Indian J Pediatr (December 2014) 81(Suppl 2):S187–S192 DOI 10.1007/s12098-014-1627-9

ORIGINAL ARTICLE

A Meta-analysis of the Diagnostic Accuracy of Autism Diagnostic Observation Schedule Module-1 for Autism Spectrum Disorders Sherab Tsheringla & K. A. Minju & Sushila Russell & Priya Mammen & Paul Swamidhas Sudhakar Russell & M. K. C. Nair

Received: 23 April 2014 / Accepted: 22 October 2014 / Published online: 7 November 2014 # Dr. K C Chaudhuri Foundation 2014

Abstract Objective Autism Diagnostic Observation Schedule (ADOS) is considered gold standard for the diagnosis of Autism Spectrum Disorders (ASD). The authors evaluated the cumulative diagnostic accuracy of ADOS-Module 1 (ADOSM1) using the original diagnostic algorithm with meta-analysis and metaregression. Methods The authors, electronically and manually searched for studies from 1999 to 2013 that evaluated the accuracy of ADOSM1 using the original diagnostic algorithm in detecting ASD. Primary results of Sensitivity (Sn), Specificity (Sp) and Diagnostic Odds Ratio (DOR) for ADOSM1 were summarized using random-effects model. Summary Receiver Operating characteristic Curves and its Area Under the Curve (SROCAUC) were used to summarize overall diagnostic accuracy of ADOSM1. The modifying effects of quality of study and sample size, on the diagnostic odds ratio, were investigated using meta-regression. Results A total of 7 cross-sectional studies provided data on 4,057 children. The pooled Sn, Sp, DOR and SROC-AUC for the overall diagnostic accuracy of ADOSM1 were: 0.91 (95 % CI=0.88 to 0.93), 0.27 (95 % CI=0.24 to 0.30), 5.40 (95 % CI=1.51 to 19.23) and 0.52 respectively. Meta-regression analysis showed a non-significant relationship between ADOSM1 and study quality as well as sample size. There were subgroup differences in the DOR.

S. Tsheringla : K. A. Minju : S. Russell : P. Mammen : P. S. S. Russell (*) Child and Adolescent Psychiatry Unit, Department of Psychiatry, Christian Medical College, Vellore 632 002, Tamil Nadu, India e-mail: [email protected] M. K. C. Nair Child Development Centre, Thiruvananthapuram Medical College, Thiruvananthapuram, Kerala, India

Conclusions The authors conclude that ADOSM1 with the original diagnostic algorithm lacks overall diagnostic accuracy and pooled specificity to confirm the diagnosis of Autism Spectrum Disorders. ADOSM1 with the revised diagnostic algorithm should be used instead for the diagnosis of this group of disorders. Keywords ADOS . Autism . Diagnosis . Meta-analysis

Introduction There is a wide range of screening and diagnostic measures for autism that are compatible with International Classification of Diseases or Diagnostic and Statistical Manual. The popular screening measures are Childhood Autism Rating Scale, Gilliam Autism Rating Scale and Checklist for Autism in Toddlers, whereas the widely used diagnostic measures are Developmental, Dimensional and Diagnostic Interview, Diagnostic Interview for Social and Communication Disorders, Autism Diagnosis Interview Revised and Autism Diagnostic Observation Schedule [1]. Among these measures, the Autism Diagnostic Observation Schedule (ADOSM1) is considered the gold standard measure in the diagnosis of Autism Spectrum Disorder (ASD). This measure has two diagnostic algorithms namely, the original and the revised algorithms. The original algorithm has separate threshold scores for the Social and Communication domains and does not include items related to repetitive behaviors/ restricted interests, but in the revised algorithm, the domains and cut-off values for Social and Communication have been collapsed into a single domain as well as items on repetitive behavior are included [2, 3]. The diagnostic accuracy of ADOS-Module 1 (ADOSM1) using the original diagnostic algorithm, among young children up to 2 y of age, varies from 0.79 to 0.84 [4, 5]. Despite having high diagnostic accuracy, a recent review suggests [6] that as an

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individual confirmatory measure for ASD, the diagnostic accuracy of ADOSM1 is not as high as Developmental, Dimensional And Diagnostic Interview (3Di) with a diagnostic accuracy of 0.99 [7, 8] or Visual Impairment and Social Communication Schedule (VISS) with a diagnostic accuracy of 0.95 [9] and is only comparable with the time tested Childhood Autism Rating Scale with a diagnostic accuracy of 0.86 [10]. This notion is further supported by the fact that the combined use of ADOS M1 with Autism diagnostic interview-revised (ADI-R) further improves the diagnostic accuracy to 0.88 [11]. As evidence-based medicine expands from therapy to diagnosis, the role of meta-analysis acquires added importance in reviewing the cumulative evidence about the diagnostic accuracy of clinical tests [12]. The authors chose to study ADOS as it is considered the gold standard among the diagnostic measures for autism, and also in the past the authors have validated Childhood Autism Rating Scale for the screening purpose among the Indian population [13]. Therefore, the authors conducted this meta-analysis of published data to evaluate the cumulative diagnostic accuracy of ADOSM1 to diagnose ASD using the original diagnostic algorithm among young children.

Material and Methods A systematic electronic search strategy was undertaken to identify the diagnostic accuracy studies of ADOSM1 for ASD in MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, High-wire Press and Google Scholar published between 1999 and 2013. The term “Autism Diagnostic Observation Schedule” and “ADOS” was combined with MeSH terms of “Autism Spectrum Disorders”, “Autism” “diagnostic accuracy”, “sensitivity and specificity” and “validation”. The electronic search did not incorporate any search filter to improve the retrieval of as many articles as possible. After a review of the identified titles and abstracts, several hundred of these articles deemed potentially relevant were retrieved. The authors augmented their electronic search with a hand search of additional relevant articles in reference lists of retrieved articles and articles that were considered appropriate by colleagues and experts. Whenever clarifications were needed authors were contacted by email. To qualify for inclusion, studies were required to meet predetermined criteria regarding study design, study population, interventions evaluated, and outcome measured to improve the homogeneity of the studies included. Thus to be included in the present meta-analysis, studies had to compare the ability of ADOSM1 as the index test and DSMV/IVTR or best estimate diagnosis by clinical consensus as reference standard (using clinical interview, semi-structured interview or interviewing schedules) among young children (2–5 y) either as out-patient or in-patient with ADOSM1 score of ≥7

Indian J Pediatr (December 2014) 81(Suppl 2):S187–S192

for identifying ‘cases’ of ASD and ADOSM1 score of

A meta-analysis of the diagnostic accuracy of Autism Diagnostic Observation Schedule Module-1 for autism spectrum disorders.

Autism Diagnostic Observation Schedule (ADOS) is considered gold standard for the diagnosis of Autism Spectrum Disorders (ASD). The authors evaluated ...
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