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
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