Autism: Clinical pearls for primary care

The parents of a 3-year-old boy tell you that he has just started receiving special education services under the category of autism spectrum disorder. What are the most important next steps for you to take, and how do you care for this patient in the long-term?

Autism spectrum disorder (ASD, henceforth referred to as autism) consists of qualitative impairments in social interactions and communication and the presence of restricted or repetitive behaviors, interests, or activities as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).¹ "Autistic disorder," "Asperger disorder," and "pervasive developmental disorder not otherwise specified" are expected to be combined in the 2013 DSM-V into 1 label: ASD.

Increasing numbers of children are being diagnosed with autism. Centers for Disease Control and Prevention 2006 data estimated the prevalence to be 1 in 110 children.² Primary care physicians (PCPs) reported an average of 37 visits from patients with autism per year.³

Screening and surveillance

Early identification of autism is important because effective intervention therapies started during preschool years are proven to be more effective than those started after a child's fifth birthday.

The AAP recommends that PCPs use an ASD-specific screening tool to screen all patients at 18 months and at 24 to 30 months or when ASD concerns are raised by physicians or caregivers.⁷ The ASD-specific screening tools are more likely to identify ASD than general developmental screening tools. The Modified Checklist for Autism in Toddlers (M-CHAT) is one such ASD-specific screening tool and is available online ( http://www2.gsu.edu/~psydlr/site/official_M-CHAT_website.html).⁸

Referrals for initial ASD concerns

If autism is suspected, families can be referred to educational services (early intervention for children ages <3 years) or their school district's special education department (children ages >3 years), as well as medical services. Children eligible for early intervention or educational services will be provided with an Individualized Family Service Plan (IFSP) within 45 days of the referral or Individualized Education Plan (IEP) within 60 school-in-session days, respectively. Medical referrals should include an audiologic evaluation (even if neonatal screening was normal) and a medical autism evaluation by healthcare professionals with expertise in ASD. Because a formal diagnosis typically takes time, children with suspected autism should be referred for intervention even before a formal diagnosis is made. One example is an immediate speech therapy referral. Speech therapy often is warranted regardless of the final autism diagnosis and typically can be implemented relatively promptly.