"When the M-CHAT is positive, an early intervention agency referral is indicated but clinicians need to be careful about how to best explain this result to parents. Clinicians need to combine their less structured surveillance with the results of the M-CHAT to determine the need for an expensive, comprehensive autism-specific evaluation and early intervention plan," he said.
• The use of system-wide programs to help support health care providers with previsit screening and referral care coordination. The nearly 50% of screening test positive referred children who are subsequently deemed ineligible for early intervention services can still benefit from participation in evidence-based community programs that are not supported by the Individuals with Disabilities Education Act (IDEA), such as the Triple P: Positive Parenting Program or Head Start. Whenever a screening test is positive and/or an early intervention referral is generated, the practitioner and a system-wide care coordination program should provide at-risk children with a "back-up plan."
• Early return office visits. Greater emphasis should be placed on early return office visits (in addition to an early intervention referral) whenever a psychometrically sound screening test – particularly an autism-specific screening test – is abnormal at an AAP-recommended well-child visit. Return visits ideally should be scheduled within a month, and parents should be asked if connection with the referral source has been made, Dr. Marks said.
Also, more in-depth assessments with secondary developmental-behavioral and/or medical screening tests should be conducted at this visit, and feedback data from referral sources should be reviewed if possible, with prompt action taken on their recommendations, he added.
For their study, Dr. Marks and his colleagues reviewed 250 articles on a dozen relevant topics and concluded that the current AAP algorithm is indeed in need of revisions that incorporate these six provisions. So they developed a proposed revision of the developmental and behavioral algorithm.
"It’s clear when you look closely at the literature over the past 5 years that pediatricians are frequently missing young children with suspected developmental delays, social-emotional problems, and autism. Busy pediatricians, who typically use informal milestone checklists at 20-minute well-child checks, have a tendency to minimize parents’ concerns and dismiss the need for a community referral – perhaps out of their innate need to reassure," said Dr. Marks.
"Meanwhile," Dr. Marks said, "when pediatricians do decide to refer, there are frequently unnecessary delays in early intervention services due to inefficient communication between medical homes and early intervention agencies or negative parental perceptions about the referral. Especially for overwhelmed, high-risk families, a ‘sugar-coated’ or ‘straight talking’ clinician-parent conversation really needs to occur prior to the referral."
Combined with what may be a "wishful thinking approach" on the part of parents who suspect there is a problem, this is causing unnecessary delays in referrals of early intervention for children with suspected delays, he said.
Mapping out the steps for screening and surveillance in greater detail and adding the proposed action steps has the potential for improving outcomes, he said.
In their article, he and his colleagues also noted that their proposed changes to AAP policy would likely "increase the need for a collaborative or integrated medical home model of care."
Dr. Marks had no disclosures to report in regard to his research. Coauthor Frances Page Glascoe, Ph.D. is the author of, and receives royalties for, the Parent’s Evaluation of Developmental Status (PEDS) and PEDS: Developmental Milestones.