Journal of Autism and Developmental Disorders

https://doi.org/10.1007/s10803-018-3668-9

ORIGINAL PAPER

Training Physical Therapists in Early ASD Screening

Ayelet Ben‑Sasson1 · Osnat Atun‑Einy2 · Gal Yahav‑Jonas3 · Shimona Lev‑On4 · Tali Gev5

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Physical therapists (PTs) are often one of the first professionals to evaluate children at risk. To examine the effect of an early
screening training on pediatric PTs’: (1) knowledge of autism spectrum disorder (ASD), (2) clinical self-efficacy, and (3)
identification of markers. Twenty-six PTs participated in a 2-day “Early ASD Screening” workshop. The ASD Knowledge
and Self-Efficacy Questionnaire, and video case study analysis were completed pre- and post-training. Changes following
training were significant for ASD knowledge related to etiology and learning performance, early signs, risk factors, and
clinical self-efficacy. Rating the videoed case study after the training, was significantly more accurate than it was before.
Training PTs is important for enhancing early identification of ASD.

Keywords  Early screening · ASD · Physical therapy · Training · Knowledge · Self-efficacy · Healthcare providers

Introduction of ASD are highly dependent on the knowledge and skills of

There is consensus regarding the high priority for early
identification of children with autism spectrum disorder
(ASD; Baghdadli et al. 2003; Barbaro et al. 2011; Corsello
2005; Pierce et al. 2016; Yeargin-Allsopp et al. 2003). Early
screening and diagnosis are critical for obtaining adequate,
early, specialized interventions that promote better outcomes
for children with ASD (Dawson et al. 2010; Harris and Han-
dleman 2000; Sallows and Graupner 2005; Szatmari et al.
2003; Rogers and Vismara 2008). Early screening may also
shorten the duration of uncertainty families often encounter
in the process of obtaining a diagnosis for their child (Sip-
erstein and Volkmar 2004). Early screening and diagnosis
Electronic supplementary material  The online version of this
article (https​://doi.org/10.1007/s1080​3-018-3668-9) contains
supplementary material, which is available to authorized users.
early childhood professionals. However, unique challenges
exist in implementing current diagnostic guidelines for
ASD for very young children because there are no biologi-
cal markers for ASD and experienced clinicians are lacking
(Zwaigenbaum et al. 2009).
Pediatric healthcare professionals, such as pediat-
ric physical therapists (PTs), are in a position to closely
observe a child’s development, offering an opportunity to
detect young children at-risk for ASD. It is well-recog-
nized that early screening and diagnosis of children with
ASD pose specific challenges. Among these are the reli-
ance on behavioral observations, typical variations in com-
munication development, the heterogeneous early mani-
festations and developmental trajectories of ASD, and the
instability of early diagnosis (Johnson and Myers 2007;
Zwaigenbaum et al. 2009). The regressive type of ASD

1
* Ayelet Ben‑Sasson Department of Occupational Therapy, University of Haifa,
asasson@univ.haifa.ac.il 3498838 Haifa, Israel
2
Osnat Atun‑Einy Department of Physical Therapy, University of Haifa,
osnat.atuneiny@gmail.com 3498838 Haifa, Israel
3
Gal Yahav‑Jonas Association for Children at Risk, 9 Hazvi St.,
gal.yahav@gmail.com Tel Aviv 67197, Israel
4
Shimona Lev‑On Weinberg Child Development Center, Sheba Tel-Hashomer
shimonalev@gmail.com Hospital, Ramat Gan 52621, Israel
5
Tali Gev Department of Psychology, Bar-Ilan University,
gevtali@gmail.com Ramat Gan 5290002, Israel

13
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(Siperstein and Volkmar 2004) is an example of the hetero-
geneous trajectory which can confound screening. There-
fore, ASD screening is a complex process which requires
professionals to conduct ongoing observations for early
markers and to prompt parental involvement (Johnson
and Myers 2007). Pediatric professionals should undergo
training in order to become familiar with the signs and
symptoms of ASD (Dillenburger et al. 2016; Filipek et al.
1999; Janvier et al. 2016).
Pediatric PTs are uniquely positioned to conduct ASD
screening for young children. They are often one of the first
healthcare professionals to treat children at developmental
risk and may be the first professional to whom parents raise
concerns regarding social-communication development. In
addition, PTs treat children who have an increased likeli-
hood for ASD, as they specialize in assessing and treating
motor delays and young children at developmental risk,
including those born preterm. PTs are likely to encounter
children with ASD because motor delays are characteristic
of some infants and toddlers who are eventually diagnosed
with ASD (Brisson et al. 2012; Bhat et al. 2011, 2012; Landa
and Garrett-Mayer 2006; Ozonoff et al. 2008; Provost et al.
2007; West 2018). Research suggests that developmental
motor delays during early childhood may represent a poten-
tial early marker for ASD before more diagnostically specific
signs develop (Harris 2017; Lemcke et al. 2013; Sacrey et al.
2015). Studies that examined motor development of infant
siblings of children with ASD, found that a significantly
greater proportion of siblings showed delayed motor per-
formance (Bhat et al. 2012; LeBarton and Iverson 2016).
Very low birth weight infants later diagnosed with ASD
showed less midline head position than typically develop-
ing children (Gima et al. 2018). Preterm infants, who fre-
quently receive PT are at increased risk for ASD (Goyen and
Lui 2002; Johnson et al. 2010; Limperopoulos et al. 2008).
Although motor developmental delays and premature birth
are not specific to ASD (Harris 2017; Ozonoff et al. 2008;
Provost et al. 2007), their co-occurrence suggests increased
ASD risk among children undergoing PT.
The ongoing therapeutic interaction also enables the PT
to gather and analyze a representative sample of the child’s
social behavior over time. This is of particular value given
the challenge of screening infants who have an inhibited
temperament and for discerning communication problems of
varying etiologies. However, basic training for PTs does not
focus on ASD screening as a core competency. In a USA-
based study, PTs reported receiving less academic training
in ASD than occupational therapists (OTs) or speech and
language pathologists (SLPs) do (Self et al. 2010). There
is a call for PTs to expand their clinical knowledge of early
interventions to cognition, communication, social interac-
tions and object interactions (Lobo et al. 2013). Expanding
the scope of screening to include the child’s pattern of play
13
Journal of Autism and Developmental Disorders
and communication would allow PTs to identify children
at-risk for ASD.
ASD Knowledge Among Healthcare Professionals
One of the barriers to screening is lack of knowledge in the
area of ASD among healthcare providers (Self et al. 2010).
Studies from around the world indicate a lack of ASD-spe-
cific knowledge among pediatric allied healthcare profes-
sionals including SLPs, OTs and psychologists (Dillenburger
et al. 2016; Imran et al. 2011; Schwartz and Drager 2008).
Healthcare professionals often have outdated beliefs regard-
ing the etiology of the disorder, as well as its social, emo-
tional and cognitive aspects (Heidgerken et al. 2005; Imran
et al. 2011).
Moreover, knowledge regarding early signs of ASD in
toddlers is lacking among pediatricians (Crais et al. 2014;
Heidgerken et al. 2005), with only 8% using an ASD-specific
measure, mostly relying upon informal assessments (Dosreis
et al. 2006; Sices et al. 2003). A recent survey of providers,
including PTs OTs and SLPs, indicated a need to increase
knowledge of early signs of ASD in order to aid early recog-
nition and diagnosis (Dillenburger et al. 2016). Knowledge
of early signs was low among OTs, SLPs and PTs based on
the same questionnaire implemented in the current study,
regardless of profession and experience level (Atun-Einy and
Ben-Sasson 2018). This underscores the need for training
in this area.
Existing ASD Training Programs for Healthcare
Professionals
The importance of early ASD diagnosis has led to programs
for imparting ASD knowledge to doctors and medical resi-
dents (e.g., Elmensdorp 2011) and raising awareness of ASD
in the general population (Peacock and Lin 2012). The pro-
grams focus on various topics and target different audiences,
including using specific ASD screening tools (e.g., Honig-
feld et al. 2012; Kobak et al. 2011), integrating general ASD
screening at the age of 1 year (Pierce et al. 2011), raising
public awareness of ASD (Daniel et al. 2009; Peacock and
Lin 2012), and changing misconceptions about the condition
(e.g., Clark et al. 2016; Major et al. 2013‫)‏‬.
Training programs that focused on the use of specific
ASD screening tools resulted in an increased use of these
tools (Kobak et al. 2011), as well as high satisfaction rates
among participants (Honigfeld et al. 2012; Kobak et al.
2011; Pierce et al. 2011). For example, physicians partici-
pating in a workshop related to the Modified Checklist for
Autism in Toddlers (M-CHAT; Robins et al. 2001) versus
those who did not, reported greater use of ASD-specific
screening tools, identifying ASD at younger ages and rec-
ognizing the need for more primary care visits (Kairys
Journal of Autism and Developmental Disorders
and Petrova 2016). Evidence from a 2-day workshop for
pediatricians that included ASD screening tools, indicated
a rise in the number of cases referred for an ASD diagnostic
evaluation, alongside high concurrence rates with diagnostic
outcomes, and a boost in self-reported clinical confidence
(Swanson et al. 2014). Given the recognized need to com-
bine the use of ASD screening tools with clinical assess-
ment (Barbaro et al. 2011), it is important to provide training
about early signs of ASD to healthcare professionals.
Two workshops that addressed early ASD recognition
among healthcare providers had mixed results. One 2.5 h
workshop was delivered to pediatric nurses in Australia.
At its conclusion, the nurses reported a positive change in
their ability to focus on communicative behaviors, and they
identified a large number of at-risk children (Barbaro et al.
2011). Findings from another workshop were ambiguous.
This workshop targeted physicians, pediatricians and medi-
cal residents directly involved in early childhood develop-
mental assessment and taught them about ASD and its early
signs. The training included two sessions, 60 and 30 min
long, and involved presentations and filmed case studies.
Following the workshop there was no difference in the gen-
eral knowledge and attitudes scores between the trained
group and control group, but workshop participants listed
more symptoms of ASD and were better able to identify a
lack of social smiling and abnormal interest in game pieces
in the filmed case studies. The physicians in the workshop
group reported greater confidence in identifying children
with ASD and in discussing the disorder with parents, as
well as satisfaction with the amount of training they received
in the field (Elmensdorp 2011). Allied healthcare profession-
als have rarely been included in such programs.
Clinical Self‑Efficacy
In addition to knowledge and skills, an important outcome
measure of these training programs is clinical self-efficacy.
Clinical self-efficacy refers to an individual’s beliefs about
their ability to successfully perform a particular behavior
(Bandura 1986). Healthcare professionals’ self-efficacy
beliefs have been shown to influence their clinical behavior
(e.g., Godin et al. 2008; Greenhalgh et al. 2004). Evidence
shows that lack of clinical self-efficacy hinders implementa-
tion of clinical knowledge (Godin et al. 2008).
In our previous work using the questionnaire included
in this study, four types of clinical self-efficacy emerged: in
diagnosis and intervention delivery, in communicating with
parents, need for additional training in confidence, and avail-
able resources for caring for children with ASD. We found a
significant correlation between knowledge and self-efficacy
among allied health professionals. Increasing knowledge in
ASD may increase their clinical confidence.
In light of these needs, the current study was framed as a
pilot designed to develop and to test the efficacy of an ASD-
specific training program for PTs. We focused on changes in:
(1) knowledge and attitudes regarding ASD in general, and
early signs of ASD in particular, (2) self-efficacy pertaining
to ASD detection, and (3) clinical skills in identifying risk
level, urgency of referral, and ASD markers based on a video
case study shown at the beginning and end of the training
workshop.
Methods
Procedure
Participants completed a 16-h workshop over 2 days, titled
The Early ASD Screening Workshop. The workshop focused
on early screening of ASD and was designed to support and
advance PTs’ ability to detect early signs of ASD in pediat-
ric patients. The training curriculum was developed based
on current research in the field (see Appendix A for details
regarding the topics and their evidence base).
The workshop dealt with the process of ASD screening,
early markers, the importance and challenges of screening,
as well as specific screening tools and opportunities in PT
for such screening. It expanded on the following specific
early signs: joint attention, imitation, response to name,
eye contact, and object exploration (see Appendix A). The
rationale for focusing on these signs related to their per-
sistence in early screening research and the potential to
identity them at an early age and readily elicit them in the
context of a PT session. The teaching methods in the work-
shop included frontal lectures, group discussions, analyzing
filmed and written case studies, and role playing. Workshop
format was based on active learning, which combines varied
forms of delivery, including “real-life examples” in training
health care professionals (Dillenburger et al. 2016; Menon
et al. 2009; Oxman et al. 1995). Lectures were delivered by
pediatric OTs, developmental psychologist who was a spe-
cialist in ASD and early childhood, while lessons describ-
ing motor development and PT in ASD were delivered by a
specialist in pediatric PT. During the workshop participants
received handouts, a reference list and links to relevant edu-
cational resources (e.g., https​://www.wellc​hildl​ens.com/).
The study was approved by the Ethics Committee of Uni-
versity of Haifa. Participants were recruited through local
child development centers, pediatric PT clinics, PT gradu-
ate programs, professional meetings, professional platforms
on Facebook, through the Ministry of Health’s Director of
Physiotherapy, and personal acquaintance with pediatric
PTs. Among 50 therapists who were interested in participat-
ing, 39 met the inclusion criteria, 27 of whom registered for
13
 Journal of Autism and Developmental Disorders

the workshop. One participant was excluded from analyses Table 1  Background Information
due to attending only the second day. Variables N (%)
Participants signed a consent form prior to the workshop.
Preceding the workshop, participants were sent the ASD Number of patients with ASD
Knowledge and Self-Efficacy Questionnaire to complete  None 2 (7.7)
and return via mail or e-mail. The same questionnaire was  1–10 Cases 22 (84.6)
completed on site, at the end of the training. The participants  10–20 Cases 2 (7.7)
were asked not to use external sources of information while Referral of children under 3 with an ASD concern in the past year
completing the questionnaire. At the beginning and end of  None 7 (26.9)
the workshop, participants completed a video case study  1–3 11 (42.3)
analysis, and a workshop satisfaction report. After train-  4–6 Children 4 (15.38)
ing was completed, participants were mailed a certificate  Unknown 4 (15.38)
of attendance signed by the National “Child Development Work ­settinga
and Rehabilitation Department” of the Ministry of Health.  Child development center 23 (88.5)
 School 2 (7.7)
Participants  Rehabilitation daycare 4 (15.38)
 Private clinic/other 2 (7.4)
The study included 26 female pediatric PTs. Inclusion Education
criteria were: (1) licensed in PT, (2) experience working  BA 22 (84.6)
with children under the age of 24 months, (3) no previous  MA 3 (11.5)
specialized education in ASD, (4) no experience working  Unknown 1 (3.8)
in a specialized setting for children with ASD, in order to Years of experience with young children
target a group of trainees with similar ASD knowledge and  Up to 1 3 (11.5)
experience. The final sample included 26 participants at an  1–5 3 (11.5)
average age of 43.42 (SD = 10.84, Min–Max = 30–65), with  5–10 7 (26.9)
an average of 14.98 (SD = 9.60, Min–Max = 3–35) years  > 10–15 13 (50)
of experience, who work an average of 25.76 (SD = 9.62, Years of experience in early screening and diagnosis
Min–Max = 4–40) hours per week. Table 1 presents demo-  Up to 5 7 (26.9)
graphics and information on the clinical experience of the  5–10 7 (26.9)
sample.  > 10 12 (46.2)
Family history of ASD 4 (15.4)
Measures a
 Not mutually exclusive categories

ASD Knowledge and Self-Efficacy Questionnaire (Atun-Einy

and Ben-Sasson 2018). This is a self-report survey aimed to
assess health care providers’ knowledge and self-efficacy in
the area of ASD in general and in early ASD signs and risk
factors in particular. The questionnaire includes 79 items,
divided into four sections:
(1) Knowledge and beliefs about ASD (30 items). Items are
rated on a six-point Likert scale or “I have no specific
knowledge”. Five mean factor scores are computed:
Misconceptions, Social Affective Symptoms, Interven-
tion, Etiology and Learning Performance, and Related
Conditions and Features. In addition, two total scores
are calculated for this part—an average score (some
items are reversed so that higher scores reflect greater
knowledge), and the percentage of items marked “I
have no specific knowledge”. For calculating mean
scores, “I have no knowledge” ratings are transformed
into ‘0’ values.
(2) Knowledge of ASD early markers (9 items). Rated as
in Part 1 and yields an average knowledge score and
percentage of no knowledge rating. In addition, this
part includes two open-ended questions asking for a
description of early ASD markers, and ASD risk fac-
tors.
(3) Knowledge of diagnostic criteria for ASD (26 items).
Each item was designed to match one of three catego-
ries: core diagnostic features (10), helpful diagnostic
features (12), or features irrelevant to the diagnosis (4).
Items are rated as matching one of the categories. Per-
cent of correct answers is computed for this part.
(4) Self-efficacy in ASD (14 items). Items are rated from
‘1’ highly disagree to ‘4’ highly agree. Four factor
scores are computed: Self-Efficacy in ASD Clinical
Skills, Resources, Training, Parent Communication
(some items are reversed so higher scores reflect higher
self-efficacy).

13
Journal of Autism and Developmental Disorders
In a previous paper, the psychometric properties of this
measure were tested with 234 allied healthcare profession-
als (82 PTs, 85 OTs, and 67 SLPs). Findings indicated high
internal and test–retest reliability, and factor analysis demon-
strated good construct validity (Atun-Einy and Ben-Sasson
2018).
Case Study Analysis
The workshop began and ended with participants analyzing
the same case study. The case study analysis included view-
ing a 5-min video of a baby, at ages 10–12 months, during
interactions with family members at home and play time.
The child was later diagnosed with ASD Participants were
blinded to his later diagnosis. They were asked to rate the
baby’s level of risk on three scales: global developmental
delay, ASD, and sensory processing. Risk was rated on a
10-point scale from 1 (no risk) to 10 (very high risk). Par-
ticipants were also asked to rate urgency of referral to an
ASD expert from 1 (no need to refer) to 10 (highly urgent
to refer). Two open-ended questions asked about early ASD
signs observed, and for additional information they would
obtain to verify the diagnosis.
The case study analysis was validated by an expert panel
of eight clinicians (pediatric PTs, OTs, and a developmen-
tal psychologist), each with at least 5 years of experience in
early ASD identification and intervention. The panel’s rat-
ing of the case study served as a standard to determine the
correct answers. A high degree of inter-rater reliability was
found among the experts’ scoring (ICC = 0.79, 0.31–0.97
across the three risk scales). The three types of risk and
urgency for referral were scored as the difference between
the therapist’s answer and the average answer of the experts.
The two open-ended questions were coded for the number of
signs and types of information listed relative to the experts’
answers.
Satisfaction Report
This survey was designed to measure satisfaction with the
training. Four mean scores were computed based on 23 items
corresponding to the following categories rated on a six-
point Likert-type scale (1 = strongly disagree, 6 = strongly
agree): (1) novelty of the knowledge gained, (2) clarification
of pre-existing knowledge, (3) clarity of materials, and (4)
quality of teaching methods.
Data Analysis
Three participants were excluded from analyses of Part 3 of
the ASD Knowledge and Self-Efficacy Questionnaire as they
did not complete it. Two participants missed one lecture.
However, they were included, as the results did not differ
with or without their data.
Non-parametric, within subject tests were conducted
due to the non-normal distribution of most of the variables
and the small sample size. Wilcoxon signed-rank tests were
computed to examine changes in ASD Knowledge and Self-
Efficacy Questionnaire scores from pre- to post-training. To
estimate change in scores that exceed test–retest effects,
the reliable change index (RCI; Jacobson and Truax 1991;
Jacobson et al. 1984) was computed for the group and for
each participant. The RCI is compared to a Z threshold of
1.96 to determine its significance. The RCI implies that the
larger the inter-rater reliability, the smaller the change that
is needed following intervention. Individual RCI scores
enables viewing the direction of individual changes as
increased, decreased or stable. RCI could only be computed
for variables for which test–retest coefficients were available
from prior research with this questionnaire (Atun-Einy and
Ben-Sasson 2018).
The open-ended questions of Part 2 of the questionnaire
were scored for the number of early signs and risk factors
specific to ASD mentioned, based on categories that were
pre-defined in a content analysis procedure. The first and
third authors analyzed 63 responses of healthcare providers
(outside of this study) to these two questions. Each author
extracted the number and types of distinct ASD signs and
risk factors mentioned in answers. The authors conducted
five rounds of discussions regarding disagreements until an
85% agreement was reached. In this study, the number of
ASD signs and risk factors mentioned pre- and post-training
was based on the presence of the aforementioned catego-
ries coded in previous research. Wilcoxon signed-rank tests
compared the number of signs and risk factors mentioned
before and after training. McNemar tests were conducted to
compare the types of risk factors and signs mentioned before
versus after training.
The case study analysis was scored by creating an abso-
lute difference score between the participants’ and the
experts’ rating for the three risk scales and urgency for infor-
mation. Wilcoxon signed-rank tests compared pre- and post-
training differences. Spearman correlations were conducted
to examine relation between change in knowledge, self-
efficacy and skills and therapist’s background information.
Results
Changes in the ASD Knowledge Questionnaire
Scores
Comparison of the before and after scores in the five fac-
tors of Part 1 showed a statistically significant change and
a significant mean group RCI score in factor 4: Etiology
13
 Journal of Autism and Developmental Disorders

and Performance, for which 58% participants increased in Changes in Self‑Efficacy

knowledge (see Fig. 1). Table 2 presents the rate of increase
at the individual level for all questionnaire scores. A Wil- Wilcoxon signed-rank tests indicated statistically and RCI
coxon signed-rank test showed a significant increase in the significant increases in the total self-efficacy score. Look-
participants’ mean score for Part 1 ASD Knowledge and a ing at the factor scores, for the Self-efficacy in ASD clinical
decrease in the number of items answered with “I have no skills factor, the individual RCI scores of 62% of participants
specific knowledge” after the training; however, mean RCI increased and for the Need for ASD training factor score 50%
did not reach significance (see Table 2). increased (see Table 2).
For Part 2, Knowledge of ASD Early Markers, a Wil-
coxon signed-rank test showed a significant increase,
Changes in Case Study Analysis
Z = − 4.38, p < 0.001, effect size r = 0.60. Mean group RCI
was significant, with 54% showing an increase in knowl-
A Wilcoxon signed-rank test demonstrated that participants’
edge and 46% showing stability (see Table 2; Fig. 2). For
ratings of degree of three types of risk in a filmed case study
the open-ended question listing early ASD signs in Part 2,
were significantly closer to that of experts after the work-
Wilcoxon signed-rank tests indicated a significant increase
shop (see Table 3). Urgency of obtaining additional infor-
in the number of early signs the participants listed after
mation was also significantly increased between pre- and
the workshop as compared to before, Z = − 3.28, p = 0.001,
post-training. For the open ended answers coded, Wilcoxon
effect size r = 0.46 (Mpre = 4.56, SDpre = 2.53, Medpre = 4 vs.
signed-rank test found significant increase in the number of
Mpost = 7.12, SDpost = 3.53, Medpost = 7). Similarly, there was
ASD symptoms identified (Mpre = 3.04, SDpre = 1.59, Med-
a significant increase in the mean number of risk factors
listed by participants before the workshop [0.60 (SD = 1.08, pre = 3, Mpost = 4.73, SDpost = 2.15, Medpost = 5, Z = − 3.05,
p = 0.002) and in the relevant additional information
Med = 0)]; relative to after [2.56 (SD = 1.55, Med = 2.5),
requested (Mpre = 2.27, SDpre = 2.27, Medpre = 2, Mpost = 4.69,
Z = − 3.73, p < 0.001, effect size r = 0.52]. Next, changes in
SDpost = 2.20, Medpost = 5), Z = − 3.96, p < 0.001.
the types of risk factors mentioned were examined using
McNemar’s test (Fig. 3). This test showed premature birth
(p < 0.001) and genetics (p < 0.001) were mentioned as risk Satisfaction with the Training Program
factors significantly more often. None of the participants
listed parental concerns as a risk factor before the workshop; Among the participants, 25/26 completed the satisfaction
however, 34% listed it after. questionnaire at the end of the second training day. Mean
As for Part 3, Advanced ASD Diagnostic Criteria, a Wil- satisfaction scores in all four categories of the questionnaire
coxon signed-rank test showed a significant increase after were high: (1) novelty of the knowledge gained (M = 5.44,
the workshop in the percentage of correct answers, but the SD = 0.44), (2) refinement of pre-existing knowledge
RCI was not significant (Table 2). (M = 5.72, SD = 0.46), (3) clarity of materials (M = 5.41,

Fig. 1  Part 1. Etiology and

learning performance knowl-
edge factor score pre- and
post-training

13
Journal of Autism and Developmental Disorders

Table 2  Change in ASD Knowledge and Self-Efficacy

Variables Pearsona Pre-test M, Med Post-test M, Med Z Effect size RCI Type of change N (%)
(SD) (SD)
Increase Decrease Same

Part 1: knowledge and beliefs about ASD

 Total mean 0.78 4.08, 4.25 (0.81) 4.71, 4.87 (0.53) − 4.28*** 0.59 1.65 8 (30.77) 0 (0) 18 (69.23)
knowledge
 % of “No specific 0.75 11.12, 5.00 (14.14%) 5.00, 3.33 (7.13%) − 2.26* 0.31 − 0.72 3 (11.50) 0 (0) 23 (88.46)
knowledge”
­ratingb
 Factor 1: miscon- 0.84 5.03, 5.17 (0.81) 5.63, 5.67 (0.27) − 3.55*** 0.49 1.87 9 (34.62) 0 (0) 17 (65.38)
ceptions
 Factor 2: social 0.73 4.64, 4.80 (0.84) 4.89, 5.30 (0.86) − 1.85 0.25 0.55 3 (11.54) 1 (3.84) 22 (84.62)
affective symp-
toms
 Factor 3: inter- 0.85 3.83, 4.20 (1.42) 4.41, 4.80 (1.27) − 1.45 0.23 0.82 7 (26.92) 2 (7.69) 15 (57.69)
vention
 Factor 4: etiology 0.86 3.64, 3.93 (1.08) 4.70, 4.71 (0.68) − 4.26*** 0.59 2.62* 15 (57.69) 0 (0) 11 (42.31)
and perfor-
mance
 Factor 5: related 0.65 3.25, 3.50 (1.24) 3.90, 4 (0.82) − 2.64** 0.36 0.89 4 (15.38) 1 (3.84) 21 (80.77)
conditions and
features
Part 2: ASD early markers
 ASD early mark- 0.76 3.46, 3.83 (1.19) 4.91, 4.94 (0.51) − 4.38*** 0.60 2.50* 14 (53.84) 0 (0) 12 (46.15)
ers
 % of “No specific 0.83 18.38, 11.11 (22.65) 2.14, 0 (6.3) − 3.47** 0.48 − 2.81* 0 (0) 15 (57.70) 11 (42.30)
knowledge”
­ratingb
Part 3: advanced knowledge of ASD diagnostic criteria
 % of correct 0.58 46.60, 50 (19.80) 64.20, 65.38 (12.53) − 3.49*** 0.49 1.37 9 (34.62) 1 (3.84) 16 (61.54)
answers
Part 4: self-efficacy
 Factor 1: self- 0.85 1.95, 2.17 (0.57) 2.39, 2.42 (0.57) − 3.31** 0.48 2.51* 16 (69.57) 2 (8.70) 5 (21.74)
efficacy in  ASD
clinical skills
 Factor 2: 0.77 2.97, 3 (0.63) 3.09, 3 (0.64) − 1.59 0.22 0.49 2 (8.70) 1 (4.35) 19 (82.61)
resources
 Factor 3: training 0.76 1.41, 1.5 (0.44) 1.86, 2 (0.45) − 2.78** 0.40 2.20* 13 (50.00) 1 (4.35) 8 (34.78)
 Factor 4: parent 0.60 2.41, 2.5 (0.69) 2.34, 2.50 (0.72) − 2.87 0.40 − 0.10 3 (13.04) 2 (8.70) 17 (73.91)
communication

*RCI exceeds 1.96

a
 Pearson moment correlations are based on test–retest results reported in Atun-Einy and Ben-Sasson (2018)
b
 This is the only variable for which an increase indicates less knowledge

SD = 0.54), (4) quality of teaching methods (M = 5.67, Discussion

SD = 0.38).
Change and Professional Background
Spearman Rho correlations indicated that there were no
significant (p > .05) correlations between ASD Knowledge
and Self-Efficacy Questionnaire change scores and years of
clinical experience, years of experience in the pediatric field,
and number of young children under care.
This is the first study to test the efficacy of a workshop aimed
at promoting early detection of ASD among PTs. This train-
ing focused on social-communication markers (e.g., joint
attention, response to name and social gaze) and sensory-
motor markers (e.g., visual disengagement, atypical visual
exploration and gaze, repetitive object play, sensory sensi-
tivity) because they might manifest in a PT session, but are
not part of routine PT training. The rationale for this training

13
 Journal of Autism and Developmental Disorders

Fig. 2  Part 2. Early signs of 6

ASD knowledge pre- and post-
training
5

Mean
3

2 Pre
Post

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

Participant Number

Fig. 3  Percentage reporting in 90
Part 2: each type of risk factor
pre- and post-training 80
70
60
50
40
Pre 30
Post 20

10
0

Table 3  Change in case study rating relative to expert ratings

Variables Experts Pre-training Post-training Statistics Effect size (r)
M (SD) M difference (SD) M difference (SD)

ASD risk 8.87 (1.55) 2.92 (2.03) 1.05 (0.98) − 3.82*** 0.53
Sensory processing risk 7.62 (1.4) 2.65 (2) 1.58 (1.04) − 2.51** 0.34
Global developmental risk 7.57 (1.81) 2.23 (1.71) 1.22 (0.93) − 2.45* 0.34
Urgency of referral 9 (1.92) 3 (2.47) 0.96 (0.82) − 3.61*** 0.50

Rating is out of 10. Mean differences pre and post-training were calculated relative to the mean answer of the experts
*p < 0.05; **p < 0.01; ***p < 0.001

13
Journal of Autism and Developmental Disorders
was to enable PTs to make use of their ongoing clinical
encounters with young children who may be at risk for ASD,
for screening. Findings showed that following training, PTs
significantly increased their knowledge of the etiology of
ASD, its signs and risk factors, and learning performance
features. Importantly, their ability to identify early markers
of ASD and to seek specific information for verifying risk
was increased, based on the analysis of a video case study.
Furthermore, their perceived clinical self-efficacy increased.
Nonetheless, at the group level, changes in knowledge
regarding diagnostic features, basic social-affective symp-
toms, interventions, comorbid features, misconceptions and
self-efficacy related to communicating with parents, were
inconsistent. Based on the findings from this pilot study,
we are cautiously optimistic of the potential impact of this
training and recommend its further investigation.
Changes in Knowledge and Skills in Early Detection
Increases in knowledge regarding early signs of ASD were
observed in Part 2 of the questionnaire. The percent of items
for which participants reported lack of knowledge and the
variance within the group decreased. Participants demon-
strated greater awareness of the developmental regression
type of ASD and risk factors after the workshop. Changes
in clinical reasoning and skills were apparent in the partici-
pants’ analysis of the case study. Studies have shown that
increasing awareness and expanding clinical reasoning can
promote early detection of ASD (Barbaro et al. 2011; Daniel
et al. 2009).
The effect of the training was also evident in the increased
number of early ASD markers and ASD-specific risk factors
listed by the participants, that would raise their suspicion for
ASD. This is similar to previous findings regarding medi-
cal personnel following training (Elmensdorp 2011). Since
screening is highly dependent upon observation, clinical
skills in eliciting and recognizing early markers needs to be
improved, and not only by introducing standardized screen-
ing tools. Fewer participants listed social–environmental
factors (e.g., parental neglect, abuse) after the training, and
at the same time, more participants listed genetic factors,
premature birth, and parental concerns as risk-factors. This
is consistent with the observed change in knowledge regard-
ing etiology in Part 1 of the questionnaire, which included
items referring to the genetic basis of ASD such as “ASD has
a strong genetic basis in its etiology” and “ASD tends to run
in families”. These results suggest that training can increase
one’s awareness of risk factors coupled with knowledge of
signs in early childhood. In turn, this can promote faster
and more accurate identification and referral for diagnostic
assessment.
Analysis of a filmed case study before and after train-
ing indicated an increase in screening competencies.
Post-training, participants were able to identify additional
early ASD signs presented by the child and could list more
information they would request in a clinical intake for this
child. ASD risk rating and urgency of referral had a stronger
effect with a decrease in variance than the changes in their
rating of global developmental risk and sensory risk. As
expected, the participants’ answers before the workshop
regarding global delay and sensory risk were close to those
of the experts. This demonstrates the skills of PTs in devel-
opmental risk assessment, and the possibility of extending
these skills through training to include ASD risk assessment.
The changes we found in analyzing a case study were not
observed in Elmensdorp’s (2011) training study. We used
a more detailed rating scale (10-point scale) as opposed to
the yes/no answer format used in that study. Also, we relied
on active learning methods and our participants were pedi-
atric PTs as opposed to pediatricians and medical residents.
These findings stress the recommendation for incorporat-
ing filmed case studies to bridge the gap between classroom
and clinical practice (Richardson 1999; Scott et al. 2012).
The case study analysis was the only measure in the current
study which approximated the clinical application of the
knowledge gained. Therefore, these findings are clinically
valuable.
Changes in ASD Knowledge
Of the four factors from Part 1 of the questionnaire assess-
ing knowledge and attitudes regarding ASD, the greatest
improvement was evident in the etiology and learning per-
formance factor, which was statistically significant, had a
high effect size, and a high mean RCI. This factor includes
seven items, four of which relate to the genetic basis of ASD
and three to learning performance. The training may have
impacted these types of knowledge by teaching about the
genetic risk factors and epidemiology, as well as addressing
performance factors that improve testability of children with
ASD. In contrast, changes in knowledge related to the other
four factors: interventions, social affective symptoms and
secondary characteristics were inconsistent. The curriculum
did not cover interventions applied to children with ASD;
hence, the lack of change in the intervention factor is not sur-
prising. However, we expected improvements in knowledge
regarding social-affective symptoms, as this was part of the
workshop’s core curriculum. It is possible that the question-
naire was not sensitive enough to assess knowledge change
in this domain, as the workshop dealt with qualities of early
social-effective signs as opposed to the basic information
sampled in Part 1 (e.g., children with ASD do not show
social attachments, even to parents/primary caregivers).
As for secondary characteristics (e.g., “Most children with
ASD have eating problems”), the change was significant,
but not high enough to differentiate it from spontaneous
13

change resulting from repeated testing (i.e., the RCI was
not significant).
The core diagnostic features of ASD in the DSM-V were
reviewed briefly in the workshop, to maintain the goal of
enhancing screening ability rather than diagnostic skills.
The average RCI did not show a meaningful change in the
rate of correctly classified ASD features in Part 3 of the
questionnaire. However, at the individual level, the rate of
correct responses increased among 30% of the participants.
In addition, Part 3 may be less sensitive to small differences
in knowledge, similar to previous research indicating that
Part 3 was not sensitive to differences between experienced
and non-experienced providers (Atun-Einy and Ben-Sasson
2018).
Changes in Clinical ASD Self‑Efficacy
The self-efficacy part of the questionnaire included four
factors: clinical self-efficacy, need for additional training,
confidence in communication with parents, and available
resources for referring at-risk children. Results showed a
significant increase after the workshop in clinical self-
efficacy and in the need for additional training. The RCI
in self-confidence regarding diagnosing and treating ASD
increased among 69.6% of the participants. Previous stud-
ies also showed increased confidence in identifying children
with ASD following ASD training programs geared towards
doctors (Elmensdorp 2011) and nurses (Barbaro et al. 2011).
Increasing confidence, although not a sufficient dimension
for promoting early ASD screening by PTs, is critical for
increasing the likelihood of translating knowledge change
into practice.
Training did not improve confidence in communicating
with parents. Overall, the participants reported insufficient
confidence in communicating with parents about ASD. At
the same time, in the open-ended questions, they reported
an increased recognition of parental concerns as an early
risk factor. Following the workshop, in Part 4, 32.0% of
the participants agreed or strongly agreed that they were
worried about hurting parents if they asked them whether
they had concerns about ASD, and 62.5% agreed or strongly
agreed that it was not their role to probe for concerns. After
the workshop, 50% of the participants agreed or strongly
agreed that they would feel comfortable or confident discuss-
ing early warning signs of ASD with parents. A possible
explanation for these results is that the workshop focused on
detecting early signs of ASD, not communication with par-
ents. Furthermore, in our previous research with this ques-
tionnaire, we found that the factor of communicating with
parents was not associated with level of ASD experience and
PTs reported much less confidence in communicating with
parents as compared with SLPs and OTs (Atun-Einy and
Ben-Sasson 2018). Training in parent communication skills
13
Journal of Autism and Developmental Disorders
is needed, specifically in probing about concerns regarding
the communicative development of their child during diag-
nostic testing and treatment.
Another significant result in the self-efficacy part of the
questionnaire was that 50% of the participants reported a
need for additional training. Increased knowledge regarding
the heterogeneous nature of ASD and the complexities of
screening for ASD may have led to the realization that iden-
tifying and diagnosing ASD requires specific, advanced clin-
ical skills and raised the need for additional training. These
findings agree with research showing that most SLPs, those
with moderate knowledge and those with high self-efficacy,
expressed a need for additional training (Adam 2014).
The participants reported a high level of satisfaction
with the training program in terms of relevance to daily PT
services and in terms of training methods. They reported
acquiring new knowledge and refining prior knowledge.
These findings are valuable as this was an initial examina-
tion of a new training program.
Training Change and Participant Professional
Background
Changes in knowledge were not associated with clinical or
diagnostic experience. This indicates that the workshop was
relevant to professionals at different points in their career.
Given the low variance of these professional background
variables in our sample and the similarities in their training,
this explanation should be taken with caution. The effect of
years of experience may have been obscured by the relatively
recent increase in PTs involvement in ASD treatment (Atun-
Einy et al. 2013). Thus, PTs in the field for a shorter period
might have received more exposure to ASD-related materi-
als during their education and clinical training. In contrast,
previous studies found an association between knowledge
and years of experienced among allied healthcare clinicians,
including those answering the same questionnaire used in
the current study (Adam 2014; Atun-Einy and Ben-Sasson
2018). The fact that clinical experience was not related to
PTs knowledge of ASD indicates their low involvement in
the treatment of children with ASD and supports the choice
of PTs as the target population for the workshop.
Limitations
This pilot study had some methodological limitations. The
relatively small convenience sample reflects the overall
small population from which to recruit pediatric PTs. This
small sample may have impeded the possibility of observ-
ing change across measures. In terms of study design,
there was no control group or follow-up phase. Changes
in clinical recognition of early markers was tested by
having participants rate one videotape, rather than rating
Journal of Autism and Developmental Disorders
multiple cases or actual children. Assessing behavioral
changes among healthcare clinicians is a complex process,
and the effect of knowledge on behavior can be limited
(Scott et al. 2012). Although some studies found changes
in clinical behavior following training, they focused on
the use of specific measures (Kairys and Petrova 2016;
Swanson et al. 2014). The participants in Barbaro et al.’s
study (2011) reported a change in clinical behavior and
improved focus while evaluating social-communicative
skills. As opposed to our study, they taught the partici-
pants a specific evaluation measure to guide them. We rec-
ommend that future studies examine short- and long-term
changes in the application of the knowledge in a clinical
setting, to support the carryover of new knowledge into
practice.
Conclusions
This pilot study provides preliminary evidence to the effi-
cacy of the “Early ASD Screening” workshop for training
PTs. This intensive, 2-day, problem-based training was
effective in increasing knowledge regarding early signs,
risk factors, and etiology of ASD, as well as improving
performance and clinical self-efficacy of a group of pediat-
ric PTs in recognizing ASD-specific behaviors in a young
child. Our study points to the possibility of involving PTs,
who are routinely engaged with young children, in the
detection of ASD. These changes were independent of pre-
vious experience with diagnosing young children or years
of pediatric experience. As for changes in clinical skills,
when watching a filmed case study, participants showed
greater accuracy in evaluating ASD risk, recognizing ASD
markers, and recognizing additional information needed
to decide whether to refer a child for further evaluation.
Evidence from this study suggests the need for workshops
with modules teaching communication with parents and
early intervention techniques. Future research, studying
the efficacy of this training for other professions and its
carryover to practice would be beneficial.
Acknowledgments  We wish to thank Mrs. Malka Stoller, Head of Pedi-
atric Physical Therapy Services, the Ministry of Health, Israel and Mrs.
Danya Hofi head of the Physical Therapy School in Tel-Hashomer, Tel-
Aviv University. This study was part of the third author’s master thesis.
Author Contributions  AB and OA have made substantial contributions
to conception, design, acquisition of data, analysis, and manuscript
writing. GY was involved in the design and coordination of the work-
shop, data management, analysis and helped draft the manuscript. SL
and TG participated in the acquisition of the data by delivering parts
of the workshop and in revising the manuscript. All authors read and
approved the final manuscript.
Compliance with Ethical Standards 
Conflict of interest  All authors declare that they have no conflict of
interest.
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.
Informed Consent  Informed consent was obtained from all individual
participants included in the study.
References
Adam, Y. (2014). Diagnosis and treatment of ASD: Knowledge, self-
efficacy and attitudes of speech–language pathologists in Israel.
Unpublished Master’s Thesis. University of Tel-Aviv, Israel (in
Hebrew).
Atun-Einy, O., & Ben-Sasson, A. (2018). Pediatric allied health-
care professionals’ knowledge and self-efficacy regarding ASD.
Research in Autism Spectrum Disorders, 47, 1–13. https​://doi.
org/10.1016/j.rasd.2017.12.001.
Atun-Einy, O., Lotan, M., Harel, Y., Shavit, E., Burstein, S., & Kemp-
ner, G. (2013). Physical therapy for young children diagnosed
with autism spectrum disorders—Clinical frameworks model
in an Israeli setting. Frontiers in Pediatrics, 1, 19. https​://doi.
org/10.3389/fped.2013.00019​.
Baghdadli, A., Pascal, C., Grisi, S., & Aussilloux, C. (2003). Risk fac-
tors for self-injurious behaviors among 222 young children with
autistic disorders. Journal of Intellectual Disabilities Research,
47, 622–627. https​://doi.org/10.1046/j.1365-2788.2003.00507​.x.
Bandura, A. (1986). Social foundations of thought and action: A social
cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.
Barbaro, J., Ridgway, L., & Dissanayake, C. (2011). Developmental
surveillance of infants and toddlers by maternal and child health
nurses in an Australian community-based setting: Promoting
the early identification of autism spectrum disorders. Journal
of Pediatric Nursing, 26(4), 334–347. https​://doi.org/10.1016/j.
pedn.2010.04.007.
Bhat, A., Galloway, J., & Landa, R. (2012). Relation between early
motor delay and later communication delay in infants at risk for
autism. Infant Behavior and Development, 35(4), 838–846. https​
://doi.org/10.1016/j.infbe​h.2012.07.019.
‫‏‬Bhat, A. N., Landa, R. J., & Galloway, J. C. (2011). Current perspec-
tives on motor functioning in infants, children, and adults with
autism spectrum disorders. Physical Therapy, 91(7), 1116–1129.
https​://doi.org/10.2522/ptj.20100​294.
Brisson, J., Warreyn, P., Serres, J., Foussier, S., & Adrien-Louis, J.
(2012). Motor anticipation failure in infants with autism: A retro-
spective analysis of feeding situations. Autism: The International
Journal of Research and Practice, 16(4), 420–429. https​://doi.
org/10.1177/13623​61311​42338​5.
Clark, A., Browne, S., Boardman, L., Hewitt, L., & Light, S. (2016).
Implementing UK Autism Policy and National Institute for Health
and Care Excellence guidance—Assessing the impact of Autism
training for frontline staff in community learning disabilities
teams. British Journal of Learning Disabilities, 44(2), 103–110.
https​://doi.org/10.1111/bld.12116​.
Corsello, C. M. (2005). Early intervention in autism. Infants and Young
Children, 18(2), 74–85. https​://doi.org/10.1097/00001​163-20050​
4000-00002​.
13

Crais, E. R., McComish, C. S., Humphreys, B. P., Watson, L. R.,
Baranek, G. T., Reznick, J. S., Christian, R. B., & Earls, M.
(2014). Pediatric healthcare professionals’ views on autism
spectrum disorder screening at 12–18 months. Journal of
Autism and Developmental Disorders. https​://doi.org/10.1007/
s1080​3-014-2101-2.
Daniel, K., Prue, C., Taylor, M., Thomas, J., & Scales, M. (2009).
‘Learn the signs. Act early’: A campaign to help every child
reach his or her full potential. Public Health, 123, e11–e16.
https​://doi.org/10.1016/j.puje.2009.06.002.
Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson,
J., Donaldson, J., & Varley, J. (2010). Randomized, controlled
trial of an intervention for toddlers with autism: The Early
Start Denver Model. Pediatrics, 125(1), e17–e23. https​://doi.
org/10.1542/peds/2009-0958.
Dillenburger, K., McKerr, L., Jordan, J. A., & Keenan, M. (2016).
Staff training in autism: The one-eyed wo/man…. International
Journal of Environmental Research and Public Health, 13(7),
716. https​://doi.org/10.3390/ijerp​h1307​0716.
Dosreis, S., Weiner, C. L., Johnson, L., & Newschaffer, C. J. (2006).
Autism spectrum disorder screening and management practices
among general pediatric providers. Journal of Developmental
and Behavioral Pediatrics, 27(2), S88–S94.
Elmensdorp, S. T. (2011). Training physicians on the early behavio-
ral characteristics of autism: The use of a brief, group didactic
training module. Doctoral Dissertation. University of Califor-
nia, Santa Barbara, CA.
Filipek, P. A., Accardo, P. J., Baranek, G. T., Cook, E. H., Dawson,
G., Gordon, B., Gravel, J. S., Johnson, C. P., Kallen, R. L.,
Levy, S. E., Minshew, N. J., Ozonoff, S., Prizant, B. M., Rapin,
I., Rogers, S. J., Stone, W. L., Teplin, S., Tuchman, R. F., &
Volkmar, F. R. (1999). The screening and diagnosis of autistic
spectrum disorders. Journal of Autism and Developmental Dis-
orders, 29(6), 439–484.
Gima, H., Kihara, H., Watanabe, H., Nakano, H., Nakano, J., Koni-
shi, Y., et al. (2018). Early motor signs of autism spectrum dis-
order in spontaneous position of the head. Experimental Brain
Research, 236, 1139–1148.
Godin, G., Bélanger-Gravel, A., Eccles, M., & Grimshaw, J.
(2008). Healthcare professionals’ intentions and behav-
iours: A systematic review of studies based on social cogni-
tive theories. Implementation Science, 3(1), 36. https​: //doi.
org/10.1186/1748-5908-3-36.
Goyen, T., & Lui, K. (2002). Longitudinal motor development of
“apparently normal” high-risk infants at 18 months, 3 and 5
years. Early Human Development, 70(1), 103–115. https​://doi.
org/10.1016/S0378​-3782(02)00094​-4.
Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O.
(2004). Diffusion of innovations in service organizations: System-
atic review and recommendations. The Milbank Quarterly, 82(4),
581–629. https​://doi.org/10.1111/j,0887-378X.2004.00325​.x.
Harris, S. L., & Handleman, J. S. (2000). Age and IQ at intake as pre-
dictors of placement for young children with autism: A four- to
six-year follow-up. Journal of Autism and Developmental Disor-
ders, 30(2), 137–142. https​://doi.org/10.1023/A:10054​59606​120.
Harris, S. R. (2017). Early motor delays as diagnostic clues in autism
spectrum disorder. European Journal of Pediatrics, 176(9), 1259–
1262. https​://doi.org/10.1007/s0043​1-017-2951-7.
Heidgerken, A. D., Geffken, G., Modi, A., & Frakey, L. (2005). A
survey of autism knowledge in a health care setting. Journal of
Autism and Developmental Disorders, 35(3), 323–330. https:​ //doi.
org/10.1007/s1080​3-005-3298-x.
Honigfeld, L., Chandhok, L., & Spiegelman, K. (2012). Engaging pedi-
atricians in developmental screening: The effectiveness of aca-
demic detailing. Journal of Autism and Developmental Disorders,
42(6), 1175–1182. https​://doi.org/10.1007/s1080​3-011-1344-4.
13
Journal of Autism and Developmental Disorders
Imran, N., Chaudry, M. R., Azeem, M. W., Bhatti, M. R., Choudhary,
Z. I., & Cheema, M. A. (2011). A survey of Autism knowledge
and attitudes among the healthcare professionals in Lahore, Paki-
stan. BMC Pediatrics, 11(1), 107. https​://doi.org/10.1007/s1080​
3-011-1344-4.
Jacobson, N. S., Follette, W. C., & Revenstorf, D. (1984). Psycho-
therapy outcome research: Methods for reporting variability and
evaluating clinical significance. Behavior Therapy, 15(4), 336–
352. https​://doi.org/10.1016/S0005​-7894)84)80002​-7.
Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statis-
tical approach to defining meaningful change in psychotherapy
research. Journal of Consulting and Clinical Psychology, 59(1),
12. https​://doi.org/10.1037/0022-006X.59.1.12.
Janvier, Y. M., Harris, J. F., Coffield, C. N., Louis, B., Xie, M., Cidav,
Z., & Mandell, D. S. (2016). Screening for autism spectrum dis-
order in underserved communities: Early childcare providers as
reporters. Autism, 20, 364–373. https​://doi.org/10.1177/13623​
61315​58505​5.
Johnson, C. P., & Myers, S. M. (2007). Identification and evaluation
of children with autism spectrum disorders. Pediatrics, 120(5),
1183–1215.
Johnson, S., Hollis, C., Kochhar, P., Hennessy, E., Wolke, D., & Mar-
low, N. (2010). Autism spectrum disorders in extremely preterm
children. The Journal of Pediatrics, 156(4), 525–531. https​://doi.
org/10.1016/j.peds.2009.10.041.
Kairys, S. W., & Petrova, A. (2016). Role of participation of pedia-
tricians in the “Activated Autism Practice” program in prac-
ticing children with Autism Spectrum Disorders at the pri-
mary pare setting. Global Pediatric Health, 3, 1–6. https​://doi.
org/10.1177/23337​94X16​66354​4&%23x20​0F;.
Kobak, K. A., Stone, W. L., Ousley, O. Y., & Swanson, A. (2011).
Web-based training in early autism screening: Results from a pilot
study. Telemedicine and E-Health, 17(8), 640–644. https​://doi.
org/10.1089/tmj.2011.0029.
Landa, R. J., & Garrett-Mayer, E. (2006). Development in infants with
autism spectrum disorders: A prospective study. Journal of Child
Psychology and Psychiatry, 47(6), 629–638. https​://doi.org/10.1
111/j.1469-7610.2006.01531​.x.
LeBarton, E. S., & Iverson, J. M. (2016). Associations between gross
motor and communicative development in at-risk infants. Infant
Behavior and Development, 44, 59–67. https​://doi.org/10.1016/j/
infbe​h.2016.05.003.
Lemcke, S., Juul, S., Parner, E. T., Lauritsen, M. B., & Thorsen, P.
(2013). Early signs of autism in toddlers: A follow-up study in
the Danish National Birth Cohort. Journal of Autism and Devel-
opmental Disorders, 43(10), 2366–2375‫‏‬. https​://doi.org/10.1007/
s1080​3-013-1785-z.
Limperopoulos, C., Bassan, H., Sullivan, N. R., Soul, J. S., Robertson,
R. L. Jr., Moore, M., Ringer, S. A., Volpe, J. J., & du Plessis,
A. J. (2008). Positive screening for autism in ex-preterm infants:
Prevalence and risk factors. Pediatrics, 121(4), 758–765. https​://
doi.org/10.1542/peds.2007-2158.
Lobo, M. A., Harbourne, R. T., Dusing, S. C., & McCoy, S. W. (2013).
Grounding early intervention: Physical therapy cannot just be
about motor skills anymore. Physical Therapy, 93(1), 94–103.
https​://doi.org/10.2522/ptj.20120​158.
Major, N. E., Peacock, G., Ruben, W., Thomas, J., & Weitzman, C.
C. (2013). Autism training in pediatric residency: Evaluation of
a case-based curriculum. Journal of Autism and Developmen-
tal Disorders, 43(5), 1171–1177. https​://doi.org/10.1007/s1080​
3-012-1662-1.
Menon, A., Korner-Bitensky, N., Kastner, M., McKibbon, K., & Straus,
S. (2009). Strategies for rehabilitation professionals to move evi-
dence-based knowledge into practice: A systematic review. Jour-
nal of Rehabilitation Medicine, 41(13), 1024–1032. https​://doi.
org/10.2340/16501​977-0451.
Journal of Autism and Developmental Disorders
Oxman, A. D., Thomson, M. A., Davis, D. A., & Haynes, R. B. (1995).
No magic bullets: A systematic review of 102 trials of interven-
tions to improve professional practice. Canadian Medical Asso-
ciation Journal, 153(10), 1423–1431.
Ozonoff, S., Young, G. S., Goldring, S., Greiss-Hess, L., Herrera, A.
M., Steele, J., et al. (2008). Gross motor development, move-
ment abnormalities, and early identification of Autism. Journal
of Autism and Developmental Disorders, 38(4), 644–656. https​://
doi.org/10.1007/s1080​3-007-0430-0.
Peacock, G., & Lin, S. C. (2012). Enhancing early identification and
coordination of intervention services for young children with
autism spectrum disorders: Report from the act early regional
summit project. Disability and Health Journal, 5(1), 55–59. https​
://doi.org/10.1016/j.dhjo.2011.10.001.
Pierce, K., Carter, C., Weinfeld, M., Desmond, J., Hazin, R., Bjork, R.,
& Gallagher, N. (2011). Detecting, studying, and treating autism
early: The one-year well-baby check-up approach. The Journal
of Pediatrics, 159(3), 458–465. https​://doi.org/10.1016/j.jpeds​
.2011.02.036.
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. https​
://doi.org/10.1016/j.jpeds​.2016.06.004.
Provost, B., Lopez, B. R., & Heimerl, S. (2007). A comparison of
motor delays in young children: Autism spectrum disorder,
developmental delay, and developmental concerns. Journal of
Autism and Developmental Disorders, 37(2), 321–328. https​://
doi.org/10.1007/s1080​3-006-0170-6.
Richardson, B. (1999). Professional development: 2. Professional
knowledge and situated learning in the workplace. Physiotherapy,
85(9), 467–474. https:​ //doi.org/10.1016/S0031-​ 9406(05)65471-​ 5.
Robins, D. L., Fein, D., Barton, M. L., & Green, J. A. (2001). The
Modified Checklist for Autism in Toddlers: An initial study inves-
tigating the early detection of autism and pervasive developmental
disorders. Journal of Autism and Developmental Disorders, 31(2),
131–144. https​://doi.org/10.1023/A:10107​38829​569.
Rogers, S. J., & Vismara, L. A. (2008). Evidence-based comprehensive
treatments for early autism. Journal of Clinical Child and Adoles-
cent Psychology, 37(1), 8–38.
Sacrey, L. A. R., Zwaigenbaum, L., Bryson, S., Brian, J., Smith, I. M.,
Roberts, W., Szatmari, P., Roncadin, C., Garon, N., Novakm, C.,
Vaillancourt, T., McCormick, T., MacKinnon, B., Sanne, J., &
Armstrong, V. (2015). Can parents’ concerns predict autism spec-
trum disorder? A prospective study of high-risk siblings from 6 to
36 months of age. Journal of the American Academy of Child and
Adolescent Psychiatry, 54(6), 470–478. https​://doi.org/10.1016/j.
jaac.2015.03.014.
Sallows, G. O., & Graupner, T. D. (2005). Intensive behavioral treat-
ment for children with autism: Four-year outcome and predictors.
American Journal on Mental Retardation, 110(6), 417–438. https​
://doi.org/10.1352/0895.
Schwartz, H., & Drager, K. D. (2008). Training and knowledge in
autism among speech–language pathologists: A survey. Language,
Speech, and Hearing Services in Schools, 39(1), 66–77. https​://
doi.org/10.1044/0161-1461(2008/007).
Scott, S. D., Albrecht, L., O’Leary, K., Ball, G. D., Hartling, L.,
Hofmeyer, A., Jones, C. A., Klassen, T. P., Burns, K., New-
ton, A. S., Thompson, D., & Dryden, D. M. (2012). Systematic
review of knowledge translation strategies in the allied health
professions. Implementation Science, 7(1), 70. https ​ : //doi.
org/10.1186/1748-5908-7-70.
Self, T. L., Coufal, K., & Parham, D. F. (2010). Allied healthcare pro-
viders’ role in screening for autism spectrum disorders. Journal
of Allied Health, 39(3), 165–174‫‏‬.
Sices, L., Feudtner, C., McLaughlin, J., Drotar, D., & Williams, M.
(2003). How do primary care physicians identify young children
with developmental delays? A national survey. Journal of Devel-
opmental and Behavioral Pediatrics, 24(6), 409–417. https​://doi.
org/10.1097/00004​703-20031​2000-00002​.
Siperstein, R., & Volkmar, F. (2004). Brief report: Parental reporting
of regression in children with pervasive developmental disorders.
Journal of Autism and Developmental Disorders, 34(6), 731–734.
https​://doi.org/10.1007/s1080​3-004-5294-y.
Swanson, A. R., Warren, Z. E., Stone, W. L., Vehorn, A. C., Dohrmann,
E., & Humberd, Q. (2014). The diagnosis of autism in commu-
nity pediatric settings: Does advanced training facilitate practice
change? Autism, 18(5), 555–561. https​://doi.org/10.1177/13623​
61313​48150​7.
Szatmari, P., Bryson, S. E., Boyle, M. H., Streiner, D. L., & Duku, E.
(2003). Predictors of outcome among high functioning children
with autism and Asperger syndrome. Journal of Child Psychology
and Psychiatry, 44(4), 520–528. https​://doi.org/10.1111/1469-
7610.00141​.
West, K. L. (2018). Infant motor development in autism spectrum dis-
order: A synthesis and meta-analysis. Child Development. https​
://doi.org/10.1111/cdev.13086​.
Yeargin-Allsopp, M., Rice, C., Karapurkar, T., Doernberg, N., Boyle,
C., & Murphy, C. (2003). Prevalence of autism in a US metro-
politan area. JAMA, 289(1), 49–55. https​://doi.org/10.1001/
jama.289.1.49.
Zwaigenbaum, L., Bryson, S., Lord, C., Rogers, S., Carter, A., Carver,
L., Chawarska, K., Constantino, J., Dawson, G., Dobkins, K.,
Fein, D., Iverson, J., Klin, A., Landa, R., Messinger, D., Ozo-
noff, S., Sigman, M., Stone, W., Tager-Flusberg, H., & Yirmiya,
N. (2009). Clinical assessment and management of toddlers
with suspected autism spectrum disorder: Insights from studies
of high-risk infants. Pediatrics, 123(5), 1383–1391. https​://doi.
org/10.1542/peds/2008-1606.
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