Summary of Recommendation and Evidence
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for autism spectrum disorder (ASD) in young children for whom no concerns of ASD have been raised by their parents or a clinician (Table 1). I statement.
|Population||Children aged 18 to 30 months for whom no concerns of ASD have been raised by their parents or a clinician|
|Grade: I (insufficient evidence)|
|Risk assessment||Although a number of potential risk factors for ASD have been identified, there is insufficient evidence to determine if certain risk factors modify the performance characteristics of ASD screening tests, such as the age at which screening is performed or other characteristics of the child or family.|
|Screening tests||The most commonly studied tool is the Modified Checklist for Autism in Toddlers (M-CHAT) and its subsequent revisions. A positive finding should lead to a follow-up interview, which, if positive, should lead to a full diagnostic workup for ASD.|
|Treatment and interventions||Treatments for ASD include behavioral, medical, educational, speech/language, and occupational therapy and complementary and alternative medicine approaches. Treatments for young children are primarily behavioral interventions, particularly early intensive behavioral and developmental interventions.|
|Balance of benefits and harms||The USPSTF concludes that there is insufficient evidence to assess the balance of benefits and harms of screening for ASD in young children for whom no concerns of ASD have been raised.|
|Other relevant USPSTF recommendations||The USPSTF has made a recommendation on screening for speech and language delays and disorders among children 5 years or younger. This recommendation is available on the USPSTF website (http://www.uspreventiveservicestaskforce.org).|
See the Clinical Considerations for suggestions for practice regarding the I statement.
ASD is a developmental disorder characterized by persistent and significant impairments in social interaction and communication and restrictive and repetitive behaviors and activities, when these symptoms cannot be accounted for by another condition. In 2010, the prevalence of ASD in the United States was estimated at 14.7 cases per 1,000 children, or 1 in 68 children, with substantial variability in estimates by region, sex, and race/ethnicity.1
The USPSTF found adequate evidence that currently available screening tests can detect ASD among children aged 18 to 30 months.
BENEFITS OF EARLY DETECTION AND INTERVENTION OR TREATMENT
The USPSTF found inadequate direct evidence on the benefits of screening for ASD in toddlers and preschool-age children for whom no concerns of ASD have been raised by family members, other caregivers, or health care professionals. There are no studies that focus on the clinical outcomes of children identified with ASD through screening. Although there are studies suggesting treatment benefit in older children identified through family, clinician, or teacher concerns, the USPSTF found inadequate evidence on the efficacy of treatment of cases of ASD detected through screening or among very young children. Treatment studies were generally very small, few were randomized trials, most included children who were older than would be identified through screening, and all were in clinically referred rather than screen-detected patients.
HARMS OF EARLY DETECTION AND INTERVENTION OR TREATMENT
The USPSTF found that the harms of screening for ASD and subsequent interventions are likely to be small based on evidence about the prevalence, accuracy of screening, and likelihood of minimal harms from behavioral interventions.
The USPSTF concludes that there is insufficient evidence to assess the balance of benefits and harms of screening for ASD in children aged 18 to 30 months for whom no concerns of ASD have been raised. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
PATIENT POPULATION UNDER CONSIDERATION
This recommendation applies to children who have not been diagnosed with ASD or developmental delay and for whom no concerns of ASD have been raised by parents, other caregivers, or health care professionals.
A number of tests are available for screening for ASD in children younger than 30 months. The most commonly studied tool is the Modified Checklist for Autism in Toddlers (M-CHAT) and its subsequent revisions (Modified Checklist for Autism in Toddlers With Follow-Up [M-CHAT-F] and Modified Checklist for Autism in Toddlers–Revised, With Follow-Up [M-CHAT-R/F]). The M-CHAT-R/F is a parent-rated scale, and a positive finding leads to a follow-up interview. If the follow-up interview is positive, a full diagnostic workup for ASD is indicated. The screening process assesses communication skills, joint attention, repetitive movement, and pretend play.
TREATMENTS AND INTERVENTIONS
Treatments for ASD include behavioral, medical, educational, speech/language, and occupational therapy and complementary and alternative medicine approaches. Treatments for young children in the target age group for routine screening for ASD are primarily behavioral interventions, particularly early intensive behavioral and developmental interventions, which may include approaches incorporating applied behavior analysis principles, parent training components, and play- or interaction-based interventions. Among the behavioral interventions, those based on applied behavior analysis have the highest-quality data supporting their effects on cognitive and language outcomes. These interventions can be delivered in a home or school setting and are generally time-intensive, with some programs requiring up to 40 hours a week.2
SUGGESTIONS FOR PRACTICE REGARDING THE I STATEMENT
Potential Preventable Burden. Autism spectrum disorder can cause significant social, communication, and behavioral challenges for affected children and place substantial strain on family members and other caregivers. Treatment and maturation may reduce the effects of the core symptoms of ASD for some children, but others may experience long-term effects on education, employment, and ability to live independently.2 It is important that clinicians listen carefully to parents when concerns are raised by the parents or during an examination and make prompt use of validated tools to assess the need for further diagnostic testing and services. Disparities have been observed in the frequency and age at which ASD is diagnosed among children by race/ethnicity, socioeconomic status, and language of origin, creating concern that certain groups of children with ASD may be systematically underdiagnosed.3 It is important to note that an “I” statement is not a recommendation for or against screening. In the absence of evidence about the balance of benefits and harms, clinicians should use their clinical judgment to decide if screening in children without overt signs and symptoms is appropriate for the population in their care.
Potential Harms. Although there is limited evidence about the harms of screening for ASD in children, reported potential harms include misdiagnosis and the anxiety associated with further testing after a positive screening result, particularly if confirmatory testing is delayed because of resource limitations. Behavioral treatments are not generally thought to be associated with significant harms but can place a large time and financial burden on the family. Other treatments for ASD are less well studied and were not included in this review.
Current Practice. A 2004 survey of pediatricians in Maryland and Delaware found that 8% screened specifically for ASD. Few data are available regarding the current prevalence of screening for ASD by clinicians in the United States.4 More recent surveys have found higher rates, although they remain less than 60%.5–8
The Centers for Disease Control and Prevention provides web-based continuing education for clinicians called Autism Case Training (available at http://www.cdc.gov/ncbddd/actearly/autism/case-modules/index.html), as well as other information about ASD for families (available at http://www.cdc.gov/ncbddd/autism/families.html).
The Health Resources and Services Administration's website provides links to training resources for professionals (available at http://mchb.hrsa.gov/programs/autism/trainingforprofessionals.html).
The M-CHAT screening tool is available online for free at https://m-chat.org/. Other professional and advocacy organizations have also developed toolkits and resources.
The USPSTF has made a recommendation on screening for speech and language delays and disorders among children 5 years or younger (available at http://www.uspreventiveservicestaskforce.org).
This recommendation statement was first published in JAMA. 2016;315(7):691–696.
The “Other Considerations,” “Discussion,” and “Recommendations of Others” sections of this recommendation statement are available at http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/autism-spectrum-disorder-in-young-children-screening.
The USPSTF recommendations are independent of the U.S. government. They do not represent the views of the Agency for Healthcare Research and Quality, the U.S. Department of Health and Human Services, or the U.S. Public Health Service.