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Cited by 102Autism Spectrum Disorder ResearchChild Nutrition and Feeding IssuesBehavioral and Psychological Studies

Sensitivity and Specificity of Proposed DSM-5 Criteria for Autism Spectrum Disorder in Toddlers

Open access
Barton, Marianne L., Robins, Diana L., Jashar, Dasal, Brennan, Laura, Fein, Deborah·2013·Journal of Autism and Developmental Disorders
DOI 10.1007/s10803-013-1817-8PMC PMC3684196
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Abstract

Autism spectrum disorder (ASD) diagnosis is based on behavioral presentation; changes in conceptual models or defining behaviors may significantly impact diagnosis and uptake of ASD-specific interventions. The literature examining impact of DSM-5 criteria is equivocal. Toddlers may be especially vulnerable to the stringent requirements of impairment in all three social-communication symptoms and two restricted/repetitive symptoms. Receiver operating characteristic (ROC) curves identified optimal cutoffs for sums of ADOS and ADI-R criteria mapped to each criterion for 422 toddlers. The optimal modification of DSM-5 criteria (sensitivity = 0.93, specificity = 0.74) required meeting the ROC-determined cutoffs for 2/3 Domain A criteria and 1 point for 1/4 Domain B criteria. This modification will help insure that ASD is identified accurately in young children, facilitating ASD-specific early intervention.

Integrity signals

Registry

Crossref · 10.1007/s10803-013-1817-8

Cites

38 of 38 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

7 of 25 cited sources checked · 3 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Receiving a diagnosis early and starting intensive treatment is linked to more favorable outcomes for every child with ASD.

    “A series of studies (Ben-Itzchak, Lahat, Burgin, & Zachor, 2008; Dawson et al., 2009; Rogers & Vismara, 2008) have now demonstrated that early identification and intensive early intervention are associated with more favorable outcomes for all children with ASDs.”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites Ben-Itzchak, Lahat, Burgin, & Zachor, 2008 source
    • cites Dawson et al., 2009 source

      The Discussion reports better group outcomes after intensive early intervention for toddlers with ASD, and the Abstract’s Conclusions underscore the importance of early detection and intervention. The trial did not test early identification separately or demonstrate favorable outcomes for every child with ASD: the Results (Diagnosis) report improved diagnostic status for 7 children in the intervention group, while 2 had a change to a more severe diagnosis. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites Rogers & Vismara, 2008 source

      In “Treatments for Early Autism” (page unavailable), the review reports better outcomes among children who began treatment younger and developmental gains among groups receiving focused interventions. But the “Sallows and Graupner (2005)” section reports poor outcomes for about half the children despite years of intensive treatment. The source therefore supports an association for some children or groups, not the claim of favorable outcomes for every child with ASD. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
  • Premisecitation

    There is some overlap between criterion A1 and criterion A3 in social communication.

    “there is some overlap between criterion A 1 and criterion A 3 (Huerta et al., 2012)”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Huerta et al., 2012 source
  • Findingown data

    For 422 toddlers, ROC analysis found the best cutoff values for total ADOS and ADI-R item scores assigned to each DSM-5 criterion.

    “Receiver operating characteristic (ROC) curves identified optimal cutoffs for sums of ADOS and ADI-R criteria mapped to each criterion for 422 toddlers.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The ADOS and ADI-R items mapped to each DSM-5 criterion validly measure those criteria.
  • Findingreasoning

    Sensitivity estimates in this sample are lower than those reported by Huerta and colleagues (2012).

    “sensitivity estimates in this sample are not as high as those reported by Huerta and colleagues (2012).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Huerta and colleagues (2012)

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Findingown data

    Both mappings of ADOS and ADI-R items onto DSM-5 criteria have no ADOS items contributing to the third social-communication symptom (A3) from Module 1 ADOS.

    “It is notable that both mappings of ADOS and ADI-R items on to DSM-5 criteria (see Table 3) have no ADOS items that contribute to this third social-communication symptom from the Module 1 ADOS.”
    Quote in the paperSubstantial claim
  • May combine two claims. 19
  • Classified as probably not a substantial claim. 6

  • May combine two claims.

    Premisecitation

    A small subset of children with ASD may lose the diagnosis and reach an optimal outcome; such children probably have less severe symptoms and stronger cognitive skills.

    “In addition, several recent studies have revealed that a small portion of children with ASDs may be able to progress sufficiently to lose their ASD diagnosis and attain an “optimal outcome”, and these children are likely to be those with relatively milder symptoms and higher cognitive functioning.”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites Fein et al., 2013 source
    • cites Helt et al., 2008 source

      The Preliminary Conclusions About Recovery (p. 11) say that some children with documented ASD lose the diagnosis and function within the generally normal range, and identify higher intelligence among possible predictors. But Predictors of Outcome: Child Characteristics (p. 8) explicitly says that severity of autistic symptoms is not a good predictor of optimal outcome, so the claim about relatively milder symptoms is not supported. (LLM, conf=0.90)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Huerta and colleagues reported sufficient sensitivity for PDD-NOS, Asperger's disorder, girls, and children with nonverbal IQ under 70, but the corresponding specificity values varied widely and were frequently too low.

    “In addition, they report adequate sensitivity for children diagnosed with PDD-NOS and Asperger's Disorder, and for girls and children with nonverbal IQs below 70.Specificity estimates for those groups were highly variable and often unacceptably low.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Huerta, Bishop, Duncan, Hus, and Lord (2012) source

      The Results report DSM-5 sensitivity of .77–.94 for children with Asperger disorder or PDD-NOS, .88–.93 for females, and .93–.97 for children with nonverbal IQ ≤70. The Results also describe low specificity that varies by sample and assessment method, but the cited passages do not give corresponding specificity estimates for each of those diagnostic and demographic groups. Page numbers were unavailable in our copy. (LLM, conf=0.83)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Huerta and colleagues reported that the new criteria detected 91% of children who had a DSM-IV-TR PDD diagnosis, with specificity estimated at .53.

    “They report that the new DSM-5 criteria identified 91% of the children with DSM-IV-TR diagnoses of PDD with specificity estimated at .53.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Huerta, Bishop, Duncan, Hus, and Lord (2012) source

  • May combine two claims.

    Findingown data

    The best modification of the DSM-5 criteria had sensitivity .93 and specificity .74 and required meeting the ROC-derived cutoffs for two of three Domain A criteria and one point for one of four Domain B criteria.

    “The optimal modification of DSM-5 criteria(sensitivity=.93, specificity=.74) required meeting the ROC-determined cutoffs for 2/3Domain A criteria and 1 point for 1/4 Domain B criteria.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The ADOS and ADI-R items mapped to each DSM-5 criterion validly measure those criteria.
    • Rests on an assumption: The DSM-IV-TR diagnoses assigned by experienced clinicians are a valid reference standard for ASD.

  • Classified as probably not a substantial claim.

    Findingreasoning

    The authors' team did not find it straightforward to distinguish among DSM-5 symptoms or to map specific behavioral criteria onto these symptoms.

    “Our team, which has a great deal of collective research and clinical experience with autism in toddlers, did not find it straightforward to distinguish among DSM-5 symptoms or to map specific behavioral criteria onto these symptoms.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The current sample consisted of children below age three, with a mean age of 25 months.

    “the current sample focused on children below the age of three, with a mean age of 25 months.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    All five solutions II through VI had adequate sensitivity and specificity, exceeding .70.

    “All five of these solutions demonstrated adequate sensitivity and specificity, according to the expectation that these values should exceed .70 (see American Academy of Pediatrics et al., 2006)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites American Academy of Pediatrics et al., 2006

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Findingown data

    In this sample, using the liberal threshold of one point for each of the three Domain A symptoms and any two of the four Domain B symptoms (the Huerta et al. solution) produced high sensitivity but unacceptably low specificity.

    “Using a very liberal threshold of 1 point for each of the three A symptoms, and for any two of the four B symptoms led to high sensitivity, but unacceptably low specificity.”
    • Also stated in: § Discussion · plain
      “Such a threshold resulted in relatively high sensitivity, but unacceptably low specificity.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Huerta and colleagues (2012)

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    DSM-5 merges impaired social interaction and limited social communication into one category and retains restricted/repetitive behaviors as the second required symptom category.

    “In DSM-5, impaired social interaction and limited social communication have been integratedinto one category. Restricted and repetitive behaviors are retained as the second category of symptoms required for diagnosis of an ASD.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites APA, 2011

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationreasoning

    The missed cases are most likely to be children with less severe ASD, such as those with a prior PDD-NOS diagnosis, higher cognitive ability, or younger age.

    “This appears most likely to affect children with milder forms of the disorder, including those previously diagnosed with PDD-NOS, those with higher cognitive function, and those who are younger and may be less likely to exhibit the full range of symptoms.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The proposed modification would improve accurate identification of ASD in young children and thereby support early ASD-specific intervention.

    “This modification will help insure that ASD is identified accurately in young children, facilitating ASD-specific early intervention.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The sample of 422 toddlers is representative enough to estimate sensitivity and specificity of DSM-5 criteria in young children suspected of ASD.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    DSM-5 eliminates the specific PDD subcategories and conceptualizes autism as a broad spectrum.

    “First, autism is conceptualized as a broad spectrum of disorders and the specific diagnostic sub-categories contained under the rubric of Pervasive Developmental Disorders (PDD) in DSM-IV-TR have been eliminated.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites APA, 2011

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationown data

    Some Domain B symptoms may be difficult to identify in toddlers, possibly specific to ADOS Module 1.

    “This may be specific to Module 1 of the ADOS, indicating that some Domain B symptoms might be difficult to identify in toddlers.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Participants were excluded from the current sample when ADOS and ADI(-R) had not been administered.

    “Participants were excluded from the current sample if ASD diagnostic measures (ADOS and ADI(-R)) were not administered.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationnone given

    Symptom presentation in young children is often less clear because symptoms may still be emerging when children are referred for early evaluation.

    “Symptom presentation in young children is often less clear as symptoms may still be emerging when children are referred for early evaluation.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationnone given

    A subset of children was recruited from early intervention sites and cannot be considered representative of the general population.

    “a subset of children was recruited from early intervention sites and cannot be considered representative of the general population.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    The current participants represent a broader cross section of the population, including some with limited access to diagnostic services and those most likely to be affected by changes in the diagnostic threshold.

    “they represent children from a broader cross section of the population, including some with limited access to diagnostic services and those most likely to be most affected by changes in the diagnostic threshold.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Huerta and colleagues used a liberal symptom threshold, which left specificity estimates low.

    “Nonetheless, these authors relied upon a relatively liberal symptom threshold that left specificity estimates quite low.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductnone given

    The present study is not a field study of the new diagnostic criteria and relies on data collected during diagnostic evaluations using DSM-IV-TR criteria.

    “the present study is not a field study of the new diagnostic criteria and is therefore reliant upon data collected during diagnostic evaluations using DSM-IV-TR criteria.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Repetitive behaviors may emerge in some children in the fourth year of life, and few children exhibit restricted interests in the toddler years.

    “Some authors (e.g., Bishop, Richler, & Lord, 2006; Lord, 1995; Moore & Goodson, 2003; Stone et al.,1999; Wiggins, Robins, Adamson, Bakeman, & Henrich, 2012)have suggested that repetitive behaviors may emerge in some children in the fourth year of life and that few children exhibit restricted interests in the toddler years.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Bishop, Richler, & Lord, 2006 source
    • cites Lord, 1995 source
    • cites Moore & Goodson, 2003

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationreasoning

    Those children were likely at greater risk of receiving an ASD diagnosis, and their presence may have inflated estimates of sensitivity.

    “Those children were likely at greater risk of receiving an ASD diagnosis and their presence may have inflated estimates of sensitivity.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Huerta and colleagues (2012) did not report the mean age of their under-four group or how many children were below age three.

    “Although Huerta and colleagues (2012) included a sample of children under the age of four in their large study,they do not report the mean age of that group or how many children in their sample were below the age of three.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Huerta and colleagues (2012)

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

22 of 22

  • The paper relies on this without support.

    The ADOS and ADI-R items mapped to each DSM-5 criterion validly measure those criteria.

    “Receiver operating characteristic (ROC) curves identified optimal cutoffs for sums of ADOS and ADI-R criteria mapped to each criterion for 422 toddlers.”

  • The paper relies on this without support.

    The DSM-IV-TR diagnoses assigned by experienced clinicians are a valid reference standard for ASD.

    “all received DSM-IV-TR diagnoses based on the judgment of experienced clinicians.”

  • The paper relies on this without support.

    The sample of 422 toddlers is representative enough to estimate sensitivity and specificity of DSM-5 criteria in young children suspected of ASD.

    “The current study is designed to address the question of estimated sensitivity and specificity of the proposed DSM-5 criteria in a sample of 422 toddlers aged 16-40 months.”

  • The paper relies on this without support.

    There is poor agreement among experts about which ADI-R and ADOS symptoms map onto which DSM-5 criteria or how those criteria are best defined.

    “Finally, there is poor agreement among experts about which ADI-R and ADOS symptoms map onto which DSM-5 criteria or how those criteria are best defined.”

  • The paper relies on this without support.

    Autism is a highly heterogeneous disorder.

    “In addition, autism is clearly a highly heterogeneous disorder.”

  • The paper relies on this without support.

    Heterogeneity may be even more pronounced in the youngest children.

    “It may well be the case that heterogeneity is even more pronounced in the youngest children.”

  • The paper relies on this without support.

    Toddlers' behavior may be more affected by situational variables than older children's behavior.

    “Toddlers' behavior may also be more affected by situational variables”

  • The paper relies on this without support.

    Parents of toddlers may have less experience than parents of older children with developmental processes and age-related expectations.

    “their parents may have less experience than the parents of older children with developmental processes and age related expectations.”

  • The paper relies on this without support.

    Some behaviors listed in criterion A3 (relationships) are rarely observed in very young children, especially those with developmental delays, including interest in and interaction with peers.

    “In addition some of the behaviors listed in criteria A 3 (relationships) are rarely observed in very young children, especially those with developmental delays, including interest in and interaction with peers.”
9 of 9

Cites

Flagged first, then by citations

3 of the 41 references couldn’t be matched to a known paper.

Research works printed but not linked: 3

  1. LeCouteur, A., Rutter, M., Lord, C., & DiLavore, P. (2004). Toddler research autism diagnostic interview, revised edition. Los Angeles, CA: Western Psychological Services.
  2. Matson, J. L., Boisjoli, J. A., & Wilkins, J. (2007). The Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT). Baton Rouge, LA: Disability Consultants, LLC.
  3. Matson, J. L., & Gonzalez, M. L. (2007). Autism spectrum disorders—Diagnosis—Child version. Baton Rouge, LA: Disability Consultants, LLC.

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Related

Authors
Barton, M. L., Robins, D. L., Jashar, D., Brennan, L., & Fein, D.
Affiliations
  • University of Connecticut (US)
  • Georgia State University (US)
Corresponding author
Robins, Diana L.
ORCID
Venue
Journal of Autism and Developmental Disorders
Publisher
Springer Science and Business Media LLC
Published
2013-03-31
Volume
43
Issue
5
Pages
1184-1195
ISSN
  • 0162-3257 (ISSN-L)
  • 1573-3432
DOI
10.1007/s10803-013-1817-8
PMC
PMC3684196
OpenAlex
W2001531509
Cited by
102
References
41
Citations by year
2025: 5 · 2024: 2 · 2023: 2 · 2022: 5 · 2021: 16 · 2020: 5 · 2019: 4 · 2018: 5 · 2017: 10 · 2016: 16 · 2015: 10 · 2014: 14 · 2013: 8
FWCI
8.74
Type
journal article
Language
en
Open access
Licence
www.springer.com/tdm (tdm)
Locations
  • Journal of Autism and Developmental Disorders (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Institutes of Health
  • National Institute of Child Health and Human Development
  • Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01HD039961)
Topics
  • Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
  • Health Sciences › Medicine › Psychiatry and Mental health › Child Nutrition and Feeding Issues
  • Social Sciences › Psychology › Developmental and Educational Psychology › Behavioral and Psychological Studies
Keywords
autism spectrum disorder, toddlers, DSM-5 diagnostic criteria, sensitivity and specificity, Autism Diagnostic Observation Schedule, ADI-R, restricted and repetitive behaviors, diagnostic thresholds, early diagnosis, early intervention
MeSH terms
Child Development Disorders, Pervasive, Child, Preschool, Female, Humans, Infant, Male, Surveys and Questionnaires, Sensitivity and Specificity, Early Intervention, Educational, Diagnostic and Statistical Manual of Mental Disorders

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