Why should pediatricians use a structured screening like the Modified Checklist for Autism in Toddler-Revised (MCHAT-R) to screen for autism spectrum disorders (ASD) in toddlers?  After all, parents don’t like to fill out seemingly endless forms, and with all the topics doctors are required to cover in well-child visits, it can be easy to skip the formal screen in favor of “eyeballing” a child’s behavior or relying on parent report.   Next time you’re faced with a screaming toddler or a stressed-out parent and you’re tempted to skip the screen, consider the following.

Under identification of ASD symptoms is likely when relying on observations or parent report.  Why?

• The subtle signs of ASD exhibited by younger children will not be obvious during brief well-child visits. Many children can look “typical” for brief periods of time, and behaviors like poor eye contact and low expressive language can be blamed on anxiety or stress about being at the doctor, when they may actually be indicators of ASD. 
• Informal parent report of ASD symptoms is strongly influenced by a parent’s experience, expectations and culture. Parents who are unfamiliar with typical social development may not notice or report a child’s avoidance of eye contact or absence of pointing.  Parents from cultures that value deference to professionals, like physicians, may wait for the doctor to ask about possible ASD symptoms rather than volunteering observations or concerns. 

Using the MCHAT-R, combined with Follow Up Interview when indicated, is an accurate and efficient strategy for identifying children in need of additional assessment.  How do we know?

• Research on the MCHAT-R indicates a low level of specificity, meaning that the tool overidentifies possible ASD cases (i.e., a high false positive rate). However, a higher than expected false positive rate is often desirable when using broad screening measures, as it makes it less likely that true positive cases will be missed.
• To address this low specificity, it is now recommended that all positive screens be followed up using the MCHAT-R Follow Up Interview. When used together, the positive predictive value of the tools is strong, meaning that children with positive results on the MCHAT-R and the Follow Up Interview are likely to meet criteria for ASD (http://bit.ly/2fnEjrp).

Your practice can receive reimbursement for completing developmental screening.  How?

• Screening at 18 and 24-month well-child visits is recommended by the American Academy of Pediatrics. This recommendation provides a rationale for entities like Medicare and private insurance to reimburse for screening.
• Using a validated tool, like the MCHAT-R, allows you to bill using the 96110 (and 99420 in some states) code for Developmental Screening.
• Reimbursement rates vary by state and insurance provider, but averages around $10 per screen. You can increase your practice’s revenue while ensuring that your patients receive appropriate assessment and intervention. 

How can I start or increase screening in my practice?

• The MCHAT-R and Follow Up Interview are available on paper and in computerized formats.
• Computerized screening has the benefit of being dynamic, with skip patterns that adapt to parent responses. This minimizes parent time spent completing the screen and makes scoring automatic for office staff.
• A computerized Follow Up Interview guides the clinician through following up on positive responses, making this process more efficient than paper flow charts for the interview.
• A study of parent preferences for screening modalities showed that parents preferred using computerized screening tools, using either a smartphone or tablet, to paper screening.¹

Using the MCHAT-R and Follow Up Interview typically takes less than 5 minutes and has many benefits.  This systematic assessment process can help start a discussion with parents, educate parents about signs and symptoms of ASD, gather data to support your clinical observations and more accurately identify children in need of additional assessment and intervention. 

CHADIS offers tools to help doctors and parents screen kids with autism, including the MCHAT-R and the MCHAT-R Follow up. www.chadis.com

CHADIS is a unique screening, decision support and patient engagement system designed to streamline and optimize healthcare by providing Clinicians with evidence-based data that improves diagnosis and management of health, emotional, developmental and behavioral concerns. Ask your physician for any of the many resources CHADIS has on autism (ASD).

1- Raymond A Sturner, MD^1,5, Barbara J Howard, MD^1,4, Lindsay Andon, BS², Sid J.   Schneider, PhD³, Tanya Morrel, PhD⁴. Comparing Alternative Modalities For Pre-Visit Screening for Different Demographic Groups, Pediatric Academics Societies, Annual Meeting, Denver CO. May, 2011

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