Standardized autism screening during pediatric well visits identified more, younger children with high likelihood for autism diagnosis

Recently published in the Journal of the American Academy of Child & Adolescent Psychology, the multi-site study tested whether using standardized autism toddler screening — the Modified Checklist for Autism in Toddlers, Revised, with Follow-Up (M-CHAT-R/F) — during pediatric well-child visits would result in a higher number of children receiving an autism diagnosis at a younger age compared to usual care.

Usual care is generally a combination of screening that is not standardized, or low fidelity (meaning that clinicians did not use the screening tool as it was intended) and clinical judgment to determine whether to refer a child for diagnostic evaluation and early intervention.

In the study, 31 pediatric practices across three sites near Philadelphia, Pennsylvania; Storrs, Connecticut; and Sacramento, California were randomly assigned to an experimental condition involving training and supervision in the universal, standardized, high-fidelity use of M-CHAT-R/F, or to usual care.

Pediatric practices in both groups referred toddlers who showed signs of autism during 18-month well-child visits to the research team for a diagnostic evaluation.

“We found that the practices randomly assigned to standardized screening — meaning the screener was administered and scored the same way for every child — identified children with a high likelihood of autism more frequently and more timely compared to practices in the usual care group,” said Giacomo Vivanti, PhD, an associate professor in the Autism Institute and lead author of the study. “This resulted in 186 children referred to a diagnostic evaluation — and their average age was 20.6 months, compared to 39 children with an average age of 23.6 months referred by practices in the usual care group.”

The research team found that most of the children who attended the evaluation in both conditions received a diagnosis of autism. Children referred by practices that used standardized autism screening had a wider range of clinical presentations, including milder manifestations in areas like language and cognition, compared to those referred from usual care practices — indicating that using the screening may counteract the tendency to only refer children with more obvious impairments.

The study results indicate that routine, standardized screening for all children at toddler well visits, coupled with immediate referrals for diagnosis for those showing likelihood of autism during the screening, is superior to relying on non-standardized use of screeners or clinicians’ judgment for identifying children with autism.

“The earlier identification of autism allows for autism-specific early intervention at a younger age, which improves outcomes across the rest of their lives,” said Diana Robins, PhD, the director of the Autism Institute and creator of the M-CHAT-R/F, who was the principal investigator in the study.

The research team envisions that policies and guidelines align to support the use of routine, standardized autism screening for all children at toddler well visits.

“Although the American Academy of Pediatrics has been recommending universal, standardized autism screening at 18- and 24-month well-child visits for nearly 20 years, it is clear that community implementation lags behind best practices,” said Vivanti and Robins.

They added that they hope that these findings will emphasize the need to administer, score, and follow recommended actions of screeners according to their instructions, rather than using screeners in non-standardized ways, or relying on clinical judgment to determine whether or not to refer toddlers for autism evaluations and early intervention, effectively over-riding when a screener indicates that referrals are needed.