Guidelines for Early Identification, Screening, and Clinical Management of Children With Autism Spectrum Disorders

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COMMENTARY

Guidelines for Early Identification, Screening, and

Clinical Management of Children With Autism

Spectrum Disorders

Stanley I. Greenspan, MDa_{, T. Berry Brazelton, MD}b_{, Jose´ Cordero, MD, MPH}c_{, Richard Solomon, MD, MPH, FAAP}d_,

Margaret L. Bauman, MD, FAANPe_{, Ricki Robinson, MD, MPH, FAAP}f_{, Stuart Shanker, DPhil}g_{, Cecilia Breinbauer, MD, MPH}h

a_{Department of Psychiatry, Behavioral Sciences, and Pediatrics, George Washington University, Washington, DC; Departments of}b_{Pediatrics (Emeritus) and}e_Neurology, Harvard Medical School and Departments of Neurology and Pediatrics and Learning and Developmental Disabilities Evaluation and Rehabilitation Services (LADDERS), Massachusetts General Hospital, Boston, Massachusetts;c_{School of Public Health, University of Puerto Rico, San Juan, Puerto Rico;}d_{Ann Arbor Center for Developmental} and Behavioral Pediatrics, Ann Arbor, Michigan;f_{Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California;} g_{Department of Philosophy and Psychology and the Milton and Ethel Harris Research Initiative, York University, Toronto, Ontario, Canada;}h_{Interdisciplinary Council on} Developmental and Learning Disorders, ICDL Graduate School, Kentﬁeld, California

The authors have indicated they have no ﬁnancial relationships relevant to this article to disclose.

C

ONGRATULATIONS TO THEAmerican Academy of Pe-diatrics (AAP). Two of their recent clinical reports published inPediatrics, “Identification and Evaluation of Children With Autism Spectrum Disorders”1_and

“Man-agement of Children With Autism Spectrum Disorders,”2

will enable pediatricians to address parent concerns sooner, facilitating the early identification of children with autism spectrum disorders (ASDs). As physicians and developmentalists with decades of accumulated ex-perience in working with children with developmental challenges, we applaud and welcome these publications. However, we would like to expand on these reports. In this commentary we (1) describe a broader functional/ developmental framework for screening for ASDs, (2) provide a critique of the current trend toward behavioral treatments as primary intervention strategies, and (3) present research evidence for functional/developmental approaches.

A broader and more refined “functional” develop-mental framework3_{looks for compromises in the child’s}

healthy milestones and helps parents and other caregiv-ers work with the child to improve that area of func-tioning and overall healthy progression.* This approach helps families identify challenges early in the first and second years of life and to begin to help their children before the 18- and 24-month screenings recommended by the AAP.4_{An overfocus on specific problem behaviors}

without a framework for promoting healthy develop-ment may prove to be counterproductive.5

Screening that focuses on specific behaviors or symp-toms (eg, whether a child responds to his or her name toward the end of the first year) may identify a percent-age of children who will later fail to meet criteria for ASDs (ie, false-positive results). There are often multiple reasons for a specific behavior. For example, an other-wise developmentally healthy child who does not re-spond to his name may be evidencing negativism with

his caregivers because of family dynamics or may be in need of a full hearing evaluation rather than showing an early warning sign of an ASD. Similarly, another “warn-ing sign,” diminished eye contact, may have a basis in other factors (eg, overly reactive to visual stimuli, ex-treme shyness, etc). In short, children may have specific behaviors that are positive on the screening checklist for signs of ASDs but otherwise evidence an overall healthy pattern of development. These and other behaviors most certainly deserve additional clinical evaluation, but wor-rying the family with a potential diagnosis of an ASD at that stage may be premature.

A broader and more refined functional developmen-tal framework for identifying children at risk for ASDs looks for compromises in the ability to:

1. initiate and sustain engagement, shown by persisting smiles and other wooing behaviors between the care-giver and the child (starting at 3– 6 months and up);

2. engage in social reciprocity with caregivers, showing a range of different emotional expressions, vocaliza-tions, and motor gestures (starting at 8 –12 months and up);

3. solve social problems with caregivers, evidenced by the child’s use of many gestures to communicate and negotiate obtaining what they want (starting at 12–18 months and up).

When a full evaluation for ASDs is warranted, the as-sessment team must be sufficiently experienced and

*There is now available a social emotional growth chart, and a simple questionnaire can help pediatricians and parents monitor the progression of healthy functioning and look for early patterns of both adaptive and maladaptive functioning. This growth chart is now part of the Bailey Assessment Scale (and is available as a separate tool) and evidences a high degree of speciﬁcity (90%) and sensitivity (87%) for ASDs (see www.icdl.com/staging/conferences/ conferences/2007/SEGCHandouts.shtml).

Abbreviations:AAP, American Academy of Pediatrics; ASD, autism spectrum disorder Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.

www.pediatrics.org/cgi/doi/10.1542/peds.2007-3833 doi:10.1542/peds.2007-3833

Accepted for publication Dec 28, 2007

Dr Cordero was formerly afﬁliated with the National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia.

Address correspondence to Stanley I. Greenspan, MD, 7201 Glenbrook Road, Bethesda, MD 20814. E-mail: [email protected].

828 GREENSPAN et al

at Viet Nam:AAP Sponsored on August 29, 2020

www.aappublications.org/news

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comprehensive in its approach. Unfortunately, some families who have gone through formal evaluation at major medical centers report that only a few of the centers observed parent/infant or toddler interactions for more than a few minutes and based their conclusions on somewhat stressful testing situations.6 _If

subquently targeted interventions that overfocus on se-lected behaviors are implemented, overall healthy de-velopmental functioning may be compromised rather than facilitated.

In the AAP report on clinical management, the au-thors reviewed some of the core areas of functioning that characterize healthy development and are disrupted in ASD, such as the capacity for joint attention. Yet, in reviewing specific interventions, the authors empha-sized the “evidence” supporting behavioral interventions but failed to sufficiently emphasize the limitations of this approach. Several comprehensive and well-done studies of developmental outcomes as the result of using behav-ioral approaches exclusively have failed to replicate the original Lovaas study findings7_{and have demonstrated}

that behavioral interventions alone seem to produce only modest educational gains and little to no emotional or social gains (core deficits of ASDs) in comparison to control groups.8–10

Finally, we would like to expand on the AAP articles’ description of developmental approaches to interven-tion.11–17_{Play-based or social-pragmatic interventions are}

characterized by contingent, reciprocal, fun interactions with children that address the core deficits in autism including engageability, love of people, problem-solving, creativity, and emotional thinking. The importance of developmental approaches was supported by the Na-tional Research Council/NaNa-tional Academy of Sciences 2001 report Educating Children With Autism,18 _which

mentioned a number of evidence-based approaches, in-cluding the DIR/Floortime model.19–22 _{The National}

Academy of Sciences report also emphasized the fact that there have been no comparative studies on different interventions and no definitive evidence behind any 1 approach over another. The report emphasized the im-portance of tailoring the approach to the individual child (eg, some children with ASDs are overreactive to sensa-tions, whereas others are underreactive). This last point is at the heart of comprehensive developmental ap-proaches, which view the child’s functional capacities (individual strengths and vulnerabilities) as a guide for how best to foster adaptive development.

The Developmental, Individual Difference, Relation-ship-based/Floortime model is not a specific “play-based” technique but, rather, a framework that in-cludes working with a child at his or her developmental level, orchestrating a variety of therapies to improve individual differences in sensory-motor, language, and social functioning, and supporting family and other learning relationships. In addition to occupational ther-apy, speech therther-apy, and family support, specific tech-niques may include elements of more structured ap-proaches, such as behavioral strategies, as well as Floortime and other relationship-based interactions. The DIR/Floortime model enables clinicians and caregivers to

tailor their interactions to the child’s unique functional profile. (For a full description see www.icdl.com/staging/ dirFloortime/overview/index.shtml.) A recently pub-lished study23_{demonstrated the efficacy of this approach}

in a large community sample, with only modest costs. Thus, a comprehensive intervention program should be based on a framework that identifies and guides the best strategies for each aspect of a child’s individual develop-mental profile.

In conclusion, the AAP’s laudatory effort would benefit from emphasizing the importance of taking a functional approach to developmental challenges and identifying any sign of disruption in healthy functioning as an important basis for an early evaluation. A complete evaluation should then result in a more accurate defini-tion of each child’s developmental profile and thereby provide the mechanism through which more effective intervention can be designed and implemented to bring about improved overall healthy functioning.

REFERENCES

1. Johnson CP, Myers SM; American Academy of Pediatrics, Council on Children With Disabilities. Identification and eval-uation of children with autism spectrum disorders.Pediatrics. 2007;120(5):1183–1215

2. Myers SM, Johnson CP; American Academy of Pediatrics, Council on Children With Disabilities. Management of children with autism spectrum disorders: guidance for the clinician in rendering pediatric care.Pediatrics.2007;120(5):1162–1182 3. Greenspan S.Greenspan Social-Emotional Growth Chart. San

An-tonio, TX: Harcourt Assessment; 2004

4. Landa RJ, Holman KC, Garret-Mayer E. Social and communi-cation development in toddlers with early and later diagnosis of autism spectrum disorders. Arch Gen Psychiatry. 2007;64(7): 853– 864

5. Centers for Disease Control and Prevention (CDC); Interdiscipli-nary Council on Developmental and Learning Disorders (ICDL) Work Group on Early Identification and Preventive Intervention. CDC/ICDL collaboration report on a framework for early identi-fication and preventive intervention of emotional and develop-mental challenges. Available at: www.icdl.com/bookstore/catalog/ documents/CDC-ICDLCollaborationReport.pdf. Accessed Febru-ary 27, 2008

6. Greenspan SI, Wieder S. Developmental patterns and out-comes in infants and children with disorders in relating and communication: a chart review of 200 cases of children with autistic spectrum disorders. J Dev Learn Disord. 1997;1(1): 87–141

7. Lovaas OI. Behavioral treatment and normal educational and intellectual functioning in young autistic children.J Consult Clin Psychol.1987;55(1):3–9

8. Smith T. Discrete trial training in the treatment of autism.Focus Autism Other Dev Disabl.2001;16(2):86 –92

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12. Drew A, Baird G, Baron-Cohen S, et al. A pilot randomized

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control trial of parent training intervention for pre-school chil-dren with autism. Eur Child Adolesc Psychiatry. 2002;11(6): 266 –272

13. Ingersoll B, Dvortcsak A, Whalen C, Sikora D. The effects of a developmental, social-pragmatic language intervention on rate of expressive language production in young children with au-tistic spectrum disorders.Focus Autism Other Dev Disabl.2005; 20(4):213–222

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16. Rogers SJ, DiLalla DL. A comparative study of the effects of a developmentally based instructional model on young children with autism and young children with other disorders of behav-ior and development.Top Early Child Spec Educ. 1991;11(2): 29 – 47

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18. National Research Council, Division of Behavioral and Social Sciences and Education, Committee on Educational Interven-tions for Children With Autism.Educating Children With Autism. Lord C, McGee JP, eds. Washington, DC: National Academy Press; 2001

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830 GREENSPAN et al

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DOI: 10.1542/peds.2007-3833

2008;121;828

Pediatrics

L. Bauman, Ricki Robinson, Stuart Shanker and Cecilia Breinbauer

Stanley I. Greenspan, T. Berry Brazelton, José Cordero, Richard Solomon, Margaret

Children With Autism Spectrum Disorders

Guidelines for Early Identification, Screening, and Clinical Management of

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DOI: 10.1542/peds.2007-3833

2008;121;828

Pediatrics

L. Bauman, Ricki Robinson, Stuart Shanker and Cecilia Breinbauer

Stanley I. Greenspan, T. Berry Brazelton, José Cordero, Richard Solomon, Margaret

Children With Autism Spectrum Disorders

Guidelines for Early Identification, Screening, and Clinical Management of

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