Autism Training program meets 'critical need' for earlier identification

A Vanderbilt research program that trains community pediatricians to diagnose autism within their individual practices may lead to more effective treatment of the disorder that now affects an estimated one in 88 children.

Vanderbilt University Medical Center researchers released today in the journal Autism the results of a three-year study that evaluated the effectiveness of a training program designed to enhance autism spectrum disorder (ASD) identification and assessment within community pediatric settings across Tennessee.

After participating in training to learn strategies for conducting rapid diagnostic assessments following positive ASD screenings, pediatricians reported significant changes in their screening and consultation practices, with 85 percent reporting an increase in numbers of children with autism evaluated within their practice.

The study also found that pediatric providers were nearly as accurate as specialists in their diagnoses, with agreement seen in more than 90 percent of all cases.

"Ideally, definitive early diagnosis of ASD would be rapidly accomplished by a team of developmental specialists, and children at risk for diagnosis would obtain services immediately after screening positive.

Zachary Warren

The reality is that such diagnostic teams, or even individual professionals, are not available in most locations," said corresponding author Zachary Warren, Ph.D., associate professor of Pediatrics, Psychiatry and Special Education and director of the Vanderbilt Kennedy Center's Treatment and Research Institute for Autism Spectrum Disorders (TRIAD) at Vanderbilt University.

"Even when available, the waitlists for diagnostic services are so long that children referred for evaluation wait extended periods of time for diagnosis. As a parent, I cannot fathom how stressful it would be to be told that your child may have autism, and we'll let you know the answer to that question in six to 12 months."

Despite screening initiatives, advocacy efforts and increased public awareness, the most recent Centers for Disease Control and Prevention data regarding autism prevalence suggest that the diagnosis is still not made until 4-5 years of age.

The increased prevalence of autism and documented benefits of early intensive intervention have created a need for flexible systems for obtaining accurate, time-efficient diagnoses, the authors wrote.

"Although the field has made great advances in early screening for autism, the steps taken after a positive ASD screening in community settings are much less clear and often problematic for clinicians, families and systems of care alike," Warren said.

"Essentially, more children are being referred for a very limited number of expert diagnostic assessment resources. Because of this, wide-scale screening for ASD at young ages may in fact increase wait times for diagnostic assessment. Given this context, it is critical to develop enhanced ASD-specific diagnostic training programs if we hope to shift the age of diagnosis and promote earlier access to early intervention."

Amy Swanson

The training was designed to teach enhanced diagnostic consultation and interactive screening procedures to community pediatricians so that they could offer families the opportunity to be rapidly evaluated within practice rather than being referred to a specialty clinic, where they would likely have to wait many months before being seen.

"The findings provide initial evidence suggesting early accurate diagnosis of autism may be possible and appropriate within many community pediatric practices," said Amy Swanson, M.A., TRIAD Research and Training Coordinator and lead author of the study.

"Given the potentially harmful consequences of lengthy waits for comprehensive diagnostic evaluations, the potential impact of such training programs for advanced autism diagnosis within community practice settings could be quite powerful."

Key findings:

• Community pediatric providers were more likely to conduct independent autism assessments within their practice, rather than referring the child for outside evaluation.
• Community pediatric providers showed high agreement in ASD classification with expert clinicians.
• A dramatic shift was seen in pediatric providers' sense of the appropriateness for a child to receive a diagnosis from his or her primary care provider, without or before a comprehensive evaluation.
• A dramatic shift in the comfort level of discussing ASD diagnoses with caregivers was seen.
• There was a significant increase in the number of diagnoses made within respective provider practices.

This study builds on pilot findings from 2009 by presenting a more comprehensive evaluation of the training model and utilizing a broader sample of pediatric providers.

Although this training program targeted the state of Tennessee, Vanderbilt's research team has also provided this training in several other states and presented the model to the Society for Developmental and Behavioural Pediatrics.

Preschoolers With ADHD: 90 Percent of Pediatric Specialists Not Following Treatment Clinical Guidelines

A recent study by pediatricians from the Cohen Children's Medical Center of New York examined to what extent pediatric physicians adhere to American Academy of Pediatrics (AAP) clinical guidelines regarding pharmacotherapy in treating young patients with Attention Deficit Hyperactivity Disorder (ADHD).

The results showed that more than 90 percent of medical specialists who diagnose and manage ADHD in preschoolers do not follow treatment guidelines recently published by the AAP.

Andrew Adesman

"It is unclear why so many physicians who specialize in the management of ADHD -- child neurologists, psychiatrists and developmental pediatricians -- fail to comply with recently published treatment guidelines," said Andrew Adesman, MD, senior investigator and chief of developmental and behavioral pediatrics at Cohen Children's Medical Center in New Hyde Park.

"With the AAP now extending its diagnosis and treatment guidelines down to preschoolers, it is likely that more young children will be diagnosed with ADHD even before entering kindergarten.

Primary care physicians and pediatric specialists should recommend behavior therapy as the first line treatment."

Current clinical guidelines for pediatricians and child psychiatrists associated with the American Academy of Child & Adolescent Psychiatry (AACAP) recommend that behaviour therapy be the initial treatment approach for preschoolers with ADHD, and that treatment with medication should only be pursued when counseling in behavior management is not successful.

The study also found that more than one-in-five specialists who diagnose and manage ADHD in preschoolers recommend pharmacotherapy as a first-line treatment alone or in conjunction with behavior therapy.

Although the AAP recommends that pediatricians prescribe methylphenidate when medication is indicated, more than one-third of specialists who prescribe medication for preschool ADHD said they 'often' or 'very often' choose a medication other than methylphenidate initially (19.4 percent amphetamines; 18.9 percent non-stimulants).

"Although the AAP's new ADHD guidelines were developed for primary care pediatricians, it is clear that many medical subspecialists who care for young children with ADHD fail to follow recently published guidelines," said Jaeah Chung, MD, the study's principal investigator who also practices at Cohen Children's.

"At a time when there are public and professional concerns about over-medication of young children with ADHD, it seems that many medical specialists are recommending medication as part of their initial treatment plan for these children."