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ECHO Autism

Screening
and Next Steps
This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under cooperative agreement UA3 MC11054 – Autism
Intervention Research Network on Physical Health. This content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be
inferred by HRSA, HHS or the US Government. This work was conducted through the Autism Speaks Autism Treatment Network serving as the Autism Intervention Research Network on Physical Health.
Speaker Disclosures
•We have nothing to disclose and no
conflict of interest.
•Our sincere thanks to the ECHO Autism
team led by Dr. Kristin Sohl at

ECHO Autism
Objectives
•Difference between developmental
screening, monitoring and assessment
•Introduction to MCHAT as a screening
tool
•A practical approach to assessment for
autism in the office
•Immediate next steps after diagnosis

ECHO Autism
1 in 6 children has a developmental delay

ECHO Autism
How BIG is the problem?

The prevalence of childhood disability


in Low and Middle Income Countries is 15%
(WHO World Disability Report 2010,
Lancet series on ECD)

India has an estimated 52 million


children with disabilities

ECHO Autism
EARLY DIAGNOSIS – Why use an instrument?

Without With
instruments Instruments
Developmental 30% diagnosis 70-80%
Difficulties Palfrey ve ark., J Peds diagnosis
1987
Squires ve ark., JDBP
1996

Mental health 20% diagnosis 80-90%


problems Lavigne ve ark. Pediatrics diagnosis
1993
Sturner,, JDBP 1991
Data from ECHO Autism Ummeed 2018

ECHO Autism
ECHO Autism
Screening vs Diagnostic tests
Screening tests Diagnostic tests

Purpose To detect potential disease To establish presence/absence of


indicators disease
Target population Large numbers of asymptomatic, Symptomatic individuals to establish
but potentially at risk individuals diagnosis, or asymptomatic
individuals with a positive screening
test
Test method Simple, acceptable to patients maybe invasive, expensive but
and staff justifiable as necessary to establish
diagnosis
Positive result threshold Generally chosen towards high Chosen towards high specificity (true
sensitivity not to miss potential negatives).
disease
More weight given to accuracy and
precision than to patient
acceptability
Positive result Essentially indicates suspicion of Result provides a definite diagnosis
disease (often used in
ECHO Autism
combination with other risk
MONITORING VS SCREENİNG

S S
C C
R R
E E
E E
N N
I I
N N
G G

MONITORING+SUPPORTING
Why screen/ monitor for Autism?

Estimated to affect 1 out of every 68


children.
Four times more common in boys as
compared to girls.

There are over 5 lakh children under the


age of 15 with autism in India

ECHO Autism
Why Screen/ Monitor for Autism ?
•Takes the guesswork out of it

•Early detection → early intervention → better


developmental outcome and reduced cost of
care

•ASDs can be diagnosed in children as young as


12 months

•Move child and family forward


ECHO Autism
Evidence
Rating

ECHO Autism
Observe child’s development through
standardized instruments
AAP recommendations –
Three step process
•Developmental Surveillance (all well child
checks)
•Structured developmental screenings at 9,
12,18, 24 and 30 months
•ASD specific screening at 18 and 24 months

(AAP, Johnson, et al., 2007)

ECHO Autism
What is necessary yet practical?

•Developmental monitoring at routine visits


•NOT only when concerns are raised
•Example of monitoring tool –
•GMCD ( Ertem et al Pediatrics 2008, Lancet GH
2018)
•Examples of general developmental screenings
•ASQ, PEDS DM
•ASD specific screening
•M-CHAT

ECHO Autism
MCHAT R/F
• Use between 16 months- 30 months
• Standard is 18 months and 24 month
well child checks
• Repeat because of risk of regression
•Step 1– Parent completes MCHAT-R
•Step 2 – Providers scores MCHAT-R
• 2 minutes
•If positive, Step 3 select follow-up items
based on the failed MCHAT-R items

ECHO Autism
ECHO Autism
MCHAT-R Scoring

ECHO Autism
Example
•24 month old, full term little boy
•Negative past medical history
•Family history – father slow learner?
•Loss of language ( previously used
words)
•Hyperactive
•Denied admission to preschool

ECHO Autism
Items 1-10
6 at risk answers
#1, #2, #4, #6, #7, #9

ECHO Autism
Items 1-10
6 at risk answers
#1, #2, #4, #6, #7, #9

items 11-20
7 at risk answers
#12,#14, #16,#17,#18,#19,#20

ECHO Autism
MCHAT-R Scoring

ECHO Autism
MCHAT-R Follow-Up
•Complete the Follow-Up Questions for
the “failed” items only
•Each question has it’s own page
•Go straight to those pages and ask follow-up
questions for the specific question

ECHO Autism
Scoring MCHAT-R Follow-Up

ECHO Autism
Positive Screen → Take Action
Multipronged approach
•Review screening results with the parents
•Referral to audiologist (speech delay)if
hearing screen not done
•Assessment for Autism diagnosis
•Referral to community resources

ECHO Autism
Diagnostic Tools
•ADOS
•ADI

•Others used in India INCLENS, ISSA, CARS

•Gold standard against which the ADOS and


ADI have been validated is expert opinion
therefore clinical skill in recognizing autism is
critical
ECHO Autism
Comprehensive assessment
1.Health, developmental, and behavioral history
with family history

2. Physical examination including a thorough


search for
dysmorphic features, neurologic abnormalities and
neurocutaneous stigmata . Head circumference

3. Developmental and/or psychometric evaluation


(depending
on age/skill level)
ECHO Autism
Free play
Materials – pop up toy, utensils, doll, toy
cars, toy phone, alphabet blocks
Focus of assessment –
•Does he want to share enjoyment with
parent? How?
•How does he explore toys?
•Repetitive actions?

ECHO Autism
Response to name
Call out to the child when he can’t see you
directly. Ask parent to do same if no response
Focus of assessment –
•Is the response consistent?
•Quality of response?

ECHO Autism
Bubbles
•Blow a stream of bubbles and wait. See how
the child requests, responds
•Focus – initiation of joint attention, shared
enjoyment, requesting

ECHO Autism
Pretend Play
•Set up a pretend play scenario e.g tea party,
birthday. Encourage child to take the lead
•Focus of assessment – How does the child
add to the pretend play? Is he able to treat
the doll as a representation of an animate
being?

ECHO Autism
Social Game
•Play peek a boo or tickling game with the
child
•Focus of assessment – does the child try to
initiate the routine? Does he use facial
expression, vocalization and gestures to
communicate? Is there social anticipation?

ECHO Autism
4. Determination of the presence of a
categorical DSM V diagnosis, preferably with
standardized tools
5. Assessment of the parents’ knowledge of
ASDs, coping skills, and available resources
and supports.

ECHO Autism
Developmental Screening Flowchart for ECHO Autism
ADMINISTER MCHAT-R AT 18, 24 OR
MCHAT-R SCREEN WITH LOW RISK: CONTINUE TO PROVIDE DEVELOPMENTAL
BEFORE AGE 4 WITH PCP OR PARENT
TOTAL SCORE 0-2 MONITORING & STANDARDIZED SCREENING
CONTERN

MCHAT-R SCREEN WITH


MEDIUM RISK: TOTAL SCORE 3-7 OR 1.
HIGH RISK: TOTAL SCORE 8-20 CONDUCT MCHAT-R FOLLOW UP INTERVIEW
(MCHAT-R / FU NOT REQUIRED)

MCHAT-R FOLLOW UP INTERVIEW: MCHAT-R SCREEN WITH LOW RISK:


HIGH RISK OR SCORE >2 TOTAL SCORE 0-2

REFERRAL FOR HEARING EVALUATION, INTERVENTION – OFFER REASSURANCE TO THE FAMILY


SPEECH, OT IF AVAILABLE
INCREASE VISITS
SCHEDULE DIAGNOSTIC ASSMT
MONITOR CONCERNS
REVIEW HISTORY, PHYSICAL & AUTISM SYMPTOM INVENTORY CONSIDER HEARING TEST

IF SPEECH IS DELAYED, REFER FOR HEARING TEST AND SPEECH/LANGUAGE EVALUATION

2. ADMINISTER DIAGNOSTIC TEST

CONCERN FOR AUTISM

YES NO

SCHEDULE ECHO AUTISM CASE PRESENTATION** EVALUATION FOR OTHER DEVELOPMENTAL DISABILITIES (SPEECH DELAY, ADHD, ETC)

REFERRAL FOR AUTISM INTERVENTION SERVICES REFER TO DEVELOPMENT CENTER FOR EVALUATION

WRITE SCRIPTS FOR SPEECH and OT MONITOR CONCERNS

EVALUATE CO-OCCURING MEDICAL CONCERNS INCREASE VISITS

SHARE “WHAT IS AUTISM?” RESOURCE WITH FAMILY OFFER REASSURANCE TO THE FAMILY

COMMUNICATE DEVELOPMENTAL ASSESSMENT WITH FAMILY

** Include MCHAT Score, MCHAT F/U results, Diagnostic test results, Core Symptoms Inventory and developmental history when presenting to ECHO Autism
ECHO Autism
www.echoautism.com