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Sunday, December 20, 2015

An Argument for Universal Screening

In The Politics of AutismI discuss screening and diagnosis.

At Autism, David Mandell and William Mandy have an editorial titled "Should All Young Children be Screened for Autism Spectrum Disorder?"
Recently, the US Preventive Services Task Force (USPSTF) added its influential voice to the debate, publishing draft guidelines that do not recommend universal screening (US Preventative Services Task Force, 2015). ... They observed that studies of early intervention in ASD mainly recruit children who are referred from specialist ASD services. The task force argues that findings from such research may not be generalizable to children identified by screening, who they describe as ‘younger and possibly less severely affected’. On this basis, the USPSTF concludes that a recommendation of universal ASD screening cannot be made.
This is flawed logic and demonstrates remarkable naiveté about the process by which children with ASD are identified and enter treatment. The contention that most early intervention studies are conducted with children 12–24 months older than those who would be identified by screening is highly questionable. Screening rarely leads directly to treatment. It leads to a referral for a specialized evaluation, often with a wait of a year or more (Zuckerman et al., 2015). Once the diagnosis is confirmed, families then may have to wait again until treatment is initiated. Most children picked up by universal screening at, say, 18 months would be aged at least 36 months by the time they had sat on waiting lists for full assessment and then treatment, and therefore of similar age to the participants in most trials of early intervention.
The USPSTF naiveté about the process by which screening leads to treatment extends to their understanding of the broader societal context in which such health policies play out. For example, the USPSTF did not appear to consider the potential effect of universal screening on reducing inequalities in health care. Children with ASD who are poor and who live in poorly resourced and rural communities are at elevated risk of being diagnosed late, or not at all (Daniels and Mandell, 2014; Durkin et al., 2010). Along with other policies, such as better education for parents and clinicians, universal screening aimed at early detection of ASD could be a powerful means of reducing social inequalities in ASD identification and treatmen