Professional Resource

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Member Corner: Kelley Abrams, Ph.D. & Jayne Singer, Ph.D.

Recently a member posted on Member Connect that she and her colleagues had been “seeing younger and younger children with red flags for Autism Spectrum Disorder [ASD],” asking members for diagnostic tools that are specifically designed for infants and toddlers. Two members shared very helpful information that we didn’t want you to miss!

Member:

Kelley Abrams, Ph.D., Developmental Psychologist, www.kelleyabrams.com

My name is Kelley Abrams, Ph.D. I am a developmental psychologist and 2003 Fellow with Zero to Three. On the topic of Autism evaluations and younger children, I wanted to share information about a new tool being developed at Cognoa, Inc, which utilizes machine learning, that is showing promising high sensitivity and specificity such that it might prove useful as a diagnostic aid, even within the primary care setting.

The tool is delivered via a mobile app and involves a short parent questionnaire and a few brief home videos of the child’s behavior scored by trained analysts. The platform also contains other child development and parent support information, including developmentally appropriate/therapeutic at-home activities.

The tool has been clinically validated in at-risk children 18 months through age 5. A prospective validation study in a more general population is underway. To date, it has significantly outperformed other standard screening tools, and was found to be 83% specific at 90% sensitivity for correctly identifying children 18 months - age 5 diagnosed with autism.

I would be happy to provide more information to anyone who is interested. Please feel free to contact me. I am so pleased to read about other efforts across the country at lowering the age of diagnosis, which unfortunately remains at a national average of over 4 years old.

Member:

Jayne Singer, Ph.D., Clinical Psychologist, Brazelton Touchpoints Center, Boston Children’s Hospital, Jayne.singer@childrens.harvard.edu

Here at Boston Children’s Hospital, I co-founded an early autism detection service within the Developmental Medicine Center. It began as one morning clinic per month more than ten years ago and now, there are 3-4 morning clinics per week– so, yes, we are definitely seeing more younger children presenting for evaluations of signs of autism. I am a strong proponent of early diagnosis since the research is so clear that the younger the child gains access to specialty services, the better the outcomes. It is critical that children are diagnosed well under the age of three years.

The goal is to see the youngest children referred in for ASD evaluations as quickly as possible and connect them with services as early as possible for best outcomes. Here in Massachusetts, a child cannot access autism specialty services without an evaluation independent of Early Intervention (EI), and a formal diagnosis. Typically, for the “fast- track”, a child is younger than 27 months, has a “failed” M-CHAT [Modified Checklist for Autism in Toddlers], has at least one person involved with them who is specifically concerned about autism, and does not have an existing ASD diagnosis and/or services already from another diagnostic process. (Children can be seen for a second opinion – i.e., no referral is turned away– but children without services are given priority to be seen first.]) Primary pediatricians across the state conduct the M-CHAT at 18-month and 24-month well-child visits. They and EI are typically the referral sources.

In clinic, the child is seen by a team consisting of a psychologist and a developmental pediatrician. The psych conducts developmental testing (Bayley III, REEL3, Bayley Social-Emotional, ADOS-T); the pediatrician conducts a developmental history and physical exam that includes such things as examination of the subcutaneous skin with a Wood’s Lamp for signs of physical/medical conditions that can be associated with symptoms of ASD. The Bayley III cognitive scale is conducted in order to best interpret the ADOS-T; as the child should have a developmental mental age of at least 12 months to validly interpret the ADOS-T. When a child’s cognitive functioning is below 12 months, one option is to conduct the AOSI (created by Dr. Alice Clark at UMass Boston). The other is to apply clinical judgment upon what verbal and non-verbal communication skills, social reciprocity, and level of play skills we would expect from a child of the patient’s cognitive age; along with observations of any repetitive, self-stimulatory behaviors (e.g., even if an 18-month old’s cognitive age is say, 11 months, we still should expect social eye contact, person permanence, social referencing, gesturing, and imitation if the child does not have autism). The ‘new’ option within the DC:0-5 of suspected early autism crosswalks to the same ICD diagnostic code for ASD (i.e., F84) and has been very useful. Of course, some young children do show global developmental delays at such a severe level that it is not clear yet whether autism is the explanation for their behavior. Most of the time, though, careful diagnostics do tease this out. The youngest child for whom I’ve proceeded with an ASD diagnosis was 12 months old; and his was a clear case of notable regression from 9 til 12 months in the context of having an older brother with autism.

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