Pediatric and psychiatric models of autism care in Mexico: Differences in diagnostic tools and prescribed interventions

Low- and middle-income countries face heterogeneity in the way clinicians' approach Autism Spectrum Disorder (ASD) diagnosis and treatment. The current study analyzes the diagnostic tools, laboratory tests, pharmacological and psychosocial interventions received by patients during the steps to diagnosis and treatment of two specialized care centers. Researchers interviewed families with a child with ASD receiving services at either a child psychiatric or a pediatric hospital. Of the total sample, 47% reported clinicians not using a diagnostic tool, 20% reported not receiving any psychosocial intervention, and 88% reported receiving a pharmacological prescription. Patients at the pediatric hospital were more likely to receive interventions with some components of Applied Behavioral Analysis, Early Start Denver Model, Treatment and Education of Autistic and Related Communication Handicapped Children, and Sensory integration therapy; while patients at the psychiatric hospital were more likely to undergo learning, daily living skills, and socialization therapies. Patients at the psychiatric hospital received significantly more requests to obtain auditory and vision tests whilst genetic testing and imaging were more common in the pediatric hospital. The range and variability in terms of diagnostic tools, laboratory tests, and treatment options observed for both sites reflect a lack of consensus. Recommendations to improve ASD diagnostic and treatment in Mexico are given.

Assessing autism with DSM-IV and DSM-5 criteria using the Childhood Autism Rating Scale (CARS)

Introduction. The Childhood Autism Rating Scale (CARS) is an observational instrument for assessing autism. It is the most widely used instrument for the diagnosis of autism in Mexico. Objective. To study the psychometric properties in the Mexican population using DSM-IV and DSM-5 criteria. Method. This is an observational, cross-sectional study. Participants (N = 137) were 78.8% male, with an age range between 2 and 18 years, mean 8.5. Parents completed the M-CHAT, the ABC, the ADI-R, and semi-structured clinical interviews with DSM-IV. We inferred DSM-5 criteria by selecting atypical sensory items from the ABC. Results. The internal consistency for the total CARS items was α = .88. The concurrent validity of the CARS and the DSM-IV criteria showed a Spearman coefficient of correlation of rs = .62. The convergent validity with the ADI-R showed moderate correlations, rs = .32 to .61, with the DSM-IV k = .33 and DSM-5 k = .36. The concordance with the DSM-IV and DSM-5 was 71% and 84.5%, sensitivity was 58.1% and 46-7%, and specificity 76.6% and 90.5%, respectively. The discriminant analysis showed that the CARS correctly classified 97% of children with autism, 70% with pervasive developmental disorders not otherwise specified (PDD-NOS), and 12.5% with Asperger’s syndrome. Discussion and conclusion. The Mexican version of the CARS is a valid and reliable instrument for diagnosing autism in Mexican children and adolescents.

Hispano-American Brain Bank on Neurodevelopmental Disorders: An initiative to promote brain banking, research, education, and outreach in the field of neurodevelopmental disorders

Neurodevelopmental disorders (NDDs) are conditions that present with brain dysfunction due to alterations in the processes of brain development. They present with neuropsychiatric, cognitive, and motor symptoms. Autism spectrum disorder (ASD) and Fragile X syndrome (FXS) are two of the most common NDDs. Human brain tissue is a scarce resource that is obtained from postmortem donations. In the case of NDDs, specifically autism, the reduced donation rate of brains prevents researchers to investigate its pathology and fine anatomy. The Hispano-American Brain Bank of Neurodevelopmental Disorders (Banco Hispanoamericano de CErebros de trastornos del NEurodesarrollo) or CENE is a large-scale brain bank for neurodevelopmental disorders in Hispano-America and the US. CENE's objectives are to collect and distribute brains of patients with NDDS, with a focus on ASD and FXS, to perform research, promote education of future scientists, and enhance public awareness about the importance of human tissue availability for scientific research on brain function and disease. CENE has thus far established a bilingual system of nodes and teams in several American countries including California-US, Pennsylvania-US, México, Puerto Rico, Colombia, and Dominican Republic. CENE ensures that postmortem NDD samples used in research better match the world's genetic and ethnic diversity. CENE enables and expands NDD brain research worldwide, particularly with respect to ASD and FXS.

Measurement invariance of the Childhood Autism Rating Scale (CARS) across six countries

The Childhood Autism Rating Scale (CARS) is a simple and inexpensive tool for Autism spectrum disorder (ASD) assessments, with evidenced psychometric data from different countries. However, it is still unclear whether ASD symptoms are measured the same way across different societies and world regions with this tool, since data on its cross-cultural validity are lacking. This study evaluated the cross-cultural measurement invariance of the CARS among children with ASD from six countries, for whom data were aggregated from previous studies in India (n = 101), Jamaica (n = 139), Mexico (n = 72), Spain (n = 99), Turkey (n = 150), and the United States of America (n = 186). We analyzed the approximate measurement invariance based on Bayesian structural equation modeling. The model did not fit the data and its measurement invariance did not hold, with all items found non-invariant across the countries. Items related to social communication and interaction (i.e., relating to people, imitation, emotional response, and verbal and nonverbal communication) displayed lower levels of cross-country non-invariance compared to items about stereotyped behaviors/sensory sensitivity (i.e., body and object use, adaptation to change, or taste, smell, and touch response). This study found that the CARS may not provide cross-culturally valid ASD assessments. Thus, cross-cultural comparisons with the CARS should consider first which items operate differently across samples of interest, since its cross-cultural measurement non-invariance could be a source of cross-cultural variability in ASD presentations. Additional studies are needed before drawing valid recommendations in relation to the cultural sensitivity of particular items.

Pathways to a Diagnosis of Autism Spectrum Disorder

OBJECTIVE

This study aimed to analyze the pathways to obtaining a diagnosis of autism spectrum disorder (ASD) within the Mexican health system.

METHODS

Parents of children with ASD (N=186) were approached at specialized health centers and interviewed about the sequence of professionals they contacted that led to a diagnosis. The authors established the pathway to diagnosis, time of first parental concerns, time of first consultation, age of the child at diagnosis, and other measures. A Sankey plot was used to illustrate the complexity of the pathway to diagnosis. Diagnostic delays among children with autism were compared with delays among subsamples of children with Asperger's syndrome. Regression analysis was used to evaluate the effect of socioeconomic and clinical variables on diagnostic delays.

RESULTS

The median diagnostic delay was 27 months (interquartile range [IQR] 8-36), and three professional contacts (IQR 3-6) were needed to achieve a diagnosis. Patients switched between primary and tertiary care even in later stages of the pathway. Patients with Asperger's syndrome had longer delays than patients with autism, and girls and older patients took more time to receive a diagnosis. Parental concerns regarding language, developmental issues, and perceived developmental regression resulted in shorter diagnostic delays.

CONCLUSIONS

Pathways to diagnosis of ASD are long and involve multiple contacts, with patients alternating between primary and specialized care. This pattern reflects failures in the diagnostic protocols and referral systems of clinical centers in Mexico, and such issues may be experienced in countries with similarly overwhelmed health care systems.

Trastornos psiquiátricos y su asociación con el ciberacoso en una muestra de adolescentes mexicanos

No disponible

Are Tattoos an Indicator of Severity of Non-Suicidal Self-Injury Behavior in Adolescents?

OBJECTIVE

To compare adolescents with non-suicidal self-injury behavior and tattoos [NSSI (T+)] with another group with non-suicidal self-injury behavior without tattoos [NSSI (T-)].

METHODS

Adolescents (n=438) 42.6% males from the community (M=12.3, SD=1.3), completed the Self-Injury Schedule.

RESULTS

The lifetime prevalence of tattoos performed with the purpose to feel pain was 1.8%. Compared to the NSSI (T-) group, the NSSI (T+) group was significantly more likely to meet the DSM-5 frequency criteria of 5 self-injury events in 1 year, practice more than one method of self-injury, and topography, more suicidal intentionality, more negative thoughts and affective emotions before, during, and after self-injury and more academic and social dysfunction.

CONCLUSION

Adolescents from the community who practice tattooing to feel pain, show a distinct phenotype of NSSI. Health professionals and pediatricians should assess tattooing characteristics such as intention (to feel pain), frequency, and presence of non-suicidal self-injury behavior and suicide intentionality.

[Internal consistency and criterion validity and reliability of the Mexican Version of the Child Behavior Checklist 1.5-5 (CBCL/1.5-5)]

OBJECTIVE

To investigate the validity and internal consistency of the Mexican version of the CBCL/1.5 -5 that assesses the most common psychopathology in pre-school children in clinical and epidemiological settings.

PATIENTS AND METHOD

A total of 438 parents from two groups, clinical-psychiatric (N= 62) and community (N= 376) completed the CBCL/1.5-5/Mexican version.

RESULTS

The internal consistency was high for total problems α=0.95, and internalized α=0.89 and externalized α=0.91 subscales. The test re-test (one week) using the intraclass correlation coefficient (ICC) was ≥ 0.95 for the internalized, externalized, and total problems subscales. The ROC curve for the criterion status of clinically-referred vs. non-referred using the total problems scale ≥ 24 resulted in an AUC (area under curve) of 0.77, a specificity 0.73, and a sensitivity of 0.70.

CONCLUSIONS

The CBCL/1.5 -5/Mexican version is a reliable and valid tool.

Nonsuicidal self-injury in a community sample of older children and adolescents of Mexico City

INTRODUCTION

In Mexico, as in other countries, studies do not distinguish between attempted suicide and suicidal and nonsuicidal self-injury (NSSI). The aim of this study was to investigate self-injury and its prevalence using several definitions, in addition to studying the frequency of the proposed DSM-5 criteria for NSSI in adolescent girls and boys.

METHODOLOGY

The study was observational, descriptive, cross-sectional, and comparative using a nonrandomized sample of adolescent girls and boys from official high schools who completed the self-injury questionnaire.

RESULTS

The participants were 533 older children and adolescents with a mean (SD) age of 13.37 (0.95) years, age range 11 to 17 years, and 54% female sex distribution. The prevalence of NSSI defined according to proposed DSM-5 criteria was 5.6% (N=30) and, according to a broad definition using only item 51 (“Do you hurt yourself without intending to end your life?”), 17.1% (N=140). Prevalence defined by the number of events in the last month (1-3 events) was 9.9% (N=53), in the last 6 months (1-3 events), 11.6% (N=62), and in the last year (5 events), 12.6% (N=67). The age at onset was 11.9 (1.39) years (range 6-15 years). Most DSM-5 criteria were more frequent in girls than boys.

CONCLUSIONS

Suicidal and nonsuicidal self-injury are frequent in the community. Important points for decision-making in schools and medical practice are discussed.

Confiabilidad interevaluador del K-SADS-PL-2009/trastornos del espectro autista (TEA)

El incremento en la prevalencia de los trastornos del espectro autista (TEA) provocó que dejaran de considerarse como poco frecuentes. La Entrevista Diagnóstica de Autismo Revisada (ADI-R; Autism Diagnostic Interview-Revised) y la Cédula de Observación General para el Diagnóstico del Autismo (ADOS-G, Autism Diagnostic Observation Schedule-Generic) se consideran estándares de oro para diagnósticar TEA. Sin embargo, ninguno de estos instrumentos evalúa la comorbilidad asociada. La nueva versión de la Entrevista de Diagnóstico Psiquiátrico para Niños y Adolescentes, K-SADS-PL-2009, agregó un apartado para el diagnóstico de los TEA. Objetivo. El propósito de este estudio fue traducir, adaptar y analizar la confiabilidad interevaluadora del K-SADS-PL-2009/TEA. Método. La muestra se conformó por 40 niños y adolescentes, de ambos sexos, con un rango de edad de cuatro a 17 años, con un diagnóstico presuntivo de trastorno del espectro autista. La versión original del K-SADS-PL-2009/TEA fue traducida al español por dos de los autores y retraducida al inglés por un traductor certificado ciego al estudio. Resultados. Confiabilidad interevaluador. Los coeficientes de correlación intraclase fueron de buenos a excelentes para los siguientes diagnósticos en el presente y pasado: autismo 0.79 y 0.74; trastorno de Asperger 0.85 y 1.0; trastorno generalizado del desarrollo no especificado (TGDNE) 0.72 y 0.41. Los coeficientes kappa para las evaluaciones realizadas por los expertos fueron de buenos a excelentes para los siguientes diagnósticos en el presente y en el pasado: autismo 0.89 y 0.87; Asperger 0.77 y 1.00; TGDNE 0.69 y 0.64. La concordancia entre el diagnóstico realizado en el servicio de urgencias y el corroborado posteriormente por medio del instrumento diagnóstico fue de 37.5%, con un índice de error diagnóstico de 67.5%. Conclusiones. El K-SADS-PL-2009/TEA mostró una buena confiabilidad interevaluador y puede usarse en niños y adolescentes mexicanos para propósitos clínicos y de investigación.

M-CHAT Mexican Version Validity and Reliability and Some Cultural Considerations

The Modified Checklist for Autism in Toddlers (M-CHAT) questionnaire is a brief measure available in Spanish which needs to be validated for the Mexican population. Parents of children from (1) community with typical development (TD) and (2) psychiatric outpatient unit completed the CBCL/1.5–5 and the Mexican/MM-CHAT-version. The study sample consisted of 456 children (age M = 4.46, SD = 1.12), 74.34% TD children and 26.65% with Autism Spectrum Disorders (ASD). The MM-CHAT mean score for failed key items was higher for the ASD group compared with the TD group. Internal consistency for the Mexican/M-CHAT version was .76 for total score and .70 for the 6 critical items. Correlations between the MM-CHAT and the CBCL/1.5: PDD and Withdrawn subscales and with ADI-R dimensions: B non verbal) and A were high, and were moderate with ADI-R dimensions B1 (verbal) and C The failure rate of the MM-CHAT between the groups did not reproduce all the critical items found in other studies. Although the instrument has good psychometric properties and can be used for screening purposes in primary settings or busy specialized psychiatric clinics, these results support evidence for cultural differences in item responses, making it difficult to compare M-CHAT results internationally.

[Bullying and its association with psychiatric disorders in a Mexican students sample]

OBJECTIVE

To study the relationship between bullying behavior and psychopathology.

MATERIALS AND METHODS

A total of 1 092 students identified their peers' bullying status based on the Bull-S questionnaire. Parents completed the Child Behavior Checklist (CBCL) to determine psychopathology levels.

RESULTS

The bullying group had associations with anxiety, somatic symptoms, oppositionalism and behavior problems; the bully-victims group had associations with attention, oppositionalism and behavior problems; victims had higher anxiety scores.These differences were significant compared with the control group.

CONCLUSIONS

Bullying is associated with psychopathology, which requires timely psychiatric attention.

[2D:4D finger ratio and language development]

INTRODUCTION

A possible hormonal influence in language development has been suggested in the recent years. The 2D:4D finger ratio is an indirect measure for prenatal androgen exposure. It is negatively related to prenatal testosterone and positively related to prenatal estrogen, resulting in a lower ratio for men and a larger ratio for women. It can be explored in children as young as 2 years old.

AIM

To study if an association exists between the 2D:4D finger ratio and language development (vocabulary) and/or language problems.

SUBJECTS AND METHODS

The lengths of the second digit (index finger) (2D) and the fourth digit (ring finger) (4D) were measured in 97 preschoolers and the Language Development Survey was administered to the parents.

RESULTS

A weak negative correlation between language development (vocabulary) and right 2D:4D ratio was found in both sexes for children aged 4 or less years, significant only in boys. A strong negative correlation between language articulation problems and right 2D:4D ratio in both sexes for children aged 3 or less years, and a lower negative correlation between articulation problems and right 2D:4D ratio were found for boys aged 4 or less years.

CONCLUSION

Findings suggest an important role for testosterone in language development (vocabulary) and a possible influence on articulation problems, probably through higher testosterone levels.

Validity and reability of the CBCL/6-18. Includes DSM scales

INTRODUCTION

The Child Behavior Checklist (CBCL/6-18) is the most commonly used parent-completed instrument that assesses child and adolescent psychopathology. It has been used in epidemiology and clinical studies. The last version contains DSM-oriented subscales.

OBJECTIVE

Investigate the psychometric properties of the CBCL/6-18 and develops a valid and reliable Mexican version.

METHOD

Psychologists and child psychiatrists adapted the Spanish version of CBCL/6-18, and a back translation was done by a native English speaker. Discrepancies in the adaptation were solved by consensus. The checklist was applied to children in the community and to outpatients from a psychiatric children hospital. Reliability was evaluated by estimating internal consistency (Cronbach's alpha) on all scales: retest at one week was evaluated with intraclass correlation coefficients (ICC). A ROC curve was performed to estimate a cut-off which correctly identified children from the clinically referred patients and children recruited in the community (non-referred). Mean differences for the groups were calculated with the Student's t test.

RESULTS

The Mexican version of the CBCL/6-18 showed that the Cronbach's alpha coefficient was 0.90 for internalizing problems, 0.94 for externalizing problems and 0.97 for the total problem scale. The ICC was 0.97 for the total problem scale. Significant differences were found between the mean score in broad band, narrow and the new DSM/oriented scales.

CONCLUSIONS

The Mexican version of CBCL/6-18 is a reliable and valid screening instrument for clinical and epidemiologic use.