DBP & the Medical Home:From ASD 2 TD &

Samuel H. Zinner, MDUniversity of Washington, Seattle

Center on Human Development and Disability

http://depts.washington.edu/dbpeds

DBP: Basic FeaturesDBP: Basic Features

• GROWTH• Typical• Atypical• Failure to thrive and obesity

– Clinical Skills• Ability to use growth charts

DBP: Basic FeaturesDBP: Basic Features

• DEVELOPMENT• 4 developmental domains• Atypical findings on screening tools• Initial evaluation and referral

– Clinical Skills• Evaluate domains using screening tools

DBP: Basic FeaturesDBP: Basic Features

• BEHAVIOR• Normal behaviors & common problems• Emotional & medical conditions & behavioral impacts• Appropriate, inappropriate & severe problems• Somatic complaints• Family dysfunctions

– Clinical Skills• Identify behavioral and ψ-social problems• Counsel parents & kids about behavioral management

Medical Home: Basic Features

• High-quality primary care for all

• Enhances primary care

• No choice to provide a Medical Home

• Choice exists about quality of MH:– Poor

– Good

– Great

Medical Home: What it is(and what it ain’t)

YES

• An approach to: → identifying needs

→ access supports

→ partnership

NO

• Location

Medical Home: What it is(and what it ain’t)

YES

• An approach to: Care Coordination

Chronic Care Mgt

NO

• Location

Medical Home: History

• 1967 (AAP): MH is a location

• 1992 (AAP): No, it isn’t

• 2002 (AAP): Policy Statement

• 2007 (4 assn’s): Joint Principles

Medical Home: History

• 2007 (4 assn’s): Joint Principles

available at

www.medicalhomeinfo.org

Medical Home: Special Needs

CYSHCNFeatures: Increased type or amount of needed

health and related services in:

• Physical

• Developmental

• Behavioral

• Emotional

CYSHCN: examples

• Complex disorders

• Technology-dependent

• ADHD and learning disabilities

• Diabetes

• Asthma

• Autism and Tourette syndrome

• Anxiety and depression

CYSHCN: unmet needs

• Mental health

• Communication and mobility aids

• Equipment

• Dental

• Respite

• Family support

• Care coordination

Medical Home

Barriers?

• Time• Staff availability• Reimbursement• Resources

CYSHCN: Costs

American Academy of Pediatrics

Top Priority:

• Medical Home

• Reimbursement

Medical Home: Down to BUZZnessThe 7 characteristics

1. Accessible

2. Continuous

3. Comprehensive

4. Family-centered

5. Coordinated

6. Compassionate

7. Culturally effective

Medical Home: Resources

• Purposes of resources– Augment medical care

– Non-medical supports

– Building partnerships

• Care Coordination

Medical Home: Resources

• Identify possible sources• Family-to-family

• Educational system

• Title V and Federal agencies

• AAP/AAFP

• Specialists

• Community organizations

Autism: History

• Hippocrates’ “Divine Disease”

• Ancient Rome - insanity

• Medieval Europe - demons

• Psychoanalytic theory – neurosis

Autism: History

• “Blame the Parent” – ‘40s through ‘60s

• Genetic studies (1970s)

• Neuroimaging & Neurochemical (1980s)

Autism: History

• DSM-III (1980) Infantile Autism

• DSM-IV (1994) Autistic Disorder

• DSM-IV-TR (2000) Autistic Disorder

• DSM-V (2012) Everything’s comin’ up Autism

Autism: Prenatal Factors

• Parents: older & other features• Intrauterine growth factors• Cesarean• Lower Apgar & other perinatal• Likely, obstetric complications are

consequences of genetic factors

POSSIBLE pre- & peri-natal factors

• Prenatal testosterone:

the “extreme male brain”

Autism: Environmental theories• Toxins

–Methyl Hg, lead, other metals

–Alcohol

–Yeast

• Foods: opioid theory & leaky gut

–Casein

–Gluten

Autism: Environmental theories• Vaccinations

–MMR

–Thimerosal (Ethyl Hg preserv.)

Autism: AssociationsSeizures

• Common (~25%)

• No common pattern to seizures

• No diagnostic guidelines

• No treatment guidelines

Autism: AssociationsSleep

• 50% of kids –Sleep initiation

–Awakenings/fragmented sleep

Autism: AssociationsGastro-intestinal

• Are behaviors due to G.I. pain?–Esophagitis

–Lactose intolerance

–Motility–Hyper-immune reaction

• Rx in autism & G.I. impact

Autism: AssociationsNutrition

• Often limited dietary variety–Aversion to change?

–Sensory?

–Gastrointestinal?

–Allergies?

–Self-correcting metabolic?

Autism: AssociationsDental

• Hygiene– Decay

– Gingivitis

• Self-injurious behavior– Bruxism (tooth-grinding)

– Self-extractions

• Medications (e.g. anticonvulsants)

• Pain

Autism: AssociationsAbuse/Neglect

• Physical

• Sexual

Autism on the rise?

• Autism and/or Mental retardation

Note: “Mental Retardation” changed to

“Intellectual & Developmental Disabilities”

DBP: Medical Evaluation

• History– Medical (including gestation)

– Birth and Developmental

– Family

– Social and Environmental

• Examination– Dysmorphology, skin findings, eyes, other

– Neurological assessment

– Family and interactions

Autism: Management Behavioral Options

• The focus of any management plan

• Rx may be part of management

Autism: Management Behavioral Options

• Core Symptoms–Communication Skills–Social Impairments–Play and Imagination–Ritualistic and Stereotyped Interests

and Behaviors

Autism: ManagementMedical Options

• Comorbid Conditions–Seizures–ADHD symptoms–Tics and other movements–Outbursts/aggression–Mood

Autism: ManagementMedical Options

• Comorbid Conditions–Anxiety–Elimination–Sleep–Self-injurious behaviors–Other (e.g., GERD)

Autism: ManagementMedical Options

• Selecting a Medication–Select which behavior

–There is no “Autism Medication”

–“Start Low, Go Slow”

–Expect trial and error

–“Polypharmacy”

Management:tics

• Experimental: Integrative –Six categories

•Medical•Nutritional•Foreign substances•Behavioral and cognitive•Manual and energy medicine•Mind-Body

Treatment: “Integrative Medicine” Options

–Guidelines: NIH• Assess safety & effectiveness

• Examine practitioner’s expertise

• Consider service delivery

• Consider costs

• Consult your healthcare provider

Tic Disorders: Characteristics

• Premonitory urge

• Tics can usually be suppressed

PANDAScontroversial

Pediatric

Autoimmune

Neuropsychiatric

Disorders

Associated with

Streptococcal infections

Diagnostic Pitfalls 101

• Subject or clinician unaware

• Waxing & waning nature of tics

• Tics are suppressible

Diagnostic Pitfalls 102

• Not rare

• Usually not catastrophic

• Few have coprolalia

• You may not see the tics

Management

• Perspectives:

– The child

– The parent

– The school

– You

Management:“co-morbid” conditions

– OCD & other anxiety disorders– ADHD – Learning difficulties– Behavioral Disorders– Sleep disturbances– Other self-injurious behaviors– Family dysfunction

Take Home Points:Clarifying Common Misconceptions

• TS is not rare

• Tics are usually mild, not catastrophic

• In most people with TS, tics are one of many related complications

• Address main problems, often not tics

Resources:

Developmental-Behavioral Pediatrics

depts.washington.edu/dbpeds