DBP & the Medical Home: From ASD 2 TD & Samuel H. Zinner, MD University of Washington, Seattle Center on Human Development and Disability

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 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

Medical Home: Special Needs CYSHCN Features: 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 BUZZness The 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: 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