Rethinking Screening for Autism
Clinicians – this one is for you!
What’s the problem?
The process for children to receive a diagnosis of autism spectrum disorder (ASD) frequently involves an evaluation by a team of specially trained professionals such as a developmental behavioral pediatrician (although the laws vary from state to state). Unfortunately, there are very few of these professionals which results in long waitlists. Families with concerns that their child might have autism spectrum disorder (ASD) often have to wait a year or more for an appointment. This wait be frustrating for caregivers who want to know whether or not their child has ASD. It can also limit families’ access to ASD specific services, like applied behavior analysis (ABA) therapy, which may not be available without an official diagnosis. Research tells us the earlier we can provide services, the better; our lab wanted to see what we could do to reduce the wait for an ASD evaluation.
Types of screeners
Before a child is referred for an evaluation, someone must have concerns that the child may have ASD. This can often be determined through a screening tool.
There are two types of screeners:
- Level 1 screeners are given all kids to determine their risk for developmental delays including ASD.
- Level 2 screeners are given to kids who are already at risk for ASD. They can help differentiate ASD from other types of developmental delays.
Level 2 screeners are not used frequently in practice, but they are a great tool! Instead of referring all kids with various developmental delays for an ASD evaluation, level 2 screeners help identify the kids at greater risk for ASD. Less children to evaluate leads to shorter waitlists for ASD evaluations.
What was the study?
Dr. Roberts and her colleagues, looked at a level 2 screening tool called the Screening Tool for Autism in Toddlers and Young Children (STAT). During the STAT, a clinician does a variety of play activities with the child and scores the child’s behavior as “pass” or “fail.” For example, the clinician rolls a ball to the child and encourages the child to roll it back. If the child joins in a game of rolling it back and forth they pass the item. There is a total “cutoff” score of items passed which determines whether or not the child is at risk for autism.
Previous research tells us that the STAT might not be great at determining children with autism from children with other developmental delays. To improve the performance of the STAT, this study’s goal was to determine whether there was a better way to score it.
What did they find?
The researchers found that using two cutoffs can help identify which children need a full special evaluation and which ones may not.
The two cutoffs creates three groups of children.
A. Low score cutoff: identifies the kids who are very unlikely to have ASD. Kids who score at this cutoff (or below) don’t need a full assessment.
B. Between the two cut-offs: identifies the kids who are difficult to determine whether or not they have ASD. Since these cases are unclear, they would still need an assessment with a specially trained team of professionals to determine whether a diagnosis of ASD is appropriate.
C. High score cutoff: identifies kids who are very likely to have ASD. These kids will still need an diagnosis to access all services, but they might not need an evaluation with a specially trained team. Maybe a clinician or a general pediatrician could diagnosis these children (Disclaimer: all providers have to abide by their state guidelines as to who can give a medical ASD diagnosis).
By only sending children in group B for a full diagnostic assessment, this would greatly reduce the waitlist.
Tips for EI providers
1. Learn to use a level two screener to improve ASD identification in EI. This alone will help you identify what kids need an evaluation the most! Consider getting trained in the STAT yourself.
2. If you use the STAT, use a two-cutoff scoring system to get more information than just pass or fail. This system can help you have more clinically meaningful conversations about ASD likelihood with families! You can find the new scoring system in the article.
3. Follow your state guidelines to refer for ASD diagnostic services as appropriate!
Roberts, M. Y., Stern, Y., Hampton, L. H., Grauzer, J. M., Miller, A., Levin, A., … & Estabrook, R. (2019). Beyond pass‐fail: Examining the potential utility of two thresholds in the autism screening process. Autism Research, 12(1), 112-122.