Early detection of autism
– comparison of two screening tools
Dutt R. D.1, Jain A.2,
Dutt C. K.3
1Dr. R. D. Dutt, PGDDN, Pediatrics Neurologist, Associate Professor
.O.D, Department of Pediatrics, 2Dr. Ashish Jain, Assistant
Professor, Department of Pediatrics, Bundelkhand Medical College,
Sagar, M.P., 3Dr. Mrs Chandra Kala Dutt, Assistant Professor,
Department of Surgery, KRH G.R. Medical College, Gwalior,
M.P, India
Address for
Correspondence: Dr. Ashish Kumar Jain, Department of
Pediatrics, BMC, Sagar, Email -drrddutt@rediffmail.com
Abstract
Introduction:
The aim of the study was comparison of a newly developed test
Trivandrum Autism behaviour checklist with gold standard test, CHAT. Method: The present
study was done in pediatric OPD (Bundelkhand Medical College, Sagar,
(MP). The study was done in the children of 24 to 36 month of age over
a period of one year. The study including sex, age of the father
& mother, education of father & mother, place of
residence, antenatal history, natal & neonatal history,
immunization history, developmental history and also two tools
– CHAT & TABC. Result:
There are many factors taken during study but there is relation between
these factors and Autism. However, Autism is more common in age group
of 21 to 30 month of age and also common in male than female. It is
more common in urban areas. It is shown that the Birth weight of babies
were 2.5 to 3.00kg. The incidence is also high in immunized children.
There is no relation with age and education of the parents, Antenatal
History, Developmental history. In present study, the maximum no. of
cases were screened by CHAT test (28 case) while 11 cases by TABC case.
However, 11 cases were screen by both CHAT and TABC. In study
sensitivity of the TABC (Trivandrum Autism behaviour checklist) 39.2 it
is low, hence TABC is not good test for screening. Specificity 99.4 it
is high, hence TABC is good test for diagnosis or confirmatory test. Conclusion: It is
shown that chat is a good test for screening of Autism then TABC. The
TABC is good test for the diagnosis or confirmation of the disease.
Key words -
CHAT test, TABC (Trivandrum Autism behaviour checklist) test, Autism
Manuscript received: 4th
February 2017, Reviewed:
14th February 2017
Author Corrected:
21st February 2017,
Accepted for Publication: 28th February 2017
Introduction
Autism is a developmental disorder that appears in first three years of
life and is characterized by impaired social communication and
interaction. Autism is also characterized by restricted and repetitive
behaviour. It is also called as pervasive developmental disorder.
Fombonne E et al study shows the prevalence to be 0.9/1000 with highest
prevalence rate in rural areas [1]. Studies conducted across the world
have shown that the cases of autism have increased from 50% to 2000%
[2]. This number could have increased partly due to improvement in
awareness and clinical practice [3].
The exact cause of autism is unknown. Autism is linked to genetic
predisposition and also to infections occurring during prenatal,
perinatal or postnatal phases [4-7]. Certain environmental factors
could also act as trigger. Siblings of children with autism are at a
higher risk of developing autism. Drugs like thalidomide and valproic
acid taken during pregnancy are believed to be risk factors for autism
[8,9]. High parental age is also believed to be one of the risk factors
[10]. Despite profound research the pathophysiology of autism is still
not well understood. There is alteration of brain system and this is
believed to occur immediately after conception [11].
Several screening tools have been developed for successful diagnosis of
autism. Adequate use of these tools requires training and experience.
The signs and symptoms of the toddlers should be monitored for early
diagnosis of autism. They primarily include impaired social
interaction, language problems, repetitive behaviour, delayed
developmental milestones, absent protodeclarative pointing and history
of frequent infections. There is no known cure. These children can
benefit with speech and behavioural interventions if started at early
stage.
The prognosis of patients with autism is dependent on their
intelligence quotient (IQ). Patients with low functioning IQ may find
it difficult to live independently throughout their entire life.
Patients with high functioning IQ may be able to carry out their
responsibilities independently and even progress in life.
Methodology
Aims- The
aim of our study to publish is to diagnosed autism earlier as possible.
Objective: The
object of this study is to identify autistic child as early as possible
by chat & TABC. To compare the two test (CHAT & TABC)
to diagnose the autism as earlier as
possible.
Type of study-
It is cross sectional case study.
Sample collection-
These children are coming from Sagar Division MP as well as U.P.,
Chattishgarh and Maharashtra in OPD of Bundelkhand Medical College,
Sagar (MP)
Sampling method-
Patients were interrogated in the Bundelkhand Medical College, Sagar
for any signs of autism.
Inclusion Criteria-
Normal Children from 24 to 36 months in age coming in OPD
Exclusion Criteria-
Cerebral palsy, Global Developmental delay patients
Duration study-
one year.
Present study was done is pediatrics O.P.D. in Bundelkhand Medical
College, Sagar –M.P.). We have taken children of 24-36 months
age group. There is no difference on the basis of sex, religion and
education. We have compare these babies with CHAT screen and TABC score.
We have examine children in following orders. - age, sex, Birth order,
Place of Residence, Age of the father & mother, Presenting
Complaints, Anternatal History, Natal & Neonatal History,
Immunization History, Developmental History.
Tools- CHAT (Check list for Autism Toddlers) Research Centre at the
University of Cambridge
Questions for the parents
1. Does your child ever pretend, for example to make a cup of
tea by using a toy cup and teapot or pretend other things?
2. Does your child ever use his or her index finger to point,
to indicate interest in something?
3. Does your child take an interest in other children?
4. Does your children enjoy playing peek-a-boo or
hide-and-seek?
5. Does your child ever bring objects over to you to show you
something?
[If the answer to two or more of the above is "No" than autism is
suspected (except in the presence of server generalized developed
delays)]
Physicians' observation
1. During the appointment, has the child made eye contact with
you?
2. Get the child's attention, then point across the room at an
interesting object and say "Oh look! There's a (name object)". Watch
the child's face. Does the child look across to see what you are
pointing at?
3. Get the child's attention, the give the child a miniature
toy cup and teapot and say, "Can you make a cup of tea? "Does the child
pretend to pour out tea, drink it, etc? (May use other objects for
pretend play).
4. Say to the child, "Where's the light? or "Show me the
light" does the child point with his or her index finger at the light?
[If the answer to two or more of the above is, "No" autism is
suspected].
Trivandrum Autism Behavioural Checklist, Child Development Centre
Trivandrum (TABC)
I. Social
Interaction
a. Inability to establish and/or maintain
eye contact.
b. Child does not respond when called,
sometimes appear to be deaf.
c. Difficulty in mixing and praying with
other children of same age.
d. Lack of appropriate emotional
responses.
e. Can do certain tasks well, but not the
tasks involving social understanding.
II. Communication
a. Difficulty in
comprehension/communication.
b. May/May not indicate needs by gestures
or leading adults by the hand.
c. Echolalia/using nonsensical words and
muttering to self.
d. Lack of pretend play.
III. Behavioral
Characteristics
a. Like sameness in every day routine.
b. Inappropriate attachment to objects.
c. Unusual body movement such ah flapping
hands, or rocking and jumping.
d. Extreme restlessness, hyperactivity
over passivity or prefers to be alone all the time.
e. Not responsive to normal teaching
methods.
IV. Sensory
Integration
a. Doesn't like to be hugged or
touch/Apparent insensitivity to pain.
b. Intolerance/Addition to certain
sounds, tastes, odours, visuals.
c. No understanding or fear of real
dangers/excessive fear for heights, changes in position.
d. Enjoy spinning or rotating objects.
e. Inappropriate laughing and
giggling/Crying spells with extreme distress for no apparent reasons.
f. Difficulty in fine motor skills/a
tendency to fall/clumsiness/ resistance to new motor movement
activities.
Note: Scoring
is done by asking these various questions in all four headings and
totaling is done. In each case.
1. Never 1 marks (Nil)
2. Sometimes – 2 (Less than
50%).
3. Often – 3 (More than 50%)
4. Always – 4 (More than 90%).
Calculations of scoring
1. 20-35 scoring – no autism
2. 36-43 likely autism
3. 44 and above severe autism.
Analysis of Data- By
gold standard test – calculated sensitivity, specificity,
positive predictive value, negative predicative value, likely hood
ratio – positive & negative, Accuracy, prevalence,
odds, probability.
Observation
Table-1: Age of children
|
Age group
|
No. of child
|
|
24-30 Month
|
118 (58.70%)
|
|
31-36 Month
|
83 (41.29%)
|
|
Total
|
201
|
Out of 201, 118(58.70) children were 24-30 month of age
group 83(41.29%) child were 31-36 month of age group.
Table-2: Birth Weight
|
Name
|
No. of cases
|
|
1-1.5
kg
|
0
(0%)
|
|
1.5
to 2.5 kg
|
45
(22.38%)
|
|
2.5
to 3.0 kg
|
110
(54.71%)
|
|
3.0
to 3.8 kg
|
46
(22.88%)
|
|
Total
|
201
|
Most of babies birth weight was in 2.5 – 3 Kg.
(110, followed by 3-3.5 kg. (46), 1.9-2.5 kg. (45) and no case in 1-1.5
kg birth weight.
Table-3: Checklist of
Autism in Toddlers (CHAT)
|
Question Parents
|
Physicians Obs.
|
Both
|
|
1
|
128 (63.68%)
|
1
|
49 (24.37%)
|
|
|
2
|
18 (8.99%)
|
2
|
34 (26.91%)
|
|
|
3
|
1 (.49%)
|
3
|
10 (4.97%)
|
|
|
4
|
2 (.99%)
|
4
|
3 (1.49%)
|
|
|
5 (No)
|
52 (25.87%)
|
|
105 (52.23%)
|
|
|
|
|
|
|
13.93%
|
Out of 201, no symptoms were reported in 52 cases, one
symptoms reported in 128 cases and 2 symptoms were reported in 18 cases
and 3 symptoms reported in one case only and 4 symptoms reported in 2
cases.
Table-4: Trivandrum
Autism Behavioural Checklist (TABC)
|
Score
|
No Autism
|
Likely Autism
|
Severe Autism
|
|
20-35
|
190 (94.52%)
|
|
|
|
36-43
|
|
9 (4.47%)
|
|
|
44- above
|
|
|
2 (.99%)
|
|
Total
|
190 (94.52%)
|
9 (4.47%)
|
2 (.99%)
|
Out of 201, 191 cases have no autism, 8 cases have likely
autism and 2 cases have severe autism.
Table -5: Results of Study
|
|
Chat
|
TABC
|
Both
Chat+TABC
|
|
Positive
|
28 (13.93%)
|
11 (5.47%)
|
11(5.47%)
|
|
Negative
|
173 (86.06%)
|
190 (94.52%)
|
190 (94.52%)
|
|
Total
|
201
|
201
|
201
|
Table shows 28 cases were screen by chat while 11 cases by
TABC. In both tools 11 cases were positive.
Table -6: Analysis of Data
|
Specificity
|
Sensitivity
|
|
CHAT
|
TABS
|
CHAT
|
TABS
|
|
99.4
|
99.99
|
39.2
|
18.18
|
Specificity for chat was 99.4% while TABS had 99.9%.
Sensitivity for chat was 39.2% while 18.18% were for TABS.
Discussion
The Trivandrum Autism Behavioral Checklist TABC test is one simple tool
developed by the Child development centre, Medical College,
Thiruvanthapuram, India which has been found to be equally good to
screen the children for Autism. As per our study the frequency of
occurrence of Autism is 1.5%. More and more children are currently
being diagnosed for Autism then before.
In present study, out of 201 children of 24-36 months, it shows the
autism is more common in the age group of 24-30 months (58.70%). The
forborne also reported 57.91 cases [1]. In present study, it shows that
autism in more common in male (55.72%) than female children (44.27%).
This is because of male babies suffer more than female children
naturally. In present study, most of the babies (87.56%) delivered with
mothers age group of 21-30 years of age as also reported by Di martion
A et al [2]. In present study, out of 201 most of the father came in
the age group of 21-30 years of age (66.16%) cases followed by 31-35
years of age (17.91%) as reported by Jin [3].
In present study, out of 201 children, higher children came in the
birth order of II (48.7%) as compared with 49% as reported by HAS [4]
followed by birth order 41.29% and birth order III (8.9%). In present
study out of 201, most of the father (63.18% cases) were educated, as
9.45% father were schooled up to primary level, 24.87% father were
studies up to high school and 25.37% had degree in various subjects as
also reported by crespi B et al [5]. In present studies, out of 201,
most of the children belonged to urban area (52.36%). Children came
from villages were 47.26% as also reported by Reichow B [6]. Out of 201
mother, 98.50% mother have no positive antenatal history. 1.49% mothers
had infection during pregnancy as also reported by Patterson et al [7].
In present study, out of 201, most of babies were in the age group of
2.5-3.4kg weight group (54.72%). It is followed by 3.00 Kg –
above (22.8%), similar findings were also reported by Rossignol DA et
all [8].
In present study, out of 201 children, babies receive no vaccine were
27.36% cases. 4.97% child received only 1 dose of DPT & OPV
while 7.46% children received only 2 doses DPT & OPV. 16.41%
cases received 3 doses of DPT & OPV. 16.14% children received
only measles vaccines & 83.55% did not received measles
vaccine. 16.41% babies also received MMR vaccine. While 83.55% not
received MMR as reported by Doja A et al [9].
In present study it has been divide in two parts 1 part comprises of
asking questions from the parents and the direct observations of child
by physician. In study 25.87% parents giving answer of questions
– YES, 63.68% parents giving answer of one questions
– NO, 8.91% parents giving answer of two questions
– NO, 0.49% parents giving answer of three questions
– NO, 0.99% parents giving answer of four questions
– NO
In present study, in 52.73% children physician observation were
– YES. 24.37% children physician observation were –
No only in one observations. 16.91% children physician observation were
– No only in two observations. 4.97% children physician
observation were – No only in three observations. 1.49%
children physician observation were – No only in four
observations. Total cases detected are 13.93% as reported by Baird et
al [10].
In present study, 94.52% babies did not have any symptoms and sign of
autism, 4.47% babies have likely autism and .99% have autism. Similar
findings were reported by Bieverc et al [11] while 11 cases were
detected by both test.
Conclusion
In present study, the maximum no. of cases were screened by CHAT test
(28 case) while 11 cases by TABC case. However, 11 cases were screen by
both CHAT and TABC. In study sensitivity of the test 39.2 it is low,
hence TABC is not good test for screening. Specificity 99.4 it is high,
hence TABC is good test for diagnosis or confirmatory test. I
concluded, it is shown that chat is a good test for screening of Autism
then TABC. The TABC is good test for the diagnosis or confirmation of
the disease.
Funding:
Nil, Conflict of
interest: None initiated.
Permission from IRB:
Yes
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How to cite this article?
Dutt R. D, Jain A, Dutt C.K. Early detection of autism –
comparison of two screening tools. Int J Pediatr Res.
2017;4(11):688-693.doi:10. 17511/ijpr.2017.11.09.