AAP suggests children be screened twice for autism before 2 years of age

December 2007

SAN FRANCISCO – Since the prevalence of autistic spectrum disorders has significantly increased, the AAP now recommends that every child be screened for autism twice before the age of 2 years.

“There is no question that there has been an increase in the prevalence of autism spectrum disorders as they are currently defined and operationally diagnosed,” Scott M. Myers, MD, a neurodevelopmental pediatrician at the Janet Weis Children’s Hospital and Geisinger Medical Center, in Danville, Pa., told Infectious Diseases in Children. “To a large extent, this is related to liberalization of the way the diagnostic criteria are applied and ascertainment, how hard we are looking for these disorders and what tools we are using to look for them. Whether there has been a true secular, biological increase in these disorders is a question that remains open to debate.”

James Coplan, MD, of the University of Pennsylvania, told Infectious Diseases in Children, “there are some data to suggest that the prevalence of children who meet the definition of autism are somewhere in the neighborhood of about 1%, and with some children, it is very clear from the beginning that they have this disorder. These are the children who come into the world with autism.”

Identifying the disorder

Autistic spectrum disorders encompass many characteristics and include autistic disorder and Asperger’s syndrome, which are further categorized as pervasive developmental disorders. A child with autistic disorder may have an impairment with social interaction and communication. Children with Asperger’s syndrome also have difficulties in social interactions, but they are different from children with other spectrum disorders in that a child with Asperger’s syndrome has no general delay in language or cognitive development. Although delays in language development may prompt a parent to be concerned with their child’s development, Myers and Chris Plauche Johnson, MD, identified in a recent clinical report earlier for parents to look for that may lead to an earlier diagnosis:

• The child does not respond when a parent calls their name.
• The child does not turn and look when a parent points at an object or does not point at an object themselves to show a parent an interesting object.
• A lack of babbling.
• Failure to make eye contact.
• Smiling late.

If a child does not babble or point by 12 months, does not speak single words by 16 months, does not speak two-word spontaneous phrases by 24 months, and has a loss of language or social skills at any age, an immediate evaluation should be requested.

“Autism spectrum disorders occur in nearly one out of 150 children according to more recent epidemiological studies from the CDC and others, so general pediatricians will be taking care of children with autism. A recent survey suggested that 44% of general pediatricians have reported taking care of at least 10 children with this disorder,” Myers said.

“This is a problem that physicians will see and find that it is associated with significant morbidity, an increase in health care utilization and an increase in health care and other costs. Pediatricians are in a position where they are crucial in the early recognition of these disorders and can guide families to diagnostic resources, take part in the medical evaluation after a diagnosis has been made and take care of these children longitudinally. These are chronic conditions,” he said.

In another clinical report by Myers and Johnson, the researchers reiterated the importance of identifying these disorders as early as possible for better outcomes with early intensive intervention.

“Autism does not go away, but therapy may help the child cope in regular environments. Therapy helps children want to learn and communicate,” Johnson, clinical professor of pediatrics at the University of Texas Health Science Center, said in a press release.

Autism spectrum disorder treatment programs may have different strategies, but according to the researchers, they share common goals, which include but are not limited to:

• Intervention as soon as diagnosis is considered, rather than waiting until a definitive diagnosis.
• Intensive intervention consisting of at least 25 hours per week, 12 months a year of active engagement with the child.
• A low student–teacher ratio to meet individualized goals.
• Emphasis on promoting functional, spontaneous communication.

Challenging behaviors such as aggression and self-injury that are associated with autism spectrum disorders in some children can be treated behaviorally and, in some cases with pharmacologic interventions.

“Many parents are interested in complementary and alternative medicine treatments, so it is important for pediatricians to maintain open communication and continue to work with these families, even if there is disagreement about treatment choices,” Myers said. “It is also important to critically evaluate the scientific evidence of effectiveness and risk of harm and convey this information to families.”

“The more information the physician can give a family, the better, because when there is an absence of good information, the void is often filled with bad information from unreliable sources. So rather than avoiding discussion of unsubstantiated theories and treatments, it is better to act proactively on this matter,” Myers said.

For more information:

• Myers S, Johnson C. Management of children with autism spectrum disorders. Pediatrics. 2007;120:1162-1182.
• Johnson C, Myers S. Identification and evaluation of children with autism spectrum disorders. Pediatrics. 2007;120:1183-1215.
• Check out this newspaper’s February issue for a round table discussion on this subject, or visit www.aap.org.