A new screening programme for autism in a general population of Swedish toddlers

Persistence of the developmental language disorder diagnosis, neurodevelopmental trajectories and attendance at offered interventions

AIM

To study the diagnostic stability of developmental language disorders, other neurodevelopmental disorders and interventions received until age 6 years in children who screened positive for language delay, but not for autism, at age 2.5 years.

METHODS

In 2016, in Gothenburg, Sweden, 100 monolingual or multilingual children underwent language assessment at a mean age of 2.9 years. At age 6 years, 85 of these children underwent language assessment. A review of paediatric records was performed after the clinical assessment to obtain information about other neurodevelopmental disorders and interventions received.

RESULTS

At age 6 years, 74/85 (87%) of the children had persistent language disorders, and 20/85 (24%) had been diagnosed with at least one additional neurodevelopmental disorder. Five of them had autism. In general, families only attended half of the offered intervention sessions irrespective of intervention type and no difference between monolingual and multilingual families was found.

CONCLUSIONS

The persistence of language disorder and the presence of later additional neurodevelopmental disorders highlight the importance of longitudinal and multidisciplinary monitoring of children with delayed language development. Further studies and analyses are warranted to investigate the reasons behind the poor attendance rate for interventions offered.

Encountering children with suspected neurodevelopmental disorders in Child Health Services: Swedish nurses' experiences

PURPOSE

To describe nurses' experiences encountering children with suspected neurodevelopmental disorders in Child Health Services.

DESIGN AND METHODS

This qualitative inductive study was conducted in Sweden. Twenty nurses were interviewed individually on a virtual platform using a semi-structured interview guide with open-ended and explorative questions. Interviews were audio recorded and transcribed verbatim and analyzed using qualitative content analysis.

RESULTS

Nurses expressed responsibility for finding deviations in children but described an equilibrium of giving children time to develop without delaying referrals. Nurses had profound competence and intuition, but subjective intuition of assessment evoked a feeling of uncertainty. Nurses were sensitive and open-minded to different and contradictory parental reactions. Reactions were difficult and frustrating to manage, and communication needed to be versatile and flexible to achieve a partnership. When uncertain in an assessment they obtained complementary additional information from the child's preschool teacher. Nurses had several collaborators inside and outside the Child Health Services team and felt successful when correctly referred but frustrated with extended waiting times and protracted interplay.

CONCLUSIONS

The results suggest further education for nurses about neurodevelopmental disorders and communication tools like Motivational Interviewing. Furthermore, screening for assessing neurodevelopmental disorders, guidelines in referral management and a care coordinator for multiple referrals should be implemented.

PRACTICE IMPLICATIONS

Improvements in Child Health Services nurses' competence, screening methods and referral management could lead to more efficient care interventions and support that can promote health and well-being in the short and long-term for children and families.

Bridging gaps in healthcare: child health services and specialist care collaboration for young children with autism and coexisting conditions

Aim

This study aimed to evaluate a clinical project aiming to address gaps in healthcare for young children in an immigrant, low-resource district from early identification of regulatory problems, autism, and other neurodevelopmental symptoms by child health services to assessment and interventions in specialist care.

Methods

A mixed-model design was employed, consisting of a description of the clinical project and data from healthcare statistics to evaluating the care chain. Qualitative in-depth interviews were conducted to capture the perspectives of participating child health nurses. Data were analyzed using content analysis.

Results

The mean age for referral from primary to specialist care for suspected autism decreased from 38 to 27 months at (n = 59). A total of 55 children were diagnosed with autism. The mean age at autism diagnosis decreased from 44 to 31 months. Waiting times from referral to intervention were shortened. Interventions were already initiated in primary care at the time of referral. Qualitative analyses of nurse experiences revealed three main categories: (1) new and increased knowledge, (2) great importance for every child and family, and (3) an efficient method with fewer gaps, which holds further potential for development.

Conclusion

Professionals' increased knowledge of early symptoms in children, combined with novel healthcare methods for close collaboration, made it possible to bridge the gaps and provide young children and their families with early assessments and essential early interventions. The study results point to opportunities for integrated healthcare and collaboration with families and preschools.

Speech sound error patterns may signal language disorder in Swedish preschool children with autism

BACKGROUND

Within cohorts of children with autism spectrum disorder (ASD) there is considerable variation in terms of language ability. In the past, it was believed that children with ASD either had delayed articulation and phonology skills or excelled in those areas compared to other language domains. Very little is known about speech sound ability in relation to language ability and non-verbal ability in Swedish preschool children with ASD.

AIM

The current study aimed to describe language variation in a group of 4-6-year-old children with ASD, focusing on in-depth analyses of speech sound error patterns with and without non-phonological language disorder and concomitant non-verbal delays.

METHOD & PROCEDURES

We examined and analysed the speech sound skills (including consonant inventory, percentage of correct consonants and speech sound error patterns) in relation to receptive language skills in a sample of preschool children who had screened positive for ASD in a population-based screening at 2.5 years of age. Seventy-three children diagnosed with ASD participated and were divided into subgroups based on their receptive language (i.e., non-phonological language) and non-verbal abilities.

OUTCOMES & RESULTS

The subgroup division revealed that 29 children (40%) had language delay/disorder without concurrent non-verbal general cognitive delay (ALD), 27 children (37%) had language delay/disorder with non-verbal general cognitive delay (AGD), and 17 children (23%) had language and non-verbal abilities within the normal range (ALN). Results revealed that children with ALD and children with AGD both had atypical speech sound error patterns significantly more often than the children with ALN.

CONCLUSIONS & IMPLICATIONS

This study showed that many children who had screened positive for ASD before age 3 years - with or without non-verbal general cognitive delays - had deficits in language as well as in speech sound ability. However, individual differences were considerable. Our results point to speech sound error patterns as a potential clinical marker for language problems (disorder/delay) in preschool children with ASD.

WHAT THIS PAPER ADDS

What is already known on the subject Children with autism spectrum disorder (ASD) have deficits in social communication, restricted interests and repetitive behaviour. They show very considerable variation in both receptive and expressive language abilities. Previously, articulation and phonology were viewed as either delayed in children with ASD or superior compared with other (non-phonological) language domains. What this paper adds to existing knowledge Children with ASD and language disorders also have problems with speech sound error patterns. What are the potential or actual clinical implications of this work? About 75% of children with ASD experience language delays/disorders, as well as speech sound problems, related to speech sound error patterns. Understanding/acknowledging these phonological patterns and their implications can help in the diagnosis and intervention of speech sound disorders in children with ASD. Direct intervention targeting phonology might lead to language gains, but more research is needed.

Autism Detection in Early Childhood (ADEC) in a Low-Income Spanish-Speaking Population in Guayaquil (Ecuador)

Autism Spectrum Disorder (ASD) must be present early in development, but may not fully manifest until social demands exceed capacities. In the absence of adequate biological or brain imaging markers to detect and diagnose autism, diagnosis relies on clinical judgment based on observation of symptoms. Many tools have been developed in English-speaking countries (questionnaires for parents, symptom checklists for professionals, observation systems, etc.). Screening in countries with other languages requires cultural and linguistic adaptation of these instruments. This paper presents the adaptation of the ADEC (Autism Detection in Early Childhood).

METHODS

The original version of the ADEC was translated and culturally and linguistically adapted to the characteristics of the population of Guayaquil (Ecuador).

PARTICIPANTS

A pilot study was conducted with a sample of 613 children aged 18-48 months.

RESULTS

Cronbach's alpha values (0.89) indicate high internal consistency. The correlation between the MCHAT-R/F follow-up interview and the ADEC (mean r = 0.93) indicates high construct validity. In terms of predictive validity, using the original cut-off points of the ADEC, they show excellent diagnostic ability. The sensitivity and specificity results (sensitivity 1.00; specificity 0.92; positive predictive value 0.83; negative predictive value 0.99) are even better than those obtained in a similar study in the Mexican population.

CONCLUSIONS

Considering that the MCHAT R/F is a parent-reported instrument, the Guayaquil Spanish version of the ADEC (ADEC-GU) seems to be a suitable instrument to be used in a complementary way as a second-level screening instrument for autism, before resorting to a full diagnostic process.

Screening for Autism Spectrum Disorder in Young Children: Still Not Enough Evidence

BACKGROUND

Early detection of autism spectrum disorder (ASD) has the potential to significantly reduce the impact of the condition, however previous reviews have found little evidence to support screening programs for ASD in young children.

METHODS

We conducted a review with the aim of updating evidence on 3 aspects: (a) diagnostic stability of ASD in young children; (b) accuracy of ASD screening tools in young children; and (c) the benefits of early interventions in screen-detected young children with ASD.

RESULTS

A total of 33 studies were included in our review. Five studies looking at diagnostic stability reported estimates ranging from 71.9% to 100%, however the majority only included a follow-up of 24 months and all studies raised concerns regarding the risk of bias due particularly to lack of blinding, sample size, and patient flow. A total of 25 studies, reported in 26 articles, were identified that reported accuracy data on 11 screening tools. Most of the reports were concerned with versions of M-CHAT, reporting sensitivity estimates from 0.67 to 1.0; however, many of these were deemed to be of high risk of bias due to lack of blinding and follow-up. Four studies reported on early interventions in screen-detected children; however, the majority did not find significant improvements on the relevant outcomes.

CONCLUSIONS

Overall, the evidence on screening for ASD in young children captured by this review is not conclusive regarding the 3 aspects of screening in this population. Future studies should attempt to ensure blinded diagnostic assessments, include longer follow-up periods and limit attrition.

A feasibility study of a new instrument for detection of autism signs in preschool settings. Psychometric properties of the joint attention observation schedule preschool (JA-OBS preschool)

Background

Identifying signs of autism is essential for enabling timely diagnosis and intervention. Children from multiethnic and socioeconomic disadvantaged settings are typically diagnosed with autism later than their general peers. This feasibility study explored the psychometric properties of a new instrument, Joint Attention Observation Schedule Preschool (JA-OBS Preschool), in children with suspected autism.

Methods

Data were collected from a prospective longitudinal study of 46 children aged 2-4 years who lived in a multiethnic, low resource area. The children had been referred from the Child Health Centre to a multiprofessional team for a neuropsychiatric assessment. In the diagnostic process, the instrument JA-OBS Preschool for observation of a child's capability of engaging in joint attention was included. Descriptive statistics and Cronbach's alfa were used to analyze the psychometric properties, including internal consistency reliability and inter-rater consistency.

Results

All 46 children with suspected autism screened positive on the JA-OBS Preschool. The internal consistency reliability of the instrument was calculated at 0.8 (Cronbach's alfa). Percent agreement between two examiners in JA-OBS Preschool ranged from 77% to 100%.

Conclusion

JA-OBS Preschool was found to be a promising instrument for identifying signs of autism in children in this setting. However, further research is needed to determine the psychometric properties of the JA-OBS Preschool in a general child population as well as in a younger age group.

A proposed service model for early identification of autism spectrum disorder in ethnic communities in Southern Israel

Early autism spectrum disorder (ASD) detection is a precondition for effective intervention and facilitates significant improvements in functioning. In Israel, toddlers undergo general developmental screening by public health nurses (PHNs) at maternal and child health centres (MCHCs). Nevertheless, there are disparities among ethnic groups in the reported incidence of ASD. By means of an ecological model (EM), we identified strategies that improve ASD detection in the Bedouin community by investigating the social and policy factors that affect diagnosis. We conducted in-depth interviews with 18 policy makers and service providers and three focus groups of PHNs and paediatricians. We mapped the strategies for identifying toddlers with ASD based on the three EM levels. Correlations were established by comparing the codes within and between the EM levels. At the macro-level, the policy makers' strategy for improving ASD detection in the Bedouin community reflected the ideology, values and goals of the PHNs and included the MCHCs as the sole institution involved in detecting ASD. At the meso-level of the service providers, the key elements of the strategy consisted of actualising the professional potential of PHNs and patients' case management. At the micro-level was the population that utilises the services and complies with recommendations. A correlation was established between the PHNs' values and goals and patients' case management. Actualising their professional potential influenced the population's compliance. To reduce gaps in ASD diagnosis between Bedouin communities and the general population, it is necessary to identify and change the policy factors that influence access to services for children with ASD at every EM level while incorporating PHNs from the Bedouin community in future services. Culturally appropriate policies, screening policies and interventions must be developed to serve the needs of Bedouin children.

A longitudinal case study of six children with autism and specified language and non-verbal profiles

Language skills as well as general cognitive skills show a considerable variation in children with autism spectrum disorder (ASD). In previous studies, at least three profiles based on these skills have been suggested; autism with language and non-verbal cognitive skills within the average/normal range (ALN), autism with language disorder (ALD) without concurrent non-verbal cognitive disability, and autism with language disorder and cognitive disability, i.e. autism with a more general delay (AGD). The aim of the present longitudinal case study is to illustrate these three groups more thoroughly by presenting the developmental trajectories of children belonging to each profile. Six children were chosen based on their language and cognitive profiles from the first age 3-year assessment. They came from a larger group of children with ASD identified by autism screening at child health-care centres at age 2.5 years. These six children represent one boy and one girl from each of the three subgroups ALN, ALD and AGD, and were assessed a second time at age 5 and a third time at age 8 years, regarding expressive and receptive language skills, autistic severity and non-verbal cognitive skills. Although preliminary, our results indicate a rather stable developmental trajectory from age 3 to 8 years characterising children with autism based on language and non-verbal cognitive functioning. Thus, in order to help intervention planning and increase predictions of outcome, it seems important to specify both linguistic and cognitive level already at the first assessment in children with ASD.

Multi-professional and multi-agency model PLUSS to facilitate early detection and support of pre-school children with neurodevelopmental difficulties - a model description

Background

Neurodevelopmental difficulties, such as problems in social inter-relatedness, communication, motor coordination, and attention, are frequent in preschoolers and constitute a risk for later negative consequences. This article describes the development of a multi-professional and multi-agency model, PLUSS, to facilitate care and interventions for preschoolers with neurodevelopmental difficulties.

Methods

The PLUSS model was developed for children aged 1.5–5 years with a need for a further assessment of neurodevelopmental symptoms. The model is evaluated using a quasi-experimental study design along with qualitative interviews that study preschool teacher, and parent experiences of PLUSS. Outcomes of interest are a) implementation, b) effectiveness related to processes and multi-agency collaboration, c) capacity building among professionals, d) child-related outcomes with a longitudinal follow-up as well as d) parental wellbeing and satisfaction.

Results

The model was launched in 2019 and so far, approximately 130 children have been assessed. Results from a pilot study with 62 children (27–72 months; boys: girls 2.65:1) show that the total mean SDQ score in parental rating was 15 ± 6 and in preschool teacher ratings 14 ± 7, exceeding the Swedish cut-off of 12. 54 parents have participated in parental training and rate high levels of satisfaction (mean score 4.5, max 5.0). In addition, 74 pre-school professionals have been trained in early signs of neurodevelopmental difficulties to facilitate early detection. Feedback from participants indicates high satisfaction with educational activities (mean score 4.2, max 5.0 = very satisfied).

Conclusions

The pilot study shows that the screening procedure can detect children with clinically significant problems. In addition, participant satisfaction is high in parent- and preschool teacher training. The longitudinal study approach enables both child follow-up and evaluation of interventions provided by the working model.

Trial registration

Clinical Trials 2021, PLUSS identifier, NCT04815889. First registration 25/03/2021.

Tools for early screening of autism spectrum disorders in primary health care - a scoping review

BACKGROUND

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that manifests itself in early childhood. Early diagnosis of these disorders allows for the initiation of early therapy, which is crucial for the child's further functioning in society.

OBJECTIVES

This review aims to gather and present the existing ASD screening tools that can be used in primary care and adapted to different countries conditions linguistically and culturally.

ELIGIBILITY CRITERIA

We searched for English-language publications on ASD screening tools for children aged 0-3 years suitable for use in primary care (i.e. free, requiring no additional training or qualifications).

SOURCES OF EVIDENCE

Four databases were explored to find English studies on ASD screening tools intended for the rapid assessment of children aged 0-3.

CHARTING METHODS

The information sought (specific features of the questionnaires relevant to primary health care workers, psychometric and diagnostic values of a given cultural adaptation of screening tools, and the linguistic and cultural changes made) were extracted and collected to create profiles of these tools.

RESULTS

We found 81 studies which met inclusion criteria and underwent full data extraction. Three additional data sources were included. These allowed to create 75 profiles of adaptations for 26 different screening tools and collect data on their psychometric values and characteristic features.

CONCLUSIONS

The results of our study indicate the availability of several diagnostic tools for early ASD screening in primary care setting concordant culturally and linguistically with a given population. They could be an effective method of accelerating the diagnostic process and starting personalized therapy faster. However, most tools have significant limitations - some are only available for research purposes, while others do not have scientific evidence to prove their effectiveness.

The Bidirectional Social-Cognitive Mechanisms of the Social-Attention Symptoms of Autism

Differences in social attention development begin to be apparent in the 6th to 12th month of development in children with Autism Spectrum Disorder (ASD) and theoretically reflect important elements of its neurodevelopmental endophenotype. This paper examines alternative conceptual views of these early social attention symptoms and hypotheses about the mechanisms involved in their development. One model emphasizes mechanism involved in the spontaneous allocation of attention to faces, or social orienting. Alternatively, another model emphasizes mechanisms involved in the coordination of attention with other people, or joint attention, and the socially bi-directional nature of its development. This model raises the possibility that atypical responses of children to the attention or the gaze of a social partner directed toward themselves may be as important in the development of social attention symptoms as differences in the development of social orienting. Another model holds that symptoms of social attention may be important to early development, but may not impact older individuals with ASD. The alterative model is that the social attention symptoms in infancy (social orienting and joint attention), and social cognitive symptoms in childhood and adulthood share common neurodevelopmental substrates. Therefore, differences in early social attention and later social cognition constitute a developmentally continuous axis of symptom presentation in ASD. However, symptoms in older individuals may be best measured with in vivo measures of efficiency of social attention and social cognition in social interactions rather than the accuracy of response on analog tests used in measures with younger children. Finally, a third model suggests that the social attention symptoms may not truly be a symptom of ASD. Rather, they may be best conceptualized as stemming from differences domain general attention and motivation mechanisms. The alternative argued for here that infant social attention symptoms meet all the criteria of a unique dimension of the phenotype of ASD and the bi-directional phenomena involved in social attention cannot be fully explained in terms of domain general aspects of attention development.

Construction of a tool for assessment of joint attention in Egyptian Cairene children

Background

Joint attention (JA) is a basic social communicative skill important for language development. JA deficits appear prior to language acquisition. Because autism is often not diagnosed until a child is three or four years of age, it is important to look for indicators prior to language acquisition such as JA to provide appropriate treatment at a younger age. Therefore, the aim of this study is to construct an objective tool for assessment of joint attention skills in young Egyptian children to detect the presence of autistic behaviour in high-risk children in order to conduct plans for early intervention. The questionnaire was constructed to assess the five main components of JA and was termed Egyptian Joint Attention Questionnaire. The questions were formulated in the colloquial Egyptian Arabic language and in an ‘easy-to understand’ design that would be comprehensible by mothers. No question was directly translated from another questionnaire. Ten typically developing (TD) children, with an age range of 18–54 months, were included in the pilot study of the test design. It was applied to 90 TD children and 30 autistic children (contrast group) within the same age range. Participant's responses were statistically analysed to assess the validity and reliability of the questionnaire and to compare the responses related to TD children and autistic children.

Results

There was high internal consistency and reliability of the questionnaire (Cronbach’s α = 0.9, Intra-class correlation = .776), with a statistically significant difference between TD and autistic children (P < 0.001).

Conclusions

The questionnaire is a valid and reliable assessment tool that could be used in early detection of autistic Egyptian children.

DSM-5 symptom expression in toddlers

LAY ABSTRACT

Children with autism show more social-communication symptoms and repetitive behaviors than children with typical development or those diagnosed with other developmental disorders; however, non-autistic children often show some behaviors that are associated with autism. We compared the behavioral reports from caregivers of children in these three groups to identify the behaviors that were specific to autism. Children with autism were found to show more of these behaviors, and behaviors that are particularly indicative of autism were identified. These behaviors included social symptoms (approaching others to interact, showing things, looking back while showing, responding to an approaching child, spontaneous imitation) and repetitive behavior symptoms (specific, inflexible play, unusual body movements, strong specific interest, carrying around an unusual object, sensory seeking, and sensory hyper-reactivity).These findings may aid professionals in determining the most appropriate diagnosis for a child between the ages of 12 and 36 months.

Detection of Early Warning Signs in Autism Spectrum Disorders: A Systematic Review

Due to the exponential increase of autism spectrum disorders’ prevalence in Western countries, it is necessary to improve early detection and intervention to enhance developmental milestones. This systematic review identified the most effective screening instrument, which can be used at an early age and which identifies the maximum number of autism cases. We identified several instruments with adequate predictive properties—the Autism Parent Screen for Infants (APSI), Battelle Development Inventory, second edition (BDI-2); Brief Infant-Toddler Social and Emotional Assessment (BITSEA); First Year Inventory (FYI); Infant-Toddler Checklist/Communication and Symbolic Behavior Scales Developmental Profile (ITC/CSBS-DP); Program of Research and Studies on AUTISM (PREAUT-Grid); Checklist for Early Signs of Developmental Disorders (CESDD); Social Attention and Communication Study (SACS); and the Screening Tool for Autism in Toddlers and Young Children (STAT)—that can be applied from 12 months of age in Western countries. The ITC/CSBS-DP has been proposed for universal screening from 12 months of age onwards, complemented by the Modified Checklist for Autism in Toddlers, Revised/Revised with Follow-Up (M-CHAT-R/F), which can be used from 15 months of age onwards. This strategy could improve early detection in at-risk children within the current health system, thus allowing for early intervention.

Spanish Cultural Validation of the Modified Checklist for Autism in Toddlers, Revised

The Modified Checklist for Autism in Toddlers-revised/follow-up (M-CHAT-R/F) was developed to reduce the number of cases requiring telephone verification. The aim of this study was to validate a Spanish version of the M-CHAT-R/F in the Spanish public health system. The M-CHAT-R/F was translated, culturally adapted, and then administered to 6625 children. Of the 39 positive screening cases, 15 children were diagnosed with autism spectrum disorder (ASD) and 24 with non-ASD disorders or delays. The sensitivity was 0.79 and specificity of 0.99. Positive and negative predictive values were 0.39 and 0.99, respectively. These results are similar to the English equivalent, though observed prevalence was lower. This study supports Spanish National Health System policy makers to consider a universal ASD screening program.

Inherited Risk for Autism Through Maternal and Paternal Lineage

BACKGROUND

Autism spectrum disorder (ASD) is highly familial, with a positively skewed male-to-female ratio that is purported to arise from the so-called female protective effect. A serious implication of a female protective effect is that familial ASD liability would be expected to aggregate asymptomatically in sisters of affected probands, who would incur elevated rates of ASD among their offspring. Currently, there exist no data on second-generation recurrence rates among families affected by ASD.

METHODS

We analyzed data from the Swedish National Patient Register and the Multi-Generation Register for a cohort of children born between 2003 and 2012. ASD was ascertained in both the child and parental generations.

RESULTS

Among 847,732 children, 13,103 (1.55%) children in the cohort were diagnosed with ASD. Among their maternal/paternal aunts and uncles, 1744 (0.24%) and 1374 (0.18%) were diagnosed with ASD, respectively. Offspring of mothers with a sibling(s) diagnosed with ASD had higher rates of ASD than the general population (relative risk, 3.05; 95% confidence interval, 2.52-3.64), but not more than would be predicted for second-degree relatives within a generation, and only slightly more than was observed for fathers with siblings with ASD (relative risk, 2.08; 95% confidence interval, 1.53-2.67). Models adjusting for temporal trends and for psychiatric history in the parental generation did not alter the results.

CONCLUSIONS

These findings establish a robust general estimate of ASD transmission risk for siblings of individuals affected by ASD, the first ever reported. Our findings do not suggest female protective factors as the principal mechanism underlying the male sex bias in ASD.

Culturally diverse families of young children with ASD in Sweden: Parental explanatory models

BACKGROUND

Research suggests that families' knowledge and cultural perceptions of autism spectrum disorder (ASD), and beliefs about its etiology and prognosis, can affect parents' recognition of the first signs of autism in their children and influence help seeking and treatment decisions.

OBJECTIVE

This study investigated explanatory models of autism among parents of young children with ASD in the multicultural context of Sweden.

METHOD

Seventeen parents from diverse cultural, ethnic and linguistic backgrounds participated in semi-structured interviews. A deductive approach to qualitative content analysis was used to analyze data. Five domains of the Explanatory Model supplementary module of the Cultural Formulation Interview (CFI) were used as coding categories, operationalized as 'Parents' understanding of autism'; 'Autism prototypes'; 'Causal explanations'; 'Course of autism', and 'Help seeking and treatment expectations'.

RESULTS

The results showed that parents' prior knowledge of autism and experience of young children's typical developmental trajectories, as well as the opinions of children's grandparents and preschool teachers, affected symptom recognition and help seeking. There were differences in parents' explanatory models before and after ASD diagnosis. Initial interpretations of the disorder included medical conditions and reaction to environmental influences, while genetic, supernatural/religious factors, and vaccinations were mentioned as definite causes after obtaining a clinical diagnosis. Parents also held multiple explanatory models, influenced by the views of family members and information obtained from media or from health care professionals. Parents' treatment decisions included use of available state-funded support services, and complementary and alternative treatments.

CONCLUSION

The results demonstrate the utility of the CFI's Explanatory Model supplementary module in autism research. Implications for clinical practice are discussed.

A High Prevalence of Autism Spectrum Disorder in Preschool Children in an Immigrant, Multiethnic Population in Sweden: Challenges for Health Care

This study examines the prevalence of autism spectrum disorder (ASD) in preschool children in an immigrant population. Possible risk factors for ASD and individual needs for the children and their families are described, as well as implications for health care. The estimated minimum prevalence for ASD in the area was 3.66% for children aged 2–5 years. Multiple risk factors and extensive individual needs for the children and their families were observed. The high prevalence of ASD and the plethora of needs in immigrant communities pose challenges for health care. A coordinated health care system is necessary to meet the many and individual needs.

Screening Tools for Autism Spectrum Disorder in Primary Care: A Systematic Evidence Review

CONTEXT

Recommendations conflict regarding universal application of formal screening instruments in primary care (PC) and PC-like settings for autism spectrum disorder (ASD).

OBJECTIVES

We systematically reviewed evidence for universal screening of children for ASD in PC.

DATA SOURCES

We searched Medline, PsychInfo, Educational Resources Informational Clearinghouse, and Cumulative Index of Nursing and Allied Health Literature.

STUDY SELECTION

We included studies in which researchers report psychometric properties of screening tools in unselected populations across PC and PC-like settings.

DATA EXTRACTION

At least 2 authors reviewed each study, extracted data, checked accuracy, and assigned quality ratings using predefined criteria.

RESULTS

We found evidence for moderate to high positive predictive values for ASD screening tools to identify children aged 16 to 40 months and 1 study for ≥48 months in PC and PC-like settings. Limited evidence evaluating sensitivity, specificity, and negative predictive value of instruments was available. No studies directly evaluated the impact of screening on treatment or harm.

LIMITATIONS

Potential limitations include publication bias, selective reporting within studies, and a constrained search.

CONCLUSIONS

ASD screening tools can be used to accurately identify percentages of unselected populations of young children for ASD in PC and PC-like settings. The scope of challenges associated with establishing direct linkage suggests that clinical and policy groups will likely continue to guide screening practices. ASD is a common neurodevelopmental disorder associated with significant life span costs.^1,2 Growing evidence supports functional gains and improved outcomes for young children receiving intensive intervention, so early identification on a population level is a pressing public health challenge.^3,4.

Systematic Review of Level 1 and Level 2 Screening Tools for Autism Spectrum Disorders in Toddlers

The present study provides a systematic review of level 1 and level 2 screening tools for the early detection of autism under 24 months of age and an evaluation of the psychometric and measurement properties of their studies. Methods: Seven databases (e.g., Scopus, EBSCOhost Research Database) were screened and experts in the autism spectrum disorders (ASD) field were questioned; Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines and Consensus-based Standard for the selection of health Measurement INstruments (COSMIN) checklist were applied. Results: the study included 52 papers and 16 measures; most of them were questionnaires, and the Modified-CHecklist for Autism in Toddler (M-CHAT) was the most extensively tested. The measures' strengths (analytical evaluation of methodological quality according to COSMIN) and limitations (in term of Negative Predictive Value, Positive Predictive Value, sensitivity, and specificity) were described; the quality of the studies, assessed with the application of the COSMIN checklist, highlighted the necessity of further validation studies for all the measures. According to COSMIN results, the M-CHAT, First Years Inventory (FYI), and Quantitative-CHecklist for Autism in Toddler (Q-CHAT) seem to be promising measures that may be applied systematically by health professionals in the future.

Autism With and Without Regression: A Two-Year Prospective Longitudinal Study in Two Population-Derived Swedish Cohorts

Two community-based cohorts of children with autism spectrum disorder, examined using similar assessment protocols, were pooled (n = 301) and subdivided according to history of regression. Those with regression (n = 62), 20.5% of the combined cohort, were contrasted with those without regression (n = 241) at first assessment (age range 19–60 months) and at 2-year follow-up on a range of measures. The regression group was significantly more functionally impaired, with regard to intellectual function (p < .001), language development (p < .001), and to severity of autism (p < .01) at both T1 and T2. Only 14 (23.3%) had a clearly identified underlying etiology [24 (18.6%) in the non-regressive group]. There were no significant differences between those who had regressed ‘from normal’ and those who had regressed ‘from low’ functioning.

Neurodevelopmental problems should be considered in children with febrile seizures

AIM

Clinical developmental phenotyping of four- to five-year-old children with febrile seizures (FSs).

METHODS

Children with FS (n = 157, corresponding to 3.7% of the targeted general population of four-five-year-olds) had been identified at child healthcare centres in Gothenburg. Parents of 73 children (41 boys, 32 girls) accepted participation in the present study. The assessments included a neuropaediatric assessment, Movement ABC, Wechsler Preschool and Primary Scale of Intelligence-III and parent questionnaires (Five-to-Fifteen (FTF) and Strengths and Difficulties Questionnaire (SDQ)). Hospital records were reviewed, when applicable.

RESULTS

One-third of the children had at least one DSM-5 neurodevelopmental disorder diagnosis or marked developmental problems within areas of attention, activity regulation, behaviour, speech and language, general cognition or motor functioning. No differences were found between children with single vs recurrent or simple vs complex FS.

CONCLUSION

Febrile seizure are relatively often associated with Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations (ESSENCEs). We found no indications that ESSENCE might be caused by FS per se. However, the results suggest that child healthcare professionals should consider the possibility of ESSENCE in children with a history of FS.

Toddler Screening for Autism Spectrum Disorder: A Meta-Analysis of Diagnostic Accuracy

Great efforts focus on early detection of autism spectrum disorder, although some scientists and policy-makers have questioned early universal screening. The aim of this meta-analysis was to evaluate the diagnostic accuracy of the different screening tools. Several electronic databases were used to identify published studies. A Bayesian model was used to estimate the screening accuracy. The pooled sensitivity was 0.72 (95% CI 0.61–0.81), and the specificity was 0.98 (95% CI 0.97–0.99). Subgroup analyses to remove heterogeneity indicated sensitivity was 0.77 (95% CI 0.69–0.84), and specificity was 0.99 (95% CI 0.97–0.99; SD ≤ 0.01). Level 1 screening tools for ASD showed consistent statistically significant results and therefore are adequate to detect autism at 14–36 months.

Cingulate impairments in ADHD: Comorbidities, connections, and treatment

The entire cingulate cortex is engaged in the structure/function abnormalities found in attention-deficit/hyperactivity disorder (ADHD). In ADHD, which is the most common developmental disease, impaired impulse control and cognition often trace to anterior midcingulate cortex (aMCC) in Go/No-go tests, decoding and reading, the Stroop Color and Word Test, and the Wisconsin Card Sorting Test (WCST), with volume deficits in anterior cingulate cortex (ACC) and posterior midcingulate cortex (pMCC). Volumes in pMCC correlate positively with the WCST and negatively with total and nonperseverative errors on the WCST. Activation and connectivity on N-back tests show connections for high and low spatial working memory, but patients have increased activation in PCC and decreased connectivity between MCC and PCC for high load. Students struggle in class due to malfunctioning aMCC, pregenual anterior cingulate cortex (pACC), and dorsal posterior cingulate cortex (dPCC), and to core deficits in response/task switching in aMCC. Gene mutations are found in the DA transporter and DA4 and DA5 receptors. Methylphenidate decreases hyperactivity in aMCC. The DA system is controlled by cholinergic receptors in the daMCC and genetics show nAChR mutations in alpha 3, 4, and 7 receptors. At 25 years, a modified Eriksen flanker/No-go task and voxel-based morphometry (VBM) show prenatal smoking, lifetime smoking at 13 years, and novelty seeking. Prenatal exposure to nicotine exhibits weaker responses in aMCC during cognitive tasks for hyperactivity/impulsiveness but not inattention. AZD1446 (ɑ4β2 nAChR agonist) improves the Groton Maze task due to high nAChR in dPCC/RSC engaged in spatial orientation. Environmental factors associated with childhood ADHD relate to pesticides, organochlorine, and air pollutants. Network connection segregation shows increased amygdala local nodal, but decreased ACC and PCC connections, reflecting emphasis on local periamygdala connections at the expense of cortical connections. Thus, ADHD children/adolescents respond impulsively to the significance of stimuli without having cortical inhibition. Finally, controls show negative relationships between aMCC and the default mode network, and ADHD compromises this relationship, showing decreased connectivity between ACC and precuneus/PCC.

Experiences Of Immigrant Parents In Sweden Participating In A Community Assessment And Intervention Program For Preschool Children With Autism

BACKGROUND

Barriers inherent in service systems for autism can hinder parents from getting help for their children, and this is probably especially true for immigrant parents. In order to provide accessible assessment and interventions for preschool children with autism, a multidisciplinary team was established in one district of a Swedish city, with a majority population of immigrants.

AIM

The aim of the present study was to gain knowledge of the parents' experiences of participating in the community assessment and intervention program.

METHODS AND PROCEDURES

A qualitative study with semi-structured interviews was conducted with parents of 11 children aged 3-5, who had been diagnosed with autism and participated in the community intervention program for at least 1 year. The interviews were recorded and transcribed verbatim, and data were analyzed following a phenomenological hermeneutical method.

RESULTS

The overall meaning of the parents' narratives was interpreted as "A new way of understanding my child made life more hopeful and more challenging than before". Their experience was interpreted as a process, captured in the three main themes: "An overwhelming diagnosis", "Cooperating with the team", and "Growing as a parent".

CONCLUSION

As lacking knowledge of available resources and support seems to be an important barrier to access services, the results underscore the importance of providing individually tailored services including comprehensive societal support to immigrant families with young children suffering from autism. The study also highlights the importance of addressing the parents' previous awareness and knowledge of autism early in the assessment process, as well as continually involving parents in the intervention program, and this may enhance parental growth.

Current profiles and early predictors of reading skills in school-age children with autism spectrum disorders: A longitudinal, retrospective population study

This study explores current reading profiles and concurrent and early predictors of reading in children with autism spectrum disorder. Before the age of 3 years, the study cohort underwent a neurodevelopmental assessment following identification in a population-based autism screening. At age 8 years, reading, language and cognition were assessed. Approximately half of the sample ( n = 25) were ‘poor readers’ at age 8 years, meaning that they scored below the normal range on tests of single word reading and reading comprehension. And 18 were ‘skilled readers’ performing above cut-offs. The final subgroup ( n = 10) presented with a ‘hyperlexic/poor comprehenders’ profile of normal word reading, but poor reading comprehension. The ‘poor readers’ scored low on all assessments, as well as showing more severe autistic behaviours than ‘skilled readers’. Group differences between ‘skilled readers’ and ‘hyperlexics/poor comprehenders’ were more subtle: these subgroups did not differ on autistic severity, phonological processing or non-verbal intelligence quotient, but the ‘hyperlexics/poor comprehenders’ scored significantly lower on tests of oral language. When data from age 3 were considered, no differences were seen between the subgroups in social skills, autistic severity or intelligence quotient. Importantly, however, it was possible to identify oral language weaknesses in those that 5 years later presented as ‘poor readers’ or ‘hyperlexics’.

Development problems were common five years after positive screening for language disorders and, or, autism at 2.5 years of age

AIM

This study identified whether children who had screened positive for either developmental language disorder (DLD) or autism spectrum disorder (ASD) at the age of 2.5 years had neurodevelopmental assessments five years later.

METHODS

Our study cohort were 288 children born from 1 July 2008 to 20 June 2009 who screened positive for DLD and, or, ASD at 2.5 years. Of these, 237 children were referred to, and assessed, at the Paediatric Speech and Language Pathology clinic (n = 176) or the Child Neuropsychiatry Clinic (n = 61) at the Queen Silvia Children's Hospital, Gothenburg, Sweden. Clinical registers covering all relevant outpatient clinics were reviewed five years later with regard to established diagnoses.

RESULTS

When the 237 were followed up five years later, 96 (40%) had established neurodevelopmental disorders or problems, often beyond DLD and ASD. Co-existing problems were common in this cohort and multidisciplinary assessments were indicated. The other 60% did not appear in subsequent clinic records. It is likely that this 40% was a minimum rate and that more children will be referred for developmental problems later.

CONCLUSION

Five years after they had been screened positive for DLD and, or autism at 2.5 years, 40% of our cohort had remaining or other developmental problems.

A systematic review of screening tools in non-young children and adults for autism spectrum disorder

BACKGROUND

Existing reviews of screening tools for Autism Spectrum Disorder (ASD) focus on young children, and not all screening tools have been examined against validated diagnostic procedures.

AIMS

To examine the validity of screening tools for ASD in non-young children and adults to provide clinical recommendations about the use of these tools in a variety of clinical settings.

METHODS AND PROCEDURES

Electronic databases, including MEDLINE, EMBASE, PsychINFO, Cochrane Library and CINAHL, were searched through March 2017. Studies examining the validity of ASD screening tools against the Autism Diagnostic Observation Schedule and/or the Autism Diagnostic Interview - Revised in non-young children (age 4 or above) and adults were included. Three authors independently reviewed each article for data extraction and quality assessment.

OUTCOMES AND RESULTS

14 studies met the inclusion criteria, of which 11 studies were with children (4-18 years of age) and 3 studies included adults only (19 years of age and above). Included studies were conducted in a general population/low-risk sample (N = 3) and a clinically referred/high-risk sample (N = 11). In total 11 tools were included.

CONCLUSIONS AND IMPLICATIONS

Only three screening tools (the Autism-Spectrum Quotient, the Social Communication Questionnaire, and the Social Responsiveness Scale) were examined in more than 2 studies. These tools may assist in differentiating ASD from other neurodevelopmental and psychiatric disorders or typically developed children. In young adult populations, the paucity of the existing research in this group limits definitive conclusion and recommendations.

Systematic review: cultural adaptation and feasibility of screening for autism in non-English speaking countries

Background

Screening children for autism has gained wider acceptance within clinical practice, and early intervention has improved outcomes. Increasingly, adapting an existing screening instrument is a common, fast method to create a usable screening tool, especially for countries with limited resources and/or expertise. However, concerns have been raised regarding adaptation adequacy and the feasibility of screening across cultural groups. This study systematically examined the levels of cultural adaptation and feasibility aspects considered when screening for autism in non-English speaking countries to build upon the sparse knowledge that exists on this topic in the literature.

Methods

Nineteen studies, obtained from five electronic databases, were examined. PRISMA guidance was used for this review. The Ecological Validity Framework model, and Bowen Recommendations for Feasibility were adopted to extract relevant data, which was synthesised narratively.

Results

Cultural adaptation within the included studies mostly involved language translation with little information offered to enable conclusions on how the processes were guided and maintained. Few cultural adjustments involved modifying screening methods; clarifying difficult concepts and changing instrument content were employed to address the core values, competence, beliefs, and norms of the adapted culture. However, less attention was given to adapt the screening goals within the context of cultural values, and customs or to consider interactional match between the clients and assessors. The review also highlighted an acceptable level of practicality to screen for autism but did not encourage integrating autism screening within routine practice or beyond the study context for different cultures.

Conclusion

Concurring with previous literature, we agree that knowledge on cultural adaptation for autism screening instruments is limited and not sufficiently documented to establish adaptation levels (process and/or contents), and prove adequacy. However, this review provides an infrastructure to improve future adaptation processes. Integrating autism screening as routine medical practice is not encouraged and warrants further feasibility studies to minimize wasted resources and improve screening effectiveness in various health care systems.

Young children who screen positive for autism: Stability, change and "comorbidity" over two years

BACKGROUND

Autism spectrum disorder (ASD) is a developmental disorder with a wide variety of clinical phenotypes and co-occurrences with other neurodevelopmental conditions. Symptoms may change over time.

AIMS

The aim of the present study was to prospectively follow 96 children, initially assessed for suspected ASD at an average age of 2.9 years.

METHODS AND PROCEDURES

All children had been identified with autistic symptoms in a general population child health screening program, and had been referred to the Child Neuropsychiatry Clinic in Gothenburg, Sweden for further assessment by a multi-professional team at Time 1 (T1). This assessment included a broad neurodevelopmental examination, structured interviews, a cognitive test and evaluations of the child́s adaptive and global functioning. Two years later, at Time 2 (T2), the children and their parents were invited for a follow-up assessment by the same team using the same methods.

OUTCOMES AND RESULTS

Of the 96 children, 76 had met and 20 had not met full criteria for ASD at T1. Of the same 96 children, 79 met full ASD criteria at T2. The vast majority of children with ASD also had other neurodevelopmental symptoms or diagnoses. Hyperactivity was observed in 42% of children with ASD at T2, and Intellectual Developmental Disorder in 30%. Borderline Intellectual Functioning was found in 25%, and severe speech and language disorder in 20%. The children who did not meet criteria for ASD at T2 had symptoms of or met criteria for other neurodevelopmental/neuropsychiatric disorders in combination with marked autistic traits. Changes in developmental profiles between T1 and T2 were common in this group of young children with ASD. The main effect of Cognitive level at T1 explained more than twice as much of the variance in Vineland scores as did the ASD subtype; children with IDD had significantly lower scores than children in the BIF and AIF group. Co-existence with other conditions was the rule.

CONCLUSIONS AND IMPLICATIONS

Reassessments covering the whole range of these conditions are necessary for an optimized intervention-adapted to the individual child's needs.

Early Detection and Intervention of ASD: A European Overview

Over the last several years there has been an increasing focus on early detection of Autism Spectrum Disorder (ASD), not only from the scientific field but also from professional associations and public health systems all across Europe. Not surprisingly, in order to offer better services and quality of life for both children with ASD and their families, different screening procedures and tools have been developed for early assessment and intervention. However, current evidence is needed for healthcare providers and policy makers to be able to implement specific measures and increase autism awareness in European communities. The general aim of this review is to address the latest and most relevant issues related to early detection and treatments. The specific objectives are (1) analyse the impact, describing advantages and drawbacks, of screening procedures based on standardized tests, surveillance programmes, or other observational measures; and (2) provide a European framework of early intervention programmes and practices and what has been learnt from implementing them in public or private settings. This analysis is then discussed and best practices are suggested to help professionals, health systems and policy makers to improve their local procedures or to develop new proposals for early detection and intervention programmes.

Joint-Attention and the Social Phenotype of School-Aged Children with ASD

The validity of joint attention assessment in school-aged children with ASD is unclear (Lord, Jones, Journal of Child Psychology and Psychiatry 53(5):490-509, 2012). This study examined the feasibility and validity of a parent-report measure of joint attention related behaviors in verbal children and adolescents with ASD. Fifty-two children with ASD and 34 controls were assessed with the Childhood Joint Attention Rating Scale (C-JARS). The C-JARS exhibited internally consistency, α = 0.88, and one factor explained 49% of the scale variance. Factor scores correctly identified between 88 and 94% of the children with ASD and 62-82% of controls. These scores were correlated with the ADOS-2, but not other parent-report symptom measures. The C-JARS appears to assess a unique dimension of the social-phenotype of children with ASD.

Preschool to School in Autism: Neuropsychiatric Problems 8 Years After Diagnosis at 3 Years of Age

The study presents neuropsychiatric profiles of children aged 11 with autism spectrum disorder, assessed before 4.5 years, and after interventions. The original group comprised a community sample of 208 children with ASD. Parents of 128 participated-34 with average intellectual function, 36 with borderline intellectual function and 58 with intellectual disability. They were interviewed using the Autism-Tics, AD/HD and other Comorbidities interview. Criteria for a clinical/subclinical proxy of ASD were met by 71, 89 and 95 %, respectively. Criteria for at least one of ASD, AD/HD, Learning disorder or Developmental Coordination Disorder were met by 82, 94 and 97 %. More than 90 % of children with a preschool diagnosis of ASD have remaining neuropsychiatric problems at 11, despite early intervention.

Instrumentos para Rastreamento de Sinais Precoces do Autismo: Revisão Sistemática

Resumo O rastreamento dos sinais precoces do autismo é crucial para um diagnóstico também precoce, viabilizando uma intervenção efetiva que possibilite a melhora no desenvolvimento e na qualidade de vida do indivíduo com autismo. O objetivo deste estudo foi identificar os instrumentos disponíveis para rastreamento dos sinais do autismo em crianças com até 36 meses de idade. Para tanto, foi conduzida uma revisão de artigos publicados entre 2004 e 2015 nas bases de dados eletrônicas SciELO, PubMed, PsycINFO e Lilacs. Foram encontrados 11 instrumentos em 34 artigos analisados, sendo que apenas um instrumento foi traduzido para o português, o que indica uma escassez desses instrumentos no Brasil. Considerando a relevância da identificação e do diagnóstico precoce do autismo para a melhoria da qualidade de vida do sujeito, acredita-se que é essencial que estudos sobre instrumentos para rastreamento precoce sejam conduzidos no país.

Children who screen positive for autism at 2.5 years and receive early intervention: a prospective naturalistic 2-year outcome study

BACKGROUND

Previous research has stressed the importance of early identification and intervention for children with autism spectrum disorders.

METHODS

Children who had screened positive for autism at the age of 2.5 years in a general population screening and then received a diagnosis of autism spectrum disorder were enrolled in an intervention program provided by Swedish habilitation services. The following interventions were available: a comprehensive intervention based on Applied Behavior Analysis - Intensive Learning (IL) - in two settings, which included home- and preschool-based (IL Regular) and only home-based (IL Modified) and eclectic interventions.

RESULTS

There was considerable variability in terms of outcome, but intervention group status was not associated with any of the chosen outcome variables.

CONCLUSION

The main finding was that the type of intervention was not critical for outcome of adaptive or global functioning. The variability in outcome demonstrates the need for continuous assessments and evaluation of the child's function and behavior throughout the intervention period.

Autism Screening With Online Decision Support by Primary Care Pediatricians Aided by M-CHAT/F

BACKGROUND AND OBJECTIVE

Autism spectrum disorders (ASDs) often go undetected in toddlers. The Modified Checklist for Autism in Toddlers (M-CHAT) With Follow-up Interview (M-CHAT/F) has been shown to improve detection and reduce over-referral. However, there is little evidence supporting the administration of the interview by a primary care pediatrician (PCP) during typical checkups. The goal of this study was to evaluate the feasibility, validity, and reliability of the M-CHAT/F by PCPs with online prompts at the time of a positive M-CHAT screen.

DESIGN

Forty-seven PCPs from 22 clinics completed 197 M-CHAT/Fs triggered by positive M-CHAT screens via the same secure Web-based platform that parents used to complete M-CHATs before an 18- or 24-month well-child visit. A second M-CHAT/F was administered live or by telephone by trained research assistants (RAs) at the Kennedy Krieger Institute Center for Autism and Related Disorders. The Autism Diagnostic Observation Schedule, Second Edition, and the Mullen Scales of Early Learning were administered as criterion measures. Measures of agreement between PCPs and RAs were calculated, and measures of test performance compared.

RESULTS

There was 86.6% agreement between PCPs and RAs, with a Cohen's κ of 0.72. Comparison of sensitivity, specificity, positive predictive value (PPV), and overall accuracy for M-CHAT/F between PCPs and RAs showed significant equivalence for all measures. Use of the M-CHAT/F by PCPs resulted in significant improvement in PPV compared with the M-CHAT alone.

CONCLUSIONS

Minimally trained PCPs can administer the M-CHAT/F reliably and efficiently during regular well-child visits, increasing PPV without compromising detection.

Autism spectrum disorders before diagnosis: results from routine developmental surveillance at 18 months

AIM

This study investigated the results from the national, routine 18-month developmental surveillance at Child Healthcare Centres (CHCs) on children later diagnosed with autism spectrum disorder (ASD).

METHODS

Child Healthcare Centre records of 175 children, diagnosed with ASD before 4.5 years in Stockholm County, Sweden, were reviewed regarding the results of the eight-item neurodevelopmental surveillance. Results were contrasted with normative data from the general child population in Stockholm County.

RESULTS

More than one-third of the total ASD group, including half of the group with ASD and intellectual disability (ID), did not pass the required number of items, compared to one in 50 in the general child population. Of those with ASD and ID who had passed, more than one-third experienced developmental regression after 18 months of age. If the CHC surveillance had considered reported regulatory problems - crying, feeding and sleeping - then another 10% of the children with ASD and ID could have been identified during this surveillance.

CONCLUSION

The existing CHC surveillance traced half of the group of children who were later diagnosed with ASD combined with intellectual disability. Adding an item on regulatory problems to the 18-month surveillance would have increased this number by another 10%.

Negotiating knowledge: parents' experience of the neuropsychiatric diagnostic process for children with autism

BACKGROUND

Parents often recognize problems in their child's development earlier than health professionals do and there is new emphasis on the importance of involving parents in the diagnostic process. In Gothenburg, Sweden, over 100 children were identified as having an autism spectrum disorder (ASD) in 2009-11 through a general population language and autism screening of 2.5 year olds at the city's child healthcare centres.

AIMS

To increase understanding of parents' lived experience of the neuropsychiatric diagnostic process, i.e. the period from the initial screening at age 2.5 years to the 2-year follow-up of the ASD diagnosis.

METHODS & PROCEDURES

A qualitative design, a phenomenological hermeneutic method, was used. Interviews were conducted with parents of 11 children who were diagnosed with ASD 2 years prior. The parents were interviewed about their experiences of the neuropsychiatric diagnostic process, i.e. the time before the screening, the time during the neuropsychiatric multidisciplinary evaluation and the time after diagnosis. The interviews lasted for 45-130 min, and an interview guide with set questions was used. Most of the interviews were conducted at the parents' homes.

OUTCOMES & RESULTS

The essence that emerged from the data was negotiating knowledge, and the three themes capturing the parents' experiences of going through the process of having their child diagnosed with ASD were seeking knowledge, trusting and challenging experts, and empowered but alone.

CONCLUSIONS & IMPLICATIONS

The parents expected intervention to start directly after diagnosis but felt they had to fight to obtain the resources their child needed. After the process, they described that they felt empowered but still alone, i.e. although they received useful and important information about their child, they were left to manage the situation by themselves. As for clinical implications, the study points to the necessity of developing routines to support the parents during and after the diagnostic process. Recommended measures include developing a checklist outlining relevant contacts and agencies, establishing a coordinator responsible for each child, dividing the summary meeting at the clinic into two parts, making more than one visit to the preschool, and providing a parental training programme.

Screening of Egyptian toddlers for autism spectrum disorder using an Arabic validated version of M-CHAT; report of a community-based study (Stage I)

BACKGROUND

Although there is a recommendation that toddlers be screened for Autism spectrum disorder (ASD) during their 18- and 24-month well-care child visits, diagnosis often occurs well after the child turns 4 years old. Such delayed diagnosis hinders the implementation of early intervention thus worsens the long-term prognosis of ASD.

OBJECTIVE

The current community-based study in its stage I aimed at early screening of Egyptian toddlers for ASD using an Arabic validated version of Modified Checklist for Autism in Toddlers (M-CHAT).

METHODOLOGY

A cross-sectional community-based descriptive study was carried out enrolling 5546 Egyptian toddlers. They were randomly recruited from those attending Primary Health Care Units in six Egyptian governorates with a fair representation of the urban, semi-urban, and rural Egyptian populations. An Arabic validated version of M-CHAT was used as a screening tool for ASD.

RESULTS

The current study revealed failure of M-CHAT (suspected to have ASD and needs further evaluation) in 1320 out of the enrolled 5546 Egyptian toddlers (23.8%).

CONCLUSION

M-CHAT as a screening tool for ASD has flagged a considerable percent of the enrolled toddlers that necessitates referral for further evaluation (stage II) to settle the diagnosis of ASD in the true positive cases. Perfecting the delicate balance between sensitivity and specificity for ASD screening tools is crucial in order not to miss early detection of ASD cases and at the same time, to avoid over-diagnosis with subsequent abuse of the limited healthcare resources in developing countries.

Longitudinal comparison between male and female preschool children with autism spectrum disorder

Epidemiological studies have highlighted a strong male bias in autism spectrum disorder (ASD), however few studies have examined gender differences in autism symptoms, and available findings are inconsistent. The aim of the present study is to investigate the longitudinal gender differences in developmental profiles of 30 female and 30 male age-matched preschool children with ASD. All the children underwent a comprehensive evaluation at T0 and at T1. Our results have shown no significant interaction between time and gender for predicting autism symptoms, developmental quotient, parental stress, children's adaptive skills and behavior problems. Shedding light on the developmental trajectories in ASD could help clinicians to recognize children with ASD at an earlier age and contribute to the development of appropriate treatments.

Prenatal acquired cytomegalovirus infection should be considered in children with autism

AIM

The aim of the study was to evaluate the prevalence of congenital cytomegalovirus infection (CMV) in a representative sample of children with autism spectrum disorder.

METHODS

In a representative group of 115 preschool children with autism spectrum disorder, of whom 33 also had intellectual disability, the dried blood spots from the newborn metabolic screening were analysed for CMV DNA using TaqMan polymerase chain reaction.

RESULTS

One of the 33 children with autism spectrum disorder and intellectual disability - 3% of that group - had congenital CMV infection. The corresponding prevalence in newborn infants in Sweden is 0.2%. None of the 82 children without intellectual disability had congenital CMV.

CONCLUSION

The finding lends some further support for congenital CMV being one of the many aetiologies underlying autism spectrum disorder with intellectual disability. The rate of 3% of congenital CMV in children with autism spectrum disorder with intellectual disability has implications for the medical work-up. The finding of congenital CMV also indicates the need for repeated hearing assessments in the child. There is a need for similar studies with much larger samples.