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  1. 1. Autism Spectrum Disorders: Making AAP Policy and the Toolkit Work for You
  2. 2. Speakers <ul><li>Scott M. Myers, MD, FAAP Geisinger Medical Center, Danville, PA </li></ul><ul><li>Mark Rosenberg, MD, FAAP Child Health Associates, Chicago, IL </li></ul>The speakers have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. They do not intend to discuss an unapproved/investigative use of a commercial product/device in their presentation.
  3. 3. Objectives <ul><li>Describe the recommendations put forth in the 2 AAP Autism Clinical Reports (Nov 2007) </li></ul><ul><li>Utilize the AAP Autism Screening Algorithm in office practice </li></ul><ul><li>Identify strategies for implementing at least 2 tools from the AAP Autism Toolkit </li></ul>
  4. 4. <ul><li>Lack of typical motivation for social interaction and affective contact </li></ul><ul><li>Profound disturbances in communication </li></ul><ul><ul><li>lack of speech, echolalia, literalness, pronominal reversal </li></ul></ul><ul><li>Unusual responses to the environment, resistance to change </li></ul>Leo Kanner Autistic Disturbances of Affective Contact Nervous Child 1943;2:217-53
  5. 5. Autistic Disorder DSM-IV (APA, 1994) <ul><li>Qualitative impairment in social interaction </li></ul><ul><li>Qualitative impairment in communication </li></ul><ul><li>Restricted, repetitive and stereotyped patterns of behavior, interests, and activities </li></ul><ul><li>Delay or abnormality in social interaction, language use for social communication, or symbolic or imaginative play with onset before age 3 </li></ul>
  6. 6. Autism Spectrum Disorders <ul><li>Autistic Disorder </li></ul><ul><li>Asperger Syndrome </li></ul><ul><li>Pervasive Developmental Disorder Not Otherwise Specified (PDD NOS) </li></ul><ul><li>Behaviorally defined conditions </li></ul><ul><li>Caused by neurological dysfunction of multiple etiologies </li></ul><ul><li>Spectrum of varying severity </li></ul>
  7. 7. Epidemiology <ul><li>1 out of 6 children are diagnosed with a developmental disorder/behavioral problem </li></ul><ul><li>Current detection rates are lower than prevalence </li></ul><ul><li>Prevalence of ASDs is 1 in 150 children 1 </li></ul><ul><li>44% of PCPs report caring for at least 10 children with ASD; however, only 8% routinely screen 2 </li></ul>1 CDC. Prevalence of autism spectrum disorders – ADDM network, 14 sites, US 2002. MMWR 2007;56(1):12-28. 2 Dosreis S, Weiner CL, Johnson L, Newschaffer CJ. Autism spectrum disorder screening and management practices among general pediatric providers. J Dev Behav Pediatr . 2006;27:S88–S94
  8. 8. Important Roles of Primary Care Physicians <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>
  9. 9. AAP Clinical Reports: Guidance for the Clinician in Rendering Pediatric Care Pediatrics , November, 2007 AAP, 2007 Autism Resource Toolkit
  10. 10. Identification and Evaluation of Children With ASDs <ul><li>Diagnostic criteria </li></ul><ul><li>Epidemiology </li></ul><ul><ul><li>Prevalence 1/150 </li></ul></ul><ul><li>Etiology </li></ul><ul><li>Neuropathology and neuroimaging </li></ul><ul><li>Clinical signs </li></ul><ul><li>Coexisting conditions </li></ul><ul><li>Surveillance and screening </li></ul><ul><ul><li>Algorithm </li></ul></ul><ul><li>Referral for evaluation and services </li></ul><ul><li>Comprehensive evaluation </li></ul><ul><li>Genetic counseling </li></ul><ul><li>Prognosis </li></ul>Johnson CP, Myers SM, and the Council on Children with Disabilities, Pediatrics 2007;120:1183-1215
  11. 11. Key Points <ul><li>Conduct ASD surveillance at all preventative well child visits and whenever there is a concern </li></ul><ul><li>Screen all children at 18 and 24 months </li></ul><ul><li>Increased vigilance in younger siblings with a 10x increased risk </li></ul><ul><li>Refer for hearing evaluation and early intervention services as soon as an ASD is seriously considered rather than waiting for a definitive diagnosis </li></ul><ul><li>Early recognition  access to intervention  improved outcomes </li></ul>Johnson CP, Myers SM, and the Council on Children with Disabilities, Pediatrics 2007;120:1183-1215
  12. 12. Management of Children With ASDs <ul><li>Educational Interventions </li></ul><ul><ul><li>Preschool and School Programs </li></ul></ul><ul><ul><li>Specific Strategies </li></ul></ul><ul><ul><ul><li>Applied Behavior Analysis </li></ul></ul></ul><ul><ul><ul><li>Structured Teaching </li></ul></ul></ul><ul><ul><ul><li>Developmental Models </li></ul></ul></ul><ul><ul><ul><li>Speech and Language Therapy </li></ul></ul></ul><ul><ul><ul><li>Social Skills Instruction </li></ul></ul></ul><ul><ul><ul><li>Occupational Therapy </li></ul></ul></ul><ul><ul><ul><li>Sensory Integration Therapy </li></ul></ul></ul><ul><li>Medical Management </li></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Gastrointestinal Problems </li></ul></ul><ul><ul><li>Sleep Disturbance </li></ul></ul><ul><ul><li>Challenging Behaviors </li></ul></ul><ul><ul><li>Psychopharmacology </li></ul></ul><ul><ul><li>Complementary and Alternative Medicine </li></ul></ul><ul><li>Family Support </li></ul><ul><ul><li>Parents </li></ul></ul><ul><ul><li>Siblings </li></ul></ul>Myers SM, Johnson CP, and the Council on Children with Disabilities, Pediatrics 2007;120:1162-1182
  13. 13. Key Points <ul><li>Chronic management within a medical home is required </li></ul><ul><li>Educational interventions, including behavioral strategies and habilitative therapies, are the cornerstones of treatment </li></ul><ul><li>Early, intensive intervention is recommended </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
  14. 14. Key Points <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>Pediatricians can help families to understand how to evaluate the scientific merits of various therapies and guide them to scientifically validated treatments </li></ul>Myers SM, Johnson CP, and the Council on Children with Disabilities, Pediatrics 2007;120:1162-1182
  15. 15. Developmental Screening/ASD Policy <ul><li>Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. July 2006 </li></ul><ul><ul><li>Routine developmental surveillance at each well-child visit </li></ul></ul><ul><ul><li>Developmental screening at 9,18, and 30 months </li></ul></ul><ul><li>Identification and Evaluation of Children With Autism Spectrum Disorders. Nov 2007 </li></ul><ul><ul><li>Autism-specific screening at 18, 24 months </li></ul></ul><ul><li>Management of Children With Autism Spectrum Disorders. Nov 2007 </li></ul>
  16. 17. 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>
  17. 18. Goals <ul><li>Improve early identification of children with autism spectrum disorders in primary care so they can receive treatment services as early as possible </li></ul><ul><li>Empower pediatricians to take a strong role in the management of children with ASDs and their associated conditions in the medical home </li></ul>
  18. 19. 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
  19. 20. Toolkit Content <ul><li>Hard copies of the following resources are included: </li></ul><ul><li>CDC/ Learn the Signs. Act Early. Developmental Growth Chart </li></ul><ul><li>“ Understanding Autism Spectrum Disorders” Parent booklet </li></ul><ul><li>“ Is Your One-Year-Old Communicating With You” Parent Brochure </li></ul>
  20. 21. 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
  21. 22. 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
  22. 23. Screening for Autism Spectrum Disorder in Your Office <ul><li>Rationale for screening </li></ul><ul><li>Means to screen </li></ul><ul><li>Reimbursement </li></ul><ul><li>Resources </li></ul>
  23. 24. Screening for Autism Spectrum Disorder in Your Office <ul><li>SCREENING CONFORMS TO BRIGHT FUTURES GUIDELINES </li></ul><ul><li>SCREENING AS QUALITY IMPROVEMENT: </li></ul><ul><li>AMERICAN BOARD OF PEDIATRICS PERFORMANCE CRITERIA </li></ul>
  24. 25. Screening for Autism Spectrum Disorder in Your Office <ul><li>The need: </li></ul><ul><ul><li>Parents want to know how their child is doing </li></ul></ul><ul><ul><li>Parents want to know how they are doing </li></ul></ul><ul><li>The means: </li></ul><ul><ul><li>Given limited time use of developmental screening tools promotes efficiency </li></ul></ul>
  25. 26. Resources for Pediatricians <ul><li>AAP Clinical Reports </li></ul><ul><li>Autism Toolkit </li></ul><ul><li>Web sites: </li></ul><ul><ul><li>WWW.DBPEDS.ORG </li></ul></ul><ul><ul><li>WWW.EDOPC.ORG </li></ul></ul><ul><ul><li>WWW.MEDICALHOMEINFO.ORG </li></ul></ul>
  26. 27. REIMBURSEMENT <ul><li>DEVELOPMENTAL SCREENING TOOLS </li></ul><ul><ul><li>96110 ROUTINE SCREENING TOOL </li></ul></ul><ul><ul><ul><li>MAY USE MORE THAN ONCE PER VISIT </li></ul></ul></ul><ul><ul><li>96111 DETAILED DEVELOPMENTAL VISIT </li></ul></ul><ul><li>RISK ASSESSMENT </li></ul><ul><ul><li>99420 POST PARTUM DEPRESSION </li></ul></ul><ul><li>PROLONGED SERVICES CODES </li></ul><ul><ul><li>99354-5 ADDITION TO PREVENTIVE VISIT </li></ul></ul>
  27. 28. RESOURCES FROM TOOLKIT <ul><li>Early Intervention Referral Form </li></ul><ul><li>Emergency Care Form </li></ul><ul><li>Community Resources </li></ul>
  28. 29. EI Referral Form
  29. 30. EMS Form
  30. 31. Community Resources
  31. 32. Questions?