Rapid Recognition: Training Pediatricians to Assess Autism

CINDY SANDERS

Rapid Recognition: Training Pediatricians to Assess Autism

Dr. Quentin Humberd, TNAAP Immediate Past President
One in 1,923 (1999) … one in 264 (2003) … one in 150 (today) … the prevalence rate of being diagnosed with an autism spectrum disorder (ASD) continues to escalate. Unfortunately, the number of trained professionals able to provide an accurate diagnosis is not rising nearly as quickly.

In a field where conventional wisdom — and a growing body of evidence — suggests early intervention is a key element in impacting outcomes, time is clearly of the essence.

In 2007, the Bureau of TennCare announced a grant given to the Tennessee chapter of the American Academy of Pediatrics (TNAAP) to attempt to get more eyes focused on the issue of accurately assessing children suspected of falling somewhere on the autism spectrum.

The program, Screening Tools and Referral Training — Evaluation and Diagnosis (START-ED), is set up as a cooperative effort between the Vanderbilt Kennedy Center’s internationally renowned Treatment and Research Institute for Autism Spectrum Disorders (TRIAD) and TNAAP.

Wendy Stone, PhD, a clinical psychologist and the TRIAD director, said the program was the brainchild of Clarksville pediatrician Dr. Quentin Humberd, the immediate past president of TNAAP who is subspecialty certified in developmental and behavioral pediatrics.

“It was really his idea to empower pediatricians to have methods to identify autism,” said Stone, who is also a Vanderbilt Kennedy Center investigator and a professor of pediatrics at the university.

“It’s really to give pediatricians methods for assessment,” she continued. “Even if they do the screenings recommended by the AAP at 18 and 30 months, there’s a really long wait for the diagnostic evaluation, and the diagnosis is often required to be eligible to participate in interventions.”
Humberd, who now runs the Exceptional Family Member Program for military families at Fort Campbell, said there has been a national emphasis on developmental, behavioral and emotional screening since 2001.

“Just a few years ago, the average age of diagnosis by a physician was 48 months. This is the same age as a greeter at Wal-Mart can diagnose a child with autism,” he said dryly. The point, he continued, is that by the time an autistic child is four-to-five years of age, it is pretty evident their social patterns and emotional behaviors are quite different from their peers.

Since 2003, TNAAP has been working closely with TennCare officials to improve compliance with the federal EPSDT (Early Periodic Screening, Diagnosis, & Treatment) mandate. The two organizations partnered to provide office-based screening tools for autism and have trained approximately 200 practices to date.

“We feel it is realistic to begin the diagnosis as early as 24 months,” Humberd said, adding that Dr. Stone created STAT (the Screening Tool for Autism in Two Year Olds), which uses 12 interactive measures to screen children between 24 and 36 months of age. “There is a window of opportunity to help children with interventions, many of which have been developed at Vanderbilt.”

Humberd noted that the successful screening initiative brought to light another problem, an increased need for professionals who could accurately diagnose those children suspected of ASD during the screening. This capability didn’t exist in Tennessee or anywhere else in the country.

Building on that basis, five pediatricians were invited to participate in the START ED pilot program funded by the TennCare grant. Those selected had a wealth of general pediatric experience but no specialty training in autism.
Stone said the five came to TRIAD for a two-day intensive training session this past summer. Physicians learned to employ a three-prong method to diagnose autism in younger children – 1) structured interactions with young children, 2) parent interviews to collect detailed information about the child’s social interaction and communication in play and development, and 3) incidental observations such as watching the child as they moved from the waiting room to the exam room or how the child reacts when new people come into a room.

Next, the pediatricians returned to their practices with camcorders so their field autism screenings and assessments could be videotaped and sent back to Vanderbilt for review and feedback.

The project has just entered its next phase where the trained pediatricians will conduct independent assessments from start to finish. The physicians will then send a mix of children to TRIAD - those for which there are areas of concern and those which show no early warning signs of autism - for evaluation by the experts.

“It is to assess reliability,” Stone said. “What we want is to agree with them. Then, it will suggest the training is effective.”

She added that if the training is deemed effective, TRIAD and TNAAP will certainly look at ways to expand the program across the state. Humberd pointed out autism doesn’t have a gold standard test to give clinicians a definite “yes/no” answer. However, he said, in the videotape phase of the START ED pilot, the physicians and experts have agreed about 75 percent of the time.
It’s imperative, he added, to effectively train more physicians. While certainly not a moneymaker, Humberd said it is sustainable with current billing codes to complete one or two assessments a week, each of which take about an hour.

“It’s a very important service to provide to the communities,” he stressed. Humberd added with today’s prevalence rates, every single practice could be expected to have six or more children with ASD under their care.

“It’s more prevalent than Down syndrome, more prevalent than childhood diabetes and far more prevalent than childhood cancer. We want to get kids in early, before their third birthday, so they can get into state interventions and hopefully change outcomes,” he concluded.



April 2008