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

2. 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 Zou,a developmental pediatrician in China, are standardizing a new unpublished diagnostic test in China.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.

3. DSM-IV Criteria for Diagnosis
At least 6 characteristics from the following 3 domains to qualify for diagnosis of autism
1- Social skills
2- Communication
3- Behavior

4. 4

5. 5

6. 6

7. Literature Review LFASD versus HFASD HFASD versus Typically Developing
Bartak & Rutter (1976) found more language delay, severe personal relationships and more disruptive behavior than HFASD
HFASD versus Typically Developing
Steinhausen & Metzke (2004) more disruptive behavior
Tsatsanis (2005) more weakness in cognitive functions
Baranek et al. (2005) problems in motor development
Tager-Flushberg (2004) problems in complex language
Ozonoff et al. (2004) problems in Executive Function

8. Literature Review One study with Chinese children (Zhang & Ji, 2005)
LFASD versus Intellectually Disabled
LFASD had 25% prenatal birth problems vs 62.5% of ID
LFASD only 1 child had cerebral palsy vs 31% had “other developmental disorders”

9. Purpose of the study
To 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

10. Subjects
LFASD (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)

11. ASD groups
Previously diagnosed by developmental pediatricians using the ADI-R, SRS, and/or a behavioral protocol.
All subjects spoke Mandarin
Non-ASD groups
Recruited from well-baby-care clinics throughout China
ID group administered WISC-Chinese, scores below 70 IQ

12. Research Team: Centers Involved
Guangzhou:
Third Affiliated Hospital & Guangzhou Center for Children with ASD
Shenzhen Hospital for Children and Pregnant Woman
Chongqing Children’s Hospital
Hainan Children’s Hospital
Harbin Medical University Autism Center
Shanghai Children’s Hospital
ShiJia-Zhuang Medical University
Tianjin Medical University
Nanjing Medical University

13. CADS Domains used for comparisons

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

16. CADS Seven Domains Motor/Vocal Imitation Stereotyped behaviors
Sensory behaviors
Play behaviors
Social Interaction
Receptive Language
Expressive Language

18. Motor Area (3 Domains) Motor/Vocal Imitation Domain (11 items)
Stereotyped Behavior Domain (13 items)
Sensory Domain (10 items)

19. 19

20. Social Area (2 Domains) Play Domain (10 items)
Social Interaction Domain (21 items)

21. 21

22. Language Area (2 Domains)
Receptive Language Domain (10 items)
Expressive Language Domain (17 items)

24. Supplemental Area (2 Domains)
Academic & Educational Domain (15 items)
Executive Function Domain (30 items)

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

26. 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

27. Moderate Severe Squeals LFASD ID 34% (1) 22% (0) 21% (2) 6% (0) 3 √
Moderate
Severe
Total Scores
Squeals
LFASD ID
34% (1)
22% (0)
21% (2)
6% (0)
3 √
Unusual interest toy
30% (1)
3% (0)
69% (2)
0% (0) 3√

28. LFASD Results

29. LFASD Results LFASD versus Intellectually Disabled
Six Domains were significantly different
The LFASD group performed less well on all six Domains

31. Individual Item contrasts
LFASD versus ID

33. Play Behavior items for LFASD
No independent play skills
Tends to play alone
No interest in social play
No interest in others
Shows inappropriate play with children
Has no regular playmates
Has limited attention span

34. Stereotyped Behavior items for LFASD
Squeals more
Unusual interest in certain part of a toy
Peculiar interests in objects
Has a particular, or unusual way of ordering toys or things
Excessively rigid

35. Sensory Behavior items for LFASD
Over reaction to noise
Inappropriate reaction to a pinch
Inappropriate reaction to textures
Eats restricted foods
Inappropriate reaction to visual stimuli

36. 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

37. Receptive Language items for LFASD
Does not select objects upon command
Does not point to nose, eyes, ears
Does not point to pictures
Inappropriate response to verbal command
Inappropriately nods and responds to speaker
Does not correctly respond to “wh” questions

38. Expressive Language items for LFASD
Echoes or repeats words
Prosody of speech not normal
Difficulty labeling or naming objects
Gets words out of order
Frequently talks to him/herself
Inappropriate use of pronouns
Inability to initiate or direct discourse
Makes socially inappropriate comments

39. HFASD Results

40. HFASD Results HFASD group versus Typically Developing children
Three Domains were significantly different
The HFASD group performed less well on all three Domains

42. Individual Item contrasts
HFASD versus TD

43. Stereotyped Behavior items for HFASD
Stares to side
Rocks back/forth
Flaps hands/fingers
Squeals

44. Sensory Interactive Behavior items for HFASD
Over reaction to noise
Eats restricted foods

45. Play Behavior items for HFASD
Plays alone
Has inappropriate play behavior with other children
No turn taking in social play
Does not seek help from others

46. Profile of Four Children
CADS profile 4 children
HFASD, LFASD, TD, ID

47. Higher the score--more severe the problem
Remember:
Higher the score--more severe the problem

49. Future Analysis and Contrasts
Comparing three levels of ASD
Mild Functioning
Moderate Functioning
Severe Functioning

50. Bell Shape Curve For ASD Group

51. Severity Rating of the ASD
Range Of Scores
MILD GROUP
(Level I)
> 1 StD
(n=66)
20%
range
Upper 25th
(n=67)
21%
MODERATE GROUP
(Level II)
1StD
(n=210)
64%
range
Middle 50th
(n=175)
54%
SEVERE GROUP
(Level III)
< 1StD
(n=50)
15%
range
Lower 25th
(n=84)
26%
*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

52. Conclusions
LFASD group demonstrated more difficulty on six Domains compared to ID group
Domains:
Stereotyped Behaviors
Sensory
Play
Social
Receptive Language
Expressive Language

53. Conclusions
HFASD group demonstrated more difficulty on three Domains compared to TD group
Domains:
Stereotyped Behaviors
Sensory
Play

54. 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.

55. 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),
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:
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),
TAGER-FLUSHBERG, H., 2004, Strategies for conducting research on language in autism. Journal of Autism and Developmental Disorders, 34,
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,