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Increasing Universal ASD Screening in Primary Care: A Pragmatic Trial with a Six-Month Follow-up
Although the American Academy of Pediatrics recommends universal use of ASD-specific screening at 18 and 24 months, compliance by primary care providers (PCPs) is limited by time constraints and lack of confidence regarding ASD care. The Modified Checklist for Autism in Toddlers–Revised with Follow-up (M-CHAT-R/F, Robins, 2014), is a well-validated screener comprising a 20-item parent checklist and a follow-up interview for positive initial screens, designed to reduce false positives. However, limited time allotments for well-child visits often result in the omission of the follow-up interview, leading to potential over-diagnosis.
Objectives:
To examine the effectiveness of an intervention for community-based PCPs designed to: (1) increase the use of the M-CHAT-R/F at 18 month well-child visits, and (2) increase PCP self-efficacy regarding clinical care for toddlers with possible ASD.
Methods:
Sample. 61 PCPs from 10 practices in 4 counties across Washington State were enrolled. PCPs had a mean age of 45.2 years and mean of 13.7 years in practice. The majority were MDs (72.9%) and female (75.0%).
Procedures. A stepped wedge design was used to randomly assign each county to the timing of intervention. Survey data were collected at baseline (T1) and 6-months post-intervention (T2). The intervention comprised a 2-hour, interactive training workshop conducted in each PCP practice. Workshops focused on the introduction of a novel online version of the M-CHAT-R/F, along with information about the importance of universal ASD screening at 18 months, early behavioral features of ASD, strategies for talking to families about ASD concerns, and local ASD resources.
Online M-CHAT-R/F. An online version of the M-CHAT-R/F was developed using REDCap (Research Electronic Data Capture; Harris et al., 2009) and is accessed via tablets. This version triggers the follow-up questions when appropriate, and provides automated scoring. Medical staff access the results via the final screen, which is color-coded to indicate pass/fail status, and can log-in directly to REDCap to review the specific items failed.
Measures. Self-report measures of screening practices and self-efficacy regarding ASD care were collected at T1 and T2. At T2 only, feasibility and acceptability of the online M-CHAT-R/F were measured with items adapted from the User Rating Profile (URP; Chafouleas et al., 2011), and objective data on 18-month screening rates were obtained from the REDCap database.
Results:
The percent of PCPs using the M-CHAT-R/F follow-up interview increased from 37% to 91%. Significant increases in PCPs’ self-efficacy in caring for young children with ASD were found (see Table 1). Provider ratings indicated high levels of feasibility and acceptability for the online M-CHAT-R/F (Table 2). At T2, 7 of the 10 practices were using the online M-CHAT-R/F routinely at 18-month visits.
Conclusions:
This brief community-based intervention was effective for increasing PCPs’ use of universal ASD screening at a 6-month follow-up period. PCPs rated the online M-CHAT-R/F as feasible and acceptable. While automation of the M-CHAT-R/F scoring removed a common barrier to screening (i.e., lack of time), improvements in provider self-efficacy regarding ASD care may have also contributed to increased rates of universal screening.