We compared ratings on the Three-Item Direct Observation Screen test for autism spectrum disorders completed by pediatric residents with the Social Communication Questionnaire parent reports as an augmentative tool for improving autism spectrum disorder screening performance. We examined three groups of children (18-60 months) comparable in age (18-24 month, 24-36 month, 36-60 preschool subgroups) and gender distribution: n = 86 with "Diagnostic and Statistical Manual of Mental Disorders" (4th ed., text rev.) autism spectrum disorders; n = 76 with developmental delay without autism spectrum disorders; and n = 97 with typical development. The Three-Item Direct Observation Screen test included the following (a) "Joint Attention," (b) "Eye Contact," and (c) "Responsiveness to Name." The parent Social Communication Questionnaire ratings had a sensitivity of 0.73 and specificity of 0.70 for diagnosis of autism spectrum disorders. The Three-Item Direct Observation Screen test item "Joint Attention" had a sensitivity of 0.82 and specificity of 0.90, "Eye Contact" had a sensitivity of 0.89 and specificity of 0.91, and "Responsiveness to Name" had a sensitivity of 0.67 and specificity of 0.87. In the Three-Item Direct Observation Screen test, having at least one of the three items positive had a sensitivity of 0.95 and specificity of 0.85. Age, diagnosis of autism spectrum disorder, and developmental level were important factors affecting sensitivity and specificity. The results indicate that augmentation of autism spectrum disorder screening by observational items completed by trained pediatric-oriented professionals can be a highly effective tool in improving screening performance. If supported by future population studies, the results suggest that primary care practitioners will be able to be trained to use this direct procedure to augment screening for autism spectrum disorders in the community.