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 BUZZness The 7 characteristics 1.Accessible 2.Continuous 3.Comprehensive 4.Family-centered 5.Coordinated 6.Compassionate 7.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: Associations Seizures Common (~25%) No common pattern to seizures No diagnostic guidelines No treatment guidelines

26. Autism: Associations Sleep 50% of kids –Sleep initiation –Awakenings/fragmented sleep

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

28. Autism: Associations Nutrition Often limited dietary variety –Aversion to change? –Sensory? –Gastrointestinal? –Allergies? –Self-correcting metabolic?

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

30. Autism: Associations Abuse/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: Management Medical Options Comorbid Conditions –Seizures –ADHD symptoms –Tics and other movements –Outbursts/aggression –Mood

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

37. Autism: Management Medical 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. PANDAS controversial 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