Skip to main content

Multi-stage Screening in Early Intervention: A Critical Strategy for Improving ASD Identification and Addressing Disparities

Abstract

Health disparities in ASD detection affect children’s access to subsequent interventions. We examined potential disparities in implementation of a multi-stage ASD screening and diagnostic evaluation protocol in Part C Early Intervention with 4943 children ages 14–36 months (mean 22.0 months; 62.9% boys, 73.3% children of color, 34.9% non-English-primary language, 64.5% publicly-insured). Participation and follow-through were high (64.9% and 65.3% at first- and second-stage screening, respectively, 84.6% at diagnostic evaluation). Logistic regressions identified predictors of screening participation and outcomes at each stage; demographic differences (race, language, public insurance) were observed only at first-stage screening and reflected higher participation for children of color and higher positive screens for publicly-insured children. Results suggest the multi-stage screening protocol shows promise in addressing disparities in early diagnosis.

This is a preview of subscription content, access via your institution.

Fig. 1

References

  • Akshoomoff, N. (2006). Use of the Mullen Scales of Early Learning for the assessment of young children with autism spectrum disorders. Child Neuropsychology, 12(4–5), 269–277. https://doi.org/10.1080/09297040500473714.

    Article  PubMed  PubMed Central  Google Scholar 

  • Arunyanart, W., Fenick, A., Ukritchon, S., Imjaijitt, W., Nortbrup, V., & Weitzman, C. (2012). Developmental and autism screening. Infants and Young Children, 25(3), 175–187.

    Article  Google Scholar 

  • Baio, J., Wiggins, L., Christensen, D. L., Maenner, M. J., Daniels, J., Warren, Z., et al. (2018). Prevalence of autism spectrum disorder among children aged 8 years—Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2014. MMWR Surveillance Summaries, 67(6), 1–23.

    Article  PubMed Central  Google Scholar 

  • Briggs-Gowan, M., & Carter, A. S. (2006). Brief infant toddler social emotional assessment (BITSEA). London: Pearson.

    Google Scholar 

  • Chambers, D. A., & Norton, W. E. (2016). The Adaptome: Advancing the science of intervention adaptation. American Journal of Preventive Medicine, 51, S124–S131.

    Article  PubMed  PubMed Central  Google Scholar 

  • Chinman, M., Woodward, E. N., Curran, G. M., & Hausmann, L. R. M. (2017). Harnessing implementation science to increase the impact of health disparity research. Medical Care, 55(Suppl. 92), 16–23. https://doi.org/10.1097/MLR.0000000000000769.

    Article  Google Scholar 

  • Crais, E. R., McComish, C. S., Humphreys, B. P., Watson, L. R., Baranek, G. T., Rexnick, J. S., et al. (2014). Pediatric healthcare professionals’ views on autism spectrum disorder screening at 12–18 months. Journal of Autism and Developmental Disorders, 44(9), 2311–2328.

    Article  PubMed  Google Scholar 

  • Curran, G. M., Bauer, M., Mittman, B., Pyne, J. M., & Stetler, C. (2012). Effectiveness-implementation hybrid designs: Combining elements of clinical effectiveness and implementation research to enhance public health impact. Medical Care, 50(3), 217–226. https://doi.org/10.1097/MLR.0b013e3182408812.

    Article  PubMed  PubMed Central  Google Scholar 

  • Daniels, A. M., Halladay, A. K., Shih, A., Elder, L. M., & Dawson, G. (2014). Approaches to enhancing the early detection of autism spectrum disorders: A systematic review of the literature. Journal of the American Academy of Child & Adolescent Psychiatry, 53(2), 41–152.

    Article  Google Scholar 

  • Daniels, A. M., & Mandell, D. S. (2014). Explaining differences in age at autism spectrum disorder diagnosis: A critical review. Autism, 18(5), 583–597. https://doi.org/10.1177/1362361313480277.

    Article  PubMed  Google Scholar 

  • Dawson, G. (2016). Why it’s important to continue universal autism screening while research fully examines its impact. JAMA Pediatrics, 170(6), 527–528.

    Article  PubMed  Google Scholar 

  • Dreyer, B. (2016). American Academy of Pediatrics (AAP) statement on US Preventive Services Task Force final recommendation statement on autism screening. Retrieved October 30, 2019, from https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Statement-on-US-Preventive-Services-Task-Force-Final-Recommendation-Statement-on-Autism-Screening.aspx.

  • Dunst, C. J., & Bruder, M. B. (2006). Early intervention service coordination models and service coordinator practices. Journal of Early Intervention, 28(3), 155–165.

    Article  Google Scholar 

  • Earls, M. F., Andrews, J. E., & Hay, S. S. (2009). A longitudinal study of developmental and behavioral screening and referral in North Carolina’s Assuring Better Child Health and Development participating practices. Clinical Pediatrics, 48, 824–833.

    Article  PubMed  Google Scholar 

  • Fein, D., Carter, A., Bryson, S. E., Carver, L. J., Charman, T., Chawarska, K., et al. (2016). Commentary on USPSTF final statement on universal screening for autism. Journal of Developmental and Behavioral Pediatrics: JDBP, 37(7), 573.

    Article  PubMed  Google Scholar 

  • Fountain, C., King, M. D., & Bearman, P. S. (2011). Age of diagnosis for autism: Individual and community factors across 10 birth cohorts. Journal of Epidemiology and Community Health, 65(6), 503–510. https://doi.org/10.1136/jech.2009.104588.

    Article  PubMed  Google Scholar 

  • Giserman Kiss, I., Feldman, M., Sheldrick, R. C., & Carter, A. S. (2017). Developing autism screening criteria for the brief infant toddler social emotional assessment (BITSEA). Journal of Autism and Developmental Disorders, 47(5), 1269–1277. https://doi.org/10.1007/s10803-017-3044-1.

    Article  PubMed  Google Scholar 

  • Godoy, L., Mian, N. D., Eisenhower, A. S., & Carter, A. S. (2014). Pathways to service receipt: Modeling parent help-seeking for childhood mental health problems. Administration and Policy in Mental Health and Mental Health Services Research, 41(4), 469–479. https://doi.org/10.1007/s10488-013-0484-6.

    Article  PubMed  Google Scholar 

  • Guevara, J. P., Gerdes, M., Localio, R., Huang, Y. V., Pinto-Martin, J., Minkovitz, C. S., et al. (2013). Effectiveness of developmental screening in an urban setting. Pediatrics, 131, 27–30.

    Article  Google Scholar 

  • Guthrie, W., Wallis, K., Bennett, A., Brooks, E., Dudley, J., Gerdes, M., et al. (2019). Accuracy of autism screening in a large pediatric network. Pediatrics, 144(4), e20183963.

    Article  PubMed  Google Scholar 

  • Harstad, E., Huntington, N., Bacic, J., & Barbaresi, W. (2013). Disparity of care for children with parent-reported autism spectrum disorders. Academic Pediatrics, 13(4), 334–339.

    Article  PubMed  Google Scholar 

  • Jarquin, V. G., Wiggins, L. D., Schieve, L. A., & Van Naarden-Braun, K. (2011). Racial disparities in community identification of autism spectrum disorders over time; metropolitan Atlanta, Georgia, 2000–2006. Journal of Developmental and Behavioral Pediatrics, 32, 179–187. https://doi.org/10.1097/DBP.0b013e31820b4260.

    Article  PubMed  Google Scholar 

  • Joseph, R. M., O’Shea, T. M., Allred, E. N., Heeren, T., Hirtz, D., Paneth, N., et al. (2017). Prevalence and associated features of autism spectrum disorder in extremely low gestational age newborns at age 10 years. Autism Research, 10(2), 224–232. https://doi.org/10.1002/aur.1644.

    Article  PubMed  Google Scholar 

  • Keating, K., Daily, S., Cole, P., Murphey, D., Pina, G., Ryberg, R., et al. (2019). State of babies yearbook: 2019. Washington, DC: ZERO TO THREE and Bethesda MD: Child Trends.

  • Keil, A., Breunig, C., Fleischfresser, S., & Oftedahl, E. (2014). Promoting routine use of developmental and autism-specific screening tools by pediatric primary care clinicians. WMJ: official publication of the State Medical Society of Wisconsin, 113(6), 227–231.

    Google Scholar 

  • Kogan, M. D., Vladutiu, C. J., Schieve, L. A., Ghandour, R. M., Blumberg, S. J., Zablotsky, B., et al. (2018). The prevalence of parent-reported autism spectrum disorder among US children. Pediatrics, 142(6), e20174161.

    Article  PubMed  Google Scholar 

  • Kozlowski, A. M., Matson, J. L., Horovitz, M., Worley, J. A., & Neal, D. (2011). Parents’ first concerns of their child's development in toddlers with autism spectrum disorders. Developmental Neurorehabilitation, 14(2), 72–78. https://doi.org/10.3109/17518423.2010.539193.

    Article  PubMed  Google Scholar 

  • Kruizinga, I., Visser, J. C., van Batenburg-Eddes, T., Carter, A. S., Jansen, W., & Raat, H. (2014). Screening for autism spectrum disorders with the brief infant-toddler social and emotional assessment. PLoS ONE, 9(5), e97630. https://doi.org/10.1371/journal.pone.0097630.

    Article  PubMed  PubMed Central  Google Scholar 

  • Lad, B. K., Kulkarni, M. S., & Misra, K. B. (2008). Optimal reliability design of a system. In Handbook of performability engineering (pp. 499–519). Springer, London.

  • Lord, C., Risi, S., Lambrecht, L., Cook, Jr., E. H., Leventhal, B. L., DiLavore, P. C., et al. (2000). The autism diagnostic observation schedule—generic: A standard measure of social and communication deficits associated with the spectrum of autism. Journal of Autism and Developmental Disorders, 30(3), 205–223. https://doi.org/10.1023/A:1005592401947.

    Article  PubMed  Google Scholar 

  • Mackie, T., Schaefer, A. J., Ramella, L., Carter, A. S., Eisenhower, A., Jimenez, M. E., et al. (2020). Understanding how parents make meaning of their child’s behaviors during screening for autism spectrum disorders: A longitudinal qualitative investigation. Journal of Autism and Developmental Disabilities. (in press).

  • Manning, S. E., Davin, C. A., Barfield, W. D., Kotelchuck, M., Clements, K., Diop, H., et al. (2011). Early diagnoses of autism spectrum disorders in Massachusetts birth cohorts, 2001–2005. Pediatrics, 127(6), 1043–1051. https://doi.org/10.1542/peds.2010-2943.

    Article  PubMed  Google Scholar 

  • Massachusetts Department of Public Health. (2016). Massachusetts early intervention summation report: Fiscal year 2015. Unpublished.

  • Massachusetts Department of Public Health. (2018). Massachusetts Early Intervention: Local program performance data on state performance plan indicators and targets: July 2017 to June 2018. Retrieved from https://www.mass.gov/lists/public-reporting-for-early-intervention#local-program-performance-data.

  • Monteiro, S. A., Dempsey, J., Berry, L. N., Voigt, R. G., & Goin-Kochel, R. P. (2019). Screening and referral practices for autism spectrum disorder in primary pediatric care. Pediatrics, 44(4), e20183326. https://doi.org/10.1542/peds.2018-3326.

    Article  Google Scholar 

  • Monteiro, S. A., Dempsey, J., Broton, S., Berry, L., Goin-Kochel, R. P., & Voigt, R. G. (2016). Early intervention before autism diagnosis in children referred to a regional autism clinic. Journal of Developmental Behavioral Pediatrics, 37(1), 15–19.

    Article  PubMed  Google Scholar 

  • Mullen, E. M. (1995). Mullen scales of early learning, AGS Edition: Manual and item administrative books. Noida: American Guidance Services Inc.

    Google Scholar 

  • Oswald, D. P., Haworth, S. M., Mackenzie, B. K., & Willis, J. H. (2015). Parental report of the diagnostic process and outcome: ASD compared with other developmental disabilities. Focus on Autism and Other Developmental Disabilities, 32(2), 150–152. https://doi.org/10.1177/1088357615587500.

    Article  Google Scholar 

  • Ozonoff, S., Young, G. S., Landa, R. J., Brian, J., Bryson, S., Charman, T., et al. (2015). Diagnostic stability in young children at risk for autism spectrum disorder: A Baby Siblings Research Consortium study. Journal of Child Psychology and Psychiatry, 56(9), 988–998. https://doi.org/10.1111/jcpp.12421.

    Article  PubMed  Google Scholar 

  • Pedersen, A., Pettygrove, S., Meaney, F. J., Mancilla, K., Gotschall, K., Kessler, D. B., et al. (2012). Prevalence of autism spectrum disorders in Hispanic and non-Hispanic white children. Pediatrics, 129(3), e629–e635. https://doi.org/10.1542/peds.2011-1145.

    Article  PubMed  Google Scholar 

  • Peters-Scheffer, N., Didden, R., Korzilius, H., & Matson, J. (2012). Cost comparison of early intensive behavioral intervention and treatment as usual for children with autism spectrum disorder in the Netherlands. Research in Developmental Disabilities, 33(6), 1763–1772. https://doi.org/10.1016/j.ridd.2012.04.006.

    Article  PubMed  Google Scholar 

  • Pierce, K., Courchesne, E., & Bacon, E. (2016). To screen or not to screen universally for autism is not the question: Why the task force got it wrong. The Journal of Pediatrics, 176, 182–194.

    Article  PubMed  PubMed Central  Google Scholar 

  • Purtle, J., Peters, R., & Brownson, R. C. (2016). A review of policy dissemination and implementation research funded by the National Institutes of Health, 2007–2014. Implementation Science, 11(1), 1.

    Article  PubMed  PubMed Central  Google Scholar 

  • Robins, D. L., Casagrande, K., Barton, M., Chen, C. M. A., Dumont-Mathieu, T., & Fein, D. (2014). Validation of the modified checklist for autism in toddlers, revised with follow-up (M-CHAT-R/F). Pediatrics, 133(1), 37–45.

    Article  PubMed  PubMed Central  Google Scholar 

  • Rotholz, D. A., Kinsman, A. W., Lacy, K. K., & Charles, J. (2017). Improving early identification and intervention for children at risk for Autism Spectrum Disorder. Pediatrics, 139(2), e20161061.

    Article  PubMed  Google Scholar 

  • Salisbury, L., Nyce, J. D., Hannum, C., Sheldrick, R. C., & Perrin, E. C. (2018). Sensitivity and specificity of 2 autism screeners among referred children between 16 and 48 months of age. Journal of Developmental and Behavioral Pediatrics, 39, 254–258.

    Article  PubMed  Google Scholar 

  • Sánchez-García, A. B., Galindo-Villardón, P., Nieto-Librero, A. B., Martín-Rodero, H., & Robins, D. L. (2019). Toddler screening for Autism Spectrum Disorder: A meta-analysis of diagnostic accuracy. Journal of Autism and Developmental Disabilities, 49(5), 1837–1852.

    Article  Google Scholar 

  • Sheldrick, R. C., Benneyan, J. C., Kiss, I. G., Briggs-Gowan, M. J., Copeland, W., & Carter, A. S. (2015). Thresholds and accuracy in screening tools for early detection of psychopathology. Journal of Child Psychology and Psychiatry, 56(9), 936–948.

    Article  PubMed  Google Scholar 

  • Sheldrick, R. C., & Carter, A. S. (2018). State-level trends in the prevalence of Autism Spectrum Disorder (ASD) from 2000 to 2012: A reanalysis of findings from the autism and developmental disabilities network. Journal of Autism and Developmental Disorders, 48(9), 3086–3092.

    Article  PubMed  PubMed Central  Google Scholar 

  • Sheldrick, R. C., Chung, P. J., & Jacobson, R. M. (2017a). Math matters: How misinterpretation of odds ratios and risk ratios may influence conclusions. Academic Pediatrics, 17(1), 1–3.

    Article  PubMed  Google Scholar 

  • Sheldrick, R. C., Frenette, E., Vera, J. D., Mackie, T., Martinez Pedraza, F., Hoch, N., et al. (2019). What drives detection and diagnosis of autism spectrum disorder? Looking under the hood of a multi-stage screening process in early intervention. Journal of Autism and Developmental Disorders, 49(6), 2304–2319. https://doi.org/10.1007/s10803-019-03913-5.

    Article  PubMed  PubMed Central  Google Scholar 

  • Sheldrick, R. C., & Garfinkel, D. (2017). Is a positive developmental-behavioral screening score sufficient to justify referral? A review of evidence and theory. Academic Pediatrics, 17(5), 464–470.

    Article  PubMed  PubMed Central  Google Scholar 

  • Sheldrick, R. C., Maye, M. P., & Carter, A. S. (2017b). Age at first identification of autism spectrum disorder: An analysis of two US surveys. Journal of the American Academy of Child & Adolescent Psychiatry, 56(4), 313–320. https://doi.org/10.1016/j.jaac.2017.01.012.

    Article  Google Scholar 

  • Silverstein, M., & Radesky, J. (2016). Embrace the complexity: The US preventive services task force recommendation on screening for Autism Spectrum Disorder. JAMA, 315(7), 661–662. https://doi.org/10.1001/jama.2016.0051.

    Article  PubMed  Google Scholar 

  • Siu, A. L., Bibbins-Domingo, K., Grossman, D. C., Baumann, L. C., Davidson, K. W., Ebell, M., et al. (2016). Screening for autism spectrum disorder in young children: US preventive services task force recommendation statement. JAMA, 315(7), 691–696.

    Article  PubMed  Google Scholar 

  • Smith, N. J., Sheldrick, R. C., & Perrin, E. C. (2013). An abbreviated screening instrument for autism spectrum disorders. Infant Mental Health Journal, 34(2), 149–155. https://doi.org/10.1002/imhj.21356.

    Article  Google Scholar 

  • Sparrow, S. S., Cicchetti, D. V., & Saulnier, C. A. (2016). Vineland adaptive behavior scales (3rd ed.). London: Pearson.

    Google Scholar 

  • St Amant, H. G., Schrager, S. M., Pena-Ricardo, C., Williams, M. E., & Vanderbilt, D. L. (2018). Language barriers impact access to services for children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 48, 333–340. https://doi.org/10.1007/s10803-017-3330-y.

    Article  PubMed  Google Scholar 

  • Stone, W. L., Coonrod, E. E., & Ousley, O. Y. (2000). Brief report: Screening tool for autism in two-year-olds (STAT): Developmentand preliminary data. Journal of Autism and Developmental Disorders, 30(6), 607–612. https://doi.org/10.1023/A:1005647629002.

    Article  PubMed  Google Scholar 

  • Stone, W. L., Coonrod, E. E., Turner, L. M., & Pozdol, S. L. (2004). Psychometric properties of the stat for early autism screening. Journal of Autism and Developmental Disorders, 34(6), 691–701. https://doi.org/10.1007/s10803-004-5289-8.

    Article  PubMed  Google Scholar 

  • Tay, H. L. (2016). Lean improvement practices: lessons from healthcare service delivery chains. IFAC-PapersOnLine, 49(12), 1158–1163.

    Article  Google Scholar 

  • Tek, S., & Landa, R. J. (2012). Differences in autism symptoms between minority and non-minority toddlers. Journal of Autism and Developmental Disorders, 42, 1967–1973.

    Article  PubMed  PubMed Central  Google Scholar 

  • Thomas, P., Zahorodny, W., Peng, B., Kim, S., Jani, N., Halperin, W., et al. (2012). The association of autism diagnosis with socioeconomic status. Autism, 16(2), 201–213. https://doi.org/10.1177/1362361311413397.

    Article  PubMed  Google Scholar 

  • Thomas, K. C., Ellis, A. R., McLaurin, C., Daniels, J., & Morrissey, J. P. (2007). Access to care for autism-related services. Journal of Autism and Developmental Disorders, 37(10), 1902–1912. https://doi.org/10.1007/s10803-006-0323-7.

    Article  PubMed  Google Scholar 

  • Thomas, R. E., Spragins, W., Mazloum, G., Cronkhite, M., & Maru, G. (2016). Rates of detection of developmental problems at the 18-month well-baby visit by family physicians' using four evidence-based screening tools compared to usual care: A randomized controlled trial. Child: Care, Health and Development, 42(3), 382–393. https://doi.org/10.1111/cch.12333.

    Article  Google Scholar 

  • Twardzik, E., Cotto-Negrón, C., & MacDonald, M. (2017). Factors related to early intervention Part C enrollment: A systematic review. Disability and Health Journal, 10(4), 467–474.

    Article  PubMed  Google Scholar 

  • United States Department of Education (2018). Part C Early Intervention Numbers and Percentages: Indicator C5 & C6. Retrieved January 21, 2020, from https://osep.grads360.org/#communities/pdc/documents/9795.

  • Valicenti-McDermott, M., Hottinger, K., Seijo, R., & Shulman, L. (2012). Age at diagnosis of autism spectrum disorders. Journal of Pediatrics, 161(3), 554–556. https://doi.org/10.1016/j.peds.2012.05.012.

    Article  Google Scholar 

  • Warren, Z. E., & Stone, W. L. (2011). Clinical best practices: Diagnosis and assessment of young children. Autism spectrum disorders, 1269–1280.

  • Zuckerman, K. E., Mattox, K., Baghaee, A., Batbayar, O., Donelan, K., & Bethell, C. (2013). Pediatrician identification of Latino children at risk for autism spectrum disorder. Pediatrics, 132(3), 445–453.

    Article  PubMed  PubMed Central  Google Scholar 

  • Zwaigenbaum, L., Bauman, M. L., Fein, D., Pierce, K., Buie, T., Davis, P. A., et al. (2015a). Early screening of autism spectrum disorder: Recommendations for practice and research. Pediatrics, 136(Supplement 1), S41–S59.

    Article  PubMed  Google Scholar 

  • Zwaigenbaum, L., Bryson, S. E., Brian, J., Smith, I. M., Roberts, W., Szatmari, P., et al. (2015b). Stability of diagnostic assessment for autism spectrum disorder between 18 and 36 months in a high-risk cohort. Autism Research. https://doi.org/10.1002/aur.1585.

    Article  PubMed  PubMed Central  Google Scholar 

  • Zwaigenbaum, L., & Maguire, J. (2019). Autism screening: Where do we go from here? Pediatrics, 144(4), e20190925.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We thank Angel Fettig for her collaboration; the staff who served as liaisons to the participating community EI agencies (Sophie Brunt, Luisa Buitrago, Frances Dumont Reyes, Melanie Feldman, Elizabeth Frenette, Noah Hoch, Latisha Morant, Gillian Nolan, Sabrina Ozit, Nora Portillo, Juan Diego Vera); our partnering EI directors and key EI staff partners (Margaret Carreira, Candace Chang, Rachael Cracknell, Johan De Besche, Lorriane Facella, Liz Kern Ferreiro, Jennifer Greenberg, April Haefner, Amanda Kasica, Sharon Keleher, Lynne McLaughlin, Jacquelyn Murphy, Sarah Patane, and Katie Timmons); and partners at the Department of Public Health (Ron Denham, Patti Fougere, Tracy Osbahr, Joan Rafferty). We also extend our gratitude to the participating children and families, Early Intervention providers, graduate students, and study staff.

Funding

This research was supported by a Health Resources Services Administration grant to Drs. Eisenhower and Carter (R40MC26195), a National Institute of Mental Health grant to Drs. Sheldrick and Carter (R01MH104400), and an Autism Speaks Dennis Weatherstone Predoctoral Fellowship (AS #7415) to Dr. Martinez Pedraza. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, NIMH, Autism Speaks, or the U.S. Government. Dr. Sheldrick is the co-creator of the POSI, which is one of the two first-stage screeners used in this study. He conducts research related to this instrument but receives no royalties. Dr. Carter is the co-creator of the POSI but receives no royalties. She is also co-creator of the BITSEA, which is one of the two first-stage screeners used in this study. Dr. Carter receives royalties on the sale of the BITSEA, which is distributed by MAPI Research Trust.

Author information

Authors and Affiliations

Authors

Contributions

AE participated in the design of the study, directed and contributed to data collection, directed data analyses, drafted sections of the manuscript, and directed the editing process. FMP conceptualized the model on which the study is based, participated in the design of the study, directed and contributed to data collection, and performed revisions of the final manuscript. RCS participated in the design of the study, assisted with data analysis and interpretation, drafted sections of the paper, and contributed to revising the final manuscript. EF performed data processing and management, assisted with data collection, contributed to the initial conceptualization of the paper, and assisted with data analysis and interpretation. NH performed data processing and management, assisted with data collection, contributed to data analysis and interpretation, and edited the final manuscript. SB performed data processing and management, assisted with data collection, and contributed to data analyses and interpretation. ASC* conceptualized the model on which the study is based, participated in the design of the study, directed and contributed to data collection, assisted with data analysis and interpretation, and contributed to revising the final manuscript.

Corresponding author

Correspondence to Alice S. Carter.

Ethics declarations

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The current study was approved by the University of Massachusetts Boston Institutional Review Board.

Informed Consent

Informed consent was obtained from individual parent participants included in the study. Children did not provide assent due to their very young age.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Eisenhower, A., Martinez Pedraza, F., Sheldrick, R.C. et al. Multi-stage Screening in Early Intervention: A Critical Strategy for Improving ASD Identification and Addressing Disparities. J Autism Dev Disord 51, 868–883 (2021). https://doi.org/10.1007/s10803-020-04429-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10803-020-04429-z

Keywords

  • Autism spectrum disorder
  • Screening
  • Health disparities
  • Early detection