assessment and management of autism spectrum disorder … conference presentations... · assessment...

Assessment and Management of Autism Spectrum Disorder in the Primary Care Setting

Stephanie Spaulding, RN, BSN, OCN, NP-S University of California Irvine March 21, 2015

Disclosures

• Relevant Financial Disclosures

I have no financial relationships or

affiliations related to this presentation

to disclose.

Disclosures

• Non-FDA Approved Uses

o Brief discussion of off-label use of

pharmacotherapeutics in specialty care

practice and implications for primary care

o Examples: Selective Serotonin Reuptake Inhibitors

(SSRIs); stimulants; alpha-2 adrenergic agonists;

atypical neuroleptics

Disclosures

Autism Spectrum Disorder: Prevalence • 5th most prevalent pediatric mental

health disorder in the United States 1

• Rapidly increasing prevalence: o 1943: RARE – 2-4 per 10,000 children2

o 2006: Approximately 1 in 110 children3

o 2010: Approximately 1 in 68 children1

Autism Spectrum Disorder: Prevalence • Disproportionately impacts boys over

girls at a rate of almost 5:1 3

o 1 in 42 boys in the United States 3

o Studies suggest comparable or higher

prevalence rates in other parts of the

world 3,4

Autism Spectrum Disorder: Etiology • 10% of cases have identifiable genetic and

chromosomal etiologies (Fragile X Syndrome,

tuberous sclerosis, metabolic syndromes) 5

• Majority of cases (90%) are idiopathic with

potentially multiple genetic determinants and

environmental contributing factors 5

Autism Spectrum Disorder: Defined

• Complex and potentially multiple etiologies

o The Autisms 6

• ASD is a group of disorders currently

diagnosed clinically by core symptoms set

forth in the Diagnostic and Statistical Manual

of Mental Disorders (DSM V) 7

Autism Spectrum Disorder: DX Criteria – The Long Form

• Diagnostic and Statistical Manual of Mental Disorders (DSM V Criteria) 7

• A. Persistent deficits in social communication and social

interaction across multiple contexts, as manifested by the

following, currently or by history (examples are illustrative,

not exhaustive):

o 1. Deficits in social-emotional reciprocity, ranging, for example,

from abnormal social approach and failure of normal back-and-

forth conversation; to reduced sharing of interests, emotions, or

affect; to failure to initiate or respond to social interactions.


• Diagnostic and Statistical Manual of Mental Disorders (DSM V Criteria Continued) 7

o 2. Deficits in nonverbal communicative behaviors used for social

interaction, ranging, for example, from poorly integrated verbal

and nonverbal communication; to abnormalities in eye contact

and body language or deficits in understanding and use of

gestures; to a total lack of facial expressions and nonverbal

communication.



o 3. Deficits in developing, maintaining, and understanding

relationships, ranging, for example, from difficulties adjusting

behavior to suit various social contexts; to difficulties in sharing

imaginative play or in making friends; to absence of interest in

peers.

• Severity is based on social communication impairments and

restricted repetitive patterns of behavior.



• B. Restricted, repetitive patterns of behavior, interests, or

activities, as manifested by at least two of the following,

currently or by history (examples are illustrative, not

exhaustive):

o 1. Stereotyped or repetitive motor movements, use of objects, or

speech (e.g., simple motor stereotypies, lining up toys or flipping

objects, echolalia, idiosyncratic phrases). 7



o 2. Insistence on sameness, inflexible adherence to routines, or

ritualized patterns or verbal nonverbal behavior (e.g., extreme

distress at small changes, difficulties with transitions, rigid

thinking patterns, greeting rituals, need to take same route or eat

food every day).

o 3. Highly restricted, fixated interests that are abnormal in

intensity or focus (e.g, strong attachment to or preoccupation with

unusual objects, excessively circumscribed or perseverative

interest).



o 4. Hyper- or hypo-reactivity to sensory input or unusual interests

in sensory aspects of the environment (e.g., apparent indifference

to pain/temperature, adverse response to specific sounds or

textures, excessive smelling or touching of objects, visual

fascination with lights or movement).

• Severity is based on social communication impairments and

restricted, repetitive patterns of behavior.



• C. Symptoms must be present in the early developmental

period (but may not become fully manifest until social

demands exceed limited capacities, or may be masked by

learned strategies in later life).

• D. Symptoms cause clinically significant impairment in

social, occupational, or other important areas of current

functioning.



• E. These disturbances are not better explained by

intellectual disability (intellectual developmental disorder)

or global developmental delay. Intellectual disability and

autism spectrum disorder frequently co-occur; to make

comorbid diagnoses of autism spectrum disorder and

intellectual disability, social communication should be below

that expected for general developmental level.



• Note: Individuals with a well-established DSM-IV diagnosis

of autistic disorder, Asperger’s disorder, or pervasive

developmental disorder not otherwise specified should be

given the diagnosis of autism spectrum disorder. Individuals

who have marked deficits in social communication, but

whose symptoms do not otherwise meet criteria for autism

spectrum disorder, should be evaluated for social

(pragmatic) communication disorder.

Autism Spectrum Disorder: Diagnosis Criteria Summary

o Communication and social interaction

deficits

o Restricted repetitive language and behaviors

o Inflexibility and rigidity

o Sensorimotor dysregulation (hypo and hyper-reactivity)

o Impact: Mild to Severe 7

Why Does This Matter to Primary Care Nurse Practitioners?

• Per the Council of Pediatric Subspecialties:

o HUGE SHORTAGE of specialty providers in

pediatric mental health across the U.S.

o Less than 7, 500 practicing child and adolescent

psychiatrists and less than 600 developmental

behavioral pediatricians

o Only 20% of children with emotional/behavioral

problems receiving any mental health treatment 8,9

Why Does This Matter to Primary Care Nurse Practitioners?

• Shortages of specialty providers and shortages in State funding can mean delays of months to over a year for access

• With no current curative interventions, early and intensive intervention has been found to be the most effective strategy for maximizing function in ASD5

Role of Nurse Practitioners in ASD Assessment and Management

• Early identification and timely referral o For Evaluation/Diagnosis, Audiology, PT, OT, Speech,

Behavioral

• Assessment and management of common

problems and comorbidities seen in ASD o Alteration in Nutrition, GI/Toileting, Sleep Disturbance

• Co-management of medications prescribed in

specialty practice

Early Identification of ASD

• Autism Spectrum Disorder often presents prior to

the age of 2 years and initial symptoms may be

apparent at birth10

• Listen to parents: Their concern is a good predictor

of atypical development prior to 24 months10,11

• Better outcomes are linked to more intensive

behavioral regimens started at a younger age

(prior to 2-3 years of age) but there is no point where

not beneficial11

Early Identification of ASD: RED FLAGS

RECOGNIZE THE SYMPTOMS:10

• Not respond consistently to their name by 12 months

• Not point at objects to show interest by 14 months

• Not play "pretend" games by 18 months (feed a baby)

• Avoid eye contact and want to be alone

• Have delayed speech and language skills

• Repeat words or phrases over and over (echolalia)

• Have trouble understanding other people's feelings or

talking about their own feelings

Early Identification of ASD: RED FLAGS

RECOGNIZE THE SYMPTOMS:10

• Give unrelated answers to questions

• Get upset by minor changes and transitions

• Have obsessive interests

• Flap their hands, rock their body, or spin in circles

• Have unusual reactions to the way things sound, smell,

taste, look, or feel

• Demonstrate repetitive or atypical play (lining up long

rows of cars, patting toys)

Early Identification of Children at Risk for ASD: Screening

American Academy of Pediatricians:12

• Screen ALL children for developmental delay: o At 9 months o At 18 months o At 24 months o At 30 months o Surveillance throughout school age years o HIGH RISK: sibling or parent with ASD,

preterm, low birth weight

Early Identification of Children at Risk for ASD: Screening Tools13, 14

Ages and Stages Questionnaires (ASQ):

o General developmental screening tool

o Parent-completed questionnaire

o P/F screen per domain: communication, gross motor, fine

motor, problem-solving, and personal adaptive skills.

Communication and Symbolic Behavior Scales (SCBS):

o Standardized tool for screening communication and

symbolic ability up to 24 months

o 1 page parent completed tool

http://agesandstages.com/what-is-asq

http://agesandstages.com/what-is-asq

Early Identification of Children at Risk for ASD: Screening Tools 13, 14

Parents’ Evaluation of Developmental Status (PEDS):

o General developmental screening tool

o Parent interview form

o Screens for developmental and behavioral problems

o Single response form used for all ages--may be useful as a

surveillance tool

BRIGANCE ® Early Childhood Screens:

o Teacher/parent rating forms

o Assess: language, motor, self-help, social-emotional,

cognitive domains

http://www.pedstest.com/




Modified Checklist for Autism in Toddlers (MCHAT)

o Parent-completed questionnaire

o Designed to identify children at risk for autism in the

general population (valid from 18 months)

Screening Tool for Autism in Toddlers and Young

Children (STAT):

o Interactive screening tool designed for children with

suspected developmental concerns

o 12 activities assessing play, communication, and imitation

o Takes 20 minutes to administer

http://www2.gsu.edu/~psydlr/Diana_L._Robins,_Ph.D..html

http://kc.vanderbilt.edu/triad/training/page.aspx?id=821

http://kc.vanderbilt.edu/triad/training/page.aspx?id=821

Early Identification of Children at Risk for ASD: Screening Tools 15

Screening tools no longer recommended by

the American Academy of Neurology and the Child

Neurology Society for primary care screening:

• Denver-II (DDST-II) • Revised Denver Pre-Screening

Developmental Questionnaire (R-DPDQ)

• Decreased specificity and sensitivity for ASD


o Screening tools do not require specialized training and are recommended for use by primary care providers

o Early referral can be made to specialty practice for additional diagnostic testing:

• ADOS-G, ADI-R, CARS-2, GARS-2


Simultaneous referral/testing: Based on individualized areas of concern without waiting for specialty practice:

• Audiology (baseline/rule out hearing impaired) • Lead screening (developmental delay/pica) • Speech Language Pathology (speech delay) • Occupational Therapy (fine motor delay) • Physical Therapy (gross motor delay) • Behavioral Therapy (ABA) (behavior concerns)

Assessment and Management of Common Concerns in ASD

• Feeding/Alteration in Nutrition

• GI Pain, Elimination, Toileting

• Sleep Disturbance

Feeding/Nutrition Issues in ASD

• Atypical feeding: identified in ASD as early as 1943

• Clinical symptoms of ASD that contribute:

o sensory issues, rigidity, social interaction deficits

• Feeding issues frequently identified by parents:

o Food selectivity (limited intake)

o Food aversions (smell, texture, color, temp, brand)

o Food refusal (preferred carbs/snacks)

o Disruptive mealtime behaviors 16

Feeding/Nutrition Issues in ASD

Long term risks of unhealthy feeding patterns in ASD: • Obesity: Recent National Health Interview Survey

(2008-2010) of over 9,500 adolescents found obesity highest in autism subgroup, with 2x higher prevalence than same-age neurotypical peers 17

• Nutritional deficiency: Meta-analysis using cumulative sample of 881 children with ASD showed:

– feeding problems were 5x more likely in children with ASD than neurotypical peers

– children with ASD had significantly lower calcium and protein intake compared to neurotypical peers18

Feeding/Nutrition Issues in ASD: Assessment

• APN assessment for this population needs to

include:16,19

o Comprehensive history--eating behaviors , diet

(?restrictive: GFCF/SF, others), pica, supplement use,

allergies, medications, past medical conditions, pain and

impaired swallow

• Use of the Brief Autism Mealtime Behavior Inventory (BAMBI) and Food Inventories

o Complete physical and neurological exam--assess

changes—pain, functionality, anemia, constipation, GI

Feeding/Nutrition Issues in ASD: Management

o Rule out physiologic/neurologic/allergic conditions:

• impaired chewing/swallowing, reflux, food allergy, obstruction

o Consider labs for suspected deficiency/MVI use:

• CBC, calcium, protein

o Track:

• height, weight, growth velocity, and eating patterns

o Counsel families on nutrition/mealtime behaviors:

• establish routine, consistent expectations, repeated reintroduction of non-preferred foods, pairing preferred with non-preferred foods, establishing behavioral limits, stretch dietary repertoire

o Refer to appropriate resources

• Nutrition, Behavioral, GI 16,19

Common GI Problems, Elimination, and Toileting Issues in ASD

Increased behavioral problems in ASD may have roots in physiologic causes, especially GI:

• Withholding patterns • Abdominal pain • Constipation/Encopresis • Diarrhea • Gastroesophageal reflux • Food allergies

GI dysfunction may occur in 9-70% of children with ASD16,20

Common GI Problems, Elimination, and Toileting Issues in ASD

• Evaluation of GI problems may be

complicated by communication deficits and

inability to localize pain symptoms

• Presentation may be atypical

• Change in behavior may be the only clue to underlying pathology16,20

Common GI Problems: Withholding Behavior in ASD

Withholding behavior can contribute to abdominal pain, constipation, encopresis, and urinary tract problems. Common triggers include:

• Unfamiliar environment • Aversive stimuli • Change associated with sensory

issues (from diaper to open air) • Change in routine • Pain secondary to constipation

Common GI Problems: Abdominal Pain in ASD

Abdominal pain behaviors in children with ASD can present typically or as:

Vocalizations:

• Frequent throat clearing, swallowing, tics, spitting

• Sobbing for no reason, sighing, whining, moaning, groaning

• Delayed echolalia with reference to stomach or tummy

• Direct verbalizations of pain with pointing (“ow”, “ouch”, “bad”) 20



Motor behaviors:

• Grimacing, wincing, teeth gritting • Constant eating/drinking (“grazing”) • Mouthing behavior: chewing shirts,

clothes, toys, pica • Applying pressure to abdomen • Unusual posturing (jaw thrust, back

arching, etc.) • Aggression, self-injury20



Changes in Overall State:

• Increased difficulty sleeping • Increased irritability • Increased agitation • Food aversion • Noncompliance with demands that

generally were done with appropriate response (increased oppositional behavior)20

Common GI Problems: Constipation in ASD

Constipation is the most common GI complaint in children with ASD and is exacerbated by diet. Consider when:

• Straining or infrequent stool • New onset of diarrhea or fecal

incontinence (encopresis) • New self-injurious behavior, tantrums,

aggression, oppositional behavior • New problem behaviors with meals • Abdominal discomfort, bloating,

flatulence20

Common GI Problems in ASD: Assessment

ALL potential GI symptoms warrant thorough evaluation:16,20

o Comprehensive history--eating behaviors , change

in general behavior, diet (restrictive: GFCF/SF, others),

pica, supplement use, allergies, medications, past medical

conditions, pain, impaired swallow, nausea,

vomiting, bowel, bladder patterns, toileting and

sleep behaviors.

o Complete physical and neurological exam--assess

changes—pain, functionality, wt change, GI signs,

impaction, rectal bleeding.

Common GI Problems: Management by Symptoms Consider for DD and management: o Constipation: Hard infrequent stool, straining

behavior, prolonged BR time, perceived abdominal discomfort, self injury, tantrums, oppositional behavior, flatulence, bloating

o RED FLAGS: fever, distension, n/v, anorexia, wt loss/gain

• Labs: TSH, T4, calcium, lead, celiac screen; trial of PEG; diet enhancements (fruit, fiber, fluids); bowel training; abdominal radiograph

• Refer to appropriate resources—GI, Nutrition, Behavioral 16,20,21

Common GI Problems: Management by Symptoms Consider for DD and management: o Diarrhea (chronic > 3 stools/d x2wks):

Overflow (encopresis), malabsorption, maldigestion, ulcerative colitis, food allergy

• Allergy panel, celiac panel, stool for occult blood, enteric pathogens/parasites (Giardia, Cryptosporidium, C. difficile); trial of PEG if suspected overflow diarrhea; lactose breath test; EGD or colonoscopy

• Refer to appropriate resources—GI, Nutrition, Behavioral16,20

Common GI Problems: Management by Symptoms Consider for DD and management: o GERD: Sleep disturbance, self-

injurious/aggressive/oppositional behavior, perceived abdominal discomfort, food aversion. Consider gastritis and intestinal inflammation.

• Trial of PPI; may require pH probe, EGD • Refer to appropriate resources—GI, Nutrition,

Behavioral 16,20

Common GI Problems: Toileting

One of the greatest sources of stress to

parents regardless of ASD


When counseling parents, be aware:

• Most children with ASD learn to urinate and have BMs in the toilet later than other children (6+ years is not unusual)

• Children with ASD may take years to achieve bladder/bowel control

• Each child is different--understand the reasons why each child might be having difficulty22


Toileting Barriers in ASD:

• Physical or medical issues (neuro, GI) • Language deficits in expressing need • Dressing/fine motor coordination • Fear (flushing noise, sitting on toilet) • Body cues (inability to sense need to go) • Change in routine (from diaper to toilet) • Change in environment (public toilet) • Aversive sensory stimuli23


Management Strategies:

• Rule out medical reasons for toileting issues (obstruction, neurological)

• Reassure parents--keep trying!!!! • Direct parents to appropriate resources:

– Autism Speaks/ATN • Refer for OT or Behavioral Assistance23

Sleep Disturbance in ASD

o Problems with sleep latency and night waking seen in 50-80% of school aged population with ASD

o Chronic insomnia may be 10x higher in ASD

o Sleep problems may increase rather than decrease as children grow older24


o Overlap of neurobiological factors seen in

both sleep disturbance and ASD

o Abnormalities in:

• GABA (an inhibitory neurotransmitter) • Melatonin (a brain hormone associated

with circadian sleep-wake cycles)24


Sleep disturbance is linked to:24

• Worsened daytime behaviors – Anxiety, aggression, tantrums

• Increased core symptoms – Stereotyped behavior, communication

deficit, ASD severity25

• Disrupted family function and caregiver

stress

Sleep Disturbance in ASD: Assessment

• Ask parents about: o Bedtime/bedtime rituals (parents needed?) o Sleeping arrangements o Patterns: latency, duration, night waking o Medications/supplements for sleep o Breathing problems, snoring, HEENT issues o Daytime sleepiness/increased behaviors

• Assessment tools: Children’s Sleep Habits

Questionnaire (CSHQ) 26

Sleep Disturbance in ASD: Management

o Rule out physiologic causes:

• Tonsils/adenoids, ears/sinus/nasal, OSA, GERD

o Sleep Hygiene:

• Routine, limit stimuli before bed (TV, computer, food, fluids, caffeine)

• Get out of bed after 15-20 min; OOB relaxing activity • Consider noise disturbance, use of white noise

o Nonbehavioral interventions:

• Consider melatonin (no standard dose: adult dose is 3.5 mg at hs – varies per individual, dark is important)

• Specialty provider: centrally acting alpha agonists • Diphenhydramine not generally effective/rebound

o Refer to appropriate resources

• ENT/GI, Sleep Study, Behavioral 24

Co-Management of Medications Used in Specialty Practice for ASD

o Limited FDA approved pharmacological interventions specifically for ASD

• There are currently TWO

o Both are atypical neuroleptics with SE profiles that impact primary care:

• aripiprazole (for irritability) • risperidone (for irritability)

o NPs: specialty care prescribed with collaborative management9

Co-Management of Medications Used in Specialty Practice for ASD

o Off-label medications used in specialty care:

• SSRIs (anxiety, depression, obsessive-compulsive behaviors)

• Stimulants (hyperactivity, inattention, impulsivity)

• Centrally acting alpha-2 adrenergic agonists (clonidine, guanfacine) (tic reduction, hyperactivity, impulsivity)

• Nonstimulant alternatives (atomoxetine) (hyperactivity, impulsivity, inattention)9

Medications in Specialty Practice for ASD: Primary Care Concerns

o Atypical Neuroleptics: Consider risk for metabolic syndrome—Ht, Wt, BMI, truncal obesity, BP, P; Labs: CBC, CMP, lipids, prolactin levels, HgbA1C

o SSRIs: Consider black box warnings for SI/SA in peds; may cause disinhibition, HA, GI SEs, wt gain, insomnia, serotonin syndrome (small risk); taper to avoid withdrawal sx9


o Stimulants: Consider appetite suppression, weight loss, mild growth suppression—Ht, Wt, BMI, BP, P, tics; consider cardiac evaluation for (+) family/personal hx

o Centrally acting alpha-2 adrenergic

agonists: Consider sedation, hypotension, bradycardia, constipation, drymouth, increased appetite—Wt, BMI, BP, P9


o Nonstimulant alternatives (SNRIs): (atomoxetine) SEs similar to stimulants (excluding tics); SEs may also include cough, dizziness, hepatotoxicity, and small risk of SI/SA—Ht, Wt, BMI, BP, P, LFTs 9

o Collaborative care is critical to our ability to manage these patients in primary care!

Last But Not Least—Support Families and Caregivers

o Knowing available community resources is essential (delays and wait times matter)

o Caregiver strain is HUGE in this population o Families are struggling to find support and

guidance—we often find it from other parents o NPs are ideally suited to help in key areas

primary care management, educational support and access to community resources

Community Resources for ASD

o Regional Center of Orange County (RCOC)

o UCI Center for Autism and Neurodevelopmental Disorders

o CHOC Early Developmental Assessment Center o Help Me Grow o Early Childhood Education Programs (IUSD,

SVUSD, Costa Mesa, others) o United Cerebral Palsy (UCP), Irvine

Conclusion: ASD and Primary Care

• Primary care NPs are critical to:

o Early identification/referral

o Management of key areas of concern

• Nutrition • GI symptoms • Toileting • Sleep

o Collaborative management

o Supporting families


WE NEED YOUR HELP!


THANK YOU!

References 1. Centers for Disease Control and Prevention. (2014). Prevalence of autism spectrum disorder

among children aged 8 years -Autism and developmental disabilities monitoring network, 11 sites, United States, 2010. Morbidity and Mortality Weekly Report Surveillance Summary, 63(SS02), 1-21.

2. Wing, L., & Potter, D. (2002). The epidemiology of autistic spectrum disorders: is the prevalence rising?. Mental retardation and developmental disabilities research reviews, 8(3), 151-161.

3. Centers for Disease Control and Prevention. (2014). Autism spectrum disorder: data & statistics. Retrieved from http://www.cdc.gov/ncbddd/autism/data.html

4. Kim, Y. S., Leventhal, B. L., Koh, Y. J., Fombonne, E., Laska, E., Lim, E. C., ... & Grinker, R. R. (2011). Prevalence of autism spectrum disorders in a total population sample. American Journal of Psychiatry, 168(9), 904-912.

5. Tchaconas, A., & Adesman, A. (2013). Autism spectrum disorders: a pediatric overview and update. Current Opinion in Pediatrics, 25(1), 130-143.

6. Geschwind, D. H., & Levitt, P. (2007). Autism spectrum disorders: developmental disconnection syndromes. Current opinion in neurobiology,17(1), 103-111.

7. American Psychiatric Association. (2013). The Diagnostic and Statistical Manual of Mental Disorders: DSM 5. bookpointUS.

8. Pediatric subspecialties. (2014, November 26). Retrieved from http://www.pedsubs.org/SubDes/ChildPsychiatry.cfm

9. Steinberg-Epstein, R., Book, T., & Wigal, S. B. (2011). Controversies surrounding pediatric psychopharmacology. Advances in pediatrics, 58(1), 153-179.

10. Centers for Disease Control and Prevention (2014). Autism spectrum disorder (ASD): signs and symptoms. Retrieved from http://www.cdc.gov/ncbddd/autism/signs.html

http://www.cdc.gov/ncbddd/autism/data.html

http://www.pedsubs.org/SubDes/ChildPsychiatry.cfm

http://www.cdc.gov/ncbddd/autism/signs.html

References 11. Matson, J. L., Beighley, J. S., Williams, L. W., & May, A. C. (2014). Conducting diagnostic

screening and assessment. In J. K. Luiselli (Ed.), Children and youth with autism spectrum disorder (ASD): recent advances and innovations in assessment, education, and intervention (pp. 3-25). Oxford: Oxford University Press.

12. Johnson, C. P., & Myers, S. M. (2007). Identification and evaluation of children with autism spectrum disorders. Pediatrics, 120(5), 1183-1215.

13. Bright Futures Steering Committee, & Medical Home Initiatives for Children With Special Needs Project Advisory Committee. (2006). Identifying infants and young children with developmental disorders in the medical home: An algorithm for developmental surveillance and screening. Pediatrics, 118(1), 405-420.

14. Centers for Disease Control and Prevention (2014). Autism spectrum disorder (ASD): screening and diagnosis for healthcare providers. Retrieved from http://www.cdc.gov/ncbddd/autism/hcp-screening.html

15. Centers for Disease Control and Prevention (2014). Autism spectrum disorder (ASD): Autism A.L.A.R.M. guidelines. Retrieved from http://www.cdc.gov/ncbddd/autism/hcp-recommendations.html

16. Kral, T. V., Eriksen, W. T., Souders, M. C., & Pinto-Martin, J. A. (2013). Eating behaviors, diet quality, and gastrointestinal symptoms in children with autism spectrum disorders: a brief review. Journal of Pediatric Nursing, 28(6), 548-556.

17. Phillips, K. L., Schieve, L. A., Visser, S., Boulet, S., Sharma, A. J., Kogan, M. D., Boyle, C. A., & Yeargin-Allsopp, M. (2014). Prevalence and impact of unhealthy weight on a national sample of US adolescents with autism and other learning and behavioral disabilities. Maternal Child Health Journal. doi:10.1007/s10995-014-1442-y

18. Sharp, W. G., Berry, R. C., McCracken, C., Nuhu, N. N., Marvel, E., Saulnier, C. A., ... & Jaquess, D. L. (2013). Feeding problems and nutrient intake in children with autism spectrum disorders: a meta-analysis and comprehensive review of the literature. Journal of Autism and Developmental Disorders, 43(9), 2159-2173.

References 19. Sharp, W. G., Jaquess, D. L., & Lukens, C. T. (2013). Multi-method assessment of feeding

problems among children with autism spectrum disorders. Research in Autism Spectrum Disorders, 7(1), 56-65.

20. Buie, T., Campbell, D. B., Fuchs, G. J., Furuta, G. T., Levy, J., VandeWater, J., ... & Winter, H. (2010). Evaluation, diagnosis, and treatment of gastrointestinal disorders in individuals with ASDs: a consensus report. Pediatrics, 125(Supplement 1), S1-S18.

21. Furuta, G. T., Williams, K., Kooros, K., Kaul, A., Panzer, R., Coury, D. L., & Fuchs, G. (2012). Management of constipation in children and adolescents with autism spectrum disorders. Pediatrics, 130(Supplement 2), S98-S105.

22. Dalrymple, N. J., & Ruble, L. A. (1992). Toilet training and behaviors of people with autism: parent views. Journal of Autism and Developmental Disorders, 22(2), 265-275.

23. Autism Speaks Autism Treatment Network/Autism Intervention Research Network on Physical Health-Behavioral Health Sciences Committee. (2012). A parent’s guide to toileting for children with autism. Boston: Autism Speaks Autism Treatment Network.

24. Durand, V. M. (2014). Sleep problems. In J. K. Luiselli (Ed.), Children and youth with autism spectrum disorder (ASD): recent advances and innovations in assessment, education, and intervention (pp. 175-192). Oxford: Oxford University Press.

25. Tudor, M. E., Hoffman, C. D., & Sweeney, D. P. (2012). Children With Autism Sleep Problems and Symptom Severity. Focus on Autism and Other Developmental Disabilities, 27(4), 254-262.

26. Owens, J. A., Spirito, A., McGuin, M., & Nobile, C. (2000). Sleep habits and sleep disturbance in elementary school-aged children. Journal of Developmental & Behavioral Pediatrics, 21(1), 27-36.

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