Autism: Need for Routine Toddler Screening Not Proven, Feds Say

In a decision on pediatric care that has dismayed autism advocates and some experts, a federal task force has ruled there is not enough evidence to show that screening all US toddlers for autism is a good idea.

That decision contradicts recommendations from the American Academy of Pediatrics (AAP) which say children should be screened for ASD at ages 18 and 24 months, along with regular developmental surveillance.

But in a statement published in JAMA on Feb. 16, the US Preventive Services Task Force (USPSTF) left the decision on whether to screen up to parents and clinicians. The USPSTF also called for more research on whether screening is reliable and if early intervention is effective.

“The current evidence is insufficient to balance the benefits and harms of screening for autism spectrum disorder (ASD) in young children for whom no concerns of ASD have been raised by parents or a clinician,” the USPSTF concluded.

The USPSTF decision applies to children 18 months to 30 months old.

Screenings involve simply asking parents standardized questions about their child’s behaviors, scoring the responses, and then making referrals to other specialists if warranted.

While leaving the choice on whether or not to screen up to parents and clinicians, the task force explained that it is not saying screening is necessarily a bad idea—just that it's not clear that everyone needs it, at least based on available studies.

The USPSTF’s final recommendation echoes a draft report published in August, 2015, one that triggered a sharp response from the Congressional House Autism Caucus. The co-chair U.S.. Reps. Chris Smith (R-NJ) and Mike Doyle (D-PA) asked the task force to re-evaluate its “ill-conceived recommendation.”

The task force’s final decision remains controversial.

It comes at a time when the prevalence of American children diagnosed with autism has risen has increased by 23% since 2008. According to the US Centers for Disease Control and Prevention, that prevalence was 1 on 150 in 2000.

The autism spectrum includes children and adults whose disabilities range from mild-to major impaired social communication, to low IQs and severely impaired functioning. The average age of diagnosis is currently believed to be around four years old.

In four accompanying editorials in JAMA reaction to the decision was split.

“There is ample evidence that justifies the current practice of universal autism screening,” Geraldine Dawson PhD argued in her JAMA editorial. Dawson is director of the Duke Center for Autism and Brain Development at the Duke University School of Medicine “Studies indicate that available screening tools do identify children with ASD who would have been otherwise missed and children who begin intervention at an earlier age have improved outcomes,” she added.

Two psychiatrists suggested in their editorial that the task force’s recommendation could have negative impacts on Medicaid funding for pediatricians who screen toddlers and pre-schoolers for developmental symptoms.

Jeremy Veenstra-VanderWeele MD of the Center for Autism and the Developing Brain at New York Presbyterian Hospital and Kelly McGuire MD of Maine Behavioral Healthcare’s Center for Autism and Developmental Disorders in Portland said the assessments are necessary.

Screening for ASD is needed now “to establish appropriate special education services mandated by the Individuals with Disabilities Education and Improvement Act," they wrote.

The task force recommendation may reinforce the current disparity of children from affluent, well-educated families being diagnosed at an earlier age than those from lower income groups, they added.

Taking the opposite position in their JAMA editorial, two pediatricians endorsed the task force’s findings. “Although this recommendation may be disappointing to many people, the USPSTF has appropriately applied its methodology to the question of ASD screening and has fulfilled its charge of applying rigorous analysis to the best available evidence,” they said.

Instead, the focus should be on the task force's “call for more research,” Michael Silverstein MD, MPH of Boston University Medical School’s division of general pediatrics, and Jenny Radesky MD, of University of Michigan School of Medicine.

The task force called for large randomized clinical trials of treatment of children whose screenings identified ASD, compared with controls.

In another JAMA editorial, Craig M. Powell MD, PhD. of the University of Texas Southwestern Medical Center in Dallas, TX said the USPSTF’s recommendation is not the “death knell” for autism screening. He sees it as but a “call to arms’’ for funding more neurological research to find ways to help patients and their families

The task force also found potential harm should there be false-positive screening results. Those could include the time and expense of the up to 40 hours a week of interventions these children may require.

Nevertheless, neither the task force recommendation nor the editorials questioned whether autism represents a huge public health problem. The lifetime cost of supporting an individual with autism ranges from $1.4 million to $2.4 million, Dawson reported in her editorial.