Broadband and Autism-Specific Screening Using the Early Screening for Autism and Communication Disorders (ESAC): Moving from Paper to the Smart ESAC for Children 12 to 36 Months of Age

Background: The American Academy of Pediatrics (AAP) recommends all children be screened for ASD at 18-24 months. However, there are no well-validated screening tools for ASD at this age and time needed to complete separate broadband and autism-specific tools has not been feasible in primary care settings. The need for validated screening tools is critical so families can access intensive, appropriate intervention services early.

Objectives: The primary objectives of this study were: 1) to replicate findings on the Early Screening for Autism and Communication Disorders(ESAC), a 30-item autism-specific parent-report screening tool that screens for ASD in children 12-36 months of age; and 2) to develop a streamlined “smart” ESAC for primary care consisting of 10 broadband questions for universal screening, which if positive, are followed seamlessly by 20 autism-specific questions.

Methods: Florida State University and University of Michigan conducted screening from two sources: 1) follow-up of over 12,000 children screened by the FIRST WORDS^® Project with the Infant-Toddler Checklist for communication delays in primary care; and 2) children referred for possible ASD to each university. Follow-up diagnostic evaluations were conducted for 647 children in 3 age groups: Early 2^nd year (12-17 months, m=15.38, n=203), Late 2^nd year (18-23 months, m=20.26, n=346), and 3^rd year (24-36 months, m=28.01, n=323). A best estimate diagnosis of ASD (n=283), developmental delay in which ASD was ruled out (DD; n=120), or typical development (TD; n=244) was made.

Prometheus Research designed and built a web-based application—the Smart ESAC, using logic to dynamically tailor questions, automatically score responses based on algorithms, and providing a calculated risk assessment and report for review by healthcare providers.

Results: Receiver Operating Characteristic (ROC) curves indicated excellent discrimination, and good sensitivity and specificity of established cutoffs for the ESAC 30 as an autism-specific screener in this large community and referral sample for all age groups. Item-Response Theory was used to analyze Item Information Function and characterize performance of each item in discriminating ASD from non-ASD. ROC curves run for each item within the three age groups indicated slightly different item sets were needed to best discriminate children with atypical development (i.e., ASD or DD) from those with typical development. The best 10 individual items within age group demonstrated acceptable item-level sensitivity and specificity and when summed, the total ESAC 30 showed good sensitivity and specificity. A pilot of the Smart ESAC is being implemented with 8 healthcare provider practices. Late breaking results will be available. 

Conclusions: These findings offer promise for a cost-effective screener as early as 12 months of age and add to the research documenting the accuracy of parent report to screen young children, which minimizes time required of primary care providers, maximizes the role of the family, and provides reasonably accurate information about whether to refer a child for a diagnostic evaluation for ASD or other developmental problems. The pilot of the Smart ESAC offers promise to make effective screening more accessible to both families and providers, key to early access to care.