dbp & the medical home: from asd 2 td &
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/1.jpg)
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
![Page 2: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/2.jpg)
DBP: Basic FeaturesDBP: Basic Features
• GROWTH• Typical• Atypical• Failure to thrive and obesity
– Clinical Skills• Ability to use growth charts
![Page 3: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/3.jpg)
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
![Page 4: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/4.jpg)
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
![Page 5: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/5.jpg)
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
![Page 6: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/6.jpg)
Medical Home: What it is(and what it ain’t)
YES
• An approach to: → identifying needs
→ access supports
→ partnership
NO
• Location
![Page 7: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/7.jpg)
Medical Home: What it is(and what it ain’t)
YES
• An approach to: Care Coordination
Chronic Care Mgt
NO
• Location
![Page 8: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/8.jpg)
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
![Page 9: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/9.jpg)
Medical Home: History
• 2007 (4 assn’s): Joint Principles
available at
www.medicalhomeinfo.org
![Page 10: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/10.jpg)
Medical Home: Special Needs
CYSHCNFeatures: Increased type or amount of needed
health and related services in:
• Physical
• Developmental
• Behavioral
• Emotional
![Page 11: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/11.jpg)
CYSHCN: examples
• Complex disorders
• Technology-dependent
• ADHD and learning disabilities
• Diabetes
• Asthma
• Autism and Tourette syndrome
• Anxiety and depression
![Page 12: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/12.jpg)
CYSHCN: unmet needs
• Mental health
• Communication and mobility aids
• Equipment
• Dental
• Respite
• Family support
• Care coordination
![Page 13: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/13.jpg)
Medical Home
Barriers?
• Time• Staff availability• Reimbursement• Resources
![Page 14: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/14.jpg)
CYSHCN: Costs
American Academy of Pediatrics
Top Priority:
• Medical Home
• Reimbursement
![Page 15: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/15.jpg)
Medical Home: Down to BUZZnessThe 7 characteristics
1. Accessible
2. Continuous
3. Comprehensive
4. Family-centered
5. Coordinated
6. Compassionate
7. Culturally effective
![Page 16: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/16.jpg)
Medical Home: Resources
• Purposes of resources– Augment medical care
– Non-medical supports
– Building partnerships
• Care Coordination
![Page 17: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/17.jpg)
Medical Home: Resources
• Identify possible sources• Family-to-family
• Educational system
• Title V and Federal agencies
• AAP/AAFP
• Specialists
• Community organizations
![Page 18: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/18.jpg)
Autism: History
• Hippocrates’ “Divine Disease”
• Ancient Rome - insanity
• Medieval Europe - demons
• Psychoanalytic theory – neurosis
![Page 19: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/19.jpg)
Autism: History
• “Blame the Parent” – ‘40s through ‘60s
• Genetic studies (1970s)
• Neuroimaging & Neurochemical (1980s)
![Page 20: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/20.jpg)
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
![Page 21: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/21.jpg)
Autism: Prenatal Factors
• Parents: older & other features• Intrauterine growth factors• Cesarean• Lower Apgar & other perinatal• Likely, obstetric complications are
consequences of genetic factors
![Page 22: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/22.jpg)
POSSIBLE pre- & peri-natal factors
• Prenatal testosterone:
the “extreme male brain”
![Page 23: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/23.jpg)
Autism: Environmental theories• Toxins
–Methyl Hg, lead, other metals
–Alcohol
–Yeast
• Foods: opioid theory & leaky gut
–Casein
–Gluten
![Page 24: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/24.jpg)
Autism: Environmental theories• Vaccinations
–MMR
–Thimerosal (Ethyl Hg preserv.)
![Page 25: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/25.jpg)
Autism: AssociationsSeizures
• Common (~25%)
• No common pattern to seizures
• No diagnostic guidelines
• No treatment guidelines
![Page 26: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/26.jpg)
Autism: AssociationsSleep
• 50% of kids –Sleep initiation
–Awakenings/fragmented sleep
![Page 27: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/27.jpg)
Autism: AssociationsGastro-intestinal
• Are behaviors due to G.I. pain?–Esophagitis
–Lactose intolerance
–Motility–Hyper-immune reaction
• Rx in autism & G.I. impact
![Page 28: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/28.jpg)
Autism: AssociationsNutrition
• Often limited dietary variety–Aversion to change?
–Sensory?
–Gastrointestinal?
–Allergies?
–Self-correcting metabolic?
![Page 29: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/29.jpg)
Autism: AssociationsDental
• Hygiene– Decay
– Gingivitis
• Self-injurious behavior– Bruxism (tooth-grinding)
– Self-extractions
• Medications (e.g. anticonvulsants)
• Pain
![Page 30: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/30.jpg)
Autism: AssociationsAbuse/Neglect
• Physical
• Sexual
![Page 31: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/31.jpg)
Autism on the rise?
• Autism and/or Mental retardation
Note: “Mental Retardation” changed to
“Intellectual & Developmental Disabilities”
![Page 32: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/32.jpg)
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
![Page 33: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/33.jpg)
Autism: Management Behavioral Options
• The focus of any management plan
• Rx may be part of management
![Page 34: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/34.jpg)
Autism: Management Behavioral Options
• Core Symptoms–Communication Skills–Social Impairments–Play and Imagination–Ritualistic and Stereotyped Interests
and Behaviors
![Page 35: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/35.jpg)
Autism: ManagementMedical Options
• Comorbid Conditions–Seizures–ADHD symptoms–Tics and other movements–Outbursts/aggression–Mood
![Page 36: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/36.jpg)
Autism: ManagementMedical Options
• Comorbid Conditions–Anxiety–Elimination–Sleep–Self-injurious behaviors–Other (e.g., GERD)
![Page 37: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/37.jpg)
Autism: ManagementMedical Options
• Selecting a Medication–Select which behavior
–There is no “Autism Medication”
–“Start Low, Go Slow”
–Expect trial and error
–“Polypharmacy”
![Page 38: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/38.jpg)
Management:tics
• Experimental: Integrative –Six categories
•Medical•Nutritional•Foreign substances•Behavioral and cognitive•Manual and energy medicine•Mind-Body
![Page 39: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/39.jpg)
Treatment: “Integrative Medicine” Options
–Guidelines: NIH• Assess safety & effectiveness
• Examine practitioner’s expertise
• Consider service delivery
• Consider costs
• Consult your healthcare provider
![Page 40: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/40.jpg)
Tic Disorders: Characteristics
• Premonitory urge
• Tics can usually be suppressed
![Page 41: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/41.jpg)
PANDAScontroversial
Pediatric
Autoimmune
Neuropsychiatric
Disorders
Associated with
Streptococcal infections
![Page 42: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/42.jpg)
Diagnostic Pitfalls 101
• Subject or clinician unaware
• Waxing & waning nature of tics
• Tics are suppressible
![Page 43: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/43.jpg)
Diagnostic Pitfalls 102
• Not rare
• Usually not catastrophic
• Few have coprolalia
• You may not see the tics
![Page 44: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/44.jpg)
Management
• Perspectives:
– The child
– The parent
– The school
– You
![Page 45: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/45.jpg)
Management:“co-morbid” conditions
– OCD & other anxiety disorders– ADHD – Learning difficulties– Behavioral Disorders– Sleep disturbances– Other self-injurious behaviors– Family dysfunction
![Page 46: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/46.jpg)
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
![Page 47: DBP & the Medical Home: From ASD 2 TD &](https://reader035.vdocument.in/reader035/viewer/2022062500/568159fd550346895dc74959/html5/thumbnails/47.jpg)
Resources:
Developmental-Behavioral Pediatrics
depts.washington.edu/dbpeds