Screening for autism spectrum disorder in young children

Article Reviews
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Read Full Text: Screening for autism spectrum disorder in young children: US preventive services task force recommendation statement (Free to download)
Journal: JAMA - Journal of the American Medical Association (Impact factor 47.6 in 2017)
Year Published: 2016
Ranked 16th on our 2014-2019 list of the 50 most influential articles

Article overview for OTs

This article outlines the recommendations from the US Preventive Services Task Force on whether all children between 18-30 months should be screened for Autism Spectrum Disorder (ASD).

The task force concluded that there was insufficient evidence to make a recommendation for screening. There simply were not enough studies about whether the benefits of screening outweigh the potential harms.

This is an article where there is a lot more to the study than you might think…so definitely keep reading!

How the recommendations were established

The US Preventive Services Task Force publishes recommendations about screening and prevention. Here’s what they found regarding screening for autism:

  1. There are screens that can detect ASD between 18-30 months of age.
  2. There simply were not high-level studies about the clinical outcomes of those children with ASD who are identified by these screens.
  3. The potential harm of treatment is likely to be small. (But, treatment can place a large time and financial burden on the family.)

Again, the evidence was simply insufficient about screening.

How was OT involved?

Occupational therapy was highlighted as a current treatment for autism.

It is important for therapists to note a few points about diagnosis of ASD:

  1. Disparities have been observed in the frequency and age at which ASD is diagnosed. Race/ethnicity, socioeconomic status, and language of origin all impact diagnosis age, creating concern that certain groups of children with ASD may be systematically underdiagnosed.
  2. The article alludes to the fact that many children are older than 18-30 months when they are diagnosed. Up-to-Date confirms that the median age of diagnosis is currently four years old.

What assessments are highlighted?

The most commonly studied tool is the Modified Checklist for Autism in Toddlers (M-CHAT) which is parent-reported and available online for free.

Who else is weighing in

This is such an important topic, and many additional agencies beyond the US Preventive Services Task Force have weighed in. And, what is really interesting is that not all of the recommendations are the same.

I have listed a few recommendations from the article. I only listed ones I was able to double check to ensure they’re still currently recommended:

Takeaways for OT

This is an important upstream issue for OTs

Screening is an important upstream issue for occupational therapy practitioners because it affects who is (and who isn’t) making it onto our caseloads.

The efficacy and wide availability of screens is also very important for us to be aware of.

A great reminder of how complex many healthcare issues are— and how, at the end of the day, it comes down to your clinical reasoning and the patient in front of you

This article is redundant on a very important topic: “clinicians should understand the evidence, but individualize decision making to the specific patient or situation.” If I may be so bold, I think this extends beyond autism screening and beyond primary care but is a nice summary of the basic role of any health care provider.

Listen to a summary in podcast form

Find other platforms for listening to the OT Potential Podcast here.

What questions/thoughts does this article raise for you?

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Love this article!! As a pediatric OT I continue to challenge myself to learn more about Autism with each year that goes so I can better serve the families I serve.

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I really enjoyed this article. I agree with the Amer. Academy of Neurology and the Child Neurology Society regarding developmental screening. The number one most important component when working with children is empowering their parents/caregivers. Screening is a first step to build a relationship and offer support to the families. Knowledge is power. They can then make informed decisions about any further treatment interventions.

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Thank you for this article @SarahLyon!

I definitely see disparities among families with low socioeconomic status and families in minorities getting to the services they are in need of or even being aware of the potential for an early diagnosis of autism. I think having a good relationship with a local developmental pediatrician has helped with early detection in my work.

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It is great to hear that you have an opportunity to work with a supportive developmental pediatrician. I am not a Peds OT so would like to know if the pediatrician administers screening tests or teaches parents to perform the M-Chat to identify any potential problems? Thank you.

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Thank you for the article Sarah! I agree with Katie that there are differences based on economic disparities. I used the M-CHAT several years ago with a mom who had twins with delays. Based on the positive results, I recommended the parents go see a developmental pediatrician to further delve into the delays and issues. The children did end up with formal diagnoses of Autism which helped them access more help. That being said, all families and parents are at different stages with the process of considering an Autism Spectrum diagnosis and some are clearly not ready and providers respond accordingly. Here is a link to an article on the stages parents go through with the process. https://themighty.com/2015/07/6-stages-of-grief-as-a-special-needs-mom/. I myself would want to know as soon as possible to get the best services started but in my experience, not everyone is ready (denial stage).

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Great article and I’m excited about the research that is being done to bring more awareness and hopefully more and earlier intervention!

I recently transitioned to working in the pediatric world so I’m learning so much about sweet kiddos with autism and about their families. I’ve seen first hand how important early diagnosis is and the challenges of families to get the appropriate resources they need for the children. A question I would love to hear feedback on is “do you think a lack of resources and ability to pay for additional services can cause some health professionals to delay diagnoses?” Also, “does lack of resources/funding contribute to fear/denial in parents?”

Just a little side note and challenge :blush:

I feel very blessed; the outpatient pediatric clinic where I work PRN in West Texas has a HUGE donor sponsorship program. The mission of the program is that every patient who has a need for services will be treated, even in financial hardships. So year round they have auctions, telethons, fun runs, etc… to raise money for the program to sponsor therapy for children. Families can apply for assistance. I can get exact number, but I’m guessing more than half of the patients are on 100% donor sponsorship. I had never seen anything like this. It was eye opening as well as an opportunity to consider how we as therapist can advocate and get scholarship programs in place to help these sweet kiddos and families!!

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Hey @Katie! The disparities between different children getting treatment is really disheartening. I agree with you that having a good relationship with our local doctors seems to be an important first step to early detection. I’m also intrigued by @Rsaltzgaber’s comments below about how funding seems to be an underlying issue.

I’m excited for (and planning on) our health care systems being rebuilt over our lifetime to have a focus on early detection/prevention/interdisciplinary care – because that is what seems to work!

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Hey @sanchala! It seems like this all depends on knowing your local doctors. Some may already perform the screening, but, for example, in rural Nebraska where I live, I can see helping the parent perform the screen then working with our general practice doctor to get a referral to the right specialist.

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Wow! Every OT should read that article! What a simple line to use- “What does your child do well?”

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@Rsaltzgaber, are you able to share where you work? I really want to read up on the business model of the program. I am always so inspired to read about different models of funding!

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I worked as a substitute paraprofessional and did a little OT work as a COTA at a public school for Autistic children aged 7-14 years old, with less than 20 children. Most were gifted in one way or another and all displayed behavioral problems and OT can definitely be helpful with teaching coping skills and also how to behave in the community as they grow into young adults and for other modalities and media most therapeutic pertaining to that individual. Like all clients, OT administers therapy to, it is customized treatment. I do believe educating parents on ASD If the pediatrician sees any warning signs to make them aware in order to get the best resources and help available early. But to have a positive attitude and know that children with ASD can have a better life if in the right supportive environment.

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I am so glad that you posted this article. Being a peds OT and working in early intervention, autism screens are a regular thing within my line of work. All kiddos that get referred to the regional center that are 18 months old or older, automatically get a MCHAT screen during their initial evaluation. While I perform the developmental evaluation, the service coordinator will complete the MCHAT with the parents. If there are any red flags, the coordinator will then recommend further testing with a psychological evaluation to figure out if it is truly autism or a pending diagnosis (maybe the kiddo is still too young to officially diagnose) or rule it out altogether.

The evaluation is free which does away with the funding limitation for the screen and they can be done in the client’s house thus eliminating transportation as an issue, but somehow the child needs to be referred to the regional center in the first place which is prolly the biggest limitation. Many families do not even know that the regional center exists and therefore are unable to utilize the resources that they provide. Also, the psychological evaluation is not mandatory so even if a child is found to have a positive MCHAT, the parents can turn down the psychological eval.

After listening to the podcast episode, I got to thinking what the numbers look like with how many kiddo’s MCHATs result in a positive and then how many actually get a psych eval. Furthermore, I’d be curious how many actually receive an official or pending diagnosis. This article definitely got me thinking :thinking:

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I work at West Texas Rehab in Abilene. You can follow them on Facebook to see all of their fundraisers and events.

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@Rsaltzgaber, I am loving looking at the West Rehab website. Your company has such a great mission – and it is so great to have a foundation dedicated to fundraising! (The goat fundraiser is also cracking me up! Sounds like something that could happen in Kenesaw!)

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Yes so Kenesaw!! Hahaha! Right at home! :slight_smile:

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Thanks for the article review. I think one of the best indicators that a child may have autism is the lack of joint attention by age 1. At that age, a child should be able to gain an adult’s attention to look at the object or action that holds their interest. That is such a simple thing to observe and takes no clinical background! How do we get that information out to more parents/grandparents?

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Wow, this is a great question that I think about a lot- how to we share information more readily with the general public? I’m really thankful for trailblazers like Rachel Coley (the OT that runs can-do kiddo) who have done a great job connecting directly with parents on a broad scale. (Rachel especially does a great job with educating parents that have concern about head-shape. Here’s her website: http://www.candokiddo.com/ )

I also wish that when I was working at a small critical access hospital, I had been more intentional about meeting with our general practice doctors to understand better then screens they were doing at well-child visits.