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-SLPDepartment of Speech-Language Pathology

Lead Clinician ~ Autism Spectrum Assessment Program

ASAPGoal: Obtain a diagnosis “as soon as

possible” in order to jump-start interventionObjective 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 testLead level (particularly for young or impaired children)Results of other relevant tests (e.g., Fragile X)

Information from families/other providers:Parent questionnaireSchool questionnaireRecent evaluations (children five years of age and over)

Obtained before appointment is scheduled, age 6 and upAge 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:

– 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

The Team

Patient’s families/caregiversPrimary care providersEducators and other outside cliniciansAutism 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 Tools1. DSM-IV TR (2000)/DSM-V (2013)

– Criteria review/clinical judgmentADOS-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 ASDParent training handoutsFollow-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– Speech Therapy (individual or group)

– Community-based services (Birth-to-Three, school)

– Subspecialty evaluation referrals

– Local support organizations

– Resources (books, clinical)

Parent Training Handouts• 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 CCMCFollow-up offered as regular DBP continuity careOutpatient speech/language therapy

Additional speech and language testingOutpatient social language therapy

IndividualSocial communication (conversation, negotiation, basic needs)Problem solvingComprehension and use of nonverbal signalsParent training

GroupReadiness for group established (social language level and behavioral

regulation)Peer modelingGeneralization 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.

jtwachtman@ccmckids.org