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 MythTruth 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 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:No babbling 12 months:No pointing or other gestures 16 months:No single words 24 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 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

InteractionAge Reciprocal smiling2 months Gaze monitoring8 months Follows a point9 months Showing objects10 months Pointing to obtain an object12 months Pointing to indicate to another an object of interest 14 months Social referencing14 months Joint Attention

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: Refer for further evaluation if concerned SocialLanguagePlay Using gestures: pointing waving shaking head Using 7-10 words Understanding 1-step command Engaging in simple pretend play

Developmental Screening Consider using a standardized parent report tool at every well child visit Examples include: Parental Evaluation of Developmental Status (PEDS) Ages and Stages Questionnaire (ASQ) Child Development Review

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 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 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