Improving Accuracy and Accessibility of Early Autism Screening

描述（由申请人提供）：本提案的目的是完成对一种新工具的计算机化适应的开发和评估，以更准确地识别具有自闭症谱系障碍（ASD）迹象的幼儿，并使该工具可供不同人群使用。早期筛查自闭症谱系障碍最近已经成为儿科实践的标准，因为有证据表明早期干预的有效性。最广泛推荐的筛查是《幼儿自闭症改良检查表》（MCHAT； Robins等，1999）。虽然MCHAT具有良好的心理测量特征，但其在初级保健中使用的主要障碍是其过高的转诊率。虽然开发了结构化访谈（MCHAT Follow Up； Kleinman等人，2007），以减少过度转诊，但其原始形式对于短暂的油井儿童访问是不切实际的。这个项目的平台是一个基于网络的决策支持系统CHADIS，它提供诸如MCHAT之类的预诊问卷，供在线完成，对其进行评分，并将结果呈现给临床医生。CHADIS还通过电子教科书提供决策支持，这些教科书与筛查结果和家长讲义中的资源相关联。在CHADIS （CHADIS MCHAT F/U）中创建了由临床医生访谈完成的MCHAT随访的计算机化版本。CHADIS MCHAT F/U是实用的，因为它提示医生只问父母几个问题，以跟踪导致MCHAT阳性评分的答案，每次临床医生输入后，测试都会自动恢复，直到获得阳性或阴性结果。预计电脑化的MCHAT和CHADIS MCHAT F/U将把过度转介率减少一半以上，从而节省费用和减轻家长的痛苦。CHADIS正在全国范围内和马里兰州的一个相当大的自闭症筛查项目网络中使用。然而，在大量低收入家庭的环境中使用受到限制，因为他们无法或不记得在访问前完成在线调查问卷。该项目的第一阶段将涉及开发用于管理MCHAT的候诊室替代方案，包括交互式语音应答（IVR）电话系统、触摸屏亭和笔记本电脑，这些设备将使结果与CHADIS MCHAT F/U相连。还将创建一个提醒系统。然后将在3个人群的家长和医生焦点小组中对这些方法进行评估。第二阶段将包括：评估三个人群中160名家长对候诊室方法的满意度，并测试CHADIS MCHAT F/U方法的阳性预测有效性。通过使用MCHAT对马里兰州网络中的4500名儿童进行筛查，并完成CHADIS MCHAT F/U，并对预期的300名阳性儿童完成ASD评估，从而确定有效性。最后，估计这些方法的相对成本和节省。据推测，新系统将显示出优势、节省和可接受性，支持第三阶段的广泛推广。公共卫生相关性：本提案的目的是完成对一种新工具的计算机化改造的开发和评估，以更准确地识别患有自闭症谱系障碍（ASD）症状的幼儿，目前每150名儿童中就有1名患有自闭症谱系障碍（ASD），并使各种人群都能使用该工具。ASD的早期筛查是儿科实践的新标准，但最广泛推荐的筛查MCHAT有很大的过度转诊率，低收入家庭在就诊前不太能够或不记得完成筛查。该项目将通过电话（IVR）、触摸屏kiosk和笔记本电脑以及电话提醒系统创建在候诊室使用MCHAT的方法；引导他们接受；然后在3个人群中测量这些方法的偏好、满意度和成本。为了减少过度转诊，在现有的基于网络的决策支持系统（CHADIS）中创建了计算机版的MCHAT和随访提示访谈，并将通过评估300名患有ASD的儿童进行验证，这些儿童的MCHAT筛查呈阳性，而不管他们的MCHAT随访结果如何。预计计算机化的MCHAT和CHADIS MCHAT F/U将提高ASD的有效筛查率，这对早期识别和干预很重要，但将过度转诊率降低一半以上，节省了成本和父母的痛苦。

DESCRIPTION (provided by applicant): The aims of this proposal are to complete development and evaluation of a computerized adaptation of a new tool to more accurately identify toddlers with signs of Autism Spectrum Disorders (ASD) and to make this tool accessible to varied populations. Early screening for ASD has recently become standard for pediatric practice following evidence of the efficacy of early intervention. The most widely recommended screen is the Modified Checklist for Autism in Toddlers (MCHAT; Robins, et. al., 1999). While the MCHAT has good psychometric characteristics, a major obstacle to its use in primary care is its large over-referral rate. While a structured interview (MCHAT Follow Up; Kleinman, et. al., 2007) was developed that reduces over-referral, it is impractical in its original form for brief well child visits. The platform for this project is a web-based decision support system, CHADIS that delivers pre-visit questionnaires such as the MCHAT for completion online, scores them and presents results to the clinician. CHADIS also provides decision support in an electronic textbook linked to screening results and resources in handouts for parents. A computerized version of the MCHAT Follow Up completed by clinician interview has been created in CHADIS (CHADIS MCHAT F/U). CHADIS MCHAT F/U is practical because it prompts doctors to ask the parents only a few questions to follow up on the answers causing the positive MCHAT score, with the test automatically rescored after each clinician input until a positive or negative result is obtained. It is anticipated that the computerized MCHAT and CHADIS MCHAT F/U will cut the over-referral rate by more than half, saving costs and parent agony. CHADIS is being used nationally and in Maryland for a sizable network of practices in an autism screening program. However, use in settings with large numbers of low income families has been limited because they are unable or do not remember to complete questionnaires online prior to visits. Phase I of this project will involve development of waiting room alternatives for administering the MCHAT including Interactive Voice Response (IVR) phone system, touch screen kiosk, and laptop computer that will allow results to be linked to CHADIS MCHAT F/U. A reminder system will also be created. These methods will then be assessed in parent and physician focus groups in 3 populations. Phase II will involve: assessing satisfaction with the waiting room methods in 160 parents in the 3 populations, and testing positive predictive validity of the CHADIS MCHAT F/U method. Validity will be determined by screening 4500 children in the Maryland network using the MCHAT, and completing the CHADIS MCHAT F/U and complete evaluations for ASD on the expected 300 positive children. Finally, relative costs and savings of these methods will be estimated. It is hypothesized that the new system will show advantages, savings, and acceptability that support widespread Phase III dissemination. PUBLIC HEALTH RELEVANCE: The aims of this proposal are to complete development and evaluation of a computerized adaptation of a new tool to more accurately identify toddlers with signs of Autism Spectrum Disorders (ASD), now affecting 1 in 150 children, and to make this tool accessible to varied populations. Early screening for ASD is a new standard for pediatric practice but the most widely recommended screen, MCHAT, has a large over- referral rate and low income families are less able to or do not remember to complete it prior to their visits. This project will create methods for using the MCHAT in the waiting room by phone (IVR), touch screen kiosk and laptop and a phone reminder system; pilot them for acceptability; then measure preference, satisfaction and costs of these methods in 3 populations. A computerized version of MCHAT and of a Follow Up prompted interview designed to reduce over-referral has been created in an existing web-based decision support system (CHADIS) and will be validated by evaluating 300 children for ASD who have positive MCHAT screens regardless of their MCHAT Follow Up results. It is anticipated that the computerized MCHAT and CHADIS MCHAT F/U will improve rates of valid screening for ASD, important to early identification and intervention, but cut the over-referral rate by more than half, saving costs and parent agony.