Early Screening For Autism: Moving Forward, Not Backward

autism speaks logo.jpegLast week a review paper published in Pediatrics suggested that there is insufficient evidence to support routine screening for autism in toddlers. While this paper — which is a conceptual piece based on literature review and not a scientific study per se — points out a number of legitimate challenges in screening for autism, the conclusion goes against the current tide of thinking which emphasizes the importance of early identification, particularly in toddlerhood. As such, my impression is that the conclusion of this paper moves our thinking backward, rather than forward.

One of the biggest changes in parenting advice in recent years has been shifting from the “wait and see” approach to “learn the signs and act early.” The idea is to help parents learn about the most important developmental milestones and to be aware of potential signals of problem areas — so that they can work with their pediatrician to track development and determine if and when intervention would be productive. Why? Simply put, early intervention is more likely to have the most pronounced long-term effects on development.

One of the most exciting areas of research on autism focuses on testing new methods for early identification and intervention. The organization Autism Speaks — which supports all kinds of cutting-edge science — nicely summarizes the idea that we should be promoting more screening and improvements in that process rather than less screening, especially as recent studies demonstrate the potential for early intervention to have meaningful effects on development.

As a scientist, I understand that we need to bring a critical eye to our current knowledge base and practices. That said, I also appreciate that we have a public service to not only maintain momentum in research and practice, but to accelerate it when we are talking about developmental disorders such as autism. Discouraging screening for autism runs contrary to the mission of keeping parents as informed as possible about their children’s development, and also could inhibit the critical partnership between parents and pediatricians.

It is certainly true that the current screening for autism is far from an exact science. And I agree that any efforts to improve this process should be a priority for research and clinical practice. But the reality is that we need to serve parents today as we continue to improve our future efforts. Let’s keep moving forward.

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  1. by Angela Sheposh

    On June 23, 2011 at 2:38 pm

    As a mom of four, one of which has significant autism, I don’t think it is a step backward necessarily, but should pediatricians be he ones to screen in the first place. My experience with peds. is that they don’t want to make a judgement from the 10 minutes that the examine the child. the idea of a parent/pediatrician “team” is so out there to me. I don’t think most peds have the time/resources to do this. My suggestion is: follow the parents lead. If a parent suspects, then this is the appropriate time to begin screening. A correct referral to the APPROPRIATE screening agency would come next. The best would be 1) developmental pediatrician 2) private child physcologist 2) school district. It would be nice if primary pediatricians triage cases/concerns (not screen) to speed up the evaluation process so that the more significant/obvious cases could be seen first. When I first went to our ped with concerns a few names were given along with the statement that it’s a long wait list and that he could not help to get us in any quicker. And so I was left on my own to make tearful calls and dispairing emails to obtain my own emergency evaluation with a private psychologist. Because of this we began services a few months later, right after henturned two.

  2. by Melanie

    On June 23, 2011 at 3:03 pm

    As a mother of a child with Autism I highly disagree with early testing not helping. My son was first screened at 16 months of age. Due to the results of that testing he was set up with Early Intervention, and private therapies. We got a referral for a Developmental Pediatrician and then for full Autism testing. All of this was finish and we had a diagnosis of Autism a few months before his third birthday. Without this testing my son wouldn’t have been diagnosised at all, nor would we have been able to get him into the preschool he will be stating in about a week. We’ve been doing private therapy for almost a year now. I’ve seen great results with this as well. His language has improved dramatically. These kids need screenings sooner, they need therapy sooner, treatments need to be done. Without these things these kids will not get everything that they need.

  3. by Jill Cordes

    On June 23, 2011 at 7:17 pm

    Hi Richard. I’m another blogger on Parents with you. I saw this and while my daughter Fia is developing completely normal, I will say I felt reassured by answering the questionare my pediatrician gave me at her 18 month appointment. It only took a few minutes but it gave me a clear idea of the types of things a parent might want to be on the look out for in regards to Autism. I have a severely autistic nephew, but even with that, I found the questions useful just for my general knowledge. I agree with you, that getting rid of tools like that, is moving backwards. It just doesn’t make much sense to me.

  4. by Julia

    On June 24, 2011 at 7:51 pm

    I definitely see what you are saying. But I think that this paper is maybe better addressed from a public health perspective rather than a theoretical perspective, if that makes any sense. Early intervention and screening should certainly be encouraged, as you say, but if the *current* screening test is not cost-effective (low specificity), then it should definitely be reevaluated…

    I guess what I mean is, if the authors’ intent was to reexamine the current screening process, then I agree; if their intent was to criticize the concept of early intervention in general, then the paper is most definitely a step in the wrong direction.

  5. by Richard Rende

    On June 25, 2011 at 10:33 am

    Thanks to everyone for their comments. Each of you raised an important point:

    Angela, I think you make an important observation about getting pediatricians more engaged in early identification and also the referral process (which you had to take on yourself). So that’s in part why I favor continuing having pediatricians perform universal screenings and hope that we can improve the method and lessen the burden on parents.

    Melanie, I think your experience serves as a great example of the spirit of “learn the signs and act early” – I’m pleased that you found intervention to be helpful and agree with you that the earlier, the better (especially given the newer interventions under study).

    Jill, I really like your comment, because it emphasizes a point I didn’t make — the screening is useful for all parents and serves to orient us to what the early signs of autism are (and what they aren’t). Sharing with parents the most important developmental signals in multiple domains (social, language, motor) gives them a clearer picture of their child’s current development.

    Julia, you raise a really important perspective that hits the nail on the head in terms of my issue with the paper and its conclusion. The authors report that one of the screening instruments has a high specificity (98%) but a lower sensitivity (20-38%) – but the next level of assessment using the gold standard diagnostic interview has a specificity of 85% and and sensitivity of 75%. So all in all this process is working reasonably well especially for a behavioral condition with (in the majority of cases) no known biomarker. The authors focus more on the need for randomized controlled trials and what they consider to be a lack of efficacious treatment. So as you point out, when you look at the big picture, it really seems to be the case that improving, rather than abandoining, early screening seems to be the most logical viewpoint that serves children and parents best.

    Thanks again to all of you for taking the time to write.