah, that makes complete sense. Perfect. Well, I really appreciate you you coming on and sharing some of your insights. I appreciate the work that you're doing for the industry. I think you're making a massive impact. So thank you so much. And I hope we get to have you on again to talk more about some of these items. I know. Happy to come back. Our show is short. We could talk about these things a long time, I bet.

SPEAKER_00 15:11

But that's great.

Timothy Zercher 15:12

Appreciate it. Absolutely. Thank you.