Differentiating Autism in a Chinese Population
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Differentiating Autism in a Chinese Population
Grace Hao, M. D., Ph.D., CCC-SLP
Thomas Layton, Ph.D., CCC-SLP
ASHANovember 17, 2012
Atlanta, Georgia
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Dr Hao is a Professor in the Department of Communication Disorders at North Carolina Central University. She has both a medical degree from China and a Ph.D. in speech-language pathology. Dr. Layton is currently the President/Co-owner of a private Center in Durham NC. He, Dr. Hao, and Dr. Zou,a developmental pediatrician in China, are standardizing a new unpublished diagnostic test in China. We do not have financial interests in the diagnostic tool, as it is currently used as part of the current research.
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DSM-IV Criteria for Diagnosis
At least 6 characteristics from the following 3 domains to qualify for diagnosis of autism
1- Social skills 2- Communication3- Behavior
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Literature ReviewLFASD versus HFASD
Bartak & Rutter (1976) found more language delay, severe personal relationships and more disruptive behavior than HFASD
HFASD versus Typically DevelopingSteinhausen & Metzke (2004) more disruptive
behaviorTsatsanis (2005) more weakness in cognitive
functionsBaranek et al. (2005) problems in motor
developmentTager-Flushberg (2004) problems in complex
languageOzonoff et al. (2004) problems in Executive
Function
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Literature ReviewOne study with Chinese children (Zhang & Ji, 2005)LFASD versus Intellectually DisabledLFASD had 25% prenatal birth problems vs
62.5% of IDLFASD only 1 child had cerebral palsy vs 31%
had “other developmental disorders”
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Purpose of the studyTo compare HFASD children to Typically Developing children (TD)
To compare Moderate/severe ASD (LFASD) children to Intellectually Disabilities (ID)
To measure individual items within seven behavior Domains
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SubjectsLFASD (n=236; mean age 46.7 m)HFASD (n = 96; mean age 53.1 m) Intellectual/Developmental Disabilities (n = 33; mean age 55.7 m)
Typically Develop. (n = 103; mean age 43.9 m)
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ASD groupsPreviously diagnosed by developmental pediatricians using the ADI-R, SRS, and/or a behavioral protocol.
All subjects spoke MandarinNon-ASD groups
Recruited from well-baby-care clinics throughout China
ID group administered WISC-Chinese, scores below 70 IQ
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Research Team: Centers Involved
Guangzhou: Third Affiliated Hospital & Guangzhou Center for Children with
ASDShenzhen Hospital for Children and Pregnant
WomanChongqing Children’s HospitalHainan Children’s HospitalHarbin Medical University Autism CenterShanghai Children’s HospitalShiJia-Zhuang Medical UniversityTianjin Medical UniversityNanjing Medical University
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CADS Domains used for comparisons
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(CADS)Chinese Autism Diagnostic Scale
First Autism Diagnostic test designed, developed, and standardized in China for Chinese population
Takes into account the cultural and language aspects
Addresses needs and frequently asked questions found in China
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CADS Seven DomainsMotor/Vocal ImitationStereotyped behaviorsSensory behaviorsPlay behaviorsSocial InteractionReceptive LanguageExpressive Language
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Motor Area (3 Domains)
Motor/Vocal Imitation Domain (11 items)
Stereotyped Behavior Domain (13 items)
Sensory Domain (10 items)
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Social Area (2 Domains)
Play Domain (10 items)
Social Interaction Domain (21 items)
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Language Area (2 Domains)
Receptive Language Domain (10 items)
Expressive Language Domain (17 items)
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Supplemental Area (2 Domains)
Academic & Educational Domain (15 items)
Executive Function Domain (30 items)
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Executive Functions Planning Organizing Time Management Flexibility/Attention Affect Working Memory
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Individual Item scoring for group comparisons Used group percentages due to unequal sample
sizes A difference of 9 percentage points or greater
between groups were required for points given A difference at Moderately Impaired level was
given 1 point A difference at Severely Impaired level was given 2
points Individual items required 2 or 3 total points to be
considered different
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Moderate Severe Total Scores
Squeals
LFASD ID
34% (1)22% (0)
21% (2)6% (0)
3 √0
Unusual interest toy
LFASD ID
30% (1)3% (0)
69% (2)0% (0)
3√0
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LFASD Results
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LFASD Results
LFASD versus Intellectually DisabledSix Domains were significantly differentThe LFASD group performed less well on all six Domains
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Individual Item contrasts
LFASD versus ID
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Play Behavior items for LFASD
No independent play skillsTends to play aloneNo interest in social playNo interest in othersShows inappropriate play with childrenHas no regular playmatesHas limited attention span
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Stereotyped Behavior items for LFASDSqueals moreUnusual interest in certain part of a toyPeculiar interests in objects Has a particular, or unusual way of ordering toys or things
Excessively rigid
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Sensory Behavior items for LFASD
Over reaction to noiseInappropriate reaction to a pinchInappropriate reaction to texturesEats restricted foodsInappropriate reaction to visual stimuli
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Social Interactive Behaviors LFASD Does not look in faces Does not smile No understanding of
gestures Does not hand a toy to adult Does not share food No empathy Does Not look at objects of
interest with others Does not point Reacts negatively to familiar
people who approach him/her
Does not help others Does not recognize social
errors Does not understand
playful remark Does not understand hints
or indirect remarks Gets upset when left at
unfamiliar places Does not seek parents or
others for support
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Receptive Language items for LFASD
Does not select objects upon commandDoes not point to nose, eyes, earsDoes not point to pictures Inappropriate response to verbal commandInappropriately nods and responds to speaker
Does not correctly respond to “wh” questions
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Expressive Language items for LFASD
Echoes or repeats wordsProsody of speech not normalDifficulty labeling or naming objectsGets words out of orderFrequently talks to him/herselfInappropriate use of pronounsInability to initiate or direct discourseMakes socially inappropriate comments
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HFASD Results
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HFASD Results
HFASD group versus Typically Developing children
Three Domains were significantly different
The HFASD group performed less well on all three Domains
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Individual Item contrasts
HFASD versus TD
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Stereotyped Behavior items for HFASDStares to sideRocks back/forthFlaps hands/fingersSqueals
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Sensory Interactive Behavior items for HFASDOver reaction to noiseEats restricted foods
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Play Behavior items for HFASDPlays alone Has inappropriate play behavior with other children
No turn taking in social playDoes not seek help from others
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Profile of Four ChildrenCADS profile 4 children
HFASD, LFASD, TD, ID
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Remember:
Higher the score--more severe the problem
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Future Analysis and ContrastsComparing three levels of ASD
Mild FunctioningModerate FunctioningSevere Functioning
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Bell Shape Curve For ASD Group
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Range Of Scores
MILD GROUP(Level I)
> 1 StD (n=66) 20% 93 - 142 rangeUpper 25th (n=67) 21% 93 - 143
MODERATE GROUP(Level II)
1StD (n=210) 64% 215 - 141 rangeMiddle 50th (n=175) 54% 209 - 142
SEVERE GROUP(Level III)
< 1StD (n=50) 15% 216 - 265 rangeLower 25th (n=84) 26% 208 - 265
*Upper number is based on Standard Deviation
*Lower number is the upper 25th percent scores, middle 50th percent scores, and lower 25th percent scores*Mild Group = high functioning; Moderate Group = middle group; Severe Group = lowest functioning
Severity Rating of the ASD
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ConclusionsLFASD group demonstrated more difficulty on six Domains compared to ID group
Domains:
1. Stereotyped Behaviors
2. Sensory
3. Play
4. Social
5. Receptive Language
6. Expressive Language
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Conclusions
HFASD group demonstrated more difficulty on three Domains compared to TD group
Domains: 1. Stereotyped Behaviors
2. Sensory
3. Play
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Conclusions
Also, findings from preliminary data supported significant differences, across 7 domains, between the HFASD and the LFASD groups, which is consistent with the DSM-V proposal for severity groupings of children with ASD.
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References
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TAGER-FLUSHBERG, H., 2004, Strategies for conducting research on language in autism. Journal of Autism and Developmental Disorders, 34, 75-80.
TSATSANIS, K., 2005, Neuropsychological characteristics in autism and related conditions., In F. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism and pervasive developmental disorders (3rd ed.), Diagnosis, development, neurobiology, and behavior. (New York: Wiley & Sons).
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