Maternal and birth risk factors for children screening positive for autism spectrum disorders on M-CHAT-R

Clinical, socio-demographic, and parental correlates of early autism traits in a community cohort of toddlers

Identifying factors linked to autism traits in the general population may improve our understanding of the mechanisms underlying divergent neurodevelopment. In this study we assess whether factors increasing the likelihood of childhood autism are related to early autistic trait emergence, or if other exposures are more important. We used data from 536 toddlers from London (UK), collected at birth (gestational age at birth, sex, maternal body mass index, age, parental education, parental language, parental history of neurodevelopmental conditions) and at 18 months (parents cohabiting, measures of socio-economic deprivation, measures of maternal parenting style, and a measure of maternal depression). Autism traits were assessed using the Quantitative Checklist for Autism in Toddlers (Q-CHAT) at 18 months. A multivariable model explained 20% of Q-CHAT variance, with four individually significant variables (two measures of parenting style and two measures of socio-economic deprivation). In order to address variable collinearity we used principal component analysis, finding that a component which was positively correlated with Q-CHAT was also correlated to measures of parenting style and socio-economic deprivation. Our results show that parenting style and socio-economic deprivation correlate with the emergence of autism traits at age 18 months as measured with the Q-CHAT in a community sample.

Prenatal, perinatal and parental risk factors for autism spectrum disorder in China: a case- control study

BACKGROUND

Autism spectrum disorder (ASD) is heritable neurodevelopmental disorders (NDDs), but environmental risk factors have also been suggested to a play a role in its development. Prenatal, perinatal and parental factors have been associated with an increased risk of ASD in children. The aim of the present study was to explore the prenatal, perinatal, and parenting risk factors in children with autism spectrum disorder (ASD) from Beijing, China by comparing them with typically developing (TD) children.

METHODS

A sample of 151 ASD children's parents who from rehabilitation institutions in Beijing were enrolled in this study, and an additional 151 children from kindergartens in Beijing were recruited as a control group (child age: mean = 4.4 years). TD children were matched according to age, sex and maternal education. We explored the maternal AQ (Autism Spectrum Quotient) scores (mean:19.40-19.71, no significant difference between two groups) to referring the genetic baseline. This study evaluated 17 factors with unadjusted and adjusted analyses.

RESULTS

Birth asphyxia was associated with a more than a thirteen-fold higher risk of ASD (adjusted odds ratio (AOR) = 13.42). Breastfeeding difficulties were associated with a higher risk of ASD(AOR = 3.46). Parenting influenced the risk of ASD, with low responding (LR) and harsh or neglectful parenting associated with a higher risk of ASD in offspring (AOR = 2.37 for LR, AOR = 3.42 for harsh parenting and AOR = 3.01 for neglectful parenting). Maternal fever during pregnancy was associated with a higher risk of ASD in offspring (AOR = 3.81).

CONCLUSIONS

Many factors were associated with ASD in offspring. Further assessment is needed to elucidate the role of modifiable environmental factors to inform prevention strategies.

Infant feeding practices and autism spectrum disorder in US children aged 2-5 years: the national survey of children's health (NSCH) 2016-2020

OBJECTIVE

To investigate the relationship between infant feeding practices and autism spectrum disorder (ASD) among children aged 2-5 years in the United States (US).

METHODS

Data from the 2016-2020 National Survey of Children's Health, a nationally representative cross-sectional survey, were utilized for this study. Questionnaires were administered to parents of children aged 2-5 years to gather information on ASD diagnosis, infant feeding practices, and demographic factors (e.g., child sex, ethnic group, and maternal age at birth). Logistic regression with sample weights was employed to assess the association between infant feeding practices and ASD, while controlling for demographic variables. Polynomial regression models were used to examine trends in exclusive breastfeeding and ever breastfeeding rates among children with and without ASD.

RESULTS

A total of 35,050 children aged 2-5 years were analyzed, including 616 diagnosed with ASD, after excluding participants with missing information on breastfeeding and ASD diagnosis. Of these children with ASD, 76.6% (n = 472) had a breastfeeding history, with 67.5% (n = 416) engaged in partial breastfeeding and 9.1% (n = 56) exclusively breastfed. Adjusted odds ratios for each additional month of breastfeeding compared to never being breastfed were 0.98 (95% CI, 0.96-1.01). The adjusted odds ratios for breastfeeding durations of > 0-6 months, > 6-12 months, > 12-24 months, and > 24 months were 0.81 (95% CI, 0.50-1.31), 0.65 (95% CI, 0.36-1.18), 0.81 (95% CI, 0.44-1.49), and 0.48 (95% CI, 0.23-1.01), respectively. Compared to children who were never breastfed, the adjusted odds ratio for children who were ever breastfed was 0.74 (95% CI, 0.47-1.18). Among children with ASD, the proportion of ever breastfeeding declined from 82.0% in 2017 to 64.3% in 2020, while exclusive breastfeeding decreased from 12.0% in 2016 to 4.2% in 2020.

CONCLUSIONS AND RELEVANCE

Although no significant association was found between infant feeding practices and ASD among US children aged 2-5 years, the rates of breastfeeding, particularly exclusive breastfeeding, were suboptimal among children with ASD. This highlights the need for specific policies and practices to promote and support breastfeeding among parents of children with ASD or those at high risk of having a child with ASD.

[As early as birth, oxytocin plays a key role in both food and social behavior]

Oxytocin (OT) is a neurohormone that regulates the so-called "social brain" and is mainly studied in adulthood. During postnatal development, the mechanisms by which the OT system structures various behaviors are little studied. Here we present the dynamic process of postnatal development of the OT system as well as the OT functions in the perinatal period that are essential for shaping social behaviors. Specifically, we discuss the role of OT, in the newborn, in integrating and adapting responses to early sensory stimuli and in stimulating suckling activity. Sensory dialogue and suckling are involved in mother-infant bonds and structure future social interactions. In rodents and humans, neurodevelopmental diseases with autism spectrum disorders (ASD), such as Prader-Willi and Schaaf-Yang syndromes, are associated with sensory, feeding and behavioral deficits in infancy. We propose that in early postnatal life, OT plays a key role in stimulating the maturation of neural networks controlling feeding behavior and early social interactions from birth. Administration of OT at birth improves sensory integration of environmental factors and the relationship with the mother as well as sucking activity as we have shown in mouse models and in babies with Prader-Willi syndrome. Long-term effects have also been observed on social and cognitive behavior. Therefore, early feeding difficulties might be an early predictive marker of ASD, and OT treatment a promising option to improve feeding behavior and, in the longer term, social behavioral problems.

To assess the magnitude of autism spectrum disorder in Jharkhand by M-CHAT-R as a screening tool

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder which is a clinically heterogenous condition with a wide range of etiological factors and causing significant public health burden. If diagnosed at an earlier age, early interventions can be started this leads to functional outcome of children with ASD with respect to social, behavior and occupational sphere. Therefore, early detection and intervention are widely recommended in these children. So screening of toddlers who were identified to be "at risk" can be diagnosed using screening questionnaires by interviewing parents. Overall with this study we can conclude that, toddlers identified to be "at risk" and those diagnosed with ASD were not uncommon and M-CHAT-R is a useful screening test for the identification of "at risk" toddlers for Autism Spectrum Disorder in Jharkhand.

Association of Breastfeeding for the First Six Months of Life and Autism Spectrum Disorders: A National Multi-Center Study in China

Previous studies have shown that exclusive breastfeeding is associated with lower odds of having autism spectrum disorders (ASD) in children, but data are lacking in Asian countries, especially China. This cross-sectional study of seven cities in China collected data from August 2016 to March 2017 from 6049 toddlers aged 16-30 months and their parents who responded to questionnaires. The breastfeeding status was collected via questionnaires based on recommendations from the World Health Organization. The standard procedure for screening and diagnosis was applied to identify toddlers with ASD. Among the 6049 toddlers (3364 boys [55.6%]; mean [SD] age, 22.7 [4.1] months), 71 toddlers (1.2%) were identified as ASD. The prevalence of exclusive breastfeeding, partial breastfeeding, and not breastfeeding was 48.8%, 42.2%, and 9.1%, respectively. Compared to toddlers with exclusive breastfeeding, toddlers with partial breastfeeding or without breastfeeding had higher odds of having ASD (odd ratios [OR]: 1.55, 95% confidence interval [CI]: 0.90-2.74; OR: 2.34, 95% CI: 1.10-4.82). We did not find significant modification of demographic characteristics on the associations. The results remained robust in multiple sensitivity analyses. Toddlers without breastfeeding for the first six months of life had higher odds of having ASD, and our findings shed light on the necessity of strengthening public health efforts to increase exclusive breastfeeding in China.

Neonatal jaundice and autism spectrum disorder: a systematic review and meta-analysis

BACKGROUND

Two meta-analyses concluded that jaundice was associated with an increased risk of autism. We hypothesize that these findings were due to methodological limitations of the studies included. Neonatal jaundice affects many infants and risks of later morbidity may prompt physicians towards more aggressive treatment.

METHODS

To conduct a systematic literature review and a meta-analysis of the association between neonatal jaundice and autism with particular attention given to low risk of bias studies. Pubmed, Scopus, Embase, Cochrane, and Google Scholar were searched for publications until February 2019. Data was extracted by use of pre-piloted structured sheets. Low risk of bias studies were identified through predefined criteria.

RESULTS

A total of 32 studies met the inclusion criteria. The meta-analysis of six low risk of bias studies showed no association between neonatal jaundice and autism; cohort studies risk ratio 1.09, 95% CI, 0.99-1.20, case-control studies odds ratio 1.29 95% CI 0.95, 1.76. Funnel plot of all studies suggested a high risk of publication bias.

CONCLUSIONS

We found a high risk of publication bias, selection bias, and potential confounding in all studies. Based on the low risk of bias studies there was no convincing evidence to support an association between neonatal jaundice and autism.

IMPACT

Meta-analysis of data from six low risk of bias studies indicated no association between neonatal jaundice and autism spectrum disorder. Previous studies show inconsistent results, which may be explained by unadjusted confounding and selection bias. Funnel plot suggested high risk of publication bias when including all studies. There is no evidence to suggest jaundice should be treated more aggressively to prevent autism.

Early Social Experience and Digital-Media Exposure in Children with Autism Spectrum Disorder

OBJECTIVE

To study the early social experience and digital media exposure in children with autism spectrum disorder (ASD) in comparison with typically developed children.

METHODS

Details of digital-media exposure and early social experience in 65 children with ASD were compared with those in a control group of equal number of typically developed children, matched for age and gender. Prenatal and perinatal factors were also studied. The diagnosis of ASD was based on the International Clinical Epidemiology Network (INCLEN) diagnostic tool and Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) diagnostic criteria. Variables which were biologically relevant and has a P value of < 0.05 in the univariate analysis were analyzed by logistic regression to obtain the adjusted effect measures.

RESULTS

Children with ASD were exposed to digital media at an earlier age and spent significantly more time with digital media and less time with their mothers, compared to typically developed children. Exposure to digital media before 21 mo was associated with risk of ASD and the risk increased when mothers spent less than 6.5 h per day with the baby. Family history of epilepsy and developmental delay, maternal stress during the antenatal period, and absence of exclusive breastfeeding during the first 6 mo were significantly more in children with ASD.

CONCLUSION

There are significant differences in the early life social experience and digital-media exposure in children with ASD compared to typically developed counterparts. Given the reported rise in prevalence of ASD, these findings stress the need for further prospective studies to explore these potentially modifiable risk factors.

Prevalence and risk factors of autism spectrum disorders in preschool children in Sharkia, Egypt: a community-based study

Background

Lateness in the diagnosis of autism spectrum disorders (ASD) results in significant disability and pressure on affected children and their families. We aimed to detect the preschool children who have high-risk criteria for ASD in Sharkia Governorate in Egypt and assess the prevalence and risk factors of ASD. A cross-sectional community-based study was done in 39 kindergartens throughout Sharkia Governorate, Egypt, using a multi-stage random sampling technique. The study included two phases, the screening phase, where 3722 preschool children were screened by Modified Check List for Toddlers/Revised (M-CHAT-R), and the diagnostic phase where the diagnosis of ASD among the high-risk children was made according to the research diagnostic criteria of Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) of ASD administrated by experienced psychiatrists and the Childhood Autism Rating Scale (CARS).

Results

This study showed that 2.8% of children were at high risk for ASD. The prevalence of ASD in Sharkia Governorate was 5.4/1000. The significant risk factors for the disorder were the presence of factories near the house, first and middle child order, congenital anomalies, child medication during the first year of life, child chronic medical condition, child attachment to TV, a medical condition affecting mother during pregnancy, and psychiatric disorders history in the family.

Conclusion

Autism spectrum disorder is prevalent in preschool children in Sharkia, Egypt, and multiple risk factors contribute to this prevalence.

Associations between Prenatal Education, Breastfeeding and Autistic-Like Behaviors in Pre-Schoolers

This study aimed to investigate the association between prenatal education and autistic-like behaviors of preschoolers as well as the mediating role of breastfeeding in their associations. A cross-sectional study via a structured questionnaire was conducted with 67,578 preschool children and parents from Longhua District of Shenzhen, China. Hierarchical logistic regression models were performed to explore the associations between maternal participation in prenatal education and autistic-like behaviors in preschoolers, as well as the mediating effect of breastfeeding in the associations. After controlling for potential confounders, logistic regression analysis indicated that maternal participation in prenatal education could significantly increase the prevalence of breastfeeding, and the strength of the association was enhanced with the increase frequency of prenatal education visits (ORs ranging from 1.191 to 1.899). While both maternal participation in prenatal education (ORs ranging from 0.732 to 0.798) and breastfeeding (OR = 0.773) were significantly associated with the lower presence of autistic-like behaviors in preschoolers. The crossover analysis indicated that children with both maternal prenatal education and breastfeeding had the lower risk of presence of autistics-like behaviors (OR = 0.569). Furthermore, mediation analysis illustrated that breastfeeding mediated the association between maternal participation in prenatal education and the presence of autistic-like behaviors in preschoolers, with a mediating effect of approximately 14.3%. Our findings suggest that maternal participation in prenatal education is significantly associated with a decreased risk of autistic-like behaviors in preschool children through increased breastfeeding in the mothers who attended prenatal education.

Autism spectrum disorder in India: a scoping review

Autism is a grand challenge in global mental health to be dealt with on a priority basis. Phenotypic knowledge, biological understanding, and evidence-based intervention studies are all from western countries. We know very little about autism in the low- and middle-income countries (LMIC). Lack of infrastructure and difficulties in operationalizing research has widened the knowledge gap. We performed a comprehensive scoping review of research in Autism Spectrum Disorder in India to have an overall impression, identify gaps, and formulate evidence-based recommendations for further study. We searched PubMed, SCOPUS, and Cochrane Library to identify relevant Indian studies. A hundred and fifty-nine publications met the inclusion criteria. Most of the research contribution in autism is from few tertiary care medical centres, technological institutes, and not-for-profit organizations. We identified various themes of research like clinical profile, interventions, biomarkers, psychological, social, epidemiological, and risk factors. Evidence-based intervention studies, translation and adaptation of standard diagnostic instruments, and qualitative research on the experience of autism appeared to be state of the art. However, epidemiological studies, biomarkers identification, risk assessment studies were of low quality. There is a need for nationwide studies with representative sampling on epidemiology, biomarkers, and risk factors for a complete evaluation of the actual burden and biology of autism in India. Also, there is a need to design implementation research to evaluate the effectiveness of evidence-based interventions in routine healthcare settings. We recommend that future research should fill these gaps in understanding autism and improving its outcome in India.

Autism spectrum disorder in the United Arab Emirates: potential environmental links

Autism spectrum disorder (ASD) has been experiencing an increase in global prevalence in recent decades. While many factors could account for this reality, certain environmental links have been shown to contribute to ASD development and etiology. The Middle East has had relatively little published research on ASD etiology although statistics indicate that ASD affects 1 in 146 births in the United Arab Emirates (UAE). This review therefore aims to examine potential causes of ASD within the UAE specifically, focusing on environmental links that may contribute to the rise in ASD cases in this population. Significantly, suboptimal breastfeeding practices, high levels of vitamin D deficiency, increased exposure to pollution, pesticides and heavy metals within the UAE may all be potentially important contributing factors to ASD in this population. Our findings support the notion that there are key links between various environmental factors and ASD prevalence in the UAE. The lack of knowledge and much research on ASD within the UAE deeply necessitates further studies on its etiology as it poses a serious public health challenge in the region and globally.

Advanced Parental Age and Risk of Positive Autism Spectrum Disorders Screening

Background:

Autism Spectrum Disorder (ASD) is a life -long neurodevelopmental disorder and significantly influences the quality of life in children. The screening of ASD in children aged between 16-30 months to early detection and early intervention for better prognosis.

Methods:

This cross-sectional study was conducted in the southwest of Iran (Yasuj) with dominant Lore ethnicity in 2017. A total of 1504 mother- child pairs with children aged between 16-30 months were selected through simple random sampling from the integrated national health system as the framework. ASD screening was implemented using the Modified checklist for autism in toddlers- revised, with follow-up interview (M-CHAT-R/F). Demographic data such as sex of children, and parental age at their time of pregnancy were collected for all children.

Results:

Risk of ASD was low, moderate and high in 1447 (96.2%), 54 (3.6%) and 3 (0.2%) in screening, respectively. The estimated rate of ASD prevalence was 80 per 10000 (12 out of 1504) or 1 in 125. Mother's age ≥35 (P value = 0.002, OR = 11.65, CI_95%: 2.49-54.35) and father's age ≥40 (P value = 0.0001, OR = 19.64, CI_95%: 4.89-78.82) were predicting factors of ASD in toddlers aged 16-30 months.

Conclusions:

Given that, increasing the age of marriage in Iran and recent trend towards delayed childbearing; children born to older parents are at a higher risk for having ASD. So, increasing the public awareness is necessary.

Role of Exclusive Breastfeeding in Conferring Protection in Children At-Risk for Autism Spectrum Disorder: Results from a Sibling Case-control Study

Background

Gut microflora influences neural development through complex mechanisms. Feeding practices, especially breastfeeding influence gut microbiome and thereby play a pivotal role in immune and neural development. Current understandings of the role of healthy distal gut microflora in the development of immune and neural systems provide insights into immunological mechanisms as one of the possible etiologies in autism spectrum disorder (ASD). Studies have shown that optimal breastfeeding is associated with lower odds of being at-risk for ASD and children with ASD are suboptimally breastfed.

Methods

The feeding practices of children with ASD (n = 30) was compared to their typically developing siblings as matched controls (n = 30). Information regarding feeding practices was collected from mothers through a semi-structured questionnaire.

Results

About 43.3% of children with ASD received exclusive breastfeeding, whereas 76.7% of their typically developing siblings were exclusively breastfed. Exclusive breastfeeding was associated with lower odds for ASD (odds ratio [OR] = 0.166; 95% confidence interval [CI] = 0.025-0.65), while early introduction of top feeds was associated with higher odds (OR = 6; 95% CI = 1.33-55.19). Difficulties in breastfeeding were attributed to child-related factors in 13.2% of the children.

Conclusion

Children with ASD are suboptimally breastfed compared to their typically developing siblings. Exclusive breastfeeding may confer protection in vulnerable children. Further studies on larger prospective sample are required to establish the association.

Autism in India: a case-control study to understand the association between socio-economic and environmental risk factors

Autism spectrum disorder is a neurodevelopmental disorder and the cause of autism is still unclear. The aim of this study was to investigate the association of socioeconomic, environmental, pregnancy and newborn-related risk factors among children with autism spectrum disorders. This was a population-based case-control study. The study included 55 children with autism spectrum disorder and 55 age and sex matched typically developing normal children (TD) between 3 and 12 years. Several socio-economic factors, environmental factors, pregnancy related, natal, post-natal factors and the first noticed signs by the parents were analyzed. Chi-square test was used to compare nominal variables. For multivariate analysis, forward stepwise logistic regression model was employed to examine the association between autism and the chances that the child develops ASD to assess the odds ratios. Male predominance was observed in the study. Logistic regression model showed statistical significance of the following factors: paternal age greater than 40 years, family history of autism, nutrition during pregnancy, mode of labor, fetal hypoxia, NICU stay and history of breast feeding. In this epidemiological study of autism in Coimbatore city, we found correlation between several environmental factors during fetal development and can be transmitted to succeeding generations, causing atypical behavior phenotypes. The exact exposure magnitude, exposure time in relation to vital developmental periods need to be studied to understand the influence of socioeconomic and environmental factors, which can be improved to prevent ASD-related challenges.

Association Between Breastfeeding Initiation and Duration and Autism Spectrum Disorder in Preschool Children Enrolled in the Study to Explore Early Development

Studies report inconsistent findings on the relationship between ASD and breastfeeding. We explored associations between ASD and breastfeeding initiation (yes/no) and duration (months categorized in tertiles) in the Study to Explore Early Development, a community-based case-control study in six sites in the Unites States. We adjusted for various child and mother demographic and pregnancy factors. Breastfeeding initiation was reported in 85.7% of mothers of children with ASD and 90.6% of mothers of controls. After adjustment, we found no significant difference in breastfeeding initiation (adjusted odds-ratio [aOR]: 0.88 and 95% confidence interval (CI) 0.60-1.28). However, mothers of children with ASD were less likely to report duration of breastfeeding in the high (≥12 months) versus low tertile (<6 months) (aOR and 95% CI: 0.61 [0.45-0.84]) or the middle (6-<12 months) versus low tertile (0.72: 0.54-0.98). The association of ASD and breastfeeding duration was slightly attenuated when the presence of the broader autism phenotype (BAP) in the mother was accounted for, but still remained for the highest tertile. This association does not appear to be totally explained by maternal BAP. We were unable to distinguish whether the difference in duration was due to difficulties breastfeeding children who later develop ASD, other factors not adjusted in our study, or greater ASD risk resulting from shorter breastfeeding duration. Longitudinal studies that compare reasons why mothers stop breastfeeding between ASD and controls and establish a temporal relation between ASD and breastfeeding are needed. Future studies should also evaluate interactions between ASD risk genes and breastfeeding. Autism Research 2019, 12: 816-829. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: In this study, we compared breastfeeding practices between mothers of children with and without autism spectrum disorder (ASD). We found that the percentage of mothers who started breastfeeding was similar between the two groups, but mothers of children with ASD breastfed for a shorter amount of time compared to mothers of children without ASD. Future studies are needed to evaluate the reasons why the duration of breastfeeding was shorter for mothers of children with ASD compared to those without ASD.

Frequency of risk factors and coexisting abnormalities in a population of Egyptian children with autism spectrum disorder

BACKGROUND

Many risk factors interact together during the critical period of development and govern the future phenotype of autism spectrum disorder (ASD). Furthermore, co-occurring abnormalities among individuals with ASD vary a lot so as their abilities.

AIM OF WORK

To investigate possible risk factors and to determine the prevalence of coexisting abnormalities in a sample of Egyptian ASD children and their influence on the severity and their communication performance.

METHODS

The diagnosis and severity of ASD for participants (N=80) was performed by DSM-5, ADIR and CARS. They were investigated regarding the possible risk factors and coexisting abnormalities. A detailed history taking, clinical examination, the Arabic preschool language scale, cognitive abilities assessment and other additional instrumental measures such as EEG were used.

RESULTS

Caesarian section and neonatal jaundice were the most common risk factors. The severity of ASD was positively related to maternal and paternal ages. Developmental language disorder, intellectual disability, attention deficit hyperactivity disorder, sleep disorder and EEG changes were more frequently detected among studied cases. The CARS scores were significantly higher in ADHD and EEG changes groups. The most severely affected CARS items in the groups with these disorders were determined.

CONCLUSION

High parental ages has an impact on the severity of ASD. ADHD, sleep disorder, and EEG changes seem to have an impact on certain elements of the adaptive behavior especially the communicative performance of ASD individuals. We recommend to seriously investigate co-morbid abnormalities and consider them during the process of management of ASD for proper intervention plans.

Toddlers at risk for Autism Spectrum Disorders from Kerala, India - A community based screening

AIMS

To study the at-risk rate for Autism Spectrum Disorders (ASD) on a parent-report questionnaire in toddlers between the ages of 16-24 months.

MATERIALS AND METHODS

6237 toddlers from Kerala, India selected by cluster random sampling were surveyed by community nurses using the Modified Checklist for Autism in Toddlers - Revised (M-CHAT-R) translated to Malayalam and culturally adapted.

RESULTS

5.5% toddlers were at risk on M-CHAT-R and 2.7% on "Best Seven".

CONCLUSIONS

M-CHAT-R and its "Best Seven" could be viable community level screening instruments, albeit with further cultural adaptation for a primarily non-English speaking population in India.