'Insufficient' Evidence to Support Widespread Autism Screening

Nancy A. Melville

February 17, 2016

The United States Preventive Services Task Force (USPSTF) has finalized its recommendation that there is insufficient evidence to support widespread autism screening in young children, despite guidelines from other groups, including the American Academy of Pediatrics (AAP), that recommend such screening.

"The task force's statement should not be seen as a recommendation for or against screening," USPSTF member Alex Kemper, MD, MPH, told Medscape Medical News.

"It means that in using the task force's methods, insufficient evidence was found to conclude whether autism detection through screening leads to better outcomes as opposed to detection based on parent or clinician concern, and it is really intended to be a call for more research in the field," said Dr Kemper, professor of pediatrics at Duke University, in Durham, North Carolina.

The recommendation, which was published online February 16 in JAMA, keeps the "I" grade, indicating insufficient evidence, that was first issued in a draft recommendation in 2015, as reported by Medscape Medical News.

The USPSTF review included 26 randomized clinical trials involving early intensive behavioral and developmental interventions for autism spectrum disorder (ASD) in young children. The results were found to be complicated by a variety of factors, including variation in intervention design and method of delivery, as well as in comparators and outcomes measured, and by inconsistencies in age, types of symptoms, and symptom severity of the children enrolled.

Dr Kemper underscored the fact that although the USPSTF's focus is primarily on scientific evidence, the recommendation should have no effect on insurance coverage for screening, owing to the role of the AAP's recommendations for screening in the Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents, which is the blueprint for well-child visits and coverage under the Affordable Care Act.

No Impact on Insurance Coverage

"I can tell you that because of the Bright Futures Guidelines, the task force's statement should have no impact on insurance coverage for autism screening whatsoever," Dr Kemper said.

The authors of one of two accompanying editorials, however, question the potential fallout from the statement, calling the recommendation "rigid" and "inflexible."

"In truth, this was a non-recommendation that stands in stark contrast to clinician groups, including the American Academy of Pediatrics, that recommend systematic screening for ASD at ages 18 and 24 months," write authors Jeremy Veenstra-VanderWeele, MD, of the Sackler Institute for Developmental Psychobiology and the Department of Psychiatry, Columbia University, New York City, and Kelly McGuire, MD, of the Center for Autism and Developmental Disorders, Maine Behavioral Healthcare, in Portland.

The editorialists further warned that "this lack of endorsement, if followed by state Medicaid boards, could eliminate the funding for pediatricians to elicit developmental symptoms in toddlers or preschoolers."

Among key criticisms raised in the editorial is one concerning the USPSTF's statement that their recommendation does not apply if concerns are raised about autism through clinical judgement.

"This non-recommendation 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," the authors write.

Without formal screening, those concerns are, in effect, left to be raised in a nonsystematic manner, they argue.

"Thus, by excluding cases with existing 'concerns' from their evaluation, the USPTF inadvertently favors nonsystematic over systematic assessment of potential ASD symptoms in this age range."

AAP Weighs In

These concerns were echoed by Susan Levy, MD, chair of the AAP's Autism Subcommittee.

"The main concern we have is the suggestion that clinicians fall back on their judgement, because that approach goes against all of the principles of screening," Dr Levy told Medscape Medical News, who is also with the Division Developmental and Behavioral Pediatrics at the Children's Hospital of Philadelphia.

"Screening in a population for a disorder involves looking at groups of individuals who are asymptomatic to determine if they have risks, and using clinical judgement has no role in screening for certain disorders.

"In fact, research as shown that when pediatricians and other providers use their clinical judgement, they will under- as well as overidentify children at risk for certain disorders."

In an official statement issued in response to the USPSTF's recommendation, the AAP stated that it agrees with the assertion of the need for more funding for research, but it added that there already is convincing evidence.

"Strong evidence already exists on the benefit of formal screening using standardized tools," the AAP notes.

It adds that "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."

Under the AAP guidelines, which date back to 2007, all children should undergo ASD screening at ages 18 and 24 months and receive regular developmental surveillance.

Among the most common methods of screening is by use of the Modified Checklist for Autism in Toddlers, a 23-item questionnaire that takes parents 5 to 10 minutes to complete regarding symptoms of ASD or developmental delay.

If responses on the questionnaire raise flags, the physician confirms the symptoms and refers the child to a specialist.

In Defense of the USPTF

In defense of the USPTF's recommendation, the authors of a second editorial argue that the I grade accurately reflects the shortcomings of the evidence.

"The I grade stems from the small size and variable quality of intervention studies and from a lack of direct evidence that screening leads to clinical improvement," write authors Michael Silverstein, MD, MPH, of the Department of Pediatrics, Boston University School of Medicine and Boston Medical Center, in Massachusetts, and Jenny Radesky, MD, of the Division of Developmental Behavioral Pediatrics, University of Michigan School of Medicine, Ann Arbor, Michigan.

"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."

They further argue that the USPTF rightly fulfilled its responsibility of focusing on the science and not having its recommendation clouded by potential implications.

"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," the authors note.

Although it is important to recognize the challenges involved with accumulating such evidence, the complexity of a clinical problem does not justify adjusting the USPSTF's standards for a positive recommendation.

Dr Kemper noted that ASD screening is indeed standard at his own center at Duke, as it is at many others.

"In my clinic, we do routinely screen for autism, but we also serve a population that has problems with access to care, and we worry that signs or symptoms of autism might otherwise be missed," he said.

"So clinicians should use their judgement and look at what others recommend to decide whether or not to systematically screen."

The authors have disclosed no relevant financial relationships.

JAMA. Published online February 16, 2016. Full text, Editorial 1, Editorial 2

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