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It's also worth remembering that education is kind of economically weird. It's not just another thing you buy. Education isn't only about individual gain. There's a social aspect as well. We want everyone to have access to quality education because having an educated populace benefits all of us. We're not there yet. (throw to inequality?)
Few would dispute that children who are exhibiting signs or symptoms of autistic spectrum disorder should be referred and tested. It’s when we talk about screening every child for autism that the debate becomes heated. But that’s the topic of this week’s Healthcare Triage.


Recently, the United States Preventative Services Task Force released its draft recommendation statement on the screening of young children for autism spectrum disorder. They decided that the current evidence was not enough to recommend widespread screening of children with no symptoms. This led many people to worry that the group was telling physicians not to screen.

The American Academy of Pediatrics disagrees with the USPSTF. For years, they have argued all children should be screened at 18 and 24 months of age. Pediatricians tend to believe that identifying this problem early and getting children help leads to the most benefit. Moreover, they believe that without universal screening, autism may be missed and treatment delayed for some kids, leading to worse outcomes.

We seem to lack the specific studies to prove the case, so what are we to do? Whenever anyone is discussing a screening test, I usually have four questions which I’ve adapted from David Sackett’s classic handbook in evidence-based medicine, which I’ve talked about in a previous episode.

1. Is the condition prevalent and severe enough to warrant screening?
2. Do we have a cost-effective means to screen the general population?
3. Does early diagnosis make a difference, that is do we have treatments available that are more successful when patients are diagnosed earlier?
4. Will an earlier diagnosis motivate people to use information gained from screening?

Autism affects about 1 in 68 children in the United States; it’s according to the Centers for Disease Control. While I’m on record as being somewhat skeptical of the actual numbers in recent years, few are arguing that autism is not prevalent and that it doesn’t have a significant impact on the lives of children and adults, so question 1 is a resounding yes.

Autism screening can be done with a tool like the Modified Checklist for Autism in Toddlers, or M-CHAT, which is a simple 23-question survey that parents fill out and that doctors score. It’s free for all primary care physicians to use. There are specific billing codes, even, which primary care physicians can use to seek reimbursement for administering the test, so question 2 is satisfied.

I’m not aware of studies of how parents of affected children comply with recommended therapy but as a pediatrician, my admittedly anecdotal experience has been that the parents of children with autism spectrum disorder are some of the most engaged and strongest advocates for their children. I know no one who thinks that question 4 would be answered negatively for a significant number of people.

That leads question 3, which asks whether early intervention works for children with autism. There’s not much disagreement there either. In its discussion of the effectiveness of early detection and treatment, the USPSTF noted the 26 good and fair randomized controlled trials studied early intensive behavioral and developmental interventions. Three of four trials found that interventions improved cognitive scores, like the IQ, 11 to 16 points. They also showed improvement in language skills. Twelve trials examining play- or interaction-based interventions showed significant improvements in measures of interactions with others.

The task force’s quibble is that these interventions were performed in children already found to have autism spectrum disorder. They weren’t conducted in kids whose positive screen led to diagnosis but who hadn’t yet been symptomatic enough to concern their parents or physicians without screening. In a perfect world, asking for a study specifically involving those children might be a reasonable request. In the real world, such a study is almost certainly not gonna happen. At least not anytime soon.

The interventions for autism are rarely pharmaceutical or device-related. As noted earlier, they’re almost always behavioral or developmental. As such, they’re not going to be funded by health industry. They will almost certainly require government funding.

In 2014, the National Institutes of Health spent $188 million on autism research. This was a fraction of the more than $30 billion spent by the NIH that year. The NIH doesn’t even have a fact sheet describing its research programs specifically directed towards autism. I search the NIH report site for any grants given for autism from the Agency for Healthcare Research and Quality in the last five years and found two. I’m a co-investigator on the first. Further, if you drill down into the autism spending, a lot of it, if not most of it, is directed towards basic science research. It’s looking at what might cause autism, how we could better predict who might develop autism, and what the mechanisms are in the brain that lead to autism. All of that is important work, but very little of the funding is directed toward studying how behavioral and developmental interventions affect children, let alone focusing specifically on those who screened positive. No study is coming soon.

The cost for caring for and supporting a person with autism spectrum disorder without an intellectual disability over a lifetime in the United States is $1.4 million. Adding an intellectual disability raises the price to $2.4 million per person.

These are costs above and beyond that of raising a child in general, including special education in childhood, medical care, residential accommodation, and productivity losses in adulthood. This means that autism costs the American economy about $175 billion a year. That’s more than the cost of cancer, strokes, and heart disease combined.

The Task Force is trying to demand a high level of evidence before recommending a screening test be performed universally. I fully endorse that feeling in general, but this is one of the groups that gives a stamp of approval to make sure that such screening is covered by the Affordable Care Act. It still will be because bright future still recommends it, but no studies satisfying the requirements of the Task Force are likely to be done soon. This means less screening will be done even though we know three things: autism is prevalent, screening works, and early intervention seems to make a difference in those diagnosed with the condition.


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