Autism: 5 misconceptions that can complicate care

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Applied Evidence

Autism: 5 misconceptions that can complicate care

J Fam Pract. 2014 June;63(6):310-314

By

Margot Savoy, MD, MPH, FAAFP, CPE

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Despite an increasing understanding of autism spectrum disorder, misinformation abounds. Here’s help dispelling common misconceptions.

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References

1. Developmental Disabilities Monitoring Network Surveillance Year 2010 Principal Investigators; Centers for Disease Control and Prevention (CDC). Prevalence of autism spectrum disorder among children aged 8 years - Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2010. MMWR. 2014;63:1-21.

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing: 2013.

3. Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee; Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006;118:405-420.

4. Screening for autism spectrum disorder in young children. US Preventive Services Task Force Web site. Available at: http://www.uspreventiveservicestaskforce.org/uspstf/uspsaut.htm. Accessed November 7, 2013.

5. Johnson CP, Myers SM; Council on Children With Disabilities. Identification and evaluation of children with autism spectrum disorders. Pediatrics. 2007;120:1183-1215.

6. Robins DL, Casagrande K, Barton M, et al. Validation of the modified checklist for Autism in toddlers, revised with followup (M-CHAT-R/F). Pediatrics. 2014;133:37-45.

7. Reichow B, Barton EE, Boyd BA, et al. Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2012;10:CD009260.

8. Rossignol DA, Frye RE. Melatonin in autism spectrum disorders: a systematic review and meta-analysis. Dev Med Child Neurol. 2011;53:783-792.

9. Oono IP, Honey EJ, McConachie H. Parent-mediated early intervention for young children with autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2013;4: CD009774.

10. Dove D, Warren Z, McPheeters ML, et al. Medications for adolescents and young adults with autism spectrum disorders: a systematic review. Pediatrics. 2012;130:717-726.

11. Cheuk DK, Wong V, Chen WX. Acupuncture for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2011;(9):CD007849.

12. Sochocky N, Millin R. Second generation antipsychotics in Asperger’s Disorder and high functioning autism: a systematic review of the literature and effectiveness of meta-analysis. Curr Clin Pharmacol. 2013;8:370-379.

13. Sinha Y, Silove N, Hayen A, et al. Auditory integration training and other sound therapies for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2011;(12):CD003681.

14. Rossignol DA. Novel and emerging treatments for autism spectrum disorders: a systematic review. Ann Clin Psychiatry. 2009;21:213-236.

15. Millward C, Ferriter M, Calver S, et al. Gluten- and casein-free diets for autistic spectrum disorder. Cochrane Database Syst Rev. 2008;(2):CD003498.

16. James S, Montgomery P, Williams K. Omega-3 fatty acids supplementation for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2011;(11):CD007992.

17. Williams K, Wray JA, Wheeler DM. Intravenous secretin for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2012;4:CD003495.

18. Green J, Charman T, McConachie H, et al; PACT Consortium. Parent-mediated communication-focused treatment in children with autism (PACT): a randomised controlled trial. Lancet. 2010;375:2152-2160.

19. Landa RJ, Holman KC, O’Neill AH, et al. Intervention targeting development of socially synchronous engagement in toddlers with autism spectrum disorder: a randomized controlled trial. J Child Psychol Psychiatry. 2011;52:13-21.

20. Kasari C, Gulsrud AC, Wong C, et al. Randomized controlled caregiver mediated joint engagement intervention for toddlers with autism. J Autism Dev Disord. 2010;40:1045-1056.

21. Dawson G, Rogers S, Munson J, et al. Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model. Pediatrics. 2010;125:e17-e23.

22. Warren Z, McPheeters ML, Sathe N, et al. A systematic review of early intensive intervention for autism spectrum disorders. Pediatrics. 2011;127:e1303-e1311.

23. Anderson KA, Shattuck PT, Cooper BP, et al. Prevalence and correlates of postsecondary residential status among young adults with an autism spectrum disorder Autism. 2013 September 9. [Epub ahead of print].

24. Roux AM, Shattuck PT, Cooper BP, et al. Postsecondary employment experiences among young adults with an autism spectrum disorder. J Am Acad Child Adolesc Psychiatry. 2013;52:931-939.

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26. Edelson MG. Are the majority of children with autism mentally retarded? A systematic evaluation of the data. Focus Autism Other Dev Disabl. 2006;21:66-83.

27. Wakefield AJ, Murch SH, Anthony A, et al. Ileal-lymphoidnodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 1998;351:637-641.

28. Uhlmann V, Martin CM, Sheils O, et al. Potential viral pathogenic mechanism for new variant inflammatory bowel disease. Mol Pathol. 2002;55:84-90.

29. Centers for Disease Control and Prevention: Immunization Safety and Autism. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/vaccinesafety/Concerns/Autism/Index.html. Accessed May 20, 2014.

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PRACTICE RECOMMENDATIONS

› Screen children for developmental delays with a standardized screening tool at 9, 18, and 24 or 30 months of age, accompanied by surveillance at all well-child visits. C
› Use a parent-completed tool rather than a directly administered tool to screen for developmental delays. C
›Advise parents of a child diagnosed with autism spectrum disorder that early intensive behavioral therapy can improve cognitive, language, and adaptive skills. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Autism spectrum disorder (ASD) affects approximately one in 68 children in the United States, according to the Centers for Disease Control and Prevention (CDC).¹ Growing public awareness of autism means that family physicians are increasingly likely to hear from anxious new (and expectant) parents. Unfortunately, misinformation about autism continues to be perpetuated, through word of mouth, the Internet, and misinformed advocacy groups. This article addresses 5 of the most common misconceptions, and can help you set the record straight and respond appropriately to parental concerns.

Misconception 1: Autism is a single condition

While autistic disorder was previously considered one of 5 pervasive developmental disorders, in 2013 the Diagnostic and Statistical Manual of Mental Disorder, 5th edition (DSM-5) redefined it. (To learn more about how shifts in our understanding of autism were reflected in each new edition of the DSM, see “Autism: Why the rise in rates?”)

ASD is now an umbrella term that encompasses autism, Asperger syndrome, pervasive developmental disorder not otherwise specified, childhood disintegrative disorder, and Rett syndrome.² The new term is meant to highlight the continuum of symptoms and frequent variability of presentation among those affected, ranging from mild to more severe impairment. Anyone who was classified under DSM-IV criteria, of course, should continue to have an autism/ASD diagnosis.

As with previous definitions, ASD is characterized by communication deficits (eg, inappropriate responses in conversation, misinterpreted nonverbal interactions, and significant challenges in age-appropriate bonding/friendship development). While previous definitions were focused on identifying school-age deficits, the update requires early childhood symptoms—regardless of the age of formal diagnosis.²

Misconception 2: Only symptomatic children should be screened for ASD

Although the decision to screen all children remains a controversial one, at least one medical society—the American Academy of Pediatrics (AAP)—calls for universal screening.³ The American Academy of Family Physicians does not have or endorse a formal guideline about screening for ASD. The US Preventive Services Task Force has a guideline, but it is in the process of being revised.⁴

Given the advances in early childhood interventions, there is little doubt that early identification of those at risk for developmental delay is beneficial. But opponents of universal screening cite concerns about unnecessary testing, anxiety, and overdiagnosis due to false positives associated with traditional screening methods.

The AAP calls for screening and surveillance. Since 2006, the AAP has recommended surveillance at all well-child visits, combined with screening for developmental delays at 9, 18, and 24 or 30 months of age, using a standardized screening tool.^3,5 A parent-completed tool (eg, the Modified Checklist for Autism in Toddlers [M-CHAT] or, most recently, the M-CHAT Revised with Follow-up⁶; Parents’ Evaluation of Developmental Status; or Ages and Stages Questionnaire, 3rd ed) should be used rather than a directly administered tool.^3,5 An algorithm detailing the AAP’s approach is available at http://www.cdc.gov/ncbddd/actearly/autism/case-modules/pdf/diagnosis/AAP%20Screening%20Guidelines.pdf.

Avoid a "wait and see" approach. Parents of children with ASD often broach the subject by the baby's first birthday.Physicians should also be prepared to evaluate any child whose parents raise concerns about his or her development during a routine visit. A “wait and see” approach is strongly discouraged. Parents of children with ASD often broach the subject by the baby’s first birthday.⁵ Common concerns include the child’s inability to babble, point or gesture meaningfully, or respond to his or her name; poor eye contact; failure to play with toys; and/or loss of (or failure to develop) language or social skills.⁵

An ASD mnemonic. The CDC, in collaboration with the AAP, the American Academy of Neurology, and the Child Neurology Society, has released a simplified guideline with the mnemonic ALARM to summarize recommendations for developmental screening, surveillance, diagnosis, and management of ASD.⁵ ALARM stands for:
• Autism is prevalent
• Listen to parents
• Act early
• Refer
• Monitor.

Misconception 3: Since ASD can't be cured, early intervention offers no benefit

While there is no cure for ASD and it is not considered reversible, there is an array of potential ASD therapies and proven benefits of early intervention. Therapies range from diet to medication and behavioral skills development, but only a few have ample evidence of efficacy (TABLE).^7-17