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ECHO AutismAutism in Primary Care

Kristin Sohl, MD; Cyndy Mehrer, DNP; Alicia Curran, BS

Family Medicine Update April 2017

ECHO AutismScreening and Next Steps

Kristin Sohl, MDDirector, ECHO AutismPediatrician, Autism Medical Specialist

ECHO Autism

1 in 6 children has a developmental delay

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ECHO Autism

Growth Tracking

ECHO Autism

•Takes the guesswork out of it

•Early detection à early intervention à better developmental outcome and reduced cost of care

•ASDs can be diagnosed in children as young as 12 months

•Move child and family forward

Why Screen?

ECHO Autism

Five Components of Screening

•Listen•Observe• Identify •Document•ShareAAP,CounselofChildrenwithDisabilities,2006

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! Three step screening 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

! Examples of general developmental screenings ! ASQ, PEDS DM

! ASD specific screening! M-CHAT

(AAP, Johnson, et al., 2007)

Observe child’s development through standardized instruments

ECHO Autism

ECHO Autism

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ASQ and Peds

ECHO Autism

Example PEDS:DM items (29 - 33 months)

ECHO Autism

PEDS:DM Recording Form

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ECHO Autism

ASQ

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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

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MCHAT-R Scoring

ECHO Autism

Example

•24 month old, full term little boy•Negative past medical history•Negative family history•Hearing test normal•MCHAT normal at 18 months

ECHO Autism

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MCHAT-R Scoring

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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

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Scoring MCHAT-R Follow-Up

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Multipronged approach!Review screening results with the parents !Referral to audiologist (speech delay)!Referral to qualified autism diagnostician!Referral to community resources

! First Steps (birth to 3)! Early Childhood Special Education (3-5 year olds)! IEP process (5+)! Clinic based speech and

occupational therapy

Positive Screen ! Take Action

ECHO Autism

!Screen for underlying medical issues!Sleep (50-80%)!Constipation (40-60%)!Seizures (10-20%)!Hearing!Abuse!Diet

!Treat underlying medical issues

While Waiting…Think Beyond the Delay

ECHO Autism

!Sleep ! How long does it take your child to fall asleep?! Once they fall asleep, do they stay asleep?! Do they snore?

!Constipation! How often do they have a BM?! Does it hurt?! Do they hold it? Are there skidmarks in the

underwear?!Seizures

! Does your child ever stare off into space and you can’t get their attention?

Some questions to ask…

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•Dental caries•Eczema•Staring spells•Abuse/neglect•Trauma

Things to consider

MedicalConcern

BehaviorDevelopment

ECHO Autism

• First Steps • Missouri’s Early Intervention

system• Birth to age 3• Provide screening• Provide in-home services if

qualify

• Outpatient Therapy• Speech• Occupational• Behavioral

Birth to 3 Resources

http://staffrehab.com/new-grad/

ECHO Autism

Strong Federal InitiativesLearn the Signs. Act Early

Birth to Five: Watch Me Thrive!

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Tools to Make Your Work Easier! Developed by CDC, in

conjunction with the AAP! Help parents become better

partners in monitoring development

! Objective, research-based information may make visits more productive

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Tools to Make Your Work Easier

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Milestone Moments Booklet

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Milestone Moments Booklet! Includes:

! Complete milestone checklists (2mo – 5yrs)! Activities to try at home ! Space to write down questions

! Intended for parent use throughout a child’s early years

! Helps parents prepare for well-child visits; gives you a parent-friendly referenceHelps parents prepare for wellyou a parent

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Milestones BrochureSelect milestones at a glance for ages 6 months to 4 years

Act Today!

! View, print, or order FREE “Learn the Signs. Act Early.” resources at www.cdc.gov/ActEarly

! If you’d like to customize these materials for your practice and print them locally, contact ActEarly@cdc.gov

! Access free continuing education courses on autism spectrum disorder at www.cdc.gov/AutismCaseTraining

ECHO Autism

ECHO Autism! Connects primary care providers

to a team of experts in autism and behavior

! Case-based learning builds confidence and knowledge in the PCP to care for children in their practices

! Reduces costs to families! Improves access for families

JOIN US –1st and 3rd Wednesday 11:45am-1:15pm

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ECHO AutismPsychotropic & Psychotherapy Treatment

for Autism Spectrum Disorders

Dr. Cynthia MehrerDoctor of Nursing Practice PMHNP-BC

ECHO Autism

Practice GuidelinesAmerican Academy of Child & Adolescent Psychiatry (AACAP)

Photo. 2013. Kevin Curtis retrieved from https://fineartamerica.com/featured/1-autistic-boy-kevin-curtis.html

ECHO Autism

Comorbid

Photo.2013.Bek Wiltbank.http://www.pediastaff.com/blog/ot-corner-anxiety-and-autism-they-dont-have-to-go-hand-in-hand-12871

Conditions Typical in Autism

•ADHD•Anxiety•Disruptive Mood

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ECHO Autism

Consider Medicine

When…•Problem behaviors put the child at risk of harming himself or others.

•Behaviors are causing difficulty and stress for the family at home.

•Behaviors are making it difficult for the school team to work with the child

ECHO Autism

ADHD Symptoms (DSM-5)

•Can’t sit still (hyperactive)

•Blurts out answers (impulsive)

• Impulsively aggressive (hit someone without thinking)

•Difficulty listening (inattentive)

•Difficulty finishing a task (inattentive, impulsive)

Rating Scales (AACAP, 2007)

Vanderbilt Parent and Teacher forms (NICHQ, 2002)

2- settings •Home•School

Drawing.2015.BrianUdell.Retrievedfromhttp://www.theautismdoctor.com/adhd-what-else-could-it-be/

ECHO Autism

Non-Stimulants (AACAP, 2014)

Alpha Agonists

•Guanfacine (Tenex) Intuniv- ER form

•Clonidine (Catapres) Kapvay- ER form

Target Behaviors

•Hyperactivity•Short attention span• Impulsive behaviors •Sleep problems• Tics

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Alpha Agonist Medicines (AACAP, 2007a)

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History!Cardiac

Monitor!B/P (Hypotension)

Common Side Effects!Sleepiness! Irritability

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ECHO Autism

StimulantsCommon Side Effects!Problems falling asleep !Less appetite! Irritability/emotional outbursts

Black Box Warning/Caution! Dependency! Cardiac History

Less Common S/E!Anxiety!Headaches!Diarrhea!Changes in heart rate!Tics

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ECHO Autism

Anxiety Symptoms•Emotional•Fearful•Worry•Avoidance•↑ SIB•Aggression•Poor sleep

SIB= self injurious behaviors

Photo.2016.D ianaG iraldo.Retrievedfrom http://theclovisroundup.com/understanding-autism -clovis-mom-shares-sons-journey/

ECHO Autism

Anti-Anxiety MedicinesSelective Serotonin Reuptake Inhibitors (SSRI’s) (AACAP, 2014, AACAP, 2007b)

SSRI’s

•Sertraline (Zoloft)•Fluoxetine (Prozac) c•Citalopram (Celexa) c•Escitalopram (Lexapro) c

C = assess for cardiac history

Target Behaviors

• Depression• Anxiety• Repeating thoughts• Repeating behaviors

Black Box Warning• Suicide Ideations

ECHO Autism

Selective Serotonin Reuptake Inhibitors (SSRI’s)Common Side Effects

•GI problems (nausea, constipation, low appetite)

•Weight gain•HeadachesLess Common Side Effects•Seizure•Suicide Ideations•Mania

Considerations

•4to6weekstoachievetherapeuticeffect

•Mosteffectivewhencombingpsychotherapy(CBT)andpsychotropicmanagement

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ECHO Autism

Irritability Symptoms

•Aggression•Meltdowns• Increased self-injury•Decreased emotional regulation

• Increased sensitivity to stimulation

Photo.2017MarkHutten.http://www.myaspergerschild.com/2013/11/tantrum-free-transitions-tips-for.htm l

ECHO Autism

Mood Dysregulation (AACAP, 2014, AACAP 2011)

Atypical Antipsychotics• Aripiprazole (Abilify)• Risperidone (Risperdal) p• Quetiapine (Seroquel) sl• Olanzapine (Zyprexa) sw

P= prolactin increase potentialSl= slit lamp exam - cataractsSw = significant wt. gain

Antipsychotic MonitoringBaseline labs & Q 6 monthsFLPHA1CCMP

BMIAIMS

Photos.N.D..RodneySewell.http://www.canadianpharmacymeds.com

/blog/childhood-temper-tantrums/

ECHO Autism

Atypical Antipsychotics

Common Side Effects•Sleepiness•Drooling• Increased appetite•Weight gain•Abnormal involuntary movements

Less Common Side Effects

•High blood sugar, diabetes

•High cholesterol•Tardive dyskinesia

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ECHO Autism

Mood Dysregulation (AACAP, 2014, AACAP 2011)

Anti-Seizure Medications

•Lamotrigine (Lamictal) Sj

•Valproic acid (Depakote,Depakene) Sj

Sj = Steven Johnson Syndrome

Anti-Seizure Medication Monitoring

Liver Function•Baseline•Q 6 months

LevelsDepakote/Depakene•Q 6 months

ECHO Autism

Anti-Seizure Medications

Common Side Effects•Sleepiness •Nausea • Vomiting

Photo.N.D.AdobeStock/dmitrimaruta.https://www.aba-network.com/blog/

Less Common Side Effects•Rashes •Liver failure•Tremor•Bone marrow suppression

ECHO Autism

PsychotherapyCognitive Behavioral Therapy (CBT) (Spain et al., 2015)

CBT in Autism (aCBT)•Communication deficits•Simple emotions•Concrete•Breaks

(aCBT) Techniques• Involve Parents• Individualize program•Goal broken into smaller steps

•Highly pictorial•Daily rehearsal

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Thank You

ECHO AutismSupporting Families

Alicia Curran, BS

Missouri LEND, Family FacultyProject CoordinatorCDC’s Act Early Ambassador to Missouri

ECHO Autism

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ECHO Autism

Supporting Families

Medical Home•Patient-centered•Comprehensive•Coordinated•Accessible•Committed to quality and safety

ECHO Autism

GriefThe Kübler-Ross Grief Cycle

•Denial Stage: Trying to avoid the inevitable•Anger Stage: Frustrated outpouring of bottled-up emotion

•Bargaining Stage: Seeking in vain for a way out•Depression Stage: Final realization of the inevitable

•Acceptance Stage: Finally finding the way forward

ECHO Autism

Extended Grief Cycle

Emotional “Roller Coaster”

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Ambiguity !Appearance of health!Lack of clarity in diagnosis!Difficulty in predicting outcomes!Day-to-day variability in functioning!Relationships

ECHO Autism

Stressors for Families

!Grief/Guilt!Tension between spouses!Tension between siblings!Adjusting to the new “normal”!Therapist coming in/out of the home/taking child to multiple therapies

ECHO Autism

Stressors for Families

!Trying to attend to other children & their activities !Tantrums!Aggression/Self Injurious Behaviors!Sleep Issues!Medical comorbidities/Special Diets!Criticism from others!Advice from EVERYONE!

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ECHO Autism

Stressors for Families

•Worry about what the future holds•Loss of friends•Financial responsibilities •Navigating systems•Events- church, family parties, friend’s houses, play-dates

•Uncertainty of what the day holds•Elopement

ECHO Autism

How can you help?

•Schedule extra time for appointments•Listen•Take time to answer questions•Value each family’s role as an equal partner •Prioritize next steps for the family•Help coordinate formal/informal supports

ECHO Autism

How can you help?

•Provide families with evidence-based resources

•Celebrate successes with families•Focus and build on the positives that each child and family possess

•Let the families know it is ok not to have all the answers today

•Encourage self-care

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How can you help?

!Encourage families to share the responsibilities of caring for their children!Encourage communication between all family members!Encourage families to go about day-to-day activities!Encourage families to learn from the past & focus on the future!End each visit on a positive note

ECHO Autism

Autism Speaks Tool Kits

!About Autism!Response to the Diagnosis!Your Role as a Parent!Building a Support Network!Support for Siblings!Taking Care of Yourself!Frequently Asked Questions!Story from a Parent

ECHO Autism

Knowledge is Power

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Abbreviation KeyADHD Attention Deficit Hyperactivity Disorder DSM-5 Diagnostic and Statistical Manual of Mental DisordersER-form Extended Release form of medicationB/P Blood pressureS/E Side effectSIB Self injurious behaviorsFLP Fasting Lipid Profile lab testHA1c Hemoglobin A1C – lab (average blood sugar in last 3 monthsCMP Comprehensive Metabolic Profile lab testBMI Body Mass IndexAIMS Abnormal Involuntary Movement ScaleQ Every

ECHO Autism

ResourcesAmerican Academy of Child & Adolescent Psychiatry (AACAP) (2014). Practice Parameter for Assessment and Treatment of Children and Adolescents with Autism Spectrum Disorder. Retrieved from http://www.jaacap.com/article/S0890-8567(13)00819-8/pdf

American Academy of Child & Adolescent Psychiatry (AACAP) (2007a). Practice Parameter for Assessment and Treatment of Children and Adolescents with Attention Deficit Hyperactivity Disorderhttp://www.jaacap.com/article/S0890-8567(09)62182-1/pdf

American Academy of Child & Adolescent Psychiatry (AACAP) (2011). Practice Parameter for use of Antipsychotic Medications in Children and Adolescents. Retrieved from https://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf

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ResourcesAmerican Academy of Child & Adolescent Psychiatry (AACAP) (2002). Practice Parameter for Use of Stimulant Medications in Children, Adolescents and Adults. Retrieved from http://www.jaacap.com/article/S0890-8567(09)60553-0/pdf

American Academy of Child & Adolescent Psychiatry (AACAP) (2002). Practice Parameter for the treatment and Assessment of Children and Adolescents with Depressive Disorders. Retrieved from http://www.jaacap.com/article/S0890-8567(09)62053-0/pdf

American Academy of Child & Adolescent Psychiatry (AACAP) (2007b). Practice Parameter for the treatment and Assessment of Children and Adolescents with Anxiety Disorders. Retrieved from http://www.jaacap.com/article/S0890-8567(09)61838-4/pdf

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ResourcesAmerican Psychiatric Association (APA) (2013). ADHD Parents Medication Guide. Retrieved from http://www.psychiatry.org/patients-families/adhd

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author

National Institute for Children’s Health Quality (NICHQ). (2002). Vanderbilt Scales. Retrieved from http://www.nichq.org/childrens-health/adhd/resources/vanderbilt-assessment-scales

Spain, D., Sin, J., Chalder, T., Murphy, D., & Happe, F. (2015). Cognitive behaviour therapy for adults with autism spectrum disorders and psychiatric co-morbidity: A review. Research in Autism Spectrum Disorders, 9, 151-162.

ECHO AutismBringingBestPracticeAutismCareto

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