Enhancing Diagnostic Follow-up and Care Coordination for Children with Autism in a Busy Resident Continuity Clinic: Leveraging the Electronic Health Record.

PURPOSE: A high-quality primary care clinic should provide clear action points and important care coordination for a child receiving a new diagnosis of autism spectrum disorder (ASD). Unfortunately, a substantial proportion of caregivers report little-to-no post-diagnosis support from their home clinics and primary care providers often report lack of training and resources in providing these supports. METHODS: We implemented an intervention package to investigate the impact on the frequency and quality of follow-up care for children with ASD in a busy, high-volume resident continuity clinic. The package consisted of a care coordination scheduling pathway and a standardized clinical template-embedded in the electronic health record (EHR)-that guided providers through best-practice recommendations and patient resources. RESULTS: As a result of these interventions, 74% of patients had ASD-specific follow-up, a more than threefold increase from baseline with a majority of providers using the EHR-embedded template to guide their visit. Providers also indicated a high degree of usability for the system and that it aided them in following best-practice guidelines for ASD care. CONCLUSION: Through explicit scheduling pathways and a novel EHR template, we saw a significant increase in ASD-specific follow-up visits and implementation of best practices for ASD care, demonstrating a new process for training and engaging primary care providers in clear action steps for post-diagnostic care without having to rely on tertiary referrals.

Enhancing developmental-behavioral pediatric rotations by teaching residents how to evaluate autism in primary care.

LAY ABSTRACT: Most physician preparation programs do not provide enough practical experiences in autism-related care. This is especially true for how to assess for and diagnose autism. Without this training, many pediatricians are not well prepared to implement appropriate care for children with autism and their families. We designed a curriculum to improve training for medical residents that involved explicit hands-on training in diagnostic identification and care coordination for toddlers at risk for autism. We collected data to assess whether our enhanced curriculum led to increased comfort level across recommended practice behaviors. Almost all the residents were able to complete the training within their rotation and our surveys indicated significant increases in residents feeling more comfortable identifying symptoms of autism, providing feedback about diagnostic decisions, and effectively connecting families with services. A significant majority of residents considered it appropriate or very appropriate for children to receive a diagnosis solely from a primary care provider. Our results suggest feasibility of the enhanced model, and this project reflects the first step in advancing incorporation of autism training into pediatric residency programs.

Increasing Access to Autism Spectrum Disorder Diagnostic Consultation in Rural and Underserved Communities: Streamlined Evaluation Within Primary Care.

OBJECTIVE: Preliminary feasibility and clinical utility research has demonstrated that implementation of a streamlined diagnostic model embedded within primary care (PC) clinics promotes early identification of young children with autism spectrum disorder (ASD). Use of this model results in dramatically reduced waits for diagnostic consultation, high levels of family/provider satisfaction, and reductions in referrals to overtaxed tertiary diagnostic centers. The current study extends this work by providing data before/after implementation of a streamlined model across a diverse range of PC clinics that provide health care to rural and underserved communities. METHODS: The streamlined assessment involved record/history review, diagnostic interview, standard rating scales, and an interactive screening tool. Eighty children between the ages of 19 and 47 months were seen across 5 different clinics. Data were collected through chart review. RESULTS: Implementation of streamlined model resulted in a significant decrease in latency to diagnostic conclusion from a mean of 144.7 to 49.9 days. Children were likely to experience a greater reduction in wait times if they were a PC patient versus a non-PC patient. CONCLUSION: Results show significant reduction in wait times for ASD diagnostic decisions across both PC and non-PC patients. By reducing waits and identifying concerns more efficiently, we may increase the ability of families to access early intervention and support services.

Decreasing disruptive behaviour during routine dental visits: a video modelling intervention for young children.

OBJECTIVE: To evaluate the benefits of a collaborative partnership between paediatric dentists and behavioural health providers in which a practical video modelling intervention, with the aim to reduce disruptive behaviours in young children, is implemented. METHODS: The video was created by a dentist using readily available technology and implemented in a busy practice setting. A clinical sample of 40 children, 3-6 years old, was recruited from a continuous sample of patients seen at the clinic. Participants were randomised into two groups and shown either the brief video model or a control video prior to a routine dental visit. All sessions were videotaped and independently scored by blinded observers. Behavioural data were recorded using 15-second partial-interval recording and included physical and vocal disruptions. Subjective measures of cooperation were also completed by observers and dental professionals. RESULTS: Independent samples t-tests show that the treatment group had a significantly lower mean percentage of intervals in which disruptive behaviour was observed [t(38) = 2.94, P = 0.008] compared with the control group. Subjective rating scales revealed significantly higher ratings of cooperation for the treatment group from the dentist [t(38) = -5.19, P = 0.000], the dental assistant [t(38) = -4.01, P = 0.001] and the blinded coder [t(38) = -3.54, P = 0.002]. Significant relationships were found between the percentage of actual disruptive behaviour and subjective ratings of the dentist (r = -0.82, P < 0.01). CONCLUSIONS: Watching a brief dentist-created video model of expected procedures can reduce disruptive behaviour and increase cooperation for young children making their first visit to a busy medical setting.

Embedding Autism Spectrum Disorder Diagnosis Within the Medical Home: Decreasing Wait Times Through Streamlined Assessment.

Long waits for diagnostic assessment prevent early identification of children suspected of having autism spectrum disorder. We evaluated the benefit of embedded diagnostic consultation within primary care clinics. Using a streamlined diagnostic model, 119 children with concerns for autism spectrum disorder were seen over 14 months. Diagnostic clarity was determined through streamlined assessment for 59% of the children, while others required follow-up. Latency from first concern to diagnosis was 55 days and median age at diagnosis was 32 months: considerably lower than national averages or comparable tertiary clinics. Findings support that embedded processes for effective triage and diagnosis within the medical home is a viable mechanism for efficient access to diagnostic services and assists in bypassing a common barrier to specialized services.

Physician Satisfaction With Integrated Behavioral Health in Pediatric Primary Care.

As the benefits of integrated behavioral health care services are becoming more widely recognized, this study investigated physician satisfaction with ongoing integrated psychology services in pediatric primary care clinics. Data were collected across 5 urban and 6 rural clinics and demonstrated the specific factors that physicians view as assets to having efficient access to a pediatric behavioral health practitioner. Results indicated significant satisfaction related to quality and continuity of care and improved access to services. Such models of care may increase access to care and reduce other service barriers encountered by individuals and their families with behavioral health concerns (ie, those who otherwise would seek services through referrals to traditional tertiary care facilities).

A Methodological Discussion of Caffeine Research and Animal Avoidance Behavior.

Introduction: We present a review of the methodological aspects of caffeine research within animal tests of escape and avoidance behavior in the presence of aversive stimuli. Method: We highlight species, methods of caffeine administration, dosage, dependent measures, and research designs commonly used in this research. Results: Typical subjects were rodents and zebrafish, with species-specific vehicles of caffeine administration and dependent measures. Behavioral tests for escape and avoidance as a function of caffeine consumption were conceptually similar across species, although the arrangement of measures was necessarily adapted to the physiological contingencies of the different species. Discussion and Conclusions: Caffeine administration preceding the presentation of aversive stimuli generally, but not exclusively, enhanced the effect of escape and avoidance of aversive stimuli. The many commonalities in methods and results across species suggest similar methods may be relevant to human subjects as well.

Phone Consultation for Behavioral Health-Related Referrals in Integrated Primary Care.

Behavioral health (BH) providers add value to primary care teams. This descriptive study illustrates one such role that the BH provider can serve. The on-site BH provider responded to patient phone inquiries regarding BH topics for pediatricians over the course of 15 months. The majority of these calls were for children 10 years and younger and related to externalizing problems. Phone calls were relatively brief (i.e., 11-15 minutes). More than half of these phone calls resulted in families scheduling an appointment with nearly 75% showing up for the initial session. Providing this type of adjunctive service may result in earlier access to care and efficiently assigning responsibilities to the appropriate team member.

Decreasing transition times in elementary school classrooms: Using computer-assisted instruction to automate intervention components.

Research suggests that students spend a substantial amount of time transitioning between classroom activities, which may reduce time spent academically engaged. This study used an ABAB design to evaluate the effects of a computer-assisted intervention that automated intervention components previously shown to decrease transition times. We examined the effects of the intervention on the latency to on-task behavior of 4 students in 2 classrooms. Data also were collected on students' on-task behavior during activities and teachers' use of prompts and praise statements. Implementation of the intervention substantially decreased students' latencies to on-task behavior and increased on-task behavior overall. Further, the 2 teachers used fewer prompts to cue students to transition and stay on task and provided more praise during intervention phases. We discuss how automating classroom interventions may affect student and teacher behavior as well as how it may increase procedural fidelity.

Functional analysis in public schools: a summary of 90 functional analyses.

Several review and epidemiological studies have been conducted over recent years to inform behavior analysts of functional analysis outcomes. None to date have closely examined demographic and clinical data for functional analyses conducted exclusively in public school settings. The current paper presents a data-based summary of 90 functional analyses conducted in public school settings from 2006 through 2009 for 69 students. Specifically, we present data on gender, age, race, diagnosis, topography of target behaviors, number of conditions, duration of sessions, duration of analysis, functional outcomes, setting, and person serving the role of therapist. Results suggest that functional analyses in schools are possible, practical, and produce results that are comparable to those in past research.