First STEPS 2014 Webinar
Management of Behavioral Issues
in Children with Autism Spectrum
Disorders
Carol Hubbard MD MPH PhD
Division of Developmental-Behavioral
Pediatrics
Maine Medical Partners Pediatric
Specialty Care
Thursday, July 10, 2014
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Maine Child Health Improvement Partnership (ME CHIP)
Mission
To optimize the health of Maine
children by initiating and
supporting measurement-based
efforts to
enhance child health care by
fostering public/private
partnerships.
Vision
All practices providing health
care to children will have the
skills, support, and opportunities
for collaborative learning
needed to deliver high quality
health care.
ME CHIP is part of the National Improvement Partnership Network (NIPN)
First STEPS 2014 July Webinar
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CME
• CME will be available for participants who have signed into the
webinar. If there are multiple people at one computer, please type
their names and email into the chat box for our attendance records.
• We do not have separate nursing CEUs- but you can get a CME
certificate.
• A CME evaluation survey will be available when you exit the
webinar and will be sent after the webinar via email. If you did not
get the email link, please email Deb Gilbert at
dgilbert@mainequalitycounts.org. We get 5-10 incorrect email
addresses each month.
• Please complete the survey via Survey Monkey within 1 week.
• A CME certificate will be emailed within 1 month of completion of
the survey. Please contact Deb Gilbert if you have not received a
CME certificate after doing the survey.
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CME Disclosure
Dr. Carol Hubbard has no conflicts of interest with
commercial products in this presentation.
First STEPS 2014 July Webinar
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Management of Behavioral Issues
in Children with
Autism Spectrum Disorders
Carol Hubbard MD MPH PhD
Division of Developmental-Behavioral Pediatrics
Maine Medical Partners Pediatric Specialty Care
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Outline
• General approach to behavior issues:
– Figuring out the purpose of a behavior: behavior analysis
– Prevention strategies
• Common behavioral issues
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–
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–
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Sleep
Toilet-training
Ritualistic, repetitive, or obsessive/compulsive behaviors
Anxiety/depression
Overactivity, impulsivity, Inattention, distractibility
Self-Injury/Aggression
• Approach to office visits
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Characteristics of children with autism
that can lead to behavior issues
• Delayed communication skills/ poor auditory
processing skills
• Literal interpretation of language
• Poor understanding of social expectations and cues
• Poor perspective-taking
• Short attention span, distractibility
• High activity level
• Sensory issues- difficulty tuning out environmental
stimuli
• Low frustration tolerance
• Anxiety
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It is important to establish
the function of behavior
Behavior = Communication !!!
•
•
•
•
To obtain something
To seek attention
Avoidance
Escape: behavior (e.g. tantrum) serves to
remove a demand placed on the child
• To overcome boredom
• Self-stimulatory-automatic reinforcement8
First STEPS 2014 July Webinar
Functional Behavioral Assessment
• The process of gathering information to figure out the
function of a behavior, and the factors that serve to
maintain it, in order to develop and implement
intervention.
• A-B-C Model:
– Antecedent- the context (time of day, setting
events, people involved, etc), and the specific
antecedent (eg verbal instruction)
– Behavior- what happens (describe specifically,
eg hitting a peer, rather than “aggression”)
– Consequence – how people react, what
happens afterward
• Look for patterns of behavior (certain time of day,
settings, when hungry, or with certain people)
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Case
Jonathan, age 4, has PDD-NOS, and an
expressive language delay, and is having
difficulty with aggression toward staff and
peers at his developmental preschool.
He hits other children at least daily, and
recently bit a little girl who was playing
near him.
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Case: results of FBA
• 6 incidents of aggression in one week
• Antecedents: occurred in the late morning,
during choice time (when other children were
very close to him, or the room was loud) or
during tabletop work
• Behavior: hit staff; pushed, hit and bit peers
• Consequences: He was removed from the
activity, to a quiet corner with pillows and his
favorite stuffed animal from home
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Case: intervention
• Function of behavior:
– Escape from over-stimulation
– Escape from demands
– To obtain access to preferred objects
• Intervention
– Prevention: closer staff involvement and coaching
during high-risk time
– Teach him to ask for space or for a break
– Planned, non-contingent access to preferred items
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Intervention 1: Prevention
Organize the environment to reduce the likelihood that the
difficult behavior will be triggered
• Stimulation level:
–
–
–
–
Avoid over-stimulating activities,
Provide calming activities,
“Sensory diet,”
Self-monitoring (How Does Your Engine Run)
• Modify expectations
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–
–
–
Break tasks down
Shorten task length
Modify materials
Provide choices
• Communication
– Clear, concise language
– Visual supports
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Visual Strategies/Supports
• 55% of communication is visual
• Makes communication non-transient
• Can help overcome problems with
receptive language or attention
• Can involve visual schedules, calendars,
choice boards, list of rules or tasks,
photos, PECS,
international NO symbol,
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Augmentative Communication
• PECS (Picture Exchange
Communication System)
• Aug. Communication
Evaluation
– Some speech therapists
– Pine Tree Society (Bath)
• Electronic Communication
Devices-Dynavox, Vantage
• iPad resources (Autism
Speaks website)
• Different from “facilitated
communication”
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Social Stories
• Social Stories (Carol Gray) are written
explanations of an event or new experience.
They explain what will happen and how the
person is expected to respond. They are also
used to address problematic behaviors. For
some children, the printed word is much more
easily processed than a verbal explanation. It
is helpful to illustrate them (or have the child
do it) or have photos on each page with brief
text
• www.thegraycenter.org
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Comic Strip Conversations
(Carol Gray)
– Comic Strip Conversations are simple
line drawings that show a conversation
between 2 or more people, including
thoughts as well as spoken words, to help
process and understand social situations
– www.thegraycenter.org
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Intervention 2: Teaching appropriate ways to
obtain the same goal
What are the skills that the child needs to be
taught so that they do not need to use the
undesired behavior?
• Self-management
• Adaptive coping
• Communication
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Teaching better ways
to obtain goals
• Teach and Reinforce a replacement behavior- needs to be
efficient, effective, easier (quicker, better) than the
maladaptive behavior
• Functional Communication Training: teach a
communicative behavior that is functionally
equivalent to the maladaptive behavior.
– Requesting items
– Requesting permission
– Requesting a break
– Requesting a delay(eg of a transition)
– Expressing emotions
– Negotiation skills
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Think Social: Michelle Garcia Winner
“Social thinking is required before the
development of social skills. Successful
social thinkers consider the points of
view, emotions, thoughts, beliefs, prior
knowledge and intentions of others
(perspective taking).”
• Four steps of communication:
•
1. Thinking about others and what they are thinking
about us
2. Establishing a physical presence
3. Thinking with our eyes
4. Using language to relate to others
•
www.socialthinking.com
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Intervention 3: Reinforcement
• Reinforce desired behavior : social
reinforcement, sensory, activities, rewards,
token systems
• Is a response (e.g. praise) truly reinforcing
for the child?
• Is an undesired behavior being
inadvertently reinforced by adult attention
(even if it is negative)?
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Intervention 4: Consequences
Use with caution. Important to know the function
of the behavior to select a consequence.
• Ignore
• Redirect
• Warning
• Time-out from activity
• Time out from group
• Contingent task
• Reinforce other students’ good behavior
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Sleep
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Daytime Sleepiness in Children
Daytime Sleepiness
Neurobehavioral Deficits Mood Disturbance
Performance Deficits:
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Academic Failure
Impaired Social
Functioning
Behavioral Dyscontrol
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• Studies vary but between 53-78% of children
with an ASD present with sleep issues
• This compares to 26-32% for typically
developing children
• Increased incidence is by parent report but has
also been confirmed in studies using actigraphy
and polysomnography
• Children with ASDs may have increased
sensitivity to noise and short sleep duration
• Not a clear association with having a diagnosis
of intellectual disability
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Most common sleep issues in ASD
• Sleep onset
• Sleep maintenance
– Children with ASDs may not wake more frequently, but
are awake for longer (up to 2-3 hours) and engage in
more disruptive behavior while awake
– Parasomnias such as night terrors, confusional
arousals, and sleep walking may be more common
• Sleep duration
• Decreased REM sleep compared to typical and
developmentally delayed children
• Issues can be caused by less than ideal bedtime
routines or bedtime associations so need to
consider standard sleep hygiene
recommendations
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First STEPS 2014 July Webinar
• Obstructive Sleep Apnea/hypopneas
should be considered- less clear data on
prevalence with ASD
• Must keep in mind the bidirectional
influence of co-morbidities such as ADHD,
anxiety, depression, and seizure disorders
• Also need to recognize the toll that a child
with poor sleep takes on the entire family
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BEARS
• 5 question screening tool
• Yields significantly more information about
sleep than standard sleep prompt “Does
your child have any sleep problems?”
• Therefore increases likelihood of
identifying sleep problems
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BEARS
• B = Bedtime problems
• E = Excessive daytime sleepiness
• A = Awakenings during the night
• R = Regularity and duration of sleep
• S = Snoring
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Behavioral approaches to sleep
• Regular bedtime and predictable bedtime
routine-consider social story or chart
• Limit naps
• Limit electronics before bed, keep lighting
low
• For awakening during the night, move
bedtime later
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Medication for sleep
• Melatonin: neurohormone that organizes
circadian physiology- sleep-wake cycle and core
body temperature rhythms
• Primarily regulated by light/dark exposure
• May also be a true genetic difference in the
secretion of melatonin in patients with ASDs.
• May be helpful for children with a true
circadian rhythm disturbance but behavioral
intervention and strategies should be
attempted first
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Medication for sleep (continued)
Melatonin
• Dosing 0.5 mg-3 mg
– Lower dosing may be more effective
– Give 1 to 2 hours before desired sleep onset
• Two actions of sedating and adjusting clock so may take up to 2
weeks to fully trial a dose
• Theoretical side effects of effect on puberty and decreased sz
threshold but well-tolerated in actual use
• Evidence for efficacy in children with ASDs (meta-analysis
Rossignal and Frye 2011) for sleep onset, duration and improved
daytime behavior
• Possibly better evidence than for other sedative/hypnotics
Clonidine: alpha agonist with side effect of sedation, also
helps impulsivity, hyperactivity. Can cause nightmares,
constipation, headaches, bradycardia, hypotension
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Toilet-training
• Cognitive and language delays as well as
decreased imitation and social modeling skills
can delay the training process.
• Tips
– Monitor readiness signals but do not wait too late to
start the process
– Regular daily sitting times (upon awakening, after
meals)
– Break the process up into steps if possible
– Do sitting with diaper on to start if too stressful
– Low threshold to treat for constipation
– Use positive incentives (stickers, small treats, take
advantage of hyperfocused interests) –can be
challenging to find
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Stereotypical, repetitive, or
obsessive/compulsive behaviors
(Matson and Dempsey)
• Repetitive “self-stimulatory” behaviors are core
diagnostic features of ASDs
• Debate about the relationship of ASDs and OCD
• “Sameness” behaviors more common in ASDs
than OCD, and less likely to ameliorate with age
• Ordering, hoarding and touching more common
in ASDs, while cleaning, checking and counting
more common in OCD
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Behavioral intervention for
stereotypies and repetitive behavior
• Functional assessment
• How “interfering” is the behavior?
• For physical stereotypies: label the behavior,
teach a replacement behavior that is
incompatible with stereotypy, give hand fidget,
reinforce alternative behavior or decreased
target behavior, allow set times to ‘stim.”
• For sameness behaviors: build variation into
daily schedule to build tolerance
• CBT (Cognitive-Behavioral Therapy): exposure
and response-prevention, for higher-functioning
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children
Cognitive Behavioral Therapy (CBT)
• May be helpful for older, higher-functioning
children
• Based on the idea that our thoughts cause our
feelings and behaviors, not external things, like
people and situations, so we can change the
way we think to feel / act better even if the
situation does not change.
• Time- limited (average # of sessions = 16)
• Highly instructive
• Homework assignments
• Exposure/response-prevention
• www.nacbt.org
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Medication for stereotypies
• SSRIs are often used – may be more helpful if the
behavior seems anxiety-driven, and if there are broader
anxiety issues
• Evidence: mixed (most studies open-label except 4 RCT)
generally showed improvement in global functioning and
in symptoms associated with anxiety and repetitive
behaviors. Side effects were generally mild, but
increased activation and agitation occurred in some
subjects (Kolevzon).
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Anxiety
• Children with ASDs generally prefer
predictability, and can be quite rigid, with
high levels of anxiety
• Causes of anxiety
– Change in routine
– Not getting what they want
– Sensory overload
– Social situations
– Specific phobias: bugs, fire-alarms
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Addressing anxiety
• Advance warning of upcoming events or
schedule changes
– Visual schedules
– Social stories http://www.thegraycenter.org/
– Sensory supports
• Allow downtime (? time for self-stim)
• Balance need for structure with practicing
flexibility
• Cognitive Behavioral Therapy
• Omega 3 fatty acids:1000-2000mg fish oil per
day
• Medication: SSRIs, atypical neuroleptics
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Depression and mood disorders
• Common in older and higher-functioning childrendiagnosis can be difficult due to flat affect, little
expression of emotion
• Consider family history
• Look for a change from baseline, or change in
functioning
• Consider seasonal affective and PMS/PMDD issues
• Counseling if higher-functioning
• Omega 3s
• Medication: SSRIs, wellbutrin, possibly atypical
neuroleptics
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Overactive, impulsive, inattentive,
and distractible behavior
• Up to 70% of children with ASDs have
ADHD symptoms
• Impairment in functioning (academic,
ADLs, social) may be due in part to ADHD
symptoms and executive dysfunction, as
well as to autism
• If possible, do ADHD assessment with
standardized questionnaires (eg Conners
or Vanderbilts) esp. if higher functioning 41
First STEPS 2014 July Webinar
Treatment of ADHD symptoms
•
•
•
•
Consider classroom placement/supports
Treat as would any child with ADHD
Collect data before and after from teachers
Best evidence for stimulants, Atomoxetine, risperidone,
and alpha-agonists
• Psychostimulants
– In studies of psychostimulants, around 50% of subjects with ASD
have shown positive clinical responses (not significantly lower
than non-autistic children with ADHD)
– Side effects included irritability, emotional outbursts, and initial
insomnia, with social withdrawal at higher doses
– Overall, may be a decreased response rate and increased
chance of side effects compared to children with ADHD s autism
• Atomoxetine (Strattera):
– Studies support efficacy
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Self-injurious behavior
• Most common forms: self-hitting or banging of
head or face, and self-biting
• Can markedly impact adaptive functioning,
interfere with normal activities, lead to a more
restrictive environment, and result in injury
• More common in autism than other
developmental disabilities
• Inversely correlated with intellectual functioning
(4% mild MR, 7% mod, 16% severe, 25%
profound)
• More common in individuals in residential
settings (estimated 17% vs 1.7% for community)43
Why does self-injurious
behavior (SIB) occur?
• Lack of environmental stimulation
(boredom)
• Reinforced by social attention, access to
preferred items, or avoidance or escape
from undesired activities
• May provide automatic reinforcing sensory
input (provide endogenous endorphins)
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How to approach SIB
• Functional assessment: situations in which the
•
•
•
•
•
behavior is most and least likely to occur, antecedents,
and consequences. Try to figure out the source of the
reinforcing component
Redirect to a safer place (eg soft pillows, carry a matt)
Reinforcement: appropriate behavior is reinforced, SIB
is ignored
Protective equipment: can block sensory input
Functional communication training
Medication: atypical neuroleptics (risperidone), SSRIs,
clonidine, naltrexone
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Risperidone in autism
(Scott and Dhillon)
• Risperidone is FDA-approved for treatment of
irritability associated with ASD in children ages 5
to 16 years
• Several well-designed short-term (8 week)
RDBCTs showed significant improvements in
irritability, stereotypy, social withdrawal, lethargy,
hyperactivity and noncompliance, (and other
studies in combo with other meds)
• Benefits were maintained up to 6m, with
improvements in adaptive functioning
(communication, daily living and social skills)
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Risperidone:adverse effects
• Increased appetite
– Weight gain: Mean gain = 7.5kg (vs expected 3-3.5kg) in 12
months
– Risk of hyperlipidemia and hyperglycemia
•
•
•
•
•
•
Somnolence (often transitory) and fatigue
Constipation
Increased salivation or dry mouth
Increased prolactin (2-4 fold, 39 vs 10 ng/ml)
Tremor and dystonia both - 12%
Tardive dyskinesia: In pooled studies with n = 1885
(for ASDs and other disorders), there were 2 cases
of TD. Risk higher with longer-term use
• Possible decreased bone density with longstanding
hyperprolactinemia
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Other atypical neuroleptics
• Aripriprazole (Abilify) and ziprasidone
(Geodon) have shown promise in small
trials of patients with ASD
• Other side effects:
– Abilify: Risk of activation or agitation
approx 25%
– Geodon: risk of arrythmias
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Working with children with ASDs
during office visits
• Talk with the parents in advance
– Prepare the child before the visit with a ‘social
story’ or photos
– Bring the child’s comfort items
– Have parents stay with the child
• Schedule a practice visit
• Prepare staff
– Defer vitals if uncomfortable
– Do not approach the child too closely, or
physically, watch for signs of distress/discomfort
– The child may approach staff closely and not
follow social expectationsso should be ready for
First STEPS 2014 July Webinar
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Office visits, continued
• Minimize waiting, and physical intervention
• Recognize that behaviors may be due to
ASDs (rigidity, anxiety) and not to
deliberate oppositionality
• Recognize the role of sensory issues
(fluorescent lights, crowded waiting room)
• May want to schedule extra time for visits
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What parents of ME children with
ASDs say about office visits
• “Wait room times – if they are long can cause escalation”
• “A lot of pediatric offices have bright colors and toys – most
kids enjoy this but our population can find that over
stimulating”
• “The doctors could make sure that the lights are not too bright
for those that have sensory issues. Maybe a sheet on the tables
for those who do not like the paper (the feel of it on their skin
or the sound it makes).”
• “I always say to my doctor when we arrive if we can be put
into a exam room as soon as possible that helps cut
down on both of the above problems. We don’t need to
be seen right away but taken out of the wait room
environment.”
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Books on behavioral
intervention
• Behavioral Intervention for Young Children With
Autism, 1996, Maurice, Green and Luce, Pro-Ed,
Inc., Austin, Texas
• A Treasure Chest of Behavioral Strategies for
Individuals with Autism, 1997, Fouse and Wheeler,
Future Horizons, Inc, Arlington, Texas
• Asperger’s Syndrome and Difficult Moments, 1997,
Myles and Southwick, Autism Asperger Pub Co,
Shawnee Mission, Kansas
• Visual Strategies for Improving Communication,
2000, Hodgdon, QuirkRoberts Publishing, Troy,
Michigan
• The Explosive Child. Latest edition 2010. Ross Green
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Behavior references
• Aman MG, CA Farmer, J Hollway, LE Arnold, Treatment of
Inattention, Overactivity and Impulsiveness in Autism Spectrum
Disorders. Child Adolesc Psychiatric Clin N Am 17 (2008) 713–738
• Cortesi F;Giannotti F;Ivanenko A;Johnson K
Sleep in children with autistic spectrum disorder.
Sleep Med 2010 Aug;11(7):659-64.
• King, B et al, Lack of efficacy of citalopram in children with ASDs
and high levels of repetitive behavior. Arch Gen Psych 2009 June;
66: 583-590.
• Kodak T and CC Piazza, Assessment and behavioral treatment of
sleeping and feeding disorders in children with autism spectrum
disorders. Child Adolesc Psychiatric Clin N Am 17 (2008) 887–905
• Kolevzon A, Mathewson KA, Hollander E. Selective serotonin
reuptake inhibitors in autism: a review of efficacy and tolerability, J
Clin Psychiatry. 2006 Mar;67(3):407-14.
• Malow BA et al, Impact of treating sleep apnea in a child with autism
spectrum disorder. Pediatric Neurology 34:4 (2006) 325-328.
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Behavior references
•
•
•
•
•
•
•
•
Matson,JL and T Dempsey. The nature and treatment of compulsions,
obsessions, and rituals in people with developmental disabilities, Res in
Devel Disabil 30 (2009) 603-611.
Miano S;Ferri R. Epidemiology and management of insomnia in children
with autistic spectrum disorders. Paediatr Drugs 2010 Apr 1;12(2):75-84.
Mindell J and Owens J. Pediatric Sleep: Diagnosis and Management of
Sleep Problems, 2nd Edition, 2009, Lippincott, Williams and Wikens.
Minshawi, NF. Behavioral Assessment and Treatment of Self-Injurious
Behavior in Autism, Child Adolesc Psychiatric Clin N Am 17 (2008) 875–886
Richdale AL and Schreck KA, Sleep problems in autism spectrum disorders:
prevalence, nature, and possible biopsychosocial aetiologies. Sleep
Medicine Reviews, XXX (2009) 1-9.
Reed HE et al, Parent-based sleep education workshops in autism. Journal
of child neurology, (2009) 1-10.
Rossignal and Frye, Melatonin in Autism Spectrum Disorders: a systematic
review and meta-analysis. Developmental Medicine & Child Neurology
2011
Scott, L and S. Dhillon, Risperidone: A review of its use in the treatment of
irritability associated with autistic disorder in children and adolescents.
Pediatr. Drugs 2007; (9):343-354.
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First STEPS 2014 July Webinar
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Upcoming First STEPS/
Snuggle ME/ ME CHIP
Early Brain and Child Development (EBCD) relates to
Improving Developmental Screening and Future Impacts on
Well Child Care
Dr. Andrew Garner, AAP
Dr. Bob Holmberg
Friday, August 15, 2014, 12n-1 pm
https://cc.readytalk.com/r/4148heefy2pc&eom
Don’t Forget…
Harvest Meeting!!
September 11, 2014
Freeport, Maine
Go to: www.mainequalitycounts.org
for a complete agenda and to
register!
QI Office Hours!!
July 23 12 noon-1PM
1-866-740-1260; 5493654#
www.readytalk.com pass code
5493654
First STEPS 2014 July Webinar
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Practice Report
Out
• What are you testing
in your practice?
• Tell us about any
breakthroughs you are
experiencing with
your work.
• Barriers?
• Learnings?
• Advice for others?
• Teeing up the
conversation:
• Martin’s Point
Brunswick
Pediatrics
• SMHC Pediatrics
First STEPS 2014 July Webinar
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Progress To-Date: General Developmental Screening
First STEPS 2014 July Webinar
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Progress To-Date: General Developmental Screening
First STEPS 2014 July Webinar
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Progress To-Date: Autism Screening
First STEPS 2014 July Webinar
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Progress To-Date: Autism Screening
First STEPS 2014 July Webinar
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Timeline for First STEPS 2014:
Improving Developmental and Autism Screening
Jan-March 2014
Complete Teamwork
and Office Screening
Assessment by
3/1/2014
Baseline Data by
3/15/2014
Review Aims, Goals,
Metrics and Training
Session Preparation
Package
All Practice Call: Intro
to 2014 Initiative
Thurs- Feb 13 or
March 13
12-1pm
April
May
June
July
August
September
Update
Practice
Assessments
9/15/14
Conference Line: 1-866-740-1260 Access Code:
5493654# webinar: www.readytalk.com 5493654
Regional Training: Implementing
Developmental and Autism
Screening in the Office
Workflow (12-4:30 pm)
Portland, March 4 (USM)
Augusta, March 18 (Senator)
Orono, April 8 (Wells
Conference Center)
Optional: Lunch with Quality
Improvement Coach Webinars
(12-1pm using above conference
line and Readytalk connection
information)
October
Final First STEPS Learning
Session: Sustaining Quality
Improvement
Thursday, Sept. 11 , 2014, 8-4pm
Harraseeket Inn, Freeport
April 23, 2014
June 4, 2014
July 23, 2014
Submit Data
Submit Data
Submit Data
Submit Data
Submit Data
Submit Data
3/15/2014
4/15/2014
5/15/2014
6/15/2014
7/15/2014
8/15/2013
All
Practice
Call
All
Practice
Call
All
Practice
Call
All
Practice
Call
All
Practice
Call
Thurs –
April 10
12-1pm
Thurs –
May 8
12-1pm
Thurs –
June 12
12-1 pm
Thurs –
July 10
12-1pm
Thurs August 14
12-1pm
First STEPS 2014 July Webinar
*Special Webinar*
October 9, 2014
12N-1PM
Considering Culture
in Developmental
and Autism
Screening
63
Contact Information
• Amy Belisle, MD, Director of Child Health Quality Improvement, Maine
Quality Counts, abelisle@mainequalitycounts.org, 207-847-3582
• Sue Butts-Dion, First STEPS Project Manager, 207-283-1560,
sbutts@maine.rr.com
• Deb Gilbert, QC for Kids Administrative Coordinator, 207-620-8526 x
1017; fax 207-620-8538, dgilbert@mainequalitycounts.org
• Nan Simpson, MSW, DSI Project Manager,
nsimpson@mainequalitycounts.org, 207-441-3722
• Sue Mackey Andrews, Consultant to QC for Kids on DSI Project,
sdmandrews@aol.com, 207-564-8245
• Bob Holmberg, MD, MPH, Consultant to QC First STEPS Project,
bobholmberg@me.com
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Funding Statements
CHIPRA/IHOC Quality Demonstration Grant
February 2010 to February 2015: The Improving Health Outcomes for Children (IHOC) work is
conducted under a Cooperative Agreement between the Maine Department of Health and Human
Services and the Muskie School of Public Service at the University of Southern Maine and is funded
by a grant from the Centers for Medicare and Medicaid Services (CMS) through Section 401(d) of
the Child Health Insurance Program Reauthorization Act (CHIPRA). This document was developed
under grant CFDA 93.767 from the U.S. Department of Health and Human Services, Centers for
Medicare & Medicaid Services. However, these contents do not necessarily represent the policy of
the U.S. Department of Health and Human Services, and you should not assume endorsement by
the Federal Government.
For more information, please contact the IHOC Project Director, Joanie Klayman at
jklayman@usm.maine.edu or 207-780-4202.
Developmental Systems Integration (DSI)
Supported by the Maine DHHS through funding from the US CDC Preventive Health and Health
Services Block Grant 3B01DP009026-13 and the US DHHS Health Resources and Services
Administration Maternal and Child Health Bureau Grant 2D89MC23149-02-00.
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