USPSTF Fails to Recommend Autism Screening for All Kids

The US Preventive Services Task Force (USPSTF) today found insufficient evidence for or against screening all toddlers between ages 18 and 30 months for autism, a judgment call that has already set off criticism from specialists who say it will lead to disparities in care.

The decision, published today in JAMA, was based on the lack of evidence of “to assess the balance of benefits and harms” of screening all children for autism spectrums disorders (ASD), when symptoms are not present and when no concerns “have been raised by their parents or a clinician.”

USPSTF’s decision doesn’t mean early screening won’t occur, but critics say it will almost certainly mean that cases of ASD will be overlooked. Under the Affordable Care Act, the group’s verdict on preventive health services typically decides if insurers will pay for benefits such as screenings.

As rates of children diagnosed with ASD rise, the call to screen all young children comes with the knowledge that earlier diagnosis and treatment bring better outcomes. The American Academy of Pediatrics (AAP) has recommended ASD screening since 2007, and many experts believe that the pediatricians’ endorsement will ensure coverage despite the USPSTF decision.

But that didn’t stop some harsh criticism today.

In an editorial in JAMA Psychiatry, Jeremy Veenstra-VenderWeele, an associate professor of psychiatry at Columbia University, said families of means who suspect something is amiss will press hard for a referral for screening, “Whereas the family without those resources won’t necessarily push or be in a position to push in the same way.”

While praising the historic work of USPSTF generally, he noted the lack of experts on the panel in developmental medicine or child mental health. He also noted that the recommendation is “most jarring when juxtaposed against the decision that the guideline should not apply to children when the healthcare professionals have concerns about ASD.”

Such concerns would not come up in a normal wellness visit, Veenstra-VenderWeele and others suggest, but would be brought up proactively by an especially astute parent. The problem is that ASD can cover a wide range of symptoms, and not all parents or caregivers know them.

The most commonly studied tool for evaluating whether a child has ASD is the Modified Checklist for Autism in Toddler, or the M-CHAT, and its revisions, along with parent interviews. If these are positive for ASD, a full diagnostic work-up is indicated, which covers communication skills, joint attention, repetitive movement, and pretend play, according to the USPSTF authors.

The USPSTF recommendation comes despite the AAP’s strong recommendation for widespread screening, and its own finding that “the harms of screening for ASD and subsequent intervention are likely to be small, based on evidence about the prevalence, accuracy of screening, and likelihood of minimal harms from behavioral interventions.”

In a statement today, AAP President Bernard Dwyer, MD, FAAP, endorsed USPSTF’s call for additional research on the impact of screening and intervention, but said, “Strong evidence already exists on the benefit of formal screening using standardized tools. This type of screening can identify children with significant developmental and behavioral challenges early, when they may benefit most from intervention, as well as those with other developmental difficulties.”

For screening to be effective, Dwyer said, “by design it must be applied to all children—not only those who exhibit overt symptoms.”

In a statement, the advocacy group Autism Speaks expressed disappointment with USPSTF’s finding.

“Autism starts very early in brain development, and its symptoms can be detected by age 2. We have a broad consensus, based on research, that early intervention for autism results in better outcomes. Yet to our great disappointment—and against expert counsel—the US Preventive Services Task Force has refused to recommend universal autism screening. Unfortunately, the USPSTF statement risks misleading families—and health insurer—on the value of autism screening for all children.’’

Reference

Siu AL, for the USPTF. Screening for autism spectrum disorder in young children: US Preventive Services Task Force Recommendation Statement. JAMA. 2016;315(7):691-969. doi:10.1001.jama.2016.0018.