Cadlc Autism Webinar 11 09
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Cadlc Autism Webinar 11 09

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The Ohio Chapter, American Academy of Pediatrics, hosted a webinar to talk about the importance of autism screening. The project was conducted as part of the Concerned About Development Learning ...

The Ohio Chapter, American Academy of Pediatrics, hosted a webinar to talk about the importance of autism screening. The project was conducted as part of the Concerned About Development Learning Collaborative (CADLC), which is part of the Autism Diagnosis Education Pilot Project, (ADEPP), a program funded through the Ohio Department of Health.

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  • Help-Me-Grow uses ASQ PEDS elicits parent concerns about child’s development; ASQ measures a range of different developmental skills Both PEDS and Ages and Stages are filled out by parent (at home or in office) and can be scored by paraprofessional in several minutes
  • Help-Me-Grow uses ASQ PEDS elicits parent concerns about child’s development; ASQ measures a range of different developmental skills Both PEDS and Ages and Stages are filled out by parent (at home or in office) and can be scored by paraprofessional in several minutes
  • Help-Me-Grow uses ASQ PEDS elicits parent concerns about child’s development; ASQ measures a range of different developmental skills Both PEDS and Ages and Stages are filled out by parent (at home or in office) and can be scored by paraprofessional in several minutes

Cadlc Autism Webinar 11 09 Cadlc Autism Webinar 11 09 Presentation Transcript

  • Why? How? Next Steps? John C. Duby, M.D. Akron Children’s Hospital Professor of Pediatrics Northeastern Ohio Universities Colleges of Medicine and Pharmacy Screening for Autism
  • Objective
    • At the end of this session, you will be able to:
    • Summarize the rationale for implementing a system of continuous developmental care for developmental surveillance and screening
    • Identify autism screening tools that can be used in primary care
    • Refer and evaluate children with social and communication concerns
  • WHAT TOOLS HAVE YOU USED?
    • How many of you have experience in use of standardized developmental screening tools?
    View slide
  • Why Should We Do This?
    • Delayed development is common!
    • It’s best practice!
    • Everyone is starting to do it!
    • Early intervention makes a difference!
    • Enhance your bottom line!
    View slide
  • Emotional , Behavioral & Developmental Problems Ohio Children ADHD 145,434 1:18 Depression, Anxiety, Eating Disorder or emotional disorder 95,619 1:28 Difficulty speaking, communicating, or being understood 93,957 1:28 Mental retardation or developmental delay 53,990 1:49 Vision difficulties even when wearing glasses 20,848 1:128 Epilepsy or Seizures 14,687 1:181 Autism 14,151 1:188 Cerebral Palsy 11,337 1:235 Using hearing aids 2,836 1:940 Down syndrome 2,719 1:980
  • It’s Best Practice!
    • National AAP Recommendations
    • Developmental surveillance at all well child visits
      • Elicit parent concerns
    • Developmental screening at 9, 18, 30 (or 24), and 48 months well child visit
      • Use standardized developmental tool
    • Screening for autism at 18 and 30 (or 24) months well child visit
    AAP guidelines 2006, Developmental screening and surveillance in primary care practice AAP guidelines 2007, Autism screening
  • It’s Best Practice! Ohio Chapter AAP recommendations
    • A system of continuous developmental care that includes emphasis on all aspects of surveillance at every well visit, and use of select standardized screening tools at certain visits.
    Approved July 24, 2009
  • It’s Best Practice! Ohio Chapter AAP recommendations Recommended Use of Standardized Screening Tools Approved July 24, 2009 Age Recommended Tool 9 months PEDS or ASQ:3 12 months ASQ:SE 18 months PEDS or ASQ:3 24 months M-CHAT with M-CHAT Follow-up Interview for those who fail 30 months PEDS or ASQ:3
  • It’s Best Practice! Ohio Chapter AAP recommendations Recommended Use of Standardized Screening Tools Approved July 24, 2009 Age Recommended Tool 36 months ASQ:SE 48 months PEDS or ASQ:3 60 months PEDS or ASQ:3 or Pediatric Symptom Checklist Annually age 6-18 Pediatric Symptom Checklist Annually age 11-18 Pediatric Symptom Checklist and/or Pediatric Symptom Checklist Youth Self Report
  • Ohio’s Experience
    • Autism and Developmental Screening Learning Collaborative
      • Fall 2008 through Spring 2009
      • 21 practices
      • Over 400 practitioners
    • Concerned About Development Learning Collaborative
      • Fall 2009
      • 33 practices
      • 425 practitioners
  • Everyone is starting to do it!
  •  
  • National Early Intervention Longitudinal Study (NEILS)
    • A sizeable percentage of children had problems that resolved by age 3
    • More than one-third (37%) of EI participants did not receive preschool special education
    • By kindergarten, 42% of EI participants did not receive special education services
    -- Hebbeler, Spiker, Bailey, Scarborough, Mallik, Simeonsson, Singer & Nelson, 2007
  • National Early Intervention Longitudinal Study (NEILS)
    • EI addresses fundamentally different issues for different children and families
    • For some families, EI provides the extra support and assistance to work through a time-limited developmental challenge
    • For some families, EI provides support to help them deal with a child with a life-threatening health condition
    • For other families, EI is the first step in a series of many systems the family will encounter with their child with a more severe disability
    -- Hebbeler, Spiker, Bailey, Scarborough, Mallik, Simeonsson, Singer & Nelson, 2007
  • Enhance your bottom line
  • Developmental Testing with Preventive Care Visit
    • 99329-25
      • Preventive medicine service, age 1-4 years, established
      • V20.2 Routine child health check
    • 96110 (for ASQ)
      • Developmental testing limited
      • V20.2 Routine child health check
      • 315.31 Expressive language disorder
    • 96110-51(for M-CHAT) or 96110 (x2)
      • Developmental testing limited
      • V20.2 Routine child health check
      • 315.31 Expressive language disorder
  • Why?
    • Delayed development is common!
    • It’s best practice!
    • Everyone is starting to do it!
    • Early intervention makes a difference!
    • Enhance your bottom line!
  • How?
    • Developmental Surveillance at all Well Visits
    • Use of Standardized Screening Tools at Select Well Visits and whenever indicated
    • Maintain a High Index of Suspicion
  • Elements of Surveillance
    • Elicit parents’ concerns
    • Review the developmental history
    • Identify risk and protective factors
    • Observe parent-child interaction
    • Reflect on provider-child interaction
    • When concerns are identified, gather information from others who know the child well
    • Keep accurate records
  • Content Developed by: Michelle M. Macias, MD† Scott W. Stuart, MD, MS† † - Medical University of South Carolina, Division of Genetics and Developmental Pediatrics, 135 Rutledge Avenue, Charleston, SC 29425 Case Study: Laura 24 month visit
  • Legend = Start = Action/Process = Decision = Stop Increasing Developmental Concern Pediatric Patient at Preventive Care Visit Perform Surveillance Does Surveillance Demonstrate Risk? Is this a 9-, 18-, or 30-month* visit? Schedule Next Routine Visit Visit Complete Administer Screening Tool Are the Screening Tool Results Positive / Concerning Schedule Early Return Visit Visit Complete Administer Screening Tool Make Referrals for: Developmental and Medical Evaluations & Early Developmental Interventions / Early Childhood Services Developmental Medical Evaluations Identify as a Child with Special Health Care Needs Initiate Chronic Condition Management Perform Surveillance Visit Complete Is a Developmental Disorder Identified? Visit Complete Are the Screening Tool Results Positive / Concerning 1 2 3 4 5a 5b 6a 6b 7 8 9 10 YES YES YES YES YES NO NO NO NO Related Evaluation and Follow Up Visit DEVELOPMENTAL SURVEILLANCE AND SCREENING PATHWAY NO
  • Modified Checklist for Autism in Toddlers (M-CHAT)
    • 23 yes-no questions
    • Measures social reciprocity, language, some motor
    • 18 months to 4 years of age
    • Detects ASD, language impairment, MR
    • Available in over 20 languages
  • M-CHAT and Autism screening
    • Failing score if 2 or more critical items or any 3 items are failed
    • Free download at firstsigns.org
    • 2 page scoring guide
    • Takes 5 minutes to complete, 1-5 to score
    • Autism screen recommended by AAP Autism Expert Panel for use at 18-24 month well-child visit
  • M-CHAT (18-30 months) Please fill out the following about how your child usually is. Please try to answer every question. If the behavior is rare (e.g. you’ve only seen it once or twice), please answer as if the child does not do it. 1. Does your child enjoy being swung, bounced on your knee, etc.? YES NO 2. Does your child take an interest in other children? YES NO 3. Does you child like climbing on things, such as up stairs? YES NO 4. Does your child enjoy playing peek-a-boo / hide-and-seek? YES NO 5. Does your child ever pretend, for example, to talk on the phone, take care of dolls or pretend other things? YES NO 6. Does your child ever use his/her index finger to point, to ask for something? YES NO 7. Does your child ever use his/her index finger to point, indicate interest in something? YES NO 8. Can your child play properly with small toys (e.g.: cars or blocks) without just mouthing, fiddling, or dropping them? YES NO 9. Does your child ever bring objects over to you (parent), to SHOW you something? YES NO 10. Does your child ever look you in the eye for more than a second or two? YES NO 11. Does your child ever seem over sensitive to noise? (e.g. plugging ears)? YES NO 12. Does your child smile in response to your face or your smile? YES NO 13. Does your child imitate you? (e.g. you make a face-will your child imitate it?)? YES NO 14. Does your child respond to his/her name when you call? YES NO 15. If you point at a toy across the room, does your child look at it? YES NO 16. Does your child walk? YES NO 17. Does your child look at things you are looking at? YES NO 18. Does your child make unusual finger movements near his/hear face? YES NO 19. Does your child try to attract your attention to his/her own activity? YES NO 20. Have you ever wondered if your child is deaf? YES NO 21. Does your child understand what people say? YES NO 22. Does your child sometimes stare at nothing or wander with nor purpose? YES NO 23. Does your child look at your face to check your reaction when faced with something unfamiliar? YES NO
  • M-CHAT (18-30 months) Please fill out the following about how your child usually is. Please try to answer every question. If the behavior is rare (e.g. you’ve only seen it once or twice), please answer as if the child does not do it. 1. Does your child enjoy being swung, bounced on your knee, etc.? YES NO 2. Does your child take an interest in other children? YES NO 3. Does you child like climbing on things, such as up stairs? YES NO 4. Does your child enjoy playing peek-a-boo / hide-and-seek? YES NO 5. Does your child ever pretend, for example, to talk on the phone, take care of dolls or pretend other things? YES NO 6. Does your child ever use his/her index finger to point, to ask for something? YES NO 7. Does your child ever use his/her index finger to point, indicate interest in something? YES NO 8. Can your child play properly with small toys (e.g.: cars or blocks) without just mouthing, fiddling, or dropping them? YES NO 9. Does your child ever bring objects over to you (parent), to SHOW you something? YES NO 10. Does your child ever look you in the eye for more than a second or two? YES NO 11. Does your child ever seem over sensitive to noise? (e.g. plugging ears)? YES NO 12. Does your child smile in response to your face or your smile? YES NO 13. Does your child imitate you? (e.g. you make a face-will your child imitate it?)? YES NO 14. Does your child respond to his/her name when you call? YES NO 15. If you point at a toy across the room, does your child look at it? YES NO 16. Does your child walk? YES NO 17. Does your child look at things you are looking at? YES NO 18. Does your child make unusual finger movements near his/hear face? YES NO 19. Does your child try to attract your attention to his/her own activity? YES NO 20. Have you ever wondered if your child is deaf? YES NO 21. Does your child understand what people say? YES NO 22. Does your child sometimes stare at nothing or wander with nor purpose? YES NO 23. Does your child look at your face to check your reaction when faced with something unfamiliar? YES NO
  • M-CHAT (18-30 months) “ AT RISK” NEEDS FURTHER EVALUATION IF: FAILS 2 CRITICAL ITEMS OR ANY 3 ITEMS. Robins, D., Fein, D., Barton, M., & Green, J. (2001). The Modified Checklist for Autism in Toddlers: An initial study investigating the early detection of autism and pervasive developmental disorders. Journal of Autism and Developmental Disorders, 31 (2), 131-144.
  • M-CHAT (18-30 months) “ AT RISK” NEEDS FURTHER EVALUATION IF: FAILS 2 CRITICAL ITEMS OR ANY 3 ITEMS. Robins, D., Fein, D., Barton, M., & Green, J. (2001). The Modified Checklist for Autism in Toddlers: An initial study investigating the early detection of autism and pervasive developmental disorders. Journal of Autism and Developmental Disorders, 31 (2), 131-144.
  • BASED ON WHAT YOU HAVE LEARNED FROM THE M-CHAT, WHAT ARE YOU THINKING?
  • Legend = Start = Action/Process = Decision = Stop Increasing Developmental Concern Pediatric Patient at Preventive Care Visit Perform Surveillance Does Surveillance Demonstrate Risk? Is this a 9-, 18-, or 30-month* visit? Schedule Next Routine Visit Visit Complete Administer Screening Tool Are the Screening Tool Results Positive / Concerning Schedule Early Return Visit Visit Complete Administer Screening Tool Make Referrals for: Developmental and Medical Evaluations & Early Developmental Interventions / Early Childhood Services Developmental Medical Evaluations Identify as a Child with Special Health Care Needs Initiate Chronic Condition Management Perform Surveillance Visit Complete Is a Developmental Disorder Identified? Visit Complete Are the Screening Tool Results Positive / Concerning 1 2 3 4 5a 5b 6a 6b 7 8 9 10 YES YES YES YES YES NO NO NO NO Related Evaluation and Follow Up Visit DEVELOPMENTAL SURVEILLANCE AND SCREENING PATHWAY NO
  • Chief Complaint : Well Visit HPI : Laura is a 18 month female who is a new patient to your office presenting for a well visit. Past Medical History : Born at full term. BW was 2550 grams and required 48 hours of supplemental 0 2 . Recurrent AOM x 7 (no PET placed to date) Medications : None Immunizations: UTD Case Study: Laura
  • Developmental History : No prior concerns. Behavioral History : No early or current concerns for colic, sleeping or eating. Social Hx : Lives with 25 y.o. single mother who works full time as a receptionist. Laura is in day care full time. Father is regularly involved in her care. Child support is in place. Both parents are high school graduates. FMH: 2 maternal cousins with speech delay. Father was a “late” walker. Case Study: Laura
  • PROVIDER : “Do you have any questions or concerns about Laura’s development, behavior or learning?” MOTHER : “I’m worried about her talking. She seems to be behind other kids her age. At the playground, other kids are saying real words. She only says a couple of words.” PROVIDER : “Do you have concerns about her ability to understand what is said?” MOTHER : “She hears everything just fine. I’m not sure she always understands me.” PROVIDER : “How does Laura communicate what she wants?” MOTHER : “Hard to say. She sometimes says a single word like ‘cup’. She will start crying and I often just have to figure out what she wants.” PROVIDER : “Does she point to things that she wants?” MOTHER : “Not really…I don’t think so.”
    • While talking with the mother, you observe:
    • Laura is interested in playing with toys provided in the examination room.
    • As she plays, she intermittently looks over at her mother.
    • Spontaneously shows mother some of the toys.
    • Very interested in playing with the pinwheel and attempts to engage the mother to play with her.
    • Fleeting eye contact.
    • When mom calls her name, she comes over to sit in mom’s lap.
    • Demonstrates immature jargoning.
  • M-CHAT Follow-up Interview
    • Ask the follow up questions for the failed items
    • Increases positive predictive value to 0.57
  • M-CHAT Follow-up Interview
    • Ask the follow up questions for the failed items
    • Increases positive predictive value to 0.74
  • Legend = Start = Action/Process = Decision = Stop Increasing Developmental Concern Pediatric Patient at Preventive Care Visit Perform Surveillance Does Surveillance Demonstrate Risk? Is this a 9-, 18-, or 30-month* visit? Schedule Next Routine Visit Visit Complete Administer Screening Tool Are the Screening Tool Results Positive / Concerning Schedule Early Return Visit Visit Complete Administer Screening Tool Make Referrals for: Developmental and Medical Evaluations & Early Developmental Interventions / Early Childhood Services Developmental Medical Evaluations Identify as a Child with Special Health Care Needs Initiate Chronic Condition Management Perform Surveillance Visit Complete Is a Developmental Disorder Identified? Visit Complete Are the Screening Tool Results Positive / Concerning 1 2 3 4 5a 5b 6a 6b 7 8 9 10 YES YES YES YES YES NO NO NO NO Related Evaluation and Follow Up Visit DEVELOPMENTAL SURVEILLANCE AND SCREENING PATHWAY NO
  • What Do I Do Now?
    • Make a referral
    • Figure out the cause
    • Do medical testing
  •  
  • Resources www.ohiohelpmegrow.org 1-800-755-4769 (GROW)
  • Do screening results demonstrate risk? Primary physician refers to HMG OR asks family to self-refer HMG assigns Service Coordinator Primary MD administers screening tools at recommended ages
    • If MD refers, HMG must contact family within 48 hours and provide feedback to MD
    • If family self-refers, MD may not receive feedback
    • SC makes home visit(s)
    • ASQ
    • Vision screening
    • Hearing status questionnaire
    • Nutrition screen
    • ASQ-SE
    • SC contacts MD for info
    • Immunizations
    • Other health care info
    • Child is evaluated
    • to determine Part C eligibility
    • Bayley or Battelle
    IFSP is developed
    • With parent consent, report could be shared with MD
    Services begin
    • With parent consent, IFSP could be shared with MD
    • With parent consent, updates/
    • progress could be shared with MD
    Date of referral 45 DAYS IFSP signed 30 days What happens when a referral is made to HMG?
  • Make A Referral!
  • What’s the diagnosis? Laura 18 month old female Results Bayley or Battelle 1.5 S.D. below mean = 77.5 Cognitive 107 Language 68 Receptive 8 Expressive 5 Motor 102 Social-Emotional 89 Adaptive Behavior 80 Physical Exam Normal: no dysmorphic features Neurological Exam Normal Vision Normal Hearing Mild left conductive loss
  • What are you thinking now?
  • Causes of Delays in Social and Communication Skills
    • Hearing Loss
    • Visual Impairment
    • Language Disorders
    • Intellectual Disability
    • Emotional Problems
    • Autism Spectrum Disorders
    • Lack of Opportunity
  • Do Medical Testing! Test Intellectual Autism Language Hearing Genetics + + - +/- MRI IQ <50 IQ < 50 - - CT Small head - - +, with Temporal EEG - - - - Newborn Screen + + + + Metabolic - - - - Lead + + + + Vision + + + + Hearing + + + +
  • Screening for Delayed Development What will you do differently after this presentation?
  • Concerned About Development Learning Collaborative
    • www.concernedaboutdevelopment.org
    • www.cadlc.org
    • Webinar Series:
      • February 3, 10, 17, and 24, 2010
      • 12:15-1:45 PM
    • Day Long Learning Sessions
      • 1/27/2010 Greenville
      • 2/11/2010 Athens
      • 2/18/2010 Dayton/Cincinnati area