Reducing Barriers to Autism Screening in Community Primary Care: A Pragmatic Trial Using Web-Based Screening

  • Author Footnotes
    1 Contributed equally.
    Kyle J. Steinman
    Address correspondence to Kyle J. Steinman, MD, MAS, Seattle Children's Hospital, 4800 Sand Point Way NE, Neurology, MB 7.420, Seattle, WA 98105
    1 Contributed equally.
    Department of Neurology, University of Washington (KJ Steinman), Seattle, Wash

    Department of Psychiatry & Behavioral Sciences, University of Washington (KJ Steinman), Seattle, Wash

    Department of Pediatrics, University of Washington, Seattle Children's Hospital (KJ Steinman), Seattle, Wash

    Center for Integrative Brain Research, Seattle Children's Research Institute (KJ Steinman), Seattle, Wash
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  • Author Footnotes
    1 Contributed equally.
    Wendy L. Stone
    1 Contributed equally.
    Department of Psychology, University of Washington (WL Stone, LV Ibañez, and SM Attar), Seattle, Wash
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  • Lisa V. Ibañez
    Department of Psychology, University of Washington (WL Stone, LV Ibañez, and SM Attar), Seattle, Wash
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  • Shana M. Attar
    Department of Psychology, University of Washington (WL Stone, LV Ibañez, and SM Attar), Seattle, Wash
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  • Author Footnotes
    1 Contributed equally.
Published:April 22, 2021DOI:



      To determine whether an intervention addressing both logistical and knowledge barriers to early screening for autism spectrum disorder (ASD) increases evidence-based screening during 18-month well-child visits and primary care providers' (PCPs’) perceived self-efficacy in caring for children with ASD.


      Forty-six PCPs from 10 diverse practices across four counties in Washington State participated. PCPs attended a 2-hour training workshop on early recognition and care for toddlers with ASD and use of a REDCap-based version of the Modified Checklist for Autism in Toddlers–Revised with Follow-up (webM-CHAT-R/F) that provided automated presentation and scoring of follow-up questions. Data were collected at baseline and 6 months following each county's training window. PCPs’ screening methods and rates and perceived self-efficacy regarding ASD care were measured by self-report and webM-CHAT-R/F use was measured via REDCap records.


      At follow-up, 8 of the 10 practices were using the webM-CHAT-R/F routinely at 18-month visits. The proportion of PCPs reporting routine M-CHAT screening increased from 82% at baseline to 98% at follow-up (16% increase, 95% confidence interval [CI] 3%–28%; McNemar exact P = .02). The proportion using the M-CHAT-R/F follow-up interview questions increased from 33% to 82% (49% increase, 95% CI 30%–68%, exact McNemar test, P < .001). Significant increases in self-efficacy were found for all seven areas assessed (Ps ≤ .008).


      This brief intervention increased PCPs’ self-reported valid use of the M-CHAT-R/F at 18 months and their self-efficacy regarding ASD care. Combining educational information with a web-based ASD screen incorporating the M-CHAT-R/F follow-up questions may increase universal ASD screening with improved fidelity.


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        • Baio J.
        Prevalence of autism spectrum disorder among children aged 8 years—autism and developmental disabilities monitoring network, 11 sites, United States, 2014.
        MMWR Surveill Summ. 2018; 67
        • Dawson G
        • Jones EJH
        • Merkle K
        • et al.
        Early behavioral intervention is associated with normalized brain activity in young children with autism.
        J Am Acad Child Adolesc Psychiatry. 2012; 51: 1150-1159
        • Zwaigenbaum L
        • Bauman ML
        • Choueiri R
        • et al.
        Early identification and interventions for autism spectrum disorder: executive summary.
        Pediatrics. 2015; 136: S1-S9
        • Kasari C
        • Gulsrud A
        • Paparella T
        • et al.
        Randomized comparative efficacy study of parent-mediated interventions for toddlers with autism.
        J Consult Clin Psychol. 2015; 83: 554-563
        • Landa RJ
        • Holman KC
        • O'Neill AH
        • et al.
        Intervention targeting development of socially synchronous engagement in toddlers with autism spectrum disorder: a randomized controlled trial.
        J Child Psychol Psychiatry. 2011; 52: 13-21
        • Hyman SL
        • Levy SE
        • Myers SM.
        Identification, evaluation, and management of children with autism spectrum disorder.
        Pediatrics. 2020; 145e20193447
        • Crais ER
        • McComish CS
        • Humphreys BP
        • et al.
        Pediatric healthcare professionals’ views on autism spectrum disorder screening at 12–18 months.
        J Autism Dev Disord. 2014; 44: 2311-2328
        • Barton ML
        • Dumont-Mathieu T
        • Fein D.
        Screening young children for autism spectrum disorders in primary practice.
        J Autism Dev Disord. 2012; 42: 1165-1174
        • Morelli DL
        • Pati S
        • Butler A
        • et al.
        Challenges to implementation of developmental screening in urban primary care: a mixed methods study.
        BMC Pediatr. 2014; 14: 16
        • Mazurek MO
        • Harkins C
        • Menezes M
        • et al.
        Primary care providers’ perceived barriers and needs for support in caring for children with autism.
        J Pediatr. 2020;
        • Self TL
        • Parham DF
        • Rajagopalan J.
        Autism spectrum disorder early screening practices: a survey of physicians.
        Commun Disord Q. 2015; 36: 195-207
        • Carbone PS
        • Campbell K
        • Wilkes J
        • et al.
        Primary care autism screening and later autism diagnosis.
        Pediatrics. 2020; 146e20192314
        • Robins DL
        • Casagrande K
        • Barton M
        • et al.
        Validation of the Modified Checklist for Autism in Toddlers, Revised With Follow-up (M-CHAT-R/F).
        Pediatrics. 2014; 133: 11
        • Guthrie W
        • Wallis K
        • Bennett A
        • et al.
        Accuracy of autism screening in a large pediatric network.
        Pediatrics. 2019; 144e20183963
        • Campbell K
        • Carpenter KLH
        • Espinosa S
        • et al.
        Use of a digital modified checklist for autism in toddlers—revised with Follow-up to improve quality of screening for autism.
        J Pediatr. 2017; 183 (133-139.e1)
        • Harrington JW
        • Bai R
        • Perkins AM.
        Screening children for autism in an urban clinic using an electronic M-CHAT.
        Clin Pediatr (Phila). 2013; 52: 35-41
        • Brooks BA
        • Haynes K
        • Smith J
        • et al.
        Implementation of web-based autism screening in an urban clinic.
        Clin Pediatr (Phila). 2016; 55: 927-934
        • Sturner R
        • Howard B
        • Bergmann P
        • et al.
        Autism screening with online decision support by primary care pediatricians aided by M-CHAT/F.
        Pediatrics. 2016; 138 (e20153036-e20153036)
        • Patsopoulos NA.
        A pragmatic view on pragmatic trials.
        Dialogues Clin Neurosci. 2011; 13: 217-224
        • Loudon K
        • Treweek S
        • Sullivan F
        • et al.
        The PRECIS-2 tool: designing trials that are fit for purpose.
        BMJ. 2015; 350
        • Ibañez LV
        • Stoep AV
        • Myers K
        • et al.
        Promoting early autism detection and intervention in underserved communities: study protocol for a pragmatic trial using a stepped-wedge design.
        BMC Psychiatry. 2019; 19: 169
      1. U.S Census Bureau. U.S. Census Bureau QuickFacts: Washington; United States. Available at:,US/PST045219. Accessed April 2, 2020.

        • Minkler M
        • Wallerstein N.
        Community-Based Participatory Research for Health: From Process to Outcomes.
        John Wiley & Sons, San Francisco, CA2011
        • Zwaigenbaum L
        • Maguire J.
        Autism screening: where do we go from here?.
        Pediatrics. 2019; 144e20190925
        • Harris PA
        • Taylor R
        • Thielke R
        • et al.
        Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377-381
        • Monteiro SA
        • Dempsey J
        • Berry LN
        • et al.
        Screening and referral practices for autism spectrum disorder in primary pediatric care.
        Pediatrics. 2019; 144e20183326
        • Briesch AM
        • Chafouleas SM
        • Neugebauer SR
        • et al.
        Assessing influences on intervention implementation: revision of the usage rating profile-intervention.
        J Sch Psychol. 2013; 51: 81-96
        • Miller JS
        • Gabrielsen T
        • Villalobos M
        • et al.
        The each child study: systematic screening for autism spectrum disorders in a pediatric setting.
        Pediatrics. 2011; 127: 866-871
        • Barger B
        • Rice C
        • Wolf R
        • et al.
        Better together: developmental screening and monitoring best identify children who need early intervention.
        Disabil Health J. 2018; 11: 420-426
        • Antezana L
        • Scarpa A
        • Valdespino A
        • et al.
        Rural trends in diagnosis and services for autism spectrum disorder.
        Front Psychol. 2017; 8
        • Daniels AM
        • Mandell DS.
        Explaining differences in age at autism spectrum disorder diagnosis: a critical review.
        Autism. 2014; 18: 583-597
        • Zuckerman KE
        • Mattox K
        • Donelan K
        • et al.
        Pediatrician identification of Latino children at risk for autism spectrum disorder.
        Pediatrics. 2013; 132: 445-453
        • Zuckerman KE
        • Sinche B
        • Cobian M
        • et al.
        Conceptualization of autism in the Latino community and its relationship with early diagnosis.
        J Dev Behav Pediatr JDBP. 2014; 35: 522-532
        • Berwick DM.
        Developing and testing changes in delivery of care.
        Ann Intern Med. 1998; 128: 651
        • Rea KE
        • Armstrong-Brine M
        • Ramirez L
        • et al.
        Ethnic disparities in autism spectrum disorder screening and referral: implications for pediatric practice.
        J Dev Behav Pediatr. 2019; 40: 493-500
        • Sturner R
        • Howard B
        • Bergmann P
        • et al.
        Comparison of autism screening in younger and older toddlers.
        J Autism Dev Disord. 2017; 47: 3180-3188
        • Sheldrick RC
        • Frenette E
        • Vera JD
        • et al.
        What drives detection and diagnosis of autism spectrum disorder? Looking under the hood of a multi-stage screening process in early intervention.
        J Autism Dev Disord. 2019; 49: 2304-2319
        • Locke J
        • Ibañez LV
        • Posner E
        • et al.
        Parent perceptions about communicating with providers regarding their early autism concerns.
        Pediatrics. 2020; (PMID:31845130)
        • Mazurek MO
        • Curran A
        • Burnette C
        • et al.
        ECHO Autism STAT: accelerating early access to autism diagnosis.
        J Autism Dev Disord. 2019; 49: 127-137
        • Sohl K
        • Mazurek MO
        • Brown R
        ECHO Autism: using technology and mentorship to bridge gaps, increase access to care, and bring best practice autism care to primary care.
        Clin Pediatr (Phila). 2017; 56: 509-511