CLINICAL PRACTICE GUIDELINE FOR THE ASSESSMENT AND TREATMENT OF CHILDREN WITH AUTISM SPECTRUM DISORDERS. Full version

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1 CLINICAL PRACTICE GUIDELINE FOR THE ASSESSMENT AND TREATMENT OF CHILDREN WITH AUTISM SPECTRUM DISORDERS Full version These guidelines are adapted from recommendations from the American Academy of Pediatrics Clinical Practice Guidelines for ASD. Approved, Quality Improvement Committee 7/14/09, 3/8/11, 3/12/13, 1/13/15

2 Diagnosis of Autism Spectrum Disorders At well baby/child visit or visit for ASD related concerns, PCP conducts surveillance screening and assessment for risk factors: - Sibling with ASD - Parental concerns - Other caregiver concerns - Pediatrician concerns Possible Diagnosis Is further assessment warranted? Undecided Psychologist assesses for differential and comorbid diagnoses Refer to network psychologist or pediatric psychiatrist to assess for ASD Assessment by psychologist ASD is ruled out as a problem for this child Assessment is unclear; reschedule for further testing in six months.. No Continue routine pediatric care Continue monitoring and re-assess in six months ASD diagnosis confirmed by psychologist and/or affirmed by ped psychiatrist Psychologist conducts additional psych testing to aid with the development of the treatment plan Are the behaviors better explained by a different diagnosis? Possibly Test for other behavioral health conditions No No additional BH conditions present Send back to PCP for additional medical testing Psychologist sends assessment report with recommendations to PCP for review and signature Other conditions present Psychologist develops recommendations and sends assessment QIC 1/2015

3 NOTE: At the present time there is no single treatment for Autism Spectrum Disorders (ASD). STEP #1: The American Academy of Pediatrics recommends that children receive developmental screenings during well baby/well child visits at 9, 18, and 30 months and specific routine screening for ASDs at 18 and 24 months. Surveillance Screening: Is there a sibling with a diagnosis of ASD? Are the parents mentioning any concerns about their child s development? Are teachers or family/friends mentioning any concerns about the child s development to the parents? Evaluate family history for developmental delays and learning disorders. Evaluate the child s developmental history. Are there delays in emotional connection and eye contact; communication, using gestures, or making sounds, forming word/sentences or responding to simple directives? Evaluation of the child should include vision and hearing tests, checking for seizures, sleep disorder issues, food allergies or sensitivities and previous head trauma. Lead screening should be performed in any child with a developmental delay or pica. Routine Screening for ASD (ages 18- and 24- months): The Checklist for Autism in Toddlers (CHAT) Autism Screening Questionnaire STEP #2: When a member three years of age or older has been in treatment with a clinician not participating in the CHP network, the member will begin using network clinicians. The member s parents sign a release of information form allowing psychological reports to be submitted for review. If the assessment is found to be incomplete, a network psychologist will perform necessary psychological testing, determine the child s current level of functioning and develop appropriate recommendations, submitting them to the member s PCP for review and approval. 2

4 STEP #3: When the initial surveillance and screen for ASD warrants further assessment from a trained CHP Network psychologist, the assessment occurs in two phases and a diagnosis of ASD is made when the DSM-IV-TR Clinical Criteria have been met. 1. Initial assessment to confirm or rule out the diagnosis of ASD. CHP Network psychologists recommend using the following assessment instruments: a) Autism Diagnostic Observation Schedule (ADOS) b) Two subtests administration of the Wechsler Abbreviated Scale of Intelligence (Not a Covered Benefit) c) NEPSY-2 subtests Affect Recognition and Theory of Mind d) For children age 9 and older the appropriate Millon Clinical scales e) Screen for Child Anxiety Related Emotional Disorders Revised f) Rorschach g) Childhood Autism Rating Scale h) Gilliam Autism Disorder scale i) Gilliam Asperger Syndrome Diagnostic scale j) Asperger Syndrome Diagnostic scale k) Social Communication Questionnaire Lifetime version l) Gordon Diagnostic System m) Child Behavior Checklist n) Connors Parent Rating scale 2. When a diagnosis of ASD is ruled out, the psychologist will assess for other conditions which might explain the parents observations and concerns about their child s development. 3. When the results of the assessment are inconclusive, the psychologist will schedule the child for retesting in six months. 4. When the diagnosis of ASD is confirmed, the psychologist will make further assessments to identify co-morbid conditions and to assist in the development of a treatment plan which would include all medically necessary forms of treatment. CHP Network psychologists recommend using the following assessment instruments to aide in the development of the Treatment Plan: a) Complete administration of the NEPSY-2 b) Wechsler Intelligence Scale for Children-fourth edition (Not a covered benefit) c) Achievement tests such as the Bracken Basic Concepts scale 4 or the Woodcock Johnson d) BRIEF e) Test of Pragmatic Language f) Pervasive Developmental Disorder Behavior Inventory g) Peabody Picture Vocabulary Test IV h) Expressive One-Word Vocabulary Test IV i) American Association of Mental Deficiency Adoptive Behavior Scale-School edition 2 STEP #4: The diagnosis of ASD is made by a trained psychologist within the CHP Network and meets the following DSM Criteria (and is reported using appropriate ICD 9 diagnostic codes) Autistic Disorder (ICD-10: F84.0) A. A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3). 3

5 1. Qualitative impairment in social interactions, as manifested by at least two of the following: a) Marked impairment in the use of multiple nonverbal behaviors such as eye-toeye gaze, facial expression, body postures, and gestures to regulate social interactions. b) Failure to develop peer relationships appropriate to developmental level. c) A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest). d) Lack of social or emotional reciprocity. 2. Qualitative impairments in communication as manifested by at least one of the following: a) Delay in or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime). b) In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others. c) Stereotyped and repetitive use of language or idiosyncratic language. d) Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level. 3. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: a) Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus. b) Apparently inflexible adherence to specific, nonfunctional routines or rituals. c) Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole body movements). d) Persistent preoccupation with parts of objects. B. Delays or abnormal functioning in at least one of the following areas, with an onset prior to age 3 years: 1) Social interactions 2) Language as used in social communication, or 3) Symbolic or imaginative play C. The disturbance is not better accounted for by Rett s Disorder or Childhood Disintegrative Disorder Asperger s Disorder (ICD-10: F84.5) A. Qualitative impairment in social interactions, as manifested by at least two of the following. 1) Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interactions. 2) Failure to develop peer relationships appropriate to developmental level. 3) A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest). 4) Lack of social or emotional reciprocity. B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: 4

6 1) Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus. 2) Apparently inflexible adherence to specific, nonfunctional routines or rituals. 3) Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole body movements). 4) Persistent preoccupation with parts of objects. C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning. D. The is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years). E. There is no clinically significant delay in cognitive development or in the development of ageappropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood. F. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia Pervasive Developmental Disorder Not Otherwise Specified (ICD-10: F83.8) (Including Atypical Autism ICD-10: F84.1) This category should be used when there is a severe and pervasive impairment in the development of reciprocal social interaction associated with impairment in either verbal or nonverbal communication skills or with the presence of stereotyped behavior, interests, and activities, but the criteria are not met for a specific Pervasive Developmental Disorder, Schizophrenia, Schizotypical Personality Disorder, or Avoidant Personality Disorder. For example, this category includes atypical autism presentations that do not meet the criteria for Autistic Disorder because of late age onset, atypical symptomatology, or sub-threshold symptomatology, or all of these Childhood Disintegrative Disorder (ICD-0: F84.3) A. Apparently normal development for at least the first 2 years after birth as manifested by the presence of age-appropriate verbal and nonverbal communication, social relationships, play and adaptive behavior B. Clinically significant loss of previously acquired skills (before age 10 years) in at least two of the following areas: 1) Expressive or receptive language 2) Social skills or adaptive behavior 3) Bowel or bladder control 4) Play 5) Motor skills C. Abnormalities of functioning in at least two of the following areas: 1) Qualitative impairment in social interaction (e.g., impairment in nonverbal behaviors, failure to develop peer relationships, lack of social or emotional reciprocity) 2) Qualitative impairments in communication (e.g., delay or lack of spoken language, inability to initiate or sustain a conversation, stereotyped and repetitive use of language, lack of varied make-believe play) 3) Restricted, repetitive and stereotyped patterns of behavior, interests, and activities, including motor stereotypes and mannerisms 5

7 D. The disturbance is not better accounted for by another specific Pervasive Developmental Disorder or Schizophrenia STEP #5: Upon completion of the assessment process, the psychologist will develop treatment recommendations based on the presence of an ASD diagnosis and information obtained through the assessment. The treatment recommendations will address communication, social interactions, and family function. Testing results are sent to the parents and the child s primary care physician. STEP #6: The test results will be reviewed, signed and dated by the testing psychologist. If the PCP is in agreement with the assessment, they will begin referrals for various services (ST, OT, ABA, etc). If the PCP has questions, they will contact the psychologist for clarifications or amendments to the testing. Once PCP is satisfied with the results, they will implement referrals. STEP #7: All recommended services described in the Treatment Plan must be provided by a CHP Network outpatient practitioner unless otherwise approved through the UM process by the Medical Director. STEP #8: Once a treatment plan is established it is important that close follow-up occur to evaluate the progress and efficacy of treatment. The Network psychologist will re-assess the child diagnosed with ASD on an annual basis for children with borderline diagnoses/mild autism. The treatment plan will be adjusted based on the annual assessment and recommendations.chp Network psychologists recommend using the following assessment instruments: a) Pervasive Developmental Disorder Behavior Inventory b) NEPSY-2 c) AAMD ABS SE d) Child Behavior Checklist e) Connors Parent and Teacher Rating scales f) Achievement testing g) Millon clinical scales h) Social Communication Questionnaire-current condition 6