Screening for Autism Spectrum Disorders During Well-child Visits in a Primary Care Setting

Patricia L. Webb, DNP, CPNP-PC

Journal for Nurse Practitioners. 2011;7(3):229-235.

Abstract and Introduction

Abstract

Early identification and intervention in children with autism spectrum disorders (ASDs) result in improved outcomes.^[1] Screening for ASDs was implemented during well-child visits. The Iowa Model, the Chronic Care Model, and the DNP Systems Change Model were used as quality improvement frameworks. The Infant-Toddler Checklist^[2] and the Modified Checklist for Autism in Toddlers^[3] were used to screen 29 children 9 to 30 months old. Two children were identified who needed early childhood intervention. Buy-in, timing, electronic health records, and choice of screening tools should be considered for successful integration of ASD screening into well-child visits.

Introduction

Autism spectrum disorders (ASDs) affect 1 of 150 US children.^[4] Interventions for ASDs that begin in the toddler and preschool years are linked with improved outcomes in cognition, language, and educational achievement.^[1,5] Early intervention also is associated with significant cost savings for families and society.^[6]

The American Academy of Pediatrics (AAP) recommends universal screening for ASDs during the toddler years.^[7] In spite of this recommendation, a recent survey of 257 pediatricians found that only 42% routinely screened for autism in young children.^[8] Reported barriers to screening included lack of time, lack of familiarity with ASD screening tools, inadequate reimbursement for screening, and reliance on clinical observations instead of more reliable screening tools to detect ASDs.^[7,8]

A quality improvement project to implement ASD screening was developed using the Doctor of Nursing Practice (DNP) Systems Change Model,^[9] the Iowa Model for Evidence-Based Practice,^[10] and the Chronic Care Model (CCM).^[11] The purpose of the project was to evaluate the integration of ASD screening into well-child visits. Can ASD screening be successfully integrated into such visits in a primary care setting? Will ASD screening increase the number of children diagnosed with ASDs by 24 to 30 months old?

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Next Section

Cite this: Screening for Autism Spectrum Disorders During Well-child Visits in a Primary Care Setting - Medscape - Mar 01, 2011.

Table 1. Examples of ASD-Specific Screening Tools for Toddlers and Preschoolers
Tool	Type	Reported Sensitivity	Reported Specificity	Availability
Checklist for Autism in Toddlers (CHAT)²¹	Parent interview/questionnaire combined with clinician interaction with child for age 18–24+ months	0.65	0.98–1.0	www.autismresearchcentre.com/tests/chat_test.asp
CHAT, Denver Modifications²²	Parent interview/questionnaire combined with clinician interaction with child for age 18–24+ months	0.85	1.0	Scambler et al.²² (CHAT scoring modifications)
Checklist for Autism in Toddlers-23 (CHAT-23)²³	Parent interview/questionnaire combined with clinician interaction with child for age 18–24+ months	0.84–0.93 (part A); 0.74 (part B)	0.77–0.85 (part A); 0.91 (part B)	Wong et al.²³ (for protocol that combines M-CHAT & CHAT items)
Modified Checklist for Autism in Toddlers (M-CHAT)^[19]	Parent questionnaire for child age 16–48 months	0.85	0.93	AAP autism toolkit²⁴ https://www2.gsu.edu/~psydlr/DianaLRobins/Official_M-CHAT_Website.html
Pervasive Developmental Disorders Screening Test-II Primary Care Screener (PDDST-II PCS)²⁵	Parent questionnaire for ages 18 to 48 months	0.92	0.91	Purchase from PsychCorp/Harcourt Assessment www.harcourtassessment.com
M-CHAT Follow-up Interview ²⁰	Questions for clinician to clarify failed responses on the M-CHAT to reduce false positives			https://www2.gsu.edu/~psydlr/DianaLRobins/Official_M-CHAT_Website.html
Tool to Screen for Social/Communication Delays in Infants/Toddlers (not ASD specific)
CSBS DP Infant-Toddler Checklist (ITC)²	Parent questionnaire for child age 6–24 months	88.9	88.9	AAP autism toolkit²⁴ https://www.brookespublishing.com/store/books/wetherby-csbsdp/index.htm

Table 2. Demographics and Screening Tool Used for Children Receiving ASD Screening
Age/Gender	9–12 months	15–20 months	24–30 months	Male	Female
	9 (31%)	11 (38%)	9 (31%)	9 (31%)	20 (69%)
Race/Ethnicity	White	Black	Undisclosed	Hispanic	Nonhispanic
	25 (86%)	3 (10%)	1 (3%)	0%	100%
Screening Tool Used	M-CHAT	ITC
	15 (52%)	14 (48%)

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