- Email: [email protected]
Cutoff scores for the Autism Spectrum Disorder – Comorbid for Children (ASD-CC)
Research in Autism Spectrum Disorders 6 (2012) 556–559
Contents lists available at ScienceDirect
Research in Autism Spectrum Disorders Journal homepage: http://ees.elsevier.com/RASD/default.asp
Cutoff scores for the Autism Spectrum Disorder – Comorbid for Children (ASD-CC) Ryan T. Thorson a, Johnny L. Matson b,* a b
University of Nebraska Medical School, Baton Rouge, LA, USA Louisiana State University, Baton Rouge, LA, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 25 May 2011 Accepted 18 July 2011 Available online 11 August 2011
Once considered rare, Autism Spectrum Disorders (ASD) are increasingly becoming viewed as common disorders. Additionally, recent studies suggest that comorbid psychopathology within ASD is more common than previously thought. Though these deficits exist, specific instruments to diagnose psychopathology in this population are not available. In this study, 639 children between 2 and 17 years of age were screened for comorbid psychopathology with the ASD-CC. Norms and cut-off scores for numerous forms of psychopathology were established. The ASD-CC is the first screening instrument for comorbid psychopathology in children with ASD over 3 years of age with published psychometric properties. ß 2011 Elsevier Ltd. All rights reserved.
Keywords: Autism Spectrum Disorders Comorbid psychopathology Children Diagnosis
1. Introduction Autism Spectrum Disorders (ASD) are considered to be neurodevelopmental in origin (Kopp, Beckung, & Gilberg, 2010; Oeseburg, Groothoff, Dijkstra, Reijneeld, & Jansen, 2010). The ASD is composed of five disorders: Autistic Disorder, Asperger’s Disorder, Rett’s Disorder, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS) (Matson & Boisjoli, 2007; Matson & Neal, 2010; Peter-Scheffer, Didden, Mulders, & Korzilius, 2010; Wing & Gould, 1979). Children with ASD tend to suffer from a number of deficits in communication, stereotypies, social deficits, and ritualized behaviors, often identified as core deficits in ASD (Fombonne & Volkmar, 2007; Leaf, Dotson, Oppenheim, Sheldon, & Sherman, 2010). Accompanying these ASD are a number of related conditions including comorbid psychopathology (Bakken et al., 2010; Gillberg, 2010; LoVullo & Matson, 2009). Diagnostic assessments have improved a great deal in recent years, and reliable and valid instruments are being developed for use in younger children every year, with one instrument normed on children as young as 16 months (Matson, Fodstad, & Mahan, 2009). Even at young ages, elevated rates of psychopathology among children with ASD have been noted and these challenges tend to follow children long-term (Smith & Matson, 2010a, 2010b, 2010c; Weissman & Bates, 2010). The ASD-CC was designed as a part of an assessment battery for diagnosing ASD, comorbid psychopathology, and behavioral issues in children and adolescents. As such, the scale can be used to track and monitor these problems throughout childhood. This study presents the first large-scale study representing a screening instrument for comorbid psychopathology in children over three years of age with ASD. As such, the ASD-CC complements existing measures. For example, the Baby and Infant Screen for Children with aUtIsm Traits, Part II does fill a similar role within 16–37 months old children and has established psychometric properties and cutoff scores (Matson, Fodstad, Mahan, & Sevin, 2009). Also, the Autism Comorbidity Interview – Present and Lifetime Version
* Corresponding author at: Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, USA. E-mail address: [email protected] (J.L. Matson). 1750-9467/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.rasd.2011.07.016
R.T. Thorson, J.L. Matson / Research in Autism Spectrum Disorders 6 (2012) 556–559
557
(ACI-PL), has been identified to accomplish the identification of comorbid psychopathology in ASD (Leyfer et al., 2006). The ACI-PL’s design is quite different and serves a different function in the diagnostic process. Thus, the ASD-CC extends the ability to evaluate comorbid psychopathology in an ASD population. 2. Methods 2.1. Participants The sample consisted of 639 children between 2 and 17 years of age (M = 8.36, SD = 3.73). Participants included both males (n = 449) and females (n = 180). The majority of the sample was identified as Caucasian (66.2%), but also included African American (8.9%), Hispanic (2.5%) and other races (3.3%), with a large number of participants choosing not to identify their race (19.1%). Participants for this study were recruited from a variety of clinic, community, and school settings throughout the United States and southern Canada. Participants in this study were currently partaking in a broader study of children with ASD in children, which included a diagnostic assessment and problem behavior assessment concurrently normed with the ASD-CC. All diagnoses (both ASD and other psychopathology) were given by licensed psychologists and/or board certified child and/or adolescent psychiatrists. 2.2. Measure The Autism Spectrum Disorder – Comorbid for Children (ASD-CC). The ASD-CC is a 49-item, informant-based rating scale designed to assess symptoms of psychopathology and emotional difficulties which commonly occur with ASD. Items are included to address conditions such as ADHD, depression, conduct disorder, eating disorders/difficulties, OCD, specific phobias, and tic disorders. Caregivers rate each item to the extent it has been a recent problem as either 0 = ‘‘not a problem or impairment; not at all’’, 1 = ‘‘mild problem or impairment’’, 2 = ‘‘severe problem or impairment’’, or X = ‘‘does not apply or don’t know’’. Inter-rater and test–retest reliability for the ASD-CC has been found to be moderately good (k = .46 and k = .51, respectively) with very good internal consistency (a = .91) reported (Matson & Dempsey, 2008). Factor analysis yielded seven subscales for the ASD-CC: 1) Tantrum Behavior, 2) Repetitive Behavior, 3) Worry/Depressed, 4), Avoidant Behavior, 5) Under-Eating, 6) Conduct, and 7) Over-Eating. Construct validity was established for Tantrum Behavior, Worry/Depressed, Repetitive Behavior, Conduct, and Over-Eating factors. The Under-Eating subscale’s validity was not as strong as other factors and the Avoidant Behavior subscale’s validity was unable to be established (Matson, Gonza´lez, & Wilkins, 2009). The ASDChild battery is composed of three informant-based assessments: 1) the Autism Spectrum Disorder – Diagnostic for Children, 2) the Autism Spectrum Disorder – Comorbid for Children, and 3) the Autism Spectrum Disorder – Problem Behaviors for Children. Within this study, only the ASD-CC assessment was utilized. 2.3. Testers and test administration The ASD-CC was administered in interview format, by an informant filling out individually, or with informants filling out the assessment electronically based on their preference. Respondents were parents or caretakers of the participants. Doctoral students in clinical psychology familiar with the instrument were available to help resolve any questions parents and caretakers had while completing these measures. 2.4. Research design Cut off scores were determined utilizing the standard deviation from central tendency method, as the sample in this study was representative of children with ASD (the target population of this assessment). Means and standard deviations were computed for all factors of the ASD-CC. Clinical significance is generally considered to be two standard deviations from the mean (Jacobson & Traux, 1991). Significance has also been identified to be one standard deviation from the mean in certain situations (Kendall & Grove, 1988). To determine means and standard deviations, results were rounded to two decimal points. Results (i.e., potential scores) were rounded to the nearest whole number, as the ASD-CC only allows for whole numbers to be used in scoring. Scores below one standard deviation were determined to be ‘‘no/minimal impairment’’. Scores of one to two standard deviations were classified as ‘‘moderate impairment’’, and scores over two standard deviations were classified as having ‘‘severe impairment’’ in each area. 3. Results The means and standard deviations for each of the 7 subscales of the ASD-CC were calculated. The means for the Tantrum Behaviors, Repetitive Behaviors, Worry/Depressed, Avoidant Behaviors, Under-Eating, Conduct Behaviors, and Over-Eating factors were 6.70, 4.91, 2.69, 4.23, 0.82, 1.49, and 1.20, with standard deviations of 4.16, 3.65, 2.75, 2.86, 1.45, 1.79, and 1.63, respectively. The classification of ‘‘No/minimal impairment’’ was utilized when scores fell within one standard deviation of the mean. Scores between one and two standard deviations of the mean were classified under ‘‘Moderate impairment’’, and scores of two or more standard deviations from the mean were classified as ‘‘Severe impairment’’. Two decimal places were
R.T. Thorson, J.L. Matson / Research in Autism Spectrum Disorders 6 (2012) 556–559
558
Table 1 Subscale means, standard deviations, and cut-off scores. Factor
Mean
Standard deviation
No/minimal impairment
Moderate impairment
Severe impairment
Tantrum Behaviors Repetitive Behaviors Worry/Depressed Avoidant Behaviors Under-Eating Conduct Behaviors Over-Eating
6.70 4.91 2.69 4.23 0.82 1.49 1.20
4.16 3.65 2.75 2.86 1.45 1.79 1.63
0–10 0–8 0–5 0–6 0–1 0–2 0–2
11–14 9–12 6–8 7–9 2–3 3–4 3–4
15 and over 13 and over 9 and over 10 and over 4 and over 5 and over 5 and over
Note: Means and standard deviations are presented for the subscales of the ASD-CC based on the standard deviation from central tendency method. Scores below one standard deviation from the mean were indicative of ‘‘No/minimal impairment’’, scores between one and two standard deviations from the mean indicated ‘‘Moderate impairment’’, and scores over two standard deviations from the mean were indicative of ‘‘Severe impairment’’.
utilized in the calculation of cut-off scores while whole numbers were utilized in the determination of final cut-off scores given the scoring system of the ASD-CC. Please see Table 1 for a summary of these scores. 4. Discussion The goal of this study was to identify ideal cut-off scores to identify the presence or absence of comorbid psychopathology within a subset of children with ASD utilizing the ASD-CC. This tool was normed within the ASD-Child battery of assessments, which is designed to allow for an evaluation of ASD, comorbid psychopathology, and behavior problems in a timely fashion that would not otherwise available (Matson, Gonza´lez, & Rivet, 2008; Matson, Gonza´lez, et al., 2009; Matson, LoVullo, Rivet, & Boisjoli, 2009). The ability to complete a screening in a timely and cost-effective fashion is another significant benefit. Utilizing the ASD-Child battery provides another method for diagnosing ASD and for determining if and when any additional diagnoses should be considered. Certainly, the need for an assessment tool such as the ASD-CC is clear given the significant diagnostic overlap between various ASD and other forms of psychopathology (De Bruin, Ferdinand, Meester, de Nijs, & Verheij, 2007; Gadow, DeVincent, Pomeroy, & Azizian, 2004; Ghaziuddin, 2002; Ghaziuddin, WeidmerMikhail, & Ghaziuddin, 1998; Morgan, Roy, & Chance, 2003). The ASD-CC fills a void in assessment for comorbid psychopathology within the ASD population, as only one other screening assessment tool exists to work with autism to measure comorbid psychopathology and two screening tools for adults (Helverschou, Bakken, & Martinsen, 2009; Leyfer et al., 2006; Matson, Fodstad, Mahan, & Sevin, 2009; Matson, Terlonge, & Gonza´lez, 2006). Reliable and valid diagnoses are vital for proper treatment and should be particularly important given the increasing prevalence of the utilization of psychotropic medications for children (Kalyva, Pellizzoni, Tavano, Iannello, & Siegel, 2010; McCracken et al., 2002; Staudenmeier & Jacoby, 1998; Woodard, Groden, Goodwin, Shanower, & Bianco, 2005; Nyden et al., 2010). Accurately diagnosed comorbid conditions could significantly assist medical doctors in providing the best possible medication regiments for children while minimizing the side effect profile as much as possible. Given the shortage of mental health professionals prescribing medications (and subsequent increase in general practitioners such as Pediatricians and Family Medicine physicians prescribing to children), the simplification and clarification of a diagnostic picture is vital (Staudenmeier & Jacoby, 1998). The ASD-CC is likely to be used as part of an assessment battery as a portion of a psychological assessment, but may also be utilized in a stand-alone fashion as a screening instrument. Clinicians may also utilize the entire ASD-Child battery independently to specifically answer questions regarding ASD. The factors on the scale do not relate to a singular DSM-IV-TR or ICD-10 diagnosis, so a level of clinical judgment is necessary with this tool, particularly given the psychometric properties of the scale. It could be utilized as a pre-screening tool which clinicians could send out prior to their formal clinical interview/ assessment. There is great utility in utilizing the results of this type of assessment to guide clinical interview questions and observations in formal assessment. The previously discussed shortage of trained mental health professionals is a significant driving factor highlighting the importance of proper diagnostic measures. Relatively brief screening measures allow clinicians to perform proper diagnostic assessment in a timely manner. Expanding on this, the ASD-CC should allow for significant improvements in diagnosis within ASD, as no other brief assessments of comorbid psychopathology currently exist that have been specifically normed with cut-off scores on a population of children with ASD (Leyfer et al., 2006). It is highly likely that the benefits from this scale will lead to improved diagnosis of psychopathology within ASD. References Bakken, T. L., Helverschou, S. B., Eilersten, D. E., Heggelund, T., Myrbakk, E., & Martinsen, H. (2010). Psychiatric disorders in adolescents and adults with autism and intellectual disability: A representative study in one country in Norway. Research in Developmental Disabilities, 31, 1669–1677. De Bruin, E. I., Ferdinand, R. F., Meester, S., de Nijs, P. F. A., & Verheij, F. (2007). High rates of psychiatric co-morbidity in PDD-NOS. Journal of Autism and Developmental Disorders, 37, 877–886. Fombonne, E., & Volkmar, F. R. (2007). Epidemiological surveys of pervasive developmental disorders Autism and pervasive developmental disorders (2nd ed.). New York, NY, USA: Cambridge University Press. pp. 33–68.
R.T. Thorson, J.L. Matson / Research in Autism Spectrum Disorders 6 (2012) 556–559
559
Gadow, K. D., DeVincent, C. J., Pomeroy, J., & Azizian, A. (2004). Psychiatric symptoms in preschool children with PDD and clinic and comparison samples. Journal of Autism and Developmental Disorders, 34, 379–393. Ghaziuddin, M. (2002). Asperger syndrome: Associated psychiatric and medical conditions. Focus on Autism and Other Developmental Disabilities, 17, 138–144. Ghaziuddin, M., Weidmer-Mikhail, E., & Ghaziuddin, N. (1998). Comorbidity of Asperger syndrome: A preliminary report. Journal of Intellectual Disability Research, 42, 279–283. Gillberg, C. (2010). The ESSENCE in child psychiatry: Early symptomatic syndromes Eliciting Neurodevelopmental (Clinical) Examinations. Research in Developmental Disabilities, 31, 1543–1551. Helverschou, S. B., Bakken, T. L., & Martinsen, H. (2009). The Psychopathology in Autism Checklist (PAC): A pilot study. Research in Autism Spectrum Disorders, 3, 179–195. Jacobson, N. S., & Traux, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12–19. Kalyva, E., Pellizzoni, S., Tavano, A., Iannello, P., & Siegel, M. (2010). Contamination sensitivity in autsim, down syndrome, and typical development. Research in Autsim Spectrum Disorders, 4, 43–50. Kendall, P. C., & Grove, W. M. (1988). Normative comparisons in therapy outcome. Behavioral Assessment, 10, 147–158. Kopp, S., Beckung, E., & Gillberg, C. (2010). Developmental coordination disorder and other motor control problems in girls with autism spectrum disorder and/or attention-deficits/hyperactivity disorder. Research in Developmental Disabilities, 31, 350–361. Leaf, J. B., Dotson, W. H., Oppeneheim, M. L., Sheldon, J. B., & Sherman, J. A. (2010). The effectiveness of a group teaching interaction procedure for teaching social skills to young children with a pervasive developmental disorder. Research in Autism Spectrum Disorders, 4, 186–198. Leyfer, O. T., Folstein, S. E., Bacalman, S., Davis, N. O., Dinh, E., Morgan, J., et al. (2006). Comorbid psychiatric disorders in children with autism: Interview development and rates of disorders. Journal of Autism and Developmental Disorders, 36, 849–861. LoVullo, S. V., & Matson, J. L. (2009). Comorbid psychopathology in adults with autsim spectrum disorders and intellectual disabilities. Research in Developmental Disabilities, 30, 1288–1296. Matson, J. L., & Boisjoli, J. A. (2007). Differential diagnosis of PDDNOS in children. Research in Autism Spectrum Disorders, 1, 75–84. Matson, J. L., & Dempsey, T. (2008). Stereotypy in adults with autism spectrum disorders: Relationship and diagnostic fidelity. Journal of Developmental and Physical Disabilities, 20, 155–165. Matson, J. L., & Neal, D. (2010). Differentiating communication disorders and autism in children. Research in Autism Spectrum Disorders, 4, 626–632. Matson, J. L., Terlonge, C., & Gonza´lez, M. (2006). Autism spectrum disorders – diagnosis (ASD-D). Baton Rouge, LA: Disability Consultants, LLC. Matson, J. L., Gonza´lez, M., & Rivet, T. T. (2008). Reliability of the Autism Spectrum Disorder – Behavior Problems for Children (ASD-BPC). Research in Autism Spectrum Disorders, 2, 696–706. Matson, J. L., Fodstad, J. C., & Mahan, S. (2009). Cutoffs, norms, and patterns of comorbid difficulties in children with developmental disabilities on the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT-Part 2). Research in Developmental Disabilities, 30, 1221–1228. Matson, J. L., Fodstad, J. C., Mahan, S., & Sevin, J. A. (2009). Cutoffs, norms, and patterns of comorbid difficulties in children with an ASD on the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT-Part 2). Research in Autism Spectrum Disorders, 3, 977–988. Matson, J. L., Gonza´lez, M., & Wilkins, J. (2009). Validity study of the Autism Spectrum Disorders – Diagnostic for Children (ASD-DC). Research in Autism Spectrum Disorders, 3, 196–206. Matson, J. L., LoVullo, S. V., Rivet, T. T., & Boisjoli, J. A. (2009). Validity of the Autism Spectrum Disorder – Comorbid for Children (ASD-CC). Research in Autism Spectrum Disorders, 3, 345–357. McCracken, J. T., McGough, J., Shah, B., Cronin, P., Hong, D., Aman, M. G., et al. (2002). Risperidone in children with autism and serious behavioral problems. The New England Journal of Medicine, 347, 314–321. Morgan, C. N., Roy, M., & Chance, P. (2003). Psychiatric comorbidity and medication use in autism: A community survey. Psychiatric Bulletin, 27, 378–381. Nyden, A., Niklasson, L., Stahlberg, O., Anckarsater, H., Wentz, E., Rastam, M., et al. (2010). Adults with autsim spectrum disorders and ADHD neuropsychological aspects. Research in Developmental Disabilities, 31, 1659–1668. Oeseburg, B., Groothoff, J. W., Dijkstra, B. J., Reijneeld, S. A., & Jansen, D. E. M. C. (2010). Pervasive developmental disorder behavior in adolescents with intellectual disability and co-occurring somatic chronic diseases. Research in Developmental Disabilities, 31, 496–501. Peter-Scheffer, N., Didden, R., Mulders, M., & Korzilius, H. (2010). Low intensity behavioral treatment supplementing preschool services for young children with autism spectrum disorders and sever to mild intellectual disability. Research in Developmental Disabilities 31 1678-1648. Smith, K. R. M., & Matson, J. L. (2010a). Social skills: Differences among disorders and epilepsy. Research in Developmental Disabilities, 31, 1366–1372. Smith, K. R. M., & Matson, J. L. (2010b). Behavior problems: Differences among intellectually disabled adults with co-morbid autism spectrum disorders and epilepsy. Research in Developmental Disabilities, 31, 1062–1069. Smith, K. R. M., & Matson, J. L. (2010c). Psychopathology: Differences among adults with intellectually disabled, comorbid autism spectrum disorders and epilepsy. Research in Developmental Disabilities, 31, 743–749. Staudenmeier, J. J., & Jacoby, I. (1998). Trends in prescribing psychotropic medications. JAMA: Journal of the American Medical Association, 280, 132–134. Weissman, A. S., & Bates, M. E. (2010). Increased clinical and neurocognitive impairment in children with autism spectrum disorders and comorbid bipolar disorder. Research in Autism Spectrum Disorders, 4, 670–680. Wing, L., & Gould, J. (1979). Severe impairments of social interaction and associated abnormalities in children: Epidemiology and classification. Journal of Autism and Developmental Disorders, 9, 11–29. Woodard, C., Groden, J., Goodwin, M., Shanower, C., & Bianco, J. (2005). The treatment of the behavioral sequelae of autism with dextromethorphan: A case report. Journal of Autism and Developmental Disorders, 35, 515–518.
Contents lists available at ScienceDirect
Research in Autism Spectrum Disorders Journal homepage: http://ees.elsevier.com/RASD/default.asp
Cutoff scores for the Autism Spectrum Disorder – Comorbid for Children (ASD-CC) Ryan T. Thorson a, Johnny L. Matson b,* a b
University of Nebraska Medical School, Baton Rouge, LA, USA Louisiana State University, Baton Rouge, LA, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 25 May 2011 Accepted 18 July 2011 Available online 11 August 2011
Once considered rare, Autism Spectrum Disorders (ASD) are increasingly becoming viewed as common disorders. Additionally, recent studies suggest that comorbid psychopathology within ASD is more common than previously thought. Though these deficits exist, specific instruments to diagnose psychopathology in this population are not available. In this study, 639 children between 2 and 17 years of age were screened for comorbid psychopathology with the ASD-CC. Norms and cut-off scores for numerous forms of psychopathology were established. The ASD-CC is the first screening instrument for comorbid psychopathology in children with ASD over 3 years of age with published psychometric properties. ß 2011 Elsevier Ltd. All rights reserved.
Keywords: Autism Spectrum Disorders Comorbid psychopathology Children Diagnosis
1. Introduction Autism Spectrum Disorders (ASD) are considered to be neurodevelopmental in origin (Kopp, Beckung, & Gilberg, 2010; Oeseburg, Groothoff, Dijkstra, Reijneeld, & Jansen, 2010). The ASD is composed of five disorders: Autistic Disorder, Asperger’s Disorder, Rett’s Disorder, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS) (Matson & Boisjoli, 2007; Matson & Neal, 2010; Peter-Scheffer, Didden, Mulders, & Korzilius, 2010; Wing & Gould, 1979). Children with ASD tend to suffer from a number of deficits in communication, stereotypies, social deficits, and ritualized behaviors, often identified as core deficits in ASD (Fombonne & Volkmar, 2007; Leaf, Dotson, Oppenheim, Sheldon, & Sherman, 2010). Accompanying these ASD are a number of related conditions including comorbid psychopathology (Bakken et al., 2010; Gillberg, 2010; LoVullo & Matson, 2009). Diagnostic assessments have improved a great deal in recent years, and reliable and valid instruments are being developed for use in younger children every year, with one instrument normed on children as young as 16 months (Matson, Fodstad, & Mahan, 2009). Even at young ages, elevated rates of psychopathology among children with ASD have been noted and these challenges tend to follow children long-term (Smith & Matson, 2010a, 2010b, 2010c; Weissman & Bates, 2010). The ASD-CC was designed as a part of an assessment battery for diagnosing ASD, comorbid psychopathology, and behavioral issues in children and adolescents. As such, the scale can be used to track and monitor these problems throughout childhood. This study presents the first large-scale study representing a screening instrument for comorbid psychopathology in children over three years of age with ASD. As such, the ASD-CC complements existing measures. For example, the Baby and Infant Screen for Children with aUtIsm Traits, Part II does fill a similar role within 16–37 months old children and has established psychometric properties and cutoff scores (Matson, Fodstad, Mahan, & Sevin, 2009). Also, the Autism Comorbidity Interview – Present and Lifetime Version
* Corresponding author at: Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, USA. E-mail address: [email protected] (J.L. Matson). 1750-9467/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.rasd.2011.07.016
R.T. Thorson, J.L. Matson / Research in Autism Spectrum Disorders 6 (2012) 556–559
557
(ACI-PL), has been identified to accomplish the identification of comorbid psychopathology in ASD (Leyfer et al., 2006). The ACI-PL’s design is quite different and serves a different function in the diagnostic process. Thus, the ASD-CC extends the ability to evaluate comorbid psychopathology in an ASD population. 2. Methods 2.1. Participants The sample consisted of 639 children between 2 and 17 years of age (M = 8.36, SD = 3.73). Participants included both males (n = 449) and females (n = 180). The majority of the sample was identified as Caucasian (66.2%), but also included African American (8.9%), Hispanic (2.5%) and other races (3.3%), with a large number of participants choosing not to identify their race (19.1%). Participants for this study were recruited from a variety of clinic, community, and school settings throughout the United States and southern Canada. Participants in this study were currently partaking in a broader study of children with ASD in children, which included a diagnostic assessment and problem behavior assessment concurrently normed with the ASD-CC. All diagnoses (both ASD and other psychopathology) were given by licensed psychologists and/or board certified child and/or adolescent psychiatrists. 2.2. Measure The Autism Spectrum Disorder – Comorbid for Children (ASD-CC). The ASD-CC is a 49-item, informant-based rating scale designed to assess symptoms of psychopathology and emotional difficulties which commonly occur with ASD. Items are included to address conditions such as ADHD, depression, conduct disorder, eating disorders/difficulties, OCD, specific phobias, and tic disorders. Caregivers rate each item to the extent it has been a recent problem as either 0 = ‘‘not a problem or impairment; not at all’’, 1 = ‘‘mild problem or impairment’’, 2 = ‘‘severe problem or impairment’’, or X = ‘‘does not apply or don’t know’’. Inter-rater and test–retest reliability for the ASD-CC has been found to be moderately good (k = .46 and k = .51, respectively) with very good internal consistency (a = .91) reported (Matson & Dempsey, 2008). Factor analysis yielded seven subscales for the ASD-CC: 1) Tantrum Behavior, 2) Repetitive Behavior, 3) Worry/Depressed, 4), Avoidant Behavior, 5) Under-Eating, 6) Conduct, and 7) Over-Eating. Construct validity was established for Tantrum Behavior, Worry/Depressed, Repetitive Behavior, Conduct, and Over-Eating factors. The Under-Eating subscale’s validity was not as strong as other factors and the Avoidant Behavior subscale’s validity was unable to be established (Matson, Gonza´lez, & Wilkins, 2009). The ASDChild battery is composed of three informant-based assessments: 1) the Autism Spectrum Disorder – Diagnostic for Children, 2) the Autism Spectrum Disorder – Comorbid for Children, and 3) the Autism Spectrum Disorder – Problem Behaviors for Children. Within this study, only the ASD-CC assessment was utilized. 2.3. Testers and test administration The ASD-CC was administered in interview format, by an informant filling out individually, or with informants filling out the assessment electronically based on their preference. Respondents were parents or caretakers of the participants. Doctoral students in clinical psychology familiar with the instrument were available to help resolve any questions parents and caretakers had while completing these measures. 2.4. Research design Cut off scores were determined utilizing the standard deviation from central tendency method, as the sample in this study was representative of children with ASD (the target population of this assessment). Means and standard deviations were computed for all factors of the ASD-CC. Clinical significance is generally considered to be two standard deviations from the mean (Jacobson & Traux, 1991). Significance has also been identified to be one standard deviation from the mean in certain situations (Kendall & Grove, 1988). To determine means and standard deviations, results were rounded to two decimal points. Results (i.e., potential scores) were rounded to the nearest whole number, as the ASD-CC only allows for whole numbers to be used in scoring. Scores below one standard deviation were determined to be ‘‘no/minimal impairment’’. Scores of one to two standard deviations were classified as ‘‘moderate impairment’’, and scores over two standard deviations were classified as having ‘‘severe impairment’’ in each area. 3. Results The means and standard deviations for each of the 7 subscales of the ASD-CC were calculated. The means for the Tantrum Behaviors, Repetitive Behaviors, Worry/Depressed, Avoidant Behaviors, Under-Eating, Conduct Behaviors, and Over-Eating factors were 6.70, 4.91, 2.69, 4.23, 0.82, 1.49, and 1.20, with standard deviations of 4.16, 3.65, 2.75, 2.86, 1.45, 1.79, and 1.63, respectively. The classification of ‘‘No/minimal impairment’’ was utilized when scores fell within one standard deviation of the mean. Scores between one and two standard deviations of the mean were classified under ‘‘Moderate impairment’’, and scores of two or more standard deviations from the mean were classified as ‘‘Severe impairment’’. Two decimal places were
R.T. Thorson, J.L. Matson / Research in Autism Spectrum Disorders 6 (2012) 556–559
558
Table 1 Subscale means, standard deviations, and cut-off scores. Factor
Mean
Standard deviation
No/minimal impairment
Moderate impairment
Severe impairment
Tantrum Behaviors Repetitive Behaviors Worry/Depressed Avoidant Behaviors Under-Eating Conduct Behaviors Over-Eating
6.70 4.91 2.69 4.23 0.82 1.49 1.20
4.16 3.65 2.75 2.86 1.45 1.79 1.63
0–10 0–8 0–5 0–6 0–1 0–2 0–2
11–14 9–12 6–8 7–9 2–3 3–4 3–4
15 and over 13 and over 9 and over 10 and over 4 and over 5 and over 5 and over
Note: Means and standard deviations are presented for the subscales of the ASD-CC based on the standard deviation from central tendency method. Scores below one standard deviation from the mean were indicative of ‘‘No/minimal impairment’’, scores between one and two standard deviations from the mean indicated ‘‘Moderate impairment’’, and scores over two standard deviations from the mean were indicative of ‘‘Severe impairment’’.
utilized in the calculation of cut-off scores while whole numbers were utilized in the determination of final cut-off scores given the scoring system of the ASD-CC. Please see Table 1 for a summary of these scores. 4. Discussion The goal of this study was to identify ideal cut-off scores to identify the presence or absence of comorbid psychopathology within a subset of children with ASD utilizing the ASD-CC. This tool was normed within the ASD-Child battery of assessments, which is designed to allow for an evaluation of ASD, comorbid psychopathology, and behavior problems in a timely fashion that would not otherwise available (Matson, Gonza´lez, & Rivet, 2008; Matson, Gonza´lez, et al., 2009; Matson, LoVullo, Rivet, & Boisjoli, 2009). The ability to complete a screening in a timely and cost-effective fashion is another significant benefit. Utilizing the ASD-Child battery provides another method for diagnosing ASD and for determining if and when any additional diagnoses should be considered. Certainly, the need for an assessment tool such as the ASD-CC is clear given the significant diagnostic overlap between various ASD and other forms of psychopathology (De Bruin, Ferdinand, Meester, de Nijs, & Verheij, 2007; Gadow, DeVincent, Pomeroy, & Azizian, 2004; Ghaziuddin, 2002; Ghaziuddin, WeidmerMikhail, & Ghaziuddin, 1998; Morgan, Roy, & Chance, 2003). The ASD-CC fills a void in assessment for comorbid psychopathology within the ASD population, as only one other screening assessment tool exists to work with autism to measure comorbid psychopathology and two screening tools for adults (Helverschou, Bakken, & Martinsen, 2009; Leyfer et al., 2006; Matson, Fodstad, Mahan, & Sevin, 2009; Matson, Terlonge, & Gonza´lez, 2006). Reliable and valid diagnoses are vital for proper treatment and should be particularly important given the increasing prevalence of the utilization of psychotropic medications for children (Kalyva, Pellizzoni, Tavano, Iannello, & Siegel, 2010; McCracken et al., 2002; Staudenmeier & Jacoby, 1998; Woodard, Groden, Goodwin, Shanower, & Bianco, 2005; Nyden et al., 2010). Accurately diagnosed comorbid conditions could significantly assist medical doctors in providing the best possible medication regiments for children while minimizing the side effect profile as much as possible. Given the shortage of mental health professionals prescribing medications (and subsequent increase in general practitioners such as Pediatricians and Family Medicine physicians prescribing to children), the simplification and clarification of a diagnostic picture is vital (Staudenmeier & Jacoby, 1998). The ASD-CC is likely to be used as part of an assessment battery as a portion of a psychological assessment, but may also be utilized in a stand-alone fashion as a screening instrument. Clinicians may also utilize the entire ASD-Child battery independently to specifically answer questions regarding ASD. The factors on the scale do not relate to a singular DSM-IV-TR or ICD-10 diagnosis, so a level of clinical judgment is necessary with this tool, particularly given the psychometric properties of the scale. It could be utilized as a pre-screening tool which clinicians could send out prior to their formal clinical interview/ assessment. There is great utility in utilizing the results of this type of assessment to guide clinical interview questions and observations in formal assessment. The previously discussed shortage of trained mental health professionals is a significant driving factor highlighting the importance of proper diagnostic measures. Relatively brief screening measures allow clinicians to perform proper diagnostic assessment in a timely manner. Expanding on this, the ASD-CC should allow for significant improvements in diagnosis within ASD, as no other brief assessments of comorbid psychopathology currently exist that have been specifically normed with cut-off scores on a population of children with ASD (Leyfer et al., 2006). It is highly likely that the benefits from this scale will lead to improved diagnosis of psychopathology within ASD. References Bakken, T. L., Helverschou, S. B., Eilersten, D. E., Heggelund, T., Myrbakk, E., & Martinsen, H. (2010). Psychiatric disorders in adolescents and adults with autism and intellectual disability: A representative study in one country in Norway. Research in Developmental Disabilities, 31, 1669–1677. De Bruin, E. I., Ferdinand, R. F., Meester, S., de Nijs, P. F. A., & Verheij, F. (2007). High rates of psychiatric co-morbidity in PDD-NOS. Journal of Autism and Developmental Disorders, 37, 877–886. Fombonne, E., & Volkmar, F. R. (2007). Epidemiological surveys of pervasive developmental disorders Autism and pervasive developmental disorders (2nd ed.). New York, NY, USA: Cambridge University Press. pp. 33–68.
R.T. Thorson, J.L. Matson / Research in Autism Spectrum Disorders 6 (2012) 556–559
559
Gadow, K. D., DeVincent, C. J., Pomeroy, J., & Azizian, A. (2004). Psychiatric symptoms in preschool children with PDD and clinic and comparison samples. Journal of Autism and Developmental Disorders, 34, 379–393. Ghaziuddin, M. (2002). Asperger syndrome: Associated psychiatric and medical conditions. Focus on Autism and Other Developmental Disabilities, 17, 138–144. Ghaziuddin, M., Weidmer-Mikhail, E., & Ghaziuddin, N. (1998). Comorbidity of Asperger syndrome: A preliminary report. Journal of Intellectual Disability Research, 42, 279–283. Gillberg, C. (2010). The ESSENCE in child psychiatry: Early symptomatic syndromes Eliciting Neurodevelopmental (Clinical) Examinations. Research in Developmental Disabilities, 31, 1543–1551. Helverschou, S. B., Bakken, T. L., & Martinsen, H. (2009). The Psychopathology in Autism Checklist (PAC): A pilot study. Research in Autism Spectrum Disorders, 3, 179–195. Jacobson, N. S., & Traux, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12–19. Kalyva, E., Pellizzoni, S., Tavano, A., Iannello, P., & Siegel, M. (2010). Contamination sensitivity in autsim, down syndrome, and typical development. Research in Autsim Spectrum Disorders, 4, 43–50. Kendall, P. C., & Grove, W. M. (1988). Normative comparisons in therapy outcome. Behavioral Assessment, 10, 147–158. Kopp, S., Beckung, E., & Gillberg, C. (2010). Developmental coordination disorder and other motor control problems in girls with autism spectrum disorder and/or attention-deficits/hyperactivity disorder. Research in Developmental Disabilities, 31, 350–361. Leaf, J. B., Dotson, W. H., Oppeneheim, M. L., Sheldon, J. B., & Sherman, J. A. (2010). The effectiveness of a group teaching interaction procedure for teaching social skills to young children with a pervasive developmental disorder. Research in Autism Spectrum Disorders, 4, 186–198. Leyfer, O. T., Folstein, S. E., Bacalman, S., Davis, N. O., Dinh, E., Morgan, J., et al. (2006). Comorbid psychiatric disorders in children with autism: Interview development and rates of disorders. Journal of Autism and Developmental Disorders, 36, 849–861. LoVullo, S. V., & Matson, J. L. (2009). Comorbid psychopathology in adults with autsim spectrum disorders and intellectual disabilities. Research in Developmental Disabilities, 30, 1288–1296. Matson, J. L., & Boisjoli, J. A. (2007). Differential diagnosis of PDDNOS in children. Research in Autism Spectrum Disorders, 1, 75–84. Matson, J. L., & Dempsey, T. (2008). Stereotypy in adults with autism spectrum disorders: Relationship and diagnostic fidelity. Journal of Developmental and Physical Disabilities, 20, 155–165. Matson, J. L., & Neal, D. (2010). Differentiating communication disorders and autism in children. Research in Autism Spectrum Disorders, 4, 626–632. Matson, J. L., Terlonge, C., & Gonza´lez, M. (2006). Autism spectrum disorders – diagnosis (ASD-D). Baton Rouge, LA: Disability Consultants, LLC. Matson, J. L., Gonza´lez, M., & Rivet, T. T. (2008). Reliability of the Autism Spectrum Disorder – Behavior Problems for Children (ASD-BPC). Research in Autism Spectrum Disorders, 2, 696–706. Matson, J. L., Fodstad, J. C., & Mahan, S. (2009). Cutoffs, norms, and patterns of comorbid difficulties in children with developmental disabilities on the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT-Part 2). Research in Developmental Disabilities, 30, 1221–1228. Matson, J. L., Fodstad, J. C., Mahan, S., & Sevin, J. A. (2009). Cutoffs, norms, and patterns of comorbid difficulties in children with an ASD on the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT-Part 2). Research in Autism Spectrum Disorders, 3, 977–988. Matson, J. L., Gonza´lez, M., & Wilkins, J. (2009). Validity study of the Autism Spectrum Disorders – Diagnostic for Children (ASD-DC). Research in Autism Spectrum Disorders, 3, 196–206. Matson, J. L., LoVullo, S. V., Rivet, T. T., & Boisjoli, J. A. (2009). Validity of the Autism Spectrum Disorder – Comorbid for Children (ASD-CC). Research in Autism Spectrum Disorders, 3, 345–357. McCracken, J. T., McGough, J., Shah, B., Cronin, P., Hong, D., Aman, M. G., et al. (2002). Risperidone in children with autism and serious behavioral problems. The New England Journal of Medicine, 347, 314–321. Morgan, C. N., Roy, M., & Chance, P. (2003). Psychiatric comorbidity and medication use in autism: A community survey. Psychiatric Bulletin, 27, 378–381. Nyden, A., Niklasson, L., Stahlberg, O., Anckarsater, H., Wentz, E., Rastam, M., et al. (2010). Adults with autsim spectrum disorders and ADHD neuropsychological aspects. Research in Developmental Disabilities, 31, 1659–1668. Oeseburg, B., Groothoff, J. W., Dijkstra, B. J., Reijneeld, S. A., & Jansen, D. E. M. C. (2010). Pervasive developmental disorder behavior in adolescents with intellectual disability and co-occurring somatic chronic diseases. Research in Developmental Disabilities, 31, 496–501. Peter-Scheffer, N., Didden, R., Mulders, M., & Korzilius, H. (2010). Low intensity behavioral treatment supplementing preschool services for young children with autism spectrum disorders and sever to mild intellectual disability. Research in Developmental Disabilities 31 1678-1648. Smith, K. R. M., & Matson, J. L. (2010a). Social skills: Differences among disorders and epilepsy. Research in Developmental Disabilities, 31, 1366–1372. Smith, K. R. M., & Matson, J. L. (2010b). Behavior problems: Differences among intellectually disabled adults with co-morbid autism spectrum disorders and epilepsy. Research in Developmental Disabilities, 31, 1062–1069. Smith, K. R. M., & Matson, J. L. (2010c). Psychopathology: Differences among adults with intellectually disabled, comorbid autism spectrum disorders and epilepsy. Research in Developmental Disabilities, 31, 743–749. Staudenmeier, J. J., & Jacoby, I. (1998). Trends in prescribing psychotropic medications. JAMA: Journal of the American Medical Association, 280, 132–134. Weissman, A. S., & Bates, M. E. (2010). Increased clinical and neurocognitive impairment in children with autism spectrum disorders and comorbid bipolar disorder. Research in Autism Spectrum Disorders, 4, 670–680. Wing, L., & Gould, J. (1979). Severe impairments of social interaction and associated abnormalities in children: Epidemiology and classification. Journal of Autism and Developmental Disorders, 9, 11–29. Woodard, C., Groden, J., Goodwin, M., Shanower, C., & Bianco, J. (2005). The treatment of the behavioral sequelae of autism with dextromethorphan: A case report. Journal of Autism and Developmental Disorders, 35, 515–518.