Dr. Hartono Gunardi, Sp.

A(K)

Staff and lecturer at Department of Child Health,

Faculty of Medicine, Delopmental Behavioural –
Community Pediatrics Division, Dr. Cipto
Mangunkusumo General Hospital, Universitas
Indonesia
Training of trainers on Vaccinology Training, WHO
Collaboration, Jakarta, 2004
Autism & ADHD awareness
Hartono Gunardi
Department of Child Health Universitas Indonesia,
Dr. Cipto Mangunkusumo Hospital, Jakarta
Outline
• ASD awareness • ADHD Awareness
• ASD screening tools • ADHD screening tools
• What is the ASD best tool? • What is the ADHD best tool?
Autism awareness
• to promote autism awareness, inclusion and
self-determination for all,
• to assure person with ASD is to achieve the
highest possible quality of life

• The United Nations General Assembly

unanimously declare
2 April as World Autism Awareness Day
 Prevalence

• WHO estimated ASD : 1 in 160 children (0.6%) 1

• Systematic review of 27 studies, prevalence = 91.92 per 10,000

population or 1 in 109 children (0.9%) 2

• Gender : male female ratio = from 6:1 to 1.8:1 3

1. WHO. Autistic Spectrum Disorders, Key Facts. 2017. 2.Adak B, Halder S. J Ment Disord Treat. 2017; 3:133
3. Saemundsen E, et al. BMJ Open, 2013
Epidemiological studies on ASD in South Asia

Hossain et al. BMC Psychiatry (2017) 17:281

Increases risk of ASD
• Extremely preterm babies1
• Intrauterine CNS infections (CMV, rubella)2
• Intrauterine drug exposure (valproate)3
• Peri- and postnatal traumatic brain injury4
• Cerebrovascular lesions4
• Severe encephalopathy4
• Genetic conditions (Tuberous sclerosis, fragile X, Rett syndrome)4

1.Dodds L, et al. J Autism Dev Disord. 2010;41(7):891–902. 2. Engman et al. Acta Paediatr. 2010;99(9):1344–
1349. 3. Rasalam AD, et al. Dev Med Child Neurol. 2005;47(8):551–555. 4. Fernell E, et al. Clinical Epidemiology
2013:5 33–43
 When to screen
Children age 18 and 24 months (AAP)
General developmental + ASD screening

Early detection and intervention :

• to improve social function, communication, and cognitive abilities
• to reduce repetitive and obsessional behaviors,

Zwaigenbaum, L, et al. Early Screening of Autism Spectrum Disorder: Recommendations for Practice and Research. Pediatrics 2015;136:S41–S59
Benefit of early detection & intervention
To improve: social function,
communication,
cognitive abilities

• To reduce: repetitive behaviors,

obsessional behaviors

Zwaigenbaum, L, et al. Early Screening of Autism Spectrum Disorder: Recommendations for Practice and Research. Pediatrics 2015;136:S41–S59
IQ and Autism Diagnostic Observation Schedule
(ADOS) severity by group and time point

Estes A, et al. J Am Acad Child Adolesc Psychiatry 2015;54(7):580–587

Parent-Report Screening Tools for Autism
1. ASD-specific screeners: parent report
a. First Year Inventory (FYI)
b. Early Screening of Autstistic Traits (ESAT)
c. Modified Checklist for Autism in Toddlers (M-CHAT)
d. Modified Checklist for Autism in Toddlers- Revised/ Follow-up
(M-CHAT R/F)
e. Quantitative Checklist for Autism in Toddlers (Q-CHAT)

Zwaigenbaum, L, et al. Early Screening of Autism Spectrum Disorder: Recommendations for Practice and Research. Pediatrics 2015;136:S41–S59
Parent-Report Screening Tools for Autism (2)
2. ASD-specific screeners: interactive observational measures
a. Screening Tools for Autism in Toddlers and Young Children (STAT)
b. The Baby and Infant Screen for Children with Autism Traits (BISCUIT)
c. Systematic Observation of Red Flags (SORF)

3. Broadband screener: parent report

a. Communication and Symbolic Behavior Scales Developmental
Profile (CSBS-DP)

Zwaigenbaum, L, et al. Early Screening of Autism Spectrum Disorder: Recommendations for Practice and Research. Pediatrics 2015;136:S41–S59
Sensitivity & Specificity of ASD screening tools

Garcı´a-Primo P, et al. Eur Child Adolesc Psychiatry (2014) 23:1005–21

Sensitivity & Specificity of ASD screening tools (2)

Garcı´a-Primo P, et al. Eur Child Adolesc Psychiatry (2014) 23:1005–21

 M-CHAT (The Modified Checklist for Autism in Toddlers)
• Level 1 screening
• Most commonly used screening tool1
• In low-risk : + interview : PPV = 0.57 to 0.65 2-4
in 16-23 months toddler: PPV = 0.28
in 24-30 months toddler: PPV = 0.61
• Largest toddler sample (18 989)
PPV for ASD = 0.54
PPV for any developmental disorder = 0.98 4
1. Lord C, et al. Lancet 2018; 392: 508–20 2. Robbin. DL, Autism. 2008;12(5):537–556 3. Kleinman JM. J
Autism Dev Disord. 2008;38(5): 827–839 4. Chlebowski C. Pediatrics 2013;131:e1121–e1127
M-CHAT R/F (The Modified Checklist for Autism in Toddlers Revised with Follow-up)

• M-CHAT Revised with Follow-up1

• Validated in 16,115 toddlers
• 20 items
• PPV for ASD = 0.475
for any developmental disorder = 0.946
Children with 3–7 items endorsed  required follow-up interview
Children with > 8 items endorsed  sufficiently high risk  refer directly

1. Robbin DL. Pediatrics. 2014;133(1):37–45

Red flags
Early developmental features and behaviours believed to be early
manifestations of ASD :
Poor or absent engagement and interaction during early infancy
Lack of babbling by 12 months
Late onset of speech (no single words by 18 months or short phrases
by 24 months)
 Absence or reduced use of socially-motivated nonverbal behaviours,
such as gestures, pointing
Loss of language or other social and communication skills
once clearly established

Pasco G. Paediatrics and Child Health. 2018;8;364-7

When is ADHD awareness month?
ADHD
• Often still remains undiagnosed and under treated.

• ADHD impulsivity
General impairment
• executive functioning impairment in self-regulation
• emotional dysregulation.
 Fig 1. Likey progression of unmanaged ADHD.

Kewley DG. Attention Deficit Hyperactivity Disorder: recognition, reality and resolution. 1999
ADHD Pooled Prevalence According to Geographic Location

Polanczyk, G, et al. The Worldwide Prevalence of ADHD. Am J Psychiatry 2007; 164:942–948

Increased prevalence of ADHD
• Children born preterm
• looked-after children
• Children + oppositional defiant disorder or conduct disorder
• Children + mood disorders (anxiety and depression)
• Children + a close family member diagnosed with ADHD
• Children + epilepsy

National Institute for Health and Care Excellencd, 2018

When to screen?
• School age children
• Range 4 – 18 years old children

• Consider ADHD if child presents with

a. can not sit still / hyperactive
b. lack of attention / does not listen / daydreaming
c. act without thinking
d. behavior problems
e. academic underachievement
What tools?
Broad band tools
• Child Behavior Checklist (CBCL)
for children ages 6 to 18
Non-Specific, allows assessment
of co-morbid problems.
Narrow band tools
• NICHQ Vanderbilt Assessment
Scales
• ADHD Rating Scales (ARS)
• Conners Rating Scale–Revised
(CRS-R)
• Conners Abbreviated Symptom
Questionaire (ASQ)
Chang L, et al. Diagnostic Accuracy of Rating Scales for Attention-Defi cit/Hyperactivity Disorder: A Meta-analysis. Pediatrics. 2016;137(3):e20152749
Methods
• Children Behaviour Checklist – • 6 databases:
Attention Problem • PubMed, Ovid Medline, Embase,
• Cumulative Index to Nursing and
• CRS-R included: • Allied Health Literature,
• Conners Parent Rating Scale– PsycINFO,
Revised Short Form (CPRSR:S)
• Conners Teacher Rating Scale- • and Web of Science.
Revised Short Form (CTRSR:S)
• Conners Abbreviated Symptom
Questionnaires (ASQ)
Results
Results
• HSROC curves and associated
AUCs for the included diagnostic
tools
• The AUCs were 0.82, 0.81, 0.82,
and 0.90 for
• CBCL-AP = 0.82,
• CPRS-R = 0.81
• CTRS-R = 0.82
• ASQ = 0.99
Pooled sensitivity and specificity

Sensitivity Specificity
CBCL – Attention Problem 0.77 0.73
Conners Parents Rating Scale - 0.75 0.75
Revised
Conners Teacher Rating Scale - 0.72 0.84
Revised
Conners Abbreviated Symptom 0.83 0.84
Questionaires (ASQ)
Chang L, et al. Diagnostic Accuracy of Rating Scales for Attention-Defi cit/Hyperactivity Disorder: A Meta-analysis. Pediatrics. 2016;137(3):e20152749
 Summary
• ASD and ADHD awareness is to increase earlier detection and
intervention to have better outcome

• The most widely used ASD screening test is M-CHAT, and its accuracy
is enhanced by M-CHAT R/F

• The most effective ADHD screening tools is Conners Abbreviated

Symptom Questionaire (ASQ)

• The diagnosis should be established according to DSM-5

Thank you