Routine Screening For Autism: Is It Really Necessary?
A just-published study in the journal Pediatrics questions the need for early autism screening of all children — screening that many autism experts have said should be routine based on research showing that early diagnosis and early intervention provide the best outcomes for autistic children. Indeed, the American Academy of Pediatrics, which publishes Pediatrics, recommends that doctors screen children for autism at regular checkups at the ages of 18 and 24 months. Says Geraldine Dawson, chief science officer for Autism Speaks in CNN:
“By screening for autism at an early age, children are able to begin intervention as soon as possible. Studies have shown that early intervention results in significant increases in cognitive and language abilities, and adaptive behavior, and gives children the best chance for a positive outcome.”
As the Toronto Sun points out, some other studies (including one previously published in Pediatrics from the Children’s Hospital of Philadelphia ) provide evidence for the advantages of autism screening for all younger children.
The authors of the new study are experts in cerebral palsy at McMaster University in Canada and I’m suspecting their not being “autism experts” specifically will be pointed out to question their findings. Conversely, the researchers being from “outside” the field of autism research could be as much an advantage, as it may enable them to evaluate the screening tools and therapeutic interventions for autism with a more balanced perspective.
A closer look at the Pediatrics study shows that one of the researchers’ concerns is that the current screening tools — tests like the CHAT, M-CHAT and SCQ which rely very much on parental responses — are useful but are not sufficiently reliable as far as correctly identifying those children who are autistic and those who are not. Further, while I’m the first to speak up for the benefits of some early intervention therapies like Applied Behavior Analysis (ABA), a teaching methodology based on Skinnerian behavior therapy, clinical reviews of studies about the outcomes of intensive ABA as is (certainly here in New Jersey) routinely recommended for young children diagnosed with autism have yet fully to validate such. Say the McMaster University researchers:
Systematic reviews of clinical trials of the effectiveness of applied behavior intervention programs on cognitive, adaptive behavior, and language development in preschool-aged children with autism revealed that compared with standard care, applied behavior intervention did not signiﬁcantly improve the cognitive outcomes of children. Results of a recent systematic review suggest that cognitive behavior therapy is an effective treatment for anxiety in people with Asperger syndrome but not for those with other ASD subtypes.Thus, more clinical trials are needed, but at present, claims regarding the efﬁcacy of applied behavior analysis have not been substantiated.
As the authors say, “at the present time, neither proven therapies nor preventive measures exist for the universal treatment of children and youth with autism, and further intervention research is needed.”
Further, the authors potentially activate a lighting rod of protests in saying that there is “little support for the effectiveness for speech and language therapy for people with autism.” My own son has received speech therapy since he was 2 years old. He can speak in one to six word phrases, in articulation that is not always clear and sometimes he’s frustrated and enraged when he can’t figure out how to get us to understand his meaning; he certainly has (and has always had) a great desire to communicate. From our experience, speech and language therapy has helped Charlie but a parent’s thoroughly unscientific observations are not the most reliable measures of the efficacy of a therapy.
Lead author Dr. Jan Willem Gorter emphasizes that
…he and his co-authors were not specifically referring to “the surveillance that is happening in doctors’ offices” at 18 and 24 months.
They were recommending against a population-wide screening program that would require screening every child at a certain age level for autism, he said. Nobody is conducting such a study at this time in the United States.
Such a study was carried out in South Korea by researchers from Yale University and George Washington University and produced another finding that has rattled some commonly-accepted notions about autism. The study in the American Journal of Psychiatry found a prevalence rate of autism in 1 in 38 children, which is far far higher than the current figure of 1 in 110 children, and even of the 1 in 94 rate in New Jersey that’s currently the highest in the US.
The value of the new Pediatrics study, and of the South Korea study, is that they point out that we should not be complacent and assume we have already found the best instruments to diagnose and evaluate autism, or are using the best possible teaching methods. The South Korea study suggests that we could be seriously underdiagnosing autism, which would suggest that the current instruments used in the US are not identifying many cases. Again, while ABA has benefited my own son tremendously, we have had to “unteach” some things he learned from his years of ABA, and not because the ABA therapists weren’t doing ABA “correctly.” Behavior-based teaching is not the only method for teaching autistic children and may not be the best — and should not be the sole — method for teaching older children and autistic teenagers and adults
The one thing I’ve learned from the past decade-plus of raising my now 14-year-old son is that, much as we’d like to say “we’ve found the perfect teaching method for everything” – or “we can spot autism in anyone, we should know” – we have to be flexible and constantly reexamine our own premises and practices: Charlie is no robot, and, the more he grows and learns and changes, the more our teaching methods and much else with him must grow, learn and change, too.
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Photo by Ed Yourdon