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Effectiveness of Screening in Early Intervention Settings to Improve Diagnosis of Autism and Reduce Health
R Christopher Sheldrick1, Alice S Carter2, Abbey Eisenhower2
1Boston University, Boston, Massachusetts.
Insights
A multistage autism spectrum disorder (ASD) screening protocol in early intervention (EI) services significantly increased autism diagnoses, particularly for Spanish-speaking families. This approach also helped reduce healthcare disparities.
Area of Science:
- Developmental Pediatrics
- Public Health Interventions
- Autism Spectrum Disorder (ASD) Research
Background:
- The American Academy of Pediatrics recommends early intervention (EI) services for children at high risk for autism spectrum disorder (ASD).
- However, existing EI services often lack effective ASD screening, potentially delaying diagnosis and intervention.
- Addressing screening gaps is crucial for timely support, especially in diverse populations.
Purpose of the Study:
- To evaluate if a multistage ASD screening protocol implemented in EI settings increases autism detection rates.
- To specifically assess the protocol's effectiveness in identifying ASD among Spanish-speaking families.
- To examine the impact of the screening protocol on reducing healthcare disparities.
Main Methods:
- A quasi-experimental design using difference-in-differences analysis with propensity score weighting.
- Administrative data from 3 implementation EI agencies and 9 comparison EI agencies (2012-2018).
- Included 33,326 children aged 14-36 months, assessing a multistage ASD protocol (questionnaires, observational screener, diagnostic evaluation).
Main Results:
- The screening protocol significantly increased ASD diagnoses by 8.1 per 1000 children per quarter (IRR, 1.6).
- Among Spanish-speaking families, ASD diagnoses increased substantially (15.4 per 1000 children per quarter; IRR, 2.6), indicating reduced disparities.
- Screening showed a greater increase in ASD diagnoses for boys compared to girls.
Conclusions:
- Multistage ASD screening in EI settings is effective in increasing autism detection and reducing language-associated healthcare disparities.
- The findings support the integration of comprehensive ASD screening protocols within early intervention services.
- Further research is needed to understand the mechanisms of action and disparities related to child sex.
Importance:
The American Academy of Pediatrics recommends referring children at elevated risk of autism spectrum disorder (ASD) for Part C early intervention (EI) services, but notes that EI services often fail to provide ASD screening.
Objective:
To evaluate the hypothesis that a multistage screening protocol for ASD implemented in 3 EI settings will increase autism detection, especially among Spanish-speaking families.
Design, Setting, And Participants:
Difference-in-differences analyses with propensity score weighting of a quasi-experimental design using administrative data on 3 implementation EI agencies and 9 comparison EI agencies from 2012 to 2018 provided by the Massachusetts Department of Public Health. Eligible children were aged 14 to 36 months, enrolled in EI, had no prior ASD diagnosis or medical condition precluding participation, and had parents who spoke English or Spanish. The final analytic sample included 33 326 unique patients assessed across 150 200 person-quarters.
Exposures:
Multistage ASD assessment protocol including ASD screening questionnaires, observational screener, and diagnostic evaluation.
Main Outcomes And Measures:
Increased incidence of ASD diagnoses as documented in Department of Public Health records and reductions in language-associated health care disparities.
Results:
Implementation of screening at 3 EI sites was associated with a significant increase in the rate of ASD diagnoses (incidence rate ratios [IRR], 1.6; 95% CI, 1.3-2.1; P < .001), representing an additional 8.1 diagnoses per 1000 children per quarter. Among Spanish-speaking families, screening was also associated with a significant increase in the rate of ASD diagnoses (IRR, 2.6; 95% CI, 1.6-4.3; P < .001), representing 15.4 additional diagnoses per 1000 children per quarter-a larger increase than for non-Spanish-speaking families (interaction IRR, 1.8; 95% CI, 1.0-3.1; P = .005). Exploratory analyses revealed that screening was associated with a larger increase in the rate of ASD diagnoses among boys (IRR, 1.8; 95% CI, 1.4-2.3; P < .001) than among girls (IRR, 1.1; 95% CI, 0.6-1.7; P = .84).
Conclusions And Relevance:
In this study, associations between increased rates of ASD diagnoses and reductions in disparities for Spanish-speaking households support the effectiveness of multistage screening in EI. This study provides a comprehensive evaluation of ASD screening in EI settings as well as a rigorous evaluation of ASD screening in any setting with a no-screening comparison condition. Given that the intervention included multiple components, mechanisms of action warrant further research, as do disparities by child sex.
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