31 Perspectives of preventive care physicians on early detection of autism spectrum disorder 2 Attitude-Behaviour Framework; Fischer et al., 2016) distinguishes three factors regarding barriers of guideline implementation and adherence, covering a) personal factors related to knowledge and attitudes, b) guideline-related factors related to barriers linked to the process of developing a guideline (for example: evidence of made recommendations and accessibility of a guideline), and c) external factors related to barriers such as organizational constraints, lack of resources and lack of collaboration (Fischer et al., 2016). In order to better understand already found barriers and develop improvement strategies, this framework can also be applied specifically related to early detection of ASD. In relation to ASD, previous research showed that personal factors as barriers in early detection include providers’ insufficient training in child development, lack of knowledge about the early risk signals of ASD and unfamiliarity with screening instruments (Dosreis et al., 2006; Pinto-Martin, 2005). More recent studies amongst primary care providers in the United States underline these finding and suggested a need for training in recognizing red flags and familiarizing with ASD specific screening tools (Crais et al., 2014). A guideline related factor in relation to early detection of ASD is the limited use of screening tools. In order to improve early detection, two screening strategies have been proposed: universal screening for ASD of all children at 18 months and 24 months (American Academy of Pediatrics, 2020) or global screening of children who have been identified as high-risk (Canadian Paediatric Society, 2019;Van Berckelaer-Onnes et al., 2015). Although choosing an effective screening strategy might be complicated, children are more likely to be identified and connected with early intervention services when developmental concerns are followed up by a screening tool (Barger et al., 2018). Therefore, the limited use of screening instruments despite scientific evidence can be viewed as an important barrier in early detection of ASD. Another, more practical, guideline related barrier can be found in the usage of electronic systems. For example, when an ASD specific screening tool is not incorporated within the electronic medical record, care providers don’t get a push reminder, which then might influence care providers' decision to screen (Fenikilé, 2015). External factors regarding obstacles in early detection of ASD previously found a) are lack of time and acceptable compensation to apply screening instruments and b) waiting lists. Since long waiting lists complicate early access to mental healthcare services (Crais et al., 2014; Dosreis et al., 2006; Pinto-Martin et al., 2005), it is possible that early identification of ASD can be viewed by some PCPs as less urgent and possibly harmful if no follow-up service is available after a screen positive result. In the Netherlands, (specialized) mental healthcare centers and psychologist practices perform careful and extensive diagnostic assessments and are responsible for giving psychiatric diagnoses (among which ASD). Amongst others, waiting lists might indeed be one of the possible barriers regarding early detection of ASD in the Netherlands, but until now, it has been unclear to what extent possible barriers found elsewhere also apply to the Dutch situation of preventive healthcare.
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