Recently, the U.S. Preventive Services Task Force (USPSTF)—the expert panel that provides recommendations about preventive services—published a draft recommendation about screening for autism spectrum disorder (ASD) in young children. The recommendation does not support early screening for ASD.
It is currently open for public comment. Many pediatric developmental specialists and researchers are concerned with the conclusions. Drs. Sarah Spence and Carolyn Bridgemohan, co-directors of Boston Children’s Hospital Autism Spectrum Center, offer some insights into the recommendation and the benefits of early screening.
What was the purpose of this review?
This review looked at the potential benefits and risks of routine screening for autism spectrum disorders in the general population of children under age 3. The authors were specifically interested in the short- and long-term effects of screening in the regular well-child visit setting.
They examined short-term outcomes, such as times to referral for evaluation, diagnosis and treatment.
To evaluate potential long-term screening outcomes, the panel also reviewed evidence of the effectiveness of early intensive interventions typically provided to young children with ASD, including ABA, the Early Start Denver Model and Relational therapies. For these interventions, effectiveness was measured by improvements in children’s cognitive, language and joint attention skills.
The authors wanted to examine any evidence of harm from screening or treatment but reported there were no studies to review.
They also wanted to look at studies that followed large groups of children over time to directly see the outcomes from screening, including looking at children receiving screening compared to those who did not get screening. The panel wanted to compare what happened to children who screened positive for ASD compared to those who screened negative but did not find any studies of this nature and acknowledged these types of long-term studies are difficult and costly to perform.
What does research show about screening for autism?
Research shows screening tools for ASD successfully identify young children (18-24 months) who have ASD or other developmental concerns requiring early intervention (such as cognitive and language delays). Screening allows doctors to refer children for diagnostic evaluation and then specialized early intervention.
Early intensive interventions result in better cognitive and language outcomes for children with ASD, and starting treatment at an earlier age results in overall better outcomes.
There is no evidence that screening or early intervention causes harm in children.
However, the USPSTF panel concluded they could neither recommend for or against ASD screening, because there are no studies showing the long-term effects of ASD screening. These studies would require a research trial where some children are screened and others are not. The children would be followed over time, and researchers would measure the timing of diagnosis and start of any treatment in any who ultimately have ASD.
Do you have any concerns with the conclusions?
In the Autism Spectrum Center, we believe in practicing evidenced-based medicine and using guidelines based on evidence to ensure high-quality care. We know the evidence shows us early identification and treatment of ASD improves outcomes, including cognitive and language development. For this reason, we continue—along with many professional groups including the American Academy of Pediatrics—to support strongly the value of ASD screening as part of regular preventative pediatric care.
We know from our colleagues in pediatric practice that regularly scheduled ASD screening ensures they review any concerns about a child’s development with the parents during their regular well-child visits. Standardized screening also ensures all children have their development closely monitored; unfortunately, children from lower income and racial minority groups are often identified and diagnosed at a much later age. Standardized screening helps close this gap.
What do you do when there is not any research to guide practice?
When we don’t have specific evidence to guide practice, we use clinical consensus and experience. In the case of ASD screening, a research trial that directly follows the effect of screening for ASD on large groups of children would not be feasible or ethical. It would involve purposely not screening some children and potentially causing delayed diagnosis and access to treatment.
In cases like this, there is simply not enough information from research to guide our care. But that does not mean using clinical consensus and experience is not good practice. Often common sense is the best guide. For example, there was never a randomized controlled trial related to the safety of parachutes when jumping out of planes, but you don’t find people questioning if that is the right thing to do. Imagine doing a research study to test that theory where only half the participants got parachutes.
How do you advise parents concerned about their child’s development?
We recommend they talk with their child’s primary care provider about any concerns related to development. Boston Children’s Autism Spectrum Center provides ASD evaluations and specialty care for children with autism.
Learn more about evaluating current autism research in the Autism Spectrum Center’s Parent Forums.