ASD Manual PDF
ASD Manual PDF
ASD Manual PDF
b. Know the currently reported estimate of the prevalence of ASD in the U.S. _________________________
____________________________________________________________________________________
____________________________________________________________________________________
c. Describe the current evidence for the genetic etiology of ASD. ___________________________________
____________________________________________________________________________________
____________________________________________________________________________________
c. List the aspects of the physical exam that are of particular importance when evaluating for ASDs._______
____________________________________________________________________________________
____________________________________________________________________________________
20
Autism Case Training:
A Developmental-Behavioral Pediatrics Curriculum
Autism Spectrum Disorder Specific-Anticipatory Guidance
Three months ago, Billy began attending a specialized preschool in the local school district; there, he receives
speech, physical, and occupational therapies. This is the third preschool Billy has attended. He was asked to leave
his previous schools because of behavioral problems. Billy’s mother reports that his current preschool teacher
recommended that she take him to the pediatrician given concerns about his behavior. Since he began preschool,
his teachers have reported that he is extremely hyperactive, does not follow directions, and largely ignores the
children in the class.
Billy’s mother reports that he has been in good health recently. She tells you that all of his milestones were delayed,
particularly his language. She denies any history of developmental regression. She adds that Billy has made some
nice progress since he began receiving EI services. He will now use single words like “juice” and “cookie” to make
requests. At home, Billy is a “handful,” but he will usually calm down when she turns on his favorite cartoon. She
describes him as a sweet and loving boy, but she also shares that he will have prolonged tantrums when denied what
he wants and that tantrums will often occur when they are attempting to leave their house. During these tantrums,
he will frequently bang his head and bite his hand, which frightens her. For some time now she has been concerned
that Billy does not like to play with his similar-aged cousins during family get-togethers, but she thought this was
because he was an only child and didn’t like to share. She had been eagerly awaiting his first day of preschool so
that he could spend more time around other children.
When asked about family history, Billy’s mother reports that her sister’s 7-year-old son is in special education, but
she is not sure what kind of evaluation has been done as her sister “does not like to talk about these kinds of things.”
She mentions that it has been hard for the family, and she finds Billy’s preschool reports to be embarrassing and
discouraging. She is frustrated and wants the best for Billy.
Case Authors
• Kimberly Macferran, MD, University of Arkansas for Medical Sciences
• Nili Major, MD, Albert Einstein College of Medicine, Children’s Hospital Montefiore: Yale University School of Medicine
• Jill J. Fussell, MD, University of Arkansas for Medical Sciences
• Pamela High, MD, Warren Alpert Medical School of Brown University
21
Autism Case Training:
A Developmental-Behavioral Pediatrics Curriculum
Autism Spectrum Disorder Specific-Anticipatory Guidance
Case Authors
• Kimberly Macferran, MD, University of Arkansas for Medical Sciences
• Nili Major, MD, Albert Einstein College of Medicine, Children’s Hospital Montefiore: Yale University School of Medicine
• Jill J. Fussell, MD, University of Arkansas for Medical Sciences
• Pamela High, MD, Warren Alpert Medical School of Brown University
22
Autism Case Training:
A Developmental-Behavioral Pediatrics Curriculum
Autism Spectrum Disorder Specific-Anticipatory Guidance
Case Authors
• Kimberly Macferran, MD, University of Arkansas for Medical Sciences
• Nili Major, MD, Albert Einstein College of Medicine, Children’s Hospital Montefiore: Yale University School of Medicine
• Jill J. Fussell, MD, University of Arkansas for Medical Sciences
• Pamela High, MD, Warren Alpert Medical School of Brown University
23
Autism Case Training:
A Developmental-Behavioral Pediatrics Curriculum
Autism Spectrum Disorder Specific-Anticipatory Guidance
The report from the developmental-behavioral pediatrician details Billy’s medical history, developmental history, current
behavior, and family history, as well as findings on physical and neurological examination. According to the report, Billy
meets the DSM 5 criteria for a diagnosis of ASD. He has persistent deficits in social communication and social interaction
across contexts and he has two or more repetitive and restrictive behaviors. According to the report he has a severity level
of 2 for social communication and a severity level of 3 for restricted and repetitive behaviors and interests.
The report also mentions that blood was drawn at that visit for a karyotype and molecular test for fragile X, but
the results are still pending as Billy only saw the specialist last week. The psychologist’s report reviewed Billy’s
performance on cognitive testing and revealed below-age-level skills in all areas, with the most pronounced
weakness in the language domain.
On formal language testing, Billy’s receptive and expressive skills were at the 15-to 18-month level. The
occupational therapist’s report described Billy’s strengths and weaknesses in fine motor skills and adaptive
functioning and detailed some of his sensory issues that impacted his day-to-day life. All of the clinicians who
evaluated Billy thoroughly described their observations of Billy’s social interactions and behaviors during their
sessions. As part of the comprehensive evaluation, Billy also underwent ADOS-2 (Autism Diagnostic Observation
Schedule-2) testing, which supported the diagnosis of autism. Observations included Billy’s wanting to play with
a wind-up toy; he threw himself on the ground when the examiner tried to take the toy away. One clinician also
mentioned that when his name was called, he did not answer.
Billy’s mother informs you that she took a copy of the reports to Billy’s school. A meeting has been scheduled to re-
assess Billy’s educational plan. She has also been reading some information on autism and is looking into a parent
support group in her community. Billy’s mother tells you that two other families they know have sons with an ASD.
She asks why there seem to be so many more children diagnosed now than in the past.
Case Authors
• Kimberly Macferran, MD, University of Arkansas for Medical Sciences
• Nili Major, MD, Albert Einstein College of Medicine, Children’s Hospital Montefiore: Yale University School of Medicine
• Jill J. Fussell, MD, University of Arkansas for Medical Sciences
• Pamela High, MD, Warren Alpert Medical School of Brown University
24
Autism Case Training:
A Developmental-Behavioral Pediatrics Curriculum
Autism Spectrum Disorder Specific-Anticipatory Guidance
Case Authors
• Kimberly Macferran, MD, University of Arkansas for Medical Sciences
• Nili Major, MD, Albert Einstein College of Medicine, Children’s Hospital Montefiore: Yale University School of Medicine
• Jill J. Fussell, MD, University of Arkansas for Medical Sciences
• Pamela High, MD, Warren Alpert Medical School of Brown University
25
Autism Case Training:
A Developmental-Behavioral Pediatrics Curriculum
Making an Autism Spectrum Disorder Diagnosis
26
Autism Case Training:
A Developmental-Behavioral Pediatrics Curriculum
Making an Autism Spectrum Disorder Diagnosis
Fetal alcohol
There is an increased risk of ASD and other neurodevelopmental disorders in children exposed to alcohol in utero.
spectrum disorders
Genetic syndrome There may or may not be a family history, depending on the specific disorder. If dysmorphic features are present, a
genetic disorder should be considered. There are certain neurogenetic syndromes that tend to be associated with ASD.
These include, but are not limited to:
• Fragile X syndrome – intellectual disability, macrocephaly, large ears, large testicles, hypotonia, and joint
hyperextensibility
• Tuberous sclerosis – hypopigmented macules, central nervous system hamartomas, seizures, intellectual disability
• Angelman syndrome – global developmental delay, hypotonia, wide-based ataxic gait, seizures, progressive spasticity
• Rett syndrome – disorder seen primarily in girls. They have apparently normal development for the first 5 months of
life and have a normal head circumference at birth. Deceleration of head growth is seen from 5 to 48 months of age
resulting in microcephaly. They lose previously acquired hand skills and begin to have hand-wringing stereotypes.
They often develop seizures.
Hearing Impairment There may be a history of recurrent otitis media or fluid. Children with hearing impairments often have speech delays, but
will typically use compensatory nonverbal forms of communication. They make eye contact and use facial expressions.
Children with ASD may be described as having “selective hearing” (i.e., may not respond when their name is called,
but are oversensitive to other noises). Children with a hearing impairment will usually be underresponsive to all noises,
although this will be somewhat variable depending on the degree of hearing loss.
27
Autism Case Training:
A Developmental-Behavioral Pediatrics Curriculum
Making an Autism Spectrum Disorder Diagnosis
Psychosocial Children who have a history of significant abuse or neglect may be withdrawn and hesitant to interact with others. They
(e.g., neglect) may also have regression of skills, such as loss of language, and behavior problems.
Sensory Children with ASD often have sensory issues such as being hypersensitive to loud noises or avoiding certain food
problems textures. A child that has sensory impairments but is not on the autism spectrum will not have the core features of ASD
(impairments in social communication, etc.).
Speech/language Children with speech/language disorders will compensate with nonverbal forms of communication such as pointing and
disorder gestures. They lack severe social deficits, although there may be some social impairment due to the communication difficulties.
Suggested Citation: Macferran K, Major N, Fussel J, High P. Differential and Etiologic Diagnosis of Autism Spectrum Disorders. Developed for the
Autism Case Training: A Developmental-Behavioral Pediatrics Curriculum. 2011.
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Autism Case Training:
A Developmental-Behavioral Pediatrics Curriculum
Autism Spectrum Disorder Specific-Anticipatory Guidance
FIGURE 1
Surveillance and screening algorithm: ASDs.
Reproduced with permission from Pediatrics Vol. 120, Page(s) 1196-97, Copyright © 2007 by the AAP
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1196 AMERICAN ACADEMY OF PEDIATRICS
Autism Case Training:
Downloaded from pediatrics.aappublications.org by guest on June 24, 2014
A Developmental-Behavioral Pediatrics Curriculum
Autism Spectrum Disorder Specific-Anticipatory Guidance
2 - Developmental surveillance is a flexible, longitudinal, continuous, and cumulative process whereby health care
2:
Perform Surveillance
professionals identify children who may have developmental problems. There are 5 components of
developmental surveillance: eliciting and attending to the parents’ concerns about their child’s development,
Score 1 for Each Risk Factor: documenting and maintaining a developmental history, making accurate observations of the child, identifying the
- Sibling with ASD risk and protective factors, and maintaining an accurate record and documenting the process and findings. The
- Parental Concern concerns of parents, other caregivers, and pediatricians all should be included in determining whether
- Other Caregiver Concern surveillance suggests that the child may be at risk of an ASD. In addition, younger siblings of children with an
- Pediatrician Concern
ASD should also be considered at risk, because they are 10 times more likely to develop symptoms of an ASD
than children without a sibling with an ASD. Scoring risk factors will help determine the next steps. (Go to step 3)
For more information on developmental surveillance, see “Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for
Developmental Surveillance and Screening” (Pediatrics 2006;118:405-420).
4 – In the absence of established risk factors and parental/provider concerns (score=0), a level-1 ASD-specific tool should be
4: administered at the 18- and 24-month visits. (Go to step 5c) If this is not an 18- or 24-month visit, (Go to step 7b).
Is this an 18- or
24-Month Visit? Note: In the AAP policy, “Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental
Surveillance and Screening”, a general developmental screen is recommended at the 9-, 18-, and 24-or 30-month visits and an ASD screening is
recommended at the 18-month visit. This clinical report also recommends an ASD screening at the 24-month visit to identify children who may regress after
18 months of age.
AAP-recommended strategies for using ASD screening tools: “Autism: Caring for Children with Autism Spectrum Disorders: A Resource Toolkit for Clinicians” (in press)*
6a:
6a – When the result of the screening is 6b: 6b – When the result of the ASD screening (at 18-
A re th e R e su lts negative, Go to step 7a A re th e R e s u lts and 24-month visits) is negative, Go to step 7b
P o sitive o r P o s itiv e o r
C o n c e rn in g? When the result of the screening is C o n c e rn in g ? When the result of the ASD screening (at 18- and 24-
positive, Go to step 8 month visits) is positive, Go to step 8
7a: 7a – If the child demonstrates risk but has a negative screening result, 7b: 7b – If this is not an
1. Provide Parental Education information about ASDs should be provided to parents. The 18- or 24-month
1. Schedule Next
2. Schedule Extra Visit Within 1
Month pediatrician should schedule an extra visit within 1 month to address Preventive Visit visit, or when the
3. Re-enter Algorithm at 1b any residual ASD concerns or additional developmental/ behavioral 2. Re-enter Algorithm at 1a result of the ASD
concerns after a negative screening result. The child will then re-enter screening is
the algorithm at 1b. A “wait-and-see” approach is discouraged. If the only risk factor is a sibling with negative, the pediatrician can inform the
an ASD, the pediatrician should maintain a higher index of suspicion and address ASD symptoms at parents and schedule the next routine
each preventive care visit, but an early follow-up within 1 month is not necessary unless a parental preventive visit. The child will then re-enter the
concern subsequently arises. algorithm at 1a.
8: 8 – If the screening result is positive for possible ASD in step 6a or 6b, the pediatrician should provide peer reviewed
1. Provide Parental Education
and/or consensus-developed ASD materials. Because a positive screening result does not determine a diagnosis of
2. Simultaneously Refer for:
ASD, the child should be referred for a comprehensive ASD evaluation, to early intervention/early childhood education
a. Comprehensive ASD Evaluation
b. Early Intervention/Early Childhood services (depending on child’s age), and an audiologic evaluation. A categorical diagnosis is not needed to access
Education Services intervention services. These programs often provide evaluations and other services even before a medical evaluation
c. Audiologic Evaluation is complete. A referral to intervention services or school also is indicated when other developmental/behavioral
3. Schedule Follow-up Visit concerns exist, even though the ASD screening result is negative. The child should be scheduled for a follow-up visit
4. Re-enter Algorithm at 1b and will then re-enter the algorithm at 1b. All communication between the referral sources and the pediatrician should
be coordinated.
AAP information for parents about ASDs includes: “Is Your One-Year-Old Communicating with You?*” and “Understanding Autism Spectrum Disorders.*”
*Available at www.aap.org
FIGURE 1
Continued
A1. D
eficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of
normal back- and- forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or
respond to social interactions.
A2. D
eficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly
integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits
in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
A3. D
eficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties
adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends;
to absences of interest in peers.
_____ B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least 2 of 4 symptoms currently or by history
B1. S tereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining
up toys or flipping objects, echolalia, idiosyncratic phrases).
B2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior
(e.g. extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need
to take same route or eat same food everyday).
B3. H ighly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or
preoccupation with unusual objects, excessively circumscribed or preservative interest).
B4. H yper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g.,
apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling
or touching of objects, visual fascination with lights or movement)
_____ C. Symptoms must be present in the early developmental periods ( but may not become fully manifest until social demands
exceed limited capacities, or may be masked by learned strategies in later life)
_____ D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
(minimum = level 1)
_____ Social Communication Severity Level (1, 2, or 3)
_____ Restricted Repetitive Behavior Severity Level (1, 2, or 3)
_____ E. These disturbances are not better explained by intellectual disability (intellectual development disorder) or global
developmental delay.
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Autism Case Training:
A Developmental-Behavioral Pediatrics Curriculum
Autism Spectrum Disorder Specific-Anticipatory Guidance
American Psychiatric Association. Pervasive developmental disorders. In: Diagnostic and Statistical Manual of Mental
Disorders. 5th ed.-text revision (DSM-5). Washington, DC: American Psychiatric Association; 2013.
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Autism Case Training:
A Developmental-Behavioral Pediatrics Curriculum
Fragile X Syndrome
Autism Spectrum Disorder Specific-Anticipatory Guidance
FACT SHEET
1-800-CDC-INFO | www.cdc.gov/actearly
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References
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Autism Case Training:
A Developmental-Behavioral Pediatrics Curriculum