First name
Susan
Middle name
E
Last name
Levy

Title

Adherence to screening and referral guidelines for autism spectrum disorder in toddlers in pediatric primary care.

Year of Publication

2020

Number of Pages

e0232335

Date Published

2020

ISSN Number

1932-6203

Abstract

<p><strong>OBJECTIVES: </strong>Although the American Academy of Pediatrics recommends screening for autism spectrum disorder (ASD) for all young children, disparities in ASD diagnosis and intervention in minority children persist. One potential contributor to disparities could be whether physicians take different actions after an initial positive screen based on patient demographics. This study estimated factors associated with physicians completing the follow-up interview for the Modified Checklist for Autism in Toddlers with Follow-up (M-CHAT-F), and referring children to diagnostic services, audiology, and Early Intervention (EI) immediately after a positive screen.</p>

<p><strong>METHODS: </strong>Children seen in a large primary care network that has implemented universal ASD screening were included if they screened positive on the M-CHAT parent questionnaire during a 16-30 month well child visit (N = 2882). Demographics, screening results, and referrals were extracted from the electronic health record.</p>

<p><strong>RESULTS: </strong>Children from lower-income families or on public insurance were more likely to have been administered the follow-up interview. Among children who screened positive, 26% were already in EI, 31% were newly referred to EI, 11% were referred each to audiology and for comprehensive ASD evaluation. 40.2% received at least one recommended referral; 3.7% received all recommended referrals. In adjusted multivariable models, male sex, white versus black race, living in an English-speaking household, and having public insurance were associated with new EI referral. Male sex, black versus white race, and lower household income were associated with referral to audiology. Being from an English-speaking family, white versus Asian race, and lower household income were associated with referral for ASD evaluation. A concurrent positive screen for general developmental concerns was associated with each referral.</p>

<p><strong>CONCLUSIONS: </strong>We found low rates of follow-up interview completion and referral after positive ASD screen, with variations in referral by sex, language, socio-economic status, and race. Understanding pediatrician decision-making about ASD screening is critical to improving care and reducing disparities.</p>

DOI

10.1371/journal.pone.0232335

Alternate Title

PLoS ONE

PMID

32379778

Title

Accuracy of Autism Screening in a Large Pediatric Network.

Year of Publication

2019

Date Published

2019 Oct

ISSN Number

1098-4275

Abstract

<p><strong>BACKGROUND: </strong>Universal screening is recommended to reduce the age of diagnosis for autism spectrum disorder (ASD). However, there are insufficient data on children who screen negative and no study of outcomes from truly universal screening. With this study, we filled these gaps by examining the accuracy of universal screening with systematic follow-up through 4 to 8 years.</p>

<p><strong>METHODS: </strong>Universal, primary care-based screening was conducted using the Modified Checklist for Autism in Toddlers with Follow-Up (M-CHAT/F) and supported by electronic administration and integration into electronic health records. All children with a well-child visit (1) between 16 and 26 months, (2) at a Children's Hospital of Philadelphia site after universal electronic screening was initiated, and (3) between January 2011 and July 2015 were included ( = 25 999).</p>

<p><strong>RESULTS: </strong>Nearly universal screening was achieved (91%), and ASD prevalence was 2.2%. Overall, the M-CHAT/F's sensitivity was 38.8%, and its positive predictive value (PPV) was 14.6%. Sensitivity was higher in older toddlers and with repeated screenings, whereas PPV was lower in girls. Finally, the M-CHAT/F's specificity and PPV were lower in children of color and those from lower-income households.</p>

<p><strong>CONCLUSIONS: </strong>Universal screening in primary care is possible when supported by electronic administration. In this "real-world" cohort that was systematically followed, the M-CHAT/F was less accurate in detecting ASD than in previous studies. Disparities in screening rates and accuracy were evident in traditionally underrepresented groups. Future research should focus on the development of new methods that detect a greater proportion of children with ASD and reduce disparities in the screening process.</p>

DOI

10.1542/peds.2018-3963

Alternate Title

Pediatrics

PMID

31562252

Title

Shared Decision Making for Children with Developmental Disorders: Recent Advances.

Year of Publication

2018

Number of Pages

364-5

Date Published

2018 May - Jun

ISSN Number

1876-2867

DOI

10.1016/j.acap.2018.02.005

Alternate Title

Acad Pediatr

PMID

29432908

Title

Shared Decision Making and Treatment Decisions for Young Children with Autism Spectrum Disorder.

Year of Publication

2016

Date Published

2016 Apr 27

ISSN Number

1876-2867

Abstract

<p><strong>OBJECTIVE: </strong>To describe influences on shared decision making (SDM) between primary care pediatricians and parents of young children with autism spectrum disorder (ASD).</p>

<p><strong>METHODS: </strong>We conducted a qualitative study using key informant interviews with 20 pediatricians of varying experience from 10 primary care practices and 20 English speaking parents of young children (ages 2-5 years) with a parent reported diagnosis of ASD. Subjects were recruited through purposive sampling. Interviews were audio taped, transcribed verbatim and analyzed using an integrated approach to data analysis. Differences in coding were resolved by consensus. We achieved thematic saturation and ceased recruitment after 20 interviews were completed within each group.</p>

<p><strong>RESULTS: </strong>Three primary themes emerged: 1) pediatricians and parents reported knowledge gaps by pediatricians about ASD treatments and community resources and ambiguity regarding the pediatrician's role in ASD care; 2) there was little communication between parents and pediatricians about treatment choices; 3) use of CAM treatments created conflict between pediatricians and parents and, as a result, parents may independently pursue treatments, without benefit of discussing safety and efficacy with pediatricians. Despite these barriers, parents desired increased support and guidance from their pediatricians, including for CAM.</p>

<p><strong>CONCLUSIONS: </strong>Much work is needed to effectively foster SDM in the context of ASD treatment decisions in primary care, including pediatrician training in ASD to enhance knowledge about evidence-based and novel treatments, clinical practice guidelines and community resources.</p>

DOI

10.1016/j.acap.2016.04.007

Alternate Title

Acad Pediatr

PMID

27132050

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