Early Autism Detection and Referral

1. Early Autism Detection and Referral

2. 1. Autism Spectrum Disorders - Basics

3. Neurodevelopmental disorder with a spectrum of clinical conditions 3 areas of dysfunction: Social interaction/social relatedness difficulty Communication impairment Restrictive/repetitive behaviors and interests What is Autism?

4. ASD Facts: Epidemiology • Conservative prevalence: 1 in 500; recent estimates: 1 in 150 • ASD more prevalent in pediatric population than: • Cancer • Diabetes • Downs Syndrome • Male to female ratio: 4 to 1

5. Autism Myths

6. DSM-IV Classification:Pervasive Developmental Disorders

7. Causation unknown Strong genetic influence Evidence supports polygenic inheritance Recurrence risk is 5-8% in siblings Autism does NOT result from: Poor parenting MMR vaccine Thimerosal preservative in vaccines ASD Causes:

8. AAP Policy Due to recent evidence that early diagnosis and intervention are associated with better long-term outcomes, the AAP Committee on Children with Disabilities recommends that pediatricians increase their knowledge on autism Pediatrics Vol. 107 No. 5 May 2001

9. ASD Facts • Present at birth, with onset of symptoms before 36 months • Accurate diagnosis possible at 18-24 months • Parents first voice concerns around 18 months, but diagnosis is typically not until 3 years or older

10. Part 1 SummaryAutism Spectrum Basics • Autism is a neurodevelopmental disorder with a broad spectrum of behavioral manifestations • Autism is not rare! At 1 in 500, each pediatrician should have up to 3 or 4 affected children in their practice

11. 2. Overview of Child Social Development

12. What are the earliest signs of Autism? Delays or abnormalities in: • Joint Attention • Social Interaction • Play Behavior

13. Social Symptoms Lack of: • Use of eye contact to regulate social interaction • Orienting to name • Joint attention behaviors: pointing & showing • Pretend play • Imitation • Nonverbal communication • Language development

14. Language Delay – Need for immediate referral 9 months: No babbling 12 months: No pointing or other gestures 16 months: No single words 24 months: No functional 2-word phrases (not echolalic) Any age: Any loss of language or social skills

15. Behavioral Red Flags Investigate further and consider autism if the child: • Doesn’t know how to play with toys in a typical fashion • Restricted patterns of interest • “Toe walks” • Has unusual attachments • Lines things up • Presents with sensory symptoms • Has odd movement patterns and/or very repetitive behaviors • Demonstrates echolalia • Throws prolonged or frequent tantrums • Is hyperactive

16. Joint Attention

17. Part 2 SummaryChild Social Development Delays or abnormalities in: • Social Interaction • Language Delay • Restricted or Repetitive Behavior

18. 3. Autism Identification

19. AAP PolicyDevelopmental Screening AAP Committee on Children with Disabilities recommends routine standardized developmental and behavioral screening Pediatrics Vol. 108 No. 1 July 2001

20. Listen to Parents Parents: • Are aware of the possibility of autism • Do have concerns when something is wrong • Do give accurate and reliable information about their children • Need your questions to generate discussion about their child’s development Child care providers are also a good resources when addressing developmental concerns of a child

21. Autism Assessment:18 – 36 months • Autism screening tools are not recommended for primary care setting • At 18-month visit use parent questioning and direct observation to assess child for: • Refer for further evaluation if concerned

22. Developmental Screening • Consider using a standardized parent report tool at every well child visit • Examples include: • Parental Evaluation of Developmental Status (PEDS) www.pedstest.com • Ages and Stages Questionnaire (ASQ) www.pbrookes.com/store/books/bricker-asq/ • Child Development Review www.childdevrev.com

23. Autism Screening Tools • CHecklist for Autism in Toddlers (CHAT) • Modified CHecklist for Autism in Toddlers (M-CHAT) • Quick and Quantitative CHecklist for Autism in Toddlers (Q-CHAT)

24. Part 3 SummaryAutism Identification • Developmental screening is recommended • The disorder can be recognized by 18-24 months when familiar with the early signs • Screening for autistic spectrum disorders either formally or informally at the 18 month visit is recommended

25. 4. Referral Process

26. Referrals for children who show signs of autism A.L.A.R.M. • Under 3 years – refer to Early Intervention • 3 years or above – refer to School District • For diagnostic confirmation consider: • Developmental & behavioral pediatrician • Child psychologist • Pediatric neurologist • Child psychiatrist

27. 0 – 3: Early Intervention Different in each state • Babies Can’t Wait Programs • Autism Centers of Excellence • University Based Developmental Disorders • Check with State Office Call 1-800-323-GROW for nearest CFC

28. Special Education • Mandated by federal IDEA legislation • Programs managed and vary by school district • Make referrals in writing! • Individualized Education Plan (IEP) for each child • Services for children with autism may include: • Speech therapy • Occupational therapy • Communication assistance (PECS) • Teacher education on classroom management

29. Treatment Options Issues to consider when choosing a treatment plan: • Evidence-based • Cost • Time • Family involvement

30. Insurance Issues • Autism assessment with observation and parental discussion falls under the general well child visit code • Implement standardized developmental screening to increase reimbursement

31. Encouraging Next Steps • Acknowledge parent’s fear and grief • Provide information on how to tell others • Provide parent with information on the referral sources • Encourage communication • Set a follow-up appointment

32. Part 4 SummaryReferral • Physician plays the role of gatekeeper • Diagnosis requires a TEAM evaluation • Early intervention makes a difference! • Advances in effective treatments