Before Our Eyes: “Frankness” of the ASD Behavioral Presentation As a Research Construct
Many individuals with ASD have a distinctive behavioral presentation that is recognizable within moments, a phenomenon we call “frankness” (i.e., frankly ASD). Clinicians have informally discussed this phenomenon for decades; however, it has never been delineated as a research construct, and thus has essentially gone unstudied. This is unfortunate, because if frankness is indeed a reliable, quantifiable behavioral phenomenon, its measurement could have both clinical and scientific utility. In the clinic, frank referrals might be triaged to expedited evaluations; in the lab, frankness could serve as a clinical correlate for basic research. Individuals with frank presentations may differ in important ways (e.g., underlying biology or response to treatment) that cannot be tested until frankness itself can be measured.
To survey the clinical community about frankness to develop hypotheses on how to operationalize and quantify frankness as a research construct.
We created a 13-item frankness questionnaire. Clinicians with experience and qualifications to diagnose ASD were invited to participate; 151 eligible clinicians, from a range of disciplines (psychology, pediatrics, neurology, and psychiatry) responded. The questionnaire included demographic information about respondents, and covered several specific topics related to frankness, including familiarity with the phenomenon, estimates of the proportion of individuals with ASD who are frank and the speed at which frankness impressions are formed, and what behavioral features might be associated with frank presentations. Data were both quantitative and qualitative, so we used a mixed methods analytic approach (Creswell et al., 2011).
An overwhelming majority (97%) of clinicians who diagnose ASD were familiar with frankness. Clinicians estimated that 40% of the ASD population has a frank presentation. In general, clinicians formed these impressions quickly; 52% reported that they observe frankness within 10 minutes of patient interaction (and 74% within 20 minutes). These factors (i.e., proportion of cases deemed frank; speed of forming frankness impressions) varied with clinician experience: clinicians who had made more ASD diagnoses considered a greater proportion of cases frank, and formed their impressions more quickly, F(2,101)=3.2, p=.045. Clinicians reported on a number of specific behaviors that contribute to their impressions of frankness, including impaired reciprocity, quality of eye contact, atypical vocal prosody, presence of motor mannerisms, and atypical gait or posture, among others.
Although unstudied empirically, “frank” presentations of ASD are highly familiar to diagnosing clinicians, suggesting a critical need for more research. Frank presentations appear to be based on a range of behaviors, including some that are central to the clinical characterization of ASD (e.g., impaired reciprocity), and others that are completely absent from the official symptomatology (e.g., atypical gait or posture). Clinicians report detecting frankness rapidly, especially when they have more experience diagnosing ASD, suggesting that expert clinicians may refer to an internal prototype that is refined over time. For our next steps, we plan to move beyond clinicians’ anecdotal reports, to test the hypotheses developed here (e.g., speed of frankness impressions, behaviors contributing to frankness) during real-world clinical evaluations and diagnosis.
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