Helping people with autism spectrum disorder manage masks and COVID-19 tests

The COVID-19 pandemic has presented many new challenges for people with autism spectrum disorder (ASD). Features of ASD, including impaired social and communication skills, repetitive behaviors, insistence on sameness, and especially sensory intolerances, make adapting to wearing face masks and the experience of a COVID-19 test particularly challenging.

Challenges of wearing face masks with ASD

Many people with ASD are highly sensitive to touch, and the face can be especially so. Wearing a face mask involves many unpleasant sensations. On the surface, there’s the scratchy texture of fabric, tight contact where the top of the mask meets the skin, and the tug of elastic on the ears. Sensations under the mask are no more pleasant and include the warm, damp smell of recycled air. In addition, the sensation of breathing in and exhaling air through the nose can feel restrictive, leading to concern and worry for many individuals with ASD. While wearing a mask is uncomfortable at best, these unpleasant sensory experiences can be intensely magnified in people with ASD.

In addition to these sensory challenges, face masks also create new social communication challenges. Autism spectrum disorder can include poor visual perception skills, making the odds of accurately reading another person’s facial expression beneath a mask, from a socially appropriate distance, more difficult than usual. Moreover, when viewing another person’s face while they are wearing a face mask, the eyes are the primary area of the face that is visible. Individuals with ASD often have difficulty making eye contact, adding yet another hurdle for them in the social-communication realm. These factors can lead to miscommunication and frustration. Because masks muffle voices, verbal communication also becomes more difficult. Fortunately, there are several strategies that can make wearing a face mask more bearable.

What to do?

• Demonstrate using the face mask on a preferred object or person, such as a stuffed animal, a doll, or a family member.
• Allow the person with ASD to choose among different types of fabric face masks to find one that is most comfortable.
• Start by practicing wearing the face mask for short durations of time, allowing for breaks when needed.
• Plan initial outings in low-demand environments that are quiet and calm, so that the individual can experience success wearing the face mask.
• Use a printed photo or digital photo of the individual wearing a face mask as a visual cue to wear the mask before outings. The photo can be stored close to the door or on a tablet that is easily accessible.
• Chew gum or suck on a hard candy while wearing a mask, for distraction and to improve the smell of recycled air beneath the mask.
• Some medical settings may have transparent face masks. These masks make the mouth visible. Susan Muller-Hershon, American Sign Language/English interpreter at Massachusetts General Hospital, notes that transparent masks can be helpful for better communication.

The challenges of a COVID-19 nasopharyngeal or throat swab test

Testing for COVID-19 requires a nasopharyngeal (through the nose) and/or oropharyngeal (through the mouth) test using a cotton swab. These tests can cause distress for people with ASD due to the associated discomfort, unfamiliarity with the procedure, and change of routine. The use of visual aids to help prepare a person with ASD, and strategically selecting a comfortable testing environment, can help with a successful procedure and reduce anxiety.

What to do?

• Prepare for a COVID-19 test using visual supports:
  • Review a social story. Social stories are a sequence of pictures and sentences to help prepare for a new experience. Some people with ASD benefit from more detailed social stories, while others do better with simpler instructions. It is important to consider which approach will work best when selecting the social story. Both detailed and simple social stories, as well as a COVID-19 testing toolkit introduction, are available.
  • Watch a video. Some individuals with ASD will benefit from watching a video prior to being tested. The New England Journal of Medicine’s nasopharyngeal test video includes a simple video and illustration.
• Consider options for where the test will happen: Discuss local testing site options with your primary care physician or pediatrician to determine the optimal test environment. Some people will do best being tested in an indoor medical clinic because it is a more familiar medical setting. Others may do better with an outdoor drive-through testing site because they will feel more comfortable being able to wait in the car. Drive-through sites may also offer the advantage of allowing the patient to hold a comforting object that would not be permitted in an indoor clinic for infection control reasons.
• When testing isn’t possible: Some individuals with ASD may not be able to tolerate a COVID-19 test, even after ample preparation. If this is the case, it is very important to continue to speak with the primary care physician or pediatrician about the person’s symptoms, and whether additional medical care is needed.

It is important for parents and healthcare providers to understand why adjusting to wearing face masks and enduring a COVID-19 test can be especially challenging for individuals with ASD. There are a number of strategies, including advanced preparation using visual aids, gradual practice, and modifying the sensory experience, as well as online resources, that can be used to help individuals with ASD and their caregivers rise to meet these challenges.

The post Helping people with autism spectrum disorder manage masks and COVID-19 tests appeared first on Harvard Health Blog.

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Cases up, but Beshear says State Fair is on and businesses can soon increase capacity to 50%; ACLU wants all inmates tested

Kentucky Health News chart shows the two-week trendline tilting about the same as the day before.

As news develops about the coronavirus and its covid-19 disease, this item may be updated. Official state guidance is at kycovid19.ky.gov.

By Melissa Patrick
Kentucky Health News

The number of coronavirus cases in Kentucky jumped again Tuesday, to 245, after two days of the lowest numbers the state had seen in some time, but Gov. Andy Beshear announced another relaxation of restrictions and gave the state fair a mostly green light.

"Today's numbers again show the virus is still out there," Beshear said at his daily briefing. " They are above yesterday's number, but below what we've seen a couple of days before that."

Beshear announced that restaurants, retail stores and others that have been operating at 33 percent capacity can increase to 50% capacity one month after they were allowed to reopen because “we have gotten the practices in” to expand. It appears that retail will be able to increase its capacity by June 20 and restaurants by June 22.

Asked if the recent upward trend is worrisome as expansion looms, Beshear said, "Our concern would be if the number of cases continues to escalate and escalate, especially with a multiplier. When we had to take the steps we took at being healthy at home, we were seeing it double every week."

He said if the numbers "can stay within a range," such as the rate of positive test results, "We believe that we still can handle the reopening and do it safely."

Beshear said at least 287,597 tests have been conducted in the state. The 245 new cases brought the state's total to 11,709, a 4.1 percent positive rate overall; more recent rates have been below 3 percent, he said Monday. At least 3,365 people have recovered from the virus, he said.

The governor said the Kentucky State Fair submitted a good plan and will be allowed to proceed "as long as we continue to have a handle on this virus." He said agricultural competitions will be allowed, but the fair will have fewer vendors and fewer activities, and most will take place outdoors. "It will look very different," he said.

Beshear said the portion of the Kentucky Exposition Center that has been converted to a field hospital will remain intact, because the state must continue to be ready for a surge of cases that could overwhelm the health care system, a current threat in states such as Arizona.

The governor reported five more deaths, bringing the state's toll to 477. The fatalities were a 95-year-old man from Warren County, a 53-year-old woman from McCracken County, a 58-year-old man from Shelby County, an 82-year-old man from Barren County, and a 69-year-old woman from Jefferson County.

Testing and tracing: Beshear continued to encourage Kentuckians to get tested, saying it provides data that we need to track the spread of the virus. He also encouraged Kentuckians to "answer the call" if a contact tracer calls them and be willing to work with them.

"If we can do that, if we can continue testing at a high capacity, and people are willing to work with the contact tracers, it means if there is a significant spike that we can approach it surgically . . . whether it's the area of the state or the potential industry, that we can approach it in a fashion where we don't have to pause anything else," he said.

WHO: Asked about the comment by a World Health Organization official, since walked back, that people who have the virus but no symptoms very rarely transmit the virus, Beshear referred the question to Health Commissioner Steven Stack, who said, "That was a premature statement."

Stack added, "The jury is still out, and I say that because that is the current state of understanding. Some modeling has shown up to 40 to 40-plus percent transmission from asymptomatic people; we just don't know yet for sure."

What we do know, Stack said, is that many people with the virus but without symptoms "are out in the communities and that they are at risk for spreading the disease. So I would not take one data point, one news story and allow that to be expanded to mislead folks that this is not a dangerous disease that does not spread from person to person because the evidence suggest that it does."

Health inequality: Monday, Beshear committed to an effort to get every black Kentuckian covered by some form of  health insurance in an effort to eliminate the health inequality that has been made more evident by the pandemic, with 15.3% of Kentucky deaths from covid-19 among African Americans, though they make up only 8.4% of the state's population.

"Eventually we want to get to make sure that everybody who doesn't have coverage, has coverage," he said, "but we have an obligation, right here and right now to do what we can for a group that has been subjected to racial inequality in health care." About 5.6 percent of Kentuckians have no health insurance; among the state's African Americans, the share is 5.8%.

In other covid-19 news Tuesday:

• Beshear said 525 covid-19 patients are in Kentucky hospitals, with 75 in intensive care. Click here for the state's detailed daily update.  
• Counties with the most new cases Tuesday were Jefferson, 91; Warren, 29; Fayette, 18; Shelby, 14 and Allen, 11. All have had elevated numbers recently. 
• In long-term care facilities, 10 more residents and 26 more staff members have tested positive for the virus, bringing the respective totals to 1,463 and 699, Beshear said. He said there have been 15 more deaths among residents, all but two of whom had already been included in the statewide death toll. In all, there have been 304 resident deaths and three staff deaths; the total of 307 is 64.4 percent of the state's covid-19 deaths. Click here for details. 
• In-home child-care programs were allowed to reopen Monday, and larger daycares can open next Monday, "but the path forward looks murky for many," Liz Moomey reports for the Lexington Herald-Leader. She reports that the centers are struggling with how to stay afloat under a reopening model that will generate less operating revenue because of limits on the number of children in each classroom, laid-off staff that have moved on to other jobs, and nervous parents. A recent survey found that 11% to 15% of Kentucky child-care providers say they may have to permanently close due to the pandemic. 
• The American Civil Liberties Union sent Beshear a letter, dated June 5, demanding that all of the 11,383 inmates in every state prison be tested for the virus, and either release or place on home confinement those who would be medically vulnerable to the virus. ACLU Legal Director Corey Shapiro said the ACLU is "receiving concerning reports about potential exposure to the pandemic at the Kentucky Correctional Institution for Women and Luther Luckett Correctional Complex, and therefore believe the Department of Corrections must act now to prevent further tragedy and loss of life." They have called for immediate action, and asked for a response by June 12.
• Nearly 900 people who participated in Louisville protests against police brutality and racial injustice over the past two weeks were tested for the coronavirus over the weekend at two free sites, reports the Louisville Courier Journal. 

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Study gives insight — and advice — on picky eating in children

As a pediatrician, I hear it again and again from parents: “My child is a picky eater.”

All children are picky eaters at some point or in some way during childhood; it’s part of how they assert their independence. But some children are pickier than others, stubbornly refusing to eat everything except a few chosen foods.

So what is a parent to do? A new article published in the journal Pediatrics gives some insight into picky eating — and into how we can prevent it and help.

What does this study on picky eaters tell us?

Picky eating starts early — and stays. Researchers looked at the habits of children ages 4 to 9, and found that picky eaters tended to stay that way. That means that parents need to start early to prevent picky eating, preferably before their child turns 2 (and that independent streak really sets in). So offer lots of different foods, including lots of different fruits and vegetables. Don’t cook a separate kids’ meal. Let your child eat what you are eating (with one important exception: no choking hazards). That obviously works best if you are eating a variety of foods, so be adventurous yourself.

Temperament plays a role. Sometimes picky eating is part of a bigger problem, as opposed to its own problem. The study found that children who had difficulty controlling their emotions tended to be very picky eaters. What does this mean for parents? If your child has behavior challenges along with picky eating, talk to your doctor. Behavioral health problems are just as important as physical health problems — and as with physical health problems, it’s always better to tackle them earlier rather than later.

Picky eaters are usually not underweight. They are often thinner than their less picky peers, but not in a way that is unhealthy. So unless your pediatrician is worried about your picky child’s weight, parents should not be.

Parenting plays a role too. The researchers found that when parents were very strict about the foods that the child could (and couldn’t!) eat, or were demanding about the child’s eating, the child was more likely to be a picky eater. Some of that could be a chicken-or-egg thing: when a child seems picky, parents might be more likely to want them to eat healthy or high-calorie foods — and really want them to finish them. However well-meaning this may be, it can make things worse.

Being positive makes a difference

Much of picky eating may be related to negative thoughts and memories about certain foods, or eating in general. The more that you are upbeat and positive about eating, the more likely your child will be that way too. Here are some ideas on how to do that:

• Have family meals — and enjoy each other during them. Eating together puts the emphasis on the social aspect of eating, rather than the food itself, which can be helpful. It’s most helpful if that social aspect is pleasant, so put aside the devices and use mealtimes as time to catch up with each other, tell funny stories and otherwise enjoy the time together.
• Don’t force a child to eat. Encourage them to try new foods, but don’t get into fights about it. And do not make them finish everything on their plate (the “clean plate club” my parents always encouraged us to be part of is not a good idea). The corollary to this, though, is that you should not let your child snack all day (or fill up on milk or juice); if possible, they should arrive at a meal hungry enough to want to eat.
• Involve your child in meal planning and preparation. Look at recipes together; be willing to try new and different things. Take them shopping with you. If you have the ability to grow some foods or spices, have your child be involved in that, too.

It may take some time for changes to take effect, so be patient. If it seems like nothing is working, talk to your doctor. Together you can figure out what to do.

The post Study gives insight — and advice — on picky eating in children appeared first on Harvard Health Blog.

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WHO official says coronavirus carriers without symptoms rarely spread virus to others; could affect guidance on wearing masks

By Melissa Patrick
Kentucky Health News

Coronavirus patients without symptoms rarely spreads the virus to others, World Health Organization officials said at a news conference Monday (at about 31:35 on the YouTube video above).

"From the data we have, it still seems to be rare that an asymptomatic person actually transmits onward to a secondary individual," said Dr. Maria Van Kerkhove, head of WHO's emerging diseases and zoonosis unit.

Current coronavirus policies are largely based on early evidence that indicated the virus could spread from asymptomatic carriers.

Guidance from the Centers for Disease Control and Prevention published April 1 cited "potential for presymptomatic transmission" as a reason for social distancing, including avoidance of congregate settings as a way to reduce the spread of the virus.

“These findings also suggest that to control the pandemic, it might not be enough for only persons with symptoms to limit their contact with others because persons without symptoms might transmit infection,” the CDC study said.

But if asymptomatic transmission proves to not be an issue, this will have a huge impact on future policies, especially as Kentucky continues to re-open its economy and grapples with how to open its schools in the fall.

State Health Commissioner Steven Stack has said people in public should wear as mask because one-fourth to one-half of people with the virus don't know they have it, and they can spread it even though they lack symptoms.

Stack didn't attend Gov. Andy Beshear's daily coronavirus briefing Monday. Beshear said he had not seen the report, and "That'll be something we have to look at and analyze." He said a cough from an asymptomatic person can spread the virus, and a mask can prevent that.

The governor said he would continue to wear a mask as long as he thinks it can protect someone else "whose body might not be able to handle this disease," not just from the science, but "in part based on faith, being my brother or sister's keeper, or faith that I know it can at least reduce it some."

Van Kerkhove acknowledged that some studies have indicated that the virus can spread via asymptomatic patients, but said again that this is not the main way it is being transmitted.

“We have a number of reports from countries who are doing very detailed contact tracing,” Van Kerkhove said. “They’re following asymptomatic cases. They’re following contacts. And they’re not finding secondary transmission onward. It’s very rare.”

Van Kerkhove stressed the importance of contact tracing symptomatic patients as the best way to reduce the spread of the disease.

“What we really want to be focused on is following the symptomatic cases,” Van Kerkhove said. “If we actually followed all of the symptomatic cases, isolated those cases, followed the contacts and quarantined those contacts, we would drastically reduce” the outbreak.

She also said more research is needed to "truly answer this question" of whether the virus can spread widely through asymptomatic carriers.

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Are statins enough? When to consider PCSK9 inhibitors

For well over 30 years, physicians have understood the role of LDL (low-density lipoprotein, or “bad”) cholesterol in the development of cardiovascular disease (CVD). LDL cholesterol levels are directly correlated with increasing CVD risk and, as summarized in a recent blog post, lowering LDL cholesterol levels, through both lifestyle changes and medications, has been shown to reduce this risk.

Statins are the first-line choice of medications for lowering LDL cholesterol. They are widely prescribed for both primary prevention (reducing CVD risk in patients without known CVD) and secondary prevention (preventing subsequent heart attacks, strokes, and other CVD events in patients with established CVD).

How do PCSK9 inhibitors work?

In 2003, researchers found a genetic mutation that caused some people to develop very high LDL cholesterol levels and CVD at a young age. This laid the groundwork for understanding the PCSK9 pathway, and ultimately the medications now known as PCSK9 inhibitors.

Our liver makes PCSK9 protein, and this protein breaks down LDL receptors, which remove LDL cholesterol from our bloodstream. So the more PCSK9 protein in our bodies, the fewer LDL receptors in our liver, and the higher our LDL cholesterol levels. PCSK9 inhibitors are monoclonal antibodies that block the PCSK9 protein from working. As a result, levels of LDL receptors increase, and LDL cholesterol levels fall. PCSK9 inhibitors work via a pathway different from statin medications, and may be used together.

The FDA approved two PCSK9 inhibitors in 2015: alirocumab (Praluent) and evolocumab (Repatha). These drugs must be given by injection, typically every two to four weeks.

Who could benefit from PCSK9 inhibitors?

The most recent cholesterol treatment guidelines, a collaborative effort from multiple professional organizations including the American Heart Association and the American College of Cardiology, were updated in 2018. These guidelines were broadened from the previous version to include LDL treatment targets, which has prompted doctors to think about adding PCSK9 inhibitors to treat select patients. In the 2018 guidelines, high-risk patients are defined as those with known CVD or with elevated cholesterol levels and diabetes. For high-risk individuals, the guidelines recommend an LDL cholesterol target of less than 70 mg/dl. This cholesterol goal can usually be achieved on a high-dose statin. But what happens if your LDL cholesterol level remains elevated?

Initial studies (FOURIER using evolocumab and ODYSSEY using alirocumab) compared these medications against placebo in patients with known atherosclerotic disease; an LDL cholesterol level above goal; and some, but not all, patients on a statin. In both trials, PCSK9 inhibitors compared against placebo demonstrated average LDL cholesterol reduction of 60%, with a favorable safety profile and robust reductions in CVD events.

A 2019 study published in JAMA Cardiology asked the question: does adding a PCSK9 inhibitor to a statin, in patients with stable CVD and LDL cholesterol levels above goal (greater than 70 mg/dl), prevent future CVD events? For this study, patients fitting this profile were randomized to receive either the PCSK9 inhibitor evolocumab or a placebo. All patients in the study continued to take their statin medication. Researchers looked at the occurrence of CVD events (heart attack, stroke, or hospitalization for heart-related reasons) during the average two-year follow-up period. They found a significant reduction in cardiac events in patients receiving the PCSK9 inhibitor plus a statin, compared to study subjects taking statin plus a placebo.

Side effects and cost of PCSK9 inhibitors

PCSK9 inhibitors are usually well tolerated. Some people experience flulike symptoms with fatigue, feeling cold, and back pain. Muscle aches and pains have also been reported. The most common side effect is pain at the injection site.

The cost of PCSK9 inhibitors has dramatically decreased from their initial pricing of around $14,000 per year. Prescription coverage has also broadened to include these medications, but restrictions still apply based on individual plans.

In summary

Over the past few years, the FDA has expanded its approval of PCSK9 inhibitors to include a larger group of people with elevated LDL cholesterol levels who are at high risk for CVD events. If your LDL cholesterol remains elevated, talk to your doctor about available treatment options.

The post Are statins enough? When to consider PCSK9 inhibitors appeared first on Harvard Health Blog.

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Second suit challenges UK's use of state to collect medical debt

The University of Kentucky should have to go to court to collect medical debts, not use the state tax agency as a collection agency, says a federal lawsuit filed against UK and state officials June 5.

"The suit argues that UK HealthCare and the state Department of Revenue are violating the 14th Amendment and the due process rights of former patients struggling to pay off hospital debts by demanding payments and garnishing their wages without going to court first," Rick Childress reports for the Lexington Herald-Leader.

The five plaintiffs ask a federal judge to make the case a class action on behalf of everyone who has had to pay UK through the Revenue Department. They also want a temporary injunction against such collections.

Another federal lawsuit "challenges the legality of UK using a state agency to collect debt in the first place," Childress notes. "Former patient Amelia Long and four others are the plaintiffs in that class-action lawsuit against Cox and Allison Ball, the state treasurer. According to that suit, UK HealthCare is the only hospital in the state which collects debts via the Revenue Department."

UK spokesman Jay Blanton said “Our policies mandate that a patient be contacted several times before a bill is forwarded to the state, a practice established by law. Moreover, in addition to multiple attempts to reach a patient, we provide counseling, and mediation with a third party if an agreement about a debt cannot be reached.”

The Revenue Department is not collecting during the covid-19 pandemic, under order of Gov. Andy Beshear, but the press release announcing the lawsuit said the agency is still sending threatening letters to debtors, Childress reports: "When collections resume, people who may have lost jobs and health insurance because of the pandemic could be affected."

Ben Carter of Lexington, one of the attorneys who filed the suit, told Childress that debt collectors usually have to sue before collecting, giving debtors a chance to defend themselves, but “That never happens in any of these cases,” he said. “There’s no incentive for UK HealthCare to get these bills right, to negotiate in good faith with our clients and their customers. They get to refer it to a debt collection agency — that’s like debt collection on steroids.”

Blanton said collecting all debts helps “spread the cost of care an ensure affordable access to more people who need such care the most.”

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Covid-19 update: Infection-control inspections indicate nursing homes were ready for pandemic; chart has county infection trends

As news develops about the coronavirus and its covid-19 disease, this item may be updated. Official state guidance is at kycovid19.ky.gov.

• State inspection records indicate that most Kentucky nursing homes were prepared for the pandemic after it began, Bailey Loosemore reports for the Louisville Courier Journal. "At least 154 of the state's 285 licensed nursing homes have received covid-19-focused infection-control inspections since late March, including eight facilities that have reported some of the highest numbers of cases." Only two "were cited for infection-related deficiencies," both "not properly wearing a mask." Two others received citations unrelated to the pandemic.
• Lexington is going through a third round of increases in new daily coronavirus cases, but not because 10 nights of protests have spread the virus, public-health officials told the Lexington Herald-Leader. It is spreading “rapidly” in the city, local health-department spokesman Kevin Hall said, but “Based on our case investigations, the protests are not contributing to the rise in cases we’ve seen this week and the couple weeks prior.” Symptoms can appear two to 14 days after infection.
• The New York Times tracks infection rates in each U.S. county over time. Here's a screenshot of the top 20 counties on its Kentucky chart as of 11 a.m. Monday:
  
  

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