AAP Recommends Autism Screening for All Infants

autismo_mundo1.jpghttp://www.medscape.com/viewarticle/565094

Artículo interesante publicado el día de hoy en MEDSCAPE. Muchas veces podemos dejar de diagnósticar el Autismo en nuestros pacientitos. Y se considera que a más temprana edad se inicie un tratamiento los resultados y la calidad de vida para estas familias será mucho mejor.

Interesting Article published today in MEDSCAPE. Many times we fail to diagnosis  Autism in our pacients. And he believes that early age begin a treatment outcomes and quality of life for these families will be much better

DR. LUIS ALFREDO RUIZ

MD Pediatrician

News Author: James Brice
CME Author: Laurie Barclay, MD
CME Author: Penny Murata, MD

Disclosures

Release Date: October 30, 2007Valid for credit through October 30, 2008

Credits Available

Physicians – maximum of 0.25 AMA PRA Category 1 Credit(s) for physicians;
Family Physicians – up to 0.25 AAFP Prescribed credit(s) for physicians;
Nurses – 0.25 nursing contact hours (None of these credits is in the area of pharmacology)


October 30, 2007 (San Francisco) — The American Academy of Pediatrics (AAP) announced today an ambitious program to promote routine screening of all infants for autism spectrum disorders (ASDs) as part of 18-month and 24-month well-baby examinations. The announcement came during the AAP’s National Conference and Exhibition here.

After months of planning, the academy moved forward with the program in light of a rising incidence of ASD and evidence suggesting that early treatment increases the probability of successful treatment, according to Chris Plauche Johnson, MD, Med, lead author of the AAP policy statement. He is also a coauthor of a separate technical report on the pediatrician’s role in ASD diagnosis and management.

The clinical reports also include a toolkit containing “screening and surveillance tools, practical forms, tables, and parent handouts to assist the pediatrician in the identification, evaluation, and management of autism spectrum disorders in children,” Dr. Johnson and colleagues write.

The incidence of ASD has increased rapidly in the United States during the past decade. It now affects an estimated 1 of every 150 children. Evidence cited in AAP reports also released today links early diagnosis with successful therapy.

The etiology of ASD is unknown. There is no cure, according to Dr. Johnson, but treatment now leads to recovery for 30% to 40% of patients. “Early recognition and intervention makes a difference in the outcomes for these children,” she said.

The AAP clinical report recommends a checklist examination that asks the infant’s caregiver to complete a detailed questionnaire in the waiting room while the pediatrician attends to the routine 18-month or 24-month examination with the infant.

Immediate Action Should Follow Positive Screening

Based on a review of these results and his or her own observations, the pediatrician may make a negative or positive determination. No action is taken when ASD is ruled out, but 3 immediate responses are triggered for positive cases, Dr. Johnson said during a press briefing. These include a referral to an autism diagnostic clinic for a definitive evaluation, a prescription for an early intervention program for treatment, and a referral to an audiologist to rule out hearing problems.

The clinical report provides detailed information on ASD signs and symptoms. Language delays usually prompt parents to raise concerns, but earlier subtle signs among toddlers could lead to earlier diagnosis, Dr. Johnson said. These include:

  • not turning when parents say the baby’s name;
  • not turning to look when the parent points saying, “Look at …”;
  • not pointing themselves to show parents an interesting object or event;
  • lack of back-and-forth babbling;
  • smiling late;
  • and failure to make eye contact.

The risk for ASD is high among siblings of diagnosed autism and Asperger disorder patients, and among children whose parents suspect they have the disease, she said.

Intensive Interventions Needed for Effective Autism Management

The second clinical report addresses ASD treatment management. It strongly advises interventions as soon as an ASD diagnosis is seriously considered rather than deferring until a definitive diagnosis is made. It calls for intensive interventions for the child at least 25 hours per week, 12 months per year with a low student-to-teacher ratio allowing sufficient one-on-one time, and parental involvement.

“Treatment involves a partnership between the pediatrician and parents. Listening to parents’ concerns will be the cornerstone to this program,” said Andy Shih, PhD, vice president of scientific affairs for Autism Speaks, a nonprofit association that helped develop the autism resource toolkit distributed with the reports.

The toolkit, developed by the AAP for practicing pediatricians, was introduced along with the recommended policies. It features software-driven screening and surveillance algorithms, age-specific autism and Asperger disorder screening tests, developmental checklists, reimbursement tips, and early intervention referral forms.

The toolkit also gives the clinician online access to 150 video clips of infants and children displaying characteristic autistic behaviors.

Pediatricians in the audience during the briefing wondered if parents would tolerate the year-long waiting times currently required to receive definitive diagnosis. One pediatrician predicted that the waiting times would grow longer as universal screening is adopted.

The referral of positive cases for immediate therapeutic intervention will at least partially mitigate parent frustration with long waiting times, Dr. Johnson said. She blamed the delays on the multidisciplinary nature of the diagnosis and a shortage of expert personnel.

Todd Dwelle, MD, a private practice pediatrician in Monterey, California, attended the plenary lecture at which the new AAP reports were announced. Dr. Dwelle said he welcomes the instruction on ASD diagnosis, but he expressed concerns about parent anxiety and practice logistics.

“If we adjust our patient flow, it should not be such a huge burden, but it is potentially scary. A lot of questions will come up, and it will certainly prolong the visit, he said.

American Academy of Pediatrics 2007 National Conference and Exhibition. Presented October 29, 2007.

Pediatrics. Published online October 29, 2007.

Study Highlights

  • Common, classic presentations of ASD are lack of speech, scripted speech, parroting without communicative intent, and pop-up and giant words.
  • Earlier prespeech deficits are often present and, if recognized, may allow earlier diagnosis. These deficits may include lack of appropriate gaze or of warm, joyful expressions with gaze; lack of alternating to-and-fro pattern of vocalizations between infant and parent; lack of recognition of parent’s voice; disregard for vocalizations (eg, own name) with keen awareness for environmental sounds; lack of expressions such as “oh-oh” or “huh.”
  • Primary care clinicians should screen for ASD at 18 and 24 months and at any other time when parents raise a concern about possible ASD.
  • Before 18 months of age, screening tools that evaluate social and communication skills may assist in systematic detection of early signs of ASD.
  • If an ASD-specific screen is negative but the parents and/or the primary care provider remain concerned, the primary care provider should schedule the child for an early, targeted clinic visit for further evaluation.
  • Clinicians can be reimbursed for administering developmental and ASD-specific screening tools.
  • Developmental screening tests, including ASD-specific tests that are completed by a parent or nonclinician staff member and are reviewed and interpreted by the clinician, can be billed appropriately using CPT code 96110.
  • Watchful waiting is not appropriate when there is a positive screening result or 2 or more risk factors. Depending on the child’s age, simultaneous referral for comprehensive ASD evaluation; early intervention/early childhood education services; and/or audiologic evaluation may be indicated.
  • Referral for developmental services should not be postponed while awaiting a definitive diagnosis of an ASD. Early intervention can be helpful by targeting the child’s specific deficits; the intervention strategy can be altered if necessary once the child is diagnosed with an ASD.
  • Educational intervention strategies should include:
    • Initiation as soon as ASD diagnosis considered vs definitive diagnosis
    • Systematic activities at least 25 hours/week, 12 months/year
    • Low student-to-teacher ratio
    • Family involvement
    • Peer interaction
    • Measurement of progress and program adjustment
    • Structured routine and physical boundaries
    • Generalization of skills to new situations
    • Curricula for communication; reduction of maladaptive behavior; social, adaptive, cognitive, and academic skills
  • Speech and language therapy is appropriate regardless of age or failure of previous therapy.
    • Collaboration with teachers, families, and peers is more effective than traditional therapy.
    • Gestures, sign language, and picture communication programs are effective.
  • Prescribing clinicians should have expertise in drug indications, contraindications, dosing, adverse effects, interactions, and monitoring.
    • Serotonin selective reuptake inhibitors could improve repetitive behavior, irritability, depressive symptoms, anger, anxiety, aggression, social interaction, language.
    • Risperidone has short-term and possible long-term effects.
    • Methylphenidate is effective, but not as much as for isolated inattention or hyperactivity.
    • Clonidine and guanfacine appear effective for repetitive behavior, irritability, and hyperactivity.
  • Parents are crucial in treatment.
  • Family members are at increased risk for stress and depression.

Pearls for Practice

  • Common, classic presentations of ASD are lack of speech, scripted speech, parroting without communicative intent, and pop-up and giant words. However, earlier prespeech deficits are often present and, if recognized, may allow earlier diagnosis.
  • All screening tools have their limitations, but primary care clinicians should choose and become familiar with at least 1 tool for each age group and use it consistently. Before a child is 18 months of age, screening tools that evaluate social and communication skills may assist in systematic detection of early signs of ASD. Referral is needed when there is a positive screening result or 2 or more risk factors.
  • Educational strategies for children with ASD include initiation as soon as diagnosis is considered, intensive individualized intervention, low student-to-teacher ratio, family component, high degree of structure, and application of skills to new situations.
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