An Autism Screening Tool for Underserved Young Children: Preliminary Findings

Background: Significant disparities have been identified among poor and minority children in the identification and treatment of ASD.  Late diagnosis leads to later enrollment in intervention and potentially poorer outcomes. Multiple barriers to early diagnosis of underserved children may include reduced utility of existing ASD screening tools which require reading comprehension and parental recognition of behaviors that may be red flags for ASD.

Objectives: The objective of this study is to improve the identification of young children with ASD from traditionally underserved populations by refining and testing the utility of a new, visual ASD screening tool, the Developmental Check- In (DCI). 

Methods: Items for the DCI were selected based on behaviors or skills noted to have the highest item discrimination on the ADOS and other measures, as well as based on clinical experience.  Both photographs and line drawings were created to depict each item. In order to determine if the visual images were identified by parents from underserved populations  as depicting the behavior or skill intended, cognitive interviews were conducted with parents of children with ASD or typically developing children  from low income, racial or ethnic minorities or those with Spanish as the primary language.   Parents were also questioned regarding preference for line drawings or photographs.   The target population of this study was children at risk for ASD between the ages of 24-60 months from minority groups, and/or with Medicaid as insurance, and/or whose parents speak Spanish as a primary language.  Subjects were drawn from hospital-based developmental clinics and from Federally Qualified Health Centers. At risk for ASD status was based on parent/caregiver or healthcare provider concern about child’s language, social, and/or behavioral development.  Parents  of subjects completed the DCI,  M-CHAT-R, Social Communication Questionnaire, a medical history form, adaptive behavior measure (ABAS) and demographic information.   The children were evaluated using the Mullen Scales of Early Learning and the ADOS-2. Hypothesis: The DCI will more accurately predict ASD diagnosis in this underserved population in comparison to MCHAT-R or SCQ.

Results: Photographs of the DCI items were better accepted and understood than were line drawings.  For several of the items, direct translation of item labels into Spanish was confusing to parents who required more descriptive labels in order to adequately identify intent of the visual depiction.  To date,   87 subjects have been evaluated with approximately 280 subjects expected by time of presentation.   Demographic data to date confirms representation of an underserved population with 55% of subjects reporting Hispanic/Latino ethnicity, 43% had a primary language other English and 97% of subjects had Medicaid coverage.  Further analyses including comparison of the DCI to other ASD screening tools will be conducted by the time of presentation.

Conclusions:  The results of this study will provide important information about the utility of a pictorial screening tool in a population in which English comprehension and literacy preclude the use of more text intensive screening strategies.