A series of neurodevelopmental disorders Have deficits in social impairment and verbal and nonverbal communication. Includes repetitive behaviors, restricted interests and rigidity. Lack basic skills in social relationships, play and communication.
Telemedicine In Schools For Children With Developmental Disabilities Felissa P. Goldstein, M.D.Board Certified Adult, Child and Adolescent PsychiatristGeorgia Partnership for Telehealth Annual Conference
Objectives Describe telemedicine for children with developmental disorders Discuss how telemedicine may be used for children with developmental disabilities in the school setting. Highlight the benefits and challenges of using telepsychiatry in school based clinics.2
Why Design a Telemedicine Program for Children on the Autism Spectrum? “I think autism is a good illness in some respects to use telemedicine for. The kids actually interact well with technology and more naturally than they do if you’re in the room. They’re not good with social relationships and they may find it easier to find someone talking to them from a television than they do face-to-face, which might make them more anxious.” Peter Yellowlees at UC Davis, in Terry 20093
Marcus Autism Center Not-for-Profit NIH Autism Center of Excellence Dedicated to diagnosis and treatment of autism and related disorders Serves approximately 5,000 children a year Multispecialty center for children and their families across Georgia and the southeast Part of Children’s Healthcare of Atlanta4
Why Design a Telemedicine Program for Children on the Autism Spectrum? Improved patient outcomes • Decreased time to first appointment • Earlier identification and treatment of autism spectrum disorders • Increased access to specialized programs for children with developmental disabilities Education and Support • Community doctors • Schools and families throughout the state Note: These benefits are critical for children with autism spectrum disorders. Telemedicine provides many other benefits.5
How is Telemedicine Currently Used ? A. Videoconferencing Patients receive psychotherapy and pharmacotherapy via telemedicine Native American children with Autism Spectrum disorders living in rural areas received psychiatric and psychological assessments by telemedicine (Savin, 2005)6
How is Telemedicine Currently Used ? B. Data Collection Behavioral Imaging software allows the parents to press a button and record the child’s behaviors. Dr. Christopher Smith (2012) had families capture video during family mealtime, playtime, and problem times. Video was sent to an expert for review and comparison to DSM criteria to make diagnoses.7
How is Telemedicine Currently Used ? C. Behavioral Therapy Numerous studies report the effectiveness of behavioral analysts guiding teachers in conducting functional behavioral and preference assessments, implementing treatment protocols and collecting data (Barretto, 2006; Machalicek, 2009 and in press) University behavioral consultants trained teachers to implement functional communication training (Gibson, 2010)8
How is Telemedicine Currently Used ? D. Education Educational consultants and university researchers used teleconferencing equipment to collaborate with teachers to develop and implement an IEP (Rule, 2006) Using in person instruction and telemedicine, university researchers taught parents and early intervention specialists how to use the Early Start Denver Model to treat children with developmental disabilities. The differing instruction methods were equally effective (Vismara, 2009)9
How is Telemedicine Currently Used? E. Autism Spectrum Disorders Diagnosis Dr Matthew Reese and his group at the University of Kansas (2012) used a modified and nonstandardized Autism Diagnostic Observation Schedule via telemedicine and compared its effectiveness with in person administration. It was equally effective except for pointing. A comparison of in person vs. telemedicine usage of the Autism Diagnostic Interview showed equal reliability except for sensory (Reese, 2012).10
How is Telemedicine Currently Used? F. Diagnostic Limitations Pub med searches using the search terms: autism, autism spectrum disorders, telemedicine, telehealth, and telepractice showed no literature on comprehensive telemedicine evaluations to diagnose autism11
How is Telemedicine Currently Used? F. Diagnostic Limitations After Marcus Autism Center convened a meeting of autism and telemedicine experts it was determined that telemedicine be used for screening and triage purposes and not for diagnoses at this time. Differing opinions on autism evaluation requirements, difficulty conducting some tests by telemedicine, and the absence of a telemedicine evaluation comparable to the “gold standard” in person assessment led to this determination.12
How is Telemedicine Provided for Children on the Autism Spectrum? The need is there How do we provide it? Here is one example – Collaboration between Children’s Healthcare of Atlanta Georgia Partnership for Telehealth Marcus Autism Center13
Diagnoses Commonly Treated via Telemedicine at Marcus Autism Center Autism spectrum disorders Developmental disorders Down syndrome, Fragile X and other genetic disorders Fetal alcohol syndrome Psychiatric disorders Self injurious behaviors Sleep disorders (nonrespiratory)14
Benefits Children are already at school School provides feedback on student performance Collaborative treatment model Less travel Less expense Access to specialist Less missed work and school hours Easier for certain patients to engage Video and audio technology rapidly improving15 Provide patient care across state
Drawbacks Parents do not always show Appointments based on school operating hours Stimulant prescriptions must be mailed and take longer for patients to receive Equipment and scheduling problems Reimbursement varies Increased paperwork Sharing bad news is hard More difficult to establish rapport Hard to schedule emergency appointments Lack of providers causes delay to first appointment16 Lack of other specialists
How is the Marcus Clinic Doing? Year Number of Appointments 2009 76 2010 348 2011 511 2012 524 Total 1459 (at approx. 34 sites)17
Summary Pediatric telemedicine may be used for psychotherapy, pharmacotherapy, data collection, IEP development, and screening for autism spectrum disorder diagnosis. Telemedicine provides training, education and support for families, schools and physicians. Telemedicine improves patients’ access to specialty care. The Marcus Autism Center collaborates with several agencies to provide patient care through rural Georgia.18
Questions??? Felissa Goldstein, M.D. The Marcus Autism Center 1920 Briarcliff Road Atlanta, GA 30329 (404) 785-9405 Felissa.Goldstein@choa.org19
References Autism Spectrum Disorders. National Institute of Mental Health., 41 pages with Jan. 2007 Addendum. http://www.nimh.nih.gov/health/publications/autism/complete- publication.shtml. Boisvert, Mary., Lang, Robert, Andrianopoulos, Mary -& Boscardin, Mary Lynn. Telepractice in the assessment and treatment of individuals with autism spectrum disorders: A systematic review. Developmental Neurorehabilitation, December 2010; 13(6): 423–432. Barretto, A, Wacker, DP, Harding, J., Lee, J., Berg, W. Using telemedicine to conduct behavioral assessments. Journal of Applied Behavioral Analysis, 39:333-340, 2006. Cheng, Keith and Myers, Kathleen. Child and Adolescent Psychiatry The Essentials. Lippincott, Williams and Wilkins, 2005. Facts for Families –American Academy of Child and Adolescent Psychiatry Filipek, Pauline, Steinberg-Epstein, Robin, and Book, Teri. Interventions for Autistic Spectrum Disorders. NeuroRX, 3:207-216, 2006. Hollander, Eric and Evdokia Anagnostou. Clinical Manual for the Treatment of Autism. American Psychiatric Publishing Inc., 2007.20
References http://www.cdc.gov/ncbddd/autism/data.html http://www.dana-farber.org/can/dictionary http://www.dsmivtr.org/index.cfm http://www.hrsa.gov/ruralhealth/about/telehealth/glossary.html http://www.merck.com/mmhe/sec23/ch285/ch285a.html King, Bryan and Bostic, Jeff. An Update on Pharmacologic Treatments for Autistic Spectrum Disorders. Child and Adolescent Psychiatric Clinics of North America. 15(1) 161-175, 2006. Johnson, Chris Plauche and Scott M. Myers. The Identification and Evaluation of Children with Autism Spectrum Disorders. Pediatrics. 120 (5) .1183-1215, 2007 Machalicek, W, O’Reilly, M, Chan, J., Lang R, Rispoli, M, Davis, T, Shogren, K, Sigafoos, J, Lancioni, G. Antonucci, M, Langthrne, P, Andrews, A, Dkidden, R. Using videoconferencing to conduct functional analysis of challenging behavior and develop classroom behavioral support plans for students with autism. Education and Training in Developmental Disabilities, 44 207-217, 2009 Machalicek, W, O’Reilly, M, Chan, J, Rispoli, M, Lang R Davis, T, Shogren, K, Sorrells, A, Lancioni, G, Sigafoos, J, Green, V, Langthrne, P, Using videoconferencing to support teachers to conduct performance assessments with students with autism and developmental disabilities.21 Research in Autism Spectrum Disorders 3:32-41, 2009.
References Machalicek, W, O’ Reilly MF, Rispoli M, Davis, T, Lang, R, Hetlinger-Franco J, Chan, J. Training teachers to assess the challenging behaviors of students with autism using video tele-conferencing. Education and Training in Developmental Disabilities, in press. Myers, Scott, and Johnson, Chris Plauche. The Management of Children with Autism Spectrum Disorders. Pediatrics, 120 (5)1162-1182, 2007. Prevalence of Autism Spectrum Disorders --- Autism and Developmental Disabilities Monitoring Network, United States, 2006, MMWR, 12/18/2009, 58(SS10);1-20. Reese, Matthew University of Kansas Autism Telemedicine Project, Thoughtleader Summit, 2012. Rule, S, Salzberg, C, Higher, T, Menlove, R, Smith, J. Technology-mediated consultation to assist rural students : a case study. Rural Special Education Quarterly, 25: 3-7, 2006. Savin, D, Garry, MT, Zuccaro, P, and Novins D. Telepsychiatry for treating rural American Indian youth. Journal of the American Academy of Child and Adolescent Psychiatry, 45:484-488, 2005. Smith, Christopher Naturalistic Observation Diagnostic Assessment. Thoughtleader Summit, 2012 Terry, Mark, Telemedicine and Autism: Researchers and clinicians are just starting to consider Telemedicine Applications for the Diagnosis and Treatment of Autism, Telemedicine and e-Health, 416-419, 2009. Vismara, LA, Young, GS, Stahmer, AC, Griffith, EM, Rogers, SJ, Dissemination of22 evidence-based practice: Can we train therapists from a distance? Journal of Autism and Developmental Disorders, 39: 1636-1651, 2009.