Validity and reliability analysis of the Chinese parent version of the Autism Spectrum Rating Scale (6-18 years)

Reliability and validity of the Autism Screen for Kids and Youth

LAY ABSTRACT

It is important that autistic children be diagnosed as early as possible so their needs can be met and their families can gain important insights into their behavior and interact with them appropriately. However, very few autism screening instruments are appropriate for children who have outgrown early childhood. The Autism Screen for Kids and Youth (ASKY) presents parents of children aged 4-18 years with 30 items that relate to autistic behaviors as defined by the current clinical diagnostic criteria for autism spectrum disorder (DSM-5 ASD). We evaluated the Hebrew instrument's performance on 167 autistic and non-autistic children and adolescents. We found that the ASKY algorithm correctly identified 92% of the autistic individuals as "probable ASD" and correctly identified 72% of the non-autistic individuals as "probable non-ASD," with these classifications showing excellent stability over time. Using total questionnaire score instead of the algorithm improved the ASKY's ability to correctly identify autistic individuals as "probable ASD" and non-autistic individuals as "probable non-ASD" to 93% and 78%, respectively. Overall, the ASKY is a promising instrument for ASD screening of older children.

The validity and reliability of the simplified Chinese version of the Social Communication Questionnaire

This study aims to validate the simplified Chinese version of the Social Communication Questionnaire (SCQ) in children aged 2-12 years from both general and clinical populations. We recruited 819 Chinese children in this study, including 505 typically developing (TD) children, 202 children with autism spectrum disorder (ASD) and 112 children with non-ASD neurodevelopmental disorders. All the children's parents completed the simplified Chinese version of the SCQ and all children with ASD were additionally assessed for intelligence and the Childhood Autism Rating Scale to confirm their diagnosis. We have developed a 40-item, 4-factor structure of SCQ with two domains (social communication and social interaction; and restricted, repetitive, and stereotyped patterns of behavior), which showed adequate goodness of fit (comparative fit index [CFI] = 0.96, Tucker-Lewis index [TLI] = 0.95, standardized root mean squared residual [SRMR] = 0.07, root mean square error of approximation [RMSEA] = 0.05), with good internal consistency (Cronbach's alpha = 0.92). We have provided different cut-offs to distinguish ASD cases from TD children (11 for children under 4 years [sensitivity: 0.96, specificity: 0.95], 12 for children 4 years and above [sensitivity: 0.93, specificity: 0.98]) or children with other neurodevelopmental disorders (14 [sensitivity: 0.85, specificity: 0.88]). Through this large sample validation, we confirmed that the simplified Chinese version of the SCQ could be used for children aged 2-12 years with relatively good psychometric properties. LAY SUMMARY: We aimed to develop the simplified Chinese version of the Social Communication Questionnaire (SCQ) for Chinese children aged 2-12 years as a screening tool to identified potential risk of autism spectrum disorder (ASD). We have developed a 40-item, 4-factor structure of SCQ with two domains, which showed adequate goodness of fit and good psychometric properties. We also provided different cut-offs to identify ASD cases in general or clinical populations.

Prevalence of Autism Spectrum Disorder in China: A Nationwide Multi-center Population-based Study Among Children Aged 6 to 12 Years

This study aimed to obtain the first national estimate of the prevalence of autism spectrum disorder (ASD) in Chinese children. We targeted the population of 6 to 12-year-old children for this prevalence study by multistage convenient cluster sampling. The Modified Chinese Autism Spectrum Rating Scale was used for the screening process. Of the target population of 142,086 children, 88.5% (n = 125,806) participated in the study. A total of 363 children were confirmed as having ASD. The observed ASD prevalence rate was 0.29% (95% CI: 0.26%-0.32%) for the overall population. After adjustment for response rates, the estimated number of ASD cases was 867 in the target population sample, thereby achieving an estimated prevalence of 0.70% (95% CI: 0.64%-0.74%). The prevalence was significantly higher in boys than in girls (0.95%; 95% CI: 0.87%-1.02% versus 0.30%; 95% CI: 0.26%-0.34%; P < 0.001). Of the 363 confirmed ASD cases, 43.3% were newly diagnosed, and most of those (90.4%) were attending regular schools, and 68.8% of the children with ASD had at least one neuropsychiatric comorbidity. Our findings provide reliable data on the estimated ASD prevalence and comorbidities in Chinese children.

Elevated serum neurofilament light chain in children autism spectrum disorder: A case control study

OBJECTIVE

We aimed to assess serum neurofilament light chain (sNfL) levels in autism spectrum disorder (ASD) and to investigate whether they are related to the severity of disease.

METHODS

The cohorts consisted of 166 children aged 3-8 (83 children diagnosed with ASD and 83 children with typically-developing). sNfL were analyzed using Single Molecule Array (Simoa) technology. ASD symptom severity was assessed according to the Chinese version of the Childhood Autism Rating Scale (CARS) score.

RESULTS

The mean age of those included ASD was 5.1 years (standard deviations [S.D.]: 1.7) and 78.3 % were boys. The mean (SD) sNfL concentrations were significantly (P < 0.001) higher in ASD than in TP children (10.2[5.0] pg/mL and 7.1[3.2]pg/mL). For each 1 pg/mL increase of sNfL, the risk of ASD would increase by 19 % (with the OR _unadjusted of 1.19 [95 % CI 1.10-1.29], P < 0.001) and 11 % (with the OR _adjusted of 1.11 [1.03-1.23], P < 0.001), respectively. sNfL concentrations in children with severe ASD were higher than in those children with mild-to-moderate ASD (12.4[5.1] pg/mL vs. 8.3[4.2]pg/mL; P < 0.001). Among ASD cases, each 1 pg/mL increase of sNfL is associated with 20 % higher unadjusted or 11 % higher adjusted odds, respectively, of severe (vs. mild-to-moderate) ASD.

CONCLUSIONS

The data showed that sNfL was elevated in ASD and related to symptom severity, suggesting that sNfL may play a role in ASD progression.

A systematic review of screening tools for the detection of autism spectrum disorder in mainland China and surrounding regions

Screening for autism spectrum disorder is the first step toward early detection and diagnosis, thereby impacting the likelihood of children accessing early intervention and, importantly, improving long-term outcomes. This systematic review aimed to (a) establish a clear baseline of autism spectrum disorder screening tools currently used throughout mainland China and surrounding regions, (b) identify the strengths and limitations of these instruments, and (c) develop specific recommendations regarding screening for autism spectrum disorder throughout Chinese-speaking countries. Databases were searched for recent (2015-2018) articles published in Chinese or English languages. Twenty-two studies (13 Chinese, 9 English) met inclusion criteria; two from Taiwan and the remainder from mainland China. Studies varied greatly in the extent of psychometric analyses and reported autism spectrum disorder prevalence. The majority of diagnoses were based on Diagnostic and Statistical Manual of Mental Disorders (4th ed. (DSM-IV) or 5th ed. (DSM-5)) criteria, although a small number of studies utilized gold-standard diagnostic assessment instruments. It is recommended that a systematic, multi-tiered, screening network be established to improve the identification of autism spectrum disorder in China and surrounding regions. Assessment and diagnosis need to be culturally appropriate, and amenable to low-resource settings. In addition, increased public awareness programs to reduce stigma will be important in improving outcomes for children with autism spectrum disorder.

[Autism spectrum disorder-like symptoms in the population with intellectual disability aged 6 to 18 years]

OBJECTIVE

To investigate the incidence of autism spectrum disorder (ASD)-like symptoms in the population with intellectual disability (ID).

METHODS

The students with ASD or ID, aged 6-18 years, who studied in a special school in Shanghai from January to June, 2017, as well as the typically developing (TD) population of the same age, who studied in a general school in Shanghai during the same period, were enrolled. Social Responsiveness Scale (SRS) was completed by their parents or other guardians, and the ASD-like symptoms were evaluated.

RESULTS

A total of 69 subjects with ASD, 74 subjects with ID and 177 TD subjects were enrolled. The ID group had a significantly higher SRS-positive rate than the TD group (47.3% vs 1.7%; P<0.001) and a significantly lower SRS-positive rate than the ASD group (47.3% vs 87.0%; P<0.001). The total score of SRS was 114±26 in the ASD group, 80±24 in the ID group and 38±19 in the TD group. The ID group had a significantly higher total score of SRS than the TD group (P<0.05), and the score on the subscale of social cognition showed the most significant difference between the two groups (Cohen's d=2.00). There were no significant differences in the total score of SRS and the scores on each subscale of SRS between the mild-to-moderate ID and severe-to-extremely severe ID groups (P>0.05), and there was no significant correlation between SRS score and IQ (P>0.05).

CONCLUSIONS

The ID population aged 6-18 years has more ASD-like symptoms than the general population, and ASD screening and intervention should be performed for the ID population as early as possible.

Reliability and validity of the translated Chinese version of Autism Spectrum Rating Scale (2-5 years)

BACKGROUND

Early autism screening is of great value, but there is lack of a screening tool of early age (2-5 years) in China. The Autism Spectrum Rating Scale (ASRS, 2-5 years) is a newly developed autism screening tool in the USA. This study aimed to evaluate the reliability and validity of the translated Chinese version of ASRS (C_ASRS) in Chinese children population before its application in China for early autism screening.

METHODS

Caregivers of general children aged 2-5 years from 17 kindergartens and autism spectrum disorder (ASD) cases from five special education schools in five cities were recruited to complete the C_ASRS. 1910 valid questionnaires from kindergarteners and 192 from ASD cases were included for analyses.

RESULTS

The item reliability (Cronbach's alpha) was more than 0.80 in the screening scale and DSM-5 scale, and 0.51-0.81 in the treatment scale. ASD cases scored higher on total score and most subscales compared to the kindergarteners (Cohen's d ranging from 1.34 to 3.37). C_ASRS showed good discriminatory validity with an area under the receiver operating characteristic curve of 0.850 (95% confidence interval: 0.819-0.881). The cutoff ≥ 60 achieved sensitivity of 65.63% and specificity of 85.63% in discriminating autism children from the general population.

CONCLUSION

The results indicate that C_ASRS (2-5 years) could be used as an early level-2 screening tool for autism screening in China and should be further revised for level-1 screening.

Cross-Cultural Revision and Psychometric Properties of the Chinese Version of the Autism Spectrum Rating Scale (2-5 Years)

Background: No sufficient biomarkers are available for early identification of autism in the general population. Currently, the diagnosis of ASD depends on behavioral assessments. A useful screening tool can help to detect early autistic symptoms and provide children an early opportunity for ASD-related interventions. This research aimed to assess cross-cultural adaptation and psychometric properties of the autism spectrum rating scale (ASRS) under the Chinese cultural environment.

Methods: Participants were recruited from 17 kindergartens and 5 special education schools across five cities (Shanghai, Guangzhou, Changsha, Chengdu, and Harbin) in China. A total of 2,181 kindergarten children and 207 ASD cases participated in this study. Mplus 7.03 was utilized to conduct exploratory factor analysis, followed by adaptive modifications to construct the revised Chinese version of the ASRS (RC_ASRS).

Results: The result showed that 62 items comprised a two-factor structure; Factor 1 (social communication, SC) included 21 items, and Factor 2 (unusual behavior, UB) included 41 items. Cronbach's alpha ranged from 0.87 to 0.91 within the RC_ASRS. The total score and the SC and UB scores were significantly higher in ASD cases than in kindergarten samples (Cohen's d ranged from 0.82 to 2.72). The total RC_ASRS score showed an area under the curve (AUC) of 0.95 (95% CI: 0.93–0.97). With a total score cut-off ≥ 60, the RC_ASRS is an excellent tool to identify ASD cases from Chinese kindergarten children (sensitivity = 88.6%, specificity = 84.5%).

Conclusions: The RC_ASRS has excellent psychometric properties and is a reliable, useful tool for early ASD screening among Chinese children.

Performance of the Autism Spectrum Rating Scale and Social Responsiveness Scale in Identifying Autism Spectrum Disorder Among Cases of Intellectual Disability

The Autism Spectrum Rating Scale (ASRS) and the Social Responsiveness Scale (SRS) have been widely used for screening autism spectrum disorder (ASD) in the general population during epidemiological studies, but studies of individuals with intellectual disability (ID) are quite limited. Therefore, we recruited the parents/caregivers of 204 ASD cases, 71 ID cases aged 6-18 years from special education schools, and 402 typically developing (TD) children in the same age span from a community-based population to complete the ASRS and SRS. The results showed that the ID group scored significantly lower on total and subscale scores than the ASD group on both scales (P < 0.05) but higher than TD children (P < 0.05). Receiver operating characteristic analyses demonstrated a similar fair performance in discriminating ASD from ID with the ASRS (area under the curve (AUC) = 0.709, sensitivity = 77.0%, specificity = 52.1%, positive predictive value (PPV) = 82.2%) and the SRS (AUC = 0.742, sensitivity = 59.8%, specificity = 77.5%, PPV = 88.4%). The results showed that individuals with ID had clear autistic traits and discriminating ASD from ID cases was quite challenging, while assessment tools such as ASRS and SRS, help to some degree.

Assessing the Accuracy of the Modified Chinese Autism Spectrum Rating Scale and Social Responsiveness Scale for Screening Autism Spectrum Disorder in Chinese Children

The reported prevalence of autism spectrum disorder (ASD) has been increasing rapidly in many parts of the world. However, data on its prevalence in China are largely missing. Here, we assessed the suitability of the modified Chinese version of a newly-developed ASD screening tool, the Modified Chinese Autism Spectrum Rating Scales (MC-ASRS) in screening for ASD in Chinese children aged 6–12 years, through comparison with the Social Responsiveness Scale (SRS) that has been widely used for ASD screening. We recruited the parents/caregivers of 1588 typically-developing children and 190 children with ASD aged 6–12 years to complete the MC-ASRS and SRS, and evaluated the validity of both scales in discriminating children with ASD from those developing typically. The results showed that MC-ASRS performed as well as SRS in sensitivity, specificity, and area-under-the-curve (both >0.95) in receiver operating characteristic analysis, with a fair false-negative rate. These results suggest that MC-ASRS is a promising tool for screening for children with ASD in the general Chinese population.

Modifying the Autism Spectrum Rating Scale (6-18 years) to a Chinese Context: An Exploratory Factor Analysis

The purpose of this study was to explore the psychometric properties of the Chinese version of the autism spectrum rating scale (ASRS). We recruited 1,625 community-based children and 211 autism spectrum disorder (ASD) cases from 4 sites, and the parents of all participants completed the Chinese version of the ASRS. A robust weighted least squares means and variance adjusted estimator was used for exploratory factor analysis. The 3-factor structure included 59 items suitable for the current sample. The item reliability for the modified Chinese version of the ASRS (MC-ASRS) was excellent. Moreover, with 60 as the cut-off point, receiver operating characteristic analysis showed that the MC-ASRS had excellent discriminate validity, comparable to that of the unmodified Chinese version (UC-ASRS), with area under the curve values of 0.952 (95% CI: 0.936-0.967) and 0.948 (95% CI: 0.930-0.965), respectively. Meanwhile, the confirm factor analysis revealed that MC-ASRS had a better construct validity than UC-ASRS based on the above factor solution in another children sample. In conclusion, the MC-ASRS shows better efficacy in epidemiological screening for ASD in Chinese children.

Chinese Norms for the Autism Spectrum Rating Scale

This study aimed to establish norms for the modified Chinese version of the Autism Spectrum Rating Scale (ASRS). Participants were recruited from Shanghai, Harbin, Guangzhou, and Changsha, China, and their parents and teachers were invited to complete the Chinese Parent version and the Teacher version of the ASRS. In both versions, boys had significantly higher sub-scale scores and total score (T-score) by 1–3 and 4–5 points respectively, than girls (both P < 0.001). Age had weak correlations with some sub-scores and the T-score (r ranged from −0.1859 to 0.0738), and some reached significance (P < 0.03). The correlations appeared stronger and were more common in females. The T-score based on Chinese norms ideally correlated with the score based on the United States norms in boys and girls for both versions. Norms for the Chinese version of the ASRS for children aged 6–12 years are proposed and may be helpful for screening individuals with autism spectrum disorders from the general population of children.