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 conditions3 areas of dysfunction:

Social interaction/social relatedness difficultyCommunication impairmentRestrictive/repetitive behaviors and interests

ASD Facts: Epidemiology

Conservative prevalence: 1 in 500; recent estimates: 1 in 150 ASD more prevalent in pediatric population than:

CancerDiabetesDowns Syndrome

Male to female ratio: 4 to 1

Autism MythsMyth 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

AutismAsperger’s Syndrome

PDD – NOS(not otherwise

Specified)

Rett’sSyndrome

ChildhoodDisintegrative

Disorder

ASD Causes:

Causation unknownStrong genetic influenceEvidence supports polygenic inheritanceRecurrence risk is 5-8% in siblings

Autism does NOT result from:

Poor parentingMMR vaccineThimerosal 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 monthsAccurate diagnosis possible at 18-24 monthsParents first voice concerns around 18 months, but diagnosis is typically not until 3 years or older

Part 1 SummaryAutism Spectrum Basics

Autism is a neurodevelopmental disorder with a broad spectrum of behavioral manifestationsAutism 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 AttentionSocial InteractionPlay Behavior

Social Symptoms

Lack of:Use of eye contact to regulate social interactionOrienting to nameJoint attention behaviors: pointing & showingPretend playImitationNonverbal communicationLanguage development

Language Delay – Need for immediate referral

9 months: No babbling

12 months: No pointing or other gestures16 months: No single words24 months: No functional 2-word phrases

(not echolalic) Any age: 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 fashionRestricted patterns of interest“Toe walks”Has unusual attachmentsLines things upPresents with sensory symptomsHas odd movement patterns and/or very repetitive behaviorsDemonstrates echolaliaThrows prolonged or frequent tantrumsIs hyperactive

Interaction Age

Reciprocal smiling 2 months

Gaze monitoring 8 months

Follows a point 9 months

Showing objects 10 months

Pointing to obtain an object 12 months

Pointing to indicate to another an object of interest

14 months

Social referencing 14 months

Joint Attention

Part 2 SummaryChild Social DevelopmentDelays or abnormalities in:

Social InteractionLanguage DelayRestricted or Repetitive Behavior

3. Autism Identification

AAP PolicyDevelopmental ScreeningAAP Committee on Children with Disabilities recommends routine standardized developmental and behavioral screening

Pediatrics Vol. 108 No. 1 July 2001

Listen to ParentsParents:

Are aware of the possibility of autismDo have concerns when something is wrongDo give accurate and reliable information about their childrenNeed 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 monthsAutism screening tools are not recommended for primary care settingAt 18-month visit use parent questioning and direct observation to assess child for:

Refer for further evaluation if concerned

Social Language Play

Using gestures: pointing waving shaking head

Using 7-10 wordsUnderstanding1-step command

Engaging in simple pretend play

Developmental ScreeningConsider using a standardized parent report tool at every well child visitExamples include:

Parental Evaluation of Developmental Status (PEDS) www.pedstest.com

Ages and Stages Questionnaire (ASQ)www.pbrookes.com/store/books/bricker-asq/

Child Development Reviewwww.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 SummaryAutism Identification

Developmental screening is recommendedThe disorder can be recognized by 18-24 months when familiar with the early signsScreening 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 Intervention3 years or above – refer to School DistrictFor diagnostic confirmation consider:

Developmental & behavioral pediatricianChild psychologistPediatric neurologistChild psychiatrist

0 – 3: Early Intervention

Different in each stateBabies Can’t Wait ProgramsAutism Centers of ExcellenceUniversity Based Developmental DisordersCheck with State Office

Call 1-800-323-GROW for nearest CFC

Special Education

Mandated by federal IDEA legislationPrograms managed and vary by school districtMake referrals in writing!Individualized Education Plan (IEP) for each childServices for children with autism may include:

Speech therapyOccupational therapyCommunication assistance (PECS)Teacher education on classroom management

Treatment Options

Issues to consider when choosing a treatment plan:

Evidence-basedCostTimeFamily involvement

Insurance Issues

Autism assessment with observation and parental discussion falls under the general well child visit codeImplement standardized developmental screening to increase reimbursement

Encouraging Next Steps

Acknowledge parent’s fear and griefProvide information on how to tell othersProvide parent with information on the referral sourcesEncourage communicationSet a follow-up appointment

Part 4 SummaryReferral

Physician plays the role of gatekeeperDiagnosis requires a TEAM evaluationEarly intervention makes a difference!Advances in effective treatments