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)
“ A flexible, longitudinal , continuous , and cumulative process whereby knowledgeable health care professionals identify children who may have developmental problems”
“ The administration of a brief standardized tool aiding the identification of children at risk of a developmental disorder”
“ 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
Autism Spectrum Disorders
Problems with socialization
Problems with communication
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 .
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
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”
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
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
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)
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
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
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 ?
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?
Respond to name?
If you point, does he look?
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
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
Application of DSM IV Criteria:
Medical History and Physical
Family History: Genetic risk factors
Assessment of Parental Understanding, coping skills and resources
Specific aspects of history to target in children with ASDs:
GI concerns :
Night waking, delayed sleep onset
Feeding behaviors :
Aversions based on taste/texture/appearance
Monitor growth and nutrition
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.
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
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
Not – presence, degree of “autistic” symptoms
Minimize core features and associated deficits
Maximize functional independence and QOL
Alleviate family stress
Sensory, fine motor, gross motor
Behaviorally Based treatments
Core and associated symptoms
Medical or biologic treatments
Support family in home and community
Cornerstone of management
Curricula should include
Ameliorization of interfering behaviors
Generalization of abilities across environments
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
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