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Developing the Inclen Appropriateness Criteria for Autism Spectrum Disorder (INAC-ASD) and Attention Deficit Hyperactivity Disorder (INAC- ADHD)

Thursday, 2 May 2013: 09:00-13:00
Banquet Hall (Kursaal Centre)
M. Nair1, S. Gulati2, V. B. Deshmukh3, A. Mohapatra3, V. K. Bhutani4, D. H. Silberberg5, N. K. Arora6 and I. Group7, (1)Department of Pediatrics, Medical College, Thiruvananthapuram, India, (2)Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India, (3)The INCLEN Trust International, New Delhi, India, (4)Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Stanford, CA, (5)Department of Neurology, University of Pennsylvania Medical Center, Philadelphia, PA, (6)INCLEN Executive Office, The INCLEN Trust International, New Delhi, India, (7)The INCLEN NDD Study Group, The INCLEN Trust International, New Delhi, India
Background:  Autism [Pervasive Developmental Disorder (PDD) or Autism Spectrum disorder (ASD)] and Attention Deficit/Hyperactivity Disorder (ADHD) have been widely recognized for many decades. Yet there are no socio culturally appropriate diagnostic criteria available, as the construct continue to evolve.

Objectives: This study aimed to develop and validate appropriateness criteria for Autism Spectrum Disorders (ASD) and ADHD that can be applied in resource constraint environment.  

Methods: An international multidisciplinary group of experts met at two face-to-face consensus meetings and reviewed the appropriateness of the current definitions as well as diagnostic criteria in the Indian context and developed the INCLEN Appropriateness Criteria: Autism Spectrum Disorder (INAC-ASD) and INCLEN Appropriateness Criteria -Attention Deficit Hyperactivity Disorder (INAC- ADHD). The INAC-ASD and INAC-ADHD criteria were based on DSM-IV-TR. The study was conducted on children aged 2-9 years by systematic random selection at the general pediatrics out-patient clinics of four tertiary care pediatric facilities. The selected subjects were administered the survey tool-kits by trained psychologists and their performance compared to other widely used tool [Childhood autism rating scale (CARS) for  ASD and Conner’s for (ADHD)] and validated through  independent testing by a team of expert child psychologists and pediatric neurologists (Team diagnosis). The team diagnosis was taken as the reference standard.

Results: The overall diagnostic accuracy for ‘PDD group’ [AUC=0.97 (95% CI=0.93-0.99),z=32.12; P=0.0001], and various accuracy parameters for diagnosing ‘PDD group’ and autism compared with the reference standard of DSM-IV-TR was high (Sn=98%, Sp=95%, PPV=91%, NPV=99%, +LR=20, -LR=0.02) and (Sn=90%, Sp=95%, PPV=90%, NPV=81%, +LR=10, -LR=0.05 respectively). The concordance rate between the INAC-ASD and DSM-IV-TR for ‘PDD group’ was 82.52% [Cohen’s κ=0.89 (95%CI=0.82 to 0.97); P=0.001]. Similarly, concordance rate between the INAC-ADHD and DSM-IV-R diagnosis of ADHD was 71.82% [Cohen’s κ=0.45 (95%CI=0.32 to 0.58); P=0.001]. The overall diagnostic accuracy for INAC- ADHD cut-off score of ≥ 8 [AUC=0.98 (95% CI=0.94-0.99), z=67.02; P=0.0001], and various diagnostic accuracy parameters for differentiating ADHD from those with other neuro-developmental disorders (Sn=87.7%, Sp=42.9%, PPV=58.1%, NPV=79.4%, +LR=1.5, -LR=0.28)and normal children (Sn=87.7%, Sp=97.2%, PPV=98.0%, NPV=83.3%, +LR=31.5, -LR=0.12) as compared with the reference standard of DSM-IV-TR was high. The internal consistency of INAC-ASD and INAC ADHD was 0.96 and 0.91 respectively. The convergent validity with CARS (r = 0.73, P= 0.001) and divergent validity with Binet-Kamat Test of intelligence was (r = -0.37; P=0.004) for INAC-ASD and the convergent validity with Conner’s 3 Parents Scale was moderate (r = 0.73, P= 0.001) for INAC-ADHD.

Conclusions: With the appropriateness of the international criteria for ASD and ADHD being documented in India, INAC-ASD and INAC-ADHD , socio-culturally appropriate tools could be used by clinicians to provide a consistent diagnostic approach and researchers to develop as well as validate intervention measures in India and similar settings elsewhere in the world.

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