1 Differentiating Autism in a Chinese Population Grace Hao, M. D., Ph.D., CCC-SLP Thomas Layton, Ph.D., CCC-SLP ASHA November 17, 2012 Atlanta, Georgia.

1

Differentiating Autism in a Chinese Population

Grace Hao, M. D., Ph.D., CCC-SLP

Thomas Layton, Ph.D., CCC-SLP

ASHANovember 17, 2012

Atlanta, Georgia

Dr Hao is a Professor in the Department of Communication Disorders at North Carolina Central University. She has both a medical degree from China and a Ph.D. in speech-language pathology. Dr. Layton is currently the President/Co-owner of a private Center in Durham NC. He, Dr. Hao, and Dr. Zou,a developmental pediatrician in China, are standardizing a new unpublished diagnostic test in China. We do not have financial interests in the diagnostic tool, as it is currently used as part of the current research.

DSM-IV Criteria for Diagnosis

At least 6 characteristics from the following 3 domains to qualify for diagnosis of autism

1- Social skills 2- Communication3- Behavior

3

4

5

6

Literature ReviewLFASD versus HFASD

Bartak & Rutter (1976) found more language delay, severe personal relationships and more disruptive behavior than HFASD

HFASD versus Typically DevelopingSteinhausen & Metzke (2004) more disruptive

behaviorTsatsanis (2005) more weakness in cognitive

functionsBaranek et al. (2005) problems in motor

developmentTager-Flushberg (2004) problems in complex

languageOzonoff et al. (2004) problems in Executive

Function

7

Literature ReviewOne study with Chinese children (Zhang & Ji, 2005)LFASD versus Intellectually DisabledLFASD had 25% prenatal birth problems vs

62.5% of IDLFASD only 1 child had cerebral palsy vs 31%

had “other developmental disorders”

8

Purpose of the studyTo compare HFASD children to Typically Developing children (TD)

To compare Moderate/severe ASD (LFASD) children to Intellectually Disabilities (ID)

To measure individual items within seven behavior Domains

9

SubjectsLFASD (n=236; mean age 46.7 m)HFASD (n = 96; mean age 53.1 m) Intellectual/Developmental Disabilities (n = 33; mean age 55.7 m)

Typically Develop. (n = 103; mean age 43.9 m)

10

ASD groupsPreviously diagnosed by developmental pediatricians using the ADI-R, SRS, and/or a behavioral protocol.

All subjects spoke MandarinNon-ASD groups

Recruited from well-baby-care clinics throughout China

ID group administered WISC-Chinese, scores below 70 IQ

11

Research Team: Centers Involved

Guangzhou: Third Affiliated Hospital & Guangzhou Center for Children with

ASDShenzhen Hospital for Children and Pregnant

WomanChongqing Children’s HospitalHainan Children’s HospitalHarbin Medical University Autism CenterShanghai Children’s HospitalShiJia-Zhuang Medical UniversityTianjin Medical UniversityNanjing Medical University

12

CADS Domains used for comparisons

13

14

15

(CADS)Chinese Autism Diagnostic Scale

First Autism Diagnostic test designed, developed, and standardized in China for Chinese population

Takes into account the cultural and language aspects

Addresses needs and frequently asked questions found in China

CADS Seven DomainsMotor/Vocal ImitationStereotyped behaviorsSensory behaviorsPlay behaviorsSocial InteractionReceptive LanguageExpressive Language

16

17

Motor Area (3 Domains)

Motor/Vocal Imitation Domain (11 items)

Stereotyped Behavior Domain (13 items)

Sensory Domain (10 items)

18

19

Social Area (2 Domains)

Play Domain (10 items)

Social Interaction Domain (21 items)

20

21

Language Area (2 Domains)

Receptive Language Domain (10 items)

Expressive Language Domain (17 items)

22

23

Supplemental Area (2 Domains)

Academic & Educational Domain (15 items)

Executive Function Domain (30 items)

24

Executive Functions Planning Organizing Time Management Flexibility/Attention Affect Working Memory

25

Individual Item scoring for group comparisons Used group percentages due to unequal sample

sizes A difference of 9 percentage points or greater

between groups were required for points given A difference at Moderately Impaired level was

given 1 point A difference at Severely Impaired level was given 2

points Individual items required 2 or 3 total points to be

considered different

26

27

  Moderate Severe Total Scores

Squeals      

LFASD ID

34% (1)22% (0)

21% (2)6% (0)

3 √0

Unusual interest toy      

LFASD ID

30% (1)3% (0)

69% (2)0% (0)

3√0

LFASD Results

28

LFASD Results

LFASD versus Intellectually DisabledSix Domains were significantly differentThe LFASD group performed less well on all six Domains

29

30

Individual Item contrasts

LFASD versus ID

31

32

Play Behavior items for LFASD

No independent play skillsTends to play aloneNo interest in social playNo interest in othersShows inappropriate play with childrenHas no regular playmatesHas limited attention span

33

Stereotyped Behavior items for LFASDSqueals moreUnusual interest in certain part of a toyPeculiar interests in objects Has a particular, or unusual way of ordering toys or things

Excessively rigid

34

Sensory Behavior items for LFASD

Over reaction to noiseInappropriate reaction to a pinchInappropriate reaction to texturesEats restricted foodsInappropriate reaction to visual stimuli

35

Social Interactive Behaviors LFASD Does not look in faces Does not smile No understanding of

gestures Does not hand a toy to adult Does not share food No empathy Does Not look at objects of

interest with others Does not point Reacts negatively to familiar

people who approach him/her

Does not help others Does not recognize social

errors Does not understand

playful remark Does not understand hints

or indirect remarks Gets upset when left at

unfamiliar places Does not seek parents or

others for support

36

Receptive Language items for LFASD

Does not select objects upon commandDoes not point to nose, eyes, earsDoes not point to pictures Inappropriate response to verbal commandInappropriately nods and responds to speaker

Does not correctly respond to “wh” questions

37

Expressive Language items for LFASD

Echoes or repeats wordsProsody of speech not normalDifficulty labeling or naming objectsGets words out of orderFrequently talks to him/herselfInappropriate use of pronounsInability to initiate or direct discourseMakes socially inappropriate comments

38

HFASD Results

39

HFASD Results

HFASD group versus Typically Developing children

Three Domains were significantly different

The HFASD group performed less well on all three Domains

40

41

Individual Item contrasts

HFASD versus TD

42

Stereotyped Behavior items for HFASDStares to sideRocks back/forthFlaps hands/fingersSqueals

43

Sensory Interactive Behavior items for HFASDOver reaction to noiseEats restricted foods

44

Play Behavior items for HFASDPlays alone Has inappropriate play behavior with other children

No turn taking in social playDoes not seek help from others

45

Profile of Four ChildrenCADS profile 4 children

HFASD, LFASD, TD, ID

46

Remember:

Higher the score--more severe the problem

47

48

Future Analysis and ContrastsComparing three levels of ASD

Mild FunctioningModerate FunctioningSevere Functioning

49

Bell Shape Curve For ASD Group

Range Of Scores

MILD GROUP(Level I)

              > 1 StD (n=66) 20% 93 - 142 rangeUpper 25th (n=67) 21% 93 - 143        

MODERATE GROUP(Level II)

    1StD (n=210) 64% 215 - 141 rangeMiddle 50th (n=175) 54% 209 - 142      

SEVERE GROUP(Level III)

    < 1StD (n=50) 15% 216 - 265 rangeLower 25th (n=84) 26% 208 - 265                

*Upper number is based on Standard Deviation

*Lower number is the upper 25th percent scores, middle 50th percent scores, and lower 25th percent scores*Mild Group = high functioning; Moderate Group = middle group; Severe Group = lowest functioning

Severity Rating of the ASD

ConclusionsLFASD group demonstrated more difficulty on six Domains compared to ID group

Domains:

1. Stereotyped Behaviors

2. Sensory

3. Play

4. Social

5. Receptive Language

6. Expressive Language

52

Conclusions

HFASD group demonstrated more difficulty on three Domains compared to TD group

Domains: 1. Stereotyped Behaviors

2. Sensory

3. Play

53

Conclusions

Also, findings from preliminary data supported significant differences, across 7 domains, between the HFASD and the LFASD groups, which is consistent with the DSM-V proposal for severity groupings of children with ASD.

54

References

BARANEK, G., PARHAM, L., & BODFISH, J., 2005, Sensory and motor features in autism: Assessment and intervention. In F. R. Volkmar, R., Paul, A. Klin, & D. Cohen (Eds.,) Handbook of autism and pervasive developmental disorders , Volume 2: Assessment, intervention, and policy (3rd ed.) (New York: Wiley & Sons).

BARTAK, L., and RUTTER, M., 1976, Differences between mentally retarded and normally intelligent autistic children, Journal of Autism and Childhood Schizophrenia. 6(2), 109-120.

HAO, G., LAYTON, T., ZOU, X., and LI, D., (in press). Evaluating Autism in a Chinese Population: The Chinese Autism Diagnostic Scale. World Journal of Pediatrics, 2013.

LAYTON, T., HAO, G., and ZOU, X., in progress. Chinese Autism Diagnostic Scale. (Durham, NC) for additional information contact: [email protected].

OZONOFF, S., COOK, I., COON, H., DAWSON, G., JOSEPH, R., KLIN, A., McMAHON, W., MISHEW, N., MUNSON, J., PENNINGTON, R., ROGERS, S., SPEINCE, M., TAGER-FLUSHBERG, H.,, WOLKMAR, F, & WRATHALL, D., 2004, Performance on Cambridge Neuropsychological Test Automated Battery subtests sensitive to frontal lobe function in people with autistic disorders: evidence from the Collaborative Programs of Excellence in Autism network. Journal of Autism and Developmental Disorders, 34(2), 139-50.

TAGER-FLUSHBERG, H., 2004, Strategies for conducting research on language in autism. Journal of Autism and Developmental Disorders, 34, 75-80.

TSATSANIS, K., 2005, Neuropsychological characteristics in autism and related conditions., In F. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism and pervasive developmental disorders (3rd ed.), Diagnosis, development, neurobiology, and behavior. (New York: Wiley & Sons).

ZANG, X. and JI, C., 2005, Autism and mental retardation of young children in China. Biomedical and Environmental Sciences, 18, 334-340.

55