A review of: Kleinman, J.M., Ventola, P.E., Pandey, J., Verbalis, A.D., Barton, M., Hodgson, S., Green, J., Dumont-Mathieu, T., Robins, D.L., Fein, D. (2008). Diagnostic Stability in Very Young Children with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders, 38(4), 606-615. DOI: 10.1007/s10803-007-0427-8

In all clinical settings I have worked, there is usually a hesitation to provide a diagnosis of autism to children under 2 years of age, mostly because of the relatively limited amount of research showing stability of such early diagnoses. Instead, we were more likely to provide a PDD-NOS diagnosis (except in the most prototypical cases) and would change the diagnosis to autism within 24 months if the presentation of the disorder remained stable and diagnostic criteria were met. In this study the researchers examined the stability of diagnoses made during late infancy and early childhood. The study included 77 children (66 males) participating in a large multi-site study of early screening of autism. The children were assessed two times. At time 1, the kids were between 16-months and 35-month old (mean 27-months). At the second evaluation, the children were between 3 years-5 months and 6 years-10 months old (mean 4 years-5 months). Diagnoses were provided on the basis of 1) clinical judgment based on DSM-IV criteria, 2) Autism Diagnostic Interview (ADI-R) 3) the Autism Diagnostic Observation Schedule (ADOS) and 4) the Childhood Autism Rating Scale (CARS). At the first evaluation 46 kids were diagnosed with autism, 15 with PDD-NOS, and 16 as non-autistic. Based on clinical judgment diagnoses, 80% of the children with an autism or PDD-NOS diagnosis at time 1 remained in the same diagnostic category at time 2. Based on ADI-R, the stability was 67%. The ADOS stability was more similar to the clinical judgment at 83%. Finally, the CARS the stability dropped to 76%. Three findings are worth noting. First, regardless of diagnostic tool used, diagnoses obtained in early childhood and late infancy appear to be relatively stable with between 70 to 80% of children with a diagnosis of ASDs continuing to have the diagnosis 2 years later. Second, the low stability of the ADI-R in this young population was very surprising given the relatively high popularity of the ADI-R as a diagnostic tool. But more surprising is the equal stability of the ADOS compared to clinical judgment. Why is this surprising? Mostly because of the dramatic difference in cost between a clinical consultation and a full ADOS evaluation. Can the ADOS cost be justified if it is as reliable as a traditional clinical evaluation? It may be, because this data only addresses the issue of stability (reliability), not the validity of the diagnosis, which is highly dependent upon the training of the clinician. Thus, it is possible that the clinical judgment was stable (reached the same diagnosis at both times), but it is possible that while stable, the clinical judgment was invalid (it was wrong at both times). Although this is highly unlikely in this case (but likely in the real world where clinical diagnoses are provided by people with insufficient related training – such as most pediatricians and family physicians), this data only allow us to reach conclusions about the stability of these different diagnostic tools.


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