Autism Spectrum Disorders: Making AAP

Policy and the Toolkit Work for You

Speakers

• Scott M. Myers, MD, FAAPGeisinger Medical Center, Danville, PA

• Mark Rosenberg, MD, FAAPChild 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

• 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

Leo Kanner Autistic Disturbances of Affective Contact

Nervous Child 1943;2:217-53

Autistic DisorderDSM-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

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

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

Pediatrics, November, 2007 AAP, 2007

Autism Resource Toolkit

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

• 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

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

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

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Community Resources

Questions?