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Community-Level Systems Change In OHIO: The Autism Diagnosis Education Project

Community-Level Systems Change In OHIO: The Autism Diagnosis Education Project. John C. Duby, MD, Director, Division of Developmental-Behavioral Pediatrics Akron Children’s Hospital Professor of Pediatrics Northeast Ohio Medical University jduby@chmca.org. June 2007: ADEPP Objectives

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Community-Level Systems Change In OHIO: The Autism Diagnosis Education Project

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  1. Community-Level Systems Change In OHIO:The Autism Diagnosis Education Project John C. Duby, MD, Director, Division of Developmental-Behavioral Pediatrics Akron Children’s Hospital Professor of Pediatrics Northeast Ohio Medical University jduby@chmca.org

  2. June 2007: ADEPP Objectives • Heighten public awareness of early signs of autism • Improve access to developmental screening • Improve coordination of medical diagnosis • Enhance access to evidence-based services Local People Local Solutions Autism Diagnosis Education Pilot Project Local Situations

  3. Ohio Chapter AAP Recommendations A system of continuous developmental care that includes emphasis on all aspects of surveillance at every well visit, and use of select standardized screening tools at certain visits. Approved July 24, 2009

  4. Barbaro, J. and Dissanayake, C. Prospective Identification of Autism Spectrum Disorders in Infancy and Toddlerhood Using Developmental Surveillance: The Social Attention and Communication Study. Journal of Developmental & Behavioral Pediatrics. 31(5):376-385, June 2010. Surveillance for Autism Positive Predictive Value 81%

  5. Ohio Chapter AAP Recommendations Recommended Use of Standardized Screening Tools Approved July 24, 2009

  6. Ohio Chapter AAP Recommendations Recommended Use of Standardized Screening Tools Approved July 24, 2009

  7. At this stage, on the basis of scientific principles and the available evidence, we believe that we do not have enough sound At this stage, on the basis of scientific principles and the available evidence, we believe that we do not have enough sound evidence to support the implementation of a routine communitywide screening program for ASDs. Ongoing research is certainly needed to assess the effectiveness and acceptability of screening programs for ASDs.

  8. The 7 Questions • Has the Effectiveness of the Screening Program (for That Condition) Been Demonstrated in a Randomized Trial? • NO • NO • Are There Efficacious Treatments for the PrimaryDisorder and/or Efficacious Preventive Maneuvers? • Not really • YES, if we look at the broad role of early intervention • Does the Current Burden of Suffering Warrant Screening? • YES • YES • Is a Good Screening Test Available? • NO • There will never be a perfect screening test • We need to consider screening as part of a system of care

  9. The 7 Questions • Will the Screening Program Reach a High Proportion of the Persons for Whom It Was Intended? • YES, if integrated into well child care • YES, if integrated into well child care • Can the Health Care System Cope With the Screening Program? • Maybe/Maybe Not • YES • Will Those With Positive Screen Results Comply With Subsequent Advice and Interventions? • Nobody Knows • YES

  10. Modified Checklist for Autism in Toddlers (M-CHAT) 23 yes-no questions Measures social reciprocity, language, some motor 18 months to 4 years of age Detects ASD, language impairment, cognitive disabilities Available in over 20 languages http://www2.gsu.edu/~psydlr/Diana_L._Robins,_Ph.D..html

  11. M-CHAT and Autism screening Failing score if 2 or more critical items or any 3 items are failed 2 page scoring guide Takes 5 minutes to complete, 1 to score Autism screen recommended by AAP Autism Expert Panel for use at 18 and 24 month well-child visit

  12. Screening for autism in older and younger toddlers withthe Modified Checklist for Autism in ToddlersPandhy et al. Autism, 2008 • Comparisons of PPP for ASD between age groups show that it is lowest for the younger/low-risk toddlers (0.28), those below the age of 24 months screened routinely at a well-child visit • PPP was significantly lower than the older/low-risk toddlers (0.61). • For children already identified to be at some developmental risk, PPP (0.79 for younger children and 0.74 for older children)

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  14. M-CHAT Follow-up Interview Ask the follow up questions for the failed items Increases positive predictive value to 0.74

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  19. CADLC Wave 2009

  20. Take Away Messages • When the doctor is worried, she is almost always right! • BUT, clinical impression alone is not quite good enough. • Comprehensive surveillance and periodic use of parent report screening tools appears judicious. • Repeated observations are better than single. • Screening tools should not be used in isolation. • Change is happening!

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