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DBP & the Medical Home: From ASD 2 TD &

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

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DBP & the Medical Home: From ASD 2 TD &

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  1. 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

  2. DBP: Basic Features • GROWTH • Typical • Atypical • Failure to thrive and obesity • Clinical Skills • Ability to use growth charts

  3. DBP: Basic Features • DEVELOPMENT • 4 developmental domains • Atypical findings on screening tools • Initial evaluation and referral • Clinical Skills • Evaluate domains using screening tools

  4. DBP: 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

  5. 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

  6. Medical Home: What it is(and what it ain’t) YES • An approach to: → identifying needs → access supports →partnership NO • Location

  7. Medical Home: What it is(and what it ain’t) YES • An approach to: Care Coordination Chronic Care Mgt NO • Location

  8. 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

  9. Medical Home: History • 2007 (4 assn’s): Joint Principles available at www.medicalhomeinfo.org

  10. Medical Home: Special Needs CYSHCN Features: Increased type or amount of needed health and related services in: • Physical • Developmental • Behavioral • Emotional

  11. CYSHCN: examples • Complex disorders • Technology-dependent • ADHD and learning disabilities • Diabetes • Asthma • Autism and Tourette syndrome • Anxiety and depression

  12. CYSHCN: unmet needs • Mental health • Communication and mobility aids • Equipment • Dental • Respite • Family support • Care coordination

  13. Medical Home Barriers? • Time • Staff availability • Reimbursement • Resources

  14. CYSHCN: Costs American Academy of Pediatrics Top Priority: • Medical Home • Reimbursement

  15. Medical Home: Down to BUZZnessThe 7 characteristics • Accessible • Continuous • Comprehensive • Family-centered • Coordinated • Compassionate • Culturally effective

  16. Medical Home: Resources • Purposes of resources • Augment medical care • Non-medical supports • Building partnerships • Care Coordination

  17. Medical Home: Resources • Identify possible sources • Family-to-family • Educational system • Title V and Federal agencies • AAP/AAFP • Specialists • Community organizations

  18. Autism: History • Hippocrates’ “Divine Disease” • Ancient Rome - insanity • Medieval Europe - demons • Psychoanalytic theory – neurosis

  19. Autism: History • “Blame the Parent” – ‘40s through ‘60s • Genetic studies (1970s) • Neuroimaging & Neurochemical (1980s)

  20. 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

  21. Autism: Prenatal Factors • Parents: older & other features • Intrauterine growth factors • Cesarean • Lower Apgar & other perinatal • Likely, obstetric complications are consequences of genetic factors

  22. POSSIBLE pre- & peri-natal factors • Prenatal testosterone: the “extreme male brain”

  23. Autism: Environmental theories • Toxins • Methyl Hg, lead, other metals • Alcohol • Yeast • Foods: opioid theory & leaky gut • Casein • Gluten

  24. Autism: Environmental theories • Vaccinations • MMR • Thimerosal (Ethyl Hg preserv.)

  25. Autism: AssociationsSeizures • Common (~25%) • No common pattern to seizures • No diagnostic guidelines • No treatment guidelines

  26. Autism: AssociationsSleep • 50% of kids • Sleep initiation • Awakenings/fragmented sleep

  27. Autism: AssociationsGastro-intestinal • Are behaviors due to G.I. pain? • Esophagitis • Lactose intolerance • Motility • Hyper-immune reaction • Rx in autism & G.I. impact

  28. Autism: AssociationsNutrition • Often limited dietary variety • Aversion to change? • Sensory? • Gastrointestinal? • Allergies? • Self-correcting metabolic?

  29. Autism: AssociationsDental • Hygiene • Decay • Gingivitis • Self-injurious behavior • Bruxism (tooth-grinding) • Self-extractions • Medications (e.g. anticonvulsants) • Pain

  30. Autism: AssociationsAbuse/Neglect • Physical • Sexual

  31. Autism on the rise? • Autism and/or Mental retardation Note: “Mental Retardation” changed to “Intellectual & Developmental Disabilities”

  32. 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

  33. Autism: Management Behavioral Options • The focus of any management plan • Rx may be part of management

  34. Autism: Management Behavioral Options • Core Symptoms • Communication Skills • Social Impairments • Play and Imagination • Ritualistic and Stereotyped Interests and Behaviors

  35. Autism: ManagementMedical Options • Comorbid Conditions • Seizures • ADHD symptoms • Tics and other movements • Outbursts/aggression • Mood

  36. Autism: ManagementMedical Options • Comorbid Conditions • Anxiety • Elimination • Sleep • Self-injurious behaviors • Other (e.g., GERD)

  37. Autism: ManagementMedical Options • Selecting a Medication • Select which behavior • There is no “Autism Medication” • “Start Low, Go Slow” • Expect trial and error • “Polypharmacy”

  38. Management:tics Experimental: Integrative Six categories Medical Nutritional Foreign substances Behavioral and cognitive Manual and energy medicine Mind-Body

  39. Treatment: “Integrative Medicine” Options • Guidelines: NIH • Assess safety & effectiveness • Examine practitioner’s expertise • Consider service delivery • Consider costs • Consult your healthcare provider

  40. Tic Disorders: Characteristics • Premonitory urge • Tics can usually be suppressed

  41. PANDAScontroversial Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections

  42. Diagnostic Pitfalls 101 • Subject or clinician unaware • Waxing & waning nature of tics • Tics are suppressible

  43. Diagnostic Pitfalls 102 • Not rare • Usually not catastrophic • Few have coprolalia • You may not see the tics

  44. Management • Perspectives: • The child • The parent • The school • You

  45. Management:“co-morbid” conditions • OCD & other anxiety disorders • ADHD • Learning difficulties • Behavioral Disorders • Sleep disturbances • Other self-injurious behaviors • Family dysfunction

  46. 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

  47. Resources: Developmental-Behavioral Pediatrics depts.washington.edu/dbpeds

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