1 Participants will: -have an understanding of the importance of early diagnosis and be able to identify early symptoms -be aware of the complexity of making a diagnosis and the need for evidence based treatment -gain an understanding of how visual supports can enhance therapy
2 Ann T. Cutler, MD, FAAP
3 Be able to identify early signs of autism spectrum disorders Be aware of AAP autism screening guidelines and the benefits and limitation of ASD screening Gain an understanding of how to present the screening process and results to parents 3
4 Neurodevelopmental disorder with a spectrum of clinical conditions with two areas of observable dysfunction DSM 5 criteria: Social communication Restricted, repetitive patterns of behavior, interests, or activities
5 Difficulties across contexts, manifested by ALL 3 of the following criteria: social-emotional reciprocity nonverbal communicative behaviors used for social interaction (i.e. gesturing) developing and maintaining relationships, appropriate to developmental level
6 manifested by at least two of the following: Stereotyped or repetitive speech, motor movements, or use of objects Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change Highly restricted, fixated interests that are abnormal in intensity or focus Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment
7 Symptoms must be present in early childhood and Symptoms together limit and impair everyday functioning
8 Prevalence of at least 1 in 88 Can be accurately diagnosed at 24 months, symptoms may be present by 12 months Average age of diagnosis is 4 years Children who are African American, live in rural areas or are children of immigrant families are diagnosed even later. Children with sensory impairments (low vision or hearing impairments) are diagnosed later.
9 Skill Reciprocal Smiling Gaze Monitoring Follows a Point Showing Objects Pointing to obtain an object Pointing to indicate to another an object of interest Social Referencing Age 2 months 8 months 9 months 10 months 12 months 14 months 14 months
10 Months Skill 4 Interest in faces, smiles back, initiates smile 6 Relates to parents with joy, smiles often when playing 9 Orients to name, moves back and forth, plays give and take 12 Uses gestures to get needs met, repeats actions, shows objects 15 Checks parent s facial expression, draws attention to objects of interest, begins to show empathy 18 Plays pretend, attracts parental attention by looks or gestures 24 Enjoys playing next to children, offers toys 36 Imagines self as character, talks for objects, plays show and tell, talks about feelings
11 Type of Play Sensorimotor- mouthing, fingering block without regard to function Functional play- using blocks as they were intended, feeding dolls Symbolic play- giving objects identities other than intended (using blocks as cars or food) Imaginative play- pretending you are building without blocks 4-12 months 12+ months 16+ months 30+ months Age
12 Myth Make no eye contact Are not affectionate Do not talk Do not point Are geniuses Have no hope for improvement Truth Look at you, but eye contact has no social purpose Are affectionate on their own terms Can use advanced words, but they have no function Usually develop pointing skill later Intellectual functioning can range from severe intellectual disability to normal intelligence Can experience positive outcomes with early, intensive intervention
13 A brief standardized assessment that helps identify children at risk of a developmental disorder. Identifies areas in which a child s development differs from his/her peers It is more effective than observing and recognizing children who may be at risk Screening tools do NOT provide a diagnosis
14 Screen to Intervene Early detection of developmental difficulties can lead to early intervention therapies or Autism specific evidence based therapies, which can lead to better prognosis Allows a platform for parents and health care providers to discuss concerns It is good practice and good business
15 o o Early Start Denver Model Children months old o o Combined 20 hours per week of ABA / relationship based treatments by therapists and 5 hours per week by parents Multiple gains, including IQ gain of 17 pts. o Dawson, et al., Pediatrics, Jan. 2010
16 Improves the social, behavioral, cognitive and language skills of a child by potentially connecting families to E-I services. Educates and empowers families Alleviated families concerns and/or uncertainty. Provides families access to appropriate information and resources
17 Surveillance and/or Best Clinical Judgment Validated Developmental Screening Tools 30% of developmental disabilities correctly identified 70-80% with developmental disabilities correctly identified (Palfrey et al. JPEDS. 1987; 111: ) (Squires et al., JDBP 1996; 17: ) 17
18 Routine screening with developmental screening tool at the 9,12,18 and 30 month visits Autism-specific screening with validated tool at 18 month visit Repeat autism screening at 24 month visit Screen at any time if a parent raises concerns
19 12 months: No babbling and 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
20 Screening tool Checklist for Autism in Toddlers (CHAT) Modified Checklist for Autism in Toddlers (M-CHAT) Autism Screening Instrument for Educational Planning (ASIEP-3) Childhood Autism Rating Scale (CARS) For Ages (Years) Who Completes Checklist 1.5 Parents and Clinicians months 1.5+ Clinician: 5 subtests 2+ Clinician Autism Behavior Checklist (ABC) 3+ Parent and Teacher Gilliam Autism Rating Scale (GARS-2) Autism Research Institute s Form E-2 Checklist Social Communication Questionnaire (SCQ) Time to complete (mins) 5 Yes Parents 5-10 Yes 3-22 Parent, Teacher, Clinician Yes 3-5 Parent Yes 4+ Parent 10 CSBS DP Infant Toddler Checklist 1 Parent 10 Yes View Free Online
21 Is a screening tool used for early detection of signs for Autism 23 item parent completed checklist Written at a 6th grade reading level Used for children 3 and under 2 step screening process
22 Social play Social interest Pretend play Joint attention: sharing of an activity with a partner Expressive and Receptive language skills Functional Play Use of pointing: either to name objects or use to direct joint attention to something Motor development Rough and tumble play Sensory
23 Directions: Please fill out the following about how your child usually is (answering yes or no). Please try to answer every question. If the behavior is rare (e.g., you ve seen it once or twice), please answer as if the child does not do it. 1.) Does your child enjoy being swung, bounced on your knee, etc.? 2.) Does your child take an interest in other children? 3.) Does your child like climbing on things, such as up stairs? 4.) Does your child enjoy playing peek-a-boo/hide-and-seek? 5.) Does your child ever pretend, for example to talk in the phone or take care of a doll or pretend other things? 6.) Does your child ever use his/her index finger to point, to ask for something? 7.) Does your child ever use his/her index finger to point, to indicate interest in something? 8.) Can your child play properly with small toys (e.g. cars or blocks) without just mouthing, fiddling, or dropping them? 9.) Does your child ever bring objects over to you (parent) to show you something?
24 10.) Does your child look you in the eye for more than a second or two? 11.) Does your child ever seem oversensitive to noise? (e.g. plugging ears?) 12.) Does you child smile in response to your face or your smile? 13.) Does your child imitate you? (e.g. you make a face-will your child imitate it?) 14.) Does your child respond to his/her name when you call? 15.) If you point at a toy across the room, does your child look at it? 16.) Does your child walk? 17.) Does your child look at things you are looking at? 18.) Does your child make unusual finger movements near his/her face? 19.) Does your child try to attract your attention to his/her own activity? 20.) Have you ever wondered if your child is deaf? 21.) Does your child understand what people say? 22.) Does your child sometimes stare at nothing or wander with no purpose? 23.) Does your child look at your face to check your reaction when faced with something unfamiliar?
25 Takes 2 minutes to score. A follow-up interview is needed for children who answer No on 2 critical items or indicate risk on 3 non-critical items Interview helps to if behaviors or delays are truly risk factors Also decreases the rate of false-positive diagnoses
26 A score of No indicates a risk for Autism 2.) Does your child take an interest in other children? 7.) Does your child ever use his/her index finger to point, to indicate interest in something? 9.) Does your child ever bring objects over to you(parent) to show you something 13.) Does your child imitate you? (e.g. you make a facewill your child imitate it?) 14.) Does your child respond to his/her name when you call? 15.) If you point at a toy across the room, does your child look at it?
27 A score of Yes indicates risk for Autism 11.) Does your child ever seem oversensitive to noise? (e.g. plugging ears? 18.) Does your child make unusual finger movements near his/her face? 20.) Have you ever wondered if your child is deaf? 22.) Does your child sometimes stare at nothing or wander with no purpose?
28 Follows a structured questionnaire If after the follow-up interview a child still indicates risk on 2 critical items or 3 noncritical items the family should be referred for an evaluation by specialist trained to evaluate ASD in children.
29 No Risk Factors One Risk Factor Two Risk Factors If 18 or 24 month old visit- administer ASD screening tool 18 months or older- Administer ASD screening tool If less than 18 months-evaluate Social and language skills Parental Education Refer for ASD eval Refer to EI/school Audiology Follow-up Johnson CJ, Myers S et al Pediatrics, 120(5), November 2007,
30 Autism screening with observation and parental discussion falls under the general well child visit code Implement standardized developmental screening and autism specific screening to increase reimbursement using the code in Illinois for approved tools
31 DO s Emphasize strengths Be positive and optimistic Validate parent concerns Use descriptive terms Provide education Recommend seeking further evaluation/develop an action plan Provide ongoing support; schedule follow-up
32 DON TS Focus on weaknesses Use diagnostic terms (e.g. Autism) Diminish parents concerns (beware of reassurance) Tell parents to wait and see if improvements are made before seeking further evaluation
33 Child and Family Connections (CFC) Assist in screening/evaluation Determine eligibility Assess needs Plan for services Identify providers Phone or fax referral to local CFC Initial evaluation is FREE! Call GROW for nearest CFC
34 Mandated by federal IDEA legislation 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 Evidence-based treatments
35 UIC Child & Family Development Center QUESTIONS?