• Like
  • Save
Webinar: Autism Identification
Upcoming SlideShare
Loading in...5
×
 

Webinar: Autism Identification

on

  • 30,050 views

 

Statistics

Views

Total Views
30,050
Views on SlideShare
30,050
Embed Views
0

Actions

Likes
0
Downloads
16
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • Paul H. Lipkin, M.D.
  • Paul H. Lipkin, M.D.

Webinar: Autism Identification Webinar: Autism Identification Presentation Transcript

  • Autism Spectrum Disorders: Identification & Management Georgina Peacock, MD, MPH, FAAP Susan L. Hyman, MD, FAAP Susan E. Levy, MD, FAAP
  • Objectives
    • By the end of the Webinar, participants will be able to:
    • Recognize the early warning signs of autism spectrum disorders (ASD)
    • Describe the recommendations put forth in the 2 AAP Autism Clinical Reports regarding identification and management of ASDs
    • Utilize the AAP Autism Screening Algorithm in office practice
    • Identify components of the AAP Autism Toolkit which will assist you in providing a medical home to children with ASD
  • Pediatrics 2006; 118: 405-420
  • Developmental Surveillance & Screening Policy Statement Goals
    • Increase identification of children with developmental disorders by child health professionals
      • Improved surveillance and screening
      • Concrete guidelines (algorithm)
      • Eliminate barriers (e.g. reimbursement, time)
    • Improve medical assessment
  • Definitions (AAP, 2006)
    • Developmental surveillance
      • “ A flexible, longitudinal , continuous , and cumulative process whereby knowledgeable health care professionals identify children who may have developmental problems”
    • Developmental screening
      • “ The administration of a brief standardized tool aiding the identification of children at risk of a developmental disorder”
      • Not diagnostic!
    • Developmental evaluation
      • “ Aimed at identifying the specific developmental disorder or disorders affecting the child ”
    • It’s more than height and weight
    • Observing how children play, learn, speak and act
    • Different areas of development
      • Social, communication, cognitive, gross motor, fine motor, adaptive
    • Monitoring milestones can offer early signs of delay including signs of autism spectrum disorders
    Child Development
  • Autism Spectrum Disorders
    • Problems with socialization
    • Problems with communication
    • Unusual behaviors
  • Parental Concerns ( Wiggins, Baio, Rice, 2006)
    • Recent study by CDC indicated most children with an ASD diagnosis had signs of a developmental problem before the age of 3 , but average age of diagnosis was 5 years .
  • Early Development
    • Babies start communicating and relating to other people at birth
    • Continued social-emotional development is key to forming strong relationships and continued learning
  • By the end of 3 months
    • Begin to develop a social smile
    • Enjoy playing with other people and may cry when playing stops
    • Become more expressive and communicate more with face and body
    • Imitate some movements and facial expressions
  • By the end of 7 months
    • Smile back at another person
    • Respond to sound with sounds
    • Enjoy social play
    • Red Flags
    • No big smiles or other warm, joyful expressions by six months or thereafter
    • No back-and-forth sharing of sounds, smiles, or other facial expressions by nine months or thereafter
  • By the end of 12 months
    • Use simple gestures
    • Imitate actions in their play
    • Respond when told “no”
    • Red Flags
    • No back-and-forth gestures, such as pointing, showing, reaching, or waving bye
    • Not answering to one’s name when called
    • No babbling – mama, dada, baba
  • Joint Attention and Social Engagement
  • By the end of 18 months
    • Do simple pretend play
    • Point to interesting objects
    • Use several single words unprompted
    • Red Flags
    • No single words by 18 months
    • No simple pretend play
  • By the end of 2 years (24 months)
    • Use 2- to 4-word phrases
    • Follow simple instructions
    • Become more interested in other children
    • Point to object or picture when named
    • Red Flags
    • No two-word meaningful phrases (without imitating or repeating)
    • Lack of interest in other children
      • Red Flag: Any loss of speech or babbling or social skills
      • Regression at any age is cause for immediate referral
  • Health Care Professional Resource Kit Stand with 200 Informational Cards Set of 15 Fact Sheets Small Posters (3)
    • www.cdc.gov/ncbddd/actearly/
    • The findings and conclusions in this presentation have not been formally
    • disseminated by the CDC and should not be construed to
    • represent any agency determination or policy.
    Learn the Signs. Act Early.
  • AAP Reports Related to Autism 2001: Complementary and Alternative Medicine in Children with Chronic Illness Pediatrics. 2001 Mar;107(3):598-601 2006: Developmental Screening Pediatrics. 2006 Jul;118(1):405-20 2007: Evaluation of Autism Pediatrics. 2007 Nov;120(5):1183-215 2007: Management of Autism Pediatrics. 2007 Nov;120(5):1162-82 2009: The Young Child with Autism Pediatrics. 2009 May;123(5):1383-91
  • Identification and Management of Children with Autism
  • Clinical Reports on Autism: 2007
    • Clinical Reports: Guidance for the clinician in rendering pediatric care
    • Clinical Practice Guidelines: Evidence-based decision-making tools for managing common pediatric conditions
    • Technical Reports: Background information to support AAP policy
  • Important Roles of Primary Care Physicians/Medical Home
    • Early recognition
      • Knowledge of signs and symptoms
      • Developmental surveillance and screening
    • Guiding families to diagnostic resources and intervention services
    • Conducting a medical evaluation
    • Providing ongoing health care
    • Supporting and educating families
  • Screening in Primary Care
    • Surveillance for Social and Communication skills
    • Screen at 18 and 24 months with specific screening test
    • Reassess at well child visits and if concerns arise
      • Later age at diagnosis for children with high functioning ASD
  • ASD Screening in Primary Care:
    • Children at Higher Risk :
      • Siblings of children with ASD: 10 x increased risk
      • Premature Infants
      • Comorbid Genetic Syndromes: e.g. Fragile X syndrome, Tuberous Sclerosis
      • Prenatal Exposures e.g. Valproic acid
    • Regression in Milestones : 25-30%
      • 15-24 months of age
      • Change in language, social awareness or behavior
  •  
  • M-CHAT: Does your child...
    • Like to be swung?
    • Take interest in other children ?
    • Like climbing?
    • Enjoy peek-a-boo?
    • Ever pretend to talk on the phone?
    • Ever use index finger to point to ask? To indicate interest?
    • Play properly with small toys?
    • Bring objects to show?
    • Look you in the eye?
    • Seem oversensitive to noise?
    • Smile in response to you?
    • Imitate you?
    • Respond to name?
    • If you point, does he look?
    • Walk?
    • Look at things you are?
    • Make unusual finger movements near face?
    • Act as if deaf?
    • Understand what people say?
    • Stare at nothing?
    • Look at your face to check reaction?
    Robins et al, 1999 http://www2.gsu.edu/~psydlr/Diana_L._Robins,_Ph.D._files/M-CHATInterview.pdf
  • Modified Checklist for Autism in Toddlers (MCHAT)
    • Positive Predictive Value (.57) Robins, Autism. 2008 Sep;12(5):537-56.
      • Proportion of children with a (+) test who have an autism spectrum disorder, Moderate
      • 9.7% of 4797 children screened +
      • 61/362 + after interview
      • 4/21 cases confirmed at 4 yrs were identified by the pediatrician
      • 17/21 cases not confirmed at 4 yrs had another developmental diagnosis
    • Age range : 16-36 months
    • 23 Questions :
    • -2 of critical items or any 3 items
  • Barriers to Screening in Office Practice
    • Screening tests too long and difficult
    • Children uncooperative
    • Reimbursement limited
      • 96110 for Screening tests like MCHAT
      • 25 modifier if MD interprets and E/M code billed
      • Have families return for counseling visit
      • Code for time and counseling
    • Do not want to alarm parents
    • Belief that delays will improve on their own
    • Referral resources unfamiliar or unavailable
  • Evaluation and Intervention Services:
    • Birth to 3 years: Early Intervention
    • 3-5 Years: School district
    • 5-21 Years: School district
    • Transition age planning and young adult service referrals
    • Assessment includes : IQ, Speech and Language, Adaptive, Motor, Social and Emotional, and Hearing
  • EI Referral Form
  • Diagnostic Evaluation:
    • Application of DSM IV Criteria:
      • History
      • Observational Measure
    • Medical History and Physical
      • Behavioral History
      • Family History: Genetic risk factors
    • Assessment of Parental Understanding, coping skills and resources
  • Community Resources
  • Specific aspects of history to target in children with ASDs:
    • Seizures
    • GI concerns :
      • Diarrhea/constipation/bloating/pain
    • Sleep problems:
      • Night waking, delayed sleep onset
    • Feeding behaviors :
      • Aversions based on taste/texture/appearance
      • Monitor growth and nutrition
    • Tics
      • In as many as 9% of children
  • Medical Work Up $11 Lead- no data, low Other $650 Any abnormality-16-68% Seizures- 25% lifetime EEG $400-$3500 MRI, any lesion-up to 48% Neuroimaging $299 $280 Amino Acids-<1% Organic Acids<1% Metabolic Testing $400 $600-3500 $500 $1400 $680 Karyotype- 5% yield Microarray- 6-27% Fragile X-1-2% MeCP2 FISH Chr 15 -1% Genetic Testing
  • A Good History and Physical is the basic medical work up for ASD.
  • Key Points
    • Medical home = center for ongoing management
    • Cornerstone of treatment
      • Educational interventions, developmental and behavioral strategies
    • Early, intensive intervention is vital
    • Pediatricians can support families by providing information and access to resources
    Myers SM, Johnson CP, and the Council on Children with Disabilities, Pediatrics 2007;120:1162-1182
  • The Autism Toolkit
    • AUTISM: Caring for Children With Autism Spectrum Disorders: A Resource Toolkit for Clinicians was developed by the AAP Autism Subcommittee to support health care professionals in the identification and ongoing management of children with ASDs in the medical home
  • Medical Management of Children with ASD Includes:
    • Effective treatment of coexisting medical problems such as seizures, challenging behaviors, and sleep disorders may allow the child to benefit more fully from educational interventions
    • Medication management of symptoms of inattention, impulsivity, irritability, aggression
    • Pediatricians can help families to understand how to evaluate the evidence regarding Complementary and Alternative therapies
  • ASD Management
    • Outcomes are variable
      • Behavioral characteristics change over time
      • Most remain on spectrum as adults
        • Ongoing problems with independent living, employment, social relationships and mental health
    • Predictors of better outcome
      • Earlier age of diagnosis and treatment
      • No cognitive impairment
      • Early language and nonverbal skills
      • Social skills
      • Not – presence, degree of “autistic” symptoms
  • Treatment
    • Goals
      • Minimize core features and associated deficits
      • Maximize functional independence and QOL
      • Alleviate family stress
    • Educational intervention
    • Developmental Therapies
      • Communication
      • Sensory, fine motor, gross motor
    • Behaviorally Based treatments
      • Core and associated symptoms
      • Social skills
    • Medical or biologic treatments
    • Support family in home and community
  • Education
    • Cornerstone of management
    • Curricula should include
      • Academic learning
      • Socialization
      • Adaptive skills
      • Communication
      • Ameliorization of interfering behaviors
      • Generalization of abilities across environments
    • Effective programs
      • Use assessment based curricula to address these goals
      • Include combinations of strategies and treatment modalities
      • Incorporate strong components of family training and support
    • Programs differ in philosophy & emphasis
    Myers & Johnson, PED 2007
  • Behavioral Intervention
    • ABA (Applied Behavioral Analysis)
      • General behavioral teaching approach involves reinforcement and consequences to shape behavior
      • All of our parents used it!
    • Involves the A, B, C’s
      • Not airway, breathing circulation
      • Antecedent Behavior Consequence
    • Also known as ABA, EIBI, DTT, DTI, etc.
  • Evolution of ABA
    • Methodology includes a data based approach to skill acquisition in a developmental format, using principles of Applied Behavioral Analysis
    • Types
      • Discrete Trial Teaching or Instruction (Lovaas)
      • Pivotal Response Training (PRT)
      • Natural language approach
      • Applied Verbal Behavior (AVB)
      • DIR™ (Developmental, Individual Difference, Relationship-Based), AKA “floortime”
      • RDI (Relationship Development Intervention)
      • Others….
    • Principles can/ should be integrated into classroom curricula
  • Speech/Language Therapy
    • Behaviorally based/ intensive structured teaching
      • E.g., Verbal Behavior
    • Augmentative strategies
      • Sign language
      • PECS
      • Aided augmentative/ alternative system(s)
    • Decrease non-communicative language
    • Developmental-pragmatic approaches
      • appropriate use of language in social situations
      • e.g., SCERTS
      • Social skills training
  • Developmental: Motor
    • OT
    • Fine motor coordination
    • Adaptive skills
    • Sensory Integration
      • Addresses sensory abnormalities
      • “ Systematic desensitization”
      • No evidence of corresponding neurological changes
    • PT
    • Coordination difficulties
    • Natural environment
      • Adaptive physical education or in the community
      • Hippotherapy
  • Medical Management Comorbid Symptoms or Conditions
    • High rates of co-morbidity
    • Tic disorders (9%)
    • Seizures (to 25%)
    • ADHD (30-75%)
    • Affective Disorders (25-40%)
      • e.g., depression or anxiety
      • Higher in HFA/ Asperger’s
    • GI Problems (10-60%)
    • Sleep Disturbance (50-75%)
    • Challenging Behaviors (10-35%)
  • Psychopharmacology
    • Adjunct to educational, developmental & behavioral treatments
    • So far no evidence of impact on core symptoms
    • Evidence supporting is variable
    • Toolkit – handouts for MD & families
    • Treat target symptoms
      • Stereotypies
      • Withdrawal
      • Obsessions
      • Irritability
      • Hyperactivity
      • attention span
      • self-injurious behavior
      • Aggression
      • sleep
  • Psychopharmacology Sleep diary; sleep hygiene; behavioral supports; investigate possible medical comorbidity/ies as cause(s) 52-73% Sleep disruption Medications; Alpha agonist (clonidine, guanfacine), others 8-10% Tics Behavioral intervention Medication (e.g., naltrexone, risperidone, others) 34% Self-injurious behavior Behavioral intervention Medication – atypical neuroleptics (risperidone, arapiprazole, others) 8-32% Disruptive, irritable or aggressive behavior Behavioral treatment, supportive counseling; Medication – SSRI, others 37% Obsessive compulsive symptoms Psychotherapy Medication – anti-depressants 2-30% Depression Behavioral treatment – relaxation, cognitive Psychopharmacotherapy – SSRI, alpha agonist 43-84% Anxiety Behavioral intervention Psychopharmacotherapy – stimulants, atomoxetine, alpha agonists, anti-anxiety 59% Attentional, impulsivity, hyperactivity Treatments Freq Symptoms/ Disorders
  • CAM Treatments Used in Children with ASD
    • Mind-body Medicine
      • Yoga
      • Music Therapy
    • Manipulative and Body-based
      • Chiropractic
      • Massage/Therapeutic Touch
      • Auditory Integration
    • Energy Medicine
      • Transcranial & magnetic stimulation
    • Biologically Based
    • Most commonly used
      • ~ 50% - biologically based
      • 30% - mind body
      • 25% - manipulation/ body based
      • ** Most use > 1 modality
  • Biologically Based CAM
    • Supplements
      • B6/Magnesium, B12
      • DMG/ TMG
      • Vitamin A, Vitamin C
      • Folate
      • Omega 3 Fatty Acids
    • Elimination Diets
      • Casein/ gluten free
    • Off-label medications
      • Secretin
    • Immune
      • Antifungal therapy
      • Immunotherapy, steroids
      • Antibiotics/Antivirals
      • Stem cell transplantation
    • Immunization-related
      • With-hold immunization
      • Chelation
    • Hyperbaric oxygen therapy (HBOT)
    Always others coming along…
  • CAM
    • Commonly used, especially in CSHCN
      • ASD ranges 30-90%
    • Many factors associated
      • fear of drug effects, desire to “cure” condition, family use of CAM for other purposes
    • Evidence for efficacy for most treatments not strong
      • Some biologically based treatments have been studied, with evidence based support (melatonin) or refuted (secretin)
      • Many with potential serious side-effects (e.g., chelation, HBOT)
  • Gluten Free/ Casein Free Diet
    • One of most commonly used CAM treatments
    • Hypothesis :
      • Exogenous opiate-like peptides = false neurotransmitters
      • Evidence – most non-blinded; few RCT emerging, no differences
    • Requires
      • elimination of ALL dairy products (not “GFCF except for ice cream…”) & elimination of barley, rye, oats & wheat products
    • Potential deficiencies
      • Inherently deficient in calcium, vitamin D
      • B vits, Iodine, others may be lower in substitute products
      • Weight typically adequate, monitor Fe status
  • Toolkit Content
    • The fully searchable CD-ROM has an extensive library of ASD-specific information and practice tools:
    • Screening and surveillance algorithms • Examples of screening tools • Guideline summary charts • Management checklists • Developmental checklists • Developmental growth charts • Web links • Early intervention referral forms and tools • Record-keeping tools • Emergency information forms • ASD coding tools • Reimbursement tips • Sample letters to insurance companies • ASD management fact sheets • Family education handouts
  • Toolkit Content
    • Asperger syndrome
    • Behavioral principles
    • CAM Treatments
    • Dietary tx
    • Eating & nutrition
    • GI problems
    • Treatment decision
    • Psychopharmacology
    • Seizures & Epilepsy
    • Sleep disorders
    • Toilet training
    Fact sheets for primary care professionals (PDF files) Topics
  • Toolkit Content
    • Behavioral challenges
    • Diet
    • Early intervention
    • GI problems
    • Childhood to adolescence
    • Guardianship
    • Lab tests
    • Medication
    • Nutrition & eating problems
    • School based services
    • Seizures & epilepsy
    • Sibling issues
    • Sleep problems
    • Support programs for families
    • Toilet training
    • Transition to adulthood
    • Vaccines
    • Visiting the doctor
    Fact sheets for primary care professionals to give families (PDF files) Topics
  • Questions?