Indian Pediatr 2014;51: 355-356
INDT-ASD : An Autism Diagnostic Tool for
DEVELOPMENTAL PEDIATRICIAN’S PERSPECTIVE
Chui Mae Wong and Swati Singhal
Department of Child Development, KK Women’s and
Children’s Hospital, Singapore.
The Diagnostic and Statistical Manual for Mental
Disorders, Version IV Text Revision (DSM-IV-TR), published by the
American Psychiatric Association in 1994 (revision in 2000), defines
Autism Spectrum Disorder (ASD) as a disorder characterized by
qualitative impairments in social interaction, with varying degrees of
difficulties in communication and marked repetitive behaviors or
restricted interests. Version 5 (DSM-5), published in 2013, has made
significant changes in the proposed criteria for autism diagnosis and
classification, although almost all the core features from the DSM-IV TR
still prevail . Studies worldwide estimate that the prevalence of ASD
has been increasing, with the US Centre for Disease Control and
Prevention (CDC) reporting it to be around 1%. There are no actual
figures for the Indian population, but it is estimated that there are
around 2.3 million affected children in India .
Screening tools, such as the Modified Checklist for
Autism in Toddlers (M-CHAT), Autism Behavior Checklist (ABC) and the
Autism Spectrum Screening Questionnaire (ASSQ), are available for use by
general pediatricians. If a child is suspected to have autism, based on
clinical suspicion or positive screening on a checklist, he/she needs
detailed evaluation to confirm the diagnosis. To diagnose autism,
various psychometric tools are available which are mapped to either the
DSM-IV TR or DSM-5. The use of these tools is not mandatory to diagnose
autism and some clinicians prefer to conduct informal assessments based
on history and their observations of the child. However, formal
assessments tools are considered superior by most professionals as they
tend to be more structured and reproducible to meet the required
diagnostic criteria. These tools include the Childhood Autism Rating
Scale (CARS), Gilliam Autism Rating Scale (GARS), Autism Diagnostic
Observation Schedule (ADOS) and the Autism Diagnostic Interview- Revised
(ADI-R). However, it is important to note that all the above tools were
developed in the Western world. There is some research to show that
neurotypical individuals from different cultures could display behavior
and mannerisms that could be misread as autism by another society .
Autism being a behavioral diagnosis, it is vital to consider an
individual’s behavior within the context of cultural background.
The proposed new tool , the INCLEN Diagnostic Tool
for Autism Spectrum Disorder (INDT-ASD), has been developed in India. It
is to be used by trained personnel and is based on both history from
primary caregivers and direct observation of a child aged 2 to 9 years.
The tool has been standardized and validated using the CARS. The
INDT-ASD certainly has some distinct advantages. It takes into account
various ethnic and religious variables present in this culturally
vibrant country, especially in respect to peer interaction and play
skills. Apart from English, it is also available in various Indian
languages, including Hindi, Malayalam, Odia, Konkani, Urdu, Khasi,
Gujarati and Telugu. This undoubtedly facilitates
interviewing of caregivers as well as interaction with the child. The
tool also clearly indicates that in cases where the history obtained is
incongruent with observations of the child, which information is to be
given precedence over the other. In a resource-constrained setting, it
appears to be an useful tool which can be completed in a short time. The
tool appears equipped to diagnose children with severe autism (41 of the
total 51 autistic children were diagnosed with severe difficulties).
However, it perhaps needs to be further evaluated to see if it can also
reliably diagnose those with high-functioning autism or Asperger
Syndrome (none of the children in the study had an Asperger diagnosis).
There was reported to be no gender differences although actual numbers
of boys and girls in the autism group were not given. Also, although the
performance of the INDT-ASD was stated to be ‘equally good among
pre-school (< 6 years) and primary school (³
6 years) children’, larger field trials would be useful to ascertain the
sensitivity and specificity of the INDT-ASD in children 2-3 years of
age, as we move worldwide towards earlier identification and
intervention in ASD. This would then also better link in with the
cut-off age of ‘4 years or more’ used in many questions in the INDT-ASD.
Longer-term longitudinal studies can also be undertaken to determine the
diagnostic stability of the INDT-ASD.
The INDT-ASD is currently mapped closely to the
DSM-IV TR. Now that the DSM-5 has been published, further research
should be done to see if it is just as efficacious for the DSM-5
criteria. It would also be interesting to see how the tool compares to
other locally developed tools, such as the Indian Scale for the
Assessment of Autism (ISAA), which has been available since 2009 .
Finally, an important aspect to note is that psychometric diagnostic
tools are to assist a clinician to conclude a diagnosis, but ultimately,
it is sound clinical judgment – based on a clear history and a thorough
behavioral observation – that is of utmost importance. It is always
prudent to consider other differential diagnoses such as cerebral palsy,
intellectual disability, neurodegenerative disorders, hearing loss and
vision loss. We hope that further training, usage, and development of
the INDT-ASD will facilitate awareness, diagnosis and early intervention
for children with autism in India.
Funding: None; Competing Interest : None
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