Presented by Elizabeth Caronna

1. ASD Screening and Diagnosis:
Increasing Capacity in Community
Primary Care Providers
Elizabeth Caronna, MD
Boston University/Boston Medical Center
Developmental Behavioral Pediatrics

2. Screening for ASD in Massachusetts
• Since December, 2007 mandated screening for
developmental and behavioral problems with
approved screening tools for children
receiving Medicaid, as part of routine EPSDT
visits linked to reimbursement
• Developmental screening follows
recommendations from American Academy of
Pediatrics (Pediatrics, 2006, 2007), except
choice of specific measures are mandated
from approved list

3. Screening for ASD in Massachusetts
• M‐CHAT screening now widely used in
pediatric practices throughout the state
• Limitations of the M‐CHAT screener result in
increased referrals to specialists on basis of
“failed M‐CHAT”
• Delays between parental/primary care
provider (PCP) concern and evaluation by
specialist

4. Barriers to Timely Diagnosis/Treatment
• Many PCPs do not
– Feel confident in their ability to identify warning signs
of ASD, or
– Know how to help families access services, even
when they are certain child has ASD
• Disparity by SES apparent as level of parental
concern may influence PCPs’ referrals
• Diagnosis by a specialist approved by Dept of
Public Health required to access intensive
services for children receiving Early Intervention

5. Increasing Capacity of PCPs
• Partnership with PCPs from community health
centers with ties to Boston Medical Center
• Goals
– Improve clinical skills to identify subtle and overt
signs of ASD in conjunction with use of screeners
– Educate PCPs about how to refer children for
treatment, available community resources
– Decrease delay in diagnosis and treatment of ASD

6. DBP “Mini Fellowship”
• 8 hours per week of DBP time
• Formal clinical ADOS training
• Weekly clinic session (autism‐specific or
general DBP clinic), evaluating patients with
direct supervision by DBP attending
• Weekly afternoon didactic session with DBP
fellows
• Weekly one on one case and topic review with
DBP attending

7. Training Results to Date
• First two mini fellows completed program
– MD from health center with large Spanish‐speaking
population
– NP practicing at Boston Medical Center to increase
links to primary care community
• Since completing program, health center MD can
provide initial diagnosis for children under 3 to
facilitate immediate initiation of intensive Early
Intervention (prior to evaluation by specialist)
• NP is first line provider to interact with PCPs who
refer patients for evaluation of ASD, prioritizes
evaluations

8. Future Plans
• Continue “Mini Fellowship” and target specific
health centers to increase capacity in
– Bilingual providers
– Nurse practitioners
• Current mini fellows
– 2 NPs from community health center serving
largely Vietnamese speaking population to
increase community linkage

9. Future Plans
• Expand training in health centers regarding
how to access services and how to advocate
for children with ASD
• Increase links with NP training programs to
enhance DBP as part of their curriculum