Clinical Validity of the ADI-R in a US-Based Latino Population

The Intersection of Systemic, Child, and Evaluation Factors in the Prediction of Autism Special Education Eligibility; Examining the Role of Race and Ethnicity

Though there is evidence autism identification has been inequitable for populations who are culturally and linguistically minoritized, there is limited research that explains the issue of disproportionality and factors contributing to its occurrence, especially within an educational setting. To explore contributors to racial/ethnic disparities in autism special education eligibility, the current investigation evaluated child and evaluation characteristics as they relate to the absence of autism eligibility. Data were obtained from the Autism and Developmental Disabilities Monitoring (ADDM) Network Study and included children with behavioral characteristics consistent with autism and educational evaluation records. Despite documented characteristics consistent with autism, only 72% of the sample received educational services under autism eligibility. To characterize children without autism eligibility, hierarchical logistic regression was used to evaluate factors documented in evaluation records predicting the absence of autism eligibility. Factors influencing autism eligibility included behavioral characteristics documented, evaluation components completed, intellectual ability, and clinical diagnoses present. There was no unique contribution of race/ethnicity in predicting the absence of autism eligibility when accounting for these previous predictors, but many of these predictors differed by racial/ethnic group. Disproportionality in autism may be the manifestation of inequitable evaluation experiences, including experiencing less comprehensive evaluations, and not receiving an autism specific assessment. Though race/ethnicity did not uniquely contribute to the absence of autism eligibility above and beyond those combined factors, it is important to evaluate and reduce inequities experienced within the autism identification process for populations who are culturally and linguistically minoritized.

Moving Through the Pipeline: Ethnic and Linguistic Disparities in Special Education from Birth Through Age Five

This study examined Oregon's early intervention (EI) and early childhood special education (ECSE) pipelines as a function of children's intersecting ethnicity and home language(s) with a focus on children from Latino/a backgrounds with communication disorders. We found differences in children's referral source and age of referral, likelihood of evaluation and placement, and type of placement for conditions related to communication, including autism spectrum disorder and hearing impairment. Results showed differences in EI and ECSE; however, disproportionality appeared greatest among Spanish-speaking Latino/a children and non-Latino/a children who spoke languages other than English compared to non-Latino/a English-speaking counterparts. Our findings suggest attending to children's intersecting ethnicity and language backgrounds in referral, evaluation, and placement add nuance to examinations of disproportionality. Results also indicate that practices related to characterizing children's communication disorders likely make substantial contributions to inequities in EI and ECSE. Precise identification of differences in service provision can lead to targeted policy and practice solutions to reduce structural barriers to care in EI/ECSE systems and improve equity, particularly as related to placement for children of color with communication concerns.

Autism Spectrum Disorder Diagnostic Criteria Changes and Impacts on the Diagnostic Scales-Utility of the 2nd and 3rd Versions of the Gilliam Autism Rating Scale (GARS)

There is joint agreement among professionals internationally on the importance of diagnosing autism spectrum disorders (ASD) in the early stages of the emergence of symptoms. Criteria changes for the diagnosis of ASD need updated versions of the scale to make the diagnosis feasible. This study aimed to evaluate the level of overlap between two different versions of the Gilliam Autism Rating Scale (GARS-2 and GARS-3), which have been updated based on changes in DSM-IV and DSM-5 on a Kurdish sample of individuals at risk of having ASD and Intellectual Disability, referred to the Bahoz center in the Kurdistan Region of Iraq. A group of 148 cases with ASD and developmental disabilities (DD) was evaluated using the 2nd and 3rd versions of the GARS scale to understand the level of cases that confirm an ASD diagnosis in both scales. Ninety-six individuals (65%) scored about the cut-off score for being diagnosed with ASD based on the GARS-2, and 137 individuals (93%) scored above the cut-off score based on the GARS-3. Moreover, keeping updated and meeting the changing demand of standardization and cultural suitability of the updating scales is a challenge. This challenge is due to the shortage of infrastructure sources and lack of established professionals in low- and middle-income countries (LMICs). Findings indicated that GARS-3, updated based on the DSM-5, tends to diagnose children with accompanying diagnoses and different levels of symptoms severity of ASD at different age levels. Further studies are needed to help professionals and policymakers in low- and middle-income countries understand the updated versions of the available scales and depend on the older version, which must be considered cautiously.

Adapting parent-focused interventions for diverse caregivers of children with intellectual and developmental disabilities: Lessons learned during global crises

Parent-focused interventions have been designed to provide training and support to caregivers who are essential in achieving positive outcomes for children with intellectual and developmental disabilities (IDD). In 2020, significant crises, including the COVID-19 pandemic and continued racial tensions, profoundly impacted the livelihood of children with IDD and their families. Many ongoing efforts to address disparities among this population were halted temporarily and required further adaptations. Researchers adapted interventions and support to address the disparities impacting children with IDD and their families with limited guidance. We provide a descriptive case analysis of four parent-focused interventions that responded to the global crises to continue serving children with IDD and their families. The four distinct programs were based on applied behavior analysis and naturalistic, developmental-behavioral paradigms that were culturally adapted for families of young children with IDD from diverse cultural and socioeconomic backgrounds. We present the qualitative reports on the challenges and benefits that arose with adapting the four parent-focused interventions for telehealth implementation. We focused specifically on adaptations made in recruitment and retention, instrumentation and measurement, research staff training, and intervention delivery. We synthesize our experience with challenges and solutions in adapting parent-focused interventions for racially/ethnically and socioeconomically diverse children with IDD and their families. We conclude with recommendations for researchers and practitioners on methods for adapting parent-focused interventions to address the significant health disparities that impact racially, ethnically, and socioeconomically diverse children with IDD and their families.

Race/ethnic inequities in conjoint monitoring and screening for U.S. children 3 and under

BACKGROUND

Non-White children with developmental disabilities are frequently identified later than White children and therefore miss out on opportunities for early intervention (EI). Recent research indicates that conjoint monitoring and screening is more strongly associated with EI receipt than monitoring or screening alone.

OBJECTIVE

To determine if there are racial/ethnic inequities in the conjoint receipt of monitoring and screening.

METHOD

A series of survey weighted and stratified logistic regression analyses were conducted on National Surveys of Children's Health (2016-2018) data with conjoint monitoring and screening, screening alone, monitoring alone, and non-receipt as outcomes for children aged 9-23 months of age. The primary predictor was child race/ethnicity (Black, Hispanic, Other, and White). Additional co-variates included child (e.g., Age), caretaker/family (e.g., poverty level), healthcare (e.g., usual source of healthcare), state EI policies, and city metropolitan status.

RESULTS

Bivariate analyses indicated significant variation in conjoint monitoring and screening across racial/ethnic groups and covariates. Bivariate analyses showed that Black and Hispanic children had significantly lower odds of conjoint monitoring and screening receipt than White children. Multivariate analyses showed that this relationship was better accounted by co-variates. The health service variable, usual source of healthcare, had the strongest relationship with receipt of conjoint monitoring and screening.

CONCLUSIONS

Black and Hispanic children are less likely to receive conjoint monitoring and screening than White children. Analyses investigating the role of usual source of healthcare seem particularly promising for understanding the sources of inequities in monitoring and screening receipt.

Validation of the Chinese Version of the Autism Diagnostic Interview-Revised in Autism Spectrum Disorder

BACKGROUND

The Autism Diagnostic Interview-Revised (ADI-R) is an essential semi-structured diagnostic tool for autism spectrum disorder (ASD). This study aims to validate the Chinese version of the ADI-R in Taiwan.

METHODS

The Chinese version of the ADI-R was translated and back-translated by professional translators and was approved by the original authors. A group of child psychiatrists and psychologists corrected medical terminology for the final version. Then, a total of 74 participants with ASD (male, 59, 79.73%) and 33 control participants without ASD (male, 16, 48.48%) were recruited. All participants were between 3 years 4 months to 41 years old (mean: 14.63 ± 7.93 years). Exploratory factor analysis (EFA) was used to measure the factor structure.

RESULTS

Cronbach's α showed good to excellent internal consistency (0.78-0.98) over the three core symptom domains of the Chinese version of the ADI-R. Pearson's correlation analysis revealed very high test-retest reliability (Pearson's correlation coefficients ranging from 0.95 to 0.99). EFA supported three categories of factors. For correct diagnosis of ASD, the Chinese version of the ADI-R had high sensitivity (97.30%), specificity (100%), positive predictive value (PPV) (100%), and negative predictive value (NPV) (94.29%). All domains also showed excellent area under the curves (0.991-1), sensitivity (94.59-98.65%), specificity (96.97-100%), Youden index (94.59-98.65%), PPV (97.78-100%), NPV (89.19-100%), positive likelihood ratio (32.55-33.00%) and negative likelihood ratio (0.00-0.05) after statistical examination.

CONCLUSION

The Chinese version of the ADI-R is a reliable and valid diagnostic tool for the diagnosis of ASD in Clinical settings in Taiwan.

The Diagnosis of Autism: From Kanner to DSM-III to DSM-5 and Beyond

In this paper we review the impact of DSM-III and its successors on the field of autism-both in terms of clinical work and research. We summarize the events leading up to the inclusion of autism as a "new" official diagnostic category in DSM-III, the subsequent revisions of the DSM, and the impact of the official recognition of autism on research. We discuss the uses of categorical vs. dimensional approaches and the continuing tensions around broad vs. narrow views of autism. We also note some areas of current controversy and directions for the future.

Children and adolescents with neurodevelopmental disorders show cognitive heterogeneity and require a person-centered approach

We aimed to identify patterns of cognitive differences and characterize subgroups of Mexican children and adolescents with three neurodevelopmental disorders (NDD): intellectual disability (ID), autism spectrum disorders (ASD) and attention deficit/hyperactivity disorder (ADHD). The sample included 74 children and adolescents 6–15 years; 34% had ID, ASD or ADHD, 47% had ID in comorbidity with ASD, ADHD or both, 11% had ASD + ADHD, 8% were children without NDD. We applied WISC-IV, Autism Diagnostic Interview-Revised, Mini-International Neuropsychiatric Structured Interview, Child Behavior Checklist, and UNICEF Child Functioning Module. We evaluated the normality of the WISC-IV sub-scales using the Shapiro-Francia test, then conducted a latent class analysis and assessed inter-class differences in terms of household, parent and child characteristics. The following four-class solution best fit the data: “Lower Cognitive Profile” (LCP), “Lower Working Memory” (LWM), “Higher Working Memory” (HWM), “Higher Cognitive Profile” (HCP). LCP included most of the children with ID, who had a low Working Memory (WM) index score. LWM included mainly children with ASD or ID + ADHD; their Perceptual Reasoning (PR) and Processing Speed (PS) index scores were much higher than those for Verbal Comprehension (VC) and WM. HWM included children with ASD or ADHD; their scores for PR, PS and VC were high with lower WM (although higher than for LWM). HCP included children without NDD and with ASD or ADHD or both and had the highest scores on all indices. Children with NDD show cognitive heterogeneity and thus require individualized treatment plans.

Measurement and Identification of Parenting Behaviors Associated with Social-Emotional Outcomes in Children: The Racial and Cultural Appropriateness of a Commonly Used Parenting Measure

OBJECTIVE

The objective of this study was to examine parenting styles (observed parent-child interactions via the Two-Bag Task) associated with young children's socioemotional outcomes, comparing children from Mexican-American and African American families with children from their White counterparts.

METHODS

The Early Childhood Longitudinal Study Birth Cohort data were used to examine 6 global parenting styles with socioemotional outcomes at 48 months of age while controlling for both time-independent and time-depending sociodemographic, maternal mental health, and child characteristics. Data were stratified by race and ethnicity, and weighted longitudinal linear regressions models were estimated using STATA/Xtmixed.

RESULTS

The 6 global parenting scores from the Two-Bag Task measures differed across White, African American, and Mexican-American groups of parents. White parents on average scored higher on parenting styles related to sensitivity, positive regard, and cognitive stimulation, whereas Mexican-American and African American parents scored lower. These parenting styles were associated with both approach to learning and social competence outcomes among White children but were nearly nonexistent for Mexican-American and African American children when adjusting for covariates.

CONCLUSION

Our results highlight the need to critically evaluate measures of parenting behaviors used in research studies with racially and ethnically diverse families. Examining the comprehensive psychometric properties and cultural appropriateness of parenting measures for diverse families is important to optimally support child development for non-White children. Furthermore, a critical lens is important to mitigate the perpetuation of inaccurate research findings for Mexican-American and African American children.

Seeing the forest and the trees: Disentangling autism phenotypes in the age of DSM-5

This paper, written in honor of Professor Ed Zigler, focuses on some of the themes in developmental disabilities research that were so central to his work. It has now been nearly 80 years since Leo Kanner first identified the prototypic form - early infantile autism - of what is now autism spectrum disorder. In this article we summarize the development of the concept and the important accumulation of knowledge over time that has now led us to the recognition of a broader autism phenotype just as, at the same time, the current official diagnostic system in the USA has narrowed the concept. We also address current controversies regarding autism as the diagnosis is impacted by age and developmental factors, gender, and cultural issues. In parallel to the work on intellectual deficiency and development pioneered by Zigler and his colleagues, we summarize some of the challenges for the years ahead.

Validating the Autism Diagnostic Interview-Revised in the Korean Population

OBJECTIVE

This study aimed to examine the validity of the Korean version of the Autism Diagnostic Interview-Revised (K-ADI-R) and determine its efficacy in identifying individuals with autism spectrum disorder (ASD).

METHODS

Data were pooled from several past and ongoing studies as well as clinical records acquired at Seoul National University Bundang Hospital from 2008 to 2017. The K-ADI-R were administered and scored by trained research reliable examiners. Measurements to investigate the validity of the K-ADI-R was through sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV), and Cohen's kappa.

RESULTS

A total of 1,271 (age 88.9±62.42 months, male=927) participants were included. The K-ADI-R yielded strong psychometric properties with high sensitivity (86.06-99.27%), specificity (84.75-99.55%), PPV (92.33-99.72%), and NPV (79.43-98.64%). There were significant differences in item scores across the K-ADI-R diagnostic algorithm regardless of age and sex (p<0.001). Agreement between the K-ADI-R and other ASD related measurements ranged between levels of good to excellent.

CONCLUSION

Despite language or cultural boundaries, the K-ADI-R demonstrated high levels of sensitivity, specificity, PPV, and NPV within a wide range of participants; hence, suggesting promising usage as a valuable diagnostic instrument for individuals with ASD.

Improving autism and developmental screening and referral in US primary care practices serving Latinos

LAY ABSTRACT

Latino children experience delays in access to diagnosis and treatment of autism spectrum disorder. Primary care-based screening of all children for autism spectrum disorder and referring them for services may reduce racial/ethnic differences and improve care. REAL-START, a yearlong screening intervention, was effective in increasing screening for autism spectrum disorder and general developmental delays, increasing therapy referrals, and shortening time for developmental assessment in primary care clinics with Latino patients.

A Conceptual Framework for Understanding the Cultural and Contextual Factors on Autism Across the Globe

Autism research is heavily skewed toward western high-income countries. Culturally appropriate screening and diagnostic instruments for autism are lacking in most low- and middle-income settings where the majority of the global autism population lives. To date, a clear overview of the possible cultural and contextual factors that may affect the process of identifying and diagnosing individuals with autism spectrum disorders (ASD) is missing. This study aims to outline these factors by proposing a conceptual framework. A multidisciplinary review approach was applied to inform the development of the conceptual framework, combining a systematic review of the relevant autism research literature with a wider literature search spanning key texts in global mental health, cultural psychiatry, cross-cultural psychology, and intellectual disability research. The resulting conceptual framework considers the identification, help-seeking, and diagnostic process at four interrelated levels: (a) the expression; (b) recognition; (c) interpretation; and (d) reporting of autism symptoms, and describes the cultural and contextual factors associated with each of these levels, including cultural norms of typical and atypical behavior, culture-specific approaches to parenting, mental health literacy, cultural beliefs, attitudes and stigma, as well as the affordability, availability, accessibility, and acceptability of services. This framework, mapping out the cultural and contextual factors that can affect the identification, help-seeking, and diagnosis of ASD may function as a springboard for the development of culturally appropriate autism screening and diagnostic instruments, and inform future cross-cultural autism research directions. The framework also has relevance for clinicians and policy makers aiming to improve support for underserved autism populations worldwide. Autism Res 2020, 13: 1029-1050. © 2020 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: The vast majority of autism research is conducted in western high-income settings. We therefore know relatively little of how culture and context can affect the identification, help-seeking, and diagnosis of autism across the globe. This study synthesizes what is known from the autism research literature and a broader literature and maps out how culture and context may affect (a) the expression, (b) recognition, (c) interpretation, and (d) reporting of autism symptoms.

Methods to Decrease Disparities in Age of Autism Diagnosis and Treatment Access among Latinx Children

Autism spectrum disorder (ASD) affects a substantial number of individuals and their families. Early diagnosis followed by intensive behavioral services is critical to reducing social communication deficits and behavioral challenges. Research has continually demonstrated health disparities with Latinx families that perpetuate lower ASD prevalence rates, later ASD diagnosis, and limited access to treatment compared with white children. Moreover, Latinx children who are diagnosed with ASD receive less intense and fewer treatment services. Given the number of Latinx children and those with ASD, social workers are likely to encounter the intersection throughout their careers. Thus, it is critical for social workers to have general knowledge about autism and the complexity of accessing diagnostic and treatment services. In this article, the authors review the literature on Latinx children and ASD, and identify opportunities for social workers to be innovative in their use of frameworks, theories, and practice approaches to reduce disparities in ASD diagnosis and treatment among Latinx children.

Association between Interictal Epileptiform Discharges and Autistic Spectrum Disorder

It has been reported that bioelectric alterations in an electroencephalogram (EEG) may play an etiological role in neurodevelopmental disorders. The clinical impact of interictal epileptiform discharges (IEDs) in association with autistic spectrum disorder (ASD) is unknown. The Autism Diagnostic Interview-Revised (ADI-R) is one of the gold standards for the diagnosis of autistic spectrum disorder. Some studies have indicated high comorbidity of IED and ASD, while other studies have not supported an association between the central symptoms of autism and IED. This review examines the high comorbidity and clinical impact of IED; patients with epilepsy are excluded from the scope of this review. ASD can be disabling and is diagnosed at an average age of 5 years old, at which point the greatest neurological development has occurred. If an association between IED and ASD is identified, a clinical tool that entails an innocuous procedure could enable diagnosis in the first years of life. However, in the absence of reports that prove an association between IED and ASD, patients should not be subjected to expensive treatments, such as the administration of anticonvulsant therapies.

Child and family characteristics moderate agreement between caregiver and clinician report of autism symptoms

Rates of autism spectrum disorder (ASD) and age at first diagnosis vary considerably across the United States and are moderated by children's sex, race, ethnicity, and availability of services. We additionally suggest that degree of caregiver-clinician agreement on ASD symptoms may play a role in ASD assessment. Since gold standard ASD assessment integrates caregiver-reported developmental history with clinician observations, differential agreement between reporters across demographic groups may contribute to a host of detrimental outcomes. Here, we investigate whether caregiver-clinician agreement on ASD symptoms varies according to child and family characteristics. Comprehensive data from 2,759 families in the Simons Simplex Collection were analyzed. Linear models were created with caregiver reports predicting clinician reports, and moderating effects of child characteristics and family factors were examined. Poorer reporter correspondence was observed when children had higher IQ scores, stronger adaptive behavior, and more behavioral difficulties. Greater disagreement was also associated with African American racial status (for younger children), lower household income, and paternal social difficulties (for older children). Children's biological sex did not moderate caregiver-clinician agreement. Marked disagreement between caregivers and clinicians could lead to suboptimal or insufficient intervention services and negative experiences for families throughout development. Such families may also be less likely to qualify for research studies, and therefore be underrepresented in the ASD literature. Modified assessment procedures may be required to improve assessment accuracy and family experiences. Autism Res 2018, 11: 476-487. © 2017 International Society for Autism Research, Wiley Periodicals, Inc.

LAY SUMMARY

Evaluation of autism spectrum disorder (ASD) incorporates both caregiver and clinician perspectives of symptoms, and disagreement between these perspectives could lead to poorer outcomes for families. Using data from 2,759 families, we show that caregiver-clinician agreement on ASD symptoms is poorer for children with higher cognitive and adaptive skills, more behavioral difficulties, lower household income, and African American racial status. These children may be at higher risk for misdiagnosis, poorer family experiences during evaluations, and poorer representation in ASD research.

The Broader Autism Phenotype in Mothers is Associated with Increased Discordance Between Maternal-Reported and Clinician-Observed Instruments that Measure Child Autism Spectrum Disorder

Autism spectrum disorder (ASD) diagnosis relies on parent-reported and clinician-observed instruments. Sometimes, results between these instruments disagree. The broader autism phenotype (BAP) in parent-reporters may be associated with discordance. Study to Explore Early Development data (N = 712) were used to address whether mothers with BAP and children with ASD or non-ASD developmental disabilities were more likely than mothers without BAP to 'over-' or 'under-report' child ASD on ASD screeners or interviews compared with clinician observation or overall impression. Maternal BAP was associated with a child meeting thresholds on a maternal-reported screener or maternal interview when clinician ASD instruments or impressions did not (risk ratios: 1.30 to 2.85). Evidence suggests acknowledging and accounting for reporting discordances may be important when diagnosing ASD.

Diagnostic Utility of the ADI-R and DSM-5 in the Assessment of Latino Children and Adolescents

Latino children in the US are systematically underdiagnosed with Autism Spectrum Disorder (ASD); therefore, it is important that recent changes to the diagnostic process do not exacerbate this pattern of under-identification. Previous research has found that the Autism Diagnostic Interview-Revised (ADI-R) algorithm, based on the Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition, Text Revision (DSM-IV-TR), has limitations with Latino children of Spanish speaking parents. We evaluated whether an ADI-R algorithm based on the new DSM-5 classification for ASD would be more sensitive in identifying Latino children of Spanish speaking parents who have a clinical diagnosis of ASD. Findings suggest that the DSM-5 algorithm shows better sensitivity than the DSM-IV-TR algorithm for Latino children.

Disparities in Diagnosis and Treatment of Autism in Latino and Non-Latino White Families

OBJECTIVES

To compare barriers to autism spectrum disorder (ASD) diagnosis and current ASD-related service use among non-Latino white (NLW) families and Latino families with English proficiency (L-EP) or limited English proficiency (L-LEP).

METHODS

We conducted a mixed-mode survey of families of children with confirmed ASD seen at specialty clinics in 3 United States cities. Bivariate and multivariate analyses compared barriers to ASD diagnosis, current service use, and unmet therapy need among NLW, L-EP, and L-LEP families.

RESULTS

Overall, barriers to ASD diagnosis were prevalent: families (n = 352) experienced a mean of 8 of 15 barriers to ASD diagnosis. The most prevalent barriers overall were "stress of diagnostic process," "parent knowledge about ASD," and "understanding medical system." Compared with NLW families, L-LEP families were more likely to experience barriers related to knowledge about ASD and trust in providers. Children in L-LEP families also had fewer current therapy hours and more unmet therapy needs than children in NLW families. L-EP families' barriers and treatment services use profile was more similar to NLW than to L-LEP families.

CONCLUSIONS

English proficiency was an important marker for barriers to ASD diagnosis and treatment in Latinos. Increasing ASD-related knowledge and provider trust may decrease disparities in the diagnosis and treatment of ASD among US Latinos.