Early Screening of Autism Spectrum Disorder: Recommendations for Practice and Research AUTHORS: Lonnie Zwaigenbaum, MD,a Margaret L. Bauman, MD,b Deborah Fein, PhD,c Karen Pierce, PhD,d Timothy Buie, MD,e Patricia A. Davis, MD,f Craig Newschaffer, PhD,g Diana L. Robins, PhD,g Amy Wetherby, PhD,h Roula Choueiri, MD,i Connie Kasari, PhD,j Wendy L. Stone, PhD,k Nurit Yirmiya, PhD,l Annette Estes, PhD,m Robin L. Hansen, MD,n James C. McPartland, PhD,o Marvin R. Natowicz, MD, PhD,p Alice Carter, PhD,q Doreen Granpeesheh, PhD, BCBA-D,r Zoe Mailloux, OTD, OTR/L, FAOTA,s Susanne Smith Roley, OTD, OTR/L, FAOTA,t and Sheldon Wagner, PhDu


This article reviews current evidence for autism spectrum disorder
(ASD) screening based on peer-reviewed articles published to December
2013. Screening provides a standardized process to ensure that
children are systematically monitored for early signs of ASD to promote
earlier diagnosis. The current review indicates that screening
in children aged 18 to 24 months can assist in early detection, consistent
with current American Academy of Pediatrics’ recommendations.
We identify ASD-specific and broadband screening tools that have
been ev-aluated in large community samples which show particular
promise in terms of accurate classification and clinical utility. We also
suggest strategies to help overcome challenges to implementing ASD
screening in community practice, as well as priorities for future research.
Pediatrics 2015;136:S41–S59


Procedures for the Evaluation of the Visual System by Pediatricians

Donahue SP, Baker CN; Committee on Practice and Ambulatory Medicine; Section on Ophthalmology; American Association of Certified Orthoptists; American Association for Pediatric Ophthalmology and Strabismus; American Academy of Ophthalmology.
Pediatrics. 2016;137(1):1-9. doi: 10.1542/peds.2015-3597. Epub 2015 Dec 7
PubMed PMDI: 26644488

Vision screening is crucial for the detection of visual and systemic disorders. It should begin in the newborn nursery and continue throughout childhood. This clinical report provides details regarding methods for pediatricians to use for screening.
This clinical report supplements the combined policy statement from the American Academy of Pediatrics (AAP), American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology, and American Association of Certified Orthoptists titled “Visual System Assessment in Infants, Children, and Young Adults by Pediatricians.” The clinical report and accompanying policy statement supplant the 2012 policy statement “Instrument-Based Pediatric Vision Screening,” the 2003 policy statement “Eye Examination in Infants, Children, and Young Adults by Pediatricians,” and the 2008 AAP policy statement “Red Reflex Examination in Neonates Infants and Children.” The policy statement articulates the screening criteria and screening methods, and the clinical report explains the various evaluation procedures that are available for use by the pediatrician or primary care physician.

Visual System Assessment in Infants, Children, and Young Adults by Pediatricians

Committee on Practice and Ambulatory Medicine; Section on Ophthalmology; American Association of Certified Orthoptists; American Association for Pediatric Ophthalmology and Strabismus; American Academy of Ophthalmology.
Pediatrics. 2016;137(1):1-3. doi: 10.1542/peds.2015-3596
PubMed PMDI: 26644485

Appropriate visual assessments help identify children who may benefit from early interventions to correct or improve vision. Examination of the eyes and visual system should begin in the nursery and continue throughout both childhood and adolescence during routine well-child visits in the medical home. Newborn infants should be examined using inspection and red reflex testing to detect structural ocular abnormalities, such as cataract, corneal opacity, and ptosis. Instrument-based screening, if available, should be first attempted between 12 months and 3 years of age and at annual well-child visits until acuity can be tested directly. Direct testing of visual acuity can often begin by 4 years of age, using age-appropriate symbols (optotypes). Children found to have an ocular abnormality or who fail a vision assessment should be referred to a pediatric ophthalmologist or an eye care specialist appropriately trained to treat pediatric patients.


Recommendations on screening for developmental delay

Canadian Task Force on Preventive Health Care
CMAJ 2016. DOI:10.1503/cmaj.151437
PubMed PMID: 27026672

This guideline focuses on population-based screening of children aged one to four years with no apparent signs of developmental delay, whose parents and clinicians have no concerns about development.
Screening refers to use of a standardized tool to search for developmental delay in children without recognized signs of such delay and whose parents or clinicians have not raised concerns. Screening differs from developmental surveillance, which refers to ongoing monitoring by clinicians of a child’s development, identification of risk factors and elicitation of parental concerns.

Key points:
  • There is no evidence from randomized controlled trials (RCTs) that screening children for developmental delay improves health outcomes.
  • There is no evidence that commonly used screening tools would consistently identify otherwise unrecognized cases, but there is evidence that the low specicity of these tools would lead to a high proportion of false positives.
  • High-quality evidence from RCTs on the effectiveness of treatment for known developmental delay is lacking; a few small trials have suggested that speech and language therapy may improve language impairment and that treatment of autism may improve cognitive function.
  • The task force recommends against use of population-based screening with standardized questionnaires in children aged 1 to 4 years with no apparent signs of developmental delay and whose parents and clinicians have no specific concerns.
  • Clinicians should remain vigilant to deficits in children’s performance in terms of gross and fine motor skills, cognition, speech and language, and personal and social abilities. They should consider further evaluation for children whose development does not meet age-expected milestones.


Confronting the Need for Evidence Regarding Prevention.

Grossman DC, Kemper AR.
Pediatrics. 2016 Feb;137(2):1-3. doi: 10.1542/peds.2015-3332. Epub2016 Jan 12. PubMed PMID: 26759409.

When both of us entered pediatrics, we learned that screening dipstick urinalyses was a standard part of well-child care, even though data from at least the 1970s questioned its rationale based on the high false-positive rate and the identification of self-limited disease. Screening seemed sensible and innocuous, and neither of us questioned it at the time. Although we were both aware of the debate about benefit, we do not recall hearing about the potential harms of dipstick screening. Over time, the evidence regarding the lack of benefit grew and the recommendation for screening urinalysis was limited to the 5-year-olds2 and then eventually dropped.3 Here is the question: Should a screening test that seems effective be adopted into routine practice with the expectation that evidence would eventually affirm its use or remove it from clinical care? Do we “do first, ask later?” We all know practices in our communities that still routinely use screening urinalyses out of concern about missing a “case” regardless of the potential harm and questionable benefit. How much do we need to know about a preventive screening test before it is recommended as “standard of care?” When do we know enough to either start or stop a service provided to all? How well do we stop a preventive service after it is shown to be ineffective?Preventive care services delivery is the cornerstone of pediatrics. From the newborn visit through adolescence, the American Academy of Pediatrics (AAP) and Bright Futures recommend 31 well-child care visits, each with specific discrete preventive services.4 We are often asked by our trainees in clinic how we decide what services to provide within the limited available time. We were taught by skilled and talented clinicians based on their personal knowledge, experience, and expert opinion about what to do.We now recognize that the standard should be higher. Pediatric preventive care services, like screening and counseling, are delivered to children who are asymptomatic and seemingly well and whose families often have no specific concerns about the target of the preventive care service. Although screening for some conditions and behaviors can lead to significant benefit, there is also the possibility of causing harm. Harms related to screening are often underrecognized, but can include physical harms (eg, diagnostic procedures after a false-positive screen, unnecessary treatments resulting from overdiagnosis), psychological harm (eg, anxiety, labeling), and induced financial strains for families (eg, missed work, co-pays for follow-up evaluation and care).5 For example, screening urinalysis can commonly identify asymptomatic bacteriuria or orthostatic proteinuria, leading to a cascade of retesting and potential treatment without benefit to the child.Understanding the relative benefits and harms of preventive services allows prioritization. The Bright Futures guidelines uses an “evidence-informed” process, combining elements of evidence-based medicine and expert opinion.6 To what degree is the continuing use of expert opinion appropriate, especially given the lack of high-quality studies regarding the outcomes of many preventive services delivered in childhood? Will we always continue to rely on expert opinion or do we have an expectation that high-quality studies will be funded and conducted to replace expert opinion as our source of guidance?The Institute of Medicine issued a report that serves as the foundation for clinical guidelines developed by many professional medical societies in adult medicine and could be a model for pediatrics.7 A related approach specific for evaluation of preventive services is used by the US Preventive Services Task Force (USPSTF), of which we are both members. The USPSTF does not consider expert opinion in the final formulation of recommendations. It is also not enough to establish that a screening test can reliably identify a targeted condition. There must also be evidence that detection of the condition in an individual with no symptoms leads to better health outcomes. Preventive services can be recommended for routine care (“A” or “B” grades), recommended against (“D” grade), or identified for discretionary use based on the preference of the patient and family (“C” grade). When there is low certainty of net benefit, based on few or low-quality published studies, the USPSTF issues an “I” (insufficient evidence) statement. There is no room for expert opinion. An I statement is an explicit call for research to close the gaps that prevent a clear recommendation. Unfortunately, there are many I’s in pediatrics.These letter assignments are only part of the development of a full recommendation. For each preventive service, there is an accompanying comprehensive systematic evidence review and the USPSTF provides a detailed statement regarding how the decision was reached and the considerations for clinical practice and future research. Although expert opinion is not considered in the recommendations process, the USPSTF is dedicated to transparency in their methods and to ensuring that all relevant high-quality data are considered. Therefore, at the start of each preventive service evaluation, a draft research plan is released for public comment and public comment is also sought for the draft systematic evidence reviews and draft recommendation statements before they are finalized.For many services we offer in pediatrics, the evidence base is incomplete. Should you screen for dyslipidemia in middle childhood, hypertension routinely during each visit starting in early childhood, or for autism in the second year of life? Although Bright Futures endorses each,4 the USPSTF has assigned an I, based on the lack of evidence.8 We understand the frustration of our colleagues regarding these differences and the challenge this creates in practice. However, identifying gaps is the only way to advance our field and ensure that we are providing the care that our patients and their families deserve. An I statement does not mean that there is no value to the preventive service or that the USPSTF is against its delivery. It is a tacit acknowledgment that we do not know if there is a net benefit to routinely providing the service to asymptomatic patients. Knowing that information can help clinicians to prioritize those activities for which a known net benefit exists.Our concern is that many are complacent with reliance on expert opinion regarding the benefit of preventive services and do not advocate for the additional research necessary to ensure the benefit of pediatric primary care. We as pediatricians are trained to serve as advocates for our patients and families. The AAP is widely recognized as among the most respectable advocacy organizations because the balance of its major focus is on child health concerns, and not just professional practice. The AAP has often taken the lead in important but contentious debates, such as firearm safety. We believe that the AAP plays a critical role in child advocacy. The AAP has led research and safety advocacy efforts by supporting the Best Pharmaceuticals for Children Act and the Pediatric Research Equity Act, both of which were designed to increase the evidence base regarding benefits and harms of medications used in children, thereby reducing the need to prescribe “off-label” for children. Now that we are beginning to achieve parity for evidence regarding treatment, why would we demand less for preventive services?We believe that the time has arrived for pediatricians and other child health providers to advocate for funding and executing research to achieve a higher-quality evidence base in pediatric preventive care. We need no less information on the optimal way to screen for hypertension in children than we do for hypertension in adults.9 We need more high-quality studies about the outcomes of early-identified cases of autism, including understanding the effectiveness of competing interventions. We should have as many trials and meta-analyses in prevention as we do for specialty treatment. We should not be afraid to question if 31 well-child visits leads to improved health outcomes compared with a lower or higher number. We should not be afraid to admit what we do not know, but then must also act to generate the missing knowledge. Pediatricians who are not involved in formal academics also can contribute to the understanding of the value of specific preventive services by participating in clinical trials conducted by practice-based research networks, such as the AAP’s Pediatric Research in Office Settings network. As clinicians, we should adopt those preventive services known to be effective, studiously avoid those associated with harm, and seek to understand the evidence for each preventive service we offer in our busy practices.E.B. White, the author of children’s books, said, “The world is full of people who have never, since childhood, met an open doorway with an open mind.” Let us together meet this particular open doorway with an open mind.


Performance of blood pressure-to-height ratio as a screening tool for elevated blood pressure in pediatric population: a systematic meta-analysis.

Yin X, Liu Q, Bovet P, Ma C, Xi B.

The aim of this study was to assess the performance of the blood pressure-to-height ratio (BPHR) for screening elevated blood pressure (BP) in children and adolescents using a meta-analysis of eligible published studies. We retrieved studies that investigated the performance of the BPHR for identifying elevated BP from Pubmed and other databases. We performed meta-analyses by subgroups of sex, age and ethnicity using a fixed or random effect model based on whether there was between-study heterogeneity. A total of 13 publications including 262830 children and adolescents aged 6-18 years on BPHR and a total of three publications including 95343 children on the modified BPHR were included in this meta-analysis. The summary results suggested that BPHR performed well to  identify pre-high BP and high BP for children aged 6-11 years and adolescents aged 12-18 years. The performance of BPHR was perfect for identifying severe high BP in adolescents aged 12-18 years. However, the modified BPHR did not improve accuracy for screening high BP in children aged 6-12 years. In summary, BPHR performed well for identifying elevated BP in children and adolescents, independently of sex, age and ethnicity group. In addition, the modified BPHR performed similarly with BPHR for screening high BP in childhood.Journal of Human
Hypertension advance online publication, 3 March 2016; doi:10.1038/jhh.2016.12.

Screening for Depression in Children and Adolescents: US Preventive Services Task Force Recommendation Statement.

Albert L. Siu, on behalf of the US Preventive Services Task Force

DESCRIPTION: This article describes the update of the 2009 US Preventive Services Task Force (USPSTF) recommendation on screening for major depressive disorder (MDD) in children and adolescents.
METHODS: The USPSTF reviewed the evidence on the benefits and harms of screening, accuracy of primary care–feasible screening tests, and benefits and harms of treatment with psychotherapy, medications, and collaborative care models in patients aged 7 to 18 years.
POPULATION: This recommendation applies to children and adolescents aged ≤18 years who do not have an MDD diagnosis.
RECOMMENDATION: The USPSTF recommends screening for MDD in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up (B recommendation). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for MDD in children aged ≤11 years (I statement).

A Novel Triage Approach to Identifying Health Concerns

Janine Bezem, Meinou Theunissen, Mascha Kamphuis, Mattijs E. Numans, Simone E. Buitendijk, Paul Kocken

BACKGROUND: We investigated the detection of health problems in preventive child health care (PCH) by a novel triage approach for routine health assessments. In the triage approach, all children were preassessed by a physician’s assistant, and only those in need of follow-up were assessed by a PCH physician or nurse. In the traditional approach, all children were assessed by a PCH physician or nurse.
METHODS: A prospective cohort design was used with data on routine assessments of 1897 children aged 5 to 6 and 10 to 11 years. Primary outcomes were the detection of overweight, visual disorders, and psychosocial problems, with type of approach (traditional vs triage) as independent variable. To assess the severity of health problems, BMI, Snellen, Strengths and Difficulties Questionnaire, and Child Behavior Checklist, scores were compared for both approaches in subgroups of children with overweight, visual disorders, or psychosocial problems.
RESULTS: No significant differences were found between the approaches in terms of the detection of incident cases of overweight, visual disorders, and psychosocial problems. Significantly higher Strengths and Difficulties Questionnaire scores were found in the subgroup with psychosocial problems when the triage approach was used. Marginal differences between the approaches were found for severity of overweight in the subgroup of overweight children.
CONCLUSIONS: A novel triage approach to PCH resulting in less involvement of physicians and nurses in routine assessments appears to detect health problems as effectively as the traditional approach in place. More research is needed to determine the long-term outcomes of the 2 approaches.

A Parent Coach Model for Well-Child Care Among Low-Income Children: A Randomized Controlled Trial.

PEDIATRICS Volume 137 , number 3 , March 2016
Tumaini R. Coker, Sandra Chacon, Marc N. Elliott, Yovana Bruno, Toni Chavis, Christopher Biely, Christina D. Bethell, Sandra Contreras, Naomi A. Mimila, Jeffrey Mercado, Paul J. Chung.

OBJECTIVE: The goal of this study was to examine the effects of a new model for well-child care (WCC), the Parent-focused Redesign for Encounters, Newborns to Toddlers (PARENT), on WCC quality and health care utilization among low-income families.
METHODS: PARENT includes 4 elements designed by using a stakeholder-engaged process: (1) a parent coach (ie, health educator) to provide anticipatory guidance, psychosocial screening and referral, and developmental/behavioral guidance and screening at each well-visit; (2) a Web-based tool for previsit screening; (3) an automated text message service to provide periodic, age-specific health messages to families; and (4) a brief, problem-focused encounter with the pediatric clinician. The Promoting Healthy Development Survey–PLUS was used to assess receipt of recommended WCC services at 12 months’ postenrollment. Intervention effects were examined by using bivariate analyses.
RESULTS: A total of 251 parents with a child aged ≤12 months were randomized to receive either the control (usual WCC) or the intervention (PARENT); 90% completed the 12-month assessment. Mean child age at enrollment was 4.5 months; 64% had an annual household income less than $20000. Baseline characteristics for the intervention and control groups were similar. Intervention parents scored higher on all preventive care measures (anticipatory guidance, health information, psychosocial assessment, developmental screening, and parental developmental/behavioral concerns addressed) and experiences of care measures (family-centeredness, helpfulness, and overall rating of care). Fifty-two percent fewer intervention children had ≥2 emergency department visits over the 12-month period. There were no significant differences in WCC or sick visits/urgent care utilization.
CONCLUSIONS: A parent coach–led model for WCC may improve the receipt of comprehensive WCC for low-income families, and it may potentially lead to cost savings by reducing emergency department utilization.


Interventions by Health Care Professionals Who Provide Routine Child Health Care to Reduce Tobacco Smoke Exposure in Children: A Review and Meta-analysis.

Daly JB, Mackenzie LJ, Freund M, Wolfenden L, Roseby R, Wiggers JH.

IMPORTANCE: Reducing child exposure to tobacco smoke is a public health priority. Guidelines recommend that health care professionals in child health settings should address tobacco smoke exposure (TSE) in children.
OBJECTIVE: To determine the effectiveness of interventions delivered by health care professionals who provide routine child health care in reducing TSE in children.
DATA SOURCES: A secondary analysis of 57 trials included in a 2014 Cochrane review and a subsequent extended search was performed. Controlled trials (published through June 2015) of interventions that focused on reducing child TSE, with no restrictions placed on who delivered the interventions, were identified. Secondary data extraction was performed in August 2015.
STUDY SELECTION: Controlled trials of routine child health care delivered by health care professionals (physicians, nurses, medical assistants, health educators, and dieticians) that addressed the outcomes of interest (TSE reduction in children and parental smoking behaviors) were eligible for inclusion in this review and meta-analysis.
DATA EXTRACTION AND SYNTHESIS: Study details and quality characteristics were independently extracted by 2 authors. If outcome measures were sufficiently similar, meta-analysis was performed using the random-effects model by DerSimonian and Laird. Otherwise, the results were described narratively.
MAIN OUTCOMES AND MEASURES: The primary outcome measure was reduction in child TSE. Secondary outcomes of interest were parental smoking cessation, parental smoking reduction, and maternal postpartum smoking relapse prevention.
RESULTS: Sixteen studies met the selection criteria. Narrative analysis of the 6 trials that measured child TSE indicated no intervention effects relative to comparison groups. Similarly, meta-analysis of 9 trials that measured parental smoking cessation demonstrated no overall intervention effect (n = 6399) (risk ratio 1.05; 95% CI, 0.74-1.50; P = .78). Meta-analysis of the 3 trials that measured maternal postpartum smoking relapse prevention demonstrated a significant overall intervention effect (n = 1293) (risk ratio 1.53; 95% CI, 1.10-2.14; P = .01). High levels of study heterogeneity likely resulted from variability in outcome measures, length of follow up, intervention strategies, and unknown intervention fidelity.
CONCLUSIONS AND RELEVANCE: Interventions delivered by health care professionals who provide routine child health care may be effective in preventing maternal smoking relapse. Further research is required to improve the effectiveness of such interventions in reducing child TSE and increasing parental smoking cessation. The findings of this meta-analysis have policy and practice implications relating to interventions by routine pediatric health care professionals that aim to reduce child exposure to tobacco smoke.


Early detection of parenting and developmental problems in toddlers: A randomized trial of home visits versus well-baby clinic visits in the Netherlands.

Staal II, van Stel HF, Hermanns JM, Schrijvers AJ.

OBJECTIVE: The early detection of parenting and developmental problems by preventive child health care (CHC) services in the Netherlands takes place almost exclusively at the well-baby clinic. This study assesses whether, compared to a visit to the well-baby clinic, a home visit improves early detection.
METHODS: 4481 eligible 18-month-old children and their parents were randomized to either a visit to the well-baby clinic or a home visit in the period from December 2006 to January 2008. A CHC nurse held structured interviews using the validated Structured Problem Analysis of Raising Kids (SPARK). Differences in the percentage of children with high or increased risks of parenting and developmental problems as assessed by the SPARK were analyzed with ordinal regression. Secondary outcomes included the percentage of parents attending, parents' concerns, needs assessment by parents and CHC professionals and user experience.
RESULTS: Response rates were 94.0% for the home visit group and 93.2% for the well-baby clinic group. Using the SPARK at home identified significantly more high-risk children compared to clinic visits (3.7 vs. 2.6%) and fewer children with increased risk (19.1 vs. 20.7%; overall p=0.028). Home visits more often involved both parents and other children. At home, parents reported more concerns. Both parents and CHC nurses more often expressed the need for support and reported significantly better experiences at home.
CONCLUSIONS: Aided by a validated structured interview, CHC professionals detect more children with high risks of parenting and child-developmental problems during home visits than during clinic visits.
CLINICAL TRIAL REGISTRATION: www.trialregister.nl Identifier: NTR1413.