In the JournalsPerspective

USPSTF: Evidence insufficient to support universal ASD screening for infants

Despite widespread criticism of its draft recommendations, the U.S. Preventive Services Task Force has recommended that evidence is currently insufficient to support universal autism spectrum disorder screening for children aged 18 to 30 months, unless concerns are raised by parents or clinicians, according to a statement published in JAMA.

“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,” Albert L. Siu, MD, MSPH, professor of population health science and policy at Mount Sinai School of Medicine, and an USPSTF member, and colleagues wrote. “Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.”

The statement defined the current recommendation as an “I statement,” meaning a statement that concludes the current evidence is insufficient, in lieu of recommending a specific course of action for physicians. The authors recommended that clinicians use their best clinical judgement to determine whether children require screening. The report noted that it is critical for clinicians to listen carefully to parents and consider all available tools when determining the need for further assessments.

Key areas of research that the authors identified as lacking adequate evidence included data related to harms caused by misdiagnosis of ASD, data related to harms caused by treatment for ASD in children without ASD and research demonstrating that early diagnosis results in long-term improvement of ASD symptoms. The authors also highlighted that while screening is fairly safe and easy to administer, the potential effects of long-term treatment on the resources and time of families are not negligible.

The task force also clarified that its recommendation is not an advocation against judicious ASD screening.

“The USPSTF will be clear when communicating this recommendation that it is not recommending for or against screening but advocating for more research,” Siu and colleagues wrote. “In the meantime, clinicians should use their clinical judgment, especially when caring for populations in which case-finding may be difficult because of language, access, or other barriers.”

In a related editorial, Geraldine Dawson, PhD, of the department of psychiatry and behavioral sciences at Duke University, examined the limitations of the USPSTF’s recommendation, while advocating for the continuation of universal ASD screening for infants, a position supported by the AAP.

“Studies indicate that available screening tools do identify children with ASD who would have been otherwise missed and children who begin intervention at an earlier age have improved outcomes,” Dawson wrote. “The current guidelines that encourage universal autism screening offer the best chance for individuals with ASD to reach their full potential and lead productive lives. We should, therefore, stay the course while continuing to advance our knowledge about the full impact of autism screening.”

In another related editorial, however, Michael Silverstein, MD, MPH, of the department of pediatrics at the Boston University School of Medicine, and Jenny Radesky, MD, of the division of developmental behavioral pediatrics at the University of Michigan School of Medicine, offered support for the USPSTF’s recommendation.

“Although this recommendation may be disappointing to many people, the USPSTF has appropriately applied its methodology to the question of ASD screening and has fulfilled its charge of applying rigorous analysis to the best available evidence,” Silverstein and Radesky wrote. “Asking the USPSTF to consider downstream policy or practice ramifications of its decision, or others’ interpretations of it, would be to devalue its critical role as an impartial evaluator of evidence. Professional societies, constituent groups, families, and individual clinicians will need to contextualize the USPSTF’s evaluation within a broader discussion on policy and patient care and assess, based on this broader context, whether universal ASD screening is warranted.” – by David Costill

 

References:

Siu AL, et al. JAMA. 2016;doi:10.1001/jama.2016.0018.
Dawson G. JAMA Pediatr. 2016;doi:10.1001/jamapediatrics.2016.0163.
Silverstein M, et al. J. JAMA. 2016;doi:10.1001/jama.2016.0051.

Disclosure: Dawson reports receiving authorship royalties from Guilford Publications and Oxford University Press and being on the scientific advisory boards of Janssen Research and Development, Roche Pharmaceuticals, Akili and Progeny for which she receives travel reimbursement and honoraria. The other authors report no relevant financial disclosures.

Despite widespread criticism of its draft recommendations, the U.S. Preventive Services Task Force has recommended that evidence is currently insufficient to support universal autism spectrum disorder screening for children aged 18 to 30 months, unless concerns are raised by parents or clinicians, according to a statement published in JAMA.

“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,” Albert L. Siu, MD, MSPH, professor of population health science and policy at Mount Sinai School of Medicine, and an USPSTF member, and colleagues wrote. “Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.”

The statement defined the current recommendation as an “I statement,” meaning a statement that concludes the current evidence is insufficient, in lieu of recommending a specific course of action for physicians. The authors recommended that clinicians use their best clinical judgement to determine whether children require screening. The report noted that it is critical for clinicians to listen carefully to parents and consider all available tools when determining the need for further assessments.

Key areas of research that the authors identified as lacking adequate evidence included data related to harms caused by misdiagnosis of ASD, data related to harms caused by treatment for ASD in children without ASD and research demonstrating that early diagnosis results in long-term improvement of ASD symptoms. The authors also highlighted that while screening is fairly safe and easy to administer, the potential effects of long-term treatment on the resources and time of families are not negligible.

The task force also clarified that its recommendation is not an advocation against judicious ASD screening.

“The USPSTF will be clear when communicating this recommendation that it is not recommending for or against screening but advocating for more research,” Siu and colleagues wrote. “In the meantime, clinicians should use their clinical judgment, especially when caring for populations in which case-finding may be difficult because of language, access, or other barriers.”

In a related editorial, Geraldine Dawson, PhD, of the department of psychiatry and behavioral sciences at Duke University, examined the limitations of the USPSTF’s recommendation, while advocating for the continuation of universal ASD screening for infants, a position supported by the AAP.

“Studies indicate that available screening tools do identify children with ASD who would have been otherwise missed and children who begin intervention at an earlier age have improved outcomes,” Dawson wrote. “The current guidelines that encourage universal autism screening offer the best chance for individuals with ASD to reach their full potential and lead productive lives. We should, therefore, stay the course while continuing to advance our knowledge about the full impact of autism screening.”

In another related editorial, however, Michael Silverstein, MD, MPH, of the department of pediatrics at the Boston University School of Medicine, and Jenny Radesky, MD, of the division of developmental behavioral pediatrics at the University of Michigan School of Medicine, offered support for the USPSTF’s recommendation.

“Although this recommendation may be disappointing to many people, the USPSTF has appropriately applied its methodology to the question of ASD screening and has fulfilled its charge of applying rigorous analysis to the best available evidence,” Silverstein and Radesky wrote. “Asking the USPSTF to consider downstream policy or practice ramifications of its decision, or others’ interpretations of it, would be to devalue its critical role as an impartial evaluator of evidence. Professional societies, constituent groups, families, and individual clinicians will need to contextualize the USPSTF’s evaluation within a broader discussion on policy and patient care and assess, based on this broader context, whether universal ASD screening is warranted.” – by David Costill

 

References:

Siu AL, et al. JAMA. 2016;doi:10.1001/jama.2016.0018.
Dawson G. JAMA Pediatr. 2016;doi:10.1001/jamapediatrics.2016.0163.
Silverstein M, et al. J. JAMA. 2016;doi:10.1001/jama.2016.0051.

Disclosure: Dawson reports receiving authorship royalties from Guilford Publications and Oxford University Press and being on the scientific advisory boards of Janssen Research and Development, Roche Pharmaceuticals, Akili and Progeny for which she receives travel reimbursement and honoraria. The other authors report no relevant financial disclosures.

    Perspective
    Benard Dreyer

    Benard Dreyer

    The American Academy of Pediatrics (AAP) agrees with the call from the U.S. Preventive Services Task Force (USPSTF) for more research on the impact of screening and interventions for children who have autism spectrum disorder (ASD), especially those in early childhood. This critically important research must be funded so we can learn how to better identify children with ASD early in life, and how to design the most effective interventions and treatments.

    However, strong evidence already exists on the benefit of formal screening using standardized tools. This type of screening can identify children with significant developmental and behavioral challenges early, when they may benefit most from intervention, as well as those with other developmental difficulties. For screening to be effective, by design it must be applied to all children – not only those who exhibit overt symptoms, or those an individual clinician judges would benefit. 

    The AAP stands behind its recommendation that all children be screened for ASD at ages 18 and 24 months, along with regular developmental surveillance. This recommendation is encapsulated in the Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents, which serves as the blueprint for well-child visits and coverage under the Affordable Care Act. Health insurance coverage of ASD screening should not be impacted by the USPSTF statement.

    Research shows that early intervention can considerably improve children’s long-term development and social behaviors. The AAP remains committed to providing its 64,000 member pediatricians with the tools and training they need to appropriately identify children with autism spectrum disorder and refer them to the treatment and services they need.

    • Benard Dreyer, MD
    • President American Academy of Pediatrics

    Disclosures: Dryer reports no relevant financial disclosures.