4 Tips for Easing Autism Screening and Referral

No pediatrician wants to tell parents that their child should be evaluated for autism spectrum disorder (ASD). The conversation can cause anxiety for both parties, admits Leslie Speer, PhD, NCSP, of Cleveland Clinic Children’s Center for Autism.

Pediatricians can alleviate stress by conducting an accurate initial screening (avoiding unnecessary referrals) and then reassuring parents if their child truly does need further evaluation. Dr. Speer offers the following recommendations.

1) Listen to parents when assessing for red flags

“It’s difficult to identify red flags during a brief office visit — particularly when young patients are not in their usual surroundings and perhaps not performing as normal,” says Dr. Speer.

Beyond watching for red flags that may or may not arise during a 10- to 20-minute visit, ask parents about their child’s day-to-day behavior. Does he typically smile at others? Does she point? Does he respond to his name? Ask parents if their child has any behaviors that concern them.

Dr. Speer points out that red flags for autism broadly fall into two groups. The first involves delays in typical development, such as:

• Little to no response to name when called
• Lack of reciprocal smile
• Limitation in shared enjoyment
• Reduced use of gestures to communicate
• Delayed imitation skills
• Lack of pretend/symbolic play
• Failure to point to request or show interest
• Limitation in joint attention
• Reduced eye contact

The second group consists of atypical behaviors, including unusual or intense interests (including sensory interests), insistence on nonfunctional routines, repetitive motor mannerisms, and repetitive use of objects or interest in parts of objects.

2) Choose a screening tool that works for your practice

There are multiple options, but the Modified Checklist for Autism in Toddlers (M-CHAT) is most widely used, typically at 18- and 24-month checkups. Recommended by the American Academy of Pediatrics, M-CHAT is a 23-item yes/no questionnaire completed by parents.

However, no screening tool is perfect. False positives can occur. The Modified Checklist for Autism in Toddlers, Revised with Follow-up (M-CHAT-R/F), provides an extra layer of detection. In addition to a simplified 20-item yes/no questionnaire, M-CHAT-R/F incorporates a five- to 10-minute follow-up interview with parents of children who screen positive. This follow-up — even if done a day or two after the initial M-CHAT or conducted by another staff member — can screen out false positives and increase pediatricians’ confidence when recommending further evaluation.

3) If unsure, refer — and offer parents peace of mind

“It’s OK to say, ‘I’m not sure, but I have concerns,’” says Dr. Speer. “There’s no harm in referring. Getting a clear diagnosis can offer peace of mind.”

While some neurologists and psychologists have autism expertise, Dr. Speer recommends referring patients to an autism center or multidisciplinary team, such as Cleveland Clinic Children’s Autism Spectrum Evaluation Team, which she co-directs with pediatric neurologist Sumit Parikh, MD.

“Experts will check for speech/language delays and other conditions, not just autism,” she says. “Identifying the issue and learning what to do about it can be empowering for parents.”

4) Reassure parents about early diagnosis

Don’t take a wait-and-see approach, advises Dr. Speer. Early diagnosis and appropriate intervention can bring better quality of life for the child and the family.

“It’s important to communicate to parents that even if their child is diagnosed with autism, he or she will still grow and progress,” she says. “The sky’s the limit for many kids when the right teaching and support are in place as soon as possible.”