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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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