Early intervention for symptoms associated with autism spectrum disorder – even before the condition is formally diagnosed – is critical for helping families improve outcomes for their children, according to updated recommendations from the American Academy of Pediatrics (AAP).
The new clinical report to guide diagnosis and care of children with autism is the AAP’s first in 12 years and reflects changes in how autism is diagnosed and treated. Specific autism screenings are recommended at 18 and 24 months, at the same time as typical well-child visits. During these visits, pediatricians gauge milestones reflecting social communication, which could provide early signs of autism, according to Susan Hyman, M.D., lead author of the report and professor at the University of Rochester Medical Center’s Golisano Children’s Hospital.
“Social milestones like eye pointing to indicate interest, pointing to share interest and engaging in pretend play are not milestones that most parents are looking for, and might miss if not specifically asked about in the form of screening,” said Hyman, past chair of the AAP’s subcommittee on Autism.
Identification of Co-Occurring Conditions Important
In addition to social milestones, pediatricians are now encouraged to screen for conditions that often occur in tandem with autism, such as ADHD, anxiety, food selectivity, and sleeping disorders. Identification of these conditions is important because children may benefit from specific interventions, according to Hyman.
“Eating and sleeping issues can be identified long before autism is diagnosed,” she said, “and you don’t need to wait for an official diagnosis to begin treatment.”
While universal screening could lead to an increased number of children referred for autism diagnostic evaluations, these screenings will still have an overall benefit to child health, noted Hyman. “If the concerns are not due to autism, the other developmental problems can be addressed. Almost all children who screen positive have symptoms worthy of further evaluation and intervention even if they do not get diagnosed with autism.”
Continued surveillance through school age increases the likelihood of catching harder-to-diagnose cases. “Some children with more typical language skills may not be identified until they enter school and social requirements are greater,” Hyman said. Hyman also encourages pediatricians to listen to parents’ concerns. “The current tests used for screening toddlers are more accurate when used with a follow-up interview with the child’s caregivers.”
Since 2007, the prevalence of autism has increased from one in 155 children to one in 59. “Odds are, every child care provider has a child with autism in their office, and the reason we do these reports is to pull together useful information for the primary care providers to deliver the needed care for the child and their family,” says Hyman.
Shared-Decision Making Can Help Interventions
Research has shown that families can help children develop adaptive skills – such as engaging in strategies to capture a child’s attention and encourage communication – and improve outcomes with early interventions. Hyman emphasizes that doctors should engage families in the decision-making process by providing them with the information and options they need to help plan interventions.
“In many cases, listening to what parents value is just as important as making recommendations for interventions based on scientific evidence,” she says. “Families may prioritize issues that the provider might not have considered, like ‘can you help me with my child’s wandering?’ ‘Can you give me information on how to handle puberty?’ ‘How do I transition my teenager to adult services?’”
Shared decision making is essential because few cases of autism are the same, according to Hyman. While the core symptoms include social communication problems and restrictive and repetitive behaviors, the disorder varies considerably given the co-occurrence of other conditions: “We have a saying: ‘if you’ve seen one person with autism you’ve seen one person with autism,’” she says.
While the autism spectrum has a lot of variability, Hyman expects that the new report will help advance community-based clinical care and allow for more targeted treatment. Hyman also assures parents that pediatric training in identifying and treating autism has become standard during the past decade.
“There has been a major effort since 2007 to train pediatricians to recognize the developmental and behavioral difference that can be seen and reported in children with autism,” she says. “And all pediatricians can refer children to Early Intervention (0-3 years) or the school system (over 3 years) for cognitive and language testing and to begin services while awaiting a formal diagnosis.”