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

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 Zou,a developmental pediatrician in China, are standardizing a new unpublished diagnostic test in China.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- Communication 3- Behavior

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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

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”

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

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)

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

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

CADS Domains used for comparisons

(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 Domains Motor/Vocal Imitation Stereotyped behaviors Sensory behaviors Play behaviors Social Interaction Receptive Language Expressive Language

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

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

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

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

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

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

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√

LFASD Results

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

Individual Item contrasts LFASD versus ID

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

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

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

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

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

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

HFASD Results

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

Individual Item contrasts HFASD versus TD

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

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

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

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

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

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

Bell Shape Curve For ASD Group

Severity Rating of the ASD Range Of Scores MILD GROUP (Level I)   > 1 StD (n=66) 20% 93 - 142 range Upper 25th (n=67) 21% 93 - 143 MODERATE GROUP (Level II) 1StD (n=210) 64% 215 - 141 range Middle 50th (n=175) 54% 209 - 142 SEVERE GROUP (Level III) < 1StD (n=50) 15% 216 - 265 range Lower 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

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

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

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.

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: tandtcommunication@earthlink.net. 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.