The New Autism Guidelines Daniel L. Coury MD

Faculty Disclosure Information In the past 12 months, I have had the following financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial service(s) discussed in this CME activity: Novartis – Consultant, Speakers Bureau Lilly – Research Grant, Consultant McNeil - Consultant Shire - Research Grant It is my obligation to disclose to you that I am on the Speakers Bureau for Novartis. However, I acknowledge that today’s activity is certified for CME credit and thus cannot be promotional. I will give a balanced presentation using the best available evidence to support my conclusions and recommendations. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation

Objectives Review the new AAP Guidelines for Diagnosis and Management of Autism Spectrum Disorders and for Developmental Surveillance Review the new AAP Guidelines for Diagnosis and Management of Autism Spectrum Disorders and for Developmental Surveillance Identify new resources for physicians and families regarding ASD Identify new resources for physicians and families regarding ASD Discuss suggested management strategies Discuss suggested management strategies

In case you missed this Pediatrics 2006, 118: July 2006

Developmental Screening Algorithm

Developmental Surveillance A flexible, longitudinal, continuous, cumulative process with 5 components: Eliciting and attending to parents concerns Eliciting and attending to parents concerns Documenting and maintaining developmental history Documenting and maintaining developmental history Making accurate observations Making accurate observations Identifying risk and protective factors Identifying risk and protective factors Maintaining an accurate record and documenting process and findings Maintaining an accurate record and documenting process and findings

Developmental Screening Algorithm Refer, Don’t Defer

Developmental Screening Algorithm If either parent or professional has concerns, there is risk and screening should be done

Key Philosophy Ongoing developmental surveillance at each health supervision visit Ongoing developmental surveillance at each health supervision visit Periodic formal developmental screening at the 9, 18 and 30 month visits Periodic formal developmental screening at the 9, 18 and 30 month visits

What Developmental Screening Tool Should I use? AAP policy statement lists 20 different tools without endorsing any single one AAP policy statement lists 20 different tools without endorsing any single one Most listed take 10 to 20 minutes Most listed take 10 to 20 minutes Parent completed screens can be both time and cost effective, such as Parent completed screens can be both time and cost effective, such as Ages and Stages Questionnaire (ASQ) Child Development Inventory (CDI) Parent’s Evaluation of Developmental Status (PEDS)

What Developmental Screening Tool Should I use? Parent completed questionnaires should be done by parents at home prior to office visit; results in waiting room less reliable Parent completed questionnaires should be done by parents at home prior to office visit; results in waiting room less reliable These can be billed using CPT 96110; require statement of interpretation in visit note, but no formal report These can be billed using CPT 96110; require statement of interpretation in visit note, but no formal report

Developmental Screening can be done online PEDS – Parents Evaluation of Developmental Status PEDS – Parents Evaluation of Developmental Status If parent completes online, and child is in 18 to 59 month age group, M-CHAT online is administered immediately afterwards If parent completes online, and child is in 18 to 59 month age group, M-CHAT online is administered immediately afterwards Both produce printout of results Both produce printout of results Both can be billed for reimbursement using CPT code 96110, and are being reimbursed in Ohio Both can be billed for reimbursement using CPT code 96110, and are being reimbursed in Ohio

Developmental Screening Algorithm

Hope you didn’t miss this Pediatrics Nov;120(5):

Identification and Evaluation of Children with ASDs Provides concise background information on definition, history, epidemiology, early signs, neuropathologic aspects and etiologic possibilities Provides concise background information on definition, history, epidemiology, early signs, neuropathologic aspects and etiologic possibilities Especially useful is an algorithm for early identification of children with ASDs Especially useful is an algorithm for early identification of children with ASDs

Pediatrics Nov;120(5):

Surveillance and Screening Algorithm for ASDs Pediatrics Nov;120(5):

Surveillance and Screening Algorithm for ASDs Pediatrics Nov;120(5):

Surveillance and Screening Algorithm for ASDs Pediatrics Nov;120(5):

Surveillance and Screening Algorithm for ASDs Pediatrics Nov;120(5):

Surveillance and Screening Algorithm for ASDs Pediatrics Nov;120(5):

OK, that makes sense, but What autism screens should I use? What autism screens should I use? What am I really looking for? What am I really looking for? Are there any really worrisome findings or red flags to watch for? Are there any really worrisome findings or red flags to watch for?

Recommended ASD Screens CHAT CHAT Parent completed or interview 18 – 24+ months; 5 minutes sensitivity low, specificity high M-CHAT M-CHAT Parent completed or interview months, minutes sensitivity moderate, specificity high

M-CHAT Sample questions Does your child… take an interest in other children? take an interest in other children? enjoy playing peek-a-boo or hide and seek? enjoy playing peek-a-boo or hide and seek? ever use his index finger to indicate interest in, or ask for, something? ever use his index finger to indicate interest in, or ask for, something? look you in the eye for more than a second or two? look you in the eye for more than a second or two? look at things you are looking at? look at things you are looking at? understand what people say? understand what people say? imitate you? imitate you?

Recommended ASD Screens Pervasive Developmental Disorders Screening Test – II, Primary Care Screener Pervasive Developmental Disorders Screening Test – II, Primary Care Screener(PDDST-II-PCS) Parent completed questionnaire; Spanish available 18 – 48 months; 10 – 15 minutes sensitivity moderate to high, specificity moderate to high Purchase: PsychCorp / Harcourt Assessment

Early Identification National initiative of the CDC to promote screening for autism and developmental delays National initiative of the CDC to promote screening for autism and developmental delays ault.htm ault.htm ault.htm ault.htm

ASD Video Glossary First Signs has an online video glossary of examples of various aspects of autism spectrum disorders First Signs has an online video glossary of examples of various aspects of autism spectrum disorders ary/asdvg_about.htm ary/asdvg_about.htm ary/asdvg_about.htm ary/asdvg_about.htm Intended for parents but also very useful for professionals Intended for parents but also very useful for professionals

ASD “Red Flags” Failure to respond to name by 12 months of age Failure to respond to name by 12 months of age Arch Pediatr Adolesc Med Apr;161(4): Failure of response to joint attention at age 14 months Failure of response to joint attention at age 14 months J Autism Dev Disord Jan;37(1): J Autism Dev Disord Jan;37(1):37-48.

ASD “Red Flags” Child should follow adult point by 14 months Child should follow adult point by 14 months Child should point to request something by 12 months Child should point to request something by 12 months Child should point to comment on something by 14 months Child should point to comment on something by 14 months

Can you make the DSM-IV-TR criteria friendlier to primary care providers?

Deficits in Reciprocal Social Interaction

Caring for Children with ASD: A Resource Toolkit for Clinicians Includes the 2 ASD Clinical Reports and the developmental screening policy statement Includes the 2 ASD Clinical Reports and the developmental screening policy statement Sample screening tools Sample screening tools Medical Home sheets, ongoing management sheets, coding recommendations Medical Home sheets, ongoing management sheets, coding recommendations

Caring for Children with ASD: A Resource Toolkit for Clinicians Sample forms for communicating with early intervention programs Sample forms for communicating with early intervention programs Guidelines for choosing medications for management of problematic behaviors (sleep, disruptive, inattentive) Guidelines for choosing medications for management of problematic behaviors (sleep, disruptive, inattentive)

Thank You Questions?