Early Identification And Intervention Services (EIIS)

EIIS Western Regional Evaluation - Target Group I: PHYSICIANS

The purpose of the physician surveys (May 2002, September 2003) was to determine:

· What services (specific to ASD) physicians in the Region are providing;

· The comfort level of physicians in diagnosing and providing interventions and treatments to children with ASD;

· The degree of physician familiarity with local services for children with ASD.

The objective of the evaluation process was to collect data at two points during project implementation in order to make comparisons of how service delivery changed over time and to determine what impacts the EIIS Autism Teams have had on the communities they serve.

Phase I:

In May 2002, all physicians and pediatricians practicing in the Western Region received an information package containing the Physician Survey, Process for Referral Package, an article by Filipeck, P.A. et al., Neurology, 2000[1] on the screening and diagnosis of autism and a “What is ASD?” information sheet.

Physicians who work with children or have a family practice were asked to complete the enclosed survey and to return it by fax to EIIS. A total of 92 information packages containing the physician survey were distributed to general practitioners (86) and pediatricians (6) across the Western Region. A total of 18 surveys were returned for a response rate of 20%.

Phase II:

In September 2003, physicians, pediatricians and psychiatrists were asked to complete a follow-up survey and to return it to EIIS by fax. The follow-up survey was the same survey sent in May 2002 and included a cover letter explaining that the follow-up survey was the second of two surveys in a series that would allow for comparisons to be made on how services have changed over time.

In total, 144 surveys were distributed to general practitioners of whom 29 completed and returned the survey (response rate: 20%). Five pediatricians also received the follow-up survey of which two were returned to EIIS (response rate: 40%). The follow-up survey was also sent to five psychiatrists, of which 2 were returned (response rate: 22%). Overall, a total of 149 surveys were distributed with 31 of them being returned, for a response rate of 21%.

Summary of Findings

Screening, Diagnosis and Intervention:

Physicians were asked about the screening, assessments and interventions they provide specific to Autistic Spectrum Disorders (ASD).

Screening:

Physicians, pediatricians and psychiatrists were asked if they offered standardized screening for ASD. No physicians or psychiatrists (0%) reported using standardized screening for ASD within their practices in either May 2002 or September 2003. Examples of standardized screening provided on the questionnaire included the Modified Checklist for Autism in Toddlers (MCHAT), Pervasive Developmental Disorders Screening Test (PDDST-II), Autism Screening Questionnaire (ASQ), and Childhood Autism Rating Scale (CARS). One of two pediatricians who responded to the September 2003 survey indicated that they offer standardized screening for ASD. No pediatricians indicated doing so in May 2002.

Diagnosis:

Seventy-two percent of physicians surveyed in 2002 and 83% surveyed in 2003 reported that they do not provide diagnostic assessment services for children with ASD. As illustrated in Figure 1, most physicians refer children to a pediatrician if ASD is suspected. In 2003, twice as many physicians as in 2002 reported that they would refer patients suspected of having ASD to a pediatrician for diagnostic assessment.

In 2003, 28% of physicians also indicated that if a suspicion of ASD existed, they would refer the child to more than one service (e.g., pediatrician and EIIS). Of the two pediatricians who responded, one indicated that they would refer children to EIIS for ASD services and the other indicated the IWK. Several physicians, 31% in 2003 and 25% in 2002, indicated that they would refer elsewhere (IWK, other, no response) if a child was suspected of having ASD.

Intervention:

As with screening, little change was observed in the types of services provided to families with children with ASD by physicians. Only a small percentage of physicians reported that they provide direct treatments or interventions to children with ASD and families with children with ASD. As illustrated in Table 2, twice as many physicians reported providing treatments to children with ASD and to families with children with ASD in 2003; however, given the small sample size, this change was not statistically significant from one year to the next.

	2002	2003
Families with children with ASD	25% (4/16)	24% (7/29)
Children with ASD	19% (3/16)	28% (8/29)

Table 2: Percentage of physicians who reported providing treatment or interventions to children with ASD and their families.

Commentary – Screening, Diagnosis and Intervention

Overall, physicians reported little change from May 2002 to September 2003 in the screening, diagnostic and intervention services they provide specific to ASD, despite the Region’s efforts to involve physicians in the identification process. In addition to sending out information packages containing screening and referral information for each of the established autism teams, many physicians were visited by local team members. During visits the process for referral information was reviewed and red flags for autism discussed. One family physician group invited the EIIS Regional Coordinator to speak about the services provided by the EIIS Autism Teams.

Although no physicians reported screening for ASD, in 2003, twice as many physicians reported that they would refer children to a pediatrician should a suspicion of ASD exist. This is a positive change towards assisting families in accessing services for their children. Although a physician referral is not required to access EIIS services, parents often express concerns about their child’s development to family practitioners. Screening for developmental delay and making appropriate and timely referrals is critical to ensuring that interventions take place as early as possible.

Unfortunately, no change was reported in the percentage of physicians who would refer a child or family to EIIS should a suspicion of ASD exist. In addition, only one of two pediatricians reported that they would make a referral to EIIS in this circumstance. Several physicians indicated that they would refer children to the IWK or elsewhere for service. Referrals to services outside the Region could result in increased delays for families as referrals are redirected to local service delivery teams. Continued professional education for physicians of local EIIS services for families with children with ASD is required to ensure appropriate referral routes are followed and delays to accessing EIIS services are minimized.

Recommendation #1: EIIS Autism Teams continue to develop awareness initiatives for physicians of local services available for families with children with ASD to ensure that appropriate referral routes are followed and delays are minimized.

Training and Knowledge

Physicians were asked to rate their level of comfort in applying their knowledge to provide assessments and interventions specific to ASD. Physicians were asked about their familiarity with the diagnostic criteria for ASD, diagnostic assessments, along with medical, nutritional, and other interventions specific to ASD (e.g., behavioural interventions, social interventions and communication-based interventions).

Over the past year, no significant change has been reported by physicians with respect to their comfort levels in applying their knowledge to provide assessments and treatments specific to ASD. When rating their comfort level in each of the knowledge areas listed, no physicians reported having training or knowledge at the “expert” level on any of the items in either 2002 or 2003. On average, physicians reported being at only an “intermediate” comfort level across the knowledge areas 10% of the time in 2002 and 7% in 2003. Thirty-six percent and 33% of physicians reported on average that they were at the “beginner” comfort level across knowledge areas specific to ASD in 2002 and 2003, respectively. Many physicians, 54% (2002) and 61% (2003), reported that they were not comfortable with applying their knowledge to provide assessment and treatments for children with ASD.

Table 3 outlines each of the knowledge items and illustrates more specifically in which areas physicians felt most comfortable. Table 4 provides additional information about comfort levels reported by pediatricians and psychiatrists. In Phases I and II, physicians reported some familiarity with the DSM-IV criteria for diagnosing ASD, however more physicians reported having no familiarity with the diagnostic criteria in Phase II. Similarly, in Phase II, more physicians also reported that they had no comfort with diagnostic assessment specific to ASD.

Knowledge Area	Comfort Level (%)								Combined % (Beginner to Expert)
	None		Beginner		Intermediate		Expert		Combined % (Beginner to Expert)
	2002	2003	2002	2003	2002	2003	2002	2003	2002	2003
Familiarity with DSM-IV Criteria for ASD	19%	32%	63%	55%	18%	13%	0%	0%	81%	68%
Diagnostic Assessment	31%	62%	56%	28%	13%	10%	0%	0%	69%	38%
Medical Interventions	44%	48%	44%	39%	12%	13%	0%	0%	59%	52%
Nutrition Specific to ASD	50%	74%	38%	19%	12%	7%	0%	0%	50%	26%
Behaviour	81%	65%	13%	32%	6%	3%	0%	0%	19%	35%
Social	75%	71%	19%	29%	6%	0%	0%	0%	25%	29%
Communication	75%	73%	19%	27%	6%	0%	0%	0%	25%	27%

Table 3: Reported comfort level of physicians (pediatricians and family practitioners) in each knowledge area (2002; n=16 - 2003; n=31).

Knowledge Area	Comfort Level (%) – Specialists (2003)
Knowledge Area	None		Beginner		Intermediate		Expert
	Ped	Psych	Ped	Psych	Ped	Psych	Ped	Psych
Familiarity with DSM-IV Criteria for ASD					(2 of 2)	(1 of 2)		(1 of 2)
Diagnostic Assessment					(1 of 1)	(1 of 2)		(1 of 2)
Medical Interventions			(1 of 2)		(1 of 2)	(1 of 2)	&