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June 2007: ADEPP Objectives Heighten public awareness of early signs of autism Heighten public awareness of early signs of autism Improve access to developmental screening Improve access to developmental screening Improve coordination of medical diagnosis Improve coordination of medical diagnosis Enhance access to evidence-based services Enhance access to evidence-based services

+ Radecki et al. Pediatrics July PS# PS#74 Significance Always/almost always use ≥ 1 formal screening tool 23%47.7%.000 Uses Ages & Stages Always/almost always 7.3%22.4%.000 Uses PEDS Always/almost always 2.4%15.9%.000 Uses MCHAT Always/almost always ___10.8%.000 Clinical assessment w/out formal tool 71%60.5%.000

+ Ohio Chapter AAP Recommendations A system of continuous developmental care that includes emphasis on all aspects of surveillance at every well visit, and use of select standardized screening tools at certain visits. Approved July 24, 2009

+ Surveillance for Autism Behavior8 months12 months 18 months24 months Eye ContactXXX Turning to Name Call XX ImitationX PointingXXX Gestures-WavingXXX Pretend PlayXX Showing BehaviorsX Fail CriteriaFail 2/2 Fail 3/4 Fail 3/5 Barbaro, J. and Dissanayake, C. Prospective Identification of Autism Spectrum Disorders in Infancy and Toddlerhood Using Developmental Surveillance: The Social Attention and Communication Study. Journal of Developmental & Behavioral Pediatrics. 31(5): , June Positive Predictive Value 81%

BehaviorStrategy Eye Contact Has the child spontaneously made eye contact with you? If not interact with the child to elicit eye contact. Turning to Name Call Call the child’s name. Does he turn to look at you? Be sure not already looking at you! Imitation Get the child’s attention. Clap your hands or smack your lips in front of the child. Does he imitate you? ( Brush/comb?) Pointing Get an object. Show it to the child and say” this is…” then put it across the room where it can be seen, and say “Where is …?” Does the child point to the object and look at your face? Gestures-Waving Elicit the social routine of waving bye-bye. Does she wave back? Pretend Play Give the child a toy cup and pot, a spoon, or a phone. Ask him to pour and drink, or feed a teddy, or make a phone call. Showing Behaviors PARENT REPORT: Does the child try to communicate with the parent in a SOCIAL manner? Not just to request food or an object.

Recommended Use of Standardized Screening Tools AgeRecommended Tool 9 monthsPEDS or ASQ:3 12 monthsASQ:SE 18 monthsPEDS or ASQ:3 24 monthsM-CHAT with M-CHAT Follow-up Interview for those who fail 30 monthsPEDS or ASQ:3 Approved July 24, 2009 Ohio Chapter AAP Recommendations

Recommended Use of Standardized Screening Tools AgeRecommended Tool 36 monthsASQ:SE 48 monthsPEDS or ASQ:3 60 monthsPEDS or ASQ:3 or Pediatric Symptom Checklist Annually age 6-18 Pediatric Symptom Checklist Annually age Pediatric Symptom Checklist and/or Pediatric Symptom Checklist Youth Self Report Approved July 24, 2009 Ohio Chapter AAP Recommendations

+ At this stage, on the basis of scientific principles and the available evidence, we believe that we do not have enough sound At this stage, on the basis of scientific principles and the available evidence, we believe that we do not have enough sound evidence to support the implementation of a routine communitywide screening program for ASDs. Ongoing research is certainly needed to assess the effectiveness and acceptability of screening programs for ASDs.

+ The 7 Questions Has the Effectiveness of the Screening Program (for That Condition) Been Demonstrated in a Randomized Trial? NO Are There Efficacious Treatments for the Primary Disorder and/or Efficacious Preventive Maneuvers? Not really YES, if we look at the broad role of early intervention Does the Current Burden of Suffering Warrant Screening? YES Is a Good Screening Test Available? NO There will never be a perfect screening test We need to consider screening as part of a system of care

+ The 7 Questions Will the Screening Program Reach a High Proportion of the Persons for Whom It Was Intended? YES, if integrated into well child care Can the Health Care System Cope With the Screening Program? Maybe/Maybe Not YES Will Those With Positive Screen Results Comply With Subsequent Advice and Interventions? Nobody Knows YES

Modified Checklist for Autism in Toddlers (M-CHAT) 23 yes-no questions Measures social reciprocity, language, some motor 18 months to 4 years of age Detects ASD, language impairment, cognitive disabilities Available in over 20 languages

M-CHAT and Autism screening Failing score if 2 or more critical items or any 3 items are failed 2 page scoring guide Takes 5 minutes to complete, 1 to score Autism screen recommended by AAP Autism Expert Panel for use at 18 and 24 month well-child visit

Screening for autism in older and younger toddlers with the Modified Checklist for Autism in Toddlers Pandhy et al. Autism, 2008 Comparisons of PPP for ASD between age groups show that it is lowest for the younger/low-risk toddlers (0.28), those below the age of 24 months screened routinely at a well-child visit PPP was significantly lower than the older/low-risk toddlers (0.61). For children already identified to be at some developmental risk, PPP (0.79 for younger children and 0.74 for older children)

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M-CHAT Follow-up Interview Ask the follow up questions for the failed items Increases positive predictive value to 0.74

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+ CADLC Wave 2009

+ Take Away Messages When the doctor is worried, she is almost always right! BUT, clinical impression alone is not quite good enough. Comprehensive surveillance and periodic use of parent report screening tools appears judicious. Repeated observations are better than single. Screening tools should not be used in isolation. Change is happening!