Reducing Barriers to Autism Screening in Community Primary Care: A Pragmatic Trial Using Web-Based Screening

Abstract

Objective: To determine whether an intervention addressing both logistical and knowledge barriers to early screening for autism spectrum disorder (ASD) increases evidence-based screening during 18-month well-child visits and primary care providers' (PCPs') perceived self-efficacy in caring for children with ASD.

Methods: Forty-six PCPs from 10 diverse practices across four counties in Washington State participated. PCPs attended a 2-hour training workshop on early recognition and care for toddlers with ASD and use of a REDCap-based version of the Modified Checklist for Autism in Toddlers-Revised with Follow-up (webM-CHAT-R/F) that provided automated presentation and scoring of follow-up questions. Data were collected at baseline and 6 months following each county's training window. PCPs' screening methods and rates and perceived self-efficacy regarding ASD care were measured by self-report and webM-CHAT-R/F use was measured via REDCap records.

Results: At follow-up, 8 of the 10 practices were using the webM-CHAT-R/F routinely at 18-month visits. The proportion of PCPs reporting routine M-CHAT screening increased from 82% at baseline to 98% at follow-up (16% increase, 95% confidence interval [CI] 3%-28%; McNemar exact P = .02). The proportion using the M-CHAT-R/F follow-up interview questions increased from 33% to 82% (49% increase, 95% CI 30%-68%, exact McNemar test, P < .001). Significant increases in self-efficacy were found for all seven areas assessed (Ps ≤ .008).

Conclusions: This brief intervention increased PCPs' self-reported valid use of the M-CHAT-R/F at 18 months and their self-efficacy regarding ASD care. Combining educational information with a web-based ASD screen incorporating the M-CHAT-R/F follow-up questions may increase universal ASD screening with improved fidelity.

Trial registration: ClinicalTrials.gov NCT02409303.

Keywords: autism spectrum disorder; primary care; screening.

Conflict of interest statement

Conflict(s) of Interest: The authors have no conflicts of interest.

Declarations of Interest: None.

Copyright © 2021 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1.. Run charts for webM-CHAT-R/F use by county and practice for the first 6 months post-training.

Each line represents an individual practice. Month 0 (0m) represents the end of the training window for each county. See Results for characterization of run chart curves.

Figure 2.. Changes in perceived self-efficacy.

Shading within each bar represents the number of PCPs rating their degree of self-efficacy at the baseline (BL) and 6-month follow-up (FU) period. Wilcoxon signed-rank test, p-values listed above each item. Survey Questions: (a) How knowledgeable do you feel about recognizing the signs of autism in children under 2 years old?; (b) How knowledgeable do you feel about selecting and using autism screening tools for children under 2 years old?; (c) How confident do you feel in the results of the autism-specific screening tools?; (d) How comfortable do you feel discussing autism concerns with parents of children under 2 years old? (e) How comfortable do you feel making a referral for assessment and intervention services for children under 2 years old with autism concerns?; (f) How knowledgeable do you feel about the diagnostic assessment resources in your community for children under 2 years old?; (g) How knowledgeable do you feel about the early intervention resources in your community for children under 2 years old? *p < .01; **p < .001. an=44 for BL; 2 providers provided no response at BL; statistical analysis compared BL to FU in 44 subjects.

Figure 3.. Changes in perceived obstacles to screening.

Shading within each bar represents the number of PCPs rating each potential obstacle to screening at the baseline (BL) and 6-month follow-up (FU) period. Wilcoxon signed-rank test, *p < .05; **p < .01. an=45 for FU; 1 provider provided no response at FU; statistical analysis compared BL to FU in 45 subjects.