In the Journals

USPSTF ASD screening recommendation elicits concern from psychiatrists

Psychiatric researchers have expressed significant concern regarding the recent recommendation from the U.S. Preventive Services Task Force on screening for autism spectrum disorder, according to an editorial in JAMA Psychiatry.

“Finding insufficient evidence that screening for ASD changes outcomes in 18- to 30-month-old children, the [U.S. Preventive Services Task Force (USPSTF)] landed in a gray zone of neither supporting nor opposing screening. Instead, they deferred decision making to families and clinicians,” Jeremy Veenstra-VanderWeele, MD, of Columbia University, New York, and Kelly McGuire, MD, MPA, of Center for Autism and Developmental Disorders, Maine Behavioral Healthcare, Portland, wrote in the editorial. “This lack of endorsement, if followed by state Medicaid boards, could eliminate the funding for pediatricians to elicit developmental symptoms in toddlers or preschoolers.”

Based on a systematic review of evidence on accuracy, benefits and potential harms of brief, formal screening instruments for ASD administered during routine primary care visits, the task force concluded that there is insufficient evidence to assess the benefits and harms of ASD screening in young children for whom no concerns of ASD have been raised by parents or clinicians. Though, it did state that there was adequate evidence for detection of ASD in children aged 18 to 30 months via detecting symptoms systematically, using tools such as the Modified Checklist for autism in Toddlers (M-CHAT).

“This nonrecommendation is most jarring when juxtaposed against the decision that the guideline should not apply to children when the health care professionals have concerns about ASD,” Veenstra-VanderWeele and McGuire wrote. “These concerns would most likely emerge from eliciting a history of relevant developmental symptoms in some nonsystematic way. Thus, by excluding cases with existing ‘concerns’ from their evaluation, the USPSTF inadvertently favors nonsystematic over systematic assessment of potential ASD symptoms in this age range. This flaw in logic suggests that the USPSTF’s methods are simply not appropriate for measures that elicit symptoms that are already a focus within primary care visits.”

The task force includes preventative care experts but no clinicians with a developmental medicine or pediatric mental health focus, according to researchers, which may have influenced the recommendation.

Early identification of concerns is essential to conducting an evaluation and entering children into a referral system that can take several months to establish a definitive diagnosis and begin ASD interventions, the researchers report.

“We hope that the USPSTF statement does not trigger a step backward to later diagnosis, later treatment, and more disparity in services for children with ASD. Clinicians, families and health care funders should instead recognize that ASD ‘screening’ simply does not fit within the rigid USPSTF box,” the researchers wrote. “Early data in single studies suggest that it may someday be possible to detect ASD risk before symptoms emerge, via blood tests or eye tracking. These sorts of measures, which would actually fit the USPSTF definition of screening, are likely still a decade away from clinical implementation. Until then, we hope that pediatricians continue the push for systematic assessment of autism symptoms in young children and avoid relying exclusively on a clinical hunch or parental concern.” – by Amanda Oldt

Disclosure: Veenstra-VanderWeele reports consulting or serving on advisory boards for Roche, Novartis, and SynapDx; receiving research funding from Roche, Novartis, SynapDx, Seaside Therapeutics and Forest; and receiving stipends for editorial work from Wiley and Springer. Please see the full study for a list of all authors’ relevant financial disclosures.

Psychiatric researchers have expressed significant concern regarding the recent recommendation from the U.S. Preventive Services Task Force on screening for autism spectrum disorder, according to an editorial in JAMA Psychiatry.

“Finding insufficient evidence that screening for ASD changes outcomes in 18- to 30-month-old children, the [U.S. Preventive Services Task Force (USPSTF)] landed in a gray zone of neither supporting nor opposing screening. Instead, they deferred decision making to families and clinicians,” Jeremy Veenstra-VanderWeele, MD, of Columbia University, New York, and Kelly McGuire, MD, MPA, of Center for Autism and Developmental Disorders, Maine Behavioral Healthcare, Portland, wrote in the editorial. “This lack of endorsement, if followed by state Medicaid boards, could eliminate the funding for pediatricians to elicit developmental symptoms in toddlers or preschoolers.”

Based on a systematic review of evidence on accuracy, benefits and potential harms of brief, formal screening instruments for ASD administered during routine primary care visits, the task force concluded that there is insufficient evidence to assess the benefits and harms of ASD screening in young children for whom no concerns of ASD have been raised by parents or clinicians. Though, it did state that there was adequate evidence for detection of ASD in children aged 18 to 30 months via detecting symptoms systematically, using tools such as the Modified Checklist for autism in Toddlers (M-CHAT).

“This nonrecommendation is most jarring when juxtaposed against the decision that the guideline should not apply to children when the health care professionals have concerns about ASD,” Veenstra-VanderWeele and McGuire wrote. “These concerns would most likely emerge from eliciting a history of relevant developmental symptoms in some nonsystematic way. Thus, by excluding cases with existing ‘concerns’ from their evaluation, the USPSTF inadvertently favors nonsystematic over systematic assessment of potential ASD symptoms in this age range. This flaw in logic suggests that the USPSTF’s methods are simply not appropriate for measures that elicit symptoms that are already a focus within primary care visits.”

The task force includes preventative care experts but no clinicians with a developmental medicine or pediatric mental health focus, according to researchers, which may have influenced the recommendation.

Early identification of concerns is essential to conducting an evaluation and entering children into a referral system that can take several months to establish a definitive diagnosis and begin ASD interventions, the researchers report.

“We hope that the USPSTF statement does not trigger a step backward to later diagnosis, later treatment, and more disparity in services for children with ASD. Clinicians, families and health care funders should instead recognize that ASD ‘screening’ simply does not fit within the rigid USPSTF box,” the researchers wrote. “Early data in single studies suggest that it may someday be possible to detect ASD risk before symptoms emerge, via blood tests or eye tracking. These sorts of measures, which would actually fit the USPSTF definition of screening, are likely still a decade away from clinical implementation. Until then, we hope that pediatricians continue the push for systematic assessment of autism symptoms in young children and avoid relying exclusively on a clinical hunch or parental concern.” – by Amanda Oldt

Disclosure: Veenstra-VanderWeele reports consulting or serving on advisory boards for Roche, Novartis, and SynapDx; receiving research funding from Roche, Novartis, SynapDx, Seaside Therapeutics and Forest; and receiving stipends for editorial work from Wiley and Springer. Please see the full study for a list of all authors’ relevant financial disclosures.