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Thursday, July 9, 2020

Progress on Screening

In The Politics of Autism, I discuss evaluation and diagnosis of young children.  Screening is an important part of the process.

Paul S. Carbone and colleagues have an article at Pediatrics titled "Primary Care Autism Screening and Later Autism Diagnosis"

From the abstract:
Of 36 233 toddlers, 73% were screened and 1.4% were later diagnosed with ASD. Hispanic children were less likely to be screened (adjusted prevalence ratio [APR]: 0.95, 95% confidence interval [CI]: 0.92–0.98), and family physicians were less likely to screen (APR: 0.12, 95% CI: 0.09–0.15). Compared with unscreened children, screen-positive children were more likely to be diagnosed with ASD (APR: 10.3, 95% CI: 7.6–14.1) and were diagnosed younger (38.5 vs 48.5 months, P < .001). The M-CHAT’s sensitivity for ASD diagnosis was 33.1%, and the positive predictive value was 17.8%. Providers routinely omitted the M-CHAT follow-up interview and had uneven referral patterns.
From the article:
Previous estimates of ASD screening have varied significantly (between 17% and 81%) and relied on physician report of “usual practice.”6,16 Our study, along with 2 recent studies, adds to understanding of ASD screening because estimates are based on data from actual visits rather than physician recall and indicates that, although ASD screening is far from universal, a high proportion of children are screened at least once.10,11
With our study, we provide important insight into disparities in ASD screening; researchers in previous studies suggested that ASD screening in primary care reduces racial and ethnic disparities in ASD identification and age of diagnosis.17 Hispanic children in our cohort were less likely to be screened compared with non-Hispanic white children, a finding supported by one previous study.11 We also found family physicians rarely administered ASD screening tools. The American Academy of Family Physicians does not recommend universal ASD screening, which may explain differences in screening between pediatricians and family physicians.18 No previous studies have had estimated rates of ASD screening among family physicians, although researchers of one qualitative study of a small group of family physicians found that, rather than screening, participants relied on developmental surveillance to identify children with ASD.19 Given that family physicians provide 16% to 21% of pediatric care, this new finding uncovers an opportunity to further increase ASD screening rates in the United States.20
Our results suggest progress toward universal ASD screening in primary care practices. Still, only half of children in our study were screened at both 18- and 24-month visits, suggesting further work to be done to encourage providers to complete screens as recommended, with more efforts to screen Hispanic children. Further advocacy and education are needed to encourage family physicians to screen for ASD. More resources are needed for implementing ASD screening at the practice and health care system level, with particular attention to administering ASD screening tools with fidelity, prompt referral of children who are found to be at-risk, and increasing the availability of ASD diagnostic providers to facilitate prompt ASD evaluations.