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

Thanks for flagging this SlideShare!

Oops! An error has occurred.

Webinar: Autism Identification

  • 32,105 views
Published

 

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
32,105
On SlideShare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
17
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide
  • Paul H. Lipkin, M.D.
  • Paul H. Lipkin, M.D.

Transcript

  • 1. Autism Spectrum Disorders: Identification & Management Georgina Peacock, MD, MPH, FAAP Susan L. Hyman, MD, FAAP Susan E. Levy, MD, FAAP
  • 2. 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
  • 3. Pediatrics 2006; 118: 405-420
  • 4. 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
  • 5. 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 ”
  • 6.
    • 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
  • 7. Autism Spectrum Disorders
    • Problems with socialization
    • Problems with communication
    • Unusual behaviors
  • 8. 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 .
  • 9. 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
  • 10. 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
  • 11. 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
  • 12. 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
  • 13. Joint Attention and Social Engagement
  • 14. 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
  • 15. 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
  • 16.
      • Red Flag: Any loss of speech or babbling or social skills
      • Regression at any age is cause for immediate referral
  • 17. Health Care Professional Resource Kit Stand with 200 Informational Cards Set of 15 Fact Sheets Small Posters (3)
  • 18.
    • 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.
  • 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. Identification and Management of Children with Autism
  • 21. 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
  • 22. 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
  • 23. 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
  • 24. 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
  • 25.  
  • 26. 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
  • 27. 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
  • 28. 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
  • 29. 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
  • 30. EI Referral Form
  • 31. 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
  • 32. Community Resources
  • 33. 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
  • 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
  • 35. A Good History and Physical is the basic medical work up for ASD.
  • 36. 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
  • 37. 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
  • 38. 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
  • 39. 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
  • 40. 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
  • 41. 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
  • 42. 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.
  • 43. 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
  • 44. 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
  • 45. 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
  • 46. 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%)
  • 47. 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
  • 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
  • 49. 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
  • 50. 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…
  • 51. 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)
  • 52. 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
  • 53. 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
  • 54. 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
  • 55. 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
  • 56. Questions?