Identifying Autism in a Brief Observation

Abstract

BACKGROUND: Pediatricians, neurologists, and geneticists are important sources for autism surveillance, screening, and referrals, but practical time constraints limit the clinical utility of behavioral observations. We analyzed behaviors under favorable conditions (ie, video of autism evaluations reviewed by experts) to determine what is optimally observable within 10-minute samples, asked for referral impressions, and compared these to formal screening and developmental testing results.METHODS: Participants (n = 42, aged 15 to 33 months) were typically developing controls and children who screened positive during universal autism screening within a large community pediatric practice. Diagnostic evaluations were performed after screening to determine group status (autism, language delay, or typical). Licensed psychologists with toddler and autism expertise, unaware of diagnostic status, analyzed two 10-minute video samples of participants' autism evaluations, measuring 5 behaviors: Responding, Initiating, Vocalizing, Play, and Response to Name. Raters were asked for autism referral impressions based solely on individual 10-minute observations. RESULTS: Children who had autism showed more typical behavior (89% of the time) than atypical behavior (11%) overall. Expert raters missed 39% of cases in the autism group as needing autism referrals based on brief but highly focused observations. Significant differences in cognitive and adaptive development existed among groups, with receptive language skills differentiating the 3 groups.CONCLUSIONS: Brief clinical observations may not provide enough information about atypical behaviors to reliably detect autism risk. High prevalence of typical behaviors in brief samples may distort clinical impressions of atypical behaviors. Formal screening tools and general developmental testing provide critical data for accurate referrals. WHAT'S KNOWN ON THIS SUBJECT:Behavioral observations influence a clinician' s decision to diagnose or refer, and may even override formal screening results. In the case of autism spectrum disorder, an expected rate of atypical behavior during the span of a medical visit is unknown. WHAT THIS STUDY ADDS:We are the first to quantify the high base rates of typical behavior in young children who have autism and language delay. When observation times are brief, the preponderance of typical behaviors may negatively impact referral decision accuracy.

Psychometric analysis of the Systematic Observation of Red Flags for autism spectrum disorder in toddlers

“…STAT, ADEC, and RITA-T) with large community-ascertained samples to determine effectiveness as level-two screeners in primary care settings. Furthermore, though the observational screening tool studied by Gabrielsen et al (2015) intended to provide a brief 10-min observational measure similar to the SORF, the screener did not adequately predict risk for ASD. This finding suggests that a longer period of observation and/or observation of more behaviors may be needed in an effective screening measure.…”

“…24–36 months) and requires administration by a trained professional familiar with ASD, greatly reducing its feasibility for implementation in community settings. A recent study (Gabrielsen et al, 2015) also examined the use of an observational rating tool during two 10-min samples of the Autism Diagnostic Observation Schedule (ADOS; Lord et al, 1999). Experts missed 39% of children with ASD when asked whether they would refer the child for an evaluation after each 10-min sample, indicating that this rating tool is not effective in detecting risk for ASD in toddlers in a brief observation during a semi-structured interaction.…”

Agreement Between a Brief Autism Observational Instrument and Established ASD Measures

“…The difficultly that practitioners report in detecting ASD during brief clinical observations (Gabrielsen et al, 2015), in combination with practical time and resource constraints during standard primary child health care visits, may increase the risk of either misidentification of children in need of further referral for ASD, or over identification of children with non specific developmental concerns and delays, producing inaccurate referrals. Further research is required to investigate how well the ABII can distinguish children with ASD from children with other developmental concerns and disabilities.…”

“…They are often the initial respondents to parental concerns (Fillipek, 1999) and can therefore initiate early referral of children for specialist ASD assessment. However, during brief healthcare visits it is difficult to elicit ASD specific information from parents (Zuckerman, Lindy & Sinche, 2015) or quantify the symptoms to assess risk (Gabrielsen et al, 2015). This can reduce the accuracy of referrals for specialist review, which itself could have several negative flow on effects, including delayed diagnosis (Reichow, Barton, Boyd & Hume, 2012).…”

Early Identification of Young Children with Autism Spectrum Disorder

“…Individual clinical judgement in the absence of adjunctive information has proven to be insufficient for identification. In a recent study, even experienced observers missed 39 % of young children with ASD after viewing a 10 min video [13]. The use of formal developmental screening tests does improve the rate of identification of developmental problems, including ASD, in young children [14].…”