The Autism Society Event and Education Recordings Archive

This presentation will discuss a pilot study that investigated pediatricians' perceptions, confidence levels, and management practices regarding children with autism spectrum disorders (ASD). A questionnaire was distributed to licensed pediatricians in Texas and Mississippi. The purpose of the project was to identify pediatricians' beliefs and procedures for referring and diagnosing children with ASD. In addition, training and educational background of pediatricians were also explored. The results and implications will be discussed in detail. Session Plan (Abstract):
Purpose
With the increasing number of children being diagnosed with an Autism Spectrum Disorder, it is imperative to study the involvement of the pediatrician in the diagnostic and treatment procedures. Lack of knowledge, lack of confidence, or lack of interest on the part of the pediatrician could contribute to a detrimental delay in diagnosis that could be crucial for the child’s developmental opportunities. With the growing number of cases of autism/ASD, it is important for pediatricians today to be able to diagnose children with these disorders and to be able to refer these children to the appropriate specialist.  Improvement in the quality of life for children with ASD and their families depends upon early intervention treatment and therapy; therefore, early diagnosis and referral for these children is essential to their success and quality of life.

Content
The current study addresses diagnostic ability, referral ability, awareness of current research, advancements, and screening tools according to practicing pediatricians. In addition, the diagnostic and treatment procedures implemented by various pediatricians concerning children with ASD, along with attempting to understand current pediatricians’ beliefs concerning ASD and prevalence rates were investigated. This included pediatrician demographics such as location (metropolitan vs. rural) and when pediatricians attended medical school.  The specific research questions for this project included: What do pediatricians know about ASD? How confident are pediatricians concerning ASD characteristics and diagnostic criteria?  How confident are pediatricians in giving referrals and treatment options?  How comfortable are pediatricians with their ability to assist families following a diagnosis of ASD?  What do pediatricians see as their role in diagnosing and helping to manage ASD?  What are pediatricians' beliefs and opinions regarding the various autism spectrum disorders and their increasing prevalence? 
Participants for this study were drawn from a population of pediatricians in two southern states, Texas and Mississippi.  Primary care pediatricians along with subspecialty pediatricians were included in the sample population.  The pediatricians contacted for the study were identified by listings found through the American Medical Association Physician Directory.  A survey was hand-delivered to the pediatrician’s office directly or mailed directly to pediatricians. The survey arrived accompanied by a consent form and a self-addressed, stamped return envelope, along with a cover letter explaining the purpose and goals of the research project.  The survey instrument used in this study was adapted from an original survey developed by researchers at the Center for Autism and Developmental Disabilities Epidemiology at the Johns Hopkins School of Public Health (Dosreis, 2006).  The instrument was constructed “to (1) assess screening, referral, and management of patients when pediatricians suspect autism spectrum disorder (ASD) and (2) inquire about pediatricians’ beliefs regarding ASD prevalence” (Dosreis, 2006).  The original survey, entitled Survey for General Pediatricians: Identifying Autism Spectrum Disorders (ASD) with Primary Care, contained five multi-component questions concerning screening, management, and beliefs, along with the demographic portion.
The results indicate that the large majority, ninety-seven percent, of pediatricians used some form of general developmental screening tool or questionnaire. The most frequently used instruments were the Denver-II (DDST-II) or the pediatrician’s own instrument. Of those pediatricians using screening tools, the majority of pediatricians (63.6%) used only one tool for screening purposes. Of the three percent of pediatricians who indicated that they did not routinely perform general developmental screening, no response was given to indicate the reason for the lack of screening. Compared with the percentage of pediatricians performing general developmental screening, a significantly smaller percentage of pediatricians, 48.5%, use some form of Autism or ASD specific screening tool within their practices.  Of those pediatricians using ASD screening tools, the most common tool used was the Modified Checklist for Autism in Toddlers (M-CHAT). The majority of screening pediatricians used only one screening tool. When asked when tools were administered, the majority of pediatricians marked all three responses, indicating that they administered tools when children failed general development screens, parents had concerns, or they suspected ASD based on history and physical exam.  The largest single reason for tool administration was suspicion of ASD on the part of the pediatrician based on history and physical exam. For those pediatricians not screening specifically for ASD, the most common reason for failure to screen was referral to a specialist.
Upon suspecting ASD, many physicians chose to take multiple actions. For each of the suggested actions, over half of the pediatricians surveyed chose that action as a response to ASD suspicion. The single action chosen by the highest percentage of pediatricians was referral to a clinical specialist. For those pediatricians choosing to administer a screening tool, equal proportions chose to administer the tool before two years of age and between two to three years of age. Pediatricians who chose to monitor symptoms and follow up with the patient chose to do so more often in patients between the ages of two and three but only by a slightly higher percentage than for patients under the age of two. When referring to a clinical specialist, a significant majority of pediatricians chose to do so before the age of two. Referral continued also for those two to three years of age and for children four to five years of age. Referral to a specialist was the only action indicated for the four to five year patient age range. Of pediatricians choosing to refer to clinical specialists, most chose to refer to a developmental pediatrician. Most pediatricians only made a referral to one specialist; however some pediatricians did indicate referral to multiple types of clinical specialists.
            The pediatricians responding to they survey, 66.7% did not choose to refer families to community organizations or support groups for ASD children. About half, 51.5%, of pediatricians indicated a comfortable awareness with biomedical treatment options while only 39.4% of pediatricians informed parents of this option. For those pediatricians not informing parents, the most common reason for doing so was a lack of familiarity with this particular option on the part of the physician. 33.3% of pediatricians advocated, or encouraged, the use of biomedical treatment. Concerning nutrition/dietary treatment options, such as a gluten-free diet for example, 69.7% of pediatricians were aware and confident with their knowledge of this option, indicating a greater knowledge of this option than of the biomedical treatment option. However, only 30.3% of physicians chose to inform parents of this option. According to 48.5 pediatricians, the most common reason for not informing patients and families was that this treatment option was deemed too experimental. This general outlook upon nutrition/dietary treatment is reinforced through data indicating that only 21.2% of pediatricians advocate this treatment option.
The large majority of pediatricians, 87.9%, felt that the rate at which Autism and ASD are diagnosed has increased in the past decade. The reasons behind this increase varied among pediatricians and many pediatricians indicated numerous reasons to which the increase could be attributed. Several items did show a general trend or consensus among responding pediatricians. In the category involving changes in ASD diagnosis, 81.8% of pediatricians attributed the diagnostic increase to a better understanding of autism as a spectrum disorder, with changes in diagnostic criteria and improved assessment tools also recognized by over half of the respondents. Within this category, 48.5% of pediatricians attributed the increase to between three and four of the possible responses. The category addressing ASD risk factors, was overall generally unsupported by the population of pediatricians. No pediatricians attributed the increase to MMR vaccine exposure or thimerosal exposure, and 30.3% indicated a possible environmental exposure. Several pediatricians indicated “other,” attributing the increase to genetics. The majority of pediatricians did not mark any response within this category and 96.9% marked either no response or one response. The final category concerned increased ASD awareness. Within this category, the majority of pediatricians, 69.7%, attributed the increase to increased media awareness concerning ASD, although greater parental acceptance of diagnosis and greater organized advocacy were also majority responses. 78.8% of pediatricians chose from one to three responses within this category.
            Of the pediatricians responding to the survey, only 30.3% were trained in ASD screening and management practices while attending medical school. However, 27.3% indicated that they received adequate training, suggesting that of those trained, the large majority felt adequately trained in the subject and practice.

Importance
The results of this project contributes to the body of knowledge concerning the relationship between the pediatrician and the child with autism and the families. In addition, because of the increased prevalence rate, it is vital that pediatricians fully understand ASD, can identify warning signs, feel confident about referrals to community resources, and receive training and education on the topic.
There are several implications of this project. First, this study helped to determine the current trends in knowledge or management practices among pediatricians. Second, the results can assist in the identification of possible obstacles that need to be addressed in pediatric primary care practice concerning ASD which is vital for early detection. Third, the project can increase awareness and can draw attention to the need for continued training and education for medical students and practicing pediatricians.  

Learning Objectives
The audience will gain knowledge about pediatricians' perceptions, confidence levels, and management practices regarding children with autism spectrum disorders (ASD). Professionals in the field of education will learn about factors that pediatricians consider when an educational referral is made for a child with suspected developmental delays. In addition, the audience will understand pediatricians' beliefs and procedures for referring and diagnosing children with ASD.  This is critical for parents who visit physicians regularly for various services. Training and educational background of pediatricians will also be explored. This will encourage trainers (universities, health agencies, school districts, medical schools) to increase workshops and training seminars that are available to the community.

Learning Objectives: