Jennifer Twatchman Slides - Association of Maternal & Child Health

Report
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
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
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
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
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:
–
–
–
–
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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
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
Referral & Scheduling Process
Signs/Symptoms
of ASD
observed/reported
• Family/Caregiver reports
concerns
• M-CHAT screening by PCP
• Individual working with
family reports concerns of
ASD
Referral
•Contact PCP to request referral.
•Once script received ->
paperwork sent to family
•Script is triaged by speech dept.
via brief interview
•Questionnaires to be completed
by family and school.
Appointment
Scheduled
• Once paperwork is
received (script,
questionnaires, previous
evaluations for children
≥5 years)appointment is
scheduled
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
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
Clinical Diagnostic Tools
1. DSM-IV TR (2000)/DSM-V (2013)
– Criteria review/clinical judgment
ADOS-2 (2012) – direct assessment instrument
2. 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)
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
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
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–
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Speech Therapy (individual or group)
Community-based services (Birth-to-Three, school)
Subspecialty evaluation referrals
Local support organizations
Resources (books, clinical)
Parent Training Handouts
•
•
•
•
•
•
•
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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
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)
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
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.
Thank you!
The Connecticut Children’s Team: Sarah Schlegel,
MD; Susan Roman, MPH, RN; Ann Milanese, MD
Questions?
[email protected]

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