A review of policy and practices in treating autism spectrum disorder (ASD) published in Policy Insights from the Behavioral and Brain Sciences suggests that the most significant obstacle to effective treatment is the challenge of early detection.
“Intensive behavioral intervention can change the course of development and outcome, especially if intervention begins early in childhood,” the researchers wrote in a recommendation statement, citing that this requires early diagnosis, which is likely to be delayed by as much as 2 years in children from disadvantaged or minority families. They stated that universal ASD screening at 18 and 24 months can significantly close this gap in access, and further, that the Modified Checklist for Autism (revised version) is highly accurate, for initially identifing ASD in minorities.2
Standard developmental screening is already recommended by the American Academy of Pediatrics (AAP) at 9, 18, 24, and 30 months, with additional evaluations specifically targeting ASD at 18 and 24 months.2 The AAP also recommends parental monitoring using tools such as the Parents’ Evaluation of Developmental Status: Developmental Milestones checklist and Ages and Stages questionnaire, although both have low ranges of specificity and high rates of false positives. While only approximately 17% of pediatricians in a 2015 survey followed those recommendations, an estimated 41% said they did do some kind of screening.4
The review pointed to several issues in current policy that hinder early diagnosis, such as a lack of generalized training in monitoring tools and differing standards for the definition of ASD. They and other investigators reported that while most clinicians rely on the Diagnostic and Statistical Manual (DSM), changes in wording to the latest version, DSM-5, might actually narrow the range of children with ASD who would qualify for autism services.5-7 Two other definitions that vary somewhat include the International Classification of Disease and Related Health Problems (ICD-10) developed by the World Health Organization (WHO) and used largely outside of the United States, and Zero to Three, a system published by the National Center for Infants, Toddlers, and Families for use only in children younger than age 5.
The investigators advocate in favor of using the broadest possible definitions to capture the full range of children with ASD. False positives, they argued, are not truly problematic as they usually reveal other types of developmental disorders that also require attention. They recommend universal screening in multiple settings, including pediatrician’s offices and daycare centers, and increasing public awareness of normal development milestones to improve early identification of children with ASD.
In addition, the researchers singled out the current dependence on funding from local tax levels as an impediment to achieving early diagnosis, especially in minorities who often live in lower-income areas.
- Fein D, Barton M, Dumont-Mathieu T. Optimizing outcomes in autism spectrum disorders. Policy Ins Behav Brain Sci. 2017:1-8.
- Khowaja MK, Hazzard AP, Robins DL. Sociodemographic barriers to early detection of autism: Screening and evaluation using the M-CHAT, M-CHAT-R, and follow-up. J Autism Dev Disord. 2015;45:1797-1808.
- Johnson CP, Myers, SM. American Academy of Pediatrics, Council on Children With Disabilities. Identification and evaluation of children with autism spectrum disorders. Pediatrics. 2007;150;1183-1215.
- Self TL, Parham DF, Rajagopalan J. Autism spectrum disorder early screening practices a survey of physicians. Communication Disorders Quarterly. 2015;36:195-207.
- Barton ML, Robins D, Jashar D et al. Sensitivity and specificity of proposed DSM-5 criteria in toddlers. J Autism Dev Disord. 2013;3:1184-1195.
- Christiansz JA, Gray KM, Taffe J, et al. ASD in the DSM-5: Diagnostic sensitivity and specificity in early childhood. J Autism Dev Disord 2016;46:2054-2063.
- McPartland JC, Reichow B, Volkmar FR. Sensitivity and specificity of proposed DSM-5 diagnostic criteria for autism spectrum disorder. J Am Acad Child Adolesc Psychiatry, 2012;51:368-383.