Early screening aap

Guidelines for Early Identification, Screening, and Clinical Management of Children With Autism Spectrum Disorders Stanley I. Greenspan, T. Berry Brazelton, José Cordero, Richard Solomon, Margaret L. Bauman, Ricki Robinson, Stuart Shanker and Cecilia Breinbauer Pediatrics 2008;121;828-830 DOI: 10.1542/peds.2007-3833

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/121/4/828

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2008 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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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, MDb, Jose´ Cordero, MD, MPHc, Richard Solomon, MD, MPH, FAAPd, Margaret L. Bauman, MD, FAANPe, Ricki Robinson, MD, MPH, FAAPf, Stuart Shanker, DPhilg, Cecilia Breinbauer, MD, MPHh a

Department of Psychiatry, Behavioral Sciences, and Pediatrics, George Washington University, Washington, DC; Departments of bPediatrics (Emeritus) and eNeurology, Harvard Medical School and Departments of Neurology and Pediatrics and Learning and Developmental Disabilities Evaluation and Rehabilitation Services (LADDERS), Massachusetts General Hospital, Boston, Massachusetts; cSchool of Public Health, University of Puerto Rico, San Juan, Puerto Rico; dAnn Arbor Center for Developmental and Behavioral Pediatrics, Ann Arbor, Michigan; fDepartment of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; gDepartment of Philosophy and Psychology and the Milton and Ethel Harris Research Initiative, York University, Toronto, Ontario, Canada; hInterdisciplinary 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 THE American Academy of Pe-

diatrics (AAP). Two of their recent clinical reports published in Pediatrics, “Identification and Evaluation of Children With Autism Spectrum Disorders”1 and “Management 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 experience 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” developmental framework3 looks for compromises in the child’s healthy milestones and helps parents and other caregivers work with the child to improve that area of functioning 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 development may prove to be counterproductive.5 Screening that focuses on specific behaviors or symptoms (eg, whether a child responds to his or her name toward the end of the first year) may identify a percentage 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 otherwise developmentally healthy child who does not respond 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 “warning sign,” diminished eye contact, may have a basis in other factors (eg, overly reactive to visual stimuli, extreme 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 worrying the family with a potential diagnosis of an ASD at that stage may be premature.

A broader and more refined functional developmental 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 caregiver and the child (starting at 3– 6 months and up); 2. engage in social reciprocity with caregivers, showing a range of different emotional expressions, vocalizations, 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 assessment team must be sufficiently experienced and 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

*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).

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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: stanleygreenspan@gmail.com.

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2008 by the American Academy of Pediatrics

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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 subsequently targeted interventions that overfocus on selected behaviors are implemented, overall healthy developmental functioning may be compromised rather than facilitated.

In the AAP report on clinical management, the authors 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 emphasized 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 behavioral 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 intervention.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 National Research Council/National Academy of Sciences 2001 report Educating Children With Autism,18 which mentioned a number of evidence-based approaches, including 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 importance of tailoring the approach to the individual child (eg, some children with ASDs are overreactive to sensations, whereas others are underreactive). This last point is at the heart of comprehensive developmental approaches, 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, Relationship-based/Floortime model is not a specific “playbased” technique but, rather, a framework that includes 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 therapy, speech therapy, and family support, specific techniques may include elements of more structured approaches, 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 published 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 developmental 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 definition 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.

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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 Antonio, TX: Harcourt Assessment; 2004 4. Landa RJ, Holman KC, Garret-Mayer E. Social and communication 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); Interdisciplinary Council on Developmental and Learning Disorders (ICDL) Work Group on Early Identification and Preventive Intervention.

CDC/ICDL collaboration report on a framework for early identification and preventive intervention of emotional and developmental challenges. Available at: www.icdl.com/bookstore/catalog/ documents/CDC-ICDLCollaborationReport.pdf. Accessed February 27, 2008 6. Greenspan SI, Wieder S. Developmental patterns and outcomes 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 9. Shea V. A perspective on the research literature related to early intensive behavioral intervention (Lovaas) for young children with autism. Autism. 2004;8(4):349 –367 10. Delprato DJ. Comparisons of discrete-trial and normalized behavioral language intervention for young children with autism. J Autism Dev Disord. 2001;31(3):315–325 11. Aldred C, Green J, Adams C. A new social communication intervention for children with autism: pilot randomized controlled treatment study suggesting effectiveness. J Child Psychol Psychiatry. 2004;45(8):1420 –1430 12. Drew A, Baird G, Baron-Cohen S, et al. A pilot randomized

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18. National Research Council, Division of Behavioral and Social Sciences and Education, Committee on Educational Interventions for Children With Autism. Educating Children With Autism.

Lord C, McGee JP, eds. Washington, DC: National Academy Press; 2001 19. Greenspan SI, Wieder S. An integrated developmental approach to interventions for young children with severe difficulties in relating and communicating. Zero to Three. 1997; 15(5):5–18 20. Greenspan SI, Wieder S. A functional developmental approach to autism spectrum disorders. J Assoc Pers Sev Handicaps. 1999; 24(3):147–161 21. Wieder S, Greenspan S. Can children with autism master the core deficits and become empathetic, creative, and reflective?

A ten to fifteen year follow-up of a subgroup of children with autism spectrum disorders (ASD) who received a comprehensive developmental, individual-difference, relationship-based (DIR) approach. J Dev Learn Disord. 2005;9:1–29 22. Greenspan SI, Wieder S. Engaging Autism: The Floortime Approach to Helping Children Relate, Communicate, and Think. Reading, MA: Perseus Books; 2005 23. Solomon R, Necheles J, Ferch C, Ruckman D. Pilot study of a parent training program for young children with autism.

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Noted by JFL, MD

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Guidelines for Early Identification, Screening, and Clinical Management of Children With Autism Spectrum Disorders Stanley I. Greenspan, T. Berry Brazelton, JosĂŠ Cordero, Richard Solomon, Margaret L. Bauman, Ricki Robinson, Stuart Shanker and Cecilia Breinbauer Pediatrics 2008;121;828-830 DOI: 10.1542/peds.2007-3833 Updated Information & Services

including high-resolution figures, can be found at: http://www.pediatrics.org/cgi/content/full/121/4/828

References

This article cites 19 articles, 7 of which you can access for free at: http://www.pediatrics.org/cgi/content/full/121/4/828#BIBL

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