43 Perspectives of preventive care physicians on early detection of autism spectrum disorder 2 in line with previous studies (Crais et al., 2014; Zuckerman et al., 2014), its existence shining through the results of previous studies focusing on ASD in minority groups. For example, it was found that minority families are less likely to contact a healthcare professional about their concerns, are more distrusting of the healthcare system and that their children are being diagnosed at a later age (Burkett et al., 2015; Zeleke et al., 2019). Therefore, it is essential for PCPs to be better culturally informed and take differences in mind when discussing ASD with families who have other cultural backgrounds. Also, it is of great importance that the there is an increased awareness on the risk of preconceptions on cultural and language differences in the process of early identification of ASD. Most desirable would be a broader cultural representation amongst PCPs. Other, more practical, improvement strategies include adapting screening instruments by translating them and make these translated versions widely available or, as with the M-CHAT, to add follow-up questions to make sure families understand the questions that are being asked (Crais et al., 2014). A guideline related barrier is the limited use of screening instruments in preventive care, despite scientific recommendations. Research reports that a specific screening tool can identify more children with ASD than either clinical judgment or parental reports (Miller et al., 2011) and early detection is most effective when developmental concerns are in tandem with a follow-up specific screener (Barger et al., 2018). PCPs mentioned unfamiliarity with screening instruments, parental acceptance and time constraints as important obstacles in the use of a screening tool. The first two obstacles are interwoven with previously describes personal barriers, i.e. limited knowledge and difficulty discussing initial worries with parents. Possible solutions can, as aforementioned, be training in recognizing red flags of ASD in infant and toddlerhood and motivational interviewing on how to discuss initial worries with parents without immediately deliberating an ASD diagnosis. The obstacle of time constraint has also previously been found as a barrier in early identification and can be explained by the increasing workload in preventive healthcare since numerous different guidelines are expected to be followed (Yarnell & Polla, 2003). As an extension of time constraints, adequate reimbursement is often not available. Without adequate reimbursement (in the form of additional training, more time and human resources), PCPs who already feel time pressure in their daily work are unlikely to integrate a screening tool or any additional services (Dobrez et al., 2001; Pinto-Martin et al., 2005). However, research suggests that a timely investment in early detection of ASD and access to early intervention can ultimately reduce both family and society costs. For example, toddlers who had received early intervention benefited from functional gains (Dawson et al., 2008), but that they also needed fewer services (Cidav et al., 2017). Both benefits result in overall costs savings, indicating that early intervention (and therefore early detection) has the potential to reduce costs in the long term (Peters-Scheffer et al., 2012; Horlin et al., 2014; Cidav et al., 2017), seeming worth the time and cost investment by policymakers and municipalities.
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