Introduction
Screening tool (long name) | Short name | Admin. time (min) | Admin. age (months) | Admin. methodb
| Items | Sensitivity | Specificity |
---|---|---|---|---|---|---|---|
Level 1a
| |||||||
CHAT | 5–10 | 18 | Parent + clinician rated | 9 + 5 | 0.18–0.38 | 0.98–1.0 | |
Social Communication Questionnaire [18] | SCQ | 15–20 | 36–82 | Parent rated | 40 | 0.74 | 0.54 |
Modified-Checklist for Autism in Toddlers [19] | M-CHAT | 5–10 | 18–30 | Parent rated | 23 | 0.87 | 0.99 |
Quantitative Checklist for Autism in Toddlers [20] | Q-CHAT | 5 | 16–30 | Parent rated | 25 | – | – |
Communication and Social Behaviour Scale-Infant and Toddlers Checklist [21] | CSBS-DP | 5–10 | 16–30 | Parent rated | 24 | – | – |
Early Screening Autistic Traits Questionnaire [22] | ESAT | 10 | 14–15 | Parent + child care worker | 14 | – | – |
First Year Inventory [23] | FYI | 10 | 12 | Parent rated | 59 | – | – |
Checklist for Early Signs of Developmental Disorders [24] | CESDD | Child care worker rated | 12 | ||||
Autism Observation Scale for Infants [1] | AOSI | 10 | 6–1 | Clinician rated | 18 | 0.84 | 0.98 |
Young autism and other developmental disorders checkup tool [25] | YACHT-18 | 10 | 18 | Clinician rated | 18 | 0.82 | 0.86 |
The Social Attention and Communication Study [26] | SACS | 5 | 8, 12, 18, 24 | Clinician rated | 15 | 0.83 | 0.99 |
Joint attention-observation schedule [27] | JA-OBS | 5–10 | 20–48 | Child Nurse Rated | 5 | 0.86 | – |
Level 2a
| |||||||
Developmental Behaviour Checklist-primary care version [28] | DBC-ES | 5–10 | 18–48 | Parent rated | 96 | 0.83 | 0.48 |
Screening tool for autism in 2 years old [29] | STAT | 20 | 24–35 | Child care worker rated | 12 | 0.83 | 0.86 |
Screening for infants with developmental deficits and/or autism [30] | SEEK | 30–40 | 8 | Parent + clinician rated | 9 + 28 | – | – |
Pervasive Developmental Disorders Rating Scale [31] | PDDRS | 60 | >12 | Parent rated | 51 | – | – |
Autistic behavioural indicators instrument [32] | ABII | 30 | 24–72 | Clinician rated | 18 | – | – |
Autism Behaviour Checklist [33] | ABC | 15 | >36 | Parent rated | 57 | 0.58 | 0.76 |
Childhood Rating Scale [34] | CARS | 15–20 | >24 | Clinician rated | 15 | 0.92–0.98 | 0.85 |
Autism detection in early childhood [35] | ADEC | 12 | 12 | Parent or nurse rated | 16 | 0.79–0.94a
| 0.88–1.00a
|
BISCUIT | 15 | 17–37 | Parent rated | 42 | 0.84 | 0.86 | |
Three-item direct observation screen test [40] | TIDOS | 5 | 18–60 | Clinician rated | 3 | 0.95 | 0.85 |
Current situation of ASD screening studies in Europe
Setting and users | Screening procedure | Study sample and resultsa
| Comments |
---|---|---|---|
United Kingdom—South East Thames region Primary health care practitioner to parents | CHAT (high + medium risk) + CHAT (high + medium risk) |
N = 16.235, M
age = 18.7 (1.1) PPV = 0.59; NPV = 1.00; Se. = 0.21; Sp. = 1.00 | Extremely low false-positive rate High false-negative rate Specifically, combination of joint attention items + pretend play indicates ASD risk Discriminating protodeclarative acts may be difficult for parents |
The Netherlands—Province of Utrecht Well-baby clinics + home Physicians to parents + psychologist to parents | 4-item + 14-item ESAT |
N = 31.724, M
age = 14.91 (1.37) PPV = 0.25; NPV = *; Se. = *; Sp. = * | High false-positive rate but no TD children At young age, hard to discriminate between ASD and TD/DD At young age, failure to detect higher functioning children/milder ASD variants/children who regress or develop autism later Drop-out because parents not yet willing to cooperate Physicians cautious in referring for ASD Screen-negative cases not followed up (Dietz et al. [43]) |
The Netherlands—Nijmegen Primary care setting + child psychiatry Primary care worker Primary care worker + parents’ self-administered test Primary care worker + parents’ self-administered test Primary care worker + parents’ self-administered test | Procedure 1: Clinical concern + 14-item ESAT Procedure 2/3: 14-item ESAT + SCQ 11 14-item ESAT + SCQ 15 Procedure 4: 14-item ESAT + CSBS-DP Procedure 5/6: 14-item ESAT + CHAT high risk 14-item ESAT + CHAT high + medium risk |
N = *, M
age = PPV = 0.68; NPV = 0.37; Se. = 0.88; Sp. = 0.14 PPV = 0.71; NPV = 0.47; Se. = 0.84; Sp. = 0.28 PPV = 0.79; NPV = 0.48; Se. = 66; Sp. = 0.64 PPV = 0.78; NPV = 0.50; Se. = 0.71, Sp. = 0.59 PPV = 0.97; NPV = 0.37; Se. = 0.18; Sp. = 0.99 PPV = 0.88; NPV = 0.45; Se. = 48; Sp. = 0.87 | No screening instrument clearly better than any other in differentiating ASD from non-ASD Trade-off between sensitivity and specificity (F.1) High false-positive rate Explore different cut-offs/item-selection within screening instruments. CHAT not administered in original form, constructed from SCQ and CSBS-DP items Screen-negative cases not followed up: where true sensitivity and specificity could not be calculated, they were calculated with the percentage of children about whom there was already some concern (Oosterling et al. [63]) |
Belgium—Flanders Child day-care setting + home Child care worker + parents’ self-administered test Child care worker + parents’ self-administered test Child care worker + parents’ self-administered test Child care worker + parents’ self-administered test | Procedure 1: CESDD + 14-item ESAT Procedure 2/3: CESDD + SCQ 11 CESDD + SCQ 15 Procedure 4: CESDD + M-CHAT Procedure 5: CESDD + FYI |
N = 7.092, M
age = 16.70 (8.19) PPV = 0.55; NPV = 0.95; Se. = 0.40; Sp. = 0.97 PPV = 0.44; NPV = 0.94; Se. = 0.70; Sp. = 0.84 PPV = 0.83; NPV = 0.91; Se. = 0.43; Sp. = 0.98 PPV = 0.29; NPV = 0.98; Se. = 0.71; Sp. = 0.87 PPV = 1.00; NPV = 0.93; Se. = 0.33; Sp. = 1.00 | First screening to include report by child care workers High false-positive rate but many developmental disorders/delays among false positives Low parent compliance rate Adaptation of original screening protocol: no telephone interview included in M-CHAT, ESAT completed by parents alone. (Dereu et al. [24]) |
Spain—Salamanca and Zamora; Madrid Well-baby clinic + home Parents’ self-administered test + researcher to parents +paediatrician Parents’ self-administered test + paediatrician/nurse to parents through web interface | Procedure 1: M-CHAT + M-CHAT telephone interview(by researchers at Univ. when needed) Procedure 2: M-CHAT + M-CHAT web-based interview |
Salamanca and Zamora
N = 8,122, M
age = 20.58 (3.2) PPV = 0.38; NPV = 0.99; Se. = 0.83; Sp. = 0.99
Madrid
N = 2,910, M
age = 23.14 (4.0) PPV = 0.26; NPV = 0.99; Se. = 0.90; Sp. = 0.99
N = 1,402, M
age = 20.21 (3.0) PPV = 0.50; NPV = 0.99; Se. = 0.67; Sp. = 0.99 | Translated and adapted; M-CHAT results similar to original M-CHAT study Explore adaptation with screening instrument, such as web-based interview instead of telephone interview Need for coordination of health services and ASD intervention units in Spain Screen-positive children followed up for 2 years Locating and contacting families for telephone interview proved very time-consuming (García-Primo et al. [64]) |
Sweden—Gothenburg (Home +) child health centre Nurse Parents’ self-administered test Parents’ self-administered test + nurse | Procedure 1: JA-OBS Procedure 2: M-CHAT (including interview) Procedure 3: M-CHAT (including interview) + JA-OBS |
N = 3.999, M
age = 36.00 (no SD reported) PPV = 0.92.5; NPV = .*; Se. = 0.86; Sp. = * PPV = 0.92; NPV = .*; Se. = 0.76; Sp. = * PPV = 0.89.6; NPV = .*; Se. = 0.95.6; Sp. = * | Interview M-CHAT was necessary; many parents had difficulties understanding questions JA-OBS raised nurse awareness about ASD Combining different instruments for professionals and parents is effective. Screen-negative cases not followed up Screening procedure implemented in developmental programme (Nygren et al. [27]) |
France—Toulouse Well-baby clinic Parents’ self-administered test + professional | M-CHAT + CHAT |
N = 1,227, M
age = 24 Preliminary data: TP = 17; TN = 1,192; FN = 1; FP = 17 | Difficulty in obtaining participation of professionals Follow-up at 30 and 36 months in order to check the diagnosis status |
Italy Paediatrician to parents | M-CHAT + M-CHAT interview by paediatrician directly |
N = 1,000, M
age = 24.4 (3.2) Preliminary data: TP = 4; TN = *; FN = *; FP = 8 PPV 0.28 | Difficulties in re-screening children with “pass result” in order to find false-negative cases |
Finland Nurse + Nurse to parents | Procedure 1(first study attempt): At 18 m.o.:CHAT + ICQ and CBCL +BITSEA |
N = 200 | CBCL (Children’s Behavioural Checklist) No longer ongoing |
Procedure 2(started later): At 12 m.o.: nurse checklist + BITSEA + ICQ + ESAT |
N = 677 | Small sample, no cases with ASD yet Planning modifications in short future |
Factors to be considered when evaluating screening studies
Factor | Key description |
---|---|
I. Broad-based analysis of qualitative indices | Need for comprehensive approach and consideration of intervention benefits of FP cases besides possible side effects |
II. Prevalence rates and PPV interpretation | “Population-based” sample vs. “High-risk” sample |
III. Age of screening | Younger age ≥ higher FP rate; difficulties in differentiating “ASD” from “other DDs” |
IV. Level of functioning and autism severity | Higher IQ and/or milder variants of ASD ≥ higher FP rate |
V. Selection and formulation of items | Specificity: play + sensory + motor skills (young age); social interaction and communication (older age); importance of formulation: ever vs. rarely |
VI. Cut-off criteria | Importance of exploring different cut-off scores for different purposes and populations |
VII. Protocol adherence | Lack of consistency of screening procedures across studies. Need for balance between protocol adherence and deviations, depending on study purpose/resources |
VIII. Informants and training | Parents, paediatricians, primary care physician, child care workers and child nurses. Good training programmes together with the tool |
IX. Parental non-compliance rate | Socio-economic, ethno-cultural and age-related factors. Importance of re-test |
X. Setting characteristics: organisation of services | Challenges of each screening context. Importance of availability and coordination between related services (i.e. screening, diagnostic and intervention services) |