Luc Lecavalier

Medication and Parent Training in Children With Pervasive Developmental Disorders and Serious Behavior Problems: Results From a Randomized Clinical Trial

OBJECTIVE Many children with pervasive developmental disorders (PDDs) have serious, functionally impairing behavioral problems. We tested whether combined treatment (COMB) with risperidone and parent training (PT) in behavior management is superior to medication alone (MED) in improving severe behavioral problems in children with PDDs. METHOD This 24-week, three-site, randomized, parallel-groups clinical trial enrolled 124 children, aged 4 through 13 years, with PDDs, accompanied by frequent tantrums, self-injury, and aggression. The children were randomized 3:2 to COMB (n = 75) or MED (n = 49). The participants received risperidone monotherapy from 0.5 to 3.5 mg/day (with switch to aripiprazole if risperidone was ineffective). Parents in the COMB group (n = 75; 60.5%) received a mean of 10.9 PT sessions. The primary measure of compliance was the Home Situations Questionnaire (HSQ) score. RESULTS Primary: intent-to-treat random effects regression showed that COMB was superior to MED on HSQ (p = .006) [effect size at week 24 (d) = 0.34]. The HSQ score declined from 4.31 (± 1.67) to 1.23 (± 1.36) for COMB compared with 4.16 (± 1.47) to 1.68 (± 1.36) for MED. Secondary: groups did not differ on Clinical Global Impressions-Improvement scores at endpoint; compared with MED, COMB showed significant reductions on Aberrant Behavior Checklist Irritability (d = 0.48; p = .01), Stereotypic Behavior (d = 0.23; p = .04), and Hyperactivity/Noncompliance subscales (d = 0.55; p = .04). Final risperidone mean dose for MED was 2.26 mg/day (0.071 mg/kg), compared with 1.98 mg/day for COMB (0.066 mg/kg) (p = .04). CONCLUSIONS Medication plus PT resulted in greater reduction of serious maladaptive behavior than MED in children with PDDs, with a lower risperidone dose.

Examining the Validity of Autism Spectrum Disorder Subtypes.

The classification of autism spectrum disorders (ASDs) is a topic of debate among clinicians and researchers with many questioning the validity of the distinction among subtypes. This manuscript examines the validity of three ASD subtypes (Autism, Asperger’s, and PDDNOS) by reviewing 22 studies published between 1994 and 2006. We reviewed studies that examined differences between the subtypes in terms of clinical and demographic characteristics, neuropsychological profiles, comorbidity, and prognosis. Results largely did not support differences between autism and Asperger’s disorder based on current diagnostic criteria. Overall, the most salient group differences were noted when samples were categorized on IQ. Drawing definitive conclusions is difficult due to the inconsistent application of diagnostic criteria and circularity in methods.

Screening Accuracy of Level 2 Autism Spectrum Disorder Rating Scales: A Review of Selected Instruments

The goal of this review was to examine the state of Level 2, caregiver-completed rating scales for the screening of Autism Spectrum Disorders (ASDs) in individuals above the age of three years. We focused on screening accuracy and paid particular attention to comparison groups. Inclusion criteria required that scales be developed post ICD-10, be ASD-specific, and have published evidence of diagnostic validity in peer-reviewed journals. The five scales reviewed were: the Social Communication Questionnaire (SCQ), Gilliam Autism Rating Scale/Gilliam Autism Rating Scale-Second Edition (GARS/GARS-2), Social Responsiveness Scale (SRS), Autism Spectrum Screening Questionnaire (ASSQ), and Asperger Syndrome Diagnostic Scale (ASDS). Twenty total studies were located, most examining the SCQ. Research on the other scales was limited. Comparisons between scales were few and available evidence of diagnostic validity is scarce for certain subpopulations (e.g., lower functioning individuals, PDDNOS). Overall, the SCQ performed well, the SRS and ASSQ showed promise, and the GARS/GARS-2 and ASDS demonstrated poor sensitivity. This review indicates that Level 2 ASD caregiver-completed rating scales are in need of much more scientific scrutiny.

Sensitivity and specificity of the Modified Checklist for Autism in Toddlers and the Social Communication Questionnaire in preschoolers suspected of having pervasive developmental disorders

This study assessed the psychometric properties of the Modified Checklist for Autism in Toddlers (M—CHAT) and the Social Communication Questionnaire (SCQ) in a sample of preschool children referred for possible pervasive developmental disorders (PDDs). The sample consisted of 82 children between the ages of 18 and 70 months (54 with a PDD diagnosis and 28 with non-PDD diagnoses). M—CHAT scores were analyzed for 56 children aged 18—48 months old and SCQ scores were analyzed for 65 children aged 30—70 months old. Optimal sensitivity and specificity were achieved using the cutoff score of any three items on the M—CHAT and lowering the cutoff score of the SCQ. The diagnostic agreement of both instruments was also compared in an overlapping subsample of 39 children aged 30—48 months. Overall, the M—CHAT and SCQ appear to more accurately classify children with PDDs who have lower intellectual and adaptive functioning.

Validity of the Autism Diagnostic Interview-Revised

The factor structure, internal consistency, and convergent validity of the Autism Diagnostic Interview-Revised (ADI-R) algorithm items were examined in a sample of 226 youngsters with pervasive developmental disabilities. Exploratory factor analyses indicated a three-factor solution closely resembling the original algorithm and explaining 38% of the variance, with one significant discrepancy: Unlike the algorithm, all nonverbal communication items were associated with the Social factor. Internal consistencies of domain scores ranged from .54 to .84. Correlations between ADI-R domain and total scores and instruments assessing adaptive behavior, psychopathology, and autism were examined. They indicated some similarities between constructs, but also that the ADI-R measures autism in a unique fashion.

Exploring the Manifestations of Anxiety in Children with Autism Spectrum Disorders.

This study explores the manifestation and measurement of anxiety symptoms in 415 children with ASDs on a 20-item, parent-rated, DSM-IV referenced anxiety scale. In both high and low-functioning children (IQ above vs. below 70), commonly endorsed items assessed restlessness, tension and sleep difficulties. Items requiring verbal expression of worry by the child were rarely endorsed. Higher anxiety was associated with functional language, IQ above 70 and higher scores on several other behavioral measures. Four underlying factors emerged: Generalized Anxiety, Separation Anxiety, Social Anxiety and Over-arousal. Our findings extend our understanding of anxiety across IQ in ASD and provide guidance for improving anxiety outcome measurement.

The structure of the Autism Diagnostic Interview‐Revised: diagnostic and phenotypic implications

BACKGROUND Multivariate statistics can assist in refining the nosology and diagnosis of pervasive developmental disorders (PDD) and also contribute important information for genetic studies. The Autism Diagnostic Interview-Revised (ADI-R) is one of the most widely used assessment instruments in the field of PDD. The current study investigated its factor structure and convergence with measures of adaptive, language, and intellectual functioning. METHODS Analyses were conducted on 1,861 individuals with PDD between the ages of 4 and 18 years (mean = 8.3, SD = 3.2). ADI-R scores were submitted to confirmatory factor analysis (CFA) and exploratory factor analysis (EFA). Analyses were conducted according to verbal status (n = 1,329 verbal, n = 532 nonverbal) and separately for algorithm items only and for all items. ADI-R scores were correlated with scores on measures of adaptive, language, and intellectual functioning. RESULTS Several factor solutions were examined and compared. CFAs suggested that two- and three-factor solutions were similar, and slightly superior to a one-factor solution. EFAs and measures of internal consistency provided some support for a two-factor solution consisting of social and communication behaviors and restricted and repetitive behaviors. Measures of functioning were not associated with ADI-R domain scores in nonverbal children, but negatively correlated in verbal children. CONCLUSIONS Overall, data suggested that autism symptomatology can be explained statistically with a two-domain model. It also pointed to different symptoms susceptible to be helpful in linkage analyses. Implications of a two-factor model are discussed.

Measuring Anxiety as a Treatment Endpoint in Youth with Autism Spectrum Disorder

Despite the high rate of anxiety in individuals with autism spectrum disorder (ASD), measuring anxiety in ASD is fraught with uncertainty. This is due, in part, to incomplete consensus on the manifestations of anxiety in this population. Autism Speaks assembled a panel of experts to conduct a systematic review of available measures for anxiety in youth with ASD. To complete the review, the panel held monthly conference calls and two face-to-face meetings over a fourteen-month period. Thirty eight published studies were reviewed and ten assessment measures were examined: four were deemed appropriate for use in clinical trials, although with conditions; three were judged to be potentially appropriate, while three were considered not useful for clinical trials assessing anxiety. Despite recent advances, additional relevant, reliable and valid outcome measures are needed to evaluate treatments for anxiety in ASD.

Effect of Parent Training vs Parent Education on Behavioral Problems in Children With Autism Spectrum Disorder: A Randomized Clinical Trial

IMPORTANCE Disruptive behavior is common in children with autism spectrum disorder. Behavioral interventions are used to treat disruptive behavior but have not been evaluated in large-scale randomized trials. OBJECTIVE To evaluate the efficacy of parent training for children with autism spectrum disorder and disruptive behavior. DESIGN, SETTING, AND PARTICIPANTS This 24-week randomized trial compared parent training (n = 89) to parent education (n = 91) at 6 centers (Emory University, Indiana University, Ohio State University, University of Pittsburgh, University of Rochester, Yale University). We screened 267 children; 180 children (aged 3-7 years) with autism spectrum disorder and disruptive behaviors were randomly assigned (86% white, 88% male) between September 2010 and February 2014. INTERVENTIONS Parent training (11 core, 2 optional sessions; 2 telephone boosters; 2 home visits) provided specific strategies to manage disruptive behavior. Parent education (12 core sessions, 1 home visit) provided information about autism but no behavior management strategies. MAIN OUTCOMES AND MEASURES Parents rated disruptive behavior and noncompliance on co-primary outcomes: the Aberrant Behavior Checklist-Irritability subscale (range, 0-45) and the Home Situations Questionnaire-Autism Spectrum Disorder (range, 0-9). On both measures, higher scores indicate greater severity and a 25% reduction indicates clinical improvement. A clinician blind to treatment assignment rated the Improvement scale of the Clinical Global Impression (range, 1-7), a secondary outcome, with a positive response less than 3. RESULTS At week 24, the Aberrant Behavior Checklist-Irritability subscale declined 47.7% in parent training (from 23.7 to 12.4) compared with 31.8% for parent education (23.9 to 16.3) (treatment effect, -3.9; 95% CI, -6.2 to -1.7; P < .001, standardized effect size = 0.62). The Home Situations Questionnaire-Autism Spectrum Disorder declined 55% (from 4.0 to 1.8) compared with 34.2% in parent education (3.8 to 2.5) (treatment effect, -0.7; 95% CI, -1.1 to -0.3; P < .001, standardized effect size = 0.45). Neither measure met the prespecified minimal clinically important difference. The proportions with a positive response on the Clinical Global Impression-Improvement scale were 68.5% for parent training vs 39.6% for parent education (P < .001). CONCLUSIONS AND RELEVANCE For children with autism spectrum disorder, a 24-week parent training program was superior to parent education for reducing disruptive behavior on parent-reported outcomes, although the clinical significance of the improvement is unclear. The rate of positive response judged by a blinded clinician was greater for parent training vs parent education. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01233414.

Autism screening tools: an evaluation of the Social Communication Questionnaire and the Developmental Behaviour Checklist-Autism Screening Algorithm.

Abstract Background This study is the first to evaluate the Social Communication Questionnaire (SCQ) and the Developmental Behaviour Checklist–Autism Screening Algorithm (DBC‐ASA) in the same sample of school‐aged children with intellectual disability (ID) with and without Pervasive Developmental Disorders (PDDs). Method Parents of 49 children (36 with PDDs and 13 with ID) completed a survey that included a demographic form, a measure of adaptive behaviour (the SIB‐R), the SCQ, and the DBC‐ASA. Results According to established cut‐offs, the SCQs sensitivity was .92 and specificity was .62, and the DBC‐ASAs sensitivity was .94 and specificity was .46. Six of the seven false positives on the DBC‐ASA had DBC Total Problem Behaviour scores above the clinical cut‐off. By contrast, all six true negatives had Total Problem Behaviour scores below the clinical cut‐off. No such pattern was noted for the SCQ. Conclusion While both instruments have good psychometric properties, the results of this study suggest that clinicians and researchers should exercise caution when utilising the DBC‐ASA to screen for PDDs in individuals with significant behaviour problems, as this could decrease its diagnostic validity.