DBP & the Medical Home: From ASD 2 TD & Samuel H. Zinner, MD University of Washington, Seattle Center on Human Development and Disability http://depts.washington.edu/dbpeds
Dec 19, 2015
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: 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: 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
Autism: Environmental theories• Toxins
–Methyl Hg, lead, other metals
–Alcohol
–Yeast
• Foods: opioid theory & leaky gut
–Casein
–Gluten
Autism: AssociationsSeizures
• Common (~25%)
• No common pattern to seizures
• No diagnostic guidelines
• No treatment guidelines
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 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
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:“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