Identifying Autism in Primary Care: Screening Tool …...Identifying Autism in Primary Care:...

Identifying Autism in Primary Care: Screening Tool for Toddlers and Young Children (STAT)

• Hilary Duckworth, PsyD, Behavioral Health Consultant• Kate Christian, LCSW, Behavioral Health Consultant• Eboni Winford, Ph.D., Behavioral Health Consultant

Cherokee Health Systems

Session # A2

CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York

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Slides and handouts are also available on the mobile app.

Learning ObjectivesAt the conclusion of this session, the participant will be able to:

•List two advantages of embedding BHCs into pediatric Well Child Check exams.

•Describe the rationale for implementing the STAT-BHC within Well Child Check exams.

•Describe two ways to utilize community health workers as extenders of the primary care team to reinforce autism spectrum interventions.

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Include the behavioral learning objectives you identified for this session

1. Stone, WL, McMahon, CR, Henderson, LM. (2008). Use of the Screening Tool for Autism in Two-Year-Olds (STAT) for children under 24 months: an exploratory study. Autism: International Journal of Research Practice, 12(5), 557-573.

2. Zwaigenbaum, L et al. (2015). Early screening of autism spectrum disorder: Recommendations for practice and research. Pediatrics, 136, S41-S59.

3. Pinto-Martin, J., Young, L., Mandell, D., Poghosyan, L., Giarelli, E., & Levy, S. (2008). Screening strategies for autism spectrum disorders in pediatric primary care. Journal of Developmental and Behavioral Pediatrics, 5, 345-350.

4. Chlebowski, C., Robins, D. L., Barton, M. L., & Fein, D. (2013). Large-scale use of the modified checklist for autism in low-risk toddlers. Pediatrics, 131(4), e1121-e1127.

5. Guevara, J.P., et al. (2013). Effectiveness of developmental screening in an urban setting. Pediatrics, 131(1), 30-37.6. Robins, D., et al. (2016). Universal autism screening for toddlers: Recommendations at odds. Journal of Autism and

Developmental Disorders, 46(5), 1880-1882.7. Glascoe, F. P. (2015). Evidence-based early detection of developmental behavioral problems in primary care: What

to expect and how to do it. Journal of Pediatric Health Care, 29(1), 46-53.

Bibliography / Reference

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Continuing education approval now requires that each presentation include five references within the last 5 years. Please list at least FIVE (5) references for this presentation that are no older than 5 years. Without these references, your session may NOT be approved for CE credit.

Learning AssessmentA learning assessment is required for CE credit.

A question and answer period will be conducted at the end of this presentation.

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Please incorporate audience interaction through a brief Question & Answer period during or at the conclusion of your presentation. This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy accreditation requirements.

Greetings from East Tennessee!

Our Mission…To improve the quality of life

for our patients through the blending of primary care and behavioral health.

Together… Enhancing Life

© Cherokee Health Systems 2018H E A L T H S Y S T E M S

CherokeePediatric Behavioral HealthINTEGRATED CARE

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Primary Service Area

HAMILTON

Te n n e s s e e

K e n t u c k y

G e o r g i a

HAMBLENGRAINGER

CLAIBORNE

MCMINN MONROE

LOUDON BLOUNTSEVIER

KNOXCOCKE

JEFFERSON

UNION

CAMPBELL

ANDERSON

N o r t hC a r o l i n a

V i r g i n i a

A r k a n s a s

M i s s i s s i p p i A l a b a m a

M i s s o u r i



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Cherokee Health SystemsCurrent Number of Employees: 715Current Annual Payroll: $41,390,679

Provider Staff:Psychologists - 47 Cardiologist - 1 Psychiatrists - 8Primary Care Physicians - 27 Nephrologist - 1 NP (Psych) - 9NP/PA (Primary Care) - 53 Pharmacists - 13 LCSWs - 68Community Workers - 37 RNs - 81 Dentists-2



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Giving our Best for Those Most in NeedImproving Access and Outcomes for the

Underserved

Calendar Year 2017

78,611 Patients Seen

409,363 Services Provided

25,242 New Patients



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Populations/Communities Served

• Rural Appalachian• Black/African American• Migrant/Agricultural Farm Workers• Latino/Hispanic• Homeless• Public Housing• Refugee – Africa, Middle East, Eastern Europe/Russia



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Setting the Stage



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Screening vs. Assessment



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Pediatric Well Child Checks



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Why WCCs?

• Routine points in medical/physical care • Wellness promotion, broad screening, further engagement of children

and families

• Appropriately matched assessment of wellness goals and health education at each stage of development

• BHC enhances visits with PCP • Generates awareness of our greater role within the primary care team,

services available, and critical tasks in healthy biopsychosocial development.

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Presentation Notes

Talking Points: Developmental screening tools are an invaluable component of identifying psychoeducational needs, deficits in health literacy, delayed or atypical developmental milestones (or markers for further assessment), as well as trauma, distress, and/or risks/safety concerns. Behavioral health in WCC often allows for ongoing surveillance of subclinical symptoms and this secondary prevention may prevention more chronic clinical concerns.



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WCC Primary Targets

• Healthy nutrition/activity level• Social development• Academic concerns• Behavioral and/or emotional support needs• SAFETY at all ages• Parent-child normative transitions/dynamic relationships• Caregiver skills/patient skills



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Examples of Stage-Matched Education and Intervention

Newborn

2 weeks

2 months

6 months9 months

Crib SafetyPostpartum depression

Feeding

Vocal productionIntroduction of new foods

Mobility



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12 months

18 months

24 months

30 months36 months


Language developmentGross and fine motor skills

Autism screenings



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4-6 years (annually)




School readinessSleep and

bedtime routinesConsistent limit-

settingElectronic limits

Injury preventionETOH, drugs, tobaccoSexual development

DrivingOnline safetyAutonomous

decision-makingSexual education

and health



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More on the Autism Screenings



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The STAT BHC

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjV4NHUuq_YAhUG0oMKHVw2D48QjRwIBw&url=http://vkc.mc.vanderbilt.edu/vkc/triad/stat/&psig=AOvVaw2sW9WAOhBFIVhvFRDCMmOP&ust=1514644964914188



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• Used with a refined, autism-specific parent questionnaire and interview

• 12 play-based items assessing key social-communicative behaviors

• ~20 minutes• Target age range: 24 to 36 months, can also be used

from 14 to 47 months• Strong psychometric properties

The Screening Tool for Autism in Toddlers and Young Children

(STAT, STAT-MD, STAT-BHC)



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Results: Using a rapid diagnostic model, diagnostic clarity (i.e., ASD vs. no ASD) determined within the initial consult session for 59% of the children. Latency to diagnosis was less than two months, compared with a minimum of 6 months for tertiary clinic assessment. The median age at diagnosis (32 months) was considerably lower than the national average of approximately 50 months.

“A Pilot Model for Embedding ASD Diagnosis within the Medical Home”, Unpublished Manuscript, Hine et. al.

Vanderbilt Kennedy Center



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BHCs• 3-hour training on autism• Periodic half hour training sessions on specific issues, like

sleep, behavior management, and feeding• Two-day training specific to the STAT • Periodic email updates on experience with the STAT• Access to the Developmental Psychology Team• Developmental psychologists consult on unclear STATs

STAT-BHC: Training and Quality Assurance



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STAT-BHC: Implementation

Failed MCHAT (or any

concern about autism)

STAT-BHC Rule ASD in or out

Small % receive further testing (ADOS,

BASC)

Intervention targets for all

kiddos focusing on

strengths and challenges



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Community Health Coordinators:• 3-hour training on Autism• 3-hour training on the STAT process and community resources• Assist parents as indicated with completion of developmental

questionnaire• Active involvement in the “next steps” discussion• Meet with the parents to review next steps• Collaborate with parents to refine topics for discussion with

providers

STAT-CHC: Training and Quality Assurance



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Primary care at CHS Non-primary care

Prior to STAT BHC 154 days (n=20) 134 days (n=20)STAT BHCAs of 3/27/17

34 days (n=20) 71 days (n=82)

Average Wait from Referral to Diagnosis or Rule Out

After implementing the STAT, Primary Care kids get in 52% quicker than non-primary care kids.

47% reduction in time till diagnosis

81% reduction in time till diagnosis



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Developmental Psychology

Team Referral

Cognitive Testing

Review CDI + STAT

ADOS (Structured

Play Assessment)

Play Observations

BASC-3

When the STAT is Unclear…



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• How often do we need a more in-depth evaluation?• Are we accounting for “restrictive, repetitive

patterns….?”• Is our diagnostic rate changing?• What happens to kids who are referred but don’t

come?• Can we spend more time doing intervention?

Common Questions About Using the STAT-BHC



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• Continue to collect data• Ongoing training and research• Expand to all pediatric clinic sites within our system• Continue to shorten the diagnostic delay

Next Steps



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Zachary Warren, Ph.D. and Amy Swanson, M.A.Vanderbilt Kennedy Center, Treatment and Research Institute for Autism Spectrum Disorder

vkc.mc.vanderbilt.edu/vkc/triad/training/stat Phone: (615) 322-6533 Email: [email protected]

For more information about the STAT:

mailto:[email protected]



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Identifying Autism in Primary Care: Screening Tool …...Identifying Autism in Primary Care:...

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