Screening for ASD in Toddlers: An Update on Recommendations and Practices Significant progress has been made in regards to early identification and early intervention for young children with autism spectrum disorder (ASD). However, a substantial gap typically appears between the time that symptoms begin to present and the average age of diagnosis. Therefore, it remains critical that clinicians and researchers focus ... Article
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Article  |   February 01, 2017
Screening for ASD in Toddlers: An Update on Recommendations and Practices
Author Affiliations & Notes
  • Lauren Swineford
    Department of Speech and Hearing Sciences, Washington State University, Spokane, WA
  • Disclosures
    Disclosures ×
  • Financial: Lauren Swineford has no relevant financial interests to disclose.
    Financial: Lauren Swineford has no relevant financial interests to disclose.×
  • Nonfinancial: Lauren Swineford has no relevant nonfinancial interests to disclose.
    Nonfinancial: Lauren Swineford has no relevant nonfinancial interests to disclose.×
Article Information
Special Populations / Autism Spectrum / Early Identification & Intervention / Part 1
Article   |   February 01, 2017
Screening for ASD in Toddlers: An Update on Recommendations and Practices
Perspectives of the ASHA Special Interest Groups, February 2017, Vol. 2, 5-10. doi:10.1044/persp2.SIG1.5
History: Received July 29, 2016 , Revised November 1, 2016 , Accepted November 13, 2016
Perspectives of the ASHA Special Interest Groups, February 2017, Vol. 2, 5-10. doi:10.1044/persp2.SIG1.5
History: Received July 29, 2016; Revised November 1, 2016; Accepted November 13, 2016

Significant progress has been made in regards to early identification and early intervention for young children with autism spectrum disorder (ASD). However, a substantial gap typically appears between the time that symptoms begin to present and the average age of diagnosis. Therefore, it remains critical that clinicians and researchers focus their attention on improving early screening and diagnostic practices to allow children to access appropriate ASD-specific intervention as early as possible. However, the United States Preventative Services Task Force recently provided recommendations regarding routine developmental surveillance that have sparked a heated debate among advocates, families, health care professionals, and researchers within the autism community. Speech-language pathologists (SLPs) play an essential role in process of screening for and early identification of ASD. Therefore, the purpose of this paper is to provide SLPs with an overview of the current recommendations and best practices related to screening for ASD.

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by impairments in social communication and reciprocity and the presence of repetitive, restricted behaviors and interests (American Psychiatric Association, 2013). ASD is considered a relatively common disorder affecting 14.7 per 1,000 (or 1 in 68) children per the most recent prevalence estimates provide by the Centers for Disease Control and Prevention (Baio, 2014). The rise in prevalence of developmental disorders such as ASD has a direct and significant impact on the services provided by speech-language pathologists (SLPs). For example, recent surveys conducted by the American Speech-Language Hearing Association (ASHA) indicated that approximately 90% of school-based SLPs served children with ASD (ASHA, 2016) and children with ASD accounted for approximately 20% of the pediatric caseloads of SLPs in outpatient clinics and offices (ASHA, 2015). Therefore, there is a clear need to for SLPs to have access to resources to expand their knowledge of evidence-based practices for screening, diagnosis, and intervention specific to ASD.
Remarkable progress has been made in terms of understanding the behavioral phenotype ASD in young children such that we now have a convergence of evidence supporting the presence of ASD symptoms in the second year of life with stable diagnoses made by experienced clinicians in children as young as age two (Guthrie, Swineford, Nottke, & Wetherby, 2013). Despite these research advances regarding early identification of ASD, a significant time lag between symptom onset and average age of diagnosis (between 4 and 6 years of age) still exists (Baio, 2014). This gap is not surprising as pointed out in a technical report related to the diagnosis and management of ASD for pediatricians that stated:

Unfortunately, there is a large gap between what is done in model programs across the country and what is generally available for most young children. Local programs are often limited by funding constraints and lack of trained personnel. Even when programs are locally available, the pediatrician may be unaware of them. (Committee on Children With Disabilities, 2001, p. 9)

Therefore, early identification of ASD remains a critical area of research as timely access to appropriate ASD-specific early intervention can lead to significant gains across developmental domains (Zwaigenbaum et al., 2015).
SLPs play a critical role in the process of early identification of ASD, as one of the earliest and most frequently noted features of ASD reported by parents of toddlers with ASD is a delay in or lack of spoken communication (Siklos & Kerns, 2007). However, early identification of ASD is not an easy task and screening for and diagnosing autism in very young children (i.e., under 24 months of age) is a relatively new practice for SLPs among other health care professionals. Further, accurate early identification requires a considerable amount of experience given the heterogeneity of ASD symptoms in very young children as well as access to valid screening and assessment tools. The first step in accurate early identification of ASD involves routine developmental surveillance (or universal screening) for all children to identify children at risk for atypical development followed by screening specifically for autism (see Filipek et al., 2000  for detailed description). Therefore, the purpose of this paper is to provide SLPs with an overview of the current recommendations and best practices related to screening for ASD. This topic is extremely timely, as recent recommendations regarding routine developmental surveillance provided by the United States Preventative Services Task Force (USPSTF; see Siu & US Preventative Services Task Force, 2016  for full recommendation statement) have sparked a heated debate among advocates, families, health care professionals, and researchers within the autism community.
Recommendations for Screening
A formal recommendation for universal screening for ASD was first provided in a policy statement from the American Academy of Pediatrics (AAP) in 2006 followed by a clinical report with an algorithm to aid pediatricians on how to conduct universal and autism specific screening (Johnson & Myers, 2007). The initial statement recommended that developmental surveillance should occur at all regularly scheduled checkups, typically referred to as well-child visits, to inquire about and document any parental concern (general developmental or ASD-specific) as well as making informed clinical observations of the child including the identification of and risk factors and maintaining a detailed developmental history. If at any visit, parental concern regarding their child's development is noted, then a standardized developmental tool to screen for ASD should be administered. Further, it was recommended that all children be screened for ASD at 18 and 24 months regardless if concerns have been raised during the developmental surveillance process (Johnson & Myers, 2007).
Despite the AAP guidelines for surveillance and screening for ASD, only a minority of pediatricians are performing routine developmental and ASD-specific screenings (e.g., Gillis, 2009; Pierce et al., 2011; Self, Parham, & Rajagopalan, 2014) with approximately 17.7% following the specific AAP guidelines (Arunyanart et al., 2012). As discussed by Crais and colleagues (2014), there are several perceived barriers including, but not limited to, lack of time and resources, limited awareness of ASD-specific screening tools, and concerns regarding the quality of screening tools, the referral process for follow-up assessment and early intervention, including long waitlists, and the effectiveness of interventions. It has been suggested that the AAP recommendation for screening for ASD was premature, and that the recommendation was likely driven by increased public awareness and the availability of more reliable screening and assessment tools rather than evidence to support the feasibility and value of a universal screening program (Al-Qabandi, Gorter, & Rosenbaum, 2011). Nevertheless, the AAP guidelines gave impetus to explore and address barriers to routine screening for ASD for health care professionals and perhaps most importantly to increase, albeit slowly, the implementation of screening for ASD in toddlers.
More recently, the USPSTF released a recommendation statement concluding that there is insufficient evidence to support routine screening for ASD in young children and emphasized the need for more research to assess the balance of benefits and harms of screening for ASD in young children (Siu & US Preventative Services Task Force, 2016). The primary reason for this recommendation was the lack of evidence on the direct effect of universal screening for ASD in young children on positive prognosis or clinical outcomes. In other words, studies have not examined the long-term outcomes of screened vs. non-screened children, and treatment efficacy studies have not been based on samples ascertained through universal autism screening (Dawson, 2016). To fully assess the benefits and harms of screening for ASD, one must consider two important areas of research: (a) the evidence related to the validity and accuracy of our screening tools and (b) the effectiveness of our interventions for children who screen positive (Mandell & Mandy, 2015). The literature reviewed to develop the USPSTF recommendation found adequate evidence for both of the above issues (discussed further below), and yet, the USPSTF disappointingly determined insufficient evidence to support universal screening. As one might expect, this recommendation was and still is quite controversial.
Evidence: Screening Tools
To reiterate, the USPSTF found sufficient evidence for valid screening tools (see Zwaigenbaum et al., 2015  for recent review of screening tools) and the AAP guidelines include implementation of an ASD-specific screening tool for all children at 18 and 24 months of age. Despite this, some pediatricians are not conducting ASD-specific screening, and those that are report limited knowledge of how to use and score the tools to capitalize on the best combination of sensitivity and specificity possible (Crais et al., 2014).
The strongest support is available for the Modified Checklist for Autism in Toddlers (M-CHAT) Follow-Up Interview (Robins, Fein, & Barton, 1999) and the M-CHAT Revised with Follow-Up (M-CHAT-R/F; Robins et al., 2009, 2014). In brief, the most recent version of the M-CHAT, the M-CHAT-R/F, is appropriate for children 16–30 months of age, has 20 yes/no questions, requires minimal training, and takes approximately 5 minutes to complete. The scoring algorithm yields three risk ranges (low-, medium-, and high-risk). It is recommended that children with scores in the medium- and high-risk ranges receive either the follow-up interview which typically takes less than 10 minutes to complete or be directly referred for developmental assessment (medium- and high risk range, respectively). The M-CHAT-R/F is available for free download for clinical, research, and educational purposes (M-CHAT, 2009). The M-CHAT-R is designed to detect as many cases of ASD (maximize sensitivity) as possible resulting in a high false positive rate. The use of the follow-up interview will decrease the number of false positives; however, some pediatricians using the M-CHAT as their ASD-specific screening tool are not aware of the follow-up interview leading to lower specificity and frustration with the tool (Crais et al., 2014). While the use of the follow-up interview does not eliminate false positives for ASD, the M-CHAT-R/F maintains clinical utility as it helps identify children who require further evaluation as they may be at risk for other developmental disorders.
While researchers continue to improve the psychometric properties and clinical utility of screening tools, it is crucial that we don't take a step backwards in improving early identification. Systematic ASD screening can lead to earlier referral including families with ethnically and racially diverse backgrounds (Miller et al., 2011) which is critical as underrepresented minority groups or those with lower socio-economic status are typically diagnosed at later ages (Daniels & Mandell, 2013). Therefore, regardless of the current USPSTF recommendation, clinicians should continue to (or begin to) conduct routine and ASD-specific screening for young children while a stronger body of evidence is developed documenting direct positive outcomes from screening (Robins et al., 2016).
Evidence: Early Intervention
In regards to the effectiveness of ASD intervention, the USPSTF concluded insufficient evidence to support universal screening for ASD. Again, this is surprising and frustrating as their review found evidence for efficacy of early intensive intervention from 26 studies randomized control trials with fair to good quality designs. Basing their recommendation solely on treatment studies with samples ascertained through universal autism screening undermines the current state of the ASD early intervention literature and the progress that has been made in the last decade.
A recent publication by Zwaigenbaum and colleagues (2015)  reviewed the current evidence for early intervention for children with ASD under 3 years of age. A total of 24 studies were reviewed including six randomized controlled trials which were used to provide intervention clinical practice recommendations. Of note, significantly improved outcomes were observed for the treatment groups relative to the comparison groups for each of the six randomized controlled trials with improvement observed in the areas of joint attention, expressive language, and parent-child-interaction measures (see Zwaigenbaum et al., 2015  for detailed description of study designs and results).
Based on the results of their review, authors provided clinical practice recommendations to guide clinicians to continue to provide best-practice intervention for young children with ASD. Research supports the combination or blend of developmental and behavioral approaches to intervention and that intervention begins as early as possible (see Schreibman et al., 2015  for a thorough description of naturalistic developmental behavioral interventions). Regardless of the specific intervention model being implemented, families and/or caregivers should be actively involved in all aspects of intervention. Further, goals of intervention should focus on the core symptoms of ASD (e.g., social communication interventions) as well as associated features such as language and cognitive skills. Lastly, as with all interventions, socioeconomic status, family characteristics, and cultural factors must be considered in the intervention delivery. In summary, it is unfortunate that the USPSTF excluded research supporting early intensive developmental and behavioral intervention for young children with ASD because of ascertainment strategies.
Screening and the Role of SLPs
At every stage of the management and treatment plan for young children with ASD, from screening, assessment, diagnosis, and treatment, SLPs play an essential role. In fact, the roles and responsibilities of SLPs as outlined by ASHA include clinical and education services including assessment, diagnosis, planning, and treatment for individuals with ASD (ASHA, n.d.). In regards to screening for ASD, SLPs can play both indirect and direct roles. For example, SLPs working with families of young children can educate and advocate for broadband and ASD-specific screenings to be conducted by their local pediatricians at well-child visits. SLPs could also directly conduct developmental and ASD-specific screenings using valid tools with strong psychometrics.
While the majority of research related to universal and ASD-specific screening involves pediatricians, it is critical that other health care professionals, specifically SLPs who are often on the “front line” of working with young children with developmental disabilities, are aware of and critically evaluating the most recent evidence to provide evidence-based driven clinical services. This becomes particularly important when recommendations by the USPSTF are made that “demonstrate remarkable naiveté about the process by which children with ASD are identified and enter treatment” (Mandell & Mandy, 2015, p. 895) that relate to a population—young children with ASD—that make up a significant proportion of our caseloads as SLPs (ASHA 2015, 2016). Luckily, most definitions of evidence-based practice, including the one used by ASHA, includes the integration of clinical expertise, external scientific evidence, and client/patient/caregiver values (ASHA, 2004). Therefore, SLPs have the flexibility to make clinical decisions regarding our continued participation in improving early identification and intervention for young children with ASD via advocacy for and administration of screening for ASD.
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