BHIPP Bulletin
Volume 7, Issue 10
April 2022
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Autism Screening in Pediatric Primary Care |
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This month's BHIPP Bulletin is a contribution from Carisa Parrish, PhD, Associate Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine, Director of Pediatric Health Psychology, Johns Hopkins Children's Center and BHIPP Consultant. Additionally, this month's BHIPP Resilience Break focused on "Autism Spectrum Disorder in Primary Care: Supporting Children and Families" and was presented by Anna Maria Wilms Floet, MD of Kennedy Krieger Institute's Center for Autism and Related Disorders. To view the full session recording, slides, and related resources: click here!
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Valid and reliable screenings in early childhood are a crucial component of effective and proactive mental health care. Well-timed screenings assist pediatricians and parents in appropriate identification of childhood difficulties. Hopefully, early identification of developmental concerns assists families with getting the evidence-based interventions started to promote optimal development and well-being in children. In the case of autism spectrum disorder (ASD), earlier identification and consistent provision of appropriate services are thought to improve a child’s long-term prognosis.
The literature on the prevalence of ASD has evolved significantly in the last several decades, now indicating that ASD is a common neurodevelopmental disorder with a prevalence of roughly 1.7% in the US. ASD is more common among boys and may occur among siblings up to 20% of the time. ASD is associated with a range of associated functional impairments and comorbidities across developmental, social, cognitive, behavioral, emotional, and educational domains. The median age of diagnosis of ASD is 40 months of age (about 3.5 years old).
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Screenings are not without challenge, as we want to optimize correct identification of true diagnoses and minimize misdiagnoses. Parents are often the first source in raising a concern about a child’s development. Research suggests that screening instruments can be accurate in correct identification of autism spectrum disorder in children as young as 18 months of age. The American Academy of Pediatrics recommends screening for ASD at 18 months and 24 months, in addition to developmental surveillance at all visits. The AAP has identified several ASD early symptoms that may serve as signs for further evaluation (see table 1 below).
Table 1. Early ASD symptoms
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Specific Screening Tools
The AAP identifies two tools that are commonly used to screen for ASD: the Modified Checklist for Autism in Toddlers, Revised, with Follow-Up (M-CHAT-R/F) and the Social Communication Questionnaire (SCQ) for preschoolers and above. The AAP provides a detailed summary of these screening tools and others, including age range, administration time, cost, EMR compatibility, psychometric properties (e.g., convergence with gold-standard measures such as the ADOS and ADI-R), and recommendations for further assessments based on screening result. See the full table with additional details here.
The revised version of the M-CHAT by Diana L. Robins, PhD, and colleagues facilitates ASD screening in children ages 16-30 months of age. Parents complete 20 yes/no items, typically within 5-10 minutes; the resulting score generates a risk category directing the clinician to next step or follow-up. The developers caution that there is a high risk for false positives, due to their desire to maximize measurement sensitivity; that is, the developers wanted to minimize the chances of missing any potential indication of ASD. However, children who screen positive on the M-CHAT-R/F tool may be at high risk for a range of other developmental delays, thus warranting an evaluation for any child with an elevated risk score on this tool. This tool is free and can be incorporated into the electronic medical record.
For children 4 years old and up, the Social Communication Questionnaire (SCQ) is a published measure to screen for ASD symptoms, developed by Michael Rutter, MD, and Catherine Lord, PhD. The SCQ has 40 yes/no questions, takes approximately 10 minutes for parents to complete, and offers a current symptoms and lifetime symptoms version. Scores are evaluated relative to a cutoff, with an elevated score indicating need for further evaluation. Scores correlate strongly with well-validated, comprehensive assessment tools for ASD (e.g., Autism Diagnostic Interview, Revised (ADI-R)). The SCQ is described as relatively inexpensive by the publisher.
Table 2. Autism screening tools
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Importance of Screening
There are several specialists who are well-prepared to diagnose ASD, including developmental-behavioral or neurodevelopmental pediatrician, psychologist, neurologist, or psychiatrist; moreover, general pediatricians and child psychologists can make an initial clinical diagnosis and support parents with referrals as needed for further evaluation. Follow-up assessments need to consider potential presence of other commonly co-occurring difficulties, such as intellectual disabilities, learning disabilities, speech/language problems, and emotional/behavioral conditions (e.g., ADHD, anxiety). An effective screening process will help pediatricians support parents in advocating for their children’s access to effective and timely assessments and intervention, across clinic, school, and home settings.
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Resources
Excerpt: Criterion A phrase “as manifested by the following” was revised to read “as manifested by all of the following” to improve the intent and clarity of the wording. The revision by the work group was consistent with the intent of the DSM-5 work group for autism spectrum disorder to maintain a high diagnostic threshold by requiring “all of the following” and not “any of the following” as could be mistakenly inferred from the previous wording of the criterion.
References:
Hyman, S. L., Levy, S. E., & Myers, S. M. (2020). Identification, Evaluation, and Management of Children With Autism Spectrum Disorder. Pediatrics, 145(1).
Lord, C., Elsabbagh, M., Baird, G., & Veenstra-Vanderweele, J. (2018). Autism spectrum disorder. Lancet (London, England), 392(10146), 508–520. https://doi.org/10.1016/S0140-6736(18)31129-2
Volkmar, F., Siegel, M., Woodbury-Smith, M., King, B., McCracken, J., & State, M. (2014). Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 53(2), 237-257. https://doi.org/10.1016/j.jaac.2013.10.013
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As always, if you have questions about the behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at
855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.
We will keep you informed about all our services and training events through our website (www.mdbhipp.org) and monthly e-newsletters. Additionally, BHIPP is on LinkedIn, Twitter, and Facebook. We invite you to follow us there to stay up-to-date on upcoming training events, pediatric mental health research, and resources for providers, families and children.
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for a webinar focused on Opioid Use Disorder Treatment Integrated with Primary Care. This session will feature a presentation by Dr. Mike Fingerhood, MD and an opportunity to receive your waiver to prescribe buprenorphine to treat OUD. Free CME and CEU credit for participation!
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Free CME and CEU credit for participation!
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Please join us for a special BHIPP Resilience Break focused on Avoiding Provider Burnout. This session will feature a presentation by BHIPP tele psychiatrist, Dr. Mary Ann Booth, MD. Free CME and CEU credit for participation!
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BHIPP in Your Neighborhood |
- May 1, 2022
- MedChi, the Maryland State Medical Society Conference
- Come visit our exhibit booth!
- May 6, 2022 12:30-2:00pm
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BHIPP and Maryland Addiction Consultation Service (MACS) webinar in honor of Children's Mental Health Matters Week: Approaches to Co-Occurring Substance Use and Psychiatric Disorders in Youth presented by Marc Fishman, MD
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Register here!
- May 19, 2022 12:30-1:30pm
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BHIPP Mental Health Crisis Training: Suicide Prevention Part I: Active Suicidality and Nonsuicidal Self-Injury presented by Robert Paine, DO
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Register here!
- May 23, 2022 12:30-1:30pm
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BHIPP Resilience Break: Avoiding Provider Burnout presented by Mary Ann Booth, MD
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Register here!
- May 25, 2022 8:00pm
- Children's Mental Health Twitter Chat with Dr. Sally Spencer-Thomas
- Follow #ElevateTheConvo
- June 16, 2022 12:30-1:30pm
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BHIPP Mental Health Crisis Training: Suicide Prevention Part II: Safety and Crisis Planning presented by Robert Paine, DO
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Register here!
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Interested in organizing a (virtual) training event? Need more information? Message our team!
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BHIPP Holiday Closures Calendar |
Please note that the telephone consultation line will be closed on the following upcoming holiday(s):
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BHIPP is supported by funding from the Maryland Department of Health, Behavioral Health Administration and operates as a collaboration between the University of Maryland School of Medicine, the Johns Hopkins University School of Medicine, Salisbury University and Morgan State University.
BHIPP and this newsletter are also supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $433,296 with approximately 20% financed by non-governmental sources. The contents of this newsletter are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government. For more information, visit www.hrsa.gov.
Copyright © 2021 Maryland Behavioral Health Integration in Pediatric Primary Care (BHIPP), All rights reserved.
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