Pediatric Resident Participation in Primary Care Autism Evaluations: A Novel Continuity Clinic Training Opportunity

Abstract

Objective:

There is a growing need for autism evaluations in young children. Wait times to evaluation are long due to the limited specialty workforce. Primary care autism evaluations are 1 solution, but many providers lack training and confidence in autism care. Literature highlights the need for improvement in developmental and behavioral pediatrics training among pediatric residents. This study evaluates resident confidence in autism care after participation in a novel autism evaluation pathway in a primary care pediatric resident continuity clinic.

Methods:

Pediatric residents led a primary care autism evaluation with a trained pediatrician in their continuity clinic. Residents were provided with enhanced autism education which included neurodiversity-affirming strategies and training on the use of an autism assessment tool. Presurveys and postsurveys were used to assess resident confidence in autism care before and after the educational intervention. Survey data were compared using Mann-Whitney U tests appropriate for ordinal, nonpaired data.

Results:

Thirty resident-led autism evaluations were conducted during the study period. There was statistically significant improvement in resident confidence in autism screening, use of assessment tools, evaluation, diagnosis, treatment recommendations, sharing resources, understanding of neurodiversity, and use of a strength-based approach after participation.

Conclusion:

Providing autism education and hands-on primary care autism evaluation training opportunities for residents in pediatric continuity clinic improves confidence in autism care. This model is 1 way to enhance autism education and training during pediatric residency which may have a positive impact on the care provided to autistic patients.

INTRODUCTION

One in 31 children is diagnosed with autism, and the prevalence continues to increase.¹ Evidence shows earlier diagnosis and intervention benefit patient outcomes.² Barriers to obtaining an autism diagnosis include limited access to providers who can conduct diagnostic evaluations.³ Recent evidence indicates wait times are long and variable with an average of 27 months from screening to diagnosis,⁴ despite studies demonstrating reliable diagnosis in the first 2 years of life.^5,6 The limited diagnostic provider workforce and a low predicted growth in specialists calls for alternative models for autism assessment.⁷

The American Academy of Pediatrics (AAP) recommends autism screening in primary care at ages 18 months and 24 months.⁸ Providers receiving education on autism demonstrate increased usage of screening tools.⁹ However, many pediatricians report lack of training and confidence in providing autism care and desire for more training in diagnostic evaluation and ongoing management of autistic patients.^10,11 Furthermore, parents of autistic children report opportunities for improvement in primary care provider (PCP) knowledge of autism care including timely referral or diagnosis and improved understanding of autism interventions and care.¹² Resident physicians report inadequate training and lack of competency in autism care.¹³ Beginning in 1997, pediatric residents were required to complete 4 weeks of training in developmental and behavioral pediatrics, yet 1 study showed this did not improve pediatricians’ comfort in providing developmental care.¹³ Furthermore, program directors reported opportunities for improvement in developmental and behavioral pediatrics training throughout residency.¹⁴ Case-based didactics and training on use of an autism assessment tool showed short-term educational benefits only.^15,16 Training on use of an assessment tool paired with inclusion of residents in autism assessments during the developmental and behavioral medicine rotation resulted in increased comfort levels in autism-related competencies.¹⁷

The scientific community has historically described autism using a medical model with focus on deficits.¹⁸ During medical training, learners are taught to use the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), criteria to diagnose autism by identifying deficits in social communication and patterns of restrictive and repetitive behaviors.¹⁹ By contrast, the autism community desires autism to be understood within a neurodiversity framework and has led efforts to shift away from a deficit-based approach to 1 of recognizing an individual’s strengths.^18,20 Medical training should consider this shift as well. While there is little literature about incorporating neurodiversity education into medical training, including autistic affirming education can improve students’ understanding of autism and desire to be inclusive of autistic individuals.²¹

More recently, PCPs are completing autism evaluations in primary care and studies show PCPs have high diagnostic accuracy, especially when characteristics are clear.²² The AAP provides guidance to pediatricians completing autism evaluations in primary care and recommends that autism evaluations include a comprehensive history including a DSM-5 focused history of autism characteristics, behavioral observation, and a structured assessment tool.⁸ Among others, 2 standardized autism assessment tools that can be used in primary care include the ASD-PEDS²³ and the Childhood Autism Rating Scale, Second Edition (CARS2).²⁴ One educational resource available to PCPs is the Autism Navigator About Autism in Toddlers, a web-based course designed to help providers learn more about autism and identify autism characteristics by using a video library comparing behaviors of typically developing children and children at risk for autism.²⁵

The purpose of this study was to evaluate pediatric resident confidence in autism care after participation in a novel continuity clinic autism training program that provided enhanced autism education and hands-on participation in an autism evaluation in primary care. This longitudinal model mentored residents from initial screening and identification of autism characteristics in their patient to participation in the autism evaluation. Residents learned how to use a neurodiversity affirming approach and how to support families after diagnosis.

METHODS

This study was deemed exempt by the Nemours Children’s Health’s institutional review board.

Primary Care Autism Evaluation Pathway

An autism evaluation pathway was created and implemented in a primary care pediatric resident continuity clinic. This clinic is in a suburban setting within a tertiary care children’s hospital. The clinic’s population is predominantly Black (33%) and non-Hispanic (66%) with approximately 50% of patients covered by Medicaid. The clinic includes up to 35 pediatric residents, 1 general academic pediatric fellow, and 11 attending pediatricians each year. Two of the attending pediatricians work in both developmental medicine and primary care and have extensive training and experience in autism evaluations and autism-related care.

Patients younger than age 4 were eligible for autism evaluation in this primary care pathway. Patients were identified for autism evaluation by at-risk M-CHAT, parental concern, or pediatrician suspicion for autism. When identified, the patient’s family was offered the option to schedule an evaluation in primary care or referral to a specialty autism center. If the need for evaluation was identified by a resident, the patient was scheduled for autism evaluation with that resident and a trained pediatrician during the resident’s next continuity clinic rotation (approximately 6–8 weeks later). If an attending physician identified the need for evaluation, the patient was scheduled with a trained pediatrician only.

Enhanced Autism Education

Residents who identified a patient eligible for the pathway were provided with educational information about autism and diagnostic evaluations. Residents were provided didactic materials including a slide presentation on autism evaluations in primary care, the AAP Clinical Practice Guideline for Identification, Evaluation, and Management of Children with Autism,⁸ and administration guidelines for use of the ASD-PEDS.²³ They were also given access to the Autism Navigator About Autism in Toddlers video library for additional learning.²⁵ Residents were expected to review these materials independently, and the amount of time spent on review was at the discretion of the resident.

After the resident reviewed the didactic material, a 30-minute to 60-minute virtual or in-person meeting was scheduled with the trained pediatrician to review skills related to history taking, behavior observation, administration of the assessment tool, diagnostic decision making, and intervention planning using a strength-based and neurodiversity-affirming framework. Residents were taught strategies to leverage patient strengths and incorporate neurodiversity-affirming language into the evaluation.

Resident-led Autism Evaluation

Residents led an autism evaluation of their patient with the support of the trained pediatrician. The evaluation was completed in one 80-minute visit during the resident’s continuity clinic and included diagnostic feedback and intervention planning. The resident independently obtained the patient’s history, conducted a DSM-5 interview for autism, and completed behavior observations. The resident exited the patient room and reviewed the history and observations with the trained pediatrician. With the trained pediatrician present, the resident administered the ASD-PEDS and the trained pediatrician provided support with the administration if needed. The resident and trained pediatrician exited the patient room to discuss the case, score the ASD-PEDS, and review diagnostic impressions. If a CARS2 assessment tool was used, it was completed by the trained pediatrician and reviewed with the resident. Diagnostic feedback and recommendations were provided to the family together with the resident and trained pediatrician. Residents were offered the opportunity to share diagnostic feedback and recommendations or to observe the trained pediatrician. The trained pediatrician modeled use of neurodiversity-affirming language and a strength-based approach during the evaluation and diagnostic feedback. Following evaluation completion, residents had the opportunity to debrief with the trained pediatrician and receive direct feedback. Residents wrote the consultation report which was reviewed and cosigned by the trained pediatrician.

Confidence Surveys

Residents completed a pre-encounter survey before receiving any enhanced autism education and a post-encounter survey after the diagnostic evaluation. The presurveys and postsurveys contained questions using a 5-point Likert Scale (1-strongly disagree, 2-disagree, 3-neutral, 4-agree, or 5-strongly agree) about perceived confidence in autism care. While residents were asked to complete both presurveys and postsurveys for the same evaluation, all survey responses were analyzed as independent observations.

The primary outcomes included confidence in recognizing autism symptoms, using standardized autism screening tools, gathering clinical information using DSM-5 criteria, using standardized assessment tools, diagnosing autism, and recommending treatment. After 5 months, additional survey questions were added to examine resident understanding of neurodiversity, their ability to discuss a new diagnosis using a strength-based approach, comfort in discussing behavior therapies with families, and ability to recommend resources (see Supplemental Digital Content 1, http://links.lww.com/JDBP/A522, of the pre-encounter and post-encounter surveys). Survey responses were assigned numerical values (1–5), and median scores of pre-encounter and post-encounter responses were compared using Mann–Whitney U tests, appropriate for unpaired ordinal data.

RESULTS

Patient encounters from March 2022 to June 2024 were included. Fifty-seven autism evaluations were completed in primary care during the study period. Residents participated in 30 autism evaluations. Twenty-six presurveys and 23 postsurveys were completed. Twelve presurveys and 13 postsurveys included additional questions related to neurodiversity. Surveys were completed by pediatric residents in postgraduate year 1 (PGY-1) (7 pre, 4 post), PGY-2 (10 pre, 8 post), and PGY-3 (9 pre, 11 post) (Fig. 1).

Figure 1.

Number of residents who participated in a primary care autism evaluation and number of surveys completed.

Eighteen (69%) presurveys and 13 (57%) postsurveys were completed by residents who participated in 1 autism evaluation in primary care. Eight (31%) presurveys and 10 (43%) postsurveys were completed by residents who participated in more than 1 autism evaluation in primary care.

All survey questions showed improvement in confidence from the presurvey to the postsurvey responses. Statistically significant findings were seen in 10 of 11 survey items, including increased confidence in (1) recognizing symptoms of autism (p = 0.018); (2) using standardized tools to screen for autism (p < 0.001); (3) knowledge of the DSM-5 criteria for autism (p < 0.001); (4) gathering clinical information from caregivers about autism (p = 0.007); (5) using standard tools to complete an autism assessment (p < 0.001); (6) diagnosing autism and discussing this diagnosis with family (p = 0.001); (7) providing treatment recommendations (p = 0.003); (8) discussing a new autism diagnosis using a strength-based approach (p = 0.014); (9) understanding of neurodiversity (p = 0.015); and (10) connecting families with additional resources (p = 0.007) (Table 1).

Table 1.

Pre-Resident and Postresident Survey Median Scores (M) on the Likert Scale Before and After Participation in Autism Education and Primary Care Autism Evaluation

Questions	Presurvey (M)	Postsurvey (M)	P
I feel confident in my ability to recognize symptoms of autism	4	4	0.018
I feel confident using standardized tools to screen for autism	3	4	<0.001
I feel confident about my knowledge of the DSM criteria for autism	3	4	<0.001
I feel confident gathering clinical information from caregivers about autism	4	4	0.007
I feel confident using standard tools to complete an autism assessment	2	4	<0.001
I feel confident making an autism diagnosis and discussing this diagnosis with family	3	4	0.001
I feel confident giving treatment recommendations for autism	2	3	0.003
I feel confident discussing a new autism diagnosis with family	3	4	0.014
I feel confident in my understanding of neurodiversity	2.5	4	0.015
I feel confident in understanding behavior therapies	2.5	4	0.093
I feel confident connecting family with additional resources	3	4	0.007

The survey included an option for free text feedback. The following resident feedback was received:

1. “I need more practice, but this is fantastic. I’m excited to see and do more of these.”

2. “This was a great experience and very helpful to work through the evaluations and provide additional recommendations based on findings.”

3. “This was a great experience. I really liked working on my observational skills and I think this will help me in the future too.”

4. “I hope to do more autism evaluations.”

5. “This is an awesome way to feel like making a difference in primary clinic.”

All residents indicated they would be interested in participating in additional autism evaluations in primary care in the future.

DISCUSSION

Pediatric resident participation in a novel autism training program in their primary care continuity clinic aimed at improving autism education and providing hands-on diagnostic training increased resident confidence in providing autism-related care. These results demonstrate beneficial learning outcomes as most survey items show a statistically significant increase in confidence after receiving autism education and completing the autism evaluation encounter. Residents indicated more confidence in their ability to provide neurodiversity-affirming care and resources to families. All residents indicated they would be interested in participating in additional autism evaluations in primary care. These results are consistent with previous findings in which residents reported learning benefits after completing hands-on training.¹⁷

This training model provides a longitudinal resident training experience and promotes continuity of care. Residents are involved in their patients’ screening and identification, diagnostic evaluation, intervention planning, and follow-up care. Providing residents with autism training may help address current challenges with pediatricians’ lack of confidence in caring for autistic patients.^10,11 Conducting autism evaluations in primary care is 1 solution to decrease wait times for autism diagnosis.²⁶ This training model may increase the trained provider workforce who is confident in completing autism evaluations in primary care, which may improve access to autism evaluations. Incorporating training on neurodiversity is an important part of autism education for pediatric residents.

While the results of this study are encouraging, several limitations should be considered. This study was limited to a small sample of pediatric resident survey data from a single continuity clinic site at 1 training institution. The survey included information on resident confidence but did not assess resident knowledge. Furthermore, postsurveys were sent to residents after completion of the autism evaluation and resident confidence was not assessed at follow-up intervals. Without longitudinal data, it is unclear if these improvements persisted over time. Some residents completed multiple autism evaluations leading to multiple survey responses. This may have introduced within-subject correlation which was not accounted for in our analysis. This model was feasible in a resident continuity clinic at 1 institution, but may not be generalizable to other residency programs. A challenge to implementation is the need for a trained pediatrician with expertise in autism evaluations to be on staff in the resident continuity clinic. Future work could examine confidence in autism care between residents who participated in this training opportunity and residents who did not, evaluate resident knowledge, and assess long-term outcomes of the training intervention.

Incorporating hands-on autism training into pediatric residents’ continuity clinic experience can increase confidence in many aspects of autism care. Future work will continue to build upon this continuity clinic autism training model.