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Autism Spectrum Disorders: Making AAP Policy and the Toolkit Work

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Autism Spectrum Disorders:
Making AAP Policy and the
Toolkit Work for You
Speakers
• Scott M. Myers, MD, FAAP
Geisinger Medical Center, Danville, PA
• Mark Rosenberg, MD, FAAP
Child Health Associates, Chicago, IL
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.
Objectives
• Describe the recommendations put
forth in the 2 AAP Autism Clinical
Reports (Nov 2007)
• Utilize the AAP Autism Screening
Algorithm in office practice
• Identify strategies for implementing at
least 2 tools from the AAP Autism
Toolkit
Leo Kanner
Autistic Disturbances of Affective Contact
Nervous Child 1943;2:217-53
• Lack of typical motivation for social
interaction and affective contact
• Profound disturbances in communication
– lack of speech, echolalia, literalness,
pronominal reversal
• Unusual responses to the environment,
resistance to change
Autistic Disorder
DSM-IV (APA, 1994)
• Qualitative impairment in social interaction
• Qualitative impairment in communication
• Restricted, repetitive and stereotyped
patterns of behavior, interests, and activities
• Delay or abnormality in social interaction,
language use for social communication, or
symbolic or imaginative play with onset
before age 3
Autism Spectrum Disorders
• Autistic Disorder
• Asperger Syndrome
• Pervasive Developmental Disorder Not
Otherwise Specified (PDD NOS)
• Behaviorally defined conditions
• Caused by neurological dysfunction of
multiple etiologies
• Spectrum of varying severity
Epidemiology
• 1 out of 6 children are diagnosed with a
developmental disorder/behavioral problem
• Current detection rates are lower than
prevalence
• Prevalence of ASDs is 1 in 150 children1
• 44% of PCPs report caring for at least 10
children with ASD; however, only 8%
routinely screen2
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
1
Important Roles of Primary
Care Physicians
• 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
AAP Clinical Reports:
Guidance for the Clinician in Rendering Pediatric Care
Autism Resource Toolkit
Pediatrics, November, 2007
AAP, 2007
Identification and Evaluation of
Children With ASDs
• Diagnostic criteria
• Epidemiology
– Prevalence 1/150
• Etiology
• Neuropathology
and neuroimaging
• Clinical signs
• Coexisting
conditions
• Surveillance and
screening
– Algorithm
• Referral for
evaluation and
services
• Comprehensive
evaluation
• Genetic counseling
• Prognosis
Johnson CP, Myers SM, and the Council on Children with Disabilities,
Pediatrics 2007;120:1183-1215
Key Points
• Conduct ASD surveillance at all preventative
well child visits and whenever there is a concern
• Screen all children at 18 and 24 months
• Increased vigilance in younger siblings with a
10x increased risk
• Refer for hearing evaluation and early
intervention services as soon as an ASD is
seriously considered rather than waiting for a
definitive diagnosis
• Early recognition  access to intervention 
improved outcomes
Johnson CP, Myers SM, and the Council on Children with Disabilities,
Pediatrics 2007;120:1183-1215
Management of Children With
ASDs
• Educational Interventions
– Preschool and School
Programs
– Specific Strategies
•
•
•
•
Applied Behavior Analysis
Structured Teaching
Developmental Models
Speech and Language
Therapy
• Social Skills Instruction
• Occupational Therapy
• Sensory Integration
Therapy
• Medical Management
– Seizures
– Gastrointestinal
Problems
– Sleep Disturbance
– Challenging Behaviors
– Psychopharmacology
– Complementary and
Alternative Medicine
• Family Support
– Parents
– Siblings
Myers SM, Johnson CP, and the Council on Children with Disabilities,
Pediatrics 2007;120:1162-1182
Key Points
• Chronic management within a medical home
is required
• Educational interventions, including
behavioral strategies and habilitative
therapies, are the cornerstones of treatment
• Early, intensive intervention is recommended
• 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
Key Points
• 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
• Pediatricians can help families to
understand how to evaluate the scientific
merits of various therapies and guide them
to scientifically validated treatments
Myers SM, Johnson CP, and the Council on Children with Disabilities,
Pediatrics 2007;120:1162-1182
Developmental Screening/ASD
Policy
• Identifying Infants and Young Children with
Developmental Disorders in the Medical Home:
An Algorithm for Developmental Surveillance and
Screening. July 2006
– Routine developmental surveillance at each well-child
visit
– Developmental screening at 9,18, and 30 months
• Identification and Evaluation of Children With
Autism Spectrum Disorders. Nov 2007
– Autism-specific screening at 18, 24 months
• Management of Children With Autism Spectrum
Disorders. Nov 2007
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
Goals
• Improve early identification of children with
autism spectrum disorders in primary care
so they can receive treatment services as
early as possible
• Empower pediatricians to take a strong role
in the management of children with ASDs
and their associated conditions in the
medical home
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
Toolkit Content
Hard copies of the following resources
are included:
• CDC/Learn the Signs. Act Early.
Developmental Growth Chart
• “Understanding Autism Spectrum
Disorders” Parent booklet
• “Is Your One-Year-Old
Communicating With You” Parent
Brochure
Toolkit Content
Fact sheets for primary care professionals
(PDF files)
Topics
• Asperger syndrome
• Behavioral
principles
• CAM Treatments
• Dietary tx
• Eating & nutrition
• GI problems
•
•
•
•
•
Treatment decision
Psychopharmacology
Seizures & Epilepsy
Sleep disorders
Toilet training
Toolkit Content
Fact sheets for primary care professionals to
give families (PDF files)
Topics
•
•
•
•
•
•
•
•
•
•
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
Screening for Autism
Spectrum Disorder in Your
Office
•
•
•
•
Rationale for screening
Means to screen
Reimbursement
Resources
Screening for Autism Spectrum
Disorder in Your Office
• SCREENING CONFORMS TO BRIGHT
FUTURES GUIDELINES
• SCREENING AS QUALITY IMPROVEMENT:
AMERICAN BOARD OF PEDIATRICS
PERFORMANCE CRITERIA
Screening for Autism Spectrum
Disorder in Your Office
• The need:
– Parents want to know how their child is
doing
– Parents want to know how they are
doing
• The means:
– Given limited time use of
developmental screening tools
promotes efficiency
Resources for Pediatricians
• AAP Clinical Reports
• Autism Toolkit
• Web sites:
– WWW.DBPEDS.ORG
– WWW.EDOPC.ORG
– WWW.MEDICALHOMEINFO.ORG
REIMBURSEMENT
• DEVELOPMENTAL SCREENING
TOOLS
– 96110 ROUTINE SCREENING TOOL
• MAY USE MORE THAN ONCE PER VISIT
– 96111 DETAILED DEVELOPMENTAL VISIT
• RISK ASSESSMENT
– 99420 POST PARTUM DEPRESSION
• PROLONGED SERVICES CODES
– 99354-5 ADDITION TO PREVENTIVE VISIT
RESOURCES FROM
TOOLKIT
• Early Intervention Referral Form
• Emergency Care Form
• Community Resources
EI Referral Form
EMS Form
Community Resources
Questions?
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