Implementing and evaluating Social Attention and Communication Surveillance (SACS) to prospectively identify autism in very young children in Nepal

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.

Development and validation of the Autism Communicative Skills Questionnaire (ACSQ): An autism screening measure in Farsi

There has been a steady increase in the number of children diagnosed with autism spectrum disorder (ASD) worldwide. However, screening tools that focus primarily on communicative development that are culturally sensitive and linguistically appropriate are needed, particularly in languages, such as Farsi, which is spoken in countries that may benefit from additional resources. Therefore, the purpose of this study was to develop and validate a screening tool, written in Farsi by Iranians, that focuses on communication and factors affecting the development of communication for children with autism. A variety of statistical analyses were conducted and implemented to assess the relevance of various questions related to communication, along with other behaviors that interfere with the development of communication, that may distinguish between children with and without ASD. Exploratory factor analysis was performed to examine the underlying structure of the Autism Communicative Skills Questionnaire (ACSQ). This study represents the first stage in the development of a comprehensive questionnaire to assist with the screening of areas that impact the development of social communication and are unique to ASD.

Diagnostic Accuracy of the Social Attention and Communication Surveillance-Revised With Preschool Tool for Early Autism Detection in Very Young Children

Importance

Early identification of children on the autism spectrum is crucial to facilitate access to early supports and services for children and families. The need for improved early autism identification tools is highlighted by the lack of sufficient diagnostic accuracy in current tools.

Objectives

To examine the diagnostic accuracy of the Social Attention and Communication Surveillance-Revised (SACS-R) and SACS-Preschool (SACS-PR) tools when used with a large, community-based, convenience sample and identify the prevalence of autism in this sample.

Design, Setting, and Participants

This diagnostic accuracy study was conducted in Melbourne, Australia, training maternal and child health nurses who monitored 13 511 children aged 11 to 42 months using the SACS-R and SACS-PR during their routine consultations (June 1, 2013, to July 31, 2018). Children identified as being at high likelihood for autism (12-24 months of age: n = 327; 42 months of age: n = 168) and at low likelihood for autism plus concerns (42 months of age: n = 28) were referred by their maternal and child health nurse for diagnostic assessment by the study team. Data analysis was performed from April 13, 2020, to November 29, 2021.

Exposures

Children were monitored with SACS-R and SACS-PR at 12, 18, 24, and 42 months of age.

Main Outcomes and Measures

Diagnostic accuracy of the SACS-R and SACS-PR was determined by comparing children's likelihood for autism with their diagnostic outcome using clinical judgment based on standard autism assessments (Autism Diagnostic Observation Schedule-Second Edition and Autism Diagnostic Interview-Revised).

Results

A total of 13 511 children (female: 6494 [48.1%]; male: 7017 [51.9%]) were monitored at least once with the SACS-R at their 12-, 18-, and 24-month-old routine maternal and child health consultations (mean [SD] age, 12.3 [0.59] months at 12 months; 18.3 [0.74] months at 18 months; 24.6 [1.12] months at 24 months) and followed up at their 42-month maternal and child health consultation (mean [SD] age, 44.0 [2.74] months) with SACS-PR (8419 [62.3%]). At 12 to 24 months, SACS-R showed high diagnostic accuracy, with 83% positive predictive value (95% CI, 0.77-0.87) and 99% estimated negative predictive value (95% CI, 0.01-0.02). Specificity (99.6% [95% CI, 0.99-1.00]) was high, with modest sensitivity (62% [95% CI, 0.57-0.66]). When the SACS-PR 42-month assessment was added, estimated sensitivity increased to 96% (95% CI, 0.94-0.98). Autism prevalence was 2.0% (1 in 50) between 11 and 30 months of age and 3.3% (1 in 31) between 11 and 42 months of age.

Conclusions and Relevance

The SACS-R with SACS-PR (SACS-R+PR) had high diagnostic accuracy for the identification of autism in a community-based sample of infants, toddlers, and preschoolers, indicating the utility of early autism developmental surveillance from infancy to the preschool period rather than 1-time screening. Its greater accuracy compared with psychometrics of commonly used autism screening tools when used in community-based samples suggests that the SACS-R+PR can be used universally for the early identification of autism.

Annual Research Review: Achieving universal health coverage for young children with autism spectrum disorder in low- and middle-income countries: a review of reviews

BACKGROUND

Autism presents with similar prevalence and core impairments in diverse populations. We conducted a scoping review of reviews to determine key barriers and innovative strategies which can contribute to attaining universal health coverage (UHC), from early detection to effective interventions for autism in low- and middle-income countries (LAMIC).

METHODS

A systematic literature search of review articles was conducted. Reviews relevant to the study research question were included if they incorporated papers from LAMIC and focused on children (<eight years old) with autism or their caregivers. The database search was supplemented with bibliographic search of included articles and key informant suggestions. Data were extracted and mapped onto a Theory of Change model toward achieving UHC for autism in LAMIC.

RESULTS

We identified 31 articles which reviewed data from over fifty countries across Africa, Latin America, Middle East, and Asia and addressed barriers across one or more of four inter-related domains: (a) the social context and family experience for a child with autism; (b) barriers to detection and diagnosis; (c) access to appropriate evidence-based intervention; and (d) social policy and legislation. Key barriers identified included: lack of appropriate tools for detection and diagnosis; low awareness and experienced stigma impacting demand for autism care; and the prevalence of specialist models for diagnosis and treatment which are not scalable in LAMIC.

CONCLUSIONS

We present a Theory of Change model which describe the strategies and resources needed to realize UHC for children with autism in LAMIC. We highlight the importance of harnessing existing evidence to best effect, using task sharing and adapted intervention strategies, community participation, and technology innovation. Scaling up these innovations will require open access to appropriate detection and intervention tools, systematic approaches to building and sustaining skills in frontline providers to support detection and deliver interventions embedded within a stepped care architecture, and community awareness of child development milestones.