A cross-cultural comparison of autistic traits in the UK, India and Malaysia

Measurement properties of screening and diagnostic tools for autism spectrum adults of mean normal intelligence: A systematic review

BACKGROUND

The autism spectrum (AS) is a multifaceted neurodevelopmental variant associated with lifelong challenges. Despite the relevant importance of identifying AS in adults for epidemiological, public health, and quality of life issues, the measurement properties of the tools currently used to screen and diagnose adults without intellectual disabilities (ID) have not been assessed.

OBJECTIVES

This systematic review addresses the accuracy, reliability, and validity of the reported AS screening and diagnostic tools used in adults without ID.

METHODS

Electronic databases and bibliographies were searched, and identified papers evaluated against inclusion criteria. The PRISMA statement was used for reporting the review. We evaluated the quality of the papers using the COSMIN Checklist for psychometric data, and QUADAS-2 for diagnostic data. For the COSMIN assessment, evidence was considered to be strong when several methodologically good articles, or one excellent article, reported consistent evidence for or against a measurement property. For the QUADAS ratings, evidence was considered to be "satisfactory" if at least one study was rated with a low risk of bias and low concern about applicability.

RESULTS

We included 38 articles comprising 32 studies, five reviews, and one book chapter and assessed nine tools (three diagnostic and six screening, including eight of their short versions). Among screening tools, only AQ-50, AQ-S, and RAADS-R and RAADS-14 were found to provide satisfactory or intermediate values for their psychometric properties, supported by strong or moderate evidence. Nevertheless, risks of bias and concerns on the applicability of these tools limit the evidence on their diagnostic properties. We found that none of the gold standard diagnostic tools used for children had satisfactory measurement properties.

CONCLUSION

There is limited evidence for the measurement properties of the screening and diagnostic tools used for AS adults with a mean normal range of measured intelligence. This may lessen the validity of conclusions and public health decisions on an important fraction of the adult autistic population. This not only justifies further validation studies of screening and diagnostic tools for autistic adults, but also supports the parallel use of self-reported information and clinical expertise with these instruments during the diagnostic process.

An Overview of Autism Spectrum Disorder, Heterogeneity and Treatment Options

Since the documented observations of Kanner in 1943, there has been great debate about the diagnoses, the sub-types, and the diagnostic threshold that relates to what is now known as autism spectrum disorder (ASD). Reflecting this complicated history, there has been continual refinement from DSM-III with 'Infantile Autism' to the current DSM-V diagnosis. The disorder is now widely accepted as a complex, pervasive, heterogeneous condition with multiple etiologies, sub-types, and developmental trajectories. Diagnosis remains based on observation of atypical behaviors, with criteria of persistent deficits in social communication and restricted and repetitive patterns of behavior. This review provides a broad overview of the history, prevalence, etiology, clinical presentation, and heterogeneity of ASD. Factors contributing to heterogeneity, including genetic variability, comorbidity, and gender are reviewed. We then explore current evidence-based pharmacological and behavioral treatments for ASD and highlight the complexities of conducting clinical trials that evaluate therapeutic efficacy in ASD populations. Finally, we discuss the potential of a new wave of research examining objective biomarkers to facilitate the evaluation of sub-typing, diagnosis, and treatment response in ASD.

Adapting an Autism Screening Tool for Use in the DeKalb County Refugee Pediatric Clinic

BACKGROUND

Minimal literature exists regarding Autism Spectrum Disorder (ASD) among refugee children in the United States. Reliable ASD screening tools, such as the M-CHAT-R/F, have yet to be culturally adapted and translated into some languages spoken in the homes of these children.

METHODS

Pediatric refugee patients (n = 13) of caregivers of Bhutanese (Nepali-speaking) descent were screened using a newly translated Nepali M-CHAT-R/F. The M-CHAT-R/F was adapted based on feedback from Bhutanese caregivers and interpreter expertise. Qualitative interviews regarding caregiver awareness of ASD were conducted.

RESULTS

Caregivers understood the majority of M-CHAT-R/F items (91%). Four items required revision. Interviews revealed minimal awareness among Bhutanese caregivers regarding ASD or child development.

DISCUSSION

The M-CHAT-R/F was adapted into Nepali using a combination of translation protocols, and is publicly available for clinical use. Future validation studies are needed which will aid in clinical screening for and epidemiologic research of ASD in this population.

Examining cross-cultural differences in autism spectrum disorder: A multinational comparison from Greece, Italy, Japan, Poland, and the United States

Autism spectrum disorder (ASD) is characterized by social and communication impairments as well as restricted, repetitive behavior patterns. Despite the fact that ASD is reported worldwide, very little research exists examining ASD characteristics on a multinational scale. Cross-cultural comparisons are especially important for ASD, since cultural differences may impact the perception of symptoms. Identifying behaviors that are similarly reported as problematic across cultures as well as identifying behaviors in which there is cultural variation could aid in the development and refinement of more universally effective measures. The present study sought to examine similarities and differences in caregiver endorsement of symptom severity through scores on the Baby Infant Screen for Children with aUtIsm Traits (BISCUIT). The BISCUIT was utilized to examine ASD core symptomology in 250 toddlers diagnosed with ASD from Greece, Italy, Japan, Poland, and the United States. Significant differences in overall ASD symptom severity and endorsement were found between multinational groups. Implications of the results are discussed.

Aripiprazole in the Treatment of Irritability in Children and Adolescents with Autism Spectrum Disorder in Japan: A Randomized, Double-blind, Placebo-controlled Study

We evaluated the efficacy and safety of aripiprazole in the treatment of irritability in children and adolescents (6-17 years) with autism spectrum disorder (ASD) in a randomized, double-blind, placebo-controlled 8-week study in Japan. Patients received flexibly dosed aripiprazole (1-15 mg/day) or placebo. Ninety-two patients were randomized to placebo (n = 45) or aripiprazole (n = 47). Aripiprazole produced a significant improvement in the mean parent/caregiver-rated Aberrant Behavior Checklist Japanese Version irritability subscale score relative to placebo from week 3 through week 8. Administration of aripiprazole provided significantly greater improvement in the mean clinician-rated Clinical Global Impression-Improvement scores than placebo from week 2 through week 8. All patients randomized to aripiprazole completed the study, and no serious adverse events were reported. Three patients in placebo group discontinued. Aripiprazole was effective and generally safe and well-tolerated in the treatment of irritability associated with ASD in Japanese children and adolescents.

Medical students' perceptions, awareness, societal attitudes and knowledge of autism spectrum disorder: an exploratory study in Malaysia

Objectives: This study aimed to investigate the perception, awareness, societal attitude, and knowledge about Autism Spectrum Disorder (ASD) in Malaysian medical students. Methods: An exploratory survey was conducted with 83 medical students in Malaysia. In the survey, the medical students were required to rate their perception, awareness, societal attitude, and their recognition of ASD symptoms. Results: The results showed the senior medical students had increased knowledge about ASD symptoms compared to the juniors, but there was no clear indicator that they had obtained the knowledge through formal training. Specifically, the medical students could better identify symptoms related to restrictive and fixation behavioral patterns than social communicative deficits. While considering the effects of societal attitude, year of study, perception about ASD course and other demographic variables, the year of study emerged as the sole predictor of the medical students' knowledge about ASD. Conclusion: The findings from this study provided evidence for the need of compulsory training on ASD in medical schools in improve the knowledge and skills of prospective medical practitioners to identify individuals with ASD. Such effort is fundamental for the early identification and intervention of ASD in developing countries such as Malaysia.

Psychometric properties of the Autism-Spectrum Quotient in both clinical and non-clinical samples: Chinese version for mainland China

BACKGROUND

The Autism-Spectrum Quotient (AQ) is widely used to quantify autistic traits, which have been evaluated in the parents of individuals with autism spectrum disorders (ASD) and in the general population. This paper's objective was to investigate the AQ's psychometric properties of the Chinese version for mainland China and to establish whether the pattern of sex differences in the quantity of autistic traits exists. We also examined the usefulness of the AQ in differentiating between individuals with ASD, schizophrenia (SCH), obsessive-compulsive disorder (OCD) and healthy controls (HC).

METHODS

In this study, the psychometric properties of the AQ were assessed in 1037 parents of children with ASD and in 1040 parents of typically developing children (TDC). Additionally, 32 participants with ASD, 37 patients with SCH, 38 OCD patients and 38 healthy controls (matched for age, gender and IQ) were assessed with the AQ.

RESULTS

The internal consistency and test-retest reliability of the AQ and AQ subscales were within an acceptable range. Parents of ASD children scored higher than TDC parents on total AQ and AQ subscales, and TDC parents scored more than parents of ASD children on 2 items of 50. Fathers scored higher than did mothers on total AQ and four subscales, with the sole exception being the subscale attention to detail. The total AQ score of the ASD group was higher than that of the SCH, OCD and HC groups, and the total AQ score of the HC group was significantly lower than that of the SCH and OCD groups, with no differences being observed between the SCH and OCD groups.

CONCLUSIONS

The Mandarin AQ demonstrated promising psychometric properties and was a reliable instrument for quantifying autistic traits in both clinical and non-clinical samples in mainland China.

Diagnostic accuracy of Indian Scale for Assessment of Autism (ISAA) in chidren aged 2-9 years

OBJECTIVE

To determine the diagnostic accuracy of Indian Scale for Assessment of Autism (ISAA) in children aged 2-9 year at high risk of autism, and to ascertain the level of agreement with Childhood Autism Rating Scale (CARS).

DESIGN

Diagnostic Accuracy study.

SETTING

Tertiary-level hospital.

PARTICIPANTS

Children aged between 2 and 9 year and considered to be at a high risk for autism (delayed development, and age-inappropriate cognition, speech, social interaction, behavior or play) were recruited. Those with diagnosed Hearing impairment, Cerebral palsy, Attention deficit hyperactivity disorder or Pervasive developmental disorders (PDD) were excluded.

METHODS

Eligible children underwent a comprehensive assessment by an expert. The study group comprising of PDD, Global developmental delay (GDD) or Intellectual disability was administered ISAA by an investigator after one week. Both evaluators were blinded. ISAA results were compared to the Experts diagnosis and CARS scores.

RESULTS

Out of 102 eligible children, 90 formed the study group (63 males, mean age 4.5y). ISAA had a sensitivity 93.3, specificity of 97.4, positive and negative likelihood ratios 85.7 and 98.7 and positive and negative predictive values of 35.5 and 0.08, respectively. Reliability was good and validity sub-optimal (r low, in 4/6 domains). The optimal threshold point demarcating Autism from No autism according to Receiver Operating Characteristic curve was ISAA score of 70. Level of agreement with CARS measured by Kappa coefficient was low (0.14).

CONCLUSIONS

The role of ISAA in 3-9 year old children at high risk for Autism is limited to identifying and certifying Autism at ISAA score of 70. It requires re-examination in 2-3 year olds.

Neuropsychological performance of Finnish and Egyptian children with autism spectrum disorder

Background

Previous studies investigating neuropsychological functioning of children with autism spectrum disorder (ASD) have only analysed certain abilities, such as executive functions or language. While comprehensive assessment of the neuropsychological profile of children with ASD has been the focus of recent research, most of the published evidence originates from single centres. Though studies on differences in neuropsychological features of children with ASD across countries are essential for identifying different phenotypes of ASD, such studies have not been conducted.

Objective

Our goal was to assess the neuropsychological abilities of children with ASD in northern Finland and Egypt and to examine the effect of age and intelligence quotient (IQ) on these abilities.

Design

Selected verbal and non-verbal subtests of the neuropsychological assessment NEPSY were used to examine 88 children with ASD in northern Finland (n=54, age M=11.2, IQ M=117.1) and Egypt (n=34, age M=8.4, IQ M=96.6).

Results

Finnish ASD children scored significantly higher than their Egyptian counterparts on the verbal NEPSY subtests Comprehension of Instructions (p<0.001), Comprehension of Sentence Structure (p<0.01), Narrative Memory (p<0.001) and Verbal Fluency (p<0.05) and on the non-verbal NEPSY subtest Design Fluency (p<0.01). Finnish and Egyptian ASD children did not differ on the subtests Memory for Faces, Object Recognition and Object Memory. In addition, we found that age and verbal IQ can have significant influence on neuropsychological performance.

Conclusions

Our results suggest a possible cultural impact on verbal and visuomotor fluency. However, the ability to recognize and memorize objects and the disability to remember faces appear to be typical for ASD and culturally independent.

Serotonin receptor gene (HTR2A) T102C polymorphism modulates individuals' perspective taking ability and autistic-like traits

Previous studies have indicated that empathic traits, such as perspective taking, are associated with the levels of serotonin in the brain and with autism spectrum conditions. Inspired by the finding that the serotonin receptor 2A gene (HTR2A) modulates the availability of serotonin, this study investigated to what extent HTR2A modulates individuals’ perspective taking ability and autistic-like traits. To examine the associations of the functional HTR2A polymorphism T102C (rs6313) with individuals’ perspective taking abilities and autistic-like traits, we differentiated individuals according to this polymorphism and measured empathic and autistic-like traits with Interpersonal Reactivity Index (IRI) and Autism-Spectrum Quotient (AQ) scale in 523 Chinese people. The results indicated that this polymorphism was significantly associated with the scores on Perspective Taking and Personal Distress subscales of IRI, and Communication subscale of AQ. Individuals with a greater number of the C alleles were less likely to spontaneously adopt the point of view of others, more likely to be anxious when observing the pain endured by others, and more likely to have communication problems. Moreover, the genotype effect on communication problems was mediated by individuals’ perspective taking ability. These findings provide evidence that the HTR2A T102C polymorphism is a predictor of individual differences in empathic and autistic-like traits and highlight the role of the gene in the connection between perspective taking and autistic-like traits.

Sex and STEM Occupation Predict Autism-Spectrum Quotient (AQ) Scores in Half a Million People

This study assesses Autism-Spectrum Quotient (AQ) scores in a 'big data' sample collected through the UK Channel 4 television website, following the broadcasting of a medical education program. We examine correlations between the AQ and age, sex, occupation, and UK geographic region in 450,394 individuals. We predicted that age and geography would not be correlated with AQ, whilst sex and occupation would have a correlation. Mean AQ for the total sample score was m = 19.83 (SD = 8.71), slightly higher than a previous systematic review of 6,900 individuals in a non-clinical sample (mean of means = 16.94) This likely reflects that this big-data sample includes individuals with autism who in the systematic review score much higher (mean of means = 35.19). As predicted, sex and occupation differences were observed: on average, males (m = 21.55, SD = 8.82) scored higher than females (m = 18.95; SD = 8.52), and individuals working in a STEM career (m = 21.92, SD = 8.92) scored higher than individuals non-STEM careers (m = 18.92, SD = 8.48). Also as predicted, age and geographic region were not meaningfully correlated with AQ. These results support previous findings relating to sex and STEM careers in the largest set of individuals for which AQ scores have been reported and suggest the AQ is a useful self-report measure of autistic traits.

Parents' and professionals' perceptions on causes and treatment options for Autism Spectrum Disorders (ASD) in a multicultural context on the Kenyan Coast

Objective

To explore parents’ and professionals’ perceived causes and treatment of Autism Spectrum Disorders (ASD) on the Kenyan Coast.

Methods

In-depth interviews and focus group discussions using guiding questions were utilized in data collection. One hundred and three participants, who included parents of children with ASD, special needs teachers, clinicians, and social workers from diverse cultural background, participated in this study. The interviews and focus groups were recorded, transcribed verbatim and then translated to English. Themes were generated using content analysis.

Results

Preternatural causes were mentioned and included evil spirits, witchcraft, and curses. Biomedical causes comprised infections, drug abuse, birth complications, malnutrition, and genetic related problems. Treatment varied from traditional and spiritual healing to modern treatment in health facilities, and included consultations with traditional healers, offering prayers to God, and visits to hospitals.

Conclusions

The results suggest that regardless of cultural backgrounds, people on the Kenyan Coast have similar views on perceived causes and treatment of ASD. These findings provide valuable conceptual understanding for professionals when planning and implementing community based rehabilitation interventions targeting children with ASD within a local context.

European clinical network: autism spectrum disorder assessments and patient characterisation

The United Nations and World Health Organisation have identified autism spectrum disorder (ASD) as an important public health issue across global mental health services. Although a range of tools exist to identify and quantify ASD symptoms, there is a lack of information about which ASD measures are used in different services worldwide. This paper presents data from a large survey of measures used for patient characterisation in major ASD research and clinical centres across Europe collected between June 2013 and January 2014. The objective was to map the use of different instruments used to characterise ASD, comorbid psychopathology and cognitive and adaptive ability for patient diagnostic and characterisation purposes across Europe. Sixty-six clinical research sites diagnosing 14,844 patients per year contributed data. The majority of sites use the well-established Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview (ADI) instruments, though the proportion of sites in Western Europe using the ADI was almost double the rate in Eastern Europe. Approximately half the sites also used the Social Communication Questionnaire (SCQ) and Social Responsiveness Scale (SRS), although use of the SRS was over three times higher in Western Europe compared with Eastern Europe. The use of free/open access measures was lower than commercially available tools across all regions. There are clinical and scientific benefits in encouraging further convergence of clinical characterisation measures across ASD research and clinical centres in Europe to facilitate large-scale data sharing and collaboration, including clinical trials of novel medications and psychological interventions.

The psychometric properties of the Quantitative-Checklist for Autism in Toddlers (Q-CHAT) as a measure of autistic traits in a community sample of Singaporean infants and toddlers

Background

There is growing research evidence that subclinical autistic traits are elevated in relatives of individuals with autism spectrum disorder (ASD), continuously distributed in the general population and likely to share common etiology with ASD. A number of measures have been developed to assess autistic traits quantitatively in unselected samples. So far, the Quantitative-Checklist for Autism in Toddlers (Q-CHAT) is one of very few measures developed for use with toddlers as young as 18 months, but little is known about its measurement properties and factor structure.

Methods

The present study examined internal consistency, factor structure, test-retest stability, and convergent validity of the Q-CHAT in a sample of toddlers in Singapore whose caregivers completed the Q-CHAT at 18 (n = 368) and 24 months (n = 396).

Results

Three factors were derived accounting for 38.1 % of the variance: social/communication traits, non-social/behavioral traits, and a speech/language factor. Internal consistency was suboptimal for the total and speech/language scores, but acceptable for the social/communication and non-social/behavioral factor scores. Scores were generally stable between 18 and 24 months. Convergent validity was found with the Pervasive Developmental Disorders subscale of the Child Behavior Checklist (CBCL) completed by caregivers when their children were 24 months. Q-CHAT total scores in this sample were higher than those reported in other unselected samples from the UK.

Conclusions

The Q-CHAT was found to have a three-factor structure, acceptable internal consistency for its two main factor scores (social/communication and non-social/behavioral), normally distributed scores in an unselected sample, and similar structure and measurement properties as those reported in other published studies. Findings are discussed in relation to existing literature and future directions for the validation of the Q-CHAT.

The broad autism phenotype predicts relationship outcomes in newly formed college roommates

Although previous studies have reported that the broad autism phenotype is associated with reduced relationship quality within established relationships, understanding how this association emerges requires assessment prior to relationship development. In the present longitudinal study, college roommates with minimal familiarity prior to cohabitation (N = 162) completed the broad autism phenotype questionnaire and intermittently reported on their relationship quality and interpersonal behaviors toward their roommate over their first 10 weeks of living together. Actor-Partner Interdependence Models demonstrated that roommates mismatched on aloofness (one high and one low) had lower relationship satisfaction than those matched on it, with the interpersonal behavior of warmth mediating this association. Because relationship satisfaction remained high when both roommates were aloof, satisfaction does not appear predicated upon the presence of aloofness generally but rather reflects a product of dissimilarity in aloof profiles between roommates. In contrast, although participants reported less relationship satisfaction and commitment with roommates higher on pragmatic language abnormalities, mismatches on this broad autism phenotype trait, and on rigid personality, were less consequential. In sum, these findings suggest that complementary profiles of social motivation may facilitate relationship quality during the early course of relationship development.

Investigating the cross-cultural validity of DSM-5 autism spectrum disorder: Evidence from Finnish and UK samples

The recent Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition ( DSM-5) reformulation of autism spectrum disorder has received empirical support from North American and UK samples. Autism spectrum disorder is an increasingly global diagnosis, and research is needed to discover how well it generalises beyond North America and the United Kingdom. We tested the applicability of the DSM-5 model to a sample of Finnish young people with autism spectrum disorder (n = 130) or the broader autism phenotype (n = 110). Confirmatory factor analysis tested the DSM-5 model in Finland and compared the fit of this model between Finnish and UK participants (autism spectrum disorder, n = 488; broader autism phenotype, n = 220). In both countries, autistic symptoms were measured using the Developmental, Diagnostic and Dimensional Interview. Replicating findings from English-speaking samples, the DSM-5 model fitted well in Finnish autism spectrum disorder participants, outperforming a Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition ( DSM-IV) model. The DSM-5 model fitted equally well in Finnish and UK autism spectrum disorder samples. Among broader autism phenotype participants, this model fitted well in the United Kingdom but poorly in Finland, suggesting that cross-cultural variability may be greatest for milder autistic characteristics. We encourage researchers with data from other cultures to emulate our methodological approach, to map any cultural variability in the manifestation of autism spectrum disorder and the broader autism phenotype. This would be especially valuable given the ongoing revision of the International Classification of Diseases–11th Edition, the most global of the diagnostic manuals.