Practice Patterns for Early Screening and Evaluation for Autism Spectrum Disorder Diagnosis in Bulgaria

  • Georgi IskrovEmail author
  • Georgi Vasilev
  • Martin Mitev
  • Ralitsa Nikolova
  • Mariya Stoykova
  • Rumen Stefanov
S.I. : Early Detection In Autism Spectrum Disorder


The aims of this study were to describe the practice patterns for early screening and evaluation for ASD diagnosis in Bulgaria, as well as to identify potential barriers and facilitators in this process. We surveyed a sample of pediatricians and pediatric psychiatrists to analyze the use of standardized instruments, application of biomarkers, parental collaboration and future policy prospects. We found a significant support for the idea of a national program for ASD in Bulgaria. These insights provide an evidence-based analysis that could help improve services, guide research and inform policies in regard to ASD. Further work is necessary to better understand other stakeholders’ opinions and perspectives, especially those of patients and their families.


Autism spectrum disorder Diagnosis Early detection Delay Health services research Health policy 



The study was conducted as a research project within the Public Health Club of the Department of Social Medicine and Public Health at the Medical University of Plovdiv, Bulgaria. The Club was led by Georgi Iskrov, Mariya Stoykova and Rumen Stefanov and formed by the following medicine students (in alphabethical order): Aylin Feyzullova, Georgi Vasilev, Hristina Cholakova, Ivan Atanasov, Ivan Sitnikov, Ivan Yakimov, Martin Mitev, Petya Konakchieva, Ralitsa Nikolova, Stefan Ivanov, Stefan Stefanov. The authors would like to thank Prof. Ricardo Canal Bedia and Álvaro Bejarano Martín for providing the original surveys for ASDEU research on early detection, diagnosis and interventions for ASD across Europe.

Authors’ contributions

GI: concept and design; analysis and interpretation of data; drafting of the manuscript; statistical analysis. GV: concept and design; acquisition of data; analysis and interpretation of data; critical revision of paper for important intellectual content. MM: concept and design; acquisition of data; analysis and interpretation of data; critical revision of paper for important intellectual content. RN: concept and design; acquisition of data; analysis and interpretation of data; critical revision of paper for important intellectual content. MS: concept and design; analysis and interpretation of data; critical revision of paper for important intellectual content; supervision. RS: concept and design; analysis and interpretation of data; critical revision of paper for important intellectual content; supervision. All authors read and approved the final manuscript.


The authors received no financial support for the research, authorship, and publication of this article.

Compliance with ethical standards

Conflicts of interest

The authors declare that they have no conflict of interest.

Ethical approval

Ethical approval was not required for this study in accordance with national and institutional guidelines. The survey was sociological from a methodological point of view, with no clinical research. No personal data were saved or analyzed.


  1. Cadman, T., Eklund, H., Howley, D., Hayward, H., Clarke, H., Findon, J., et al. (2012). Caregiver burden as people with autism spectrum disorder and attention-deficit/hyperactivity disorder transition into adolescence and adulthood in the United Kingdom. Journal of the American Academy of Child and Adolescent Psychiatry, 51(9), 879–888.CrossRefPubMedGoogle Scholar
  2. Crane, L., Batty, R., Adeyinka, H., Goddard, L., Henry, L. A., & Hill, E. L. (2018). Autism diagnosis in the United Kingdom: Perspectives of autistic adults, parents and professionals. Journal of Autism and Developmental Disorders, 48(11), 3761–3772.CrossRefPubMedPubMedCentralGoogle Scholar
  3. Crane, L., Jones, L., Prosser, R., Taghrizi, M., & Pellicano, E. (2019). Parents’ views and experiences of talking about autism with their children. Autism. Scholar
  4. Daniels, A. M., Como, A., Hergüner, S., Kostadinova, K., Stosic, J., & Shih, A. (2017). Autism in Southeast Europe: A survey of caregivers of children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 47, 2314–2325.CrossRefPubMedGoogle Scholar
  5. Daniels, A. M., & Mandell, D. S. (2014). Explaining differences in age at autism spectrum disorder diagnosis: A critical review. Autism, 18(5), 583–597. Scholar
  6. Davidovitch, M., Levit-Binnun, N., Golan, D., & Manning-Courtney, P. (2015). Late diagnosis of autism spectrum disorder after initial negative assessment by a multidisciplinary team. Journal of Developmental and Behavioral Pediatrics, 36(4), 227–234.CrossRefPubMedGoogle Scholar
  7. Dickerson, A. S., Rahbar, M. H., Pearson, D. A., Kirby, R. S., Bakian, A. V., Bilder, D. A., et al. (2017). Autism spectrum disorder reporting in lower socioeconomic neighborhoods. Autism, 21(4), 470–480.CrossRefPubMedGoogle Scholar
  8. Executive Agency Medical Audit. (2016). Ordinance № 24 of 7 July 2004 for affirmation of Medical Standard in Psychiatry, issued by the Minister of Health. Promulgated in State Gazette No. 78 of September 7, 2004, last amended and supplemented in State Gazette No. 37 of May 17, 2016. Executive Agency Medical Audit. ( Accessed 26 June 2019.
  9. García-Primo, P., Hellendoorn, A., Charman, T., Roeyers, H., Dereu, M., Roge, B., et al. (2014). Screening for autism spectrum disorders: State of the art in Europe. European Child and Adolescent Psychiatry, 23, 1005–1021.CrossRefPubMedGoogle Scholar
  10. Giallo, R., Wood, C. E., Jellett, R., & Porter, R. (2013). Fatigue, wellbeing and parental self-efficacy in mothers of children with an autism spectrum disorder. Autism, 17(4), 465–480.CrossRefPubMedGoogle Scholar
  11. Gordon-Lipkin, E., Foster, J., & Peacock, G. (2016). Whittling down the wait time: Exploring models to minimize the delay from initial concern to diagnosis and treatment of autism spectrum disorder. Pediatric Clinics of North America, 63(5), 851–859.CrossRefPubMedPubMedCentralGoogle Scholar
  12. Gregoric Kumperscak, H., Clausen, C., Anagnostopoulos, D., Barac Otasevic, Z., Boricevic Marsanic, V., Burgic, M., et al. (2019). Child and adolescent psychiatry training and mental health care in Southeast Europe. European Child and Adolescent Psychiatry. Scholar
  13. Hansen, R. L., Blum, N. J., Gaham, A., Shults, J., & DBPNet Steering Committee. (2016). Diagnosis of autism spectrum disorder by developmental-behavioral pediatricians in academic centers: A DBPNet study. Pediatrics, 137(Supplement 2), 79–89.CrossRefGoogle Scholar
  14. Harris, S. R. (2017). Early motor delays as diagnostic clues in autism spectrum disorder. European Journal of Pediatrics, 176(9), 1259–1262.CrossRefPubMedGoogle Scholar
  15. Herlihy, L. E., Brooks, B., Dumont-Mathieu, T., Barton, M. L., Fein, D., Chen, C. M., et al. (2014). Standardized screening facilitates timely diagnosis of autism spectrum disorders in a diverse sample of low-risk toddlers. Journal of Developmental and Behavioral Pediatrics, 35(2), 85–92.CrossRefPubMedPubMedCentralGoogle Scholar
  16. Hoefman, R., Payakachat, N., van Exel, J., Kuhlthau, K., Kovacs, E., Pyne, J., et al. (2014). Caring for a child with autism spectrum disorder and parents’ quality of life: Application of the CarerQol. Journal of Autism and Developmental Disorders, 44(8), 1933–1945.PubMedPubMedCentralGoogle Scholar
  17. Höfer, J., Hoffmann, F., Kamp-Becker, I., Poustka, L., Roessner, V., Stroth, S., et al. (2019). Pathways to a diagnosis of autism spectrum disorder in Germany: A survey of parents. Child and Adolescent Psychiatry and Mental Health, 13, 16. Scholar
  18. Iskrov, G., Eneva, E., Vasilev, G., Stefanov, R., Canal-Bedia, R., & Posada-de la Paz, M. (2018). Early detection, assessment and interventions in autism spectrum disorders in Bulgaria—Results of focus group discussions with stakeholders. General Medicine, 20(3), 31–36.Google Scholar
  19. Jónsdóttir, S. L., Saemundsen, E., Antonsdóttir, I. S., Sigurdardóttir, S., & Ólason, D. (2011). Children diagnosed with ASD before or after the age of 6 years. Research in Autism Spectrum Disorders, 5, 175–184.CrossRefGoogle Scholar
  20. Kelly, B., Williams, S., Collins, S., Mushtaq, F., Mon-Williams, M., Wright, B., et al. (2017). The association between socioeconomic status and autism diagnosis in the United Kingdom for children aged 5-8-years of age: Findings from the born in Bradford cohort. Autism, 2, 2. Scholar
  21. Khowaja, M. K., Hazzard, A. P., & Robins, D. L. (2015). Sociodemographic barriers to early detection of autism: screening and evaluation using the M-CHAT, M-CHAT-R, and follow-up. Journal of Autism and Developmental Disorders, 45(6), 1797–1808.CrossRefPubMedPubMedCentralGoogle Scholar
  22. Khowaja, M., Robins, D. L., & Adamson, L. B. (2018). Utilizing two-tiered screening for early detection of autism spectrum disorder. Autism, 22(7), 881–890.CrossRefPubMedGoogle Scholar
  23. Lappé, M., Lau, L., Dudovitz, R. N., Nelson, B. B., Karp, E. A., & Kuo, A. A. (2018). The diagnostic Odyssey of autism spectrum disorder. Pediatrics, 141(Suppl 4), 272–279.CrossRefGoogle Scholar
  24. Magán-Maganto, M., Bejarano-Martín, Á., Fernández-Alvarez, C., Narzisi, A., García-Primo, P., Kawa, R., et al. (2017). Early detection and intervention of ASD: A European overview. Brain Sciences, 7(12), 159. Scholar
  25. Marlow, M., Servili, C., & Tomlinson, M. (2019). A review of screening tools for the identification of autism spectrum disorders and developmental delay in infants and young children: Recommendations for use in low-and middle-income countries. Autism Research, 12(2), 176–199.CrossRefPubMedGoogle Scholar
  26. Mazurek, M. O., Handen, B. L., Wodka, E. L., Nowinski, L., Butter, E., & Engelhardt, C. R. (2014). Age at first autism spectrum disorder diagnosis: The role of birth cohort, demographic factors, and clinical features. Journal of Developmental and Behavioral Pediatrics, 35, 561–569.CrossRefPubMedGoogle Scholar
  27. Miteva, T., Jordanova, R., Iskrov, G., & Stefanov, R. (2011). General knowledge and awareness on rare diseases among general practitioners in Bulgaria. Georgian Medical News, 193, 16–19.Google Scholar
  28. Narzisi, A., Posada, M., Barbieri, F., Chericoni, N., Ciuffolini, D., Pinzino, M., et al. (2018). Prevalence of autism spectrum disorder in a large Italian catchment area: A school-based population study within the ASDEU project. Epidemiology and Psychiatric Sciences. Scholar
  29. National Center of Public Health and Analyses. (2013). Measures to improve the care of people with ASD and their caregivers, adopted by the Ministry of Health 2013. National Center of Public Health and Analyses. ( Accessed 19 March 2019.
  30. Nordahl-Hansen, A., Hart, L., & Øien, R. A. (2018). The scientific study of parents and caregivers of children with ASD: A flourishing field but still work to be done. Journal of Autism and Developmental Disorders, 48(4), 976–979.CrossRefPubMedGoogle Scholar
  31. Øien, R., & Eisemann, M. R. (2016). Brief report: Parent-reported problems related to communication, behavior and interests in children with autistic disorder and their impact on quality of life. Journal of Autism and Developmental Disorders, 46(1), 328–331.CrossRefPubMedGoogle Scholar
  32. Pejovic-Milovancevic, M., Stankovic, M., Mitkovic-Voncina, M., Rudic, N., Grujicic, R., Herrera, A. S., et al. (2018). Perceptions on support, challenges and needs among parents of children with autism: the Serbian experience. Psychiatria Danubina, 30(Suppl 6), 354–364.PubMedGoogle Scholar
  33. Penner, M., Anagnostou, E., & Ungar, W. J. (2018). Practice patterns and determinants of wait time for autism spectrum disorder diagnosis in Canada. Molecular Autism, 9, 16. Scholar
  34. Ramsey, R. K., Nichols, L., Ludwig, N. N., Fein, D., Adamson, L. B., & Robins, D. L. (2018). Brief report: Sex differences in parental concerns for toddlers with autism risk. Journal of Autism and Developmental Disorders, 48(12), 4063–4069.CrossRefPubMedGoogle Scholar
  35. Richards, M., Mossey, J., & Robins, D. L. (2016). Parents’ concerns as they relate to their child’s development and later diagnosis of autism spectrum disorder. Journal of Developmental and Behavioral Pediatrics, 37(7), 532–540.CrossRefPubMedPubMedCentralGoogle Scholar
  36. Robins, D. L. (2008). Screening for autism spectrum disorders in primary care settings. Autism, 12(5), 537–556.CrossRefPubMedPubMedCentralGoogle Scholar
  37. Robins, D. L., Adamson, L. B., Barton, M., Connell, J. E., Jr., Dumont-Mathieu, T., Dworkin, P. H., et al. (2016). Universal autism screening for toddlers: Recommendations at odds. Journal of Autism and Developmental Disorders, 46(5), 1880–1882.CrossRefPubMedPubMedCentralGoogle Scholar
  38. Rosenberg, S. A., Moody, E. J., Lee, L. C., DiGuiseppi, C., Windham, G. C., Wiggins, L. D., et al. (2018). Influence of family demographic factors on social communication questionnaire scores. Autism Research, 11(5), 695–706.CrossRefPubMedPubMedCentralGoogle Scholar
  39. Rutherford, M., Burns, M., Gray, D., Bremner, L., Clegg, S., Russell, L., et al. (2018). Improving efficiency and quality of the children’s ASD diagnostic pathway: Lessons learned from practice. Journal of Autism and Developmental Disorders, 48(5), 1579–1595.CrossRefPubMedGoogle Scholar
  40. Swain, N. R., Eadie, P. A., Prior, M. R., & Reilly, S. (2015). Assessing early communication skills at 12 months: A retrospective study of autism spectrum disorder. International Journal of Language and Communication Disorders, 50(4), 488–498.CrossRefPubMedGoogle Scholar
  41. Waizbard-Bartov, E., Yehonatan-Schori, M., & Golan, O. (2019). Personal growth experiences of parents to children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 49(4), 1330–1341.CrossRefPubMedGoogle Scholar
  42. Zuckerman, K., Lindly, O. J., & Chavez, A. E. (2016). Timeliness of autism spectrum disorder diagnosis and use of services among U.S. elementary school-aged children. Psychiatric services (Washington, DC), 68(1), 33–40.CrossRefGoogle Scholar
  43. Zwaigenbaum, L., Bauman, M. L., Choueiri, R., Fein, D., Kasari, C., Pierce, K., et al. (2015a). Early identification and interventions for autism spectrum disorder: Executive summary. Pediatrics, 136(Suppl 1), S1–S9.CrossRefPubMedGoogle Scholar
  44. Zwaigenbaum, L., Bauman, M. L., Fein, D., Pierce, K., Buie, T., Davis, P. A., et al. (2015b). Early screening of autism spectrum disorder: Recommendations for practice and research. Pediatrics, 136(Suppl 1), S41–S59.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Georgi Iskrov
    • 1
    • 2
    Email author
  • Georgi Vasilev
    • 1
  • Martin Mitev
    • 1
  • Ralitsa Nikolova
    • 1
  • Mariya Stoykova
    • 1
  • Rumen Stefanov
    • 1
    • 2
  1. 1.Department of Social Medicine and Public Health, Faculty of Public HealthMedical University of PlovdivPlovdivBulgaria
  2. 2.Institute for Rare DiseasesPlovdivBulgaria

Personalised recommendations