EAC-AZ Webinar #7 November 18 th & 25 th Robin Blitz, MD Sara Bode, MD Amber Wright, CPNP Today s Objectives Month 4 Article Review STAT Reliability Testing ADOS Interpretation AzEIP / School Testing M-CHAT-R / Follow-up QI Project Discussion Month 4 Related Medical/Behavioral Issues Supplemental Materials Review 1
AAP Autism Tool Kit (2013) Eating and Nutrition Gastrointestinal Problems Seizures and Epilepsy Sleep Disorders Toe Walking, Muscle Tone, and Motor Milestones Toilet Training American Academy of Pediatrics. (2013). In AAP Autism Toolkit. Evaluation, Diagnosis, and Treatment of Gastrointestinal Disorders in Individuals with ASDs: A Consensus Report (2010) Evidence-based recommendations for best treatment of GI disorders among children with autism not yet available Key statements are based on expert opinion by panel and review of existing evidence GI symptoms warrant thorough evaluation Behavioral symptoms can be treated while a medical workup is being completed, but not in place of Need education re: typical and atypical manifestations of GI disorders Prevalence is poorly understood Limited data regarding special diets, allergens, immune dysfunction Buie, T., Campbell, D., Fuchs III, G., Furuta, G., Levy, J., VanderWater, A., et al. (2010). Evaluation, diagnosis, and treatment of gastrointestinal disorders in individuals with ASDs: A consensus report. Pediatrics, 125, Supplement 1: S1- S18. Autism spectrum disorder and co-occurring developmental, psychiatric, and medical conditions among children in multiple populations of the United States (2010) Language delays 63.4% ADHD 21.3% Intellectual disability 18.3% Epilepsy 15.5% Learning disorder 6.3% ODD 4.0% Anxiety disorder 3.4% Levy, S., Giarelli, E., Lee, L, Schieve, L., Kirby, R., Cunniff, C., et al. (2010). Autism spectrum disorder and co-occurring developmental, psychiatric, and medical conditions among children in multiple populations of the United States. Journal of Developmental and Behavioral Pediatrics, 31 (4): 267-274. 2
Strategies to Improve Sleep in Children with Autism Spectrum Disorders (n.d.) Providing comfortable sleep setting Establish regular bedtime habits/routine/schedule Teach child to fall asleep alone Encourage behaviors that promote sleep Weiss, S. & Malow, B. (n.d.). Strategies to improve sleep in children with autism spectrum disorders: A parent s guide. https://www.autismspeaks.org/science/resourcesprograms/autism-treatment-network/tools-you-can-use/sleeptool-kit STAT Reliability Testing STAT Reliability Where is everyone? Send to Vanderbilt your scoring of their tape? Video yourself for 3 children? Who has used it and what do you think? Track use of STAT and outcomes 3
ADOS Testing Interpretation ADOS Interpretation Scoring: Social Affect (SA) Restricted and repetitive behavior (RRB) Overall total ADOS-2 Comparison Score ADOS Interpretation Social Affect (SA) Communication Pointing Gestures Reciprocal Social Interaction Eye contact Directed facial expressions Shared enjoyment Showing Reciprocal communication Rapport 4
ADOS Interpretation Restricted and repetitive behavior (RRB) Idiosyncratic use of words/phrases Unusual sensory interests Stereotypies Repetitive interests ADOS Interpretation Overall Total Rating points are assigned and transferred to scoring algorithm Totaled under each section and then added to obtain total = (SA) + (RRB) Then, the overall total is used to assign the ADOS- 2 classification: Autism Autism spectrum Non-autism ADOS Interpretation Comparison Score Determined by using table on appropriate module booklet (intersection of age and overall total score) Quantifies level of autism spectrum-related symptoms: High Moderate Low Minimal-to-No evidence 5
Early Intervention and IDEA Testing/Services AzEIP versus School Under age 3 years Early Intervention Nearly 3 years old or older School district - Child Find Benefits of Early Intervention EI - critical to the development and well-being of children and their families EI - improves outcomes for participants EI - is socially and economically effective Bailey, Pediatrics, 2005; Guralnick, The Effectiveness of Early Intervention, 1997 6
AzEIP Eligibility Criteria 50% or more delay in one or more area A child from birth to 36 months of age will be considered to exhibit developmental delay when that child has not reached 50 percent of the developmental milestones expected at his/her chronological age, in one or more of the following domains: 1. Physical: fine and/or gross motor and sensory (includes vision and hearing) 2. Cognitive 3. Language/communication 4. Social or emotional 5. Adaptive (self-help) AzEIP Eligibility Established conditions that have a high probability of developmental delay include, but are not limited to: chromosomal abnormalities metabolic disorders hydrocephalus neural tube defects (e.g., spinal bifida) IVH (grade 3 or 4) PVL cerebral palsy; significant auditory impairment / significant visual impairment failure to thrive; severe attachment disorders sensory impairments, inborn errors of metabolism, disorders reflecting disturbance of the development of the nervous system, congenital infections, and disorders secondary to exposure to toxic substances, including fetal alcohol syndrome. IDEA School Intervention Public School service 3 yrs 22 yrs. School has 60 calendar days to assess, determine eligibility, develop IEP Coordination of education and medical needs 7
School Testing Psychoeducational Testing Stanford-Binet WPPSI, WISC UNIT, C-TONI The Bell Curve Other School testing Speech / Language Assessment Articulation Expressive language / receptive language Pragmatics Processing Occupational Therapy Assessment Fine motor Sensory processing Functional Behavioral Analysis Vision / Hearing Screening 8
QI/MOC Updates MCHAT Screening Project Step 1 Retrospective chart review of 20 eligible patients seen in last 6 months at 18 and 24 mo WCC Documenting completion of MCHAT with results and action documented in the chart Short reflection on potential key drivers for process of completion and interpretation of screening as it affects your results What if I already have 100%? 25 Cycle 1 results: 20 15 10 MCHAT Completion 5 0 1 2 3 4 5 6 7 8 9 10 11 12 9
MCHAT Screening Project Monthly cycles of chart review for at least two additional cycles Chart review of at least 20 patients or all eligible patients for their 18 mo and 24 mo WCC Report number of well checks versus number of completed MCHATS and short reflection Next Steps Second chart review Include patients seen since our intervention done in September up to 20 What if I didn t have 20 patients here for 18 and 24 mo WCC? OK, just give the total seen Reflection of any process changes, if you already have 100% then reflection on process implementation for what you are planning for failed screens How do I improve my process? Intervention 1 included obtaining certification/completion of CDC Act Early Modules as well as in-person training Intervention 2: Site visits to look at process improvement Starts with identifying your key drivers for screen completion 10
Key Drivers to Success Handing out MCHAT Office Champions: Who on your team can work with you on this Screening Process? Weekly meetings: plan the office flow- who will hand out screen/score/give to provider? Obtaining screen Education to staff- they have to understand the why!!! Staff Education on scoring: Provider vs, ancillary staff Recording results in MR Scoring the Form Scheduling: process for scheduling follow ups Education on who to schedule with you Referral Other resources for additional concerns process/secondary screen MCHAT Screening Project Next Steps Email will go out this week with attachment for chart review and reflection Complete and send back We will give you assistance/guidance with our visits on process changes Email monthly reminder for 3 rd cycle in December Questions? Second Project: Sleep! Children with Autism and other behavioral/developmental disorders have a high incidence of sleep disturbances Next intervention will be on screening at risk children for sleep disturbances and offering resources/referrals as needed for sleepy hygiene 11
Next Steps for 2 nd project Baseline data: Review of 10 charts for children with Autism or Developmental delay and look for documentation of sleep schedule and guidance for improving routine/schedule Intervention #1: Introduction of Sleep Questionnaire and lecture/resources on sleep for children with Autism Spectrum Disorders Cycle 2 and 3 to be given and completed after Conference Discussion 12