Autism Guidelines Suggested

A national panel recommends sweeping changes in how family doctors evaluate children for autism, arguing that early screening should begin with infants and continue throughout childhood.

The recommendations, released Wednesday by a 25-member panel headed by a UC Irvine pediatrician and neurologist, are expected to be adopted by two influential medical societies next year as practice guidelines for physicians to use in detecting the disorder, which affects about one in 500 children.

“The reason for this is that the recognition of autism [as a problem] has skyrocketed, but we are still having referrals of children at age 4, 5 or 6 and that is way too late,” said Dr. Pauline Filipek, the UCI professor who headed the panel. “This occurs because practitioners have not been trained to diagnose autism.”

To come up with its guidelines, the panel reviewed thousands of scientific publications on the subject and discussed the issues with professionals in dozens of specialties.

The guidelines call for physicians to examine children for signs of autism during each well-baby visit.

The recommendations also describe new techniques and tools for doctors to use in recognizing autism and urge other professionals involved in early child care to be more aware of the problem.

Autism is a behavioral syndrome marked by such symptoms as social remoteness, difficulty communicating and repetitive and compulsive behaviors. The cause is not known.

Dr. Maria Minon, a pediatrician and vice president of medical affairs of Children’s Hospital of Orange County, said many youngsters would benefit from early and regular autism screening.

“I agree that this is good, and unfortunately some physicians need to be forced to pay attention to it,” she said.

The new guidelines would provide proper diagnosis of more children, have it happen sooner and lead to treatment earlier in life, Minon and others said. Such earlier intervention would help teach children better techniques for learning and social skills, Filipek said, such as not staring at people--or, conversely, refusing to look them in the eye.

The recommendations are being published this week in the Journal of Autism and Developmental Disorders. They are to be followed next year by guidelines on what doctors should do at each patient visit to screen for autism. Filipek is writing those guidelines, which will be published next summer in the journal Neurology, and will be adopted by the American Academy of Neurology and the Child Neurology Society.

Widely ignored or misunderstood for years, autism occurs in children more often than cancer, diabetes, spina bifida or Down syndrome, according to the article.

Filipek said the recommended changes may be unpopular with some health plans and physicians because they will require additional time--perhaps five to 10 minutes--during every well-baby visit to conduct developmental observation of the child. As part of these screenings, parents would also be asked to fill out an evaluation questionnaire to be reviewed by the physician.

Filipek predicted that physicians “will scream because they will be under the gun,” and the health plans, including health maintenance organizations, “will scream because we are going to tell them their policies have to change.”

Health care experts said the guidelines would not dictate treatment but could heavily influence physicians, particularly if they become the standard for treatment. In some cases, a health plan might require it, even attaching it to financial incentives or punishment, said one physician.

Filipek said that doctors “will have to be allowed to take the time to do this and be appropriately reimbursed. It will be better for the child.”

Walter Zelman, president of the California Assn. of Health Plans, said health plans would support appropriate guidelines but pointed out they would create cost pressures on physicians and the plans.

“Health plans have no problem adding services and benefits and adding time to the delivery of care. . . . The nagging problem we have is that society as a whole doesn’t seem to be willing to pay for all that they want,” he said. “The health plan, and sometimes the physician, get squeezed between the increasing demand and the reluctance to pay for it.”

Under the recommendations, first-level screenings would be conducted on all children from infancy. Among other indicators, doctors would look for such signs as whether a child was not babbling or pointing by age 12 months, had not uttered a word by 16 months, or had experienced any loss of language skills at any age. Positive results would lead to more detailed diagnosis and evaluation to differentiate autism from other developmental disorders.

Filipek decried the current state of awareness and training of physicians, though she called it an improvement over the past. “People [in medical schools and residencies] are not universally being trained about autism,” she said.

The 25-member panel included professionals from a wide range of disciplines: pediatricians, psychologists, audiologists, speech therapists and others. Filipek was named by the American Academy of Neurology to chair the panel and write the guidelines. The other panel members were named by their professional organizations.