Integrating Autism-Specific Screening in Primary Care

Autism spectrum disorders (ASD) are among the most commonly diagnosed childhood developmental disabilities. More children are diagnosed with ASD than AIDS, cancer and diabetes combined (Autism Speaks, 2013). There are three subtypes of ASD according to the Diagnostic and Statistical Manuel of Mental Disorders (4th edition), text revision (DSM-IV TR): autistic disorder; pervasive developmental disorder, not otherwise specified (PDD-NOS); and Asperger's disorder. Children with ASD have deficits or difficulties in three domains: (1) social skills, (2) communication and (3) restrictive and repetitive behaviors or activities (American Psychiatric Association [APA], 2000). One in 88 children is living with ASD (Centers for Disease Control [CDC], 2012). A new classification scheme has been proposed for DSM-V that will collapse the three conditions into one unifying diagnosis of "autism spectrum disorder". Additionally, the current three diagnostic domains will become two: deficits in social communication and restrictive and repetitive behaviors and activities (APA, 2010). The American Academy of Pediatrics (AAP) recommends that all children should be screened for ASD using an autism-specific screening tool at the 18 and 24 month well-child exam. This quality improvement project describes the implementation of the Modified Checklist for Autism in Toddlers (M-CHAT) within an existing pediatric practice that was not currently using an autism-specific screening tool. All children who were scheduled for an 18 or 24 month well-child exam were administered the M-CHAT screening tool. The M-CHAT scores were available to providers for discussion with the parents during the scheduled visit. Children who screened positive on the M-CHAT screener were referred to the local early intervention program for further evaluation and treatment. The theoretical framework that was used as a guide for this clinical practice change project was the diffusion of innovation theory. This theory was used to address the multiple factors that contribute to implementation and sustainability of a new clinical behavior (Sanson-Fisher, 2004). This quality improvement project demonstrated that it is feasible to implement the screening recommendations from the AAP. The designated primary care site was able to successfully implement the use of the M-CHAT screening tool in 100% of routine 18 and 24 month well-child exams. Positive screenings resulted in referral to early intervention for further evaluation. This project was both feasible and sustainable.