Adherence to screening and referral guidelines for autism spectrum disorder in toddlers in pediatric primary care

Abstract

Objectives Although the American Academy of Pediatrics recommends screening for autism spectrum disorder (ASD) for all young children, disparities in ASD diagnosis and intervention in minority children persist. One potential contributor to disparities could be whether physicians take different actions after an initial positive screen based on patient demographics. This study estimated factors associated with physicians completing the follow-up interview for the Modified Checklist for Autism in Toddlers with Follow-up (M-CHAT-F), and referring children to diagnostic services, audiology, and Early Intervention (EI) immediately after a positive screen. Methods Children seen in a large primary care network that has implemented universal ASD screening were included if they screened positive on the M-CHAT parent questionnaire during a 16-30 month well child visit (N = 2882). Demographics, screening results, and referrals were extracted from the electronic health record. Results Children from lower-income families or on public insurance were more likely to have been administered the follow-up interview. Among children who screened positive, 26% were already in EI, 31% were newly referred to EI, 11% were referred each to audiology and for comprehensive ASD evaluation. 40.2% received at least one recommended referral; 3.7% received all recommended referrals. In adjusted multivariable models, male sex, white versus black race, living in an English-speaking household, and having public insurance were associated with new EI referral. Male sex, black versus white race, and lower household income were associated with referral to audiology. Being from an English-speaking family,

Transitioning to Telemedicine During COVID-19: Impact on Perceptions and Use of Telemedicine Procedures for the Diagnosis of Autism in Toddlers

“…The importance of understanding provider perceptions of the benefits and barriers to ASD tele-assessment extends beyond the immediate and relatively short-term impacts of COVID-19. Delays in accessing ASD-specific diagnostic and intervention services, specifically for underserved and under-resourced populations, were present long before the pandemic (Constantino et al, 2020a, b;Durkin et al, 2017;Wallis et al, 2020;Zuckerman et al, 2017Zuckerman et al, , 2018 and will undoubtedly continue after its cessation without significant, systemic intervention. Telemedicine has the potential for increasing access to care for those families who might otherwise face delays.…”

To reduce the average age of autism diagnosis, screen preschoolers in primary care

“…In the 14 years since the initial AAP screening recommendation, ASD prevalence has increased dramatically (Maenner, 2020), and screening for ASD in primary care has become commonplace. Some estimates suggest that that over 50% of US toddlers are screened for ASD in primary care (Arunyanart et al, 2012), although significant local variability exists (Carbone et al, 2020; Wallis et al, 2020). Increased screening has likely contributed to a decrease in the age of autism diagnosis in the United States: recent data from the Early Autism and Developmental Disabilities Monitoring Network suggest that the percentage of children with ASD diagnosis by the age of 4 years has changed from 58% in 2014 to 71% in 2018 (Shaw et al, 2020).…”

“…The fact remains that despite widespread autism screening, the majority of children are not being identified with ASD until well past the toddler ages, and this age is even higher for children from low-income and or racial/ethnic minority backgrounds (Durkin et al, 2017; Maenner, 2020). Studies have demonstrated a variety of reasons for diagnostic delays such as (1) not all children attend primary care as toddlers, (2) not all of those who attend are screened for ASD, and (3) not all those who are screened are referred for ASD evaluation (Carbone et al, 2020; Guthrie et al, 2019; Wallis et al, 2020). Furthermore, emerging evidence suggests that ASD screening tools have limited sensitivity—meaning that some children who screen negative on toddler screens go on to receive an ASD diagnosis (Guthrie et al, 2019).…”

“…Furthermore, emerging evidence suggests that ASD screening tools have limited sensitivity—meaning that some children who screen negative on toddler screens go on to receive an ASD diagnosis (Guthrie et al, 2019). Predictive values of ASD screening questionnaires are low (Carbone et al, 2020; Guthrie et al, 2019; Robins et al, 2014), particularly for cases near the cutoff score—which may contribute to the fact that children with positive screening test results often are not referred (Carbone et al, 2020; Monteiro et al, 2019; Sheldrick & Garfinkel, 2017; Wallis et al, 2020). As a result, screening of toddlers is only a partial solution to delays and disparities in age of ASD diagnosis.…”

The Roadmap to Early and Equitable Autism Identification

“…Although screening rates have increased, more than 1 in 4 pediatricians report that they do not regularly offer ASD screening. Even in practices with high screening rates, disparities persist in which children are not screened, 12,13 which children are referred for a comprehensive ASD evaluation after a positive screen result, [14][15][16] and which children ultimately receive intervention services.…”