Score on a developmental screen falls below the tool'sempirical cutoff in one or more of the five domains,orthere is an established condition, or parent concern.

Children's DevelopmentalServices Agency (CDSA)

Entry Evaluation CompletedEligible for Services if:

1- Developmental Delay in one or more of the five developmental domains (delay determined by type of test adminstered, i.e. either % delay or standard deviations below mean of composite score)2-Established Condition which has a high probability of resulting in a delay (see legend below for established conditions list)

YES NO

Infant Toddler/Early Intervention Program includes Case Management/Direct Services such as OT, PT, and S&L IFSP Developed with Family

Child ServiceCoordination,

or otherappropriatecommunity

service

Transition To:3-5 Yr Old Program

with DPI

Discharge by: Age 3

Referral ProcessChildren age 0-3

(If Renewed Concern)

LEGEND: ESTABLISHED CONDITIONSA-Congenital Anomaly /Genetic Disorders/Inborn Errors of Metabolism (e.g. Down Syndrome, Fragile X, fetal alcohol syndrome, familial retardation)B-Congenital Infection (e.g. toxoplasmosis, rubella, cytomegalovirus, HIV)C-AutismD-Attachment Disorder(Per DC-03-Reactive Attachment Deprivation/Maltreatment Disorder of Infancy)E-Hearing Loss or Visual ImpairmentF-Neurologic Disease/Central Nervous System ( e.g. Cerebral Palsy, Spina Bifida, Epilepsy & Microcephaly)G-Neonatal Conditions & Associated Complications (e.g. Gestational age less than 27 weeks or birth weight less than 1000 grams, neonatal seizures, stroke, meningitis, encephalitis, etc.) DEFINITIONS IFSP-Individual Family Service Plan; PT- Physical Therapist; OT - Occupational Therapist ; S&L -Speech and Language Therapist DPI -Department of Public Instruction

Primary Care Physician (PCP) is notified ASAP about the evaluation result and service plans in order to have a follow-up with the family.

PCP shares results of Audiological Evaluation and other referrals (if any) with the CDSA as soon as results are reported.

Notes:

Autism specific evaluations and/or confirmation of an autism diagnosis are influenced by the age of the child and findings; younger children and those with less significant symptoms are more difficult to diagnose.

MCHAT is Positive (+) OR Autism Surveillance yields 2 or more + risk factors

If Global Developmental Delay, Intellectual

Disability is present, or Genetic or Neurologic disorder is suspected

CDSA Audiology Evaluation

Consider referral to D & B Pediatrician

GeneticistNeurologist

Eligibility evaluationIf developmental delay or

established condition found

IFSP

Further Autism-specific evaluation as needed

Continued Case Management, IFSP

Continued Direct Services as indicated

No ASD or Developmental Delay

found

CSC or other community services

(if renewed concern re-refer)

Primary Care Autism Screening Referral Process for Infants and Toddlers

Referral Flow Chart Legend & Notes

• Questions of autism for a specific infant or toddler: The AAP recommends simultaneous referral for ASD evaluation, EI services, and Audiology evaluation.

– leads to a referral to your Children’s Developmental Services Agency (CDSA)

– leads to a referral for an audiology evaluation– may lead to a referral to a D&B pediatrician,

geneticist, or neurologist for assistance with an etiologic workup and/or a search for coexisting conditions if indicated.

• When referring, include:– Diagnosis of autism if you have made it– Copies of child’s MCHAT– Additional information as appropriate– Copies of family’s release of information for

communication from and to pediatrician/CDSA

ACTION STEPS• As Primary Care Practices begin screening for

autism per AAP recommendations:– PCP’s:

• Discuss CDSA resources with CDSA staff

• Discuss other community resources with community partners, including CDSA

• Facilitate communication between primary practice, other diagnostic referrals, and CDSA

- CDSAs:• Discuss CDSA resources with

community PCP’s (e.g., possibility of audiological evaluation)

• Assure feedback to referring PCP’s regarding eligibility of child. (Complete ROI if it has not been obtained at the primary care practice.)

• Continue communication regarding additional assessment as needed

ACCESS I I & I I IACCESS I I & I I I

CCNC

Referral Form Developmental Screening & Surveillance

Name of Child:______________________________________________________ Date of Birth:____/___/_____Age____________ _Sex________________________ Address:____________________________________________________________ Medicaid#:_________________Insurance___________ Social Security__________ Parent/ Guardian Name:________________________________________________ Home Phone:____________________ Work Phone:__________________________ Race:_________________________ Primary Language:________________________

Developmental/Interdisciplinary Referral: Concerns: Screening Tool: ASQ PEDs MCHAT ASQ-SE Other _________________ (Please Name) The ASQ or PEDS and/or MCHAT scoresheet is attached, if completed. I have discussed this referral with parent(s) Referred By: Phone: PCP Office: Fax:

(Insert Letterhead Identification Here)

ACCESS I I & I I IACCESS I I & I I I CCNC

North Carolina Physician to Preschool Exceptional Children Program Notification Process Chart

For Children 3 to Pre-Kindergarten 5 Years of Age

e.g., Developmental Delays, MCHAT is Positive (+) OR Autism Surveillance yields 2 or more + risk factors; ASQ or PEDs scores are

raised

Physician informs family of LEA services

, Physician provides family

with Child Find information from school system

Referral for child service coordination via health

department (if appropriate)

Direct contact made between school system &

family • Interview parents about child development concerns• School system obtains existing screenings, observations, etc.• Suggested Interventions offered to family• School system or parent may initiate a referral

Eligibility determination & IEP developed, if eligible

• parental consent for services obtained, if eligible

Services begin

School system sends follow-up information to physician

• With consent for release of confidential information

School system conducts assessment or proceeds to eligibility determination

Process stopped- NO EVALUATION• Parent denies consent to make written referral • School system may utilize procedural safeguards to pursue evaluation.• No educational concerns identified

Process stopped• Parent denies consent for services• Assessments reveal no educational concerns• Not eligible for special education

NO

Physician sends notification and parental release of information form

• Contact information• Signed release of information• Health screening; including vision and hearing • Developmental screening• Behavioral health screening• Evaluation(s) in process

School system or parent initiates referral• If school system rejects referral, parent may make a written request • Parent signs informed consent to evaluate• 90 day timeline begins

YES