Objectives
By the end of the Webinar, participants will be able to:
Developmental Surveillance
& Screening Policy
Statement Goals
Increase identification of children with
developmental disorders by child health
professionals
Improved surveillance and screening
Concrete guidelines (algorithm)
Eliminate barriers (e.g. reimbursement, time)
Developmental screening
The administration of a brief standardized tool
aiding the identification of children at risk of a
developmental disorder
Not diagnostic!
Developmental evaluation
Aimed at identifying the specific developmental
disorder or disorders affecting the child
Child Development
Its more than height and
weight
Observing how children
play, learn, speak and act
Different areas of
development
Social, communication,
cognitive, gross motor, fine
motor, adaptive
Autism Spectrum
Disorders
Problems with
socialization
Problems with
communication
Unusual behaviors
Parental Concerns
(Wiggins, Baio, Rice, 2006)
Early Development
Babies start communicating
and relating to other people
at birth
Continued social-emotional
development is key to
forming strong relationships
and continued learning
Set of 15 Fact
Sheets
http://www2.gsu.edu/~psydlr/Diana_L._Robins,_Ph.D._files/M-CHATIn
terview.pdf
Like to be swung?
Take interest in other
children?
Like climbing?
Enjoy peek-a-boo?
Ever pretend to talk on the
phone?
Ever use index finger to
point to ask? To indicate
interest?
Play properly with small
toys?
Bring objects to show?
Look you in the eye?
Seem oversensitive to
noise?
23 Questions:
-2 of critical items or any 3 items
Barriers to Screening in
Office Practice
Screening tests too long and difficult
Children uncooperative
Reimbursement limited
EI Referral Form
Diagnostic Evaluation:
Application of DSM IV Criteria:
History
Observational Measure
Assessment of Parental
Understanding, coping skills and
resources
Community Resources
Sleep problems:
Night waking, delayed sleep onset
Feeding behaviors:
Aversions based on taste/texture/appearance
Monitor growth and nutrition
Tics
In as many as 9% of children
Medical Work Up
Genetic Testing
Karyotype- 5% yield
Microarray- 6-27%
Fragile X-1-2%
MeCP2
FISH Chr 15 -1%
$400
$600-3500
$500
$1400
$680
Metabolic
Testing
Amino Acids-<1%
Organic Acids<1%
$299
$280
Neuroimaging
$400-$3500
EEG
Any abnormality-16-68%
Seizures- 25% lifetime
$650
Other
$11
A Good
History and
Physical is
the basic
medical
work up for
ASD.
Key Points
Medical home = center for ongoing
management
Cornerstone of treatment
Educational interventions, developmental and
behavioral strategies
Medical Management of
Children with ASD Includes:
Effective treatment of coexisting medical
problems such as seizures, challenging
behaviors, and sleep disorders may allow
the child to benefit more fully from
educational interventions
Medication management of symptoms of
inattention, impulsivity, irritability,
aggression
Pediatricians can help families to
understand how to evaluate the evidence
regarding Complementary and
Alternative therapies
ASD Management
Outcomes are variable
Behavioral characteristics change over time
Most remain on spectrum as adults
Ongoing problems with independent living,
employment, social relationships and mental health
Treatment
Goals
Minimize core features and associated deficits
Maximize functional independence and QOL
Alleviate family stress
Educational intervention
Developmental Therapies
Communication
Sensory, fine motor, gross motor
Education
Cornerstone of
management
Curricula should
include
Academic learning
Socialization
Adaptive skills
Communication
Ameliorization of
interfering behaviors
Generalization of
abilities across
environments
Effective programs
Use assessment based
curricula to address these
goals
Include combinations of
strategies and treatment
modalities
Incorporate strong
components of family
training and support
Programs differ in
philosophy & emphasis
Myers & Johnson, PED 2007
Behavioral Intervention
ABA (Applied Behavioral Analysis)
General behavioral teaching approach involves
reinforcement and consequences to shape
behavior
All of our parents used it!
Involves the A, B, Cs
Not airway, breathing circulation
Antecedent
Behavior
Consequence
Evolution of ABA
Methodology includes a data based approach to
skill acquisition in a developmental format, using
principles of Applied Behavioral Analysis
Types
Speech/Language Therapy
Behaviorally based/ intensive structured teaching
E.g., Verbal Behavior
Augmentative strategies
Sign language
PECS
Aided augmentative/ alternative system(s)
Developmental: Motor
OT
Fine motor
coordination
Adaptive skills
Sensory Integration
Addresses sensory
abnormalities
Systematic
desensitization
No evidence of
corresponding
neurological changes
PT
Coordination
difficulties
Natural
environment
Adaptive physical
education or in the
community
Hippotherapy
Medical Management
Comorbid Symptoms or Conditions
High rates of co-morbidity
Tic disorders (9%)
Seizures (to 25%)
ADHD (30-75%)
Affective Disorders (25-40%)
e.g., depression or anxiety
Higher in HFA/ Aspergers
GI Problems (10-60%)
Sleep Disturbance (50-75%)
Challenging Behaviors (10-35%)
Psychopharmacology
Adjunct to educational,
Treat target symptoms
developmental &
Stereotypies
behavioral treatments
Withdrawal
So far no evidence of
Obsessions
impact on core symptoms Irritability
Evidence supporting is
Hyperactivity
variable
attention span
Toolkit handouts for MD
& families
self-injurious behavior
Aggression
sleep
Psychopharmacology
Symptoms/ Disorders
Attentional, impulsivity,
hyperactivity
Freq
59%
Treatments
Behavioral intervention
Psychopharmacotherapy stimulants, atomoxetine,
alpha agonists, anti-anxiety
Anxiety
43-84%
Depression
2-30%
Psychotherapy
Medication anti-depressants
Obsessive compulsive
symptoms
37%
Disruptive, irritable or
aggressive behavior
8-32%
Behavioral intervention
Medication atypical neuroleptics (risperidone,
arapiprazole, others)
Self-injurious behavior
34%
Behavioral intervention
Medication (e.g., naltrexone, risperidone, others)
Tics
8-10%
Sleep disruption
52-73%
Manipulative and
Body-based
Chiropractic
Massage/Therapeutic
Touch
Auditory Integration
Energy Medicine
Transcranial &
magnetic stimulation
Biologically Based
B6/Magnesium, B12
DMG/ TMG
Vitamin A, Vitamin C
Folate
Omega 3 Fatty Acids
Elimination Diets
Casein/ gluten free
Off-label
medications
Immune
Antifungal therapy
Immunotherapy, steroids
Antibiotics/Antivirals
Stem cell transplantation
Immunization-related
With-hold immunization
Chelation
Hyperbaric oxygen
therapy (HBOT)
Secretin
Always others coming along
CAM
Commonly used, especially in CSHCN
ASD ranges 30-90%
Requires
elimination of ALL dairy products (not GFCF except for ice
cream) & elimination of barley, rye, oats & wheat products
Potential deficiencies
Inherently deficient in calcium, vitamin D
B vits, Iodine, others may be lower in substitute products
Weight typically adequate, monitor Fe status
Toolkit Content
The fully searchable CD-ROM has an extensive library of ASDspecific information and practice tools:
Screening and surveillance algorithms
Examples of screening tools
Guideline summary charts
Management checklists
Developmental checklists
Developmental growth charts
Web links
Early intervention referral forms and tools
Record-keeping tools
Emergency information forms
ASD coding tools
Reimbursement tips
Sample letters to insurance companies
ASD management fact sheets
Family education handouts
Toolkit Content
Fact sheets for primary care professionals
(PDF files)
Topics
Asperger syndrome
Behavioral principles
CAM Treatments
Dietary tx
Eating & nutrition
GI problems
Treatment decision
Psychopharmacology
Seizures & Epilepsy
Sleep disorders
Toilet training
Toolkit Content
Fact sheets for primary care professionals to
give families (PDF files)
Topics
Behavioral challenges
Diet
Early intervention
GI problems
Childhood to adolescence
Guardianship
Lab tests
Medication
Nutrition & eating problems
School based services
Questions?