41 Perspectives of preventive care physicians on early detection of autism spectrum disorder 2 Discussion The findings in this study indicated the lack of guideline adherence five year after implementation. Second, PCPs revealed the following barriers in the early detection of ASD: 1) limited knowledge about ASD symptoms in infant-and toddlerhood, 2) professional attitude towards early detection, 3) problems in discussing initial worries with parents, 4) limited use of screening instruments, 5) perceptions regarding cultural and language differences and 6) constraints regarding availability of healthcare services. To improve early identification of ASD, PCPs mention the need for additional training in recognizing the importance of early detection, recognizing early risk signals and how to administer the CoSoS as an ASD-specific screener. Furthermore, PCPs suggest that there should be a closer collaboration between healthcare organizations. Main findings will be discussed below. State of adherence to the Dutch guideline. The Dutch ASD guideline is developed only partly in line with the leading guideline of the American Academy of Pediatrics (AAP, 2020). The AAP guideline alike, the Dutch guideline emphasizes systematically following child-development during infancy and toddlerhood. Unlike AAP recommendation, that prescribes pediatricians to screen for ASD at 18 and 24 months in all children (i.e. universal screening), the Dutch guideline prescribes preventive healthcare physicians to screen for ASD when one or more red flags for ASD are identified during general health surveillance (i.e. screening in high risk groups) (van Berckelaer-Onnes et al., 2015). Reasons for this strategy include feasibility and current insufficient evidence to assess universal screening of ASD in all children (US Preventive Services Task Force, 2016). It appears however that, whichever screening strategy is chosen, guideline adherence is suboptimal, e.g.: despite AAP guideline recommendations regarding universal screening, research estimates that little more than half of pediatricians conduct routine screening for ASD at 18-or 24 months (Arunyanart et al., 2012). This corresponds with our finding that the majority of respondents do not follow the Dutch guideline’s advice. Barriers of early detection and adherence to the guideline Six barriers of early detection of ASD and guideline adherence were revealed. In general, factors regarding barriers of guideline implementation and adherence can be divided into a) personal factors, b) guideline-related factors and c) external factors (Fischer et al., 2016). The current findings will be discussed within this framework. Naturally, factors do not stand alone but are interrelated and affect each other. Most barriers to early detection and guideline adherence are related to personal factors and include limited knowledge, professional attitude towards early detection, difficulty in discussing initial worries with parents and complications derived from cultural differences
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