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Early Autism Detection and Referral 1. Autism Spectrum Disorder (ASD) 2. Signs & Symptoms 3. Autism Identification 4. Referral Process 1. Autism Spectrum Disorders Basics What is Autism? Neurodevelopmental disorder with a spectrum of clinical conditions 3 areas of dysfunction: Social interaction/social relatedness difficulty Communication impairment Restrictive/repetitive behaviors and interests ASD Facts: Epidemiology Conservative prevalence: 1 in 500; recent estimates: 1 in 150 ASD more prevalent in pediatric population than: Cancer Diabetes Downs Syndrome Male to female ratio: 4 to 1 Autism Myths Myth Truth Children with autism … Make no eye contact. Look at or through you, but eye contact has no social purpose. Are not affectionate. Are affectionate on their own terms. Do not talk. Can use advanced words, but they have no function. Do not point. Usually develop the pointing skill later. Are geniuses. Can have intellectual functioning that ranges from severe mental retardation to normal intelligence. Have no hope for improvement. Can experience positive outcomes with early and intensive intervention. DSM-IV Classification: Pervasive Developmental Disorders Pervasive Developmental Disorders Autism Asperger’s Syndrome PDD – NOS (not otherwise Specified) Rett’s Syndrome Childhood Disintegrative Disorder ASD Causes: Causation unknown Strong genetic influence Evidence supports polygenic inheritance Recurrence risk is 5-8% in siblings Autism does NOT result from: Poor parenting MMR vaccine Thimerosal preservative in vaccines AAP Policy Due to recent evidence that early diagnosis and intervention are associated with better long-term outcomes, the AAP Committee on Children with Disabilities recommends that pediatricians increase their knowledge on autism Pediatrics Vol. 107 No. 5 May 2001 ASD Facts Present at birth, with onset of symptoms before 36 months Accurate diagnosis possible at 18-24 months Parents first voice concerns around 18 months, but diagnosis is typically not until 3 years or older Part 1 Summary Autism Spectrum Basics Autism is a neurodevelopmental disorder with a broad spectrum of behavioral manifestations Autism is not rare! At 1 in 500, each pediatrician should have up to 3 or 4 affected children in their practice 2. Overview of Child Social Development What are the earliest signs of Autism? Delays or abnormalities in: Joint Attention Social Interaction Play Behavior Social Symptoms Lack of: Use of eye contact to regulate social interaction Orienting to name Joint attention behaviors: pointing & showing Pretend play Imitation Nonverbal communication Language development Language Delay – Need for immediate referral 9 months: 12 months: 16 months: 24 months: Any age: No babbling No pointing or other gestures No single words No functional 2-word phrases (not echolalic) Any loss of language or social skills Behavioral Red Flags Investigate further and consider autism if the child: Doesn’t know how to play with toys in a typical fashion Restricted patterns of interest “Toe walks” Has unusual attachments Lines things up Presents with sensory symptoms Has odd movement patterns and/or very repetitive behaviors Demonstrates echolalia Throws prolonged or frequent tantrums Is hyperactive Joint Attention Interaction Reciprocal smiling Gaze monitoring Age 2 months 8 months Follows a point Showing objects Pointing to obtain an object Pointing to indicate to another an object of interest Social referencing 9 months 10 months 12 months 14 months 14 months Part 2 Summary Child Social Development Delays or abnormalities in: Social Interaction Language Delay Restricted or Repetitive Behavior 3. Autism Identification AAP Policy Developmental Screening AAP Committee on Children with Disabilities recommends routine standardized developmental and behavioral screening Pediatrics Vol. 108 No. 1 July 2001 Listen to Parents Parents: Are aware of the possibility of autism Do have concerns when something is wrong Do give accurate and reliable information about their children Need your questions to generate discussion about their child’s development Child care providers are also a good resources when addressing developmental concerns of a child Autism Assessment:18 – 36 months Autism screening tools are not recommended for primary care setting At 18-month visit use parent questioning and direct observation to assess child for: Social Using gestures: pointing waving shaking head Language Play Using 7-10 words Engaging in simple pretend Understanding 1-step command play Refer for further evaluation if concerned Developmental Screening Consider using a standardized parent report tool at every well child visit Examples include: Parental Evaluation of Developmental Status (PEDS) www.pedstest.com Ages and Stages Questionnaire (ASQ) www.pbrookes.com/store/books/bricker-asq/ Child Development Review www.childdevrev.com Autism Screening Tools CHecklist for Autism in Toddlers (CHAT) Modified CHecklist for Autism in Toddlers (M-CHAT) Quick and Quantitative CHecklist for Autism in Toddlers (Q-CHAT) Part 3 Summary Autism Identification Developmental screening is recommended The disorder can be recognized by 18-24 months when familiar with the early signs Screening for autistic spectrum disorders either formally or informally at the 18 month visit is recommended 4. Referral Process Referrals for children who show signs of autism A.L.A.R.M. Under 3 years – refer to Early Intervention 3 years or above – refer to School District For diagnostic confirmation consider: Developmental & behavioral pediatrician Child psychologist Pediatric neurologist Child psychiatrist 0 – 3: Early Intervention Different in each state Babies Can’t Wait Programs Autism Centers of Excellence University Based Developmental Disorders Check with State Office Call 1-800-323-GROW for nearest CFC Special Education Mandated by federal IDEA legislation Programs managed and vary by school district Make referrals in writing! Individualized Education Plan (IEP) for each child Services for children with autism may include: Speech therapy Occupational therapy Communication assistance (PECS) Teacher education on classroom management Treatment Options Issues to consider when choosing a treatment plan: Evidence-based Cost Time Family involvement Insurance Issues Autism assessment with observation and parental discussion falls under the general well child visit code Implement standardized developmental screening to increase reimbursement Encouraging Next Steps Acknowledge parent’s fear and grief Provide information on how to tell others Provide parent with information on the referral sources Encourage communication Set a follow-up appointment Part 4 Summary Referral Physician plays the role of gatekeeper Diagnosis requires a TEAM evaluation Early intervention makes a difference! Advances in effective treatments