A recent article by Canadian researcher Mona Al-Qabandi, MD and colleagues has received a lot of attention for their conclusion that current research evidence does not support routine screening for autism spectrum disorders (ASD). Since this conclusion differs greatly from previous recommendations (for instance American Academy of Pediatrics, 2007, which suggests all children receive early ASD screening), I feel it is important to take a closer look at this article.
Dr. Al-Qabandi and colleagues set out to review existing research in order to determine whether routine ASD screening would be appropriate for the entire population. Findings of various research studies were used to evaluate how routine ASD screening measured against a number of criteria.
Based on the research reviewed, Dr. Al-Qabandi and colleagues concluded that there was not enough evidence to support the implementation of routine ASD screening. The authors stressed two major concerns. First, no existing interventions have been scientifically shown to effectively treat ASD. Second, existing screening tools have not demonstrated adequate accuracy in regards to sensitivity, specificity, and positive predictive value.
As an advocate for applied behavior analysis (ABA) treatment, I strongly disagree with the authors’ assertion that no existing interventions for ASD have been scientifically validated. Vast research has revealed ABA to be an effective treatment for ASD. In one of the most well-known studies, Dr. Ivar Lovaas found 47% of children with ASD, who received intensive ABA therapy of over 40 hours per week for more than two years, achieved typical intellectual functioning (Lovaas, 1987). Moreover, a number of meta-analyses, a statistical tool that combines and evaluates the results of numerous research studies, have been conducted that support the use of ABA treatment for children with ASD (see Reichow, in press for a recent review of meta-analyses). Dr. Al-Qabandi and colleagues also failed to mention a significant body of research that shows ABA to be most effective if administered at earlier ages (for instance Granpeesheh and colleagues, 2009). Such research findings, in my opinion, imply a need to identify children with ASD as early as possible.
In the article, Dr. Al-Qabandi and colleagues disregarded studies like those described above, and placed a strong emphasis on the importance of randomized controlled trials. While randomized controlled trials are considered the gold standard in research, there is a serious ethical dilemma in randomly providing a beneficial treatment to one child while denying treatment to another, especially since early intervention is such a crucial component of ABA. Given what is known about the importance of starting treatment early, would you allow your child to be randomly placed into either a treatment or placebo group, and then let them stay in that group for multiple years? For this reason, randomized controlled trials on ABA are few, and further randomized controlled trials will likely not be conducted due to ethical concerns. On the other hand, experimentally controlled trials can and have been conducted, and the results of these studies indicate that ABA is an effective treatment for ASD (see Reichow, in press and other meta-analyses). In fact, the existing research on ABA has been enough to persuade many U.S. states to enact legislation mandating insurance companies to cover ABA treatment for children with ASD.
In regards to the author’s second concern, it is true that existing screening tools for ASD are not perfect. There is currently no simple test to identify ASD. The diagnostic process is often a long road for many children and their families. While available tools may not identify ASD with perfect accuracy, these tools do flag children who are at risk, for whom further assessments can be carried out. It is really a simple question, regardless of which disorder one is talking about; would you want to have your child screened early on a measure that is not 100 percent accurate but will detect most cases, or would you prefer to wait until later when symptom severity has increased to the point that it is easily detected? I for one would want my child evaluated as early as possible.
Although there is evidence to suggest that some children with ASD can be identified at as early an age as 18 months, the average age of diagnosis still ranges between ages 5 to 7 years. This is too late given the benefits of early intervention. Steps must be taken to ensure that children with ASD are diagnosed and given treatment as early as possible. While I feel there is evidence to suggest that routine ASD screening would be beneficial, it may take more randomized controlled trials on ABA and ASD screening programs to convince others like Dr. Al-Qabandi and colleagues. Please note that Dr. Al-Qabandi and colleagues never state that routine ASD screening would not be beneficial; rather they conclude that more empirical research is needed to justify the implementation of universal ASD screening.
If you are interested in reading Dr. Al-Qabandi and colleagues’ full article, it can be accessed here.
Al-Qabandi, M., Gorter, J. W., & Rosenbaum, P. (in press). Early autism detection: Are we ready for routine screening? Pediatrics. doi: 10.1542/peds.2010-1881
American Academy of Pediatrics. (2007). Identification and evaluation of children with autism spectrum disorders. Pediatrics, 120, 1183-1215. doi: 10.1542/peds.2007-2361
Granpeesheh, D., Dixon, D. R., Tarbox, J., Kaplan, A. M., & Wilke, A. E. (2009). The effects of age and treatment intensity on behavioral intervention outcomes for children with autism spectrum disorders. Research in Autism Spectrum Disorders, 3, 1014-1022. doi: 10.1016/j.rasd.2009.06.007
Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3-9. doi: 10.1037/0022-006X.55.1.3
Reichow, B. (in press). Overview of meta-analyses on early intensive behavioral intervention for young children with autism spectrum disorders. Journal of Autism and Developmental Disorders. doi: 10.1007/s10803-011-1218-9