AMA Updates Slant on Autism - Now a Medical Condition

[Guest guest]

" Anecdotal evidence suggests that some children can wait six months

for a complete evaluation. There are also concerns about overburdening

government-funded early intervention services. " There are some other

nuggets to be found here, too. - Lenny

Early autism screening urged, but barriers exist

Some physicians would like payment to reflect the extra case

management involved in caring for children with the disorder.

By Stagg Elliott, AMNews staff. Nov. 19, 2007.

http://www.ama-assn.org/amednews/2007/11/19/hlsb1119.htm

Doctors widely praised new guidelines that call for screening of all

young patients for autism and for medical homes for children with this

diagnosis. However, some physicians said financial realities and

inadequate access to follow-up care could interfere with implementation.

The American Academy of Pediatrics issued the recommendations in two

reports presented at its National Conference and Exhibition in San

Francisco last month. The documents appear in the November Pediatrics.

The first paper calls for children who are not babbling, pointing and

gesturing by their first birthday to be evaluated for autism. It

recommends that all 18- and 24-month-olds be screened. Those who are

suspected of having a problem should be referred immediately for more

complete assessment and to early intervention services that exist in

most communities.

" There's so much more available in terms of early treatment. There

doesn't seem to be any benefit to the wait-and-see approach, " said

Lipkin, MD, chair of the academy's Council on Children with

Disabilities, which issued the report.

This is the latest move by medical societies to improve autism

detection and get children with the disease access to services early,

when intervention can make the most difference. The AAP first called

for universal screening for developmental problems, including autism,

in 2006. The new paper spells out in more detail how to evaluate

patients with autism.

The American Medical Association also supports educating and enabling

physicians to identify children with developmental delays, autism and

other developmental disabilities.

The AAP would like doctors to do more than identify children with

autism. The academy wants to make it more likely that they have access

to primary care, in addition to the specialist services they may need,

according to the second paper.

" All children need a medical home where services can be well

coordinated. Children with autism and related disorders are not an

exception to that, " said Dr. Lipkin, who is also director of the

Center for Development and Learning at the Kennedy Krieger Institute

in Baltimore.

The report calls for physicians to give children with autism the same

kind of preventive care provided to those without disabilities, while

also addressing some of their added medical needs. For example, the

family may require genetic counseling because siblings will be at

higher risk for autism and other behavioral abnormalities. Children

with pica or who constantly mouth objects need to have their lead

levels monitored.

The document also advises doctors on helping parents sort through the

complementary and alternative therapies that many turn to. The goal is

to aid families in avoiding treatments that might cause harm and

question those not supported by science.

" It's important for pediatricians to maintain open communication and

continue to work with these families even if there is disagreement

about treatment choices, " said Myers, MD, a report co-author

and neurodevelopmental pediatrician at the Janet Weis Children's

Hospital in Danville, Pa. " At the same time, it's also important to

critically evaluate the scientific evidence of effectiveness and risk

of harm, and convey this information to the families, just as one

should for treatment with medication and for nonmedical interventions. "

Physicians applauded the reports for clarifying the early signs of

autism along with the best practices for screening and management.

" It's an outstanding contribution, " said Burke, MD, a staff

pediatrician at Hasbro Children's Hospital and assistant professor of

pediatrics at Brown University in Providence, R.I. " Physicians are

becoming more aware of autism but need both information and some

guidance about how to proceed. "

Payment and screening worries

But many doctors expressed concern about the significant barriers to

making the recommendations a routine part of practice.

" We diagnose autism more than we used to. For that reason, developing

a specific way to look for it is important, " said Dveirin, MD, a

Tucson, Ariz., pediatrician. " But for the policy statement to be

translated to reality, doctors have to get paid fairly to do it. "

The AAP paper on detection cited the billing codes required to get

reimbursed for this kind of screening, but physicians reported that

many insurance companies attempt to bundle evaluation with payment for

a well-child visit. Delivering services to an autistic child can take

much more time than for other children.

" We need to be able to be paid for the extra time and extra case

management services. This difficulty discourages many people from

wanting to take care of these children, " said Dr. Dveirin, who is

president of AAP's Arizona chapter but was speaking on his own behalf.

How to screen is also a matter of debate. Several tools have been

created, but there is little agreement on which one is best.

Recommended follow-up testing for a child suspected to have

developmental challenges may not be accessible because of a lack of

professionals to provide it. Anecdotal evidence suggests that some

children can wait six months for a complete evaluation. There are also

concerns about overburdening government-funded early intervention

services.

" We still find, in many areas, delays and problems in getting further

diagnostic testing and therapy, " said Dr. Dveirin. " This is going to

put pressure on the system. How is the system going to respond? How

much funding is there? How many therapists are there? "

Many experts said the true value of the guidelines may be less in what

they advise physicians to do and more in confirming that autism is a

medical condition.

" These unequivocally say that autism is a neurodevelopmental,

biologically-based condition, " said Schwab, MD, professor of

family medicine at the University of Wisconsin, Madison. " It's not an

educational condition or a psychiatric condition. It's just like

epilepsy or cerebral palsy. We need optimal insurance coverage for

this, just like any other medical condition in childhood. "

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