Teaching Pediatric Residents to Diagnose Autism in Primary Care: Enhancing Developmental-Behavioral Pediatric Rotations

Background: The AAP has rightly adopted guidelines wherein pediatricians are encouraged to "screen-and-refer" children for ASD at 18- and 24-months of age. However, without also giving pediatricians explicit competence and ownership over being able to diagnose ASD within practice when clearly discernible symptoms are present, this wide-scale identification of general neurodevelopmental risk—and reliance upon specialty tertiary care diagnostic centers—creates a bottleneck for patients and providers alike. When asked about barriers to providing this type of care, pediatricians report factors such as lack of clear tools, discomfort, difficulty navigating follow-up services, and uncertainty around communicating with families and other providers. Pediatricians-to-be within our residency program reported an overall lack of hands-on, applied learning opportunities to strengthen their competence in recognizing ASD in young children and caring for these patients. Thus, if we do not provide wide-scale training in the basics of ASD recognition, diagnostic triage, and post-diagnostic care coordination to future pediatric medical providers, then "screen-and-refer" will continue to lead to lengthy waits for diagnostic confirmation and service initiation, maintaining the current mean age of diagnosis as after four years of age, and postponing access to the early intervention services.

Objectives: To assess a service system intervention for training residents in within-practice ASD diagnosis and care. To assess feasibility and acceptability of integrating enhanced curricular components within our existing developmental-behavioral pediatrics (DBP) rotation.

Methods: Our curriculum was designed to improve upon previously passive shadowing experiences within young child ASD clinics by integrating procedural, physician-tailored training in within-practice diagnostic identification and care coordination. In addition to multiple web-based procedural learning activities (including an interactive tutorial teaching administration/scoring of the Screening Tool for Autism in Toddlers and Young Children [STAT] and parent feedback), residents were required to actively participate in ASD evaluations under direct supervision of an attending provider. Using online completion metrics and pre/post-rotation REDCap surveys, we analyzed data on completion of curriculum components and changes in comfort level for a range of practice behaviors.

Results: Of the first 33 residents to complete the enhanced rotation activities, 94% completed new training requirements and 85% performed STAT activities during their DBP rotation. Participants reported increased comfort with identifying symptoms/risk for ASD, distinguishing between ASD and other concerns, and making a formal diagnosis. They also reported increased comfort providing feedback about diagnostic decision and effectively connecting families with services. After exposure to new curriculum, 94% of residents reported that they felt comfortable providing primary care for children with ASD, which was an increase from 59% pre-rotation. Updated results will be reviewed in depth.

Conclusions: In line with other residency training programs across the country, DBP rotations often present very few opportunities for active resident participation that would translate into skills relevant for future independent practice. This represents a tremendous training gap that, in turn, is also an opportunity for service system intervention. This project reflects the first step in advancing incorporation of ASD training into pediatric residency programs, thus increasing access to services and information for children with concerns for ASD and their families.