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AUTISM SPECTRUM DISORDERS: INSTRUMENTS OF EARLY DETECTION Romina Moavero SCREENING TOOLS

AUTISM SPECTRUM DISORDERS - lumsa.it l2 chat m-chat q-chat pddst-ii esat itc fyi cesdd sacs m-chat q-chat fyi chat-23 biscuit stat

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AUTISMSPECTRUMDISORDERS:INSTRUMENTSOFEARLYDETECTION

RominaMoavero

SCREENINGTOOLS

SCREENINGTOOLS:Population

Level1 Level2

Population-basedscreening

Specific screeningtool after developmemtaldelayrisk confirmation at aroutine

developmental surveillance

L1 L2

CHATM-CHATQ-CHATPDDST-IIESATITCFYICESDDSACS

M-CHATQ-CHATFYICHAT-23BISCUITSTAT

Level3

LEVEL3:“GoldStandardTests”

Used inASDspecialty clinics:ADI-RADOS-2

EARLYDETECTION

EARLYDIAGNOSIS

EARLYINTERVENTION

LEVEL1

LEVEL2

LEVEL3

SCREENINGTOOLS:AGE

>18months ofage

• CHAT• M-CHAT• Q-CHAT• BISCUIT

>12months ofage

• CHAT-23• FYI• ESAT• STAT• SACS

<12months ofage

• ITC• CESDD

Inparticular…

<12months 12/14months 17/18months

Less specificityDevelopmentaldelayLanguagedelay

Early onset ASDSerious ASD

MoreSpecificityLateonset ASDRegression

SCREENINGTOOLS:Administration

INDIRECT DIRECT

Parent Questionnaire orInterview

Clinicalobservation

CHAT-CHecklist forAutism inToddlers

• L1,L2• >18months• 14items;yes/no.• 2sections:

üA(9items)indirect:parents interviewüB(5items)direct:clinical observation

Baron-Cohen,Allen,Gillberg 1992

• Pros: low price,wayofadministration (time),low percentage offalsepositiverate

• Cons:highpercentage offalsenegativerate*

CHAT-Checklist forAutism inToddlers

*Scambler Detal2001

M-CHAT- Modified Checklist forAutism inToddlers (20-48months)

• Parent report• 23items• Nosection B• Children at risk:follow-uptelephone interview• Good specificity andsensitivity

Robins etal2001

M-CHAT23

• 23items (M-CHAT)• +5items ofdirect clinical observation (Section B,CHAT)

• 4points Likert (fromNever toOften)

Wong etal2004

M-CHAT

• Pros: Low cost,wayofadministration,betterspecificity andsensitivity compared toCHAT

• Cons:highfalsenegativerate(mild ASD,highfunctioning),highfalsepositiverate

• USA:effective tool forscreeninglow-risk toddlers,reducing age ofdiagnosis by2years*

*Robins DLetal2014

• Parents questionnaire• 25items (somefromCHATandMCHAT+newitems)

• Likert Scale5points (Often,Never)• Good Sensitivity (identify mild sintomatology)• Pros:low cost,administration (time)• Cons:nofollow-updata,nostatistics information• Italy:(NIDA)

Q-CHAT-QuantitativeCheck-listforAutism inToddlers

Allison etal2008

• Level1,2• Threesections:ü Primary CareScreener,22items,Paediatrician

üDevelopmental ClinicScreener,14items ,Specialist

ü Autism ClinicSeverity Screener,12items ,Specialist• Yes(1)/No(0)• PCS:highfalsepositiverate• DCS:50%less falsepositiverate• ACSS:underestimate 40%• Italy (?)

PDDST-II-PervasiveDevelopmentalDisorder ScreeningTest-II(<18months)

• Pros:differents sections.• Cons:nomany researches (psycometricproperties should beverified)

PDDST-II-PervasiveDevelopmentalDisorder ScreeningTest-II

• Level2• Differentiate ASD/DD• Clinical Observation forSpecialist (evaluation,follow-up)

• 12items (20minutes)• 4social-communicative fields• Score0-4• Cons:professional training• Italy (?)

STAT-ScreeningTool forAutism intwo-years-old (12-36months)

Stoneetal2004

• Level1• Parents questionnaire/interview• Paediatrician• 24questions (multiplechoice)+1open(principal worries)• Score <10° centileà another caregiver questionnaire,

behaviour sample

• ASD,LanguageImpairment,Developmental Disorder• Italy (?)

ITC- Infant-Toddler Checklist (6-24months)

• Low functioning ASD• Questionnaire/Interview (yes/no)• Two sections:ü “Pre-screening”(4items):Paediatricianü Secondpart(14items):Specialist• Italy (?)• Cons: highfalsenegativerate

ESAT- Early ScreeningofAutistic Traits(14/15months)

Willemsen-Swinkels etal2006;2009

• Questionnaire 63items (multiplechoice,openquestions)• Early onset andserious ASD• Good Specificity• Italy:available forresearch,Muratorietal2009

FYI-FirstInventory(12months)

Reznick etal2007

• Level2• Parents interview +complementary clinical observation• Threesections:ü Part1(62items):differentiate ASD/DDü Part2(71items):comorbidity (ADHD,TIC,OCD)ü Part3(17items):problematic behaviour• Likert Scale3points• Pros:evaluate 3fields,low cost,easytoadministrate• Cons:highfalsepositiverate,nooutcome information• Italy (?)

BISCUIT- BabyandInfant ScreenforChildren withAutism Traits(17-37months)

Matson etal2007

• DD+ASD• Sensitivity>ESAT• Specificity<<<<• Pros: widerange ofage• Cons: Level1àhighfalsepositiveandnegativerate,noASDhighfunctioning

• Italy (?)

CESDD- Checklist forEarly Signs ofDevelopmental Disorders (3-36months)

Dereu etal2010

• Level1• 3scheduleofclinical observation (12,18,24months)• Yes/no• Paediatrician• Pros:low falsepositive,>40%identified <18months• Cons:professional training,nofollow-upinformation

SACS- SocialAttention andCommunication Study (12-24months)

BarbaroandDissanayake 2010;2013

Level1

• ITC,CESDD:specificity 90%,sensitivity 80%• M-CHAT:specificity andsensitivity >90%

• BISCUIT:specificity 95%sensitivity95%• STAT:specificity 85%sensitivity92%

Level2

AGE<18MONTHS

ASDDD+ASD

SACS(direct)FYI(indirect)ESAT(indirect:questionnaire)

L1L1

CSBS-DP(ITC,indirect:questionnaire)CESDD(direct)FYI(12Months,questionnaire)

L1,L2

AGE>18MONTHS

ASD

BISCUIT(direct+indirect)CHAT-23(direct+indirect)

M-CHAT(indirect:questionnaire)SACS(direct)

L2L1

• Screeningoutcomes areinfluenced byseveralfactors:

üage ofadministrationülevel offunctioning andautism severityüparental compliance rateüprotocol adherence

SCREENINGOUTCOMES

• Difficulties in differentiating ASD from other DD at very earlyageà high false-positive rate*

• Level of functioning and autism severity are important factorsto consider when evaluating screening methods (CHAT, M-CHAT)**

• Milder ASD and high functionning ASD could be missed atyoung age

• Performing screening through a two-stage process may helpto narrow down false-positive rate and reduce the possibleside effects of screening (false positive, false negative rate)

*Dietz etal2006,Dereu etal2010;**Scambler etal2001,Oosterling IJ2010

• Need ofroutinescreeningimplementation forASDand/orother developmental disorderà require reorganisation ofthehealth careinmany countries

• Reducethegapbetween thefirstparental concerns,thefirstconsultation andtheage at which thediagnosis is made

• GeneralPaediatrician should betrained andencouraged touseappropriatetools that canhelpindetecting possible earlysigns ofASD.

CONCLUSIONS