Autism Screening Tool Shows Promise in Low-Literacy Groups

By Megan Brooks

December 15, 2020

NEW YORK (Reuters Health) - A visually based screening tool for autism-spectrum disorder (ASD) works well in low-literacy groups, according to a new validation study.

In an unselected sample, the tool did "a good job of detecting which young kids in the group had autism," Dr. Jill Harris, coordinator of Autism Services at Children's Specialized Hospital, in New Brunswick, New Jersey, told Reuters Health by email.

Research has shown that children with ASD from low-income, minority families or those with limited proficiency in English may be diagnosed at a later age, or not at all, compared with their peers from more advantaged backgrounds, the researchers note in Pediatrics.

Existing tools may not accurately identify ASD in underserved populations and may be hard for people with low literacy to understand, they point out.

This led them to create the Developmental Check-In (DCI), a tool that uses pictures instead of written text to illustrate target behaviors in key areas such as communication, play and social interactions. It's available in English and Spanish.

In an earlier study, the DCI showed "acceptable discriminative ability" between ASD and non-ASD in a young, underserved sample at high risk for ASD, the researchers note.

Their latest study looked at how the DCI works in a general (unselected) population of low-income, racial-/ethnic-minority or Spanish-speaking families who did not necessarily have any known developmental or behavioral concerns.

This study included 64 children between 24 and 60 months of age. The parents completed the DCI, Modified Checklist for Autism in Toddlers, Revised with Follow-Up, and Social Communication Questionnaire. Children scoring positive on any measure were evaluated for ASD.

Children screening negative on both Modified Checklist for Autism in Toddlers, Revised with Follow-Up and Social Communication Questionnaire were considered not to have ASD.

Children with ASD had significantly higher scores, on average, in each category of the DCI than children without ASD (total DCI score 6.67 for ASD vs. 1.94 for non-ASD).

"The DCI demonstrated good discriminative power (area under the curve = 0.80), performing well across all age groups, genders, levels of maternal education, primary language, and included ethnic and racial groups," the researchers report in their article.

All but two DCI items - "says 1 word" and "responds to name" - discriminated ASD from non-ASD.

"Healthcare providers should know that it is important to use an autism-screening tool for all kids, whether or not they themselves or the child's parents note concerns, and that lack of response to name, which is often considered a 'red flag' for autism, did not discriminate autism in our sample of young kids," Dr. Harris told Reuters Health.

"Most parents will report that their kids respond to their name, so providers should probe how much work is needed to get that response," she advised.

The two DCI items that most discriminated ASD from non-ASD in both the current and prior study were "smiles back" and "shares interest." However, in the unselected sample, "imitates," "makes eye contact," and "plays with children" also discriminated well, the researchers report.

"We developed the DCI with parent input and parents seem to prefer the pictorial tool," Dr. Harris told Reuters Health.

"It is not available yet because we want to further validate it in a larger group of young kids, hopefully even younger and including a wider sample, not just children from under-resourced communities. We also hope to translate it into Arabic to widen its potential use," she said.

Writing in an editorial in Pediatrics, Dr. Lonnie Zwaigenbaum of the University of Alberta, in Edmonton, Canada, says, "Given the lack of progress in moving ASD diagnosis to an earlier age and pervasive disparities related to spoken language, literacy, and ethnicity, practical strategies and tools that can help mitigate barriers to early detection are an important priority. The DCI represents an important advance in that regard."

This research had no commercial funding and the authors have indicated no conflicts of interest.

SOURCE: and Pediatrics, online December 11, 2020.