Diagnostic accuracy, reliability and validity of Childhood Autism Rating Scale in India

Screening and diagnostic tools for autism spectrum disorder: Systematic review and meta-analysis

INTRODUCTION

Autism Spectrum Disorder (ASD) is a heterogeneous neurodevelopmental disorder, with main manifestations related to communication, social interaction, and behavioral patterns. The slight dynamics of change in the child over time require that the onset of clinical manifestations presented by the child be more valued, with the aim of stabilizing the condition. Faced with a variety of methods for diagnosing ASD, the question arises as to which method should be used. This systematic review aims to recommend the best tools to perform screening and diagnosis.

METHODOLOGY

This systematic review followed the PRISMA guidelines. The databases MEDLINE, Embase, CENTRAL (Cochrane), and Lilacs were accessed, and gray and manual searches were performed. The search strategy was created with terms referring to autism and the diagnosis/broad filter. The studies were qualitatively evaluated and quantitatively. Statistical analysis was performed using Meta-diSc-2.0 software, the confidence interval was 95 %.

RESULTS

The M-CHAT-R/F tool demonstrated a sensitivity of 78 % (95 % CI 0.57‒0.91) and specificity of 0.98 (95 % CI 0.88-1.00). The diagnostic tools demonstrated sensitivity and specificity respectively of: ADOS, sensitivity of 87 % (95 % CI 0.79‒0.92) and specificity 75 % (95 % CI 0.73‒0.78); ADI-R demonstrated test sensitivity of 77 % (95 % CI 0.56‒0.90) and specificity 68 % (95 % CI 0.52‒0.81), CARS test sensitivity was 89 % (95 % CI 0.78‒0.95) and specificity 79 % (95 % CI 0.65‒0.88).

CONCLUSION

It is mandatory to apply a screening test, the most recommended being the M-CHAT-R/F. For diagnosis CARS and ADOS are the most recommended tools.

Branched-chain amino acids as adjunctive-alternative treatment in patients with autism: a pilot study

The branched-chain amino acid (BCAA) is a group of essential amino acids that are involved in maintaining the energy balance of a human being as well as the homoeostasis of GABAergic, glutamatergic, serotonergic and dopaminergic systems. Disruption of these systems has been associated with the pathophysiology of autism while low levels of these amino acids have been discovered in patients with autism. A pilot open-label, prospective, follow-up study of the use of BCAA in children with autistic behaviour was carried out. Fifty-five children between the ages of 6 and 18 participated in the study from May 2015 to May 2018. We used a carbohydrate-free BCAA-powdered mixture containing 45·5 g of leucine, 30 g of isoleucine and 24·5 g of valine in a daily dose of 0·4 g/kg of body weight which was administered every morning. Following the initiation of BCAA administration, children were submitted to a monthly psychological examination. Beyond the 4-week mark, BCAA were given to thirty-two people (58·18 %). Six of them (10·9 %) discontinued after 4-10 weeks owing to lack of improvement. The remaining twenty-six children (47·27 %) who took BCAA for longer than 10 weeks displayed improved social behaviour and interactions, as well as improvements in their speech, cooperation, stereotypy and, principally, their hyperactivity. There were no adverse reactions reported during the course of the treatment. Although these data are preliminary, there is some evidence that BCAA could be used as adjunctive treatment to conventional therapeutic methods for the management of autism.

Theory of Mind Predicts Social Interaction in Children with Autism Spectrum Disorder: A Two-Year Follow-Up Study

This two-year follow-up study examined the predictive relationships of theory of mind (ToM) to social interaction by reciprocal social behaviors (RSBs) and social functioning (SF) in 106 children with ASD. The results of the path analysis showed that the earlier ToM predicted children's current component RSBs (B = 3.53, SE = 1.86, p = 0.039) and the current SF (B = 1.79-1.87, SE = 0.03-0.34, p < 0.001). The aloof and passive social interaction styles predicted fewer turn-taking of RSBs (B =  - 48.77 to - 111.17, p < 0.001) and fewer components of RSBs (B =  - 36.30 to - 81.41, p < 0.001). This finding provides empirical evidence that ToM predicts social interaction in children with ASD.

A Comparison Controlled Study Examining Outcome for Children With Autism Receiving Intensive Behavioral Intervention (IBI)

This study evaluated the effects of a center-based Intensive Behavioral Intervention (IBI) model for preschool aged children with autism. Outcomes of 25 children receiving IBI was compared to the outcomes of 14 children receiving autism specific, eclectic, special education. Both provisions were described as appropriate treatment options by the professional agency who diagnosed the children, and the decision of where to enroll the child was made by the parents after consultations with the specialists. After 14 months of treatment, children from the IBI group improved significantly on standard scores in intellectual functioning and adaptive behavior and had a significant reduction in autism severity compared to the children in the autism specific, eclectic, special education group. Results suggest that preschool aged children with autism may make large gains in intellectual and adaptive functioning and improvement in autism severity with IBI, and that effects of IBI may be similar to that of EIBI. These findings must be interpreted with caution due to the limitations inherent in the present comparison-controlled design.

Exploring the Potential Role of ADAM 17 and ADAM 22 in the Etiology of Autism Spectrum Disorders

BACKGROUND

Autism spectrum disorder (ASD) encompasses a group of disorders characterized by difficulties with social interaction and repetitive behavior. The condition is supposed to originate from early shifts in brain development, while the underlying processes are unknown. Moreover, a considerable number of patients with ASD experience digestive difficulties. Metalloproteases (ADAMs) are a class of enzymes capable of cleaving membrane-bound proteins. Members of this family, ADAM17 and ADAM22, have the ability to cleave proteins like the pro-inflammatory cytokine TNF-ά and glutamate synaptic molecules, which are both engaged in neuro-inflammation and glutamate excitotoxicity as crucial etiological mechanisms in ASD. ADAM17 and ADAM22 may also have a role in ASD microbiota-gut-brain axis connections by regulating immunological and inflammatory responses in the intestinal tract.

SUBJECTS AND METHODS

Using ELISA kits, the plasma levels of ADAM17 and ADAM22 were compared in 40 children with ASD and 40 typically developing children. All of the autistic participants' childhood autism rating scores (CARS), social responsiveness scales (SRS), and short sensory profiles (SSP) were evaluated as indicators of ASD severity.

RESULTS

Our results showed that plasma levels of ADAM17 were significantly lower in ASD children than in control children, while ADAM22 demonstrated non-significantly lower levels. Our data also indicate that while ADAM17 correlates significantly with age, ADAM22 correlates significantly with CARS as a marker of ASD severity.

CONCLUSIONS

Our interpreted data showed that alteration in ADAM17 and ADAM22 might be associated with glutamate excitotoxicity, neuroinflammation, and altered gut microbiota as etiological mechanisms of ASD and could be an indicator of the severity of the disorder.

Comparison of diagnostic validity of two autism rating scales for suspected autism in a large Chinese sample

BACKGROUND

Autism is the most common clinical developmental disorder in children. The childhood autism rating scale (CARS) and autistic autism behavior checklist (ABC) are the most commonly used assessment scales for diagnosing autism. However, the diagnostic validations and the corresponding cutoffs for CARS and ABC in individuals with suspected autism spectrum disorder (ASD) remain unclear. Furthermore, for suspected ASD in China, it remains unclear whether CARS is a better diagnostic tool than ABC. Also unclear is whether the current cutoff points for ABC and CARS are suitable for the accurate diagnosis of ASD.

AIM

To investigate the diagnostic validity of CARS and ABC based on a large Chinese sample.

METHODS

A total of 591 outpatient children from the ASD Unit at Beijing Children’s Hospital between June and November 2019 were identified. First, the Clancy autism behavior scale (CABS) was used to screen out suspected autism from these children. Then, each suspected ASD was evaluated by CARS and ABC. Receiver operating characteristic (ROC) curve analysis was used to compare diagnostic validations. We also calculated the area under the curve (AUC) for both CARS and ABC.

RESULTS

We found that the Cronbach alpha coefficients of CARS and ABC were 0.772 and 0.426, respectively. Therefore, the reliability of the CARS was higher than that of the ABC. In addition, we found that the correlation between CARS and CABS was 0.732. Next, we performed ROC curve analysis for CARS and ABC, which yielded AUC values of 0.846 and 0.768, respectively. The cutoff value, which is associated with the maximum Youden index, is usually applied as a decision threshold. We found that the cutoff values of CARS and ABC were 34 and 67, respectively.

CONCLUSION

This result indicated that CARS is superior to ABC in the Chinese population with suspected ASD.

Assessing autism with DSM-IV and DSM-5 criteria using the Childhood Autism Rating Scale (CARS)

Introduction. The Childhood Autism Rating Scale (CARS) is an observational instrument for assessing autism. It is the most widely used instrument for the diagnosis of autism in Mexico. Objective. To study the psychometric properties in the Mexican population using DSM-IV and DSM-5 criteria. Method. This is an observational, cross-sectional study. Participants (N = 137) were 78.8% male, with an age range between 2 and 18 years, mean 8.5. Parents completed the M-CHAT, the ABC, the ADI-R, and semi-structured clinical interviews with DSM-IV. We inferred DSM-5 criteria by selecting atypical sensory items from the ABC. Results. The internal consistency for the total CARS items was α = .88. The concurrent validity of the CARS and the DSM-IV criteria showed a Spearman coefficient of correlation of rs = .62. The convergent validity with the ADI-R showed moderate correlations, rs = .32 to .61, with the DSM-IV k = .33 and DSM-5 k = .36. The concordance with the DSM-IV and DSM-5 was 71% and 84.5%, sensitivity was 58.1% and 46-7%, and specificity 76.6% and 90.5%, respectively. The discriminant analysis showed that the CARS correctly classified 97% of children with autism, 70% with pervasive developmental disorders not otherwise specified (PDD-NOS), and 12.5% with Asperger’s syndrome. Discussion and conclusion. The Mexican version of the CARS is a valid and reliable instrument for diagnosing autism in Mexican children and adolescents.

Measurement invariance of the Childhood Autism Rating Scale (CARS) across six countries

The Childhood Autism Rating Scale (CARS) is a simple and inexpensive tool for Autism spectrum disorder (ASD) assessments, with evidenced psychometric data from different countries. However, it is still unclear whether ASD symptoms are measured the same way across different societies and world regions with this tool, since data on its cross-cultural validity are lacking. This study evaluated the cross-cultural measurement invariance of the CARS among children with ASD from six countries, for whom data were aggregated from previous studies in India (n = 101), Jamaica (n = 139), Mexico (n = 72), Spain (n = 99), Turkey (n = 150), and the United States of America (n = 186). We analyzed the approximate measurement invariance based on Bayesian structural equation modeling. The model did not fit the data and its measurement invariance did not hold, with all items found non-invariant across the countries. Items related to social communication and interaction (i.e., relating to people, imitation, emotional response, and verbal and nonverbal communication) displayed lower levels of cross-country non-invariance compared to items about stereotyped behaviors/sensory sensitivity (i.e., body and object use, adaptation to change, or taste, smell, and touch response). This study found that the CARS may not provide cross-culturally valid ASD assessments. Thus, cross-cultural comparisons with the CARS should consider first which items operate differently across samples of interest, since its cross-cultural measurement non-invariance could be a source of cross-cultural variability in ASD presentations. Additional studies are needed before drawing valid recommendations in relation to the cultural sensitivity of particular items.

Autism spectrum disorder in India: a scoping review

Autism is a grand challenge in global mental health to be dealt with on a priority basis. Phenotypic knowledge, biological understanding, and evidence-based intervention studies are all from western countries. We know very little about autism in the low- and middle-income countries (LMIC). Lack of infrastructure and difficulties in operationalizing research has widened the knowledge gap. We performed a comprehensive scoping review of research in Autism Spectrum Disorder in India to have an overall impression, identify gaps, and formulate evidence-based recommendations for further study. We searched PubMed, SCOPUS, and Cochrane Library to identify relevant Indian studies. A hundred and fifty-nine publications met the inclusion criteria. Most of the research contribution in autism is from few tertiary care medical centres, technological institutes, and not-for-profit organizations. We identified various themes of research like clinical profile, interventions, biomarkers, psychological, social, epidemiological, and risk factors. Evidence-based intervention studies, translation and adaptation of standard diagnostic instruments, and qualitative research on the experience of autism appeared to be state of the art. However, epidemiological studies, biomarkers identification, risk assessment studies were of low quality. There is a need for nationwide studies with representative sampling on epidemiology, biomarkers, and risk factors for a complete evaluation of the actual burden and biology of autism in India. Also, there is a need to design implementation research to evaluate the effectiveness of evidence-based interventions in routine healthcare settings. We recommend that future research should fill these gaps in understanding autism and improving its outcome in India.

Brief Parent-Mediated Intervention for Children with Autism Spectrum Disorder: A Feasibility Study from South India

The study assesses the acceptability and feasibility of a brief parent-mediated home-based intervention for children with autism spectrum disorder (ASD), deliverable in resource-limited settings, with an emphasis on addressing parental stress from a socio-cultural perspective. 50 children (2-6 years), with a DSM 5 diagnosis of ASD were randomized to intervention (n = 26) or active control group (n = 24). The intervention based on naturalistic developmental behavioral approach, focusing on joint attention, imitation, social and adaptive skills was structured to be delivered in five outpatient sessions over 12 weeks. All children were followed up at 4, 8 and 12 weeks. Parents of children randomized to the intervention group reported more improvements across parental stress and child outcome measures compared to those in the control group. The intervention was found to be acceptable and feasible, with high fidelity measures and retention rates.

Autism in India: a case-control study to understand the association between socio-economic and environmental risk factors

Autism spectrum disorder is a neurodevelopmental disorder and the cause of autism is still unclear. The aim of this study was to investigate the association of socioeconomic, environmental, pregnancy and newborn-related risk factors among children with autism spectrum disorders. This was a population-based case-control study. The study included 55 children with autism spectrum disorder and 55 age and sex matched typically developing normal children (TD) between 3 and 12 years. Several socio-economic factors, environmental factors, pregnancy related, natal, post-natal factors and the first noticed signs by the parents were analyzed. Chi-square test was used to compare nominal variables. For multivariate analysis, forward stepwise logistic regression model was employed to examine the association between autism and the chances that the child develops ASD to assess the odds ratios. Male predominance was observed in the study. Logistic regression model showed statistical significance of the following factors: paternal age greater than 40 years, family history of autism, nutrition during pregnancy, mode of labor, fetal hypoxia, NICU stay and history of breast feeding. In this epidemiological study of autism in Coimbatore city, we found correlation between several environmental factors during fetal development and can be transmitted to succeeding generations, causing atypical behavior phenotypes. The exact exposure magnitude, exposure time in relation to vital developmental periods need to be studied to understand the influence of socioeconomic and environmental factors, which can be improved to prevent ASD-related challenges.

Affiliate stigma among parents of children with autism in eastern India

Parents of children with autism experience high levels of stigma. They often internalize stigma which results in high psychological distress and has negative impact on seeking and providing care. Qualitative methodology has been used to study stigma in Indian population while quantitative studies have not been reported. The authors report affiliate stigma perception among parents of children with autism in a tertiary care medical centre using Affiliate Stigma Scale. Thirty-eight parents participated in this cross- sectional study. We discuss predictors of stigma in terms of caregiver characteristics and symptom profile. Identification of predictors of stigma perception can help in identifying populations at risk.

Dietary Patterns and Anthropometric Measures of Indian Children with Autism Spectrum Disorder

Research literature on dietary patterns & eating habits of children with Autism Spectrum Disorder (ASD) in India is limited. To explore this, a pilot study (n = 53) which included 45 boys and 8 girls (age group of 2-13 years) was conducted. Three day food records, Food Frequency Questionnaire and Children Eating Behavior Inventory were used to assess the dietary intakes and mealtime behavior problems respectively. Findings revealed lower intake of fruits and vegetables which reflected on their micronutrient status which was significantly (p ≤ 0.05) in lower amounts predominantly B-Complex, Calcium and Iron. The study has suggested a strong need for future implementation of nutritional intervention programs at the earliest to expand food variety among children with ASD of this region.

Prediction Of Playfulness By Pretend Play, Severity Of Autism Behaviors, And Verbal Comprehension In Children With Autism Spectrum Disorder

BACKGROUND

Children with autism spectrum disorder (ASD) often exhibit deficits in pretend play and have less playfulness. The purpose of this study was to evaluate the relationship between pretend play and playfulness in children with autism spectrum disorder, while controlling for severity of autism behaviors, verbal comprehension, and age.

METHODS

A sample of 72 children with ASD aged between 3 and 12 years were assessed with the Child-Initiated Pretend Play Assessment, Test of Playfulness, and Childhood Autism Rating Scale, respectively, for their pretend play, playfulness, and severity of autism behaviors. Correlation and multiple regression analyses were conducted.

RESULTS

The results of Pearson correlation coefficients revealed that the pretend play variables had mild to moderate associations with the playfulness variables (r = -0.25 to 0.68). The multiple regression analyses showed that, overall, the internal locus of control was the significant predictor of the pretend play variables (accounting for 5-47% of the variance, p < 0.001). The six pretend play variables were all important predictors of all playfulness variables (explaining 41-76% of the variance, p < 0.001-0.047). Particularly, the elaborate pretend play action was a significant predictor of all four playfulness variables. Our findings indicated that the more children with ASD engaged in pretend play, the more they experienced playfulness.

CONCLUSION

Clinicians could help children with ASD improve their feeling of being in charge of their play in order to develop better performance in pretend play. Assisting children with ASD to engage in pretend play is important to promote their internal experience of playfulness.

Factors associated with parent engagement in DIR/Floortime for treatment of children with autism spectrum disorder

Background

The Developmental, Individual-differences, Relationship-based model (DIR/Floortime) is one of the well-known therapies for autism spectrum disorder (ASD), in which its main principle is to promote holistic development of an individual and relationships between the caregivers and children. Parental engagement is an essential element to DIR/Floortime treatment and involved with various factors. Finding those supporting factors and eliminating factors that might be an obstacle for parental engagement are essential for children with ASD to receive the full benefits of treatment.

Aim

To examine the association between parents, children and provider and service factors with parental engagement in DIR/Floortime treatment.

Methods

This is a cross-sectional study of parents with children aged 2–12 years who were diagnosed with ASD. Data were collected using a parent, child, provider and service factors questionnaire. Patient Health Questionaire-9, Clinical Global Impressions-Severity and Childhood Autism Rating Scale were also used to collect data. For parent engagement in DIR/Floortime, we evaluated quality of parental engagement in DIR/Floortime and parent application of DIR/Floortime techniques at home. Finally, Clinical Global Impressions-Improvement and Functional Emotional Developmental Level were used to assess child development.

Results

Parents who were married, had lower income and higher knowledge of DIR/Floortime theory were more likely to have higher parent engagement (χ²=4.43, p=0.035; χ²=13.1, p<0.001 and χ²=4.06, p=0.044 respectively). Furthermore, severity of the diagnosis and the continuation of the treatment significantly correlated with parent engagement (χ²=5.83, p=0.016  and χ²=4.72, p=0.030 respectively). It was found that parents who applied the techniques for more than 1  hour/day, or had a high-quality parent engagement, significantly correlated with better improvement in child development (t=−2.03, p=0.049; t=−2.00, p=0.053, respectively).

Conclusion

Factors associated with parents, children, and provider and service factors had a significant correlation with parent engagement in DIR/Floortime in which children whose parents had more engagement in DIR/Floortime techniques had better improvement in child development.

Diagnostic tests for autism spectrum disorder (ASD) in preschool children

BACKGROUND

Autism spectrum disorder (ASD) is a behaviourally diagnosed condition. It is defined by impairments in social communication or the presence of restricted or repetitive behaviours, or both. Diagnosis is made according to existing classification systems. In recent years, especially following publication of the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5; APA 2013), children are given the diagnosis of ASD, rather than subclassifications of the spectrum such as autistic disorder, Asperger syndrome, or pervasive developmental disorder - not otherwise specified. Tests to diagnose ASD have been developed using parent or carer interview, child observation, or a combination of both.

OBJECTIVES

Primary objectives1. To identify which diagnostic tools, including updated versions, most accurately diagnose ASD in preschool children when compared with multi-disciplinary team clinical judgement.2. To identify how the best of the interview tools compare with CARS, then how CARS compares with ADOS.a. Which ASD diagnostic tool - among ADOS, ADI-R, CARS, DISCO, GARS, and 3di - has the best diagnostic test accuracy?b. Is the diagnostic test accuracy of any one test sufficient for that test to be suitable as a sole assessment tool for preschool children?c. Is there any combination of tests that, if offered in sequence, would provide suitable diagnostic test accuracy and enhance test efficiency?d. If data are available, does the combination of an interview tool with a structured observation test have better diagnostic test accuracy (i.e. fewer false-positives and fewer false-negatives) than either test alone?As only one interview tool was identified, we modified the first three aims to a single aim (Differences between protocol and review): This Review evaluated diagnostic tests in terms of sensitivity and specificity. Specificity is the most important factor for diagnosis; however, both sensitivity and specificity are of interest in this Review because there is an inherent trade-off between these two factors.Secondary objectives1. To determine whether any diagnostic test has greater diagnostic test accuracy for age-specific subgroups within the preschool age range.

SEARCH METHODS

In July 2016, we searched CENTRAL, MEDLINE, Embase, PsycINFO, 10 other databases, and the reference lists of all included publications.

SELECTION CRITERIA

Publications had to: 1. report diagnostic test accuracy for any of the following six included diagnostic tools: Autism Diagnostic Interview - Revised (ADI-R), Gilliam Autism Rating Scale (GARS), Diagnostic Interview for Social and Communication Disorder (DISCO), Developmental, Dimensional, and Diagnostic Interview (3di), Autism Diagnostic Observation Schedule - Generic (ADOS), and Childhood Autism Rating Scale (CARS); 2. include children of preschool age (under six years of age) suspected of having an ASD; and 3. have a multi-disciplinary assessment, or similar, as the reference standard.Eligible studies included cohort, cross-sectional, randomised test accuracy, and case-control studies. The target condition was ASD.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all studies for inclusion and extracted data using standardised forms. A third review author settled disagreements. We assessed methodological quality using the QUADAS-2 instrument (Quality Assessment of Studies of Diagnostic Accuracy - Revised). We conducted separate univariate random-effects logistical regressions for sensitivity and specificity for CARS and ADI-R. We conducted meta-analyses of pairs of sensitivity and specificity using bivariate random-effects methods for ADOS.

MAIN RESULTS

In this Review, we included 21 sets of analyses reporting different tools or cohorts of children from 13 publications, many with high risk of bias or potential conflicts of interest or a combination of both. Overall, the prevalence of ASD for children in the included analyses was 74%.For versions and modules of ADOS, there were 12 analyses with 1625 children. Sensitivity of ADOS ranged from 0.76 to 0.98, and specificity ranged from 0.20 to 1.00. The summary sensitivity was 0.94 (95% confidence interval (CI) 0.89 to 0.97), and the summary specificity was 0.80 (95% CI 0.68 to 0.88).For CARS, there were four analyses with 641 children. Sensitivity of CARS ranged from 0.66 to 0.89, and specificity ranged from 0.21 to 1.00. The summary sensitivity for CARS was 0.80 (95% CI 0.61 to 0.91), and the summary specificity was 0.88 (95% CI 0.64 to 0.96).For ADI-R, there were five analyses with 634 children. Sensitivity for ADI-R ranged from 0.19 to 0.75, and specificity ranged from 0.63 to 1.00. The summary sensitivity for the ADI-R was 0.52 (95% CI 0.32 to 0.71), and the summary specificity was 0.84 (95% CI 0.61 to 0.95).Studies that compared tests were few and too small to allow clear conclusions.In two studies that included analyses for both ADI-R and ADOS, tests scored similarly for sensitivity, but ADOS scored higher for specificity. In two studies that included analyses for ADI-R, ADOS, and CARS, ADOS had the highest sensitivity and CARS the highest specificity.In one study that explored individual and additive sensitivity and specificity of ADOS and ADI-R, combining the two tests did not increase the sensitivity nor the specificity of ADOS used alone.Performance for all tests was lower when we excluded studies at high risk of bias.

AUTHORS' CONCLUSIONS

We observed substantial variation in sensitivity and specificity of all tests, which was likely attributable to methodological differences and variations in the clinical characteristics of populations recruited.When we compared summary statistics for ADOS, CARS, and ADI-R, we found that ADOS was most sensitive. All tools performed similarly for specificity. In lower prevalence populations, the risk of falsely identifying children who do not have ASD would be higher.Now available are new versions of tools that require diagnostic test accuracy assessment, ideally in clinically relevant situations, with methods at low risk of bias and in children of varying abilities.

Updated report on tools to measure outcomes of clinical trials in fragile X syndrome

OBJECTIVE

Fragile X syndrome (FXS) has been the neurodevelopmental disorder with the most active translation of preclinical breakthroughs into clinical trials. This process has led to a critical assessment of outcome measures, which resulted in a comprehensive review published in 2013. Nevertheless, the disappointing outcome of several recent phase III drug trials in FXS, and parallel efforts at evaluating behavioral endpoints for trials in autism spectrum disorder (ASD), has emphasized the need for re-assessing outcome measures and revising recommendations for FXS.

METHODS

After performing an extensive database search (PubMed, Food and Drug Administration (FDA)/National Institutes of Health (NIH)'s www.ClinicalTrials.gov, etc.) to determine progress since 2013, members of the Working Groups who published the 2013 Report evaluated the available outcome measures for FXS and related neurodevelopmental disorders using the COSMIN grading system of levels of evidence. The latter has also been applied to a British survey of endpoints for ASD. In addition, we also generated an informal classification of outcome measures for use in FXS intervention studies as instruments appropriate to detect shorter- or longer-term changes.

RESULTS

To date, a total of 22 double-blind controlled clinical trials in FXS have been identified through www.ClinicalTrials.gov and an extensive literature search. The vast majority of these FDA/NIH-registered clinical trials has been completed between 2008 and 2015 and has targeted the core excitatory/inhibitory imbalance present in FXS and other neurodevelopmental disorders. Limited data exist on reliability and validity for most tools used to measure cognitive, behavioral, and other problems in FXS in these trials and other studies. Overall, evidence for most tools supports a moderate tool quality grading. Data on sensitivity to treatment, currently under evaluation, could improve ratings for some cognitive and behavioral tools. Some progress has also been made at identifying promising biomarkers, mainly on blood-based and neurophysiological measures.

CONCLUSION

Despite the tangible progress in implementing clinical trials in FXS, the increasing data on measurement properties of endpoints, and the ongoing process of new tool development, the vast majority of outcome measures are at the moderate quality level with limited information on reliability, validity, and sensitivity to treatment. This situation is not unique to FXS, since reviews of endpoints for ASD have arrived at similar conclusions. These findings, in conjunction with the predominance of parent-based measures particularly in the behavioral domain, indicate that endpoint development in FXS needs to continue with an emphasis on more objective measures (observational, direct testing, biomarkers) that reflect meaningful improvements in quality of life. A major continuous challenge is the development of measurement tools concurrently with testing drug safety and efficacy in clinical trials.

Culturally adapted pictorial screening tool for autism spectrum disorder: A new approach

AIM

To assess the performance of a newly designed, culturally adapted screening tool for autism spectrum disorder (ASD).

METHODS

Items for the screening tool were modeled from already documented checklists and diagnostic criteria for ASD. Each item in text was paired with a photograph that illustrated the written content, which was in the 2 main local languages. The final product had 21 items and was named the pictorial autism assessment schedule (PAAS). Performance of PAAS was tested on a clinical sample of 18-48 mo old children, diagnosis naïve, presenting with developmental deficits. Mothers completed PAAS checklist. Based on clinical diagnosis, which was taken as the gold standard, children were later grouped into ASD (Group 1) and non-ASD developmental disorders (Group 2). Mothers of a control sample of typically developing children also completed PAAS (Group 3).

RESULTS

A total of 105 children (Group 1-45, Group 2-30, Group 3-30) participated in the study. Mean age of Group 1 and Group 2 were 36 and 40 mo respectively. Majority were male in all 3 groups. Performance of PAAS in discriminating between ASD and non-ASD developmental disorders was sensitivity 88.8%, specificity 60.7%, positive predictive value (PPV) 78.4%, negative predictive value (NPV) 77.2%, likelihood ratio (LR+) 2.26, and LR- 0.18. Performance of PAAS in discriminating between ASD and typical development was sensitivity 88.0%, specificity 93.3%, PPV 95.2%, NPV 84.0%, LR+ 13.3 and LR- 0.12. The results indicated that that a positive result from PAAS was 2.26 times more likely to be found in a child with ASD than in a child with non-ASD developmental disorder. A positive result from PAAS was 13.3 times more likely to be found in a child with ASD than in a child with typical development.

CONCLUSION

PAAS is an effective tool in screening for ASD. Further study is indicated to evaluate the feasibility of using this instrument for community screening for ASD.

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.

Systematic review of tools to measure outcomes for young children with autism spectrum disorder

BACKGROUND

The needs of children with autism spectrum disorder (ASD) are complex and this is reflected in the number and diversity of outcomes assessed and measurement tools used to collect evidence about children's progress. Relevant outcomes include improvement in core ASD impairments, such as communication, social awareness, sensory sensitivities and repetitiveness; skills such as social functioning and play; participation outcomes such as social inclusion; and parent and family impact.

OBJECTIVES

To examine the measurement properties of tools used to measure progress and outcomes in children with ASD up to the age of 6 years. To identify outcome areas regarded as important by people with ASD and parents.

METHODS

The MeASURe (Measurement in Autism Spectrum disorder Under Review) research collaboration included ASD experts and review methodologists. We undertook systematic review of tools used in ASD early intervention and observational studies from 1992 to 2013; systematic review, using the COSMIN checklist (Consensus-based Standards for the selection of health Measurement Instruments) of papers addressing the measurement properties of identified tools in children with ASD; and synthesis of evidence and gaps. The review design and process was informed throughout by consultation with stakeholders including parents, young people with ASD, clinicians and researchers.

RESULTS

The conceptual framework developed for the review was drawn from the International Classification of Functioning, Disability and Health, including the domains 'Impairments', 'Activity Level Indicators', 'Participation', and 'Family Measures'. In review 1, 10,154 papers were sifted - 3091 by full text - and data extracted from 184; in total, 131 tools were identified, excluding observational coding, study-specific measures and those not in English. In review 2, 2665 papers were sifted and data concerning measurement properties of 57 (43%) tools were extracted from 128 papers. Evidence for the measurement properties of the reviewed tools was combined with information about their accessibility and presentation. Twelve tools were identified as having the strongest supporting evidence, the majority measuring autism characteristics and problem behaviour. The patchy evidence and limited scope of outcomes measured mean these tools do not constitute a 'recommended battery' for use. In particular, there is little evidence that the identified tools would be good at detecting change in intervention studies. The obvious gaps in available outcome measurement include well-being and participation outcomes for children, and family quality-of-life outcomes, domains particularly valued by our informants (young people with ASD and parents).

CONCLUSIONS

This is the first systematic review of the quality and appropriateness of tools designed to monitor progress and outcomes of young children with ASD. Although it was not possible to recommend fully robust tools at this stage, the review consolidates what is known about the field and will act as a benchmark for future developments. With input from parents and other stakeholders, recommendations are made about priority targets for research.

FUTURE WORK

Priorities include development of a tool to measure child quality of life in ASD, and validation of a potential primary outcome tool for trials of early social communication intervention.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012002223.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

A pilot feasibility study of neurofeedback for children with autism

Neurofeedback (NFB) is an emerging treatment for children with autism spectrum disorder (ASD). This pilot study examined the feasibility of NFB for children with ASD. Ten children ages 7-12 with high functioning ASD and attention difficulties received a NFB attention training intervention. A standardized checklist captured feasibility, including focus during exercises and academic tasks, as well as off-task behaviors. Active behaviors and vocalizations were the most frequent off-task behaviors. Positive reinforcement and breaks including calm breathing exercises were the most common supports. Low motivation was associated with higher feasibility challenges, yet parental involvement and accommodations were helpful. This pilot study shows that it is feasible to conduct NFB sessions with children with high functioning autism and attention difficulties.

Feeding problems among children with autism in a clinical population in India

OBJECTIVES

To compare the prevalence and profile of feeding problems (FP) and their relationship with sensory processing in children with autism and intellectual disability (ID).

METHODS

Children between ages 3 to 10 y with autism (N = 41) and ID (N = 56) were recruited and assessed with Brief Autism Mealtime Behavior Inventory, Sensory Profile Questionnaire, Childhood Autism Rating Scale and Binet-Kamat Scale of Intelligence or Gesell's Developmental Schedule. Assessments were done by independent raters. Bivariate and multivariate analyses were used appropriately.

RESULTS

The prevalence of FP were 61 and 46.4% among children with autism and ID respectively. Feeding problems were severe among children with autism (P 0.001), especially in young children with autism (P 0.05), and gender was not related to FP. Disruptive meal-time behaviors (P 0.001) and food over-selectivity (P 0.02) were significantly more among children with autism in the bivariate and multivariate analysis. Feeding problems and various dimensions of sensory processing were significantly associated after controlling the confounders.

CONCLUSIONS

These findings underscore the need for mandatory assessment of FP in children with developmental disabilities, and if present, they need to be addressed with multimodal-multidisciplinary interventions.

CDC Kerala 11: Diagnosis of autism among children between 2 and 6 y--comparison of CARS against DSM-IV-TR

OBJECTIVES

To compare diagnosis of childhood autism using CARS cut off scores of ≥30 and the new Indian cut off scores of ≥33 against the gold standard DSM-IV-TR criteria available during the study period 2009-10.

METHODS

The study was conducted at the autism clinic of Child Development centre (CDC), Kerala. Two hundred consecutive children between 2 and 6 y with symptoms suggestive of autism were administered both CARS by a trained developmental therapist and DSM-IV-TR by a developmental pediatrician on the same day, both blind to the test results of each other. Diagnosis of autism using CARS cut off scores 30 and above, as suggested in original tool administration manual and 33 and above, as suggested for diagnostic use in Indian population was compared with DSM-IV-TR diagnosis. Data was analyzed using SPSS (version 19.0) software.

RESULTS

Against DSM-IV-TR diagnosis as gold standard, the new CARS cut off scores ≥33 had a higher Specificity (74.3%), Positive predictive value (PPV) (81.9%), Positive likelihood ratio (LR) (2.66) and Negative LR (0.43), but had a lower Sensitivity (68.3%), Negative predictive value (NPV) (57.9%) and accuracy (70.5%), as compared to the cut off scores of ≥30.

CONCLUSIONS

The CARS prevalence of autism for cut off points ≥30 and ≥33 was 71.5 and 52.5% respectively against 63% prevalence by DSM-IV-TR.

CDC Kerala 10: Diagnostic accuracy of the severity scores for childhood autism rating scale in India

OBJECTIVE

To document the diagnostic accuracy of the Childhood Autism Scale (CARS) thresholds to identify mild, moderate and severe autism in India.

METHODS

The CARS scores of 623 children, with and without autism were compared against the Diagnostic and Statistical Manual for Mental Disorders 4th edition (DSM-IV-TR) for ASD diagnosis and clinical consensus between two developmental paediatricians as the reference standard for autism severity using the Receiver operating characteristics (ROC) curve analyses and contingency tables.

RESULTS

The CARS total score for mild, moderate and severe autism ranged from 30.5 to 35, 35.5-40 and ≥40.5 respectively in this study. The overall diagnostic accuracy of CARS total score in the mild range was moderate [AUC = 0.68 (95%CI = 0.62-0.88), z = 1.34; P = 0.18], moderate range was high [AUC = 0.90 (95%CI = 0.77-0.97), z = 8.62; P = 0.0001] and severe range was also high [AUC = 0.85 (95%CI = 0.77-0.90), z = 7.09; P = 0.0001].

CONCLUSIONS

There are validated severity scores for Childhood Autism Rating Scale for clinical and research use in India.

Sensory Profile Caregiver Questionnaire: a measure for sensory impairment among children with developmental disabilities in India

OBJECTIVE

There is no validated measure for assessing sensory processing among children with Developmental Disorders (DD) in India, and therefore, the authors validated the Sensory Profile Caregiver Questionnaire (SPCQ).

METHODS

Parents of 119 children with DD or typical development completed the SPCQ. The diagnosis of DD was confirmed by psychologists using standardized measures. Two experienced occupational therapists independently diagnosed sensory processing dysfunction by consensus as reference standard diagnosis. The convergent and divergent validity were assessed by another rater. The data was analyzed for diagnostic accuracy, reliability and validity appropriately.

RESULTS

A total SPCQ score of ≤ 481 (Sn = 81.58%, Sp = 85.19%; AUC = 0.90, z = 14.95; P 0.0001) is appropriate for the diagnosis of sensory processing dysfunction. The inter-rater reliability (ICC = 0.87), test- retest reliability (ICC = 0.90), internal consistency (Cronbach's α = 0.86), section-total correlation, face and content validity for the SPCQ were good. Convergent validity with the Sensory Processing Measure (r = -0.76, P 0.001), and divergent validity with the subscale scores for social skills/ oppositional behavior of ADD-H Comprehensive Teacher Rating Scale (r = 0.32; P 0.1/ r = 0.08; P 0.6) was established.

CONCLUSIONS

The SPCQ has adequate psychometric properties for use in the Indian population for identifying sensory processing dysfunction.

A meta-analysis of the diagnostic accuracy of Autism Diagnostic Observation Schedule Module-1 for autism spectrum disorders

OBJECTIVE

Autism Diagnostic Observation Schedule (ADOS) is considered gold standard for the diagnosis of Autism Spectrum Disorders (ASD). The authors evaluated the cumulative diagnostic accuracy of ADOS-Module 1 (ADOS(M1)) using the original diagnostic algorithm with meta-analysis and meta-regression.

METHODS

The authors, electronically and manually searched for studies from 1999 to 2013 that evaluated the accuracy of ADOS(M1) using the original diagnostic algorithm in detecting ASD. Primary results of Sensitivity (Sn), Specificity (Sp) and Diagnostic Odds Ratio (DOR) for ADOS(M1) were summarized using random-effects model. Summary Receiver Operating characteristic Curves and its Area Under the Curve (SROC-AUC) were used to summarize overall diagnostic accuracy of ADOS(M1). The modifying effects of quality of study and sample size, on the diagnostic odds ratio, were investigated using meta-regression.

RESULTS

A total of 7 cross-sectional studies provided data on 4057 children. The pooled Sn, Sp, DOR and SROC-AUC for the overall diagnostic accuracy of ADOS (M1) were: 0.91 (95 %CI=0.89 to 0.93), 0.73 (95 % CI=0.69 to 0.76), 44.20 (95 %CI=15.89 to 122.95) and 0.90 respectively [corrected]. Meta-regression analysis showed a non-significant relationship between ADOS(M1) and study quality as well as sample size. There were subgroup differences in the DOR.

CONCLUSIONS

It is concluded that ADOS (M1) with the original diagnostic algorithm has the overall diagnostic accuracy and pooled specificity suggesting moderate accuracy. The pooled sensitivity is high to be used as a screening test for Autism Spectrum Disorders. ADOS( M1)with the revised diagnostic algorithm should be used for diagnostic purpose [corrected] ADOS(M1) with the revised diagnostic algorithm should be used instead for the diagnosis of this group of disorders.

CDC Kerala 8: Effectiveness of a clinic based, low intensity, early intervention for children with autism spectrum disorder in India: a naturalistic observational study

OBJECTIVE

To document the effectiveness of low intensity, clinic based intervention models for Autism Spectrum Disorders (ASD) in countries with low disability resources.

METHODS

Thirty-nine participants with a mean (SD) of 36.03(11.15) mo were assessed before and after intervention with Childhood Autism rating scale (CARS), and at baseline with the Denver Developmental Screening Test for quantifying the effectiveness of the clinic-based intervention in ameliorating autism symptoms and studying the effect of developmental disability respectively. Developmental therapists in the clinic gave low-intensity group intervention for 45-60 min to the child through mother and encouraged to continue the training, for 3-4 h, at home to address the specific goals in the three ASD symptom clusters. Most of the children were also placed in play-schools. Follow-up support was given either on a weekly, fortnightly or monthly basis. Data was analyzed using appropriate bivariate and multivariate techniques.

RESULTS

There was amelioration in the severity of autism after intervention, which was statistically and clinically significant. Intervention was useful to help children with mild to severe autism.

CONCLUSIONS

Low-intensity, clinic-based intervention can be effectively used in situation where there is paucity of disability resources.

Impact of Comorbidity on Three Month Follow-up Outcome of Children with ADHD in a Child Guidance Clinic: Preliminary Report

CONTEXT

Attention deficit hyperactivity disorder (ADHD) is one of the common neurodevelopmental disorders.

AIMS

Study objective is to report impact of comorbidities on short-term outcome in children with ADHD followed in a child guidance clinic.

SETTINGS AND DESIGN

This was done in a child guidance clinic run jointly by the pediatric and psychiatry department at a tertiary teaching hospital. This is a 3 month prospective follow-up study to assess the outcome in ADHD children.

MATERIALS AND METHODS

Children attending pediatric department with behavioral problems or poor scholastic performance were screened for ADHD and further confirmation of diagnosis was done by semistructured interview of the child and parent. Children functional assessment and ADHD symptom profile was compared at baseline and at follow-up. We screened for and excluded those showing autistic spectrum disorder and having worse than mild mental retardation. Baseline variables were compared between improved and not improved subgroups and impact of these variables on outcome at 3-month follow-up was analyzed.

STATISTICAL ANALYSIS

Descriptive statistics.

RESULTS

Of the 25 children completing the study, at the end of 3 months, 15 improved (not fulfilling criteria for ADHD) and 10 did not improve. Applying Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS) for diagnosis of psychiatric comorbidities, six had associated psychiatric comorbidities. This was significantly higher in those who did not improve.

CONCLUSIONS

Presence of comorbidities at baseline was found to affect outcome at 3 month assessment in this preliminary study. Future studies with larger sample and longer follow-up are needed for finding the predictors of outcome in ADHD children in developing nations.

The utility of the Gilliam autism rating scale for identifying Iranian children with autism

PURPOSE

Screening and assessment tools for developmental disabilities such as autism may need to be adjusted to particular cultures. The aim of this study was to evaluate the use in Iran of a rating scale for autism commonly used in western society.

METHOD

A Persian translation of the GARS was completed by parents of 658 children: 442 who had been diagnosed with Autism; 112 intellectually disabled and 102 normally developing. The psychometric properties of the subscales were assessed and comparisons made across the three groups.

RESULTS

Factor analysis broadly confirmed the three subscales; each of which had high internal consistency. Individuals with autism were clearly distinguished from the other two groups and a cut-off score was identified that maximised the scale's sensitivity and specificity. Ten items were identified that best discriminated the three groups and these could form the basis for a shorter screening tool as they had good internal reliability and predictive validity.

CONCLUSIONS

Iranian parents identified items relating to impaired social interaction and repetitive behaviours as more indicative of autism rather than those relating to communication and language. Attuning screening tools to cultural contexts is an important step towards a better understanding of autism internationally. Implications for Rehabilitation Early identification of autism enables appropriate interventions to be commenced and support offered to families. Screening tools developed in western society needs to be evaluated for their suitability in other cultures internationally as well as with immigrant communities. Iranian professionals working in child development clinics could use the translated version of GARS with some confidence. In addition a shorter screening tool was developed comprising 10 autistic traits that were especially salient to an Iranian culture.

Can questions about social interaction correctly identify preschool aged children with autism?

AIM

We developed a questionnaire to assess social development (SIQ) in preschool children. Social development is often not included in medical assessment, though it may assist in early identification of autism spectrum disorder (ASD).

METHODS

Parents of 108 children with ASD, speech and language disorders, or 'developmental concerns', recruited from a clinical developmental assessment and community child health service, completed the SIQ, and also a Childhood Autism Rating Scale (CARS) assessment. Receiver Operator Characteristic (ROC) curves were generated to assess the performance of different questionnaire score thresholds in correctly identifying children with a CARS score of 30 or more. Logistic regression models were used to identify the questions which had the most predictive value for a CARS score of 30 or more.

RESULTS

An SIQ score of 14 or more correctly identified children with a CARS ≥ 30 with a sensitivity of 85%, specificity 85%, positive likelihood ratio (LR) 8.3 and negative LR 0.2. Two questions were identified as most predictive of ASD.

CONCLUSIONS

The SIQ may assist clinicians in assessing social development and in making decisions about referral for autism assessment. Evaluation of the SIQ at the point of entry to a clinical service is needed.

Priority mental health disorders of children and adolescents in primary-care pediatric setting in India 1: developing a child and adolescent mental health policy, program, and service model

India has a huge child and adolescent population. Psychiatric disorders are widely prevalent and the mental health needs of these children are well recognized. Nonetheless, there are no country-centric and child specific mental health policies, plans or programs. There is also a significant lack of human resources for child and adolescent mental health in India. This combination of factors makes the primary care a critical setting for the early identification, treatment, consultation and referral of children and adolescents with mental health and developmental needs. Even though the importance of primary care as a system for addressing the mental health care has been recognized for decades, its potential requires further development in India as the Child and Adolescent Mental Health Services (CAMHS) emerge and evolve. A country and child specific mental health policy, plan and program needs to be formulated as well an integrated, multi-tier CAMHS with a focus on the primary-care physicians as care providers for this population has to be developed.