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Autism Res. 2017 Oct;10(10):1672-1686. doi: 10.1002/aur.1817. Epub 2017 Jun 22.

The influence of parental concern on the utility of autism diagnostic instruments.

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Nic Waals Institute, Lovisenberg Diaconal Hospital, Oslo, Norway.
Norwegian Institute of Public Health, Oslo, Norway.
MRC Integrative Epidemiology Unit, School of Social and Community Medicine, University of Bristol, Bristol, UK.
Department of Psychiatry, University of California San Francisco, San Francisco.
Center for Autism and the Developing Brain, Weill Cornell Medical College, White Plains, New York, New York.
Department of Biostatistics, King's College London, London, UK.
Department of Psychology, University of Oslo, Oslo, Norway.
Mailman School of Public Health, Columbia University, New York, New York.
New York State Psychiatric Institute, New York, New York.
Neuropsychiatric Unit, Oslo University Hospital, Oslo, Norway.
Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.


The parental report-based Autism Diagnostic Interview-Revised (ADI-R) and the clinician observation-based Autism Diagnostic Observation Schedule (ADOS) have been validated primarily in U.S. clinics specialized in autism spectrum disorder (ASD), in which most children are referred by their parents because of ASD concern. This study assessed diagnostic agreement of the ADOS-2 and ADI-R toddler algorithms in a more broadly based sample of 679 toddlers (age 35-47 months) from the Norwegian Mother and Child Cohort. We also examined whether parental concern about ASD influenced instrument performance, comparing toddlers identified based on parental ASD concern (n = 48) and parent-reported signs of developmental problems (screening) without a specific concern about ASD (n = 400). The ADOS cutoffs showed consistently well-balanced sensitivity and specificity. The ADI-R cutoffs demonstrated good specificity, but reduced sensitivity, missing 43% of toddlers whose parents were not specifically concerned about ASD. The ADI-R and ADOS dimensional scores agreed well with clinical diagnoses (area under the curve ≥ 0.85), contributing additively to their prediction. On the ADI-R, different cutoffs were needed according to presence or absence of parental ASD concern, in order to achieve comparable balance of sensitivity and specificity. These results highlight the importance of taking parental concern about ASD into account when interpreting scores from parental report-based instruments such as the ADI-R. While the ADOS cutoffs performed consistently well, the additive contributions of ADI-R and ADOS scores to the prediction of ASD diagnosis underscore the value of combining instruments based on parent accounts and clinician observation in evaluation of ASD. Autism Res 2017, 10: 1672-1686.


Autism Diagnostic Interview-Revised; Autism Diagnostic Observation Schedule; early diagnosis; screening

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