Jennifer Twachtman-Bassett, M.S. CCC-SLP Department of Speech-Language Pathology

1. Filling a Need to Reduce Wait Time for Autism Assessments: The Autism Spectrum Assessment Program at Connecticut Children’s Medical Center Jennifer Twachtman-Bassett, M.S. CCC-SLP Department of Speech-Language Pathology Lead Clinician ~ Autism Spectrum Assessment Program

2. ASAP • Goal: Obtain a diagnosis “as soon as possible” in order to jump-start intervention • Objective 1: Design a diagnostic program that provides a thorough evaluation for the child and an accurate diagnostic result • Objective 2: Ensure a short timeframe from referral to scheduling to appointment to results • Objective 3: Provide preliminary parent training and support for next steps

3. 1. Thorough Evaluation & Accurate Result • Information from primary care physician: • M-CHAT (if between 16 and 30 months of age) • Hearing test • Lead level (particularly for young or impaired children) • Results of other relevant tests (e.g., Fragile X) • Information from families/other providers: • Parent questionnaire • School questionnaire • Recent evaluations (children five years of age and over) Obtained before appointment is scheduled, age 6 and up Age 12 months-5 years: Obtained by appointment time

4. 1. Thorough Evaluation & Accurate Result • Extensive training of clinicians involved in ASAP • Symptom presentation, with research updates • Diagnostic tools • Disorders with symptom overlap • Multiple diagnostic tools • Access to medical specialties if needed

5. Objective 2: Short timeframes • Effective use of clinical resources: • More SLPs than developmental-behavioral pediatricians • Informal analysis has indicated: • High level of diagnostic agreement between SLP and DBP • Specific types of patients that need coordinated appointments: • Children under 2 ½ years of age • Medically complex children (e.g. seizures) • PCP/family seeking to have a diagnosis of ASD removed • History of prematurity <30 weeks • Psychiatric component

6. Objective 2: Short timeframes • More efficient to have developmental-behavioral pediatrician available when needed • This has allowed us to open up more slots for appointments. • Autism Specialist evaluations are now offered in all of our satellites (average wait 14 days) • This program could be replicated in other locations

7. Referral & Scheduling Process

8. The Team • Patient’s families/caregivers • Primary care providers • Educators and other outside clinicians • Autism specialist (Speech-Language Pathologist with specialized training in diagnosis of ASDs) • Developmental-behavioral pediatrician

9. ASAP Process • Review of provided documentation • Parent and school questionnaires • Medical/health reports • Screeners/referral • Developmental/academic reports (testing, service provision) • Confirmatory interviews • Direct assessment • Summary and recommendations

10. Clinical Diagnostic Tools DSM-IV TR (2000)/DSM-V (2013) Criteria review/clinical judgment ADOS-2 (2012) – direct assessment instrument Other instruments, as appropriate: Gilliam Asperger’s Disorder Scale (GADS, 2001) Childhood Autism Rating Scale, Second Edition (CARS-2, 2009) Children’s Communication Checklist (CCC, 1998) Other formal tests for older children Social Language Development Test (Elementary or Adolescent)

11. Objective 3: Preliminary Parent Training and Support for Next Steps • Results sheet, and, if DBP directly involved, receipt of copy of consult letter sent to referring pediatrician • Resource list for ASD • Parent training handouts • Follow-up appointment for short-term intervention and direct parent training

12. Results Sheet: Given to Family • Tests administered • Diagnosis (ASD or not) • Brief description of relevant symptoms • Space for consideration of other diagnoses (e.g., apraxia, ADHD) • Recommendations • Speech Therapy (individual or group) • Community-based services (Birth-to-Three, school) • Subspecialty evaluation referrals • Local support organizations • Resources (books, clinical)

13. Parent Training Handouts Establishing Intentional Communication Responding to Joint Attention Making Social Connections with Your Kids Using a Visual Schedule System Expanding Object Play Symbolic Play Teaching Kids to Solve Problems The Art of the Play Date

14. Younger Child: Follow-Up & Treatment at CCMC • Follow-up scheduled • If diagnosed under two years of age, reevaluation in one year • Reevaluation for diagnostic follow-up either through coordinated ASAP appointment or the speech department only in 6-12 months • Outpatient speech/language therapy • Individual • Family training and support (short-term) • Establishing functional communication • Supporting generalization into the home • Group • Readiness for group established (social language level and behavioral regulation)

15. Older Child: Follow-up & Treatment at CCMC • Follow-up offered as regular DBP continuity care • Outpatient speech/language therapy • Additional speech and language testing • Outpatient social language therapy • Individual • Social communication (conversation, negotiation, basic needs) • Problem solving • Comprehension and use of nonverbal signals • Parent training • Group • Readiness for group established (social language level and behavioral regulation) • Peer modeling • Generalization of skills

16. Meeting Community Needs • Our triage program has resulted in increased capacity: • Wait time has been reduced from an average of 66 days in FY 2011 to an average of 32 days in FY 2012 (all appointment types combined) • In FY 2013: Increased referral volume due to grant exposure, separated appointment types. Working to reduce wait time for >5 age group and combined MD/SLP appointments (49 days), but wait for Autism Specialist appointments is 14 days.

17. jtwachtman@ccmckids.org Thank you! The Connecticut Children’s Team: Sarah Schlegel, MD; Susan Roman, MPH, RN; Ann Milanese, MD Questions?