This project will improve screening for autism spectrum disorders (ASD) and developmental problems (DP) in primary care in Maryland through the use of a computerized tool called the Child Health and Development Interactive System (CHADIS), and through the use of paper screening tools. CHADIS is designed to improve screening, education, referral to resources, and communication about developmental and mental health problems in children. Through CHADIS, parents complete questionnaires online via a secure website prior to the visit, either from home, from other internet access sites, or from the waiting room. The questionnaires include recommended standardized tools for the assessment of general developmental problems (Ages & Stages Questionnaire, Child Development Inventories) and ASD (Modified Checklist for Autism in Toddlers), as well as all other major domains of child and family functioning. Parent responses are scored and concerns highlighted on an electronic worksheet that also provides links to embedded educational text on ASD, DP, and many other topics for the primary care provider (PCP). The PCP can also select relevant literacy-adjusted text to print for parents, as well as resource listings catalogued and linked in the CHADIS database specifically to the child or family's identified needs. With consent, all relevant providers for the child can view the information, thereby coordinating care. We recognize that parents and professionals are in various stages of adopting electronic communication and thus provide a multimodal approach of computer or paper tools for both.
CHADIS is presently in use in ten states. In an independent evaluation of 102 parents, 95% found it easy to answer CHADIS questions, and 85% said they would like to use it for all check-up visits. In another study in an inner city Baltimore clinic, acceptability of CHADIS was nearly universal. CHADIS' automatic scoring and interpretation of pre-visit tests has been shown to provide the documentation required to collect from public and private insurance for the new 96110 billing code in Maryland. The efficiencies and remuneration provided by CHADIS address the time and financial obstacles to primary care screening, thus providing incentive for adoption and ongoing use for screening. This project also includes a partnership with Dr. Marian Earls, who has developed means of assisting with adoption of developmental screening in practice, through her Commonwealth Fund-supported Learning Collaborative. We are also consulting with Nancy Wiseman, the national leader of First Signs, to include public awareness of ASD. Evaluation of the relative value of alternative strategies will be conducted by an independent investigator, Dr. Craig Newschaffer. Dr. Newschaffer is a national leader in population-based autism studies and one of the authors of a study assessing ASD screening practices in Maryland, a survey which forms a baseline for this proposal.
The goals and strategies of the proposed project include the following:
- PCPs in 30 practices distributed across Maryland will be recruited via collaboration with the Maryland Chapter of the AAP. Nineteen practices representing 72 PCPs have already volunteered and requested CHADIS. We will recruit others to fulfill regional distribution, including paper-only screening.
- Questionnaires will be used to assess knowledge, attitudes, and screening and referral practices of the PCPs at the beginning, midpoint and end of this project. PCP's ability to recognize video case examples of toddlers later diagnosed with autism will also be used to evaluate skills pre- and post-project. Parent feedback will be obtained in a sub-sample.
- Participating PCPs will be trained on screening, management and referral for ASD and DP. Initial training will occur at a free, CME-eligible conference to which Infant and Toddler and Child Find staff will also be invited. Monthly interactive online training conferences for PCPs will follow. Training will include: 1. Importance of screening and early intervention; 2. Use of CHADIS and paper tools; 3. Observation skills through use of video clips of toddlers with autism created in conjunction with national expert Dr. Rebecca Landa, and a video created by First Signs; 4. Current content in CHADIS, supplemented by information from other national and local experts; 5. Use of a validated, structured follow-up interview of positive M-CHAT screening results to reduce false positives; 6. An approach developed by Drs. Sturner and Howard to reformulating well child care to focus on development in a parent-centered manner.
- Resources and parent handouts are now available in CHADIS, including all those from the Pathfinders site; others will be added with input from early childhood specialists and experts at Kennedy Krieger (Landa), First Signs (Wiseman) and Zero to Three.
- PCPs will use CHADIS or paper-based general developmental screening for one year, including the ASQ or CDI for well child visits at all AAP recommended ages (9,18, 24 or 30, 36) plus the M-CHAT at 18 and 24 months.
- Awareness of ASD will be raised through public service announcements on radio and TV stations in all regions, and through posters in offices.
- Evaluation will be by contract (Newschaffer) to determine utilization of screening tools, referral patterns, utilization of CME support, acceptability to PCPs and parents, and changes in numbers, severity, timeliness and appropriateness of referrals.
Early childhood specialists throughout Maryland will be engaged through the Baltimore County Early Childhood Committee, Midshore Mental Health, and others, to also use CHADIS. With parent permission and HIPAA safeguards, CHADIS will facilitate communication among professionals, creating a potential infrastructure for a "system of care".