1. Screening for Autism Spectrum Disorders Debra Efird, MD JFK Partners University of Colorado School of Medicine

2. Learning Objectives Know the current AAP screening guidelines for ASDs Know which screening tests to use at each age Be aware of the critical items on the MCHAT and recognize them clinically Understand the follow-up steps to take when a pt scores or is otherwise at risk for an ASD

3. Most recent recommendations Autism-specific screening recommended at the 18-month and 24/30-month well check. (Pediatrics, November 2007)

4. ASD screening and surveillance reccomendations Surveillance – recommended at all well- child visits. Autism specific screening – recommended at 18 months. A second autism specific screen is recommended at 24 to 30 months (due to possibility of regression) Bright Futures has included an autism specific screen at 18 and 24 months.

5. Standardized developmental screening vs ASD screening As already noted Journal of Pediatrics 2007 recommended Autism surveillance at every visit and Autism screening at the 18 month and 24/30 month M-CHAT (Modified Checklist for Autism in Toddlers)- is the most reliable test for the 18 and 24/30 month SCQ (Social Communication Questionnaire) is the best tool for children 4 yrs and older Important Point- ASD screening (MCHAT or SCQ) is distinct and different from Developmental Screening (ASQ or PEDs)

6. M-CHAT Robins, 2008 Good for ages 16-30 mo Free, easy to download 23 yes/no questions parent completes, 6 are critical items child is “at risk” if they fail any 2 critical items or any 3 items total Failed screen needs f/u interview Sensitivity 0.85 Specificity 0.93 with follow-up interview, ppv 0.57 Website is www.mchatscreen.comwww.mchatscreen.com

7. Social Communication Questionnaire (SCQ) give to kids 4 yrs and older w/ mental age of at least 2 ys must be purchased ($35 for a package of 20) 40 yes/no items 2 forms : “current” looks at behavior over the previous 3 months and “lifetime” focuses on entire developmental history Order from Western Psychological Services at www.wpspublish.com www.wpspublish.com

8. M-CHAT critical items 2. Does your child take an interest in other children? 7. Does your child ever use his/her index finger to point, to indicate an interest in something? 9. Does your child ever bring objects over to you to show you something? 13. Does your child imitate you? (eg if you make a face will your child imitate it?) 14. Does your child respond to his/her name when called? 15. If you point at a toy across the room, does your child look at it?

9. How can screening be done Implementation into practice may need some planning … goal is to keep screening connected to the medical home Coding and Billing for Autism or Developmental Screening 96110 – physician review of test completed by parent or non-physician staff - you can bill this code twice in one visit 96111 – physician administers test which includes direct observation of child * Parents of children who received a developmental assessment expressed greater satisfaction with their care provider (Halfon. Pediatrics. 113: 1926-33) 2004, 113: 1926-33)

10. After a child scores “at risk” on ASD screener Refer for Comprehensive ASD Evaluation Refer to Early Intervention Colorado (age 0-3) or Child Find (over age 3). These are the Early Childhood Education Services mandated by the Individuals with Disabilities Act Refer for an Audiology Evaluation And… schedule a follow-up visit so that you can make sure everything is being done as it needs to be

11. Other reasons to refer for ASD evaluation Already mentioned: failed screening test (MCHAT or SCQ) If anyone (parent, teacher, caregiver, provider, etc) has a concern you still refer even if the MCHAT or SCQ is passed) If a child has an older sibling with autism consider referral for evaluation very early See algorithm from J Peds 2007

12. After a child receives an ASD diagnosis Refer as soon as possible for Autism Intervention If you haven’t already, refer also to EI Colorado (age 0-3) or Child Find (age 3 or older) Keep in mind that Autism Treatment and Intervention is a different referral from EI/Child Find. While there is some overlap in therapy your patient deserves both. Referral for Autism Intervention and EI/Child Find should occur at the same time.

13. Where does for ASDs screening stand in Colorado Colorado Permanente Medical Group has been screening since the early part of 2008 Survey of Colorado AAP members (70 of 550 people responded) 74% screening for Autism as of December 2009 Colorado ABCD has incorporated ASD screening into their program for SDS We don’t have good data on where we stand on ASD screening but recent ADDM data shows a declining age of diagnosis which is a good sign

14. Resources available for families and providers www.autismspeaks.orgwww.autismspeaks.org has a video file that is great for teaching www.familyvoicesco.orgwww.familyvoicesco.org Family voices is an advocacy organization for providers and families www.autismcolorado.orgwww.autismcolorado.org Autism Society of Colorado for family support www.aap.orgwww.aap.org American Academy of Pediatrics, has a Autism toolkit www.cdc.govwww.cdc.gov Learn the Signs Act Early campaign, lots of free materials www.eicolorado.orgwww.eicolorado.org Early Intervention colorado website

15. references Council on Children with Disabilities, Section on DBP, et all Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening Pediatrics 2006; 118; 405-420. Plauche Johnson, Chris, MD, Scott MyersMD and the Council on Children with Disabilities Identification and Evaluation of Children with Autism Spectrum Disorders, Pediatrics 2007, 120, 1183-1215. Myers, ScottM MD, Chris Plauche JohnsonMD and the Council on Children with Disabilities Management of Children with Autism Spectrum Disorders, Pediatrics 2007, 120 1162-1182. McPheeterss, Melissa, et all A Systematic Review of Medical Treatments for Children with Autism Spectrum Disorders, Pediatrics, 2011, e1311-e1322 Warren, Zachary, et all A Systematic Review of Early Intensive Intervention for Autism Spectrum Disorders Pediatrics, 2011, e1302 to e1312. Filipek, et al J Autism Dev Disorders. 1999 Dec: 29(6): 439-84. Chawarska K, PaulR, Klin A, Hannigen S, Dichtel LE, Volkmar F J. Autism Dev Disorders. 2007; 37: 62-72. Prevalence of Autism Spectrum Disorders..Autism and Developmental Disabilities Monitoring Network, 14 sites, United States, 2002, MMWR Surveillance Summary. 2007. 56: 12-28.