The Autism Society Event and Education Recordings Archive

Autism spectrum disorders (ASDs) are no longer considered rare. According to a 2009 report from the Centers for Disease Control and Prevention, the prevalence of ASD is estimated to be 1 in 110 children or 1% of all children in the U.S. As the prevalence rate has increased, so too has awareness. The general knowledge of the medical community, health professionals and the general public about autism and related disorders has expanded due to heightened media coverage, the availability of information on the Internet and a growing body of relevant published literature (Johnson, Meyers, & Council on Children with Disabilities, 2007).

Despite increased awareness, many children are not properly diagnosed until years after the symptoms common to ASD have emerged. Oslejskova, Kontrova, Foralova, Dusek, and Nemethova (2007) affirmed that a child’s ASD diagnosis was delayed even when the parents had suggested to the physicians and/or educational professionals prior to the child’s second birthday that “something was wrong.” At the conclusion of a six-year study of 204 children, it was determined that the average age for diagnosing children with ASD was 6.8 years (81.5 months). Additionally, the average delay from the acknowledgment of the first symptoms of ASD to an official diagnosis for 201 of the participants was 51.3 months, with the shortest reported delay being 44.4 months. Howlin and Moore (1997) reported similar findings from a study of 1,300 families in Great Britain. In this study, children were diagnosed with ASD at a mean age of 6.0 years, even though parents had reported concerns for their child by 18 months of age and had sought medical assistance before the child was two years of age. Less than 10% of the children participating in the study were diagnosed on their first medical visit, whereas families from another 10% were told to schedule a return visit if they continued to be concerned, or they were told that the child would most likely “grow out of it.” The remaining families were referred to another professional (at an average age of 40 months).

It has been proposed that the delay in identifying a child with ASD may be due to the clinical nature of the diagnostic criteria. That is, with no pathognomonic marker for ASD, diagnosticians are continually challenged by the heterogeneity of features presented both across children and within the same child over a period of time. Other possible reasons for the delayed diagnostic process include the lack of well-defined diagnostic tools and/or the professionals’ apprehension over misdiagnosing a child with ASD at an early age and the subsequent effect a misdiagnosis might have on the family (Spence, Sharifi, & Wiznitzer, 2004).

Yet, amid these diagnostic challenges, an early diagnosis of ASD is essential. It provides answers for parents who are perplexed and anxious because they have believed for some time that something was “not right” with their child, but have been unable to determine the reason for their child’s atypical development (Oslejskova et al., 2007). Furthermore, there has been agreement among clinicians that children with ASD receive the most benefit from treatment when it has been initiated prior to age four. In 2000, responding to a growing concern that children were not being diagnosed with ASD until approximately six years of age, a multidisciplinary panel supported by the American Academy of Neurology and Child Neurology Society, and endorsed by the American Academy of Pediatrics (AAP), recommended that pediatric primary-care providers complete a standardized developmental screening in conjunction with the developmental surveillance performed during well-child visits (Filipek, Accardo, Ashwal, et al., 2000). One year later, the AAP issued a policy statement reinforcing the need for primary-care physicians to perform routine developmental surveillances and screenings to identify children at risk for ASD (Robins & Dumont-Mathieu, 2006). By 2007, the AAP outlined an ASD-specific surveillance and screening algorithm to assist with the identification process. Within this report, a policy statement directed physicians to include an autism-specific screening at the 18- and 24-month well-child visits (Johnson, et al., 2007).

Because delays in the identification process have reportedly affected parents’ ability to access appropriate and timely services for their child, there is motivation for other professionals to consider incorporating ASD-specific screenings into their clinical practice settings. Further, because children presenting with symptoms of ASD often have communication delays and exhibit unusual patterns of behavior, it is not atypical for parents to consult an allied health professional (e.g., speech-language pathologist [SLP], occupational therapist [OT] or physical therapist [PT]) before considering the need to contact a physician. Consequently, the accuracy of the information provided to the family by this initial contact, followed by a proper referral, may increase the likelihood of a proper and timely diagnosis for the child.

Support documenting the need for other qualified professionals to take responsibility for conducting timely ASD-specific screenings has been provided. Leach and Collins (2009) described the important role physician assistants (PAs) play in early detection of ASD symptoms in children by citing the AAP recommendations for medical personnel to conduct a developmental surveillance at all well-child visits and use a developmental screening tool at the 9-, 18-, 24- and 30-month visits. Additionally, Leach and Collins (2009) cited the recommendations provided by Johnson, Myers and the Council on Children with Disabilities, which stated that diagnostic teams should collaboratively participate in the screening, evaluation and subsequent treatment for a child with ASD. These teams may include, but are not limited to, pediatricians, PAs, SLPs, child psychologists, social workers and/or pediatric OTs. Finally, a multidisciplinary panel organized by the Child Neurology Society and American Academy of Neurology concluded that all professionals engaged in early health care should be able to identify the signs and symptoms of ASD and recognize when further evaluation is warranted (Filipek et al., 2000). This position is consistent with the expectation that all allied health professionals working with children are expected to provide developmental screenings and referrals.

Purpose

The purpose of this study was to conduct a state-wide survey of allied health-care professionals (i.e., PAs, SLPs, OTs, PTs) who do not independently diagnose children with ASD, but who would be eligible to conduct ASD-specific screenings if properly prepared to do so to determine the current state of: (1) knowledge of ASD characteristics, and (2) screening practices in various professional settings. The specific areas explored included the following: (1) the amount of pre-professional education/training these health-care professionals accrued in the area of ASD, (2) if they were trained to screen for ASD during their pre-professional education/training, (3) what screening tools they were trained to administer for suspected ASD, (4) the amount and most recent date of continuing medical education (CME) or continuing education (CE) received in the area of ASD, (5) their professional responsibility to screen children for ASD (based on the requirements of their workplace), and (6) their knowledge of available referral resources for a child to receive a complete ASD diagnostic, when appropriate. The survey also provided participants the opportunity to indicate what would help them be better prepared to screen young children for ASD.

Method

Participants

Participants were selected for this study via two public databases that included the state Board of Healing Arts, which represents PAs, OTs and PTs, and the state Speech-Language-Hearing Association, representing the SLPs. Administrators of the mailing lists confirmed that all professionals identified on the lists were licensed and professionally active allied health-care professionals within the selected Midwestern state. 

Procedure

Because the number of professionals from each mailing list was unevenly distributed (e.g., 1,252 OTs, 450 SLPs, etc.), it was determined that 85% of each group would be randomly selected as the initial participant pool (1,074 OTs, 652 PAs, 1,475 PTs, 383 SLPs). Using this participant pool, 20% of the professionals representing each group were randomly selected to receive surveys. Surveys were distributed so that zip code regions throughout the state were represented. The total number of surveys (832) sent was as follows: 130 PAs, 215 OTs, 295 PTs and 192 SLPs.

All surveys were coded with an identification number to maintain individual anonymity and to monitor the return rates among the professional groups. A second mailing was done in an attempt to increase the overall return rate. Participants who did not respond to the initial mailing received a second survey approximately two months following their receipt of the initial mailing.

Data Analysis

Chi-square statistics were used in bivariate tests of association between allied health group membership and responses to each survey question. Follow-up analyses on selected questions also tested the degree of association between (a) the role of the allied health professional and length of time in service, (b) the role of the allied health professional and whether the individual received CME/CE training for the characteristics of ASD/PDD, and (c) the individual’s length of time in practice and whether his or her training included ASD/PDD assessment/screening.

Results & Summary

The number of surveys returned by each professional group was as follows: PA-26, OT-55, PT-69 and SLP-62. Overall, 212 surveys were returned, rendering a 25% overall return rate.

Based on the results of this survey, it appears SLPs and OTs received more pre-professional education/training on the characteristics of individuals with ASD than did PAs and PTs. Additionally, a relationship was discovered between those professionals who had reportedly received this information during their preparatory coursework and the length of time they had been in the field. Overall, SLPs, OTs and PTs reported being in their respective fields of practice longer than PAs, one-third of whom reported being in the field five years or less (Langdon, 2009). These results may be due to the fact that the PA field is relatively new. It is unexpected, however, that PAs coming out of their pre-professional training would not have received information relative to ASD, a disorder that has been steadily increasing in prevalence over the past several years. As a group, respondents did not report training during their pre-professional coursework to screen for ASD. While this type of training may not have focused on particular disorders, such as ASD, students participating in SLP, OT, PT and PA programs should have received training to assess and intervene on behalf of individuals across the lifespan within their particular discipline given their professional scope of practice. Thus, information concerning developmental norms and potential discrepancies should have been provided to these professionals during their pre-professional courses. It is expected, therefore, that these professionals would have received ample information to acknowledge when a child is not developing typically and recognize the need to access appropriate screening instruments to determine whether a child is presenting with developmental differences and may be in need of additional attention/evaluation.

A number of respondents indicated they had accessed CME/CE opportunities on topics related to ASD. Given the identified work settings among the participants (e.g., hospital, preschool, education), this result would seem appropriate. When respondents were asked what would help them be better prepared to screen children for ASD, they indicated a preference for a one-day workshop, whether it be held on- or off-site. Therefore, it appears allied health-care professionals who participated in this study would be open to receiving information on how to screen children with ASD. Given the frustrations and delays families have reportedly experienced during the ASD diagnostic process, it is crucial that health-care preparation programs educate their students on proper screening and referral protocol, so that when the need presents itself, they will be better equipped to respond. Additionally, it should be reinforced that, although SLPs, OTs, PTs and PAs cannot officially diagnose ASD, these professionals can provide the necessary screening information and referral resources for families. While ASD-specific tools may not become part of the regular screening protocol for all professionals who work with children, they should become resources that can be readily accessed. In turn, this will allow the receiving diagnostician (i.e., family physician, pediatrician) the opportunity to move more expeditiously to provide families with an appropriate and well-timed diagnosis.