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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 children 1
• 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




                             Autism Resource Toolkit
Pediatrics, November, 2007            AAP, 2007
  Identification and Evaluation of
        Children With ASDs
• Diagnostic criteria                • Surveillance and
• Epidemiology                         screening
   – Prevalence 1/150                     – Algorithm
• Etiology                           • Referral for
• Neuropathology                       evaluation and
  and neuroimaging                     services
• Clinical signs                     • Comprehensive
                                       evaluation
• Coexisting
  conditions                         • 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             • Medical Management
   – Preschool and School                    – Seizures
     Programs                                – Gastrointestinal
   – Specific Strategies                       Problems
       • Applied Behavior Analysis           – Sleep Disturbance
       • Structured Teaching                 – Challenging Behaviors
       • Developmental Models                – Psychopharmacology
       • Speech and Language
                                             – Complementary and
         Therapy
                                               Alternative Medicine
       • Social Skills Instruction
       • Occupational Therapy           • Family Support
       • Sensory Integration                 – Parents
         Therapy                             – 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         • Record-keeping tools
• Examples of screening tools                   • Emergency information forms
• Guideline summary charts                      • ASD coding tools
• Management checklists                         • Reimbursement tips
• Developmental checklists                      • Sample letters to insurance companies
• Developmental growth charts                   • ASD management fact sheets
• Web links                                     • Family education handouts
• Early intervention referral forms and tools
      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    •   Treatment decision
• Behavioral           •   Psychopharmacology
  principles           •   Seizures & Epilepsy
• CAM Treatments       •   Sleep disorders
• Dietary tx           •   Toilet training
• Eating & nutrition
• GI problems
              Toolkit Content
    Fact sheets for primary care professionals to
                 give families (PDF files)
                       Topics
•    Behavioral challenges
                                   •   Seizures & epilepsy
•    Diet
                                   •   Sibling issues
•    Early intervention
                                   •   Sleep problems
•    GI problems
                                   •   Support programs for
•    Childhood to adolescence          families
•    Guardianship                  •   Toilet training
•    Lab tests                     •   Transition to adulthood
•    Medication                    •   Vaccines
•    Nutrition & eating problems   •   Visiting the doctor
•    School based services
  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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