16 Chapter 1 (Communication and Social development Signs). It is a questionnaire consisting of 14-items to be answered dichotomously as ‘yes’ or ‘no’. A score equal or higher than 3 indicates a positive screen, meaning the child is at an elevated likelihood for ASD. The CoSoS was evaluated in both a population sample and a high-likelihood sample. When compared to other screening instruments such as the M-CHAT, the CoSoS identified fewer children with a screen-positive result. However, the CoSoS (rather than the M-CHAT) is associated with more clinical referrals as most children who received a false positive on the CoSoS were diagnosed with other developmental disorders (81%) (Beuker et al., 2014; Dietz et al., 2007). The CoSoS seemed most effective when applied during two-stage screening: specifically screening for ASD in children who showed one or more “red flags” (i.e. early signs of ASD) during routine developmental surveillance (Dietz et al., 2006). These “red flags” are presented in Box 1.3. 2. DIANE project After the SOSO study, a successful program known as the DIANE project was implemented to improve early detection of ASD. In this project, physicians and nurses working at wellbaby clinics and members of special infant-toddler development teams were trained to a) recognize early signs of autism, and b) use a specially designed referral protocol consisting of a two phase screening approach for ASD, which included administering of the CoSoS questionnaire after concerns were raised during routine developmental screening. The strategies and results of the DIANE project were successful in lowering the age of diagnosis, generally for children with severe ASD and intellectual disabilities (Oosterling, 2010). However, to date there remains a significant limitation in that multiple groups of children are still being overlooked. These groups include children with milder ASD and/or above (average) intelligence, and girls and children from ethnic minorities. The current SCOPE study builds on these findings, with the aim of offering timely intervention for all children who could benefit from it (see Chapter 5). 3. Mountain of success After the initial successful effects of the DIANE project, Pijl et al. (2018) conducted a 8 year follow-up study to evaluate the sustainability of the integrated early detection program as introduced in the DIANE project. The findings of the follow-up study indicate a “mountain of success”. Figure 1.1 shows that, during the DIANE project, there was an increase in children with ASD being diagnosed before age 3. After the project had ended the number of children diagnosed decreased again, showing no difference before versus after the program. Thus, although the objectives of the early detection program were fulfilled and led to earlier referral of children with, the effects disappeared over the years when active investment had faded out (Pijl et al., 2018).
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