Transcript Developmental-Behavioral Pediatrics & the Medical Home: From

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
DBP: Basic Features
• GROWTH
• Typical
• Atypical
• Failure to thrive and obesity
– Clinical Skills
• Ability to use growth charts
DBP: Basic Features
• DEVELOPMENT
• 4 developmental domains
• Atypical findings on screening tools
• Initial evaluation and referral
– Clinical Skills
• Evaluate domains using screening tools
DBP: Basic Features
• BEHAVIOR
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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
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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
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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
CYSHCN
Features: Increased type or amount of needed
health and related services in:
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Physical
Developmental
Behavioral
Emotional
CYSHCN: examples
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Complex disorders
Technology-dependent
ADHD and learning disabilities
Diabetes
Asthma
Autism and Tourette syndrome
Anxiety and depression
CYSHCN: unmet needs
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Mental health
Communication and mobility aids
Equipment
Dental
Respite
Family support
Care coordination
Medical Home
Barriers?
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Time
Staff availability
Reimbursement
Resources
CYSHCN: Costs
American Academy of Pediatrics
Top Priority:
• Medical Home
• Reimbursement
Medical Home: Down to BUZZness
The 7 characteristics
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Accessible
Continuous
Comprehensive
Family-centered
Coordinated
Compassionate
Culturally effective
Medical Home: Resources
• Purposes of resources
– Augment medical care
– Non-medical supports
– Building partnerships
• Care Coordination
Medical Home: Resources
• Identify possible sources
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Family-to-family
Educational system
Title V and Federal agencies
AAP/AAFP
Specialists
Community organizations
Autism: History
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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
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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
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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: Associations
Seizures
• Common (~25%)
• No common pattern to seizures
• No diagnostic guidelines
• No treatment guidelines
Autism: Associations
Sleep
• 50% of kids
–Sleep initiation
–Awakenings/fragmented sleep
Autism: Associations
Gastro-intestinal
• Are behaviors due to G.I. pain?
–Esophagitis
–Lactose intolerance
–Motility
–Hyper-immune reaction
• Rx in autism & G.I. impact
Autism: Associations
Nutrition
• Often limited dietary variety
–Aversion to change?
–Sensory?
–Gastrointestinal?
–Allergies?
–Self-correcting metabolic?
Autism: Associations
Dental
• Hygiene
– Decay
– Gingivitis
• Self-injurious behavior
– Bruxism (tooth-grinding)
– Self-extractions
• Medications (e.g. anticonvulsants)
• Pain
Autism: Associations
Abuse/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: Management
Medical Options
• Comorbid Conditions
–Seizures
–ADHD symptoms
–Tics and other movements
–Outbursts/aggression
–Mood
Autism: Management
Medical Options
• Comorbid Conditions
–Anxiety
–Elimination
–Sleep
–Self-injurious behaviors
–Other (e.g., GERD)
Autism: Management
Medical 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
PANDAS
controversial
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