INTRODUCTION
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Transcript of INTRODUCTION
ACCURACY OF AUTISM DIAGNOSTIC INTERVIEW-REVISED (ADI-R)
IN CATEGORIZING EGYPTIAN CHILDREN WITH PERVASIVE DEVELOPMENTAL DISORDERS
ByHeba Elsayed Gaber
Ass. lecturer at Faculty of Medicine, Alexandria university
Supervised by: Y.Aboras, H. Azouz, T. Molokhia and M.ElBanna
INTRODUCTION
Pervasive developmental disorders (PDDs) are complex neurodevelopmental disorders characterized by core deficits in three major domains
Introduction
Social interaction and social relatedness
Verbal and nonverbal communication
Restricted interests and/or repetitive or
stereotyped behaviors
Classification of PDDS
Autism
Asperger’s syndrome
Childhood disintegrative
disorder
Pervasive developmental
disorder not otherwise specifiedRett’s syndrome
Introduction
Autism
It is characterized by qualitative behavioral abnormalities in the domains of communication, reciprocal social interaction and interests, and activities that are repetitive, restricted and stereotyped, that appear before 3 years of age
Introduction
Asperger’s Syndrome
Introduction
It shares the social-relatedness impairment and the presence of restricted interest and/or repetitive behavior, but requires that the child have no delay in language development.
Childhood disintegrative
disorder
It is a clinical syndrome characterized by disintegration of mental functions and regression of acquired language and intellectual functions after a period of normal development up to 3-4 years in children
Introduction
Pervasive developmental
disorder not otherwise specified
The diagnosis of PDD-NOS is made in individuals with some, but not all features of autistic disorder (either quantitatively or qualitatively). Social deficits are always present, along with some degree of impaired communication or restricted interests/repetitive behaviors.
Introduction
Rett’s syndrome
IntroductionIt is a rare disorder occurring almost
exclusively in females. There is an initial period of normal development followed by regression in social and language skills that can be confused with autism.
Etiology of PDDs:
Genetic causes
Parental causes
Perinatal and obstetric factors
Metallic elements
Immunological disorders
Cognitive theories
Metabolic disorders
Infections
Gastrointestinal factors
Introduction
Core symptomsDeficits in reciprocal social
interaction
Deficits in communication
Deficits in interests and activities
Symptoms of PDDsIntroduction
AIM OF THE WORK
This study is designed to formulate and apply Autism Diagnostic Interview (Lord et al, 1994) as a tool for evaluating Egyptian children with pervasive developmental disorders in order to detect its accuracy in quantifying the autistic features among different subtypes of these disorders.
Aim Of The Work
SUBJECTS
The study was applied on 80 children with age ranging from 2 to 6 years. They were divided into 3 groups:
◦ Group I: (PDD): 35 children referred with a diagnostic query regarding possible PDDs, with exclusion of children suffering from sensory deprivation and brain damage.
◦ Group II: (normal children): 25 children.
◦ Group III: (mentally retarded): 20 children with exclusion of children suffering from sensory deprivation and brain damage.
Subjects
METHODS
Each child was subjected to the protocol of evaluation for delayed language development which consists of three levels of evaluation
Elementary diagnostic procedures
Clinical diagnostic aids
Interview protocol and administration
Methods
Elementary diagnostic procedures
• Parent's interview: It includes complaint and analysis of symptoms, personal history, search of etiological factors, child’s developmental history, family history, and child’s medical history.
• Examination: Measurement of growth parameters, examination of skin ,muscle tone and reflexes.
Clinical diagnostic aids
Interview protocol and administration
Methods
Elementary diagnostic procedures
Clinical diagnostic aids
• Evaluation of the various aptitudes by formal testing• Audiological evaluation• Language evaluation
Interview protocol and administration
Methods
Elementary diagnostic procedures
Clinical diagnostic aids
• Evaluation of the various aptitudes by formal testing• Stanford Binet Intelligence scale: to assess cognitive age (mental
age) ,verbal and abstract I.Q• Vineland social maturity scale: to obtain social age and social quotient • Childhood autism Rating Scale (CARS)• Gilliam autism Rating Scale (GARS)• Childhood attention adjustment survey(CAAS): is a brief survey for
identifying behavior problems • Audiological evaluation• Language evaluation
Interview protocol and administration
Methods
Elementary diagnostic procedures
Clinical diagnostic aids
• Evaluation of the various aptitudes by formal testing• Audiological evaluation• Language evaluation
Interview protocol and administration
Methods
Elementary diagnostic procedures
Clinical diagnostic aids
• Evaluation of the various aptitudes by formal testing• Audiological evaluation• Language evaluation
• Arabic language test : formal assessment of language components and detection of language age and language abilities.
• TACS (test of acquired communication skills ), to evaluate the prelinguistic skillsInterview protocol and administration
Methods
Elementary diagnostic procedures
Clinical diagnostic aids
Interview protocol and administration
• Autism diagnostic interview(ADI-R) was translated and formulated to suit Egyptian culture and children.
• ADI-R Interview Protocol was with the informant (a parent or caregiver with the child being assessed). The assessed individual is not present during the interview. The interview typically takes l h to 2 hours to administer and score
Methods
Interview protocol and administration
• The interview consists of eight main sections:
1) The background questions about the subject’s family and education as well as on the diagnosis that have been applied and the medication that has been used.
2) This is followed by introductory questions, which are designed to provide a general picture of the subject’s behavior. This is necessary in order to provide an adequate framework for the further detailed questioning that follows. This includes item 1(current concerns about the child)
Elementary diagnostic procedures
Clinical diagnostic aids
3) The third section provides an account of early developmental milestones (item 2 through 8)4) This is followed by questioning on the age at which key language skills were acquired and on the question as to whether there has been any period involving a loss of language skills after they have been acquired, or a general loss of other skills (item 9 through 28).
5) Language and communication functioning (items 29 to 49).
6) Social development and play (items 50 to 66).7) Interests and behaviors (items 67 to 79).8) The last section (items 80 to 93) deals with a range of general behaviors that are of clinical importance – such as aggression, self injury, the occurrence of possible epileptic features.
Methods
Statistical Analysis
• The data was analyzed using statistical software package (SPSS version 16).• The following statistical tests were used:
• Correlation Coefficient(r)• Student t- test• One way ANOVA• Coefficient of reliability( Cronbach’s alpha )
Methods
Reliability
• The test reliability was done by correlation between:• Each domain to the total ADI-R score.• Each domain with the other 2 domains.• Each sub domain to its domain.
Methods
Validity
• Face validity (5 phoniatricians judged the test)• Construct validity was assessed by administering the test to 35 cases of PDD and 25
normal children• Criterion-Related Validity: to check the performance of the test against some criterion
• Convergent Validity• Divergent validity• Concurrent validity
Methods
RESULTS
Mean age in months for the 3 groups.
46.8
53.52
55.3
Mean
Group I(PDD)Group II(N)Group III(MR)
Results
Sex distribution in the 3 groups.
Results
Group I(PDD) Group II(N) Group III(MR)0%
10%
20%
30%
40%
50%
60%
70%
80% 77%
56%60%
23%
44%40%
MaleFemale
Comparison between means of the 3 groups as regards Stanford Binet Intelligence
Mental Age Abstract I.Q. Verbal I.Q. General I.Q.0
10
20
30
40
50
60
70
80
90
100
33.12
71.41
53.4
67.188
48.92
94.96 92.6 93.56
33.32
59.3751.89 53.89
Group I(PDD) N(17) Group II(N) N(25) Group III(MR) N(20)
Results
Comparison between means of the 3 groups as regards CARS, GARS, VSMS
CARS GARS VSMS S.A S.Q0
10
20
30
40
50
60
70
80
90
32.2
84.35
26.23
55.6
17.6
53.8
45.04
89.7
19.45
56.45
38.45
65.75
Group I(PDD) Group II(N) Group III(MR)
Results
Correlation studies Correlation of ADI-R score with CARS
Correlation of ADI-R score with CARS as regards mental age
Group I(PDD) Group II(N) Group III(MR)
r 0.506 0.509 0.591
p 0.01** 0.01** 0.01**
M.A >2 years M.A< 2years
r 0.473 0.239
p 0.01** >0.05
Results
Correlation studies Correlation of ADI-R scores with GARS
Group I(PDD) N(25)
Group II(N) N(23)
Group III(MR) N(20)
Total ADI-R score with total GARS score
r 0.348 -0.116 0.129
p <0.05* >0.05 >0.05
Social interaction in ADI-R and GARS
r 0.354 -0.115 -0.119
p <0.05* >0.05 >0.05
Communication in ADI-R and GARS
r -0.05 -0.168 0.279
p >0.05 >0.05 >0.05
Stereotyped behavior in ADI-R and GARS
r 0.018 -0.069 0.16
p >0.05 >0.05 >0.05
Results
Correlation studies Correlation of ADI-R with TACS
Group I(PDD) Group II(N) Group III(MR)
Total ADIR- score and total language age in TACS
r -0.811 -0.408 0.096
p 0.001*** 0.01** >0.05
Social interaction in ADI-R with social component in TACS
r -0.871 0.149 0.23
p 0.001*** >0.05 >0.05
Communication in ADI-R with language component in TACS
r 0.030 0.267 0.116
p >0.05 >0.05 >0.05
Results
Comparing means in between groups in domain A
Group I versus II Group I versus III Group II versus III
A1. Failure to use non verbal behaviors to regulate social interaction
t 8.185 6.487 -1.327
p 0.001*** 0.001*** 0.191
A2.Failure to develop peer relationships
t 6.163 4.931 -1.701
p 0.001*** 0.001*** 0.096
A3.Lack of shared enjoyment
t 15.637 9.101 -3.919
p 0.001*** 0.001*** 0.001***
A4.Lack of socioemotional reciprocity
t 10.904 8.218 -4.513
p 0.001*** 0.001*** 0.001***
A Total
t 13.576 9.887 -4.795
p 0.001*** 0.001*** 0.001***
Results
Comparing means in between groups in domain B
Group I versus II Group I versus III Group II versus III
B1. Lack of or delay in spoken language and failure to compensate through gesture
t 10.042 7.776 -0.414
p 0.001*** 0.001*** 0.681
B2(V).Relative failure to initiate or sustain conversational interchange
t 1.7666 1.577 -0.229
p 0.083 0.121 0.82
B3(V).Stereotyped, repetitive , or idiosyncratic speech
t 1.727 1.543 -0.158
p 0.089 0.129 0.875
B4.Lack of varied spontaneous make –believe or social imitative play
t 14.549 5.255 -7.849
p 0.001*** 0.001*** 0.001***
B Total
t 13.051 7.818 -0.5054
P 0.001*** 0.001*** 0.001***
Results
Comparing means in between groups in domain C
Group I versus II Group I versus III Group II versus III
C1.Encompassing preoccupations or circumscribed pattern of interest
t 4.354 3.437 1.21
p 0.001*** 0.001*** 0.268
C2.Apparently compulsive adherence to non-functional routines or rituals
t 1.854 1.949 0.892
p 0.069 0.057 0.377
C3.Stereoyped and repetitive motor mannerism
t 4.822 4.306 -
p 0.001*** 0.000*** -
C4.Preoccupaations with part of objects or non-functional elements of material
t 4.449 2.718 -1.614
p 0.001*** 0.009 0.114
C Total
t 6.792 5.472 -1.433
p 0.001*** 0.001*** 0.159
Results
Comparing mean scores: Domain A
Group I(PDD) Group II(N) Group III(MR)0
0.51
1.52
2.53
2.97
0.2 0.45
A1.
Group I(PDD) Group II(N) Group III(MR)0
0.51
1.52
2.53
3.53.11
0.04 0.3
A2.
Group I(PDD) Group II(N) Group III(MR)0123456
5.97
0.21.05
A4.
Results
Group I(PDD) Group II(N) Group III(MR)0123456 5.31
0.36
1.6
A3.
Comparing mean scores: Domain A
Group I(PDD) Group II(N) Group III(MR)0
2
4
6
8
10
12
14
16
18
17.46
0.8
3.4
A Total
Results
Comparing mean scores: Domain B
Group I(PDD) Group II(N) Group III(MR)01234567
6.37
2.52 2.7
B1.
Group I(PDD) Group II(N) Group III(MR)0
0.050.1
0.150.2
0.250.3
0.350.4
0.450.5
0.46
0.3
0.2
B2(V).
Group I(PDD) Group II(N) Group III(MR)0
0.51
1.52
2.53
3.54
4.55
4.94
0.2
2.65
B4.
Results
Group I(PDD) Group II(N) Group III(MR)0
0.050.1
0.150.2
0.250.3
0.29
0.18
0.1
B3(V).
Comparing mean scores: Domain B
Group I(PDD) Group II(N) Group III(MR)0
2
4
6
8
10
12
14 12.06
2.72
5.65
B Total
Results
Comparing mean scores: Domain C
Group I(PDD) Group II(N) Group III(MR)0
0.10.20.30.40.50.6
0.57
00.05
C1.
Group I(PDD) Group II(N) Group III(MR)0
0.050.1
0.150.2
0.250.3
0.350.310000000
000002
0.040
C2.
Group I(PDD) Group II(N) Group III(MR)0
0.2
0.4
0.6
0.8
1
1.2 1.09
0.36
0.600000000000001
C4.
Results
Group I(PDD) Group II(N) Group III(MR)0
0.10.20.30.40.50.60.70.80.9 0.830000000000001
0 0
C3.
Comparing mean scores: Domain C
Group I(PDD) Group II(N) Group III(MR)0
0.5
1
1.5
2
2.5
3
2.8
0.40.650000000000004
C Total
Results
Reliability Correlation between domains A, B, C and total ADI-R
score.
Correlation between domains
r p
Domain A with Domain B 0.887 0.001***
Domain A with Domain C 0.735 0.001***
Domain B with Domain C 0.679 0.001***
r p
Total ADI-R score with domain A 0.985 0.001***
Total ADI-R score with domain B 0.946 0.001***
Total ADI-R score with domain C 0.368 0.01**
Results
Reliability Correlation between each sub domain to its main domain.
r p
Domain A
A1. 0.926 0.001***
A2. 0.807 0.001***
A3. 0.906 0.001***
A4. 0.932 0.001***
Domain B
B1. 0.847 0.001***
B2 (V). 0.452 0.01**
B3 (V). 0.446 0.01**
B4. 0.891 0.001***
Domain C
C1. 0.679 0.01**
C2. 0.528 0.01**
C3. 0.758 0.01**
C4. 0.751 0.01**
Results
Comparison between the original cutoff values and the new cutoffs
New values Sensitivity Specificity Original values
Domain A 9 97 100 10 Domain B 7NV/8V 92 100 7NV/8V Domain C 2 83 97 3
NV: non verbal, V: verbal
Results
Differential diagnosis:
The number of children who crossed cutoff values in all domains in group I (PDD) was 26 and were diagnosed as autism. The number of children who crossed cutoff in domain A, B were 5 (suspected to be PDD-NOS ), 2 crossed cutoff in domain B only and 2 didn’t cross cutoffs in all domains.
Results
CONCLUSION
1. The results of the Arabic version of ADI-R test were highly significant and were capable of discriminating between children with and without PDDs (normal, MR).
2. The high validity and reliability of the formulated test proves its sensitivity and objectivity.
3. The obtained cut-off values were near to those of the original test except for minimal differences
CONCLUSION
RECOMMENDATIONS
The autism diagnostic interview test is recommended to be used in mental ages above 18 months due to better sensitivity and specificity.
Further evaluation is required for differentiation of other types of PDD (other than autism).
Application of the test on a larger study group for its further validation .
RECOMMENDATIONS
American Academy of Pediatrics. The pediatrician’s role in the diagnosis and management of autistic spectrum disorder in children. Pediatrics 2001; 107: 1221-26.
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed text rev), American Psychiatric Association, Washington, DC (1994).
Folstein S, Rutter M. Infantile autism: A genetic study of 21 twin pairs. J Child Psychol Psychiatry 1997; 18: 297–321.
Filipek PA, Filipek PJ. The screening and diagnosis of autistic spectrum disorders. J autism Deve Disord 1999; 29: 439–84.
Volkmar FR, Klin A, Cohen DJ. Childhood disintegrative disorder. Handbook of autism and pervasive developmental disorders .2nd ed. New York Wiley 1997: 47–59.
Walker DR, Walker A, Thompson L. Specifying PDD-NOS: A comparison of PDD-NOS, asperger syndrome, and autism. Journal of the American Academy of Child and Adolescent Psychiatry 2004; 43: 172–80.
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