Autism Spectrum Disorder: Primary Care Principles

 

Am Fam Physician. 2016 Dec 15;94(12):972-979A.

  Patient information: See related handout on autism spectrum disorder, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Autism spectrum disorder is characterized by difficulty with social communication and restricted, repetitive patterns of behavior, interest, or activities. The Diagnostic and Statistical Manual of Mental Disorders, 5th ed., created an umbrella diagnosis that includes several previously separate conditions: autistic disorder, Asperger syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. There is insufficient evidence to recommend screening for autism spectrum disorder in children 18 to 30 months of age in whom the disorder is not suspected; however, there is a growing body of evidence that early intensive behavioral intervention based on applied behavior analysis improves cognitive ability, language, and adaptive skills. Therefore, early identification of autism spectrum disorder is important, and experts recommend the use of a validated screening tool at 18- and 24-month well-child visits. Medications can be used as adjunctive treatment for maladaptive behaviors and comorbid psychiatric conditions, but there is no single medical therapy that is effective for all symptoms of autism spectrum disorder. Prognosis is heavily affected by the severity of diagnosis and the presence of intellectual disability. Children with optimal outcomes receive earlier, more intensive behavioral interventions and less pharmacologic treatment.

Autism was first described by psychiatrist Leo Kanner in 1943 as a disorder in children who had problems relating to others and a high sensitivity to changes in their environment.1 Although it appeared to be a rare disorder at that time, the prevalence of autism spectrum disorder (ASD) steadily increased. The Centers for Disease Control and Prevention's (CDC's) monitored network of 11 locations has described an autism prevalence of one in 68 children, with a male-to-female ratio of 4.5-to-1.2 These data correlate with other studies across multiple nations and widely separated locations.3,4 The increase in ASD prevalence may be partially attributed to the evolving diagnostic criteria prior to the publication of Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), an increase in social awareness, and mandatory availability of treatments. Additionally, school-aged children with higher functioning are being diagnosed with previously unrecognized ASD.57 In 2013, DSM-5 created the umbrella diagnosis of ASD, consolidating four previously separate disorders: autistic disorder, Asperger syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified.8

WHAT IS NEW ON THIS TOPIC: AUTISM SPECTRUM DISORDER

The U.S. Preventive Services Task Force concluded that current evidence is insufficient to assess the balance of benefits and harms of screening for autism spectrum disorder in young children for whom no concerns of autism spectrum disorder have been raised by their parents or a clinician.

In 2014, an Agency for Healthcare Research and Quality systematic review found a growing body of evidence that an applied behavior analysis–based early intensive behavioral intervention, delivered over an extended time frame, improves cognitive ability, language, and adaptive skills in autistic children.

More than 80% of patients with autism spectrum disorder retain the same level of severity on repeat assessment over an eight- to 10-year interval.

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Screening for autism spectrum disorder with a validated tool is recommended at 18- and 24-month well-child visits to assist with early detection.

C

33, 35

In children with autism spectrum disorder, an applied behavior analysis–based early intensive behavioral intervention delivered over an extended time frame improves cognitive ability, language, and adaptive skills.

B

39

Cognitive behavior therapy is effective at lowering anxiety in older children with autism spectrum disorder who have an average or above-average IQ.

A

39

Melatonin helps manage sleep disorders, improves daytime behavior, and has minimal adverse effects in children with autism spectrum disorder.

A

25, 26


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Screening for autism spectrum disorder with a validated tool is recommended at 18- and 24-month well-child visits to assist with early detection.

C

33, 35

In children with autism spectrum disorder, an applied behavior analysis–based early intensive behavioral intervention delivered over an extended time frame improves cognitive ability, language, and adaptive skills.

B

39

Cognitive behavior therapy is effective at lowering anxiety

The Authors

show all author info

KRISTIAN E. SANCHACK, CDR, MC, USN, is the program director of the Family Medicine Residency Program at Naval Hospital Jacksonville (Fla.)....

CRAIG A. THOMAS, LT, MC, USN, is a staff physician at Naval Hospital Pensacola (Fla). At the time the article was submitted, Dr. Thomas was a third-year resident in the Family Medicine Residency Program at Naval Hospital Jacksonville.

Address correspondence to Kristian E. Sanchack, CDR, MC, USN, Naval Hospital Jacksonville, Family Medicine Clinic, 2080 Child St., Jacksonville, FL 32214 (e-mail: Kristian.e.sanchack.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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