Reliability of the ADI-R: Multiple Examiners Evaluate a Single Case

Clinician-caregiver informant discrepancy is associated with sex, diagnosis age, and intervention use among autistic children

LAY ABSTRACT

In some cases, a clinician's perceptions of a child's autism-related behaviors are not the same as the child's caregiver's perceptions. Identifying how these discrepancies relate to the characteristics of the child is critical for ensuring that diagnosis procedures are unbiased and suitable for all children. This study examined whether discrepancies between clinician and caregiver reports of autism features related to the child's sex at birth. We also explored how the discrepancies related to the age at which the child received their autism diagnosis and how much intervention they received. We found that clinicians rated autism features higher than caregivers for boys and rated autism features lower than caregivers for girls. In addition, lower clinician relative to parent ratings was related to being diagnosed at an older age and receiving less intervention. These findings suggest that there is more to learn about the presentation of autism-related behaviors in girls. When caregiver and clinician ratings of autism features do not align, it may be important to consider caregivers' ratings to obtain a more accurate picture of the child's autism features and the support they may need.

Factors Associated with Confirmed and Unconfirmed Autism Spectrum Disorder Diagnosis in Children Volunteering for Research

PURPOSE

Diagnostic accuracy of autism spectrum disorder (ASD) is crucial to track and characterize ASD, as well as to guide appropriate interventions at the individual level. However, under-diagnosis, over-diagnosis, and misdiagnosis of ASD are still prevalent.

METHODS

We describe 232 children (MAge = 10.71 years; 19% female) with community-based diagnoses of ASD referred for research participation. Extensive assessment procedures were employed to confirm ASD diagnosis before study inclusion. The sample was subsequently divided into two groups with either confirmed ASD diagnoses (ASD+) or unconfirmed/inaccurate diagnoses (ASD-). Clinical characteristics differentiating the groups were further analyzed.

RESULTS

47% of children with community-based ASD diagnoses did not meet ASD criteria by expert consensus. ASD + and ASD- groups did not differ in age, gender, ethnicity, or racial make-up. The ASD + group was more likely to have a history of early language delays compared to the ASD- group; however, no group differences in current functional language use were reported by caregivers. The ASD + group scored significantly higher on ADI-R scores and on the ADOS-2 algorithm composite scores and calibrated severity scores (CSSs). The ASD- group attained higher estimated IQ scores and higher rates of psychiatric disorders, including anxiety disorder, disruptive behavior, and mood disorder diagnoses. Broadly, caregiver questionnaires (SRS-2, CCC-2) did not differentiate groups.

CONCLUSION

Increased reported psychiatric disorders in the ASD- group suggests psychiatric complexity may contribute to community misdiagnosis and possible overdiagnosis of ASD. Clinician-mediated tools (ADI-R, ADOS-2) differentiated ASD + versus ASD- groups, whereas caregiver-reported questionnaires did not.

Barriers to an Autistic Identity: How RRBs may Contribute to the Underdiagnosis of Females

Background

Autistic females are frequently underdiagnosed, misdiagnosed, and/or diagnosed later in life. Restricted and Repetitive Behaviors (RRBs) are increasingly critical for diagnosis and yet are commonly rated lower in females. Whether this reflects genuinely lower levels of these traits, or if female-typical RRBs have a different phenotypic presentation that may not register on current quantitative measurement tools is unclear.

Methods

Twenty-one autistic females and 21 autistic males matched on chronological age and FSIQ completed the AQ, ADOS-2, and ADI-R. Items from the ADOS-2 and ADI-R were selected that were relevant to the four areas of restricted and repetitive behavior in the DSM-5 diagnostic criteria of autism. Using a mixed-methods analytical approach, scores and comments on these measures were compared between sexes to better characterize RRBs in autistic females.

Results

There were no sex differences on the AQ, which broadly assesses autistic traits. When analyzed by the four DSM-5 RRB criteria, there were no sex differences on the ADI-R when using traditional algorithm scoring that narrows questions down to those that are more sensitive and specific in capturing autism in research samples with a high proportion of males. When incorporating additional items relevant to the DSM-5 to identify sex changes in a broader pool of items, females scored higher on stereotyped movements and speech. Females also engaged in more sensory behaviors during the ADOS-2. Qualitative analyses indicated that females were more likely to engage in stereotyped body rocking and spinning, stereotyped behaviors when anxious, to show major reactions to changes, repetitive language including listing and counting, and sensory behaviors, especially in the tactile domain.

Conclusion

Exploratory findings highlight sex differences in RRBs that may help enhance diagnostic clarity for females. Higher tactile sensory behaviors in females suggests there may be increased diagnostic sensitivity for females with the updated DSM-5 that now includes sensory components as part of the diagnostic criteria.

Evaluation of an artificial intelligence-based medical device for diagnosis of autism spectrum disorder

Autism spectrum disorder (ASD) can be reliably diagnosed at 18 months, yet significant diagnostic delays persist in the United States. This double-blinded, multi-site, prospective, active comparator cohort study tested the accuracy of an artificial intelligence-based Software as a Medical Device designed to aid primary care healthcare providers (HCPs) in diagnosing ASD. The Device combines behavioral features from three distinct inputs (a caregiver questionnaire, analysis of two short home videos, and an HCP questionnaire) in a gradient boosted decision tree machine learning algorithm to produce either an ASD positive, ASD negative, or indeterminate output. This study compared Device outputs to diagnostic agreement by two or more independent specialists in a cohort of 18-72-month-olds with developmental delay concerns (425 study completers, 36% female, 29% ASD prevalence). Device output PPV for all study completers was 80.8% (95% confidence intervals (CI), 70.3%-88.8%) and NPV was 98.3% (90.6%-100%). For the 31.8% of participants who received a determinate output (ASD positive or negative) Device sensitivity was 98.4% (91.6%-100%) and specificity was 78.9% (67.6%-87.7%). The Device's indeterminate output acts as a risk control measure when inputs are insufficiently granular to make a determinate recommendation with confidence. If this risk control measure were removed, the sensitivity for all study completers would fall to 51.6% (63/122) (95% CI 42.4%, 60.8%), and specificity would fall to 18.5% (56/303) (95% CI 14.3%, 23.3%). Among participants for whom the Device abstained from providing a result, specialists identified that 91% had one or more complex neurodevelopmental disorders. No significant differences in Device performance were found across participants' sex, race/ethnicity, income, or education level. For nearly a third of this primary care sample, the Device enabled timely diagnostic evaluation with a high degree of accuracy. The Device shows promise to significantly increase the number of children able to be diagnosed with ASD in a primary care setting, potentially facilitating earlier intervention and more efficient use of specialist resources.

More than the sum of its parts: Merging network psychometrics and network neuroscience with application in autism

Network approaches that investigate the interaction between symptoms and behaviours have opened new ways of understanding psychological phenomena in health and disorder in recent years. In parallel, network approaches that characterise the interaction between brain regions have become the dominant approach in neuroimaging research. In this paper, we introduce a methodology for combining network psychometrics and network neuroscience. This approach utilises the information from the psychometric network to obtain neural correlates that are associated with each node in the psychometric network (network-based regression). Moreover, we combine the behavioural variables and their neural correlates in a joint network to characterise their interactions. We illustrate the approach by highlighting the interaction between the triad of autistic traits and their resting-state functional connectivity associations. To this end, we utilise data from 172 male autistic participants (10–21 years) from the autism brain data exchange (ABIDE, ABIDE-II) that completed resting-state fMRI and were assessed using the autism diagnostic interview (ADI-R). Our results indicate that the network-based regression approach can uncover both unique and shared neural correlates of behavioural measures. For instance, our example analysis indicates that the overlap between communication and social difficulties is not reflected in the overlap between their functional brain correlates.

The article introduces a method to combine common practices in network psychometrics and network neuroimaging. Namely, we use the unique variance in behavioural measures as regressors to identify unique neural correlates. This enables the description of brain-level and behavioural-level data into a joint network while keeping the dimensionality of the results manageable and interpretable. We illustrate this approach by showing the network of autistic traits and their correlates in resting-state functional connectivity.

A Clinical Program for Transgender and Gender-Diverse Neurodiverse/Autistic Adolescents Developed through Community-Based Participatory Design

Objective: A series of studies report elevated rates of autism and autistic characteristics among gender-diverse youth seeking gender services. Although youth with the co-occurrence present with complex care needs, existing studies have focused on co-occurrence rates. Further, clinical commentaries have emphasized provider-centered interpretations of clinical needs rather than key stakeholder-driven clinical approaches. This study aimed to employ community-based participatory research methodologies to develop a key stakeholder-driven clinical group program.Method: Autistic/neurodiverse gender-diverse (A/ND-GD) youth (N = 31), parents of A/ND-GD youth (N = 46), A/ND-GD self-advocates (N = 10), and expert clinical providers (N = 10) participated in a multi-stage community-based participatory procedure. Needs assessment data were collected repeatedly over time from A/ND-GD youth and their parents as the youth interacted with one another through ongoing clinical groups, the curriculum of which was developed progressively through the iterative needs assessments.Results: Separate adolescent and parent needs assessments revealed key priorities for youth (e.g., the importance of connecting with other A/ND-GD youth and the benefit of experiencing a range of gender-diverse role models to make gender exploration and/or gender affirmation more concrete) and parents (e.g., the need for A/ND-related supports for their children as well as provision of an A/ND-friendly environment that fosters exploration of a range of gender expressions/options). Integration and translation of youth and parent priorities resulted in 11 novel clinical techniques for this population.Conclusions: With generally high acceptability ratings for each component of the group program, this study presents a community-driven clinical model to support broad care needs and preferences of A/ND-GD adolescents.

Identifying children with autism spectrum disorders in Iran using the Autism Diagnostic Interview-Revised

LAY ABSTRACT

The diagnosis of autism spectrum disorder is a challenging task. Most of the current assessment scales have been developed in the West. The present study examines the applicability of one of the most used scales (the Autism Diagnostic Interview-Revised) in a Middle-Eastern culture. Two studies were undertaken. In the first, the Autism Diagnostic Interview-Revised ratings given to 420 children with autism spectrum disorder, aged 4-11 years, and 110 typically developing children were contrasted. In Study 2, the Autism Diagnostic Interview-Revised ratings of 720 children with autism spectrum disorder were compared with those of 172 children with intellectual disabilities to find out whether the Autism Diagnostic Interview-Revised scale would discriminate between these two types of developmental disabilities. The studies confirmed the acceptability of the scale to Iranian parents and assessors. However, the summary scores used to determine whether a child was likely to have autism spectrum disorder were recalculated on the two domains of social communication and repetitive behaviours, which were identified in the statistical analyses that are recommended for the evaluation of assessment scales. Thus the translated scale with the modified domain scoring proved very suitable for identifying Iranian children with autism spectrum disorder. Having a common tool such as Autism Diagnostic Interview-Revised will strengthen the opportunities to undertake cross-cultural research into the impact of autism spectrum disorder on the child and families.

A Pilot Investigation of the Social Attention and Communication Surveillance (SACS) Tool for the Early Identification of Autism in Tianjin, China (SACS-C)

Introduction: Autism spectrum disorder (ASD) comprises difficulties in social communication and restrictive and repetitive behaviors. Despite an increased global prevalence, little remains known about early detection and diagnosis of autism in Mainland China. Our aim was to conduct a pilot investigation of the implementation of an Australian tool, Social Attention and Communication Surveillance (SACS), in Tianjin, China (SACS-C) by trained professionals to identify autism early compared to the Checklist for Autism in Toddlers-23 (CHAT-23) completed by parents and professionals. Materials and Methods: A total of 10,514 children were monitored across 61 Community Health Service Centres in six Tianjin districts on the SACS-C at 12, 18, and 24 months of age following a half-day training of 225 child health practitioners. Children deemed at "high likelihood" for autism on either the SACS, CHAT-23, or both, were referred for developmental assessments at the Tianjin Women and Children's Health Centre (TWCHC). Results: A total of 87 children (0.8%) were identified at "high likelihood" on the SACS-C, of whom 57 (66%) were assessed for autism; 24 children were subsequently diagnosed with autism (42.1%), and the remaining 33 (57.9%) were diagnosed with developmental and/or language delays. The SACS-C had a positive predictive value (PPV) of 42.1%, a negative predictive value (NPV) of 99.8%, and sensitivity and specificity of 53.3 and 99.7%, respectively. Only 21 children were identified at "high risk" for autism on the CHAT-23 (0.2%), over four times fewer children than the SACS-C, with 14 children assessed for autism (66%); nine were diagnosed with autism (64.3%) and the remaining five children were diagnosed with developmental and/or language delays. The CHAT-23 had an overall PPV of 64.3%, NPV of 99.6%, sensitivity of 27.3%, and specificity of 99.9%. Conclusion: This was the first large-scale study identifying autism in 12-24-month-old children in China. We ascertained the feasibility of training community health practitioners to monitor infants and toddlers for the early signs of autism, and determined the effectiveness of their use of SACS-C which had a better balance between accuracy and sensitivity in detecting autism in contrast to the CHAT-23 which missed the majority of children with autism (72.7%) vs. the SACS-C (46.7%). Given the emphasis on identifying as many children with autism as possible in Mainland China, SACS-C was identified as the tool of choice by the TWCHC. However, more work is needed to improve the psychometric properties in using the SACS-C in Mainland China so that it is comparable to its use in Australia.

Cross-Cultural Validation of the Polish Version of the ADI-R, Including New Algorithms for Toddlers and Young Preschoolers

Autism Diagnostic Interview-Revised (ADI-R) is one of the most widely used standardized diagnostic instruments for autism spectrum disorder (ASD). This article presents findings from the validation of the Polish version of the Autism Diagnostic Interview-Revised (ADI-R-PL), including new algorithms for toddlers and preschoolers. The validation group consisted of 125 participants: 65 with Autism Spectrum Disorder (ASD group) and 60 in the control group, including individuals with non-ASD disorders and typical development. The normalization group consisted of 178 participants, including 118 with ASD. The ADI-R-PL was found to have good psychometric properties. Confirmatory factor analysis supported both a bifactor structure and three-factor model. The study has generated preliminary information about the psychometric properties of the new algorithms for toddlers and young preschoolers. To the best of our knowledge, this paper is the first to propose new cutoffs in three ADI-R domains for a non-English-speaking population.

An intervention targeting social, communication and daily activity skills in children and adolescents with Down syndrome and autism: a pilot study

PURPOSE

To evaluate whether an intervention, targeting deficits in social communication, interaction and restricted activities in children and adolescents with Down syndrome and autism could lead to enhanced participation in family and school activities.

METHODS

The intervention included education for parents and school staff about autism, and workshops to identify social-communication and daily living activities that would be meaningful for the child to practice at home and at school. Thereafter, a three-month period of training for the child followed. Outcome measures comprised evaluation of goal achievement for each child, the "Family Strain Index" questionnaire and a visual scale pertaining to the parents' general opinion about the intervention.

RESULTS

On average, more than 90% of the goals were (to some extent or completely) achieved at home and at school. The mean scores of the "Family Strain Index" were almost identical at the follow-up to those before intervention. The evaluation supported that the use of strategies, intended to facilitate activities and communication, remained largely 18 months after start of the intervention.

CONCLUSION

Despite the group involved in this study being composed of older children and adolescents, most of whom had severe and profound intellectual disability, the goal achievements and parents' views on the intervention were encouraging.

Prevalence of autism and attention-deficit-hyperactivity disorder in Down syndrome: a population-based study

AIM

To investigate the prevalence of autism spectrum disorder (ASD) and attention-deficit-hyperactivity disorder (ADHD) in a population-based group of children and adolescents with Down syndrome, and to relate the findings to level of intellectual disability and to medical conditions.

METHOD

From a population-based cohort of 60 children and adolescents with Down syndrome, 41 individuals (29 males, 12 females; mean age 11y, age range 5-17y) for whom parents gave consent for participation were clinically assessed with regard to ASD and ADHD. The main instruments used were the Autism Diagnostic Interview-Revised, Autism Diagnostic Observation Schedule, Swanson, Nolan, and Pelham-IV Rating Scale, and the Adaptive Behavior Assessment System-II.

RESULTS

High rates of ASD and ADHD were found: 17 (42%) and 14 (34%) of the 41 children met DSM criteria for ASD and ADHD respectively.

INTERPRETATION

Children with Down syndrome and coexisting neurodevelopmental/neuropsychiatric disorders in addition to intellectual disability and medical disorders constitute a severely disabled group. Based on the results, we suggest that screening is implemented for both ASD and ADHD, at the age of 3 to 5 years and early school years respectively, to make adequate interventions possible.

Stop and change: inhibition and flexibility skills are related to repetitive behavior in children and young adults with autism spectrum disorders

Cognitive control dysfunctions, like inhibitory and attentional flexibility deficits are assumed to underlie repetitive behavior in individuals with autism spectrum disorders (ASD). In the present study, prepotent response inhibition and attentional flexibility were examined in 64 high-functioning individuals with ASD and 53 control participants. Performance under different task conditions were tested both in response to visual and auditory information, and requiring a motor or verbal response. Individuals with ASD showed significant more control dysfunctions than typically developing participants on the auditory computer task. Inhibitory control and attentional flexibility predicted RRB in everyday life. Specifically, response inhibition in reaction to visual information and task switching in reaction to auditory information predicted motor and sensory stereotyped behavior.

Multirater reliability of the historical, clinical, and risk management-20

The assessment and management of risk for future violence is a core requirement of mental health professionals in many settings. Despite an increasing need for violence risk assessments across diverse contexts, little is known regarding the ecological validity of many widely used risk assessment schemes or the level of reliability with which actual practicing clinicians score these instruments. The current study investigated the interrater reliability of the Historical, Clinical, and Risk Management-20 (HCR-20), a widely used structured professional tool to assess violence risk, among 21 practicing clinicians in a forensic psychiatric program in Ontario, Canada. Results suggest that clinicians with varying professional training backgrounds and experience were able to rate the HCR-20 with good to excellent levels of reliability across three patients who varied in risk level. Consistent with studies investigating rater reliability for research purposes, we found that the risk management scale of the HCR-20 was the most challenging for clinicians to rate reliably. Importantly, results from generalizability theory analyses revealed that less than 3% of the variance in HCR-20 total scores and summary risk ratings is attributable to rater effects, whereas the majority of variance is attributable to differences among patients.

Satisfactory reliability among nursing students using the instrument PVC ASSESS to evaluate management of peripheral venous catheters

PURPOSE

Nursing students should be given opportunities to participate in clinical audits during their education. However, audit tools are seldom tested for reliability among nursing students. The aim of this study was to present reliability among nursing students using the instrument PVC assess to assess management of peripheral venous catheters (PVCs) and PVC-related signs of thrombophlebitis.

METHODS

PVC assess was used to assess 67 inserted PVCs in 60 patients at ten wards at a university hospital. One group of nursing students (n=4) assessed PVCs at the bedside (inter-rater reliability) and photographs of these PVCs were taken. Another group of students (n=3) assessed the PVCs in the photographs after 4 weeks (test-retest reliability). To determine reliability, proportion of agreement [P(A)] and Cohen's kappa coefficient (κ) were calculated.

RESULTS

For bedside assessment of PVCs, P(A) ranged from good to excellent (0.80-1.0) in 55% of the 26 PVC assess items that were tested. P(A) was poor (<0.70) for two items: "adherence of inner dressing to the skin" and "PVC location." In 81% of the items, κ was between moderate and almost perfect: moderate (n=5), substantial (n=3), almost perfect (n=5). For edema at insertion site and two items on PVC dressing, κ was fair (0.21-0.40). Regarding test-retest reliability, P(A) varied between good and excellent (0.81-1) in 85%-95% of the items, and the κ ranged between moderate and almost perfect (0.41-1) in 90%-95%.

CONCLUSIONS

PVC assess demonstrated satisfactory reliability among nursing students. However, students need training in how to use the instrument before assessing PVCs.

Reliability and validity of autism diagnostic interview-revised, Japanese version

To examine the inter-rater reliability of Autism Diagnostic Interview-Revised, Japanese Version (ADI-R-JV), the authors recruited 51 individuals aged 3-19 years, interviewed by two independent raters. Subsequently, to assess the discriminant and diagnostic validity of ADI-R-JV, the authors investigated 317 individuals aged 2-19 years, who were divided into three diagnostic groups as follows: autistic disorder (AD), pervasive developmental disorder not otherwise specified, and other psychiatric diagnosis or no diagnosis, according to the consensus clinical diagnosis. As regards inter-rater reliability, intraclass correlation coefficients of greater than 0.80 were obtained for all three domains of ADI-R-JV. As regards discriminant validity, the mean scores of the three domains was significantly higher in individuals with AD than in those of other diagnostic groups. As regards diagnostic validity, sensitivity and specificity for correctly diagnosing AD were 0.92 and 0.89, respectively, but sensitivity was 0.55 for individuals younger than 5 years. Specificity was consistently high regardless of age and intelligence. ADI-R-JV was shown to be a reliable tool, and has sufficient discriminant validity and satisfactory diagnostic validity for correctly diagnosing AD, although the diagnostic validity appeared to be compromised with respect to the diagnosis of younger individuals.

Diagnostic procedures in autism spectrum disorders: a systematic literature review

At present, 'gold standard' diagnosis of autism spectrum disorders (ASD) is a lengthy and time consuming process that requires suitably qualified multi-disciplinary team (MDT) personnel to assess behavioural, historical, and parent-report information to determine a diagnosis. A number of different tools have been developed to assist in determination. To optimise the diagnostic procedures, the best diagnostic instruments need to be identified. This study is a systematic review addressing the accuracy, reliability, validity and utility of reported diagnostic tools and assessments. To be included in this review, studies must have (1) identified an ASD diagnostic tool; (2) investigated either diagnostic procedure or the tools or personnel required; (3) be presented in English; (4) be conducted in the Western world; (5) be one of three types of studies [adapted from Samtani et al. in Cochrane Database Syst Rev 3:1-13, 2011], viz. (a) cohort studies or cross-sectional studies, (b) randomised studies of test accuracy, (c) case-control studies. MEDLINE, PsychINFO, Scopus, EMBASE, and Cochrane Library databases were scrutinised for relevant literature published from 2000 inclusive on 20th January 2012. In total, 68 articles were included. 17 tools were assessed. However, many lacked an evidence base of high quality-independent studies. The Autism Diagnostic Interview-Revised (ADI-R) and Autism Diagnostic Observation Schedule (ADOS) stood out with the largest evidence base and highest sensitivity and specificity. When the ADI-R and ADOS were used in combination they revealed levels of accuracy very similar to the correct classification rates for the current 'gold standard' diagnostic procedure viz. 80.8% for ASD. There is scope for future studies on the use of the ADI-R and ADOS in combination.

Measurement Issues: Screening and diagnostic instruments for autism spectrum disorders - lessons from research and practise

BACKGROUND AND SCOPE

Significant progress has been made over the past two decades in the development of screening and diagnostic instruments for autism spectrum disorders (ASDs). This article reviews this progress, including recent innovations, focussing on those instruments for which the strongest research data on validity exists, and then addresses issues arising from their use in clinical settings.

FINDINGS

Research studies have evaluated the ability of screens to prospectively identify cases of ASD in population-based and clinically referred samples, as well as the accuracy of diagnostic instruments to map onto 'gold standard' clinical best estimate diagnosis. However, extension of the findings to clinical services must be done with caution, with a full understanding that instrument properties are sample-specific. Furthermore, we are limited by the lack of a true test for ASD which remains a behaviourally defined disorder. In addition, screening and diagnostic instruments help clinicians least in the cases where they are most in want of direction, as their accuracy will always be lower for marginal cases.

CONCLUSION

Instruments help clinicians to collect detailed, structured information and increase accuracy and reliability of referral for in-depth assessment and recommendations for support, but further research is needed to refine their effective use in clinical settings.

Brief report: approaches to 31P-MRS in awake, non-sedated children with and without autism spectrum disorder

We piloted a suite of approaches aimed to facilitate a successful series of up to four brain and muscle (31)Phosphorus-Magnetic Resonance Spectroscopy ((31)P-MRS) scans performed in one session in 12 awake, non-sedated subjects (ages 6-18), 6 with autism spectrum disorders (ASD) and 6 controls. We targeted advanced preparation, parental input, physical comfort, short scan protocols, allocation of extra time, and subject emotional support. 100% of subjects completed at least one brain scan and one leg muscle scan: 42 of 46 attempted scans were completed (91%), with failures dominated by exercise muscle scans (completed in 6/6 controls but 3/6 cases). One completed scan lacked usable data unrelated to subject/scan procedure (orthodonture affected a frontal brain scan). As a group, these methods provide a foundation for conduct and enhancement of future MR studies in pediatric subjects with ASD.

Development, cognition, and behaviour in Pitt-Hopkins syndrome

AIM

The aim of the study was to collect detailed data on behavioural, adaptive, and psychological functioning in 10 individuals with Pitt-Hopkins syndrome (PTHS), with specific attention to manifestations of autism spectrum disorder (ASD).

METHOD

The participants (four females, six males), residing in the Netherlands and Belgium, were ascertained through the Dutch national PTHS support group. Median age of participants was 10 years, the age range was between 32 and 289 months. They underwent psychiatric examinations and neuropsychological measurements using a comprehensive assessment battery. Additionally, parental information was gathered through standardized interviews and questionnaires. Findings were compared with those from the literature.

RESULTS

All participants showed profound intellectual disability, amiable demeanour with minimal maladaptive behaviours, severe impairments of communication and language, and intense, frequent motor stereotypies. Impairments in all participants were beyond what would be expected for cognitive abilities, fitting a classification of ASD.

INTERPRETATION

Patients with PTHS are characterized not only by specific physical and genetic manifestations but also by specific behavioural and cognitive characteristics. Studying behaviour and cognition may improve diagnosis and prognosis, allows recognition of comorbidities, and contributes to adequate counselling of families.

Use of artificial intelligence to shorten the behavioral diagnosis of autism

The Autism Diagnostic Interview-Revised (ADI-R) is one of the most commonly used instruments for assisting in the behavioral diagnosis of autism. The exam consists of 93 questions that must be answered by a care provider within a focused session that often spans 2.5 hours. We used machine learning techniques to study the complete sets of answers to the ADI-R available at the Autism Genetic Research Exchange (AGRE) for 891 individuals diagnosed with autism and 75 individuals who did not meet the criteria for an autism diagnosis. Our analysis showed that 7 of the 93 items contained in the ADI-R were sufficient to classify autism with 99.9% statistical accuracy. We further tested the accuracy of this 7-question classifier against complete sets of answers from two independent sources, a collection of 1654 individuals with autism from the Simons Foundation and a collection of 322 individuals with autism from the Boston Autism Consortium. In both cases, our classifier performed with nearly 100% statistical accuracy, properly categorizing all but one of the individuals from these two resources who previously had been diagnosed with autism through the standard ADI-R. Our ability to measure specificity was limited by the small numbers of non-spectrum cases in the research data used, however, both real and simulated data demonstrated a range in specificity from 99% to 93.8%. With incidence rates rising, the capacity to diagnose autism quickly and effectively requires careful design of behavioral assessment methods. Ours is an initial attempt to retrospectively analyze large data repositories to derive an accurate, but significantly abbreviated approach that may be used for rapid detection and clinical prioritization of individuals likely to have an autism spectrum disorder. Such a tool could assist in streamlining the clinical diagnostic process overall, leading to faster screening and earlier treatment of individuals with autism.

Development and behaviour in Marshall-Smith syndrome: an exploratory study of cognition, phenotype and autism

BACKGROUND

Marshall-Smith syndrome (MSS) is an infrequently described entity characterised by failure to thrive, developmental delay, abnormal bone maturation and a characteristic face. In studying the physical features of a group of patients, we noticed unusual behavioural traits. This urged us to study cognition, behavioural phenotype and autism in six patients.

METHODS

Information on development, behavioural characteristics, autism symptoms, and adaptive and psychological functioning of six MSS children was collected through in-person examinations, questionnaires, semi-structured interviews of parents and neuropsychological assessments.

RESULTS

Participants showed moderate to severe delays in mental age, motor development and adaptive functioning, with several similarities in communication, social interactions and behaviour. There was severe delay of speech and motor milestones, a friendly or happy demeanour and enjoyment of social interactions with familiar others. They exhibited minimal maladaptive behaviours. Deficits in communication and social interactions, lack of reciprocal social communication skills, limited imaginary play and the occurrence of stereotyped, repetitive behaviours were noted during assessments.

CONCLUSIONS

Systematic collection of developmental and behavioural data in very rare entities such as MSS allows recognition of specific patterns in these qualities. Clinical recognition of physical,developmental and behavioural features is important not only for diagnosis, prognosis and counselling of families, but also increases our understanding of the biological basis of the human physical and behavioural phenotype.

A national study of the prevalence of autism among five-year-old children in Iran

In Iran, more than 1.3 million five-year olds have been screened for autism over three academic years, with the Social Communication Questionnaire (SCQ). The Autism Diagnostic Interview-Revised (ADI-R) is used to confirm a diagnosis of typical autism. The resulting prevalence of 6.26 per 10,000 for typical autism is in line with rates for certain countries but is lower than those reported recently for some Western nations. This may be due to the younger age range assessed but the suitability of the tools and aspects of Iranian culture could be other reasons for the lower prevalence. International comparisons of prevalence rates is fraught with difficulties, but it is a valuable endeavour as it can identify issues around cultural and societal perceptions of children's development.

From Bayes through marginal utility to effect sizes: a guide to understanding the clinical and statistical significance of the results of autism research findings

The objectives of this report are: (a) to trace the theoretical roots of the concept clinical significance that derives from Bayesian thinking, Marginal Utility/Diminishing Returns in Economics, and the "just noticeable difference", in Psychophysics. These concepts then translated into: Effect Size (ES), strength of agreement, clinical significance, and related concepts, and made possible the development of Power Analysis; (b) to differentiate clinical significance from statistical significance; and (c) to demonstrate the utility of measures of ES and related concepts for enhancing the meaning of Autism research findings. These objectives are accomplished by applying criteria for estimating clinical significance, and related concepts, to a number of areas of autism research.

Brief report: validity of Finnish registry-based diagnoses of autism with the ADI-R

AIMS

The aim of the study was to explore the validity of registry-based diagnoses of autism in Finland using the Autism Diagnostic Interview - Revised (ADI-R). This study was designed for the Finnish Prenatal Study of Autism and Autism Spectrum Disorders (FIPS-A), an ongoing research project where registry-based diagnoses will be used for epidemiological studies.

METHODS

In this small pilot study, a clinical sample of 95 subjects diagnosed with childhood autism or pervasive developmental disorder/pervasive developmental disorder - not otherwise specified (PDD/PDD-NOS) or Asperger's syndrome according to the Finnish Hospital Discharge Register (FHDR) was gathered nationwide. A small control group consisting of siblings without any registered diagnoses of those being examined was also included in the study. Diagnoses were further re-evaluated by interviewing parents with the ADI-R.

RESULTS

The mean scores of autistic subjects clearly exceeded cut-off limits for autism on all three ADI-R domains and 96% of the subjects with registered diagnosis of childhood autism fulfilled the criteria based on the instrument as well.

CONCLUSION

These results suggest that the validity of Finnish registry-based diagnoses of childhood autism can be considered good. Our findings lay important groundwork for further population- based studies of the aetiology of autism.