Webinar: Autism Identification


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  • Paul H. Lipkin, M.D.
  • Paul H. Lipkin, M.D.
  • Webinar: Autism Identification

    1. 1. Autism Spectrum Disorders: Identification & Management Georgina Peacock, MD, MPH, FAAP Susan L. Hyman, MD, FAAP Susan E. Levy, MD, FAAP
    2. 2. Objectives <ul><li>By the end of the Webinar, participants will be able to: </li></ul><ul><li>Recognize the early warning signs of autism spectrum disorders (ASD) </li></ul><ul><li>Describe the recommendations put forth in the 2 AAP Autism Clinical Reports regarding identification and management of ASDs </li></ul><ul><li>Utilize the AAP Autism Screening Algorithm in office practice </li></ul><ul><li>Identify components of the AAP Autism Toolkit which will assist you in providing a medical home to children with ASD </li></ul>
    3. 3. Pediatrics 2006; 118: 405-420
    4. 4. Developmental Surveillance & Screening Policy Statement Goals <ul><li>Increase identification of children with developmental disorders by child health professionals </li></ul><ul><ul><li>Improved surveillance and screening </li></ul></ul><ul><ul><li>Concrete guidelines (algorithm) </li></ul></ul><ul><ul><li>Eliminate barriers (e.g. reimbursement, time) </li></ul></ul><ul><li>Improve medical assessment </li></ul>
    5. 5. Definitions (AAP, 2006) <ul><li>Developmental surveillance </li></ul><ul><ul><li>“ A flexible, longitudinal , continuous , and cumulative process whereby knowledgeable health care professionals identify children who may have developmental problems” </li></ul></ul><ul><li>Developmental screening </li></ul><ul><ul><li>“ The administration of a brief standardized tool aiding the identification of children at risk of a developmental disorder” </li></ul></ul><ul><ul><li>Not diagnostic! </li></ul></ul><ul><li>Developmental evaluation </li></ul><ul><ul><li>“ Aimed at identifying the specific developmental disorder or disorders affecting the child ” </li></ul></ul>
    6. 6. <ul><li>It’s more than height and weight </li></ul><ul><li>Observing how children play, learn, speak and act </li></ul><ul><li>Different areas of development </li></ul><ul><ul><li>Social, communication, cognitive, gross motor, fine motor, adaptive </li></ul></ul><ul><li>Monitoring milestones can offer early signs of delay including signs of autism spectrum disorders </li></ul>Child Development
    7. 7. Autism Spectrum Disorders <ul><li>Problems with socialization </li></ul><ul><li>Problems with communication </li></ul><ul><li>Unusual behaviors </li></ul>
    8. 8. Parental Concerns ( Wiggins, Baio, Rice, 2006) <ul><li>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 . </li></ul>
    9. 9. Early Development <ul><li>Babies start communicating and relating to other people at birth </li></ul><ul><li>Continued social-emotional development is key to forming strong relationships and continued learning </li></ul>
    10. 10. By the end of 3 months <ul><li>Begin to develop a social smile </li></ul><ul><li>Enjoy playing with other people and may cry when playing stops </li></ul><ul><li>Become more expressive and communicate more with face and body </li></ul><ul><li>Imitate some movements and facial expressions </li></ul>
    11. 11. By the end of 7 months <ul><li>Smile back at another person </li></ul><ul><li>Respond to sound with sounds </li></ul><ul><li>Enjoy social play </li></ul><ul><li>Red Flags </li></ul><ul><li>No big smiles or other warm, joyful expressions by six months or thereafter </li></ul><ul><li>No back-and-forth sharing of sounds, smiles, or other facial expressions by nine months or thereafter </li></ul>
    12. 12. By the end of 12 months <ul><li>Use simple gestures </li></ul><ul><li>Imitate actions in their play </li></ul><ul><li>Respond when told “no” </li></ul><ul><li>Red Flags </li></ul><ul><li>No back-and-forth gestures, such as pointing, showing, reaching, or waving bye </li></ul><ul><li>Not answering to one’s name when called </li></ul><ul><li>No babbling – mama, dada, baba </li></ul>
    13. 13. Joint Attention and Social Engagement
    14. 14. By the end of 18 months <ul><li>Do simple pretend play </li></ul><ul><li>Point to interesting objects </li></ul><ul><li>Use several single words unprompted </li></ul><ul><li>Red Flags </li></ul><ul><li>No single words by 18 months </li></ul><ul><li>No simple pretend play </li></ul>
    15. 15. By the end of 2 years (24 months) <ul><li>Use 2- to 4-word phrases </li></ul><ul><li>Follow simple instructions </li></ul><ul><li>Become more interested in other children </li></ul><ul><li>Point to object or picture when named </li></ul><ul><li>Red Flags </li></ul><ul><li>No two-word meaningful phrases (without imitating or repeating) </li></ul><ul><li>Lack of interest in other children </li></ul>
    16. 16. <ul><ul><li>Red Flag: Any loss of speech or babbling or social skills </li></ul></ul><ul><ul><li>Regression at any age is cause for immediate referral </li></ul></ul>
    17. 17. Health Care Professional Resource Kit Stand with 200 Informational Cards Set of 15 Fact Sheets Small Posters (3)
    18. 18. <ul><li>www.cdc.gov/ncbddd/actearly/ </li></ul><ul><li>The findings and conclusions in this presentation have not been formally </li></ul><ul><li>disseminated by the CDC and should not be construed to </li></ul><ul><li>represent any agency determination or policy. </li></ul>Learn the Signs. Act Early.
    19. 19. 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
    20. 20. Identification and Management of Children with Autism
    21. 21. Clinical Reports on Autism: 2007 <ul><li>Clinical Reports: Guidance for the clinician in rendering pediatric care </li></ul><ul><li>Clinical Practice Guidelines: Evidence-based decision-making tools for managing common pediatric conditions </li></ul><ul><li>Technical Reports: Background information to support AAP policy </li></ul>
    22. 22. Important Roles of Primary Care Physicians/Medical Home <ul><li>Early recognition </li></ul><ul><ul><li>Knowledge of signs and symptoms </li></ul></ul><ul><ul><li>Developmental surveillance and screening </li></ul></ul><ul><li>Guiding families to diagnostic resources and intervention services </li></ul><ul><li>Conducting a medical evaluation </li></ul><ul><li>Providing ongoing health care </li></ul><ul><li>Supporting and educating families </li></ul>
    23. 23. Screening in Primary Care <ul><li>Surveillance for Social and Communication skills </li></ul><ul><li>Screen at 18 and 24 months with specific screening test </li></ul><ul><li>Reassess at well child visits and if concerns arise </li></ul><ul><ul><li>Later age at diagnosis for children with high functioning ASD </li></ul></ul>
    24. 24. ASD Screening in Primary Care: <ul><li>Children at Higher Risk : </li></ul><ul><ul><li>Siblings of children with ASD: 10 x increased risk </li></ul></ul><ul><ul><li>Premature Infants </li></ul></ul><ul><ul><li>Comorbid Genetic Syndromes: e.g. Fragile X syndrome, Tuberous Sclerosis </li></ul></ul><ul><ul><li>Prenatal Exposures e.g. Valproic acid </li></ul></ul><ul><li>Regression in Milestones : 25-30% </li></ul><ul><ul><li>15-24 months of age </li></ul></ul><ul><ul><li>Change in language, social awareness or behavior </li></ul></ul>
    25. 26. M-CHAT: Does your child... <ul><li>Like to be swung? </li></ul><ul><li>Take interest in other children ? </li></ul><ul><li>Like climbing? </li></ul><ul><li>Enjoy peek-a-boo? </li></ul><ul><li>Ever pretend to talk on the phone? </li></ul><ul><li>Ever use index finger to point to ask? To indicate interest? </li></ul><ul><li>Play properly with small toys? </li></ul><ul><li>Bring objects to show? </li></ul><ul><li>Look you in the eye? </li></ul><ul><li>Seem oversensitive to noise? </li></ul><ul><li>Smile in response to you? </li></ul><ul><li>Imitate you? </li></ul><ul><li>Respond to name? </li></ul><ul><li>If you point, does he look? </li></ul><ul><li>Walk? </li></ul><ul><li>Look at things you are? </li></ul><ul><li>Make unusual finger movements near face? </li></ul><ul><li>Act as if deaf? </li></ul><ul><li>Understand what people say? </li></ul><ul><li>Stare at nothing? </li></ul><ul><li>Look at your face to check reaction? </li></ul>Robins et al, 1999 http://www2.gsu.edu/~psydlr/Diana_L._Robins,_Ph.D._files/M-CHATInterview.pdf
    26. 27. Modified Checklist for Autism in Toddlers (MCHAT) <ul><li>Positive Predictive Value (.57) Robins, Autism. 2008 Sep;12(5):537-56. </li></ul><ul><ul><li>Proportion of children with a (+) test who have an autism spectrum disorder, Moderate </li></ul></ul><ul><ul><li>9.7% of 4797 children screened + </li></ul></ul><ul><ul><li>61/362 + after interview </li></ul></ul><ul><ul><li>4/21 cases confirmed at 4 yrs were identified by the pediatrician </li></ul></ul><ul><ul><li>17/21 cases not confirmed at 4 yrs had another developmental diagnosis </li></ul></ul><ul><li>Age range : 16-36 months </li></ul><ul><li>23 Questions : </li></ul><ul><li>-2 of critical items or any 3 items </li></ul>
    27. 28. Barriers to Screening in Office Practice <ul><li>Screening tests too long and difficult </li></ul><ul><li>Children uncooperative </li></ul><ul><li>Reimbursement limited </li></ul><ul><ul><li>96110 for Screening tests like MCHAT </li></ul></ul><ul><ul><li>25 modifier if MD interprets and E/M code billed </li></ul></ul><ul><ul><li>Have families return for counseling visit </li></ul></ul><ul><ul><li>Code for time and counseling </li></ul></ul><ul><li>Do not want to alarm parents </li></ul><ul><li>Belief that delays will improve on their own </li></ul><ul><li>Referral resources unfamiliar or unavailable </li></ul>
    28. 29. Evaluation and Intervention Services: <ul><li>Birth to 3 years: Early Intervention </li></ul><ul><li>3-5 Years: School district </li></ul><ul><li>5-21 Years: School district </li></ul><ul><li>Transition age planning and young adult service referrals </li></ul><ul><li>Assessment includes : IQ, Speech and Language, Adaptive, Motor, Social and Emotional, and Hearing </li></ul>
    29. 30. EI Referral Form
    30. 31. Diagnostic Evaluation: <ul><li>Application of DSM IV Criteria: </li></ul><ul><ul><li>History </li></ul></ul><ul><ul><li>Observational Measure </li></ul></ul><ul><li>Medical History and Physical </li></ul><ul><ul><li>Behavioral History </li></ul></ul><ul><ul><li>Family History: Genetic risk factors </li></ul></ul><ul><li>Assessment of Parental Understanding, coping skills and resources </li></ul>
    31. 32. Community Resources
    32. 33. Specific aspects of history to target in children with ASDs: <ul><li>Seizures </li></ul><ul><li>GI concerns : </li></ul><ul><ul><li>Diarrhea/constipation/bloating/pain </li></ul></ul><ul><li>Sleep problems: </li></ul><ul><ul><li>Night waking, delayed sleep onset </li></ul></ul><ul><li>Feeding behaviors : </li></ul><ul><ul><li>Aversions based on taste/texture/appearance </li></ul></ul><ul><ul><li>Monitor growth and nutrition </li></ul></ul><ul><li>Tics </li></ul><ul><ul><li>In as many as 9% of children </li></ul></ul>
    33. 34. 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
    34. 35. A Good History and Physical is the basic medical work up for ASD.
    35. 36. Key Points <ul><li>Medical home = center for ongoing management </li></ul><ul><li>Cornerstone of treatment </li></ul><ul><ul><li>Educational interventions, developmental and behavioral strategies </li></ul></ul><ul><li>Early, intensive intervention is vital </li></ul><ul><li>Pediatricians can support families by providing information and access to resources </li></ul>Myers SM, Johnson CP, and the Council on Children with Disabilities, Pediatrics 2007;120:1162-1182
    36. 37. The Autism Toolkit <ul><li>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 </li></ul>
    37. 38. Medical Management of Children with ASD Includes: <ul><li>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 </li></ul><ul><li>Medication management of symptoms of inattention, impulsivity, irritability, aggression </li></ul><ul><li>Pediatricians can help families to understand how to evaluate the evidence regarding Complementary and Alternative therapies </li></ul>
    38. 39. ASD Management <ul><li>Outcomes are variable </li></ul><ul><ul><li>Behavioral characteristics change over time </li></ul></ul><ul><ul><li>Most remain on spectrum as adults </li></ul></ul><ul><ul><ul><li>Ongoing problems with independent living, employment, social relationships and mental health </li></ul></ul></ul><ul><li>Predictors of better outcome </li></ul><ul><ul><li>Earlier age of diagnosis and treatment </li></ul></ul><ul><ul><li>No cognitive impairment </li></ul></ul><ul><ul><li>Early language and nonverbal skills </li></ul></ul><ul><ul><li>Social skills </li></ul></ul><ul><ul><li>Not – presence, degree of “autistic” symptoms </li></ul></ul>
    39. 40. Treatment <ul><li>Goals </li></ul><ul><ul><li>Minimize core features and associated deficits </li></ul></ul><ul><ul><li>Maximize functional independence and QOL </li></ul></ul><ul><ul><li>Alleviate family stress </li></ul></ul><ul><li>Educational intervention </li></ul><ul><li>Developmental Therapies </li></ul><ul><ul><li>Communication </li></ul></ul><ul><ul><li>Sensory, fine motor, gross motor </li></ul></ul><ul><li>Behaviorally Based treatments </li></ul><ul><ul><li>Core and associated symptoms </li></ul></ul><ul><ul><li>Social skills </li></ul></ul><ul><li>Medical or biologic treatments </li></ul><ul><li>Support family in home and community </li></ul>
    40. 41. Education <ul><li>Cornerstone of management </li></ul><ul><li>Curricula should include </li></ul><ul><ul><li>Academic learning </li></ul></ul><ul><ul><li>Socialization </li></ul></ul><ul><ul><li>Adaptive skills </li></ul></ul><ul><ul><li>Communication </li></ul></ul><ul><ul><li>Ameliorization of interfering behaviors </li></ul></ul><ul><ul><li>Generalization of abilities across environments </li></ul></ul><ul><li>Effective programs </li></ul><ul><ul><li>Use assessment based curricula to address these goals </li></ul></ul><ul><ul><li>Include combinations of strategies and treatment modalities </li></ul></ul><ul><ul><li>Incorporate strong components of family training and support </li></ul></ul><ul><li>Programs differ in philosophy & emphasis </li></ul>Myers & Johnson, PED 2007
    41. 42. Behavioral Intervention <ul><li>ABA (Applied Behavioral Analysis) </li></ul><ul><ul><li>General behavioral teaching approach involves reinforcement and consequences to shape behavior </li></ul></ul><ul><ul><li>All of our parents used it! </li></ul></ul><ul><li>Involves the A, B, C’s </li></ul><ul><ul><li>Not airway, breathing circulation </li></ul></ul><ul><ul><li>Antecedent Behavior Consequence </li></ul></ul><ul><li>Also known as ABA, EIBI, DTT, DTI, etc. </li></ul>
    42. 43. Evolution of ABA <ul><li>Methodology includes a data based approach to skill acquisition in a developmental format, using principles of Applied Behavioral Analysis </li></ul><ul><li>Types </li></ul><ul><ul><li>Discrete Trial Teaching or Instruction (Lovaas) </li></ul></ul><ul><ul><li>Pivotal Response Training (PRT) </li></ul></ul><ul><ul><li>Natural language approach </li></ul></ul><ul><ul><li>Applied Verbal Behavior (AVB) </li></ul></ul><ul><ul><li>DIR™ (Developmental, Individual Difference, Relationship-Based), AKA “floortime” </li></ul></ul><ul><ul><li>RDI (Relationship Development Intervention) </li></ul></ul><ul><ul><li>Others…. </li></ul></ul><ul><li>Principles can/ should be integrated into classroom curricula </li></ul>
    43. 44. Speech/Language Therapy <ul><li>Behaviorally based/ intensive structured teaching </li></ul><ul><ul><li>E.g., Verbal Behavior </li></ul></ul><ul><li>Augmentative strategies </li></ul><ul><ul><li>Sign language </li></ul></ul><ul><ul><li>PECS </li></ul></ul><ul><ul><li>Aided augmentative/ alternative system(s) </li></ul></ul><ul><li>Decrease non-communicative language </li></ul><ul><li>Developmental-pragmatic approaches </li></ul><ul><ul><li>appropriate use of language in social situations </li></ul></ul><ul><ul><li>e.g., SCERTS </li></ul></ul><ul><ul><li>Social skills training </li></ul></ul>
    44. 45. Developmental: Motor <ul><li>OT </li></ul><ul><li>Fine motor coordination </li></ul><ul><li>Adaptive skills </li></ul><ul><li>Sensory Integration </li></ul><ul><ul><li>Addresses sensory abnormalities </li></ul></ul><ul><ul><li>“ Systematic desensitization” </li></ul></ul><ul><ul><li>No evidence of corresponding neurological changes </li></ul></ul><ul><li>PT </li></ul><ul><li>Coordination difficulties </li></ul><ul><li>Natural environment </li></ul><ul><ul><li>Adaptive physical education or in the community </li></ul></ul><ul><ul><li>Hippotherapy </li></ul></ul>
    45. 46. Medical Management Comorbid Symptoms or Conditions <ul><li>High rates of co-morbidity </li></ul><ul><li>Tic disorders (9%) </li></ul><ul><li>Seizures (to 25%) </li></ul><ul><li>ADHD (30-75%) </li></ul><ul><li>Affective Disorders (25-40%) </li></ul><ul><ul><li>e.g., depression or anxiety </li></ul></ul><ul><ul><li>Higher in HFA/ Asperger’s </li></ul></ul><ul><li>GI Problems (10-60%) </li></ul><ul><li>Sleep Disturbance (50-75%) </li></ul><ul><li>Challenging Behaviors (10-35%) </li></ul>
    46. 47. Psychopharmacology <ul><li>Adjunct to educational, developmental & behavioral treatments </li></ul><ul><li>So far no evidence of impact on core symptoms </li></ul><ul><li>Evidence supporting is variable </li></ul><ul><li>Toolkit – handouts for MD & families </li></ul><ul><li>Treat target symptoms </li></ul><ul><ul><li>Stereotypies </li></ul></ul><ul><ul><li>Withdrawal </li></ul></ul><ul><ul><li>Obsessions </li></ul></ul><ul><ul><li>Irritability </li></ul></ul><ul><ul><li>Hyperactivity </li></ul></ul><ul><ul><li>attention span </li></ul></ul><ul><ul><li>self-injurious behavior </li></ul></ul><ul><ul><li>Aggression </li></ul></ul><ul><ul><li>sleep </li></ul></ul>
    47. 48. 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
    48. 49. CAM Treatments Used in Children with ASD <ul><li>Mind-body Medicine </li></ul><ul><ul><li>Yoga </li></ul></ul><ul><ul><li>Music Therapy </li></ul></ul><ul><li>Manipulative and Body-based </li></ul><ul><ul><li>Chiropractic </li></ul></ul><ul><ul><li>Massage/Therapeutic Touch </li></ul></ul><ul><ul><li>Auditory Integration </li></ul></ul><ul><li>Energy Medicine </li></ul><ul><ul><li>Transcranial & magnetic stimulation </li></ul></ul><ul><li>Biologically Based </li></ul><ul><li>Most commonly used </li></ul><ul><ul><li>~ 50% - biologically based </li></ul></ul><ul><ul><li>30% - mind body </li></ul></ul><ul><ul><li>25% - manipulation/ body based </li></ul></ul><ul><ul><li>** Most use > 1 modality </li></ul></ul>
    49. 50. Biologically Based CAM <ul><li>Supplements </li></ul><ul><ul><li>B6/Magnesium, B12 </li></ul></ul><ul><ul><li>DMG/ TMG </li></ul></ul><ul><ul><li>Vitamin A, Vitamin C </li></ul></ul><ul><ul><li>Folate </li></ul></ul><ul><ul><li>Omega 3 Fatty Acids </li></ul></ul><ul><li>Elimination Diets </li></ul><ul><ul><li>Casein/ gluten free </li></ul></ul><ul><li>Off-label medications </li></ul><ul><ul><li>Secretin </li></ul></ul><ul><li>Immune </li></ul><ul><ul><li>Antifungal therapy </li></ul></ul><ul><ul><li>Immunotherapy, steroids </li></ul></ul><ul><ul><li>Antibiotics/Antivirals </li></ul></ul><ul><ul><li>Stem cell transplantation </li></ul></ul><ul><li>Immunization-related </li></ul><ul><ul><li>With-hold immunization </li></ul></ul><ul><ul><li>Chelation </li></ul></ul><ul><li>Hyperbaric oxygen therapy (HBOT) </li></ul>Always others coming along…
    50. 51. CAM <ul><li>Commonly used, especially in CSHCN </li></ul><ul><ul><li>ASD ranges 30-90% </li></ul></ul><ul><li>Many factors associated </li></ul><ul><ul><li>fear of drug effects, desire to “cure” condition, family use of CAM for other purposes </li></ul></ul><ul><li>Evidence for efficacy for most treatments not strong </li></ul><ul><ul><li>Some biologically based treatments have been studied, with evidence based support (melatonin) or refuted (secretin) </li></ul></ul><ul><ul><li>Many with potential serious side-effects (e.g., chelation, HBOT) </li></ul></ul>
    51. 52. Gluten Free/ Casein Free Diet <ul><li>One of most commonly used CAM treatments </li></ul><ul><li>Hypothesis : </li></ul><ul><ul><li>Exogenous opiate-like peptides = false neurotransmitters </li></ul></ul><ul><ul><li>Evidence – most non-blinded; few RCT emerging, no differences </li></ul></ul><ul><li>Requires </li></ul><ul><ul><li>elimination of ALL dairy products (not “GFCF except for ice cream…”) & elimination of barley, rye, oats & wheat products </li></ul></ul><ul><li>Potential deficiencies </li></ul><ul><ul><li>Inherently deficient in calcium, vitamin D </li></ul></ul><ul><ul><li>B vits, Iodine, others may be lower in substitute products </li></ul></ul><ul><ul><li>Weight typically adequate, monitor Fe status </li></ul></ul>
    52. 53. Toolkit Content <ul><li>The fully searchable CD-ROM has an extensive library of ASD-specific information and practice tools: </li></ul>• 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
    53. 54. Toolkit Content <ul><li>Asperger syndrome </li></ul><ul><li>Behavioral principles </li></ul><ul><li>CAM Treatments </li></ul><ul><li>Dietary tx </li></ul><ul><li>Eating & nutrition </li></ul><ul><li>GI problems </li></ul><ul><li>Treatment decision </li></ul><ul><li>Psychopharmacology </li></ul><ul><li>Seizures & Epilepsy </li></ul><ul><li>Sleep disorders </li></ul><ul><li>Toilet training </li></ul>Fact sheets for primary care professionals (PDF files) Topics
    54. 55. Toolkit Content <ul><li>Behavioral challenges </li></ul><ul><li>Diet </li></ul><ul><li>Early intervention </li></ul><ul><li>GI problems </li></ul><ul><li>Childhood to adolescence </li></ul><ul><li>Guardianship </li></ul><ul><li>Lab tests </li></ul><ul><li>Medication </li></ul><ul><li>Nutrition & eating problems </li></ul><ul><li>School based services </li></ul><ul><li>Seizures & epilepsy </li></ul><ul><li>Sibling issues </li></ul><ul><li>Sleep problems </li></ul><ul><li>Support programs for families </li></ul><ul><li>Toilet training </li></ul><ul><li>Transition to adulthood </li></ul><ul><li>Vaccines </li></ul><ul><li>Visiting the doctor </li></ul>Fact sheets for primary care professionals to give families (PDF files) Topics
    55. 56. Questions?