Figure 6-1 provides an algorithm for evaluating patients suspected of having autism. The work-up begins with recognition and screening done at well-child visits. Indications for formal developmental evaluation include the following:

• No babbling, pointing, or other gestures by age 12 months

• No single words by age 16 months

• No two-word spontaneous phrases by age 24 months

• Loss of previously learned language or social skills at any age

• Any parental concern about delayed speech and language development, typically noticed at about age 18 months

Figure 6-1 Developmental surveillance and screening algorithm within a pediatric preventive care visit. Because the 30-month visit is not yet a part of the preventive care system and is often not reimbursable by third-party payers at this time, developmental screening can be performed at age 24 months.

1. Pediatric Patient at Preventive Care Visit. Developmental concerns should be included as one of several health topics addressed at each pediatric preventive care visit throughout the first 5 years of life.

2. Perform Surveillance. Developmental surveillance is a flexible, longitudinal, continuous, and cumulative process whereby knowledgeable health care professionals identify children who may have developmental problems. Developmental surveillance has five components: (a) eliciting and attending to the parents’ concerns about their child’s development, (b) documenting and maintaining a developmental history, (c) making accurate observations of the child, (d) identifying the risk and protective factors, and (e) maintaining an accurate record and documenting the process and findings.

3. Does Surveillance Demonstrate Risk? The concerns of both parents and child health professionals should be included in determining whether surveillance suggests the child may be at risk of developmental delay. If either parents or the child health professional express concern about the child’s development, a developmental screening to specifically address the concern should be conducted.

4. Is This a 9-, 18-, or 30-Month Visit? All children should receive developmental screening using a standardized test. In the absence of established risk factors or parental or provider concerns, a general developmental screen is recommended at the 9-, 18, and 30-month visits. Additionally, autism-specific screening is recommended for all children at the 18-month visit.

5a and 5b. Administer Screening Tool. Developmental screening is the administration of a brief standardized tool that aids in the identification of children at risk of a developmental disorder. Developmental screening that targets the area of concern is indicated whenever a problem is identified during developmental surveillance.

6a and 6b. Are the Screening Tool Results Positive or Cause of Concern? When the results of the periodic screening tool are normal, the child health professional can inform the parents and continue with other aspects of the preventive visit. When a screening tool is administered as a result of concerns about development, an early return visit to provide additional developmental surveillance should be scheduled even if the screening tool results do not indicate a risk of delay.

7-8. Make Referrals for Developmental and Medical Evaluations and Early Developmental Intervention/Early Childhood Services (7). Developmental and Medical Evaluations. (8). If screening results warrant concern, the child should be scheduled for developmental and medical evaluations. Developmental evaluation is aimed at identifying the specific developmental disorder or disorders affecting the child. In addition to the developmental evaluation, a medical diagnostic evaluation to identify any underlying causes should be undertaken. Early developmental intervention/early childhood services can be particularly valuable when a child is first identified to be at high risk of delayed development because these programs often provide evaluation services and can offer other services to the child and family even before an evaluation is complete. Establishing an effective and efficient partnership with early childhood professionals is an important component of successful care coordination for children.

9. Is a Developmental Disorder Identified? If a developmental disorder is identified, the child should be identified as a child with special health care needs, and chronic condition management should be initiated (see no. 10 to follow). If a developmental disorder is not identified through medical and developmental evaluation, the child should be scheduled for an early return visit for further surveillance. More frequent visits, with particular attention paid to areas of concern, will allow the child to be promptly referred for further evaluation if any further evidence of delayed development or a specific disorder emerges.

10. Identification of a Child With Special Health Care Needs. Initial Chronic Condition Management. When a child is discovered to have a significant developmental disorder, that child becomes one with special health care needs, even if that child does not have a specific disease etiology identified. Such a child should be identified by the medical home for appropriate chronic condition management and regular monitoring and entered into the practice’s registry of children and youth with special health care needs.

(From Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee and Medical Home Initiatives for Children with Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics 2006;118:405–420, with permission.)

A number of resources are available for screening, such as the following:

• Checklist for Autism in Toddlers (CHAT)

• Child Developmental Inventory (CDI)

• Denver II Developmental Screening Test

• Parents’ Evaluation of Developmental Status (PEDS)

• Pervasive Developmental Disorders Screening Test (PDDST)

Additional Work-up

Referral to an appropriate developmental disorders center is appropriate if the diagnosis of autism spectrum disorder is entertained. A medical evaluation should also be performed in certain situations to exclude other etiologies of symptoms:

Genetic testing	If indicated by family history
Wood’s lamp examination of skin to identify depigmented macules	If tuberous sclerosis is suspected
Lead level	If lead poisoning is suspected
Metabolic screening	If an inborn error of metabolism is suspected
Electroencephalography	If seizure disorder is suspected
Central nervous system (CNS) imaging	If malignancy, hemorrhage, infection, or inflammation is suspected
Formal hearing evaluation	If there is any suspicion of hearing deficit because deafness and profound hearing loss can mimic autism
Vision screening	If any visual disturbance is suspected