introduction pervasive developmental disorders (pdds) are complex neurodevelopmental disorders...

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 symptoms

Deficits in reciprocal social interaction

Deficits in communication

Deficits in interests and activities

Symptoms of PDDs

Introduction

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


• 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.



Methods



• Evaluation of the various aptitudes by formal testing• Audiological evaluation• Language evaluation


Methods



• 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


Methods



• Evaluation of the various aptitudes by formal testing• Audiological evaluation• Language evaluation


Methods



• 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




• 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


• 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)



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

59.37

51.89 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


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


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


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


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

0.5

1

1.5

2

2.5

3

2.97

0.20.45

A1.


0.51

1.52

2.53

3.53.11

0.040.3

A2.


1

2

3

4

5

6

5.97

0.2

1.05

A4.

Results


1

2

3

4

5

6 5.31

0.36

1.6

A3.

Comparing mean scores: Domain A


2

4

6

8

10

12

14

16

18

17.46

0.8

3.4

A Total

Results

Comparing mean scores: Domain B


1

2

3

4

5

6

76.37

2.52 2.7

B1.


0.050.1

0.150.2

0.250.3

0.350.4

0.450.5

0.46

0.3

0.2

B2(V).


0.51

1.52

2.53

3.54

4.55

4.94

0.2

2.65

B4.

Results


0.05

0.1

0.15

0.2

0.25

0.3

0.29

0.18

0.1

B3(V).

Comparing mean scores: Domain B


2

4

6

8

10

12

14 12.06

2.72

5.65

B Total

Results

Comparing mean scores: Domain C


0.1

0.2

0.3

0.4

0.5

0.60.57

00.05

C1.


0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.310000000000002

0.040

C2.


0.2

0.4

0.6

0.8

1

1.21.09

0.36

0.600000000000001

C4.

Results


0.10.20.30.40.50.60.70.80.9

0.830000000000001

0 0

C3.

Comparing mean scores: Domain C


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.

REFERENCES

Spence JS, Sharifi P, Wiznitzer M. Autism Spectrum Disorder: Screening, Diagnosis and Medical evaluation. Seminars in Pediatric Neurology 2004; 11: 186- 95.

Plauché Johnson C, Myers SM .Council on Children with Disabilities: Identification and evaluation of children with autism spectrum disorders. Pediatrics 2007; 120: 1183–1215.

Groen BW, Zwiers PM, Jan van der Gaa R, Buitelaar KJ. The phenotype and neural correlates of language in autism: An integrative review Neuroscience and Biobahavioral Reviews 2008; 32: 1416-25.

REFERENCES

Thank You

introduction pervasive developmental disorders (pdds) are complex neurodevelopmental disorders...

Documents

introduction slide

work slide

years of age slide

specified retts syndrome

social deficits

normal children

exclusion of children

egyptian children