24-month Well-child Visits Research Articles

Autism screening and diagnostic outcomes among toddlers bornpreterm.

To examine the Modified Checklist for Autism in Toddlers, Revised, with Follow-Up (M-CHAT-R/F), with follow-up screening and diagnostic outcomes for children born preterm. A secondary aim was to examine diagnostic evaluation attendance after screening to inform clinical practice. Using a cross-sectional design, 9725 toddlers (4951 males; 4774 females) whose gestational age was reported were screened at 15-month, 18-month, or 24-month well-child visits; screen-positive children were invited for an autism evaluation. Screening measure performance and diagnostic outcomes were evaluated according to preterm classification (Screening: nExtPreterm = 111; nVeryPreterm = 186; nModPreterm = 1122; nFullTerm = 8306; Evaluation: nExtPreterm = 27; nVeryPreterm = 21; nModPreterm = 86; nFullTerm = 301). Screen-positive rates were highest for children born extremely preterm (51.35%) and lowest for children born at term (6.95%). Evaluation attendance for screen-positive cases did not differ according to preterm classification. Rates of autism diagnoses differed depending on preterm birth status: for children born extremely preterm, it was 16.05%; for children born very preterm, it was 2.00%; for children born moderately preterm, it was 2.89%; and for children born at term, it was 1.49%. M-CHAT-R/F sensitivity decreased with increasing gestational age, whereas specificity improved with increasing gestational age. Positive predictive value was highest for children born extremely preterm and children born at term. Negative predictive value was consistently strong across all groups. The likelihood ratio for positive screening increased with gestational age. The sensitivity and specificity of the M-CHAT-R/F are acceptable in toddlers born preterm. Autism screening-positive rates and prevalence increased with earlier preterm birth. Those born extremely preterm showed the greatest likelihood of an autism diagnosis; screening should not be delayed based on adjusted age.

Development of a school-age extension of the Modified Checklist for Autism in Toddlers through expert consensus and stakeholder input.

The American Academy of Pediatrics recommends universal screening to identify children at higher likelihood for autism at 18- and 24-month well-child visits. There are many children, however, that are missed during this toddler age who do not get diagnosed until much later in development, delaying access to autism-specific interventions. Currently, brief measures for universal autism screening for school-age children, however, are lacking. In this project, we adapted a commonly used autism screener for toddlers, the Modified Checklist for Autism in Toddlers, Revised, with Follow-Up (M-CHAT-R/F), to be used for school-age children. This measure, called the M-CHAT-School (M-CHAT-S), is a parent- and teacher-report questionnaire to be used to screen for autism in school-age children aged 4 to 8 years of age. M-CHAT-S was developed through feedback from autism experts, as well as interviews with parents and teachers to provide input on the items. Two versions of M-CHAT-S were developed, one for verbally fluent and one for minimally verbal school-age children. M-CHAT-S is a brief measure, with updated items to reflect changes in the way experts think and talk about autism, making it a useful measure to use for autism screening in elementary aged children. The next steps include further testing to ensure that M-CHAT-S performs well in identifying children with increased likelihood of autism, after which it will be made available to parents, educators, and other professionals.

Screening for Autism Spectrum Disorder in Toddlers During the 18- and 24-Month Well-Child Visits.

ObjectiveEarly screening contributes to the early detection of children with autism spectrum disorder (ASD). We conducted a longitudinal ASD screening study in a large community setting. The study was designed to investigate the diagnostic rate of ASD screening and determine the effectiveness of ASD screening model in a community-based sample.MethodsWe enrolled children who attended 18- and 24-month well-child care visits in Shanghai Xuhui District. Modified Checklist for Autism in Toddlers, Revised with Follow-up (M-CHAT-R/F) and Binomial Observation Test (BOT) were selected as screening instruments. Screen-positive children were referred to a tertiary diagnostic center for comprehensive ASD diagnostic evaluation. Screen-negative children received well-child checkups and follow-up every 3–6 months until age three and were referred if they were suspected of having ASD.ResultsA total of 11,190 toddlers were screened, and 36 screen-positive toddlers were diagnosed with ASD. The mean age at diagnosis for these children was 23.1 ± 4.55 months, diagnosed 20 months earlier than ASD children not screened. The diagnostic rate of ASD was 0.32% (95% CI: 0.23–0.45%) in this community-based sample. In addition, 12 screen-negative children were diagnosed with ASD during subsequent well-child visit and follow-up. The average diagnostic rate of ASD rose to 0.43% (95% CI: 0.32–0.57%) when toddlers were followed up to 3 years old. The positive predictive values (PPVs) of M-CHAT-R/F, M-CHAT-R high risk, and BOT for ASD were 0.31, 0.43, and 0.38 respectively.ConclusionOur findings provide reliable data for estimating the rate of ASD detection and identifying the validity of community-based screening model. M-CHAT-R/F combined with BOT can be an effective tool for early detection of ASD. This community-based screening model is worth replicating.

Interconception Care for Mothers at Well Child Visits After Implementation of the IMPLICIT Model.

Interconception care (ICC) is recommended to reduce maternal risk factors for poor birth outcomes between pregnancies. The IMPLICIT ICC model includes screening and brief intervention for mothers at well child visits (WCVs) for smoking, depression, multivitamin use, and family planning. Prior studies demonstrate feasibility and acceptability among providers and mothers, but not whether mothers recall receipt of targeted messages. Mothers accompanying their child at 12- and 24-month WCVs at four sites of a family medicine academic practice were surveyed pre (2012) and post (2018) ICC model implementation. Survey items assessed health history, behaviors, and report of whether their child's physician addressed maternal depression, tobacco use, family planning, and folic acid supplementation during WCVs. Pre and post results are compared using logistic regression adjusting for demographics and insurance. Our sample included 307 distinct mothers with 108 and 199 respondents in the pre and post periods, respectively. Mothers were more likely to report discussions with their child's doctor post-intervention for family planning (31% pre to 86% post; aOR 18.65), depression screening (63-85%; aOR 5.22), and taking a folic acid supplement (53-68%; aOR 2.54). Among mothers who smoked, the percentage that reported their child's doctor recommended cessation increased from 56 to 75% (aOR = 3.66). The IMPLICIT ICC model resulted in increased reported health care provider discussions of four key areas of interconception health by mothers attending WCVs. This model holds promise as a primary care strategy to systematically address maternal risks associated with poor pregnancy outcomes.

Autism and General Developmental Screening Practices Among Primary Care Providers.

Using standardized screening tools increases accuracy in early identification of autism. The American Academy of Pediatrics recommends systematic developmental screening at all 9-, 18-, and 24- or 30-month well-child visits (WCVs) and autism-specific screening at all 18- and 24-month WCVs. The study objectives were to examine the extent to which these guidelines have been adopted in practice among primary care providers (PCPs) and to identify potential provider-level factors associated with screening practices. Participants included 94 PCPs (79% pediatricians) from 13 states enrolled in a study of an autism training program. Self-report and chart-review data collected before training were examined. Screening practices were assessed through chart review of all 9-, 18-, and 24-month WCVs within a 30-day window. Sixty-four percent of PCPs administered developmental screening tools at all 9-month WCVs, and 62% at all 18-month WCVs. Fifty-one percent administered autism screening tools at all 18-month WCVs, and 41% at all 24-month WCVs. Screening practices varied by provider type (pediatrician vs other PCP), self-efficacy in screening and identification, and previous autism training (autism screening only), but not by years of experience. Overall, general developmental and autism-specific screenings are not being consistently administered across recommended WCVs in primary care practices. Provider self-efficacy in autism identification and screening and previous autism training were associated with increased autism screening. As such, these results suggest a need for increased training and dissemination of information on screening implementation for practicing PCPs.

To reduce the average age of autism diagnosis, screen preschoolers in primary care.

Pediatric primary care providers check for autism signs, usually using a standard checklist, at 18- and 24-month well-child visits. When the checklist shows possible autism, children should be referred for additional treatment and evaluation with an autism specialist. However, many children with autism spectrum disorder are not detected as toddlers. Low-income and minority children are particularly likely to have a late autism spectrum disorder diagnosis. Checking for autism at preschool-aged well-child visits might be one way to identify autism spectrum disorder earlier, especially for low-income and minority children.

ECHO Autism: Integrating Maintenance of Certification with Extension for Community Healthcare Outcomes Improves Developmental Screening.

Recent estimates indicate that most pediatricians do not consistently meet the American Academy of Pediatrics developmental screening guidelines, contributing to the delay of vital evaluations and interventions for autism spectrum disorder (ASD). Our objective was to evaluate the utility of Maintenance of Certification (MOC) Quality Improvement (QI) training designed to improve developmental screening rates in underserved, rural primary care practices. Trainings on best screening practices were disseminated to primary care providers (PCPs) through Extension for Community Healthcare Outcomes (ECHO) Autism, a virtual learning network. Across 2 cohorts, 24 PCPs were enrolled in MOC Part 4 training modules delivered through the ECHO Autism QI Learning Network. Throughout the 12 months of enrollment, PCPs reported information on general and ASD-specific developmental screenings conducted at 18- and 24-month well-child visits. A 1-year follow-up was conducted to assess the maintenance of screening rates. Baseline rates for general and ASD-specific developmental screenings were 53.3% and 68.3%, respectively. By the end of the 12-month learning module, screening rates increased significantly for general development (88.6%) and ASD-specific screenings (99.0%). At the 1-year follow-up, the rate for general developmental screening was 96.7% and for ASD-specific screening was 97.1%. Maintenance of Certification Part 4 training delivered through the ECHO Autism QI Learning Network was found to be incentivizing and highly effective in shaping and maintaining PCP developmental screening practices. Improved screening rates show promise in decreasing time to critical developmental evaluations, interventions, and resources. Our methodology is likely transferable to other ECHO communities and may facilitate expedient implementation of best practice standards in primary care.

Diagnosis of Autism Spectrum Disorders Requires More Than Screening

Research Article| December 01 2019 Diagnosis of Autism Spectrum Disorders Requires More Than Screening AAP Grand Rounds (2019) 42 (6): 66. https://doi.org/10.1542/gr.42-6-66 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Diagnosis of Autism Spectrum Disorders Requires More Than Screening. AAP Grand Rounds December 2019; 42 (6): 66. https://doi.org/10.1542/gr.42-6-66 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: autism spectrum disorder Source: Monteiro SA, Dempsey J, Berry LN, et al. Screening and referral practices for autism spectrum disorder in primary pediatric care. Pediatrics. 2019; 144(4): e20183326; doi: https://doi.org/10.1542/peds.2018-3326Google Scholar Investigators from Baylor College of Medicine, Houston, TX, and the University of Colorado School of Medicine, Aurora, CO, conducted a retrospective study to determine rates of (a) screening for autism spectrum disorder (ASD) at 18- and 24-month well-child visits to primary care pediatricians using the Modified Checklist for Autism in Toddlers (M-CHAT); (b) referral for those failing screening; and (c) diagnosis of ASD in children who failed the screen. For the study, the authors abstracted data on children having an 18-month and/or 24-month well-child visit between 2014 and 2016 to one of 290 pediatricians who were part of a hospital-owned network of 59 practices that shared a centralized electronic medical record (EMR) system. Within the network, use of M-CHAT at the 18- and 24-month visit is a standard practice. The rate of screening with M-CHAT at each of the visits was determined. The EMR of children who failed the M-CHAT screen (defined as a score ≥3) was reviewed to determine whether a referral to an autism specialist was made and completed, and subsequent diagnoses of ASD or other neurodevelopmental conditions, with a follow-up period of 23–46 months in these patients. Among 13,417 children eligible for screening at 18 months, the M-CHAT was completed for 12,531 (93%), while the M-CHAT was completed for 10,983 of 13,328 (82%) at 24 months. A total of 532 unique children failed 648 M-CHAT screens (3%). Of these 532 children, 2 died. For the remaining 530 patients, 165 (31%) were referred for additional evaluation by a subspecialist, including 122 at or before the 18- or 24-month visit (mean age at referral 20.8 months) and 69 later than the 24-month visit (mean age at referral 36 months). Visits with autism specialists were completed by 68 children (59%) who were referred at or before the 18- or 24-month visit, and 42 were diagnosed with an ASD at a mean age of 27 months. Among those referred later than the 24-month visit, 39 (57%) completed the subspecialist evaluation, and 31 were diagnosed with an ASD. Overall, including 17 children diagnosed through another mechanism, 96 of the 530 children (18%) who failed an M-CHAT screening were diagnosed with an ASD. An additional 314 patients (59%) were diagnosed with other neurodevelopmental conditions, including delayed speech, language disorders, and global delay by their primary care pediatrician. The authors conclude that despite high rates of screening for ASD by primary care pediatricians, rates of referral for further ASD evaluation for children who failed an M-CHAT screen were suboptimal. Dr Doherty has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. The term ASDs encompasses a broad clinical category comprised of many biologically distinct... You do not currently have access to this content.

Screening and Referral Practices for Autism Spectrum Disorder in Primary Pediatric Care

To examine screening practices for autism spectrum disorder (ASD), subsequent referrals, and diagnostic outcomes within a large network of primary pediatric care practices. Rates of ASD screening with the Modified Checklist for Autism in Toddlers (M-CHAT) at 18- and 24-month well-child visits were examined among 290 primary care providers within 54 pediatric practices between June 2014 and June 2016. Demographic, referral, and diagnostic data were abstracted from the medical records for all children who failed the M-CHAT (ie, score of ≥3) at either or both visits. Rates of M-CHAT screening were 93% at 18 months and 82% at 24 months. Among 23 514 screens, scores of 648 (3%) were ≥3 (386 at 18 months, 262 at 24 months) among 530 unique children who failed 1 or both screenings. Among screen-failed cases, 18% received a diagnosis of ASD and 59% received ≥1 non-ASD neurodevelopmental disorder diagnosis within the follow-up period. Only 31% of children were referred to a specialist for additional evaluation. High rates of ASD-specific screening do not necessarily translate to increases in subsequent referrals for ASD evaluation or ASD diagnoses. Low rates of referrals and/or lack of follow-through on referrals appear to contribute to delays in children's receipt of ASD diagnoses. Additional education of primary care providers regarding the referral process after a failed ASD screening is warranted.

Autism Can Be Reliably Diagnosed at Age 14 to 16 Months

The American Academy of Pediatrics recommends screening for autism spectrum disorder (ASD) at the 18- and 24-month well-child visits, along with

Improving the early screening procedure for autism spectrum disorder in young children: Experience from a community-based model in shanghai.

Most children with autism spectrum disorder (ASD) are not diagnosed until the age of 4, thus missing the opportunity for early intervention. The objective of this study was to investigate the feasibility of an early screening program for ASD applied during well-child visits in a community-based sample. The study lasted for 4 years and was divided into two stages. Stage I involved the implementation of the basic screening model in 2014. Toddlers received level 1 screening via section A of the Chinese-validated version of the Checklist for Autism in Toddlers (CHAT-23) during 18- and 24-month well-child visits in Xuhui District, Shanghai, China. Screen-positive children were referred to receive section B of the CHAT-23 for level 2 screening, and those still screen-positive were referred to undergo diagnosis and evaluation. Stage II involved the implementation of the improved screening model from 2015 to 2017 with the following modifications: (a) an added observational component in level 1 screening; (b) telephone follow-ups with the screen-positive families; and (c) dissemination of information on ASD to families. The results showed that 42 of 22,247 screened children were diagnosed with ASD. The ASD diagnosis rates were 0.1% in Stage I and 0.21% in Stage II. The screen-positive rate and the show rate of referral for level 1 screening increased by 76.92% and 58.43%, respectively, in Stage II compared to Stage I. Our results suggest that with appropriate logistic support, this two-level screening model is feasible and effective for the early screening of ASD during well-child visits. Autism Res 2018, 11: 1206-1217. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Difficulty in the timely identification of autism spectrum disorder (ASD) results in missed opportunities for many ASD children to receive early intervention. In this study, we established an early screening model for ASD among children aged 18-24 months in the community by relying on the three-level child healthcare system in China. The results showed that this model can effectively identify and diagnose ASD in children at an early age and thus enable early intervention.

Parental Adverse Childhood Experiences and Offspring Development at 2 Years of Age.

The study objective was to determine if maternal and paternal exposure to adverse childhood experiences (ACEs) have a significant association with negative offspring development at 24 months of age in a suburban pediatric primary care population. A retrospective cohort study was conducted of 311 mother-child and 122 father-child dyads who attended a large pediatric primary care practice. Children were born from October 2012 to June 2014, and data were collected at the 2-, 4-, and 24-month well-child visits. Multivariable Poisson regression with robust error variance was used to model the relationship between self-reported parental ACEs and the outcomes of suspected developmental delay at 24 months and eligibility for early intervention services. For each additional maternal ACE, there was an 18% increase in the risk for a suspected developmental delay (relative risk: 1.18, 95% confidence interval: 1.08-1.29). A similar trend was observed for paternal ACEs (relative risk: 1.34, 95% confidence interval: 1.07-1.67). Three or more maternal ACEs (versus <3 ACEs) was associated with a significantly increased risk for a suspected developmental delay that affected multiple domains. Similar effects were observed for early intervention services. Parental ACE exposures can negatively impact child development in multiple domains, including problem solving, communication, personal-social, and motor skills. Research is needed to elucidate the psychosocial and biological mechanisms of intergenerational risk. This research has implications for the value of parental ACE screening in the context of pediatric primary care.

Barriers to autism screening in family medicine practice: a qualitative study.

We explored potential barriers to adoption of recommended screening for autism by family physicians at 18- and 24-month well-child visits. The American Academy of Pediatrics recommends early detection and intervention of autism through the use of a standardized autism-specific screening tool on all children at the 18- and 24-month well-child visits. However, not all family physicians screen for autism. Three focus groups and six semi-structured interviews were conducted with 15 family physicians in the Kansas City metropolitan area. Verbatim transcripts were inductively coded; data were analyzed using standard text analysis. Participants had differing views on the increased incidence of autism. Most participants attributed the increase to changes in diagnostic criteria. There was no consensus on the benefit of implementing universal screening for autism during the 18- or 24-month visit. Many preferred to identify potential problems through general developmental assessments and observations. No participants used specific screening tools for autism, and only one participant was aware of such a tool (M-CHAT). Lack of adequate training on child development and screening methods as well as limited availability of community-based resources to manage children with autism was seen as major barriers to routine screening. Suggested solutions included working toward a stronger evidence base, improving physician training and continuing education, and making systemic changes in healthcare. In conclusion, universal screening for autism at the 18- and 24-month visits is not widely accepted, nor is it implemented by family physicians.

Early identification of autism: A comparison of the Checklist for Autism in Toddlers and the Modified Checklist for Autism in Toddlers

There is still debate as to what is the most effective strategy for identifying the early signs of autism in very young children. Two levels of screening having been advocated: broad-based developmental surveillance and targeted screening. Two popular tools for use in developmental surveillance are the Checklist for Autism in Toddlers (CHAT) and the Modified Checklist for Autism in Toddlers (M-CHAT). The purpose of this article is to summarise the current evidence for screening for autistic symptoms in very young children using CHAT and M-CHAT. A systematic search was carried out of electronic database and other sources for original studies which evaluated the use of CHAT and M-CHAT in screening for autism in children younger than 5 years of age. Studies were included for review if they evaluated the sensitivity and/or specificity of CHAT or M-CHAT, or described the best age to administer these instruments. The available evidence suggests that characteristic behaviours in autism should be evident in simple forms before the age of 18 months, while screening at 24 months should be conducted to identify those who regress. Administering a screening tool during 18- to 24-month well-child visits improves early identification of autism, while the stability of diagnosis at the ages of 18 months and 24 months is confirmed. M-CHAT has slightly better sensitivity and specificity compared to CHAT, and is preferable to use as a developmental surveillance screening instrument.

Lowering Developmental Screening Thresholds and Raising Quality Improvement for Preterm Children

To determine: 1) if preterm children were referred, identified and received early intervention (EI)/ early childhood special education (ECSE) services at rates equivalent to term children after implementation of a universal, periodic Ages and Stages Questionnaire (ASQ) surveillance and screening system; 2) if pediatricians sufficiently lowered their screening thresholds with preterm children;and 3) if quality improvement opportunities exist. Secondary analysis was performed on 64 lower-risk, mostly late-preterm and 1363 term children who originally presented to their 12- or 24-month well- visits. Higher-risk preemies already involved with an EI agency/ identified with a delay were excluded. Board-certified pediatricians (N=18), and nurse practitioners (N = 2), blind to the ASQ results, were secondary participants. Differences between preterm and term developmental agency referrals were examined comparing Pediatric Developmental Impression to the ASQ under natural clinic conditions using a combined in-office or mail-back data collection protocol. Medical record and county EI/ECSE follow-up outcomes were conducted at 36 to 60 months. At 12 and 24 months, preterm (versus term) referral rates were 9.5%(versus 5.6%) with Pediatric Developmental Impression and 26.2% (versus 8.1%) with the ASQ. By 36 to 60 months, 37.5% of preterm (20.8% term) children were referred to EI/ECSE; of which, 50.0% of preterm (42.4% term) children were eligible for services, 54.2%of preterm children were identified with a developmental-behavioral disorder and 29.2% of preterm (20.8% term) children did not follow-up. For ASQ-only preterm referrals,55.6% were subsequently diagnosed with a developmental delay and/or disorder.Preterm children were 2 times more likely to be eligible than term children [corrected]. Combined referral, quality improvement and outcome data suggests that clinicians should lower their threshold for administering a psychometrically sound developmental screen when providing surveillance for ex-preemies. Quality improvement opportunities exist with diligent developmental surveillance and a more collaborative, standardized, reliable and interpersonal referral process.

Impact of Implementing Developmental Screening at 12 and 24 Months in a Pediatric Practice

The purpose of this study was to investigate the effectiveness and costs of incorporating a parent-completed developmental screening tool, the Ages and Stages Questionnaire, into the 12- and 24-month well-child visits under "real-world" conditions, using a combined in-office and mail-back data collection protocol. A convenience sample of 1428 caregivers and children presenting for their 12- or 24-month well-child visit between April 2005 and March 2006 participated. Children with identified delays or disorders were excluded. Board-certified pediatricians (n = 18) and nurse practitioners (n = 2) acted as secondary participants. Pediatricians were blinded to Ages and Stages Questionnaire results when completing the Pediatric Developmental Impression. Patients with delayed Ages and Stages Questionnaire or Pediatric Developmental Impression results were referred for additional evaluation. Referral rates increased by 224%. Pediatrician referral on the basis of the Pediatric Developmental Impression was predicted significantly by suspected communication delay and gross motor delay. The Ages and Stages Questionnaire and Pediatric Developmental Impression results differed significantly, with overall agreement of 81.8%. Of Ages and Stages Questionnaire-delayed cases, 67.5% were not detected by pediatricians. Of the 78 patients referred on the basis of combined Ages and Stages Questionnaire and Pediatric Developmental Impression results, 53 would not have been referred on the basis of Pediatric Developmental Impression results alone; 37 patients qualified for special services, and 44 were scheduled for additional developmental monitoring. The rate of Ages and Stages Questionnaire return by caregivers/parents was 54%. Referral rates increased dramatically, with the greatest increase at 12 months. Although patients with pediatrician referrals were likely to qualify for services (96%), physician referrals accounted for only 42% of total referrals, which highlights the need for pediatric developmental screening. The 54% Ages and Stages Questionnaire return rate, although acceptable under study conditions, calls for alternative implementation strategies.