Jennifer Twatchman Slides - Association of Maternal & Child Health
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Transcript Jennifer Twatchman Slides - Association of Maternal & Child Health
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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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]