The essential role of pediatricians in identifying children who may be at risk for ASD cannot be overstated. This is the first update to the report from the American Academy of Pediatrics since 2007, and it reflects changes in science, the law, and the rise of care coordination.
For the first time in 12 years, the American Academy of Pediatrics (AAP) has updated its clinical reports for diagnosing and treating autism spectrum disorder (ASD) into a single publication, which calls on doctors who treat the youngest children to learn how to recognize symptoms, screen children at young ages, and refer children and families for help, because “early intervention can and does influence outcomes.”
The clinical report, “Identification, Evaluation, and Management of Children With Autism Spectrum Disorder,” states that ASD affects 1 of every 59 children (1.7%), and that the lifetime costs for caring for a child with ASD can be $1.4 million to $2.4 million, depending on the range of co-occurring intellectual disabilities. Since the AAP published its first report on identifying and managing ASD, rates of prevalence have climbed as awareness has grown, although the authors say this appears to be leveling off.
Since that time, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-V) has consolidated different subgroups of ASD into one, with core symptoms divided into 2 domains, social communication and restrictive, repetitive patterns of behavior. To meet diagnostic criteria, all 3 symptoms of social affective difference must be present, as well as 2 of 4 symptoms related to behavior.
The essential role of pediatricians in identifying children who may be at risk for ASD cannot be overstated. “It is important to identify all clinically significant delays in children with referral for appropriate diagnostic evaluation and intervention,” the clinical report states. “Problems with sleep, eating, constipation, and state regulation are common in the general population but may be particularly challenging in young children with ASD. Pediatricians can help families with management of these symptoms.”
Sections of the report are: (1) Prevalence, (2) Clinical Symptoms, (3) Screening and Diagnosis, (4) Etiologic Evaluation, (5) Interventions, and (6) Working with Families.
The report identifies what pediatricians should look for and what steps to take before a child reaches 18 months, between 18 and 30 months, and after 30 months. The report calls for screening children at 18 months and again at 24 months. It features both milestone-based warning signs, such as a child not responding to his or her name at 12 months or not engaging in pretend play at 18 months, and general behavioral signs, such as getting upset at minor changes or repetitive motions such as flapping hands or spinning in circles.
Authors discuss the difficulty of correctly diagnosing children with milder symptoms, and notes that girls may have less pronounced symptoms than boys. “Some children who are later diagnosed with ASD are initially believed to have precocious language, reading, or math skills, and it is not until the social demands of school that the social language symptoms become problematic,” the report states.
Although it is impossible to predict the trajectory of any individual child, the authors state, "Most children (≥80%) who are diagnosed with ASD after a comprehensive evaluation at less than 3 years have retained their diagnosis.”
Vaccines. The report specifically refutes claims of an association between childhood vaccines containing thimerosal and increased risk of ASD, and states, “Vaccines used for children in the United States have not contained thimerosal since 2001.”
Citing a 2012 Cochrane review and a 2014 meta-analysis that pooled data involving 1.2 million children, the authors say that evidence is lacking that immunizations increase risk of ASD in genetically vulnerable subgroups. “Media coverage of vaccine issues may inflate the perception of uncertainty by equal coverage of vaccine proponents and opponents,” the report states. “The overwhelming weight of evidence supports vaccine safety. Communicating information about vaccine safety is a critical component of pediatric practice.”
Genetics. Much is still being learned about the heritable nature of ASD, as well as the interplay between genetic and environmental factors. Siblings of those with the disorder are known to be at higher risk. It is also known that risk rises in children of older fathers and older mothers. While next-generation sequencing has identified some variants linked to ASD, no individual variant is responsible for more than 1% of cases.
Management of Co-occurring Conditions. Primary care providers should be ready to address conditions that are common alongside ASD, such as seizures, sleep problems, feeding disorders, obesity and other conditions that can have significant effects on children’s quality of life. Care coordination, including attention to dental and behavioral health, can shed light on the relationship between ASD and mood disorders that are commonly seen.
Interventions. The section on interventions states that treatment goals for children with ASD should be to (1) minimize core deficits in communication and behavior, (2) maximize functional independence, and (3) eliminate, minimize, or prevent problem behaviors. Treatments should be individualized and intensive; the report states that since the publication of the 2007 AAP clinical reports, legal requirements for educating children with ASD have increased. The report discusses both Applied Behavioral Analysis (ABA) and interventions based on developmental theory, as well as approaches for working with parents of children with ASD. Educational interventions can include steps to improve social skills, speech and language therapy, and sensory therapies.
Pediatric Recommendations. The AAP clinical report makes specific recommendations for health, education, and public health systems to work together for children with ASD:
Hyman SL, Levy SE, Myers SM. Identification, evaluation, and management of children with autism spectrum disorder [published online December 16, 2019]. Pediatrics. doi.org/10.1542/peds.2019-3447.