Autism: 5 misconceptions that can complicate care

Autism spectrum disorder (ASD) affects approximately one in 68 children in the United States, according to the Centers for Disease Control and Prevention (CDC).¹ Growing public awareness of autism means that family physicians are increasingly likely to hear from anxious new (and expectant) parents. Unfortunately, misinformation about autism continues to be perpetuated, through word of mouth, the Internet, and misinformed advocacy groups. This article addresses 5 of the most common misconceptions, and can help you set the record straight and respond appropriately to parental concerns.

Misconception 1: Autism is a single condition

While autistic disorder was previously considered one of 5 pervasive developmental disorders, in 2013 the Diagnostic and Statistical Manual of Mental Disorder, 5th edition (DSM-5) redefined it. (To learn more about how shifts in our understanding of autism were reflected in each new edition of the DSM, see “Autism: Why the rise in rates?”)

ASD is now an umbrella term that encompasses autism, Asperger syndrome, pervasive developmental disorder not otherwise specified, childhood disintegrative disorder, and Rett syndrome.² The new term is meant to highlight the continuum of symptoms and frequent variability of presentation among those affected, ranging from mild to more severe impairment. Anyone who was classified under DSM-IV criteria, of course, should continue to have an autism/ASD diagnosis.

As with previous definitions, ASD is characterized by communication deficits (eg, inappropriate responses in conversation, misinterpreted nonverbal interactions, and significant challenges in age-appropriate bonding/friendship development). While previous definitions were focused on identifying school-age deficits, the update requires early childhood symptoms—regardless of the age of formal diagnosis.²

Misconception 2: Only symptomatic children should be screened for ASD

Although the decision to screen all children remains a controversial one, at least one medical society—the American Academy of Pediatrics (AAP)—calls for universal screening.³ The American Academy of Family Physicians does not have or endorse a formal guideline about screening for ASD. The US Preventive Services Task Force has a guideline, but it is in the process of being revised.⁴

Given the advances in early childhood interventions, there is little doubt that early identification of those at risk for developmental delay is beneficial. But opponents of universal screening cite concerns about unnecessary testing, anxiety, and overdiagnosis due to false positives associated with traditional screening methods.

The AAP calls for screening and surveillance. Since 2006, the AAP has recommended surveillance at all well-child visits, combined with screening for developmental delays at 9, 18, and 24 or 30 months of age, using a standardized screening tool.^3,5 A parent-completed tool (eg, the Modified Checklist for Autism in Toddlers [M-CHAT] or, most recently, the M-CHAT Revised with Follow-up⁶; Parents’ Evaluation of Developmental Status; or Ages and Stages Questionnaire, 3rd ed) should be used rather than a directly administered tool.^3,5 An algorithm detailing the AAP’s approach is available at http://www.cdc.gov/ncbddd/actearly/autism/case-modules/pdf/diagnosis/AAP%20Screening%20Guidelines.pdf.

Avoid a "wait and see" approach. Parents of children with ASD often broach the subject by the baby's first birthday.Physicians should also be prepared to evaluate any child whose parents raise concerns about his or her development during a routine visit. A “wait and see” approach is strongly discouraged. Parents of children with ASD often broach the subject by the baby’s first birthday.⁵ Common concerns include the child’s inability to babble, point or gesture meaningfully, or respond to his or her name; poor eye contact; failure to play with toys; and/or loss of (or failure to develop) language or social skills.⁵

An ASD mnemonic. The CDC, in collaboration with the AAP, the American Academy of Neurology, and the Child Neurology Society, has released a simplified guideline with the mnemonic ALARM to summarize recommendations for developmental screening, surveillance, diagnosis, and management of ASD.⁵ ALARM stands for:
• Autism is prevalent
• Listen to parents
• Act early
• Refer
• Monitor.

Misconception 3: Since ASD can't be cured, early intervention offers no benefit

While there is no cure for ASD and it is not considered reversible, there is an array of potential ASD therapies and proven benefits of early intervention. Therapies range from diet to medication and behavioral skills development, but only a few have ample evidence of efficacy (TABLE).^7-17

Patients with ASD are less likely to have ever lived on their own than those with learning disabilities, intellectual disabilities, or emotional disturbances.Randomized controlled trials of early developmental and behavioral therapy have shown some promise in decreasing symptoms associated with ASD and improving parent-child communication and social engagement.^18-21 A systematic review found that young children with ASD can improve cognitive performance, language skills, and adaptive behavioral skills through behavioral interventions or more comprehensive approaches using developmental and behavioral frameworks.²² In addition to increasing the likelihood of overall school success, early intervention programs that improve communication and social skills can have a significant impact on the individual’s eventual quality of life (QOL), employability, and independence.^23-25

TABLE
Therapeutic options for ASD: What works?^7-17

^{ASD, autism spectrum disorder; IV, intravenous; SOR, strength of recommendation.
*SOR: A, Good-quality patient-oriented evidence; B, inconsistent or limited-quality patient-oriented evidence; C, consensus, usual practice, opinion, disease-oriented evidence, case series.}

Misconception 4: Individuals with ASD are more intellectually disabled and can't function independently

As many as 96% of children with ASD have a coexisting developmental disability, such as generalized developmental delay (found in 80% of those with ASD), learning disabilities (affecting 60%), or attention-deficit/hyperactivity disorder (in 42%).²⁶ Although many parents—and some physicians—assume that children with ASD are intellectually disabled, in fact, less than one in 5 (19%) has an intellectual disability.²⁶

Individuals with ASD do, however, often have difficulty living independently. In one study of post high school living arrangements, those with ASD were less likely to have ever lived on their own than those with learning disabilities, intellectual disabilities, or emotional disturbances.²³

Another analysis found that only about half (53.4%) of young adults with ASD had ever worked for pay outside the home since leaving high school—the lowest rate among disability groups.²⁴ Of those who had worked outside the home, young adults with ASD earned an average of $8.10 per hour, significantly lower than the comparison groups. Not surprisingly, young adults with ASD who had better conversational and/or functional skills had a higher likelihood of ever having had worked for pay outside the home.²⁴

Social participation also is considered an indicator of overall QOL and independent function. Young adults with ASD were found to be significantly more likely than those with other types of developmental delays to be socially isolated—never seeing friends, getting calls from friends, or being invited to activities. Lower communication and functional skills, as well as living with a parent, were predictors of less social participation in young adults with ASD.²⁵

Misconception 5: Thimerosal vaccines cause ASD

The controversy and concern about a correlation between mercury and ASD began in the late 1990s, when a published study appeared to link thimerosal-containing vaccines to the increasing incidence of autism.²⁷ This notion appeared to be further strengthened by a 2002 study,²⁸ done by the same researchers and reaching similar conclusions. Since then, the correlation has been disproven by a number of studies and further review of the initial studies revealed them to be flawed.²⁹

Despite the lack of evidence to support any long-term effects from the minimal exposure to mercury in the preservative, in July 1999, US Public Health Service agencies, the AAP, and vaccine manufacturers agreed that thimerosal should be reduced or eliminated in vaccines as a precautionary measure.³⁰ With the exception of a limited number of multidose influenza vaccines, childhood vaccines are now thimerosal-free.

Fact: Early referral is key

When and where to refer parents for additional evaluation of a child with developmental delays depends on the resources in your community. Typically, a team of providers participates in the evaluation and management of a child with ASD, often including a developmental pediatrician, psychiatrist and other mental health professional, neurologist, speech pathologist, audiologist, physical therapist, and special education teacher.

Although every community may not have easy access to a pediatric subspecialist referral center, all 50 states and US territories are required by law to provide access to early intervention programs under Part C of the 2004 Individuals with Disabilities Education Act.31 (For a list of resources, see “Autism spectrum disorder: Where to learn more”.)

Help families prepare

Despite a lack of evidence connecting thimerosal to autism, the agent has been removed from most childhood vaccines as a precautionary measure.Advise families whom you refer for evaluation that they are unlikely to have a definitive answer after the first visit. Explain that the evaluation is quite thorough and generally takes several visits. Typically, a child suspected of developmental delay will undergo a comprehensive evaluation, including history and physical exam, blood work (including lead testing and, in some locations, genetic testing), hearing and vision screening, speech and language evaluation, and sensorimotor and cognitive evaluation. Additional information may be requested from daycare providers, preschool teachers, or others who spend significant amounts of time with the child.

Once a diagnosis is made, the team will work with the parents to develop an individualized care plan for the child, which often includes a mix of cognitive, physical, and speech development services in addition to nutrition and support services. The primary care physician, of course, will continue to oversee, monitor, and coordinate care.

CORRESPONDENCE
Margot Savoy, MD, MPH, FAAF P, CPE, FA BC, Christiana Care Health System, Department of Family & Community Medicine, 1401 Foulk Road, Suite 100B, Wilmington, DE 19803; [email protected]

Autism spectrum disorder (ASD) affects approximately one in 68 children in the United States, according to the Centers for Disease Control and Prevention (CDC).¹ Growing public awareness of autism means that family physicians are increasingly likely to hear from anxious new (and expectant) parents. Unfortunately, misinformation about autism continues to be perpetuated, through word of mouth, the Internet, and misinformed advocacy groups. This article addresses 5 of the most common misconceptions, and can help you set the record straight and respond appropriately to parental concerns.

Misconception 1: Autism is a single condition

While autistic disorder was previously considered one of 5 pervasive developmental disorders, in 2013 the Diagnostic and Statistical Manual of Mental Disorder, 5th edition (DSM-5) redefined it. (To learn more about how shifts in our understanding of autism were reflected in each new edition of the DSM, see “Autism: Why the rise in rates?”)

ASD is now an umbrella term that encompasses autism, Asperger syndrome, pervasive developmental disorder not otherwise specified, childhood disintegrative disorder, and Rett syndrome.² The new term is meant to highlight the continuum of symptoms and frequent variability of presentation among those affected, ranging from mild to more severe impairment. Anyone who was classified under DSM-IV criteria, of course, should continue to have an autism/ASD diagnosis.

As with previous definitions, ASD is characterized by communication deficits (eg, inappropriate responses in conversation, misinterpreted nonverbal interactions, and significant challenges in age-appropriate bonding/friendship development). While previous definitions were focused on identifying school-age deficits, the update requires early childhood symptoms—regardless of the age of formal diagnosis.²

Misconception 2: Only symptomatic children should be screened for ASD

Although the decision to screen all children remains a controversial one, at least one medical society—the American Academy of Pediatrics (AAP)—calls for universal screening.³ The American Academy of Family Physicians does not have or endorse a formal guideline about screening for ASD. The US Preventive Services Task Force has a guideline, but it is in the process of being revised.⁴

Given the advances in early childhood interventions, there is little doubt that early identification of those at risk for developmental delay is beneficial. But opponents of universal screening cite concerns about unnecessary testing, anxiety, and overdiagnosis due to false positives associated with traditional screening methods.

The AAP calls for screening and surveillance. Since 2006, the AAP has recommended surveillance at all well-child visits, combined with screening for developmental delays at 9, 18, and 24 or 30 months of age, using a standardized screening tool.^3,5 A parent-completed tool (eg, the Modified Checklist for Autism in Toddlers [M-CHAT] or, most recently, the M-CHAT Revised with Follow-up⁶; Parents’ Evaluation of Developmental Status; or Ages and Stages Questionnaire, 3rd ed) should be used rather than a directly administered tool.^3,5 An algorithm detailing the AAP’s approach is available at http://www.cdc.gov/ncbddd/actearly/autism/case-modules/pdf/diagnosis/AAP%20Screening%20Guidelines.pdf.

Avoid a "wait and see" approach. Parents of children with ASD often broach the subject by the baby's first birthday.Physicians should also be prepared to evaluate any child whose parents raise concerns about his or her development during a routine visit. A “wait and see” approach is strongly discouraged. Parents of children with ASD often broach the subject by the baby’s first birthday.⁵ Common concerns include the child’s inability to babble, point or gesture meaningfully, or respond to his or her name; poor eye contact; failure to play with toys; and/or loss of (or failure to develop) language or social skills.⁵

An ASD mnemonic. The CDC, in collaboration with the AAP, the American Academy of Neurology, and the Child Neurology Society, has released a simplified guideline with the mnemonic ALARM to summarize recommendations for developmental screening, surveillance, diagnosis, and management of ASD.⁵ ALARM stands for:
• Autism is prevalent
• Listen to parents
• Act early
• Refer
• Monitor.

Misconception 3: Since ASD can't be cured, early intervention offers no benefit

While there is no cure for ASD and it is not considered reversible, there is an array of potential ASD therapies and proven benefits of early intervention. Therapies range from diet to medication and behavioral skills development, but only a few have ample evidence of efficacy (TABLE).^7-17

Patients with ASD are less likely to have ever lived on their own than those with learning disabilities, intellectual disabilities, or emotional disturbances.Randomized controlled trials of early developmental and behavioral therapy have shown some promise in decreasing symptoms associated with ASD and improving parent-child communication and social engagement.^18-21 A systematic review found that young children with ASD can improve cognitive performance, language skills, and adaptive behavioral skills through behavioral interventions or more comprehensive approaches using developmental and behavioral frameworks.²² In addition to increasing the likelihood of overall school success, early intervention programs that improve communication and social skills can have a significant impact on the individual’s eventual quality of life (QOL), employability, and independence.^23-25

TABLE
Therapeutic options for ASD: What works?^7-17

^{ASD, autism spectrum disorder; IV, intravenous; SOR, strength of recommendation.
*SOR: A, Good-quality patient-oriented evidence; B, inconsistent or limited-quality patient-oriented evidence; C, consensus, usual practice, opinion, disease-oriented evidence, case series.}

Misconception 4: Individuals with ASD are more intellectually disabled and can't function independently

As many as 96% of children with ASD have a coexisting developmental disability, such as generalized developmental delay (found in 80% of those with ASD), learning disabilities (affecting 60%), or attention-deficit/hyperactivity disorder (in 42%).²⁶ Although many parents—and some physicians—assume that children with ASD are intellectually disabled, in fact, less than one in 5 (19%) has an intellectual disability.²⁶

Individuals with ASD do, however, often have difficulty living independently. In one study of post high school living arrangements, those with ASD were less likely to have ever lived on their own than those with learning disabilities, intellectual disabilities, or emotional disturbances.²³

Another analysis found that only about half (53.4%) of young adults with ASD had ever worked for pay outside the home since leaving high school—the lowest rate among disability groups.²⁴ Of those who had worked outside the home, young adults with ASD earned an average of $8.10 per hour, significantly lower than the comparison groups. Not surprisingly, young adults with ASD who had better conversational and/or functional skills had a higher likelihood of ever having had worked for pay outside the home.²⁴

Social participation also is considered an indicator of overall QOL and independent function. Young adults with ASD were found to be significantly more likely than those with other types of developmental delays to be socially isolated—never seeing friends, getting calls from friends, or being invited to activities. Lower communication and functional skills, as well as living with a parent, were predictors of less social participation in young adults with ASD.²⁵

Misconception 5: Thimerosal vaccines cause ASD

The controversy and concern about a correlation between mercury and ASD began in the late 1990s, when a published study appeared to link thimerosal-containing vaccines to the increasing incidence of autism.²⁷ This notion appeared to be further strengthened by a 2002 study,²⁸ done by the same researchers and reaching similar conclusions. Since then, the correlation has been disproven by a number of studies and further review of the initial studies revealed them to be flawed.²⁹

Despite the lack of evidence to support any long-term effects from the minimal exposure to mercury in the preservative, in July 1999, US Public Health Service agencies, the AAP, and vaccine manufacturers agreed that thimerosal should be reduced or eliminated in vaccines as a precautionary measure.³⁰ With the exception of a limited number of multidose influenza vaccines, childhood vaccines are now thimerosal-free.

Fact: Early referral is key

When and where to refer parents for additional evaluation of a child with developmental delays depends on the resources in your community. Typically, a team of providers participates in the evaluation and management of a child with ASD, often including a developmental pediatrician, psychiatrist and other mental health professional, neurologist, speech pathologist, audiologist, physical therapist, and special education teacher.

Although every community may not have easy access to a pediatric subspecialist referral center, all 50 states and US territories are required by law to provide access to early intervention programs under Part C of the 2004 Individuals with Disabilities Education Act.31 (For a list of resources, see “Autism spectrum disorder: Where to learn more”.)

Help families prepare

Despite a lack of evidence connecting thimerosal to autism, the agent has been removed from most childhood vaccines as a precautionary measure.Advise families whom you refer for evaluation that they are unlikely to have a definitive answer after the first visit. Explain that the evaluation is quite thorough and generally takes several visits. Typically, a child suspected of developmental delay will undergo a comprehensive evaluation, including history and physical exam, blood work (including lead testing and, in some locations, genetic testing), hearing and vision screening, speech and language evaluation, and sensorimotor and cognitive evaluation. Additional information may be requested from daycare providers, preschool teachers, or others who spend significant amounts of time with the child.

Once a diagnosis is made, the team will work with the parents to develop an individualized care plan for the child, which often includes a mix of cognitive, physical, and speech development services in addition to nutrition and support services. The primary care physician, of course, will continue to oversee, monitor, and coordinate care.

CORRESPONDENCE
Margot Savoy, MD, MPH, FAAF P, CPE, FA BC, Christiana Care Health System, Department of Family & Community Medicine, 1401 Foulk Road, Suite 100B, Wilmington, DE 19803; [email protected]

Autism spectrum disorder (ASD) affects approximately one in 68 children in the United States, according to the Centers for Disease Control and Prevention (CDC).¹ Growing public awareness of autism means that family physicians are increasingly likely to hear from anxious new (and expectant) parents. Unfortunately, misinformation about autism continues to be perpetuated, through word of mouth, the Internet, and misinformed advocacy groups. This article addresses 5 of the most common misconceptions, and can help you set the record straight and respond appropriately to parental concerns.

Misconception 1: Autism is a single condition

While autistic disorder was previously considered one of 5 pervasive developmental disorders, in 2013 the Diagnostic and Statistical Manual of Mental Disorder, 5th edition (DSM-5) redefined it. (To learn more about how shifts in our understanding of autism were reflected in each new edition of the DSM, see “Autism: Why the rise in rates?”)

ASD is now an umbrella term that encompasses autism, Asperger syndrome, pervasive developmental disorder not otherwise specified, childhood disintegrative disorder, and Rett syndrome.² The new term is meant to highlight the continuum of symptoms and frequent variability of presentation among those affected, ranging from mild to more severe impairment. Anyone who was classified under DSM-IV criteria, of course, should continue to have an autism/ASD diagnosis.

As with previous definitions, ASD is characterized by communication deficits (eg, inappropriate responses in conversation, misinterpreted nonverbal interactions, and significant challenges in age-appropriate bonding/friendship development). While previous definitions were focused on identifying school-age deficits, the update requires early childhood symptoms—regardless of the age of formal diagnosis.²

Misconception 2: Only symptomatic children should be screened for ASD

Although the decision to screen all children remains a controversial one, at least one medical society—the American Academy of Pediatrics (AAP)—calls for universal screening.³ The American Academy of Family Physicians does not have or endorse a formal guideline about screening for ASD. The US Preventive Services Task Force has a guideline, but it is in the process of being revised.⁴

Given the advances in early childhood interventions, there is little doubt that early identification of those at risk for developmental delay is beneficial. But opponents of universal screening cite concerns about unnecessary testing, anxiety, and overdiagnosis due to false positives associated with traditional screening methods.

The AAP calls for screening and surveillance. Since 2006, the AAP has recommended surveillance at all well-child visits, combined with screening for developmental delays at 9, 18, and 24 or 30 months of age, using a standardized screening tool.^3,5 A parent-completed tool (eg, the Modified Checklist for Autism in Toddlers [M-CHAT] or, most recently, the M-CHAT Revised with Follow-up⁶; Parents’ Evaluation of Developmental Status; or Ages and Stages Questionnaire, 3rd ed) should be used rather than a directly administered tool.^3,5 An algorithm detailing the AAP’s approach is available at http://www.cdc.gov/ncbddd/actearly/autism/case-modules/pdf/diagnosis/AAP%20Screening%20Guidelines.pdf.

Avoid a "wait and see" approach. Parents of children with ASD often broach the subject by the baby's first birthday.Physicians should also be prepared to evaluate any child whose parents raise concerns about his or her development during a routine visit. A “wait and see” approach is strongly discouraged. Parents of children with ASD often broach the subject by the baby’s first birthday.⁵ Common concerns include the child’s inability to babble, point or gesture meaningfully, or respond to his or her name; poor eye contact; failure to play with toys; and/or loss of (or failure to develop) language or social skills.⁵

An ASD mnemonic. The CDC, in collaboration with the AAP, the American Academy of Neurology, and the Child Neurology Society, has released a simplified guideline with the mnemonic ALARM to summarize recommendations for developmental screening, surveillance, diagnosis, and management of ASD.⁵ ALARM stands for:
• Autism is prevalent
• Listen to parents
• Act early
• Refer
• Monitor.

Misconception 3: Since ASD can't be cured, early intervention offers no benefit

While there is no cure for ASD and it is not considered reversible, there is an array of potential ASD therapies and proven benefits of early intervention. Therapies range from diet to medication and behavioral skills development, but only a few have ample evidence of efficacy (TABLE).^7-17

Patients with ASD are less likely to have ever lived on their own than those with learning disabilities, intellectual disabilities, or emotional disturbances.Randomized controlled trials of early developmental and behavioral therapy have shown some promise in decreasing symptoms associated with ASD and improving parent-child communication and social engagement.^18-21 A systematic review found that young children with ASD can improve cognitive performance, language skills, and adaptive behavioral skills through behavioral interventions or more comprehensive approaches using developmental and behavioral frameworks.²² In addition to increasing the likelihood of overall school success, early intervention programs that improve communication and social skills can have a significant impact on the individual’s eventual quality of life (QOL), employability, and independence.^23-25

TABLE
Therapeutic options for ASD: What works?^7-17

^{ASD, autism spectrum disorder; IV, intravenous; SOR, strength of recommendation.
*SOR: A, Good-quality patient-oriented evidence; B, inconsistent or limited-quality patient-oriented evidence; C, consensus, usual practice, opinion, disease-oriented evidence, case series.}

Misconception 4: Individuals with ASD are more intellectually disabled and can't function independently

As many as 96% of children with ASD have a coexisting developmental disability, such as generalized developmental delay (found in 80% of those with ASD), learning disabilities (affecting 60%), or attention-deficit/hyperactivity disorder (in 42%).²⁶ Although many parents—and some physicians—assume that children with ASD are intellectually disabled, in fact, less than one in 5 (19%) has an intellectual disability.²⁶

Individuals with ASD do, however, often have difficulty living independently. In one study of post high school living arrangements, those with ASD were less likely to have ever lived on their own than those with learning disabilities, intellectual disabilities, or emotional disturbances.²³

Another analysis found that only about half (53.4%) of young adults with ASD had ever worked for pay outside the home since leaving high school—the lowest rate among disability groups.²⁴ Of those who had worked outside the home, young adults with ASD earned an average of $8.10 per hour, significantly lower than the comparison groups. Not surprisingly, young adults with ASD who had better conversational and/or functional skills had a higher likelihood of ever having had worked for pay outside the home.²⁴

Social participation also is considered an indicator of overall QOL and independent function. Young adults with ASD were found to be significantly more likely than those with other types of developmental delays to be socially isolated—never seeing friends, getting calls from friends, or being invited to activities. Lower communication and functional skills, as well as living with a parent, were predictors of less social participation in young adults with ASD.²⁵

Misconception 5: Thimerosal vaccines cause ASD

The controversy and concern about a correlation between mercury and ASD began in the late 1990s, when a published study appeared to link thimerosal-containing vaccines to the increasing incidence of autism.²⁷ This notion appeared to be further strengthened by a 2002 study,²⁸ done by the same researchers and reaching similar conclusions. Since then, the correlation has been disproven by a number of studies and further review of the initial studies revealed them to be flawed.²⁹

Despite the lack of evidence to support any long-term effects from the minimal exposure to mercury in the preservative, in July 1999, US Public Health Service agencies, the AAP, and vaccine manufacturers agreed that thimerosal should be reduced or eliminated in vaccines as a precautionary measure.³⁰ With the exception of a limited number of multidose influenza vaccines, childhood vaccines are now thimerosal-free.

Fact: Early referral is key

When and where to refer parents for additional evaluation of a child with developmental delays depends on the resources in your community. Typically, a team of providers participates in the evaluation and management of a child with ASD, often including a developmental pediatrician, psychiatrist and other mental health professional, neurologist, speech pathologist, audiologist, physical therapist, and special education teacher.

Although every community may not have easy access to a pediatric subspecialist referral center, all 50 states and US territories are required by law to provide access to early intervention programs under Part C of the 2004 Individuals with Disabilities Education Act.31 (For a list of resources, see “Autism spectrum disorder: Where to learn more”.)

Help families prepare

Despite a lack of evidence connecting thimerosal to autism, the agent has been removed from most childhood vaccines as a precautionary measure.Advise families whom you refer for evaluation that they are unlikely to have a definitive answer after the first visit. Explain that the evaluation is quite thorough and generally takes several visits. Typically, a child suspected of developmental delay will undergo a comprehensive evaluation, including history and physical exam, blood work (including lead testing and, in some locations, genetic testing), hearing and vision screening, speech and language evaluation, and sensorimotor and cognitive evaluation. Additional information may be requested from daycare providers, preschool teachers, or others who spend significant amounts of time with the child.

Once a diagnosis is made, the team will work with the parents to develop an individualized care plan for the child, which often includes a mix of cognitive, physical, and speech development services in addition to nutrition and support services. The primary care physician, of course, will continue to oversee, monitor, and coordinate care.

CORRESPONDENCE
Margot Savoy, MD, MPH, FAAF P, CPE, FA BC, Christiana Care Health System, Department of Family & Community Medicine, 1401 Foulk Road, Suite 100B, Wilmington, DE 19803; [email protected]