Two new clinical reports from the American Academy of Pediatrics will help pediatricians recognize autism spectrum disorders (ASDs) earlier and guide families to effective interventions, which will ultimately improve the lives of children with ASDs and their families. The first clinical report, “Identification and Evaluation of Children With Autism Spectrum Disorders,” provides detailed information on signs and symptoms so pediatricians can recognize and assess ASDs in their patients. Language delays usually prompt parents to raise concerns to their child’s pediatrician – usually around 18 months of age. However, there are earlier subtle signs that if detected could lead to earlier diagnosis.
Most children, at some time during early development, form attachments with a stuffed animal, special pillow or blanket. Children with ASDs may prefer hard items (ballpoint pens, flashlight, keys, action figures, etc.). They may insist on holding the object at all times.
The report advises pediatricians to be cognizant of signs of ASD, as well as other developmental concerns, at every well-child visit by simply asking the parents if they or their child’s other caregivers have any concerns about their child’s development or behavior. If concerns are present that may relate to ASD, the clinician is advised to use a standardized screening tool. The report also introduces universal screening, which means pediatricians conduct formal ASD screening on all children at 18 and 24 months regardless of whether there are any concerns.
“Red Flags” that are absolute indications for immediate evaluation include: no babbling or pointing or other gesture by 12 months; no single words by 16 months; no two-word spontaneous phrases by 24 months; and loss of language or social skills at any age. Early intervention can make a huge difference in the child’s prognosis. “Autism doesn’t go away, but therapy can help the child cope in regular environments,” said Chris Plauche Johnson, MD, MEd, FAAP, and co-author of the reports. “It helps children want to learn and communicate.”
Educational strategies and associated therapies, which are the cornerstones of treatment for ASDs, are reviewed in the second AAP clinical report, “Management of Children With Autism Spectrum Disorders.” Early intervention is crucial for effective treatment. The report strongly advises intervention as soon as an ASD diagnosis is seriously considered rather than deferring until a definitive diagnosis is made. The child should be actively engaged in intensive intervention at least 25 hours per week, 12 months per year with a low student-to-teacher ratio allowing for sufficient one-on-one time. Parents should also be included.
Pediatricians who treat children with ASDs should recognize that many of their patients will use nonstandard therapies. The report says it’s important for pediatricians to become knowledgeable about complementary and alternative medicine (CAM) therapies, ask families about current and past CAM use, and provide balanced information and advice about treatment options, including identifying risks or potential harmful effects. They should avoid becoming defensive or dismissing CAM in ways that convey a lack of sensitivity or concern, but they should also help families to understand how to evaluate scientific evidence and recognize unsubstantiated treatments.
“Many parents are interested in CAM treatments such as various vitamin and mineral supplements, chelation therapy, and diet restrictions. It’s important for pediatricians to maintain open communication and continue to work with these families even if there is disagreement about treatment choices, ” said co-author of the reports Scott M. Myers, MD, FAAP. “At the same time, it’s also important to critically evaluate the scientific evidence of effectiveness and risk of harm and convey this information to the families, just as one should for treatment with medication and for non-medical interventions.”
Although use of the gluten-free/casein-free diet for children with ASDs is popular, there is little evidence to support or refute this intervention. More studies are in progress, and it is anticipated that these studies will provide substantially more useful information regarding the efficacy of the gluten-free/casein-free diet.
Tantrums, aggressive behaviors, and self-injury are common among children with ASDs, and medical factors may cause or exacerbate these behaviors. Behavior management strategies are often the most effective treatment for challenging behaviors. In some children, medications are effective in addition to the behavioral strategies. The report addresses the medical issues that some children with ASDs encounter such as seizures, gastrointestinal problems, and sleep disturbance, and provides guidance for medication management.
Both reports will also be part of the new AAP practical resource for pediatricians "AUTISM: Caring for Children with Autism Spectrum Disorders: A Resource Toolkit for Clinicians,” which includes screening and surveillance tools, guideline summary charts, management checklists, developmental checklists, developmental growth charts, early intervention referral forms and tools, sample letters to insurance companies and family handouts.
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