The Impact of Using Standardized Autism Screening on Referral to Specialist Evaluation for Young Children on the Autism Spectrum: A Cluster-Randomized Controlled Trial

Abstract

Objective

We tested whether the implementation of standardized, high-fidelity screening for autism during routine well-child check-ups results in the following: increasing the number of children with suspected autism referred to diagnostic evaluation; lowering the age at which they are referred; and facilitating autism diagnosis for children across a more diverse range of demographic backgrounds and clinical presentations, including those with subtle manifestations.

Method

As part of a multisite cluster randomized trial, pediatric practices were randomly assigned to an experimental condition involving training and supervision in the universal, standardized, high-fidelity implementation of the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F), or a usual care condition. Children in both conditions identified as having a high likelihood of autism during well-child visits were referred to a diagnostic evaluation conducted by clinicians naive to referral source.

Results

Children referred to the diagnostic evaluation from the practices in the experimental condition were more numerous (n = 186) and younger (mean age = 20.65 months) than those referred from the practices in the usual care condition (n = 39; mean age = 23.58 months). Children referred by experimental practices who received an autism diagnosis had milder clinical presentations across measures of cognitive, language, adaptive, and social–communication functioning, compared to those referred from usual care practices. Demographic characteristics were similar across groups.

Conclusion

Standardized, high-fidelity implementation of autism screening during pediatric well-child visits facilitates the identification of children with high autism likelihood at a younger age, including those presenting with more subtle clinical manifestations.

Plain language summary

This study evaluated whether screening all children for autism with a standardized tool during toddler well-child check-ups (a) increases the number of children referred for autism evaluation, (b) reduces the age at which children are referred, and (c) increases the diverse representation among children referred, including those with milder autism-related behaviors. Pediatric practices were randomly assigned to routine screening using the Modified Checklist for Autism in Toddlers, Revised, with Follow-Up (M-CHAT-R/F) during their 18-month well-child visit, or a usual care condition. Practices using routine screening referred many more children to receive a diagnostic evaluation (n=186) compared to those in the usual care condition (n=39), referred them when they were younger (mean age of 20.65 months, compared to 23.58 months) and increased the diverse representation of the children referred, including those with milder clinical presentations. Routine screening deployed the same way for all children attending pediatric well-child visits facilitates the identification of children with high autism likelihood at a younger age, including those presenting with more subtle clinical manifestations.

Clinical trial registration information

Promoting Positive Outcomes for Individuals With ASD: Linking Early Detection, Treatment, and Long-term Outcomes; https://clinicaltrials.gov/study/NCT03333629.