USPSTF finds insufficient evidence for autism screening in all children

The U.S. Preventive Services Task Force (USPSTF) has found insufficient evidence to recommend screening young children for autism spectrum disorder (ASD) if no concerns have been noted by parents or a clinician, according to a new recommendation statement published in JAMA.

The recommendation applies to children aged 18 to 30 months who have not been diagnosed with ASD or other developmental delays.

The USPSTF based its recommendations on evidence regarding the accuracy, benefits, and potential adverse effects of brief, formal screening instruments for ASD. The task force also considered the benefits and potential adverse effects of early behavioral treatment for children diagnosed with ASD through these screening procedures.

The Modified Checklist for Autism in Toddlers (M-CHAT) and its revisions (Modified Checklist for Autism in Toddlers with Follow-Up [M-CHAT-F] and Modified Checklist for Autism in Toddlers – Revised, with Follow-Up [M-CHAT-R/F]) are the most commonly studied ASD screening tools. The strongest evidence exists for the M-CHAT-F and M-CHAT-R/F, with studies finding 50% positive predictive values for both tests. One study found that the majority of children who tested positive but did not have ASD were diagnosed with other developmental delays.

The potential harms of screening and treatment include misdiagnosis; the time, effort, and mental strain associated with more testing; and the time and monetary burden that behavioral treatments can have on a family. Overall, the USPSTF declared the potential harms of screening to be “no greater than small.”

The USPSTF did not find any randomized clinical trials pertaining to the overarching question: Does screening for ASD in young children improve symptoms, behavior, functioning, or quality of life? While there were studies concerning the efficacy of behavioral and developmental interventions for children with ASD, it was not clear if these studies are applicable to children who would be identified through ASD screening.

In response to public comments, the USPSTF emphasizes that these recommendations only extend to asymptomatic children. If a parent or clinician has a concern about a child’s development, the USPSTF advises clinicians to use their clinical judgment along with validated diagnostic tools to determine if further diagnosis or testing is needed.

In a related commentary also published in JAMA, Michael Silverstein, MD, MPH, wrote, “In considering the USPSTF’s recommendation, the issue of ‘direct evidence’ is critical. Although validation studies might prove a screening test to be good at identifying a certain condition, and separate interventional studies might show improvement in those treated for that condition, this piecemeal analytic framework demonstrates only the strength of individual links in a complicated process chain that includes screening, diagnostic evaluation, engagement with treatment, and improved health outcomes.”