Developmental and Autism-Specific Screening Practices Among Primary Care Providers

Background: Early identification of autism spectrum disorder (ASD) is essential for facilitating access to early intervention. However, the average age of ASD diagnosis in the United States is over 4 years, with many parents waiting ≥3 years between first concerns and diagnosis. The use of standardized screening tools is more accurate for early identification than informal discussion or clinical judgment alone, and the Academy of Pediatrics (AAP) recommends systematic general developmental screening at all 9, 18, and 24- or 30-month well-child visits (WCVs) and autism-specific screening at all 18- and 24-month WCVs. However, in the decade since these guidelines were published, the extent to which they have been adopted has not been directly examined. A few studies have used self-report surveys to estimate developmental screening practices; however, potential response bias and/or difficulties with recall may limit the accuracy of these estimates.

Objectives: The study objectives were to: 1) directly examine the extent to which primary care providers (PCPs) are administering developmental and autism-specific screenings at regular well-child visits in accordance with AAP-recommendations, and 2) examine potential provider-level factors that are associated with screening practices, including provider type, years of practice, previous autism training, and self-efficacy regarding ASD screening.

Methods: Participants included 114 PCPs enrolled in a larger study of a new ASD training program. The sample included general pediatricians (72%) and other PCPs (28%) providing care for underserved children in 14 states. Data collected at baseline (prior to training) were examined in the current study, including demographic information and self-efficacy regarding autism screening and identification. Screening practices were directly assessed through chart review for all 9, 18, 24, and 30-month WCVs in the 30 days prior to the date of chart review. Note that most PCPs did not conduct WCVs for all age ranges within the 30-day baseline assessment window.

Results: Regarding general developmental screening, 64% (57/89) of PCPs administered tools at all 9-month WCVs, 62% (54/87) at all 18-month WCVs, 57% (50/88) at all 24-month WCVs, and 73% (40/55) at all 30-month WCVs. Regarding ASD-specific screening, 52% (45/87) administered tools at all 18-month WCVs, and 42% (37/88) at all 24-month WCVs. Neither PCP general developmental screening practices (percentage of relevant visits in which screening tools were used) nor ASD-specific screening practices varied by provider type (pediatrician vs. other). Providers with prior training in ASD demonstrated similar use of ASD-specific screening tools compared to those with no prior training, and years of experience were not significantly associated with ASD screening. However, PCP-reported self-efficacy regarding autism screening and identification was significantly associated with percent of children the PCP screened for ASD at month 18- and 24-month WCVs (r=0.3, p=0.002).

Conclusions: AAP guidelines for developmental and ASD-specific screening have not been uniformly adopted in actual practice, ranging somewhat across visit timepoint and screening tool. Screening practices do not appear to be related to provider type or experience, but providers with greater self-efficacy regarding ASD screening had greater use of ASD screening tools. Results suggest a need for PCP training in screening implementation.