› Screen children for developmental delays with a standardized screening tool at 9, 18, and 24 or 30 months of age, accompanied by surveillance at all well-child visits. C
› Use a parent-completed tool rather than a directly administered tool to screen for developmental delays. C
›Advise parents of a child diagnosed with autism spectrum disorder that early intensive behavioral therapy can improve cognitive, language, and adaptive skills. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Autism spectrum disorder (ASD) affects approximately one in 68 children in the United States, according to the Centers for Disease Control and Prevention (CDC).1 Growing public awareness of autism means that family physicians are increasingly likely to hear from anxious new (and expectant) parents. Unfortunately, misinformation about autism continues to be perpetuated, through word of mouth, the Internet, and misinformed advocacy groups. This article addresses 5 of the most common misconceptions, and can help you set the record straight and respond appropriately to parental concerns.
Misconception 1: Autism is a single condition
While autistic disorder was previously considered one of 5 pervasive developmental disorders, in 2013 the Diagnostic and Statistical Manual of Mental Disorder, 5th edition (DSM-5) redefined it. (To learn more about how shifts in our understanding of autism were reflected in each new edition of the DSM, see “Autism: Why the rise in rates?”)
ASD is now an umbrella term that encompasses autism, Asperger syndrome, pervasive developmental disorder not otherwise specified, childhood disintegrative disorder, and Rett syndrome.2 The new term is meant to highlight the continuum of symptoms and frequent variability of presentation among those affected, ranging from mild to more severe impairment. Anyone who was classified under DSM-IV criteria, of course, should continue to have an autism/ASD diagnosis.
As with previous definitions, ASD is characterized by communication deficits (eg, inappropriate responses in conversation, misinterpreted nonverbal interactions, and significant challenges in age-appropriate bonding/friendship development). While previous definitions were focused on identifying school-age deficits, the update requires early childhood symptoms—regardless of the age of formal diagnosis.2
Misconception 2: Only symptomatic children should be screened for ASD
Although the decision to screen all children remains a controversial one, at least one medical society—the American Academy of Pediatrics (AAP)—calls for universal screening.3 The American Academy of Family Physicians does not have or endorse a formal guideline about screening for ASD. The US Preventive Services Task Force has a guideline, but it is in the process of being revised.4
Given the advances in early childhood interventions, there is little doubt that early identification of those at risk for developmental delay is beneficial. But opponents of universal screening cite concerns about unnecessary testing, anxiety, and overdiagnosis due to false positives associated with traditional screening methods.
The AAP calls for screening and surveillance. Since 2006, the AAP has recommended surveillance at all well-child visits, combined with screening for developmental delays at 9, 18, and 24 or 30 months of age, using a standardized screening tool.3,5 A parent-completed tool (eg, the Modified Checklist for Autism in Toddlers [M-CHAT] or, most recently, the M-CHAT Revised with Follow-up6; Parents’ Evaluation of Developmental Status; or Ages and Stages Questionnaire, 3rd ed) should be used rather than a directly administered tool.3,5 An algorithm detailing the AAP’s approach is available at http://www.cdc.gov/ncbddd/actearly/autism/case-modules/pdf/diagnosis/AAP....
Physicians should also be prepared to evaluate any child whose parents raise concerns about his or her development during a routine visit. A “wait and see” approach is strongly discouraged. Parents of children with ASD often broach the subject by the baby’s first birthday.5 Common concerns include the child’s inability to babble, point or gesture meaningfully, or respond to his or her name; poor eye contact; failure to play with toys; and/or loss of (or failure to develop) language or social skills.5
An ASD mnemonic. The CDC, in collaboration with the AAP, the American Academy of Neurology, and the Child Neurology Society, has released a simplified guideline with the mnemonic ALARM to summarize recommendations for developmental screening, surveillance, diagnosis, and management of ASD.5 ALARM stands for:
• Autism is prevalent
• Listen to parents
• Act early
Misconception 3: Since ASD can't be cured, early intervention offers no benefit
While there is no cure for ASD and it is not considered reversible, there is an array of potential ASD therapies and proven benefits of early intervention. Therapies range from diet to medication and behavioral skills development, but only a few have ample evidence of efficacy (TABLE).7-17