View in EDS HTML Full Text PDF Full Text

Validation of the Autism Spectrum Screening Questionnaire, Mandarin Chinese Version (CH-ASSQ) in Beijing, China

Saved in:
Bibliographic Details
Title: Validation of the Autism Spectrum Screening Questionnaire, Mandarin Chinese Version (CH-ASSQ) in Beijing, China
Language: English
Authors: Guo, Yan-Qing, Tang, Yilang, Rice, Catherine, Lee, Li-Ching, Wang, Yu-Feng, Cubells, Joseph F.
Source: Autism: The International Journal of Research and Practice. Nov 2011 15(6):713-727.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: http://sagepub.com
Peer Reviewed: Y
Page Count: 15
Publication Date: 2011
Document Type: Journal Articles
Reports - Research
Descriptors: Attention Deficit Hyperactivity Disorder, Schizophrenia, Autism, Foreign Countries, Mandarin Chinese, Screening Tests, Pervasive Developmental Disorders, Mental Disorders, Comparative Analysis, Parents, Scores, Urban Schools, Questionnaires, Cutting Scores, Translation
Geographic Terms: China (Beijing)
DOI: 10.1177/1362361310396383
ISSN: 1362-3613
Abstract: Background: This study screened children in Beijing, China, in order to establish the validity of a Mandarin Chinese translation of the ASSQ. Methods: We recruited children diagnosed with autism spectrum disorders (ASDs), attention deficit/hyperactivity disorder (ADHD), childhood-onset schizophrenia (COS) (DSM-IV diagnoses made independently by two senior psychiatrists) and unaffected children attending a public school in Beijing. Their parents were asked to complete the CH-ASSQ. Results: Data from the parents of 94 children with ASD (mean age: 81 plus or minus 47 months), 45 with ADHD (106 plus or minus 27 months), 26 with COS (166 plus or minus 36 months), and 120 unaffected control (72 plus or minus 16 months) were collected. The total scores of ASSQ in children with ASD, ADHD, COS, and unaffected controls were 25.3 plus or minus 9.2, 10.4 plus or minus 7.1, 12.2 plus or minus 10.6, and 5.2 plus or minus 6.6 respectively. Total ASSQ scores of children with ASD were significantly higher than in any other group (all p less than 0.0001). ROC analysis of ASD versus unaffected control subjects showed the area under curve was 0.957, with a cutoff of 12 having the maximum sensitivity (0.957) and specificity (0.825). Conclusions: Our pilot data suggest that CH-ASSQ successfully differentiates clinically diagnosed ASD patients from unaffected controls, as well as from patients with ADHD and COS. The instrument might therefore be useful for screening for ASD in urban Mandarin Chinese-speaking populations. (Contains 1 figure and 3 tables.)
Abstractor: As Provided
Number of References: 48
Entry Date: 2012
Accession Number: EJ953857
Database: ERIC
Full text is not displayed to guests.
FullText Links:
  – Type: pdflink
    Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHj0k_4E0hTGH8RJwT4gCJyBsGNe_WN95AvKlDbXJGqwxwHa1r8txKIVtRyZnRUuiwgBAAAA4TCB3gYJKoZIhvcNAQcGoIHQMIHNAgEAMIHHBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDITnGYZc4h3AKfnnvQIBEICBmYF3AdH5zZ7bP-SvD_-ZktVVPtVNOS5HEyI925UluGTGwkvQKBzJd7GSKILVu3tovm45MCggE3nouTJaH8YCp1AEJjWPSHxLIhXwqcarW9kXzmyzwtgEiY8XTBeV7Jjz2aKqX0SDjT-DeAi4vTw1WDBMy-T21uY2uv9UJTM6xBTByYQtpaEpcpJuU-p0cs-zlfvNC6rSCTDGRQ==
Text:
  Availability: 1
  Value: <anid>AN0070401826;f9d01nov.11;2012Jan19.15:18;v2.2.460</anid> <title id="AN0070401826-1">Validation of the Autism Spectrum Screening Questionnaire, Mandarin Chinese Version (CH-ASSQ) in Beijing, China </title> <p>AUTspautAutismAutism1362-36131461-7005SAGE PublicationsSage UK: London, England10.1177/136236131039638310.1177_1362361310396383ArticlesValidation of the Autism Spectrum Screening Questionnaire, Mandarin Chinese Version (CH-ASSQ) in Beijing, ChinaGuoYan-QingPeking University Health Sciences Center, Institute of Mental Health, Beijing, ChinaTangYilangDepartment of Human Genetics, Emory University School of Medicine, Atlanta, Georgia, USARiceCatherineCenters for Disease Prevention and Control, Atlanta, Georgia, USALeeLi-ChingBloomberg School of Public Health, John Hopkins University, Baltimore, Maryland, USAWangYu-FengPeking University Health Sciences Center, Institute of Mental Health, Beijing, ChinaCubellsJoseph F.Department of Human Genetics, and Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USAjoseph f. cubells, MD, PhD, Emory University School of Medicine, 615 Michael Street, Suite 301, Atlanta, Georgia, USA 30322. email: jcubell@emory.edu112011156713727© 2011 The National Autistic Society, SAGE Publications2011The National Autistic Society, SAGE PublicationsBackground: This study screened children in Beijing, China, in order to establish the validity of a Mandarin Chinese translation of the ASSQ.Methods: We recruited children diagnosed with autism spectrum disorders (ASDs), attention deficit/hyperactivity disorder (ADHD), childhood-onset schizophrenia (COS) (DSM-IV diagnoses made independently by two senior psychiatrists) and unaffected children attending a public school in Beijing. Their parents were asked to complete the CH-ASSQ.Results: Data from the parents of 94 children with ASD (mean age: 81 ± 47 months), 45 with ADHD (106 ± 27 months), 26 with COS (166 ± 36 months), and 120 unaffected control (72 ± 16 months) were collected. The total scores of ASSQ in children with ASD, ADHD, COS, and unaffected controls were 25.3 ± 9.2, 10.4 ± 7.1, 12.2 ± 10.6, and 5.2 ± 6.6 respectively. Total ASSQ scores of children with ASD were significantly higher than in any other group (all p < .0001). ROC analysis of ASD versus unaffected control subjects showed the area under curve was 0.957, with a cutoff of 12 having the maximum sensitivity (0.957) and specificity (0.825).Conclusions: Our pilot data suggest that CH-ASSQ successfully differentiates clinically diagnosed ASD patients from unaffected controls, as well as from patients with ADHD and COS. The instrument might therefore be useful for screening for ASD in urban Mandarin Chinese-speaking populations.autismscreeningASSQvaliditycutoffMandarin ChineseThe autism spectrum disorders (ASDs) are neuro-developmental disorders defined by significant and unusual development in the areas of social interaction, communication, and restricted and repetitive behaviors and interests (American Psychiatric Association. Task Force on DSM-IV, 2000). By definition, symptoms of ASDs must be present before the age of three; and ASDs are typically considered lifelong disorders. ASDs are part of the broader category of pervasive developmental disorders (PDD) and include autistic disorder, Asperger disorder, and pervasive developmental disorder-not otherwise specified (PDD-NOS). Each of the behaviors associated with ASDs may range from mild to severe. Some individuals may have relatively good verbal skills and only a minimal language delay but significantly impaired social skills, while others may be nonverbal or have very little ability or interest in communicating or interacting with others. There is no biologic test used to determine ASD diagnosis. Typically, a diagnosis is made after a thorough clinical evaluation. Such an evaluation might include clinical observations, parent interviews, developmental histories, psychological testing, speech and language assessments, and possibly the use of one or more structured or semi-structured diagnostic instruments such as the Autism Diagnostic Interview-Revised (ADI-R) (Lord et al., 1994) and Autism Diagnostic Observation Schedule (ADOS) (Lord et al., 2000).Accurate identification and diagnosis of ASDs is fundamentally important for clinical and population-based studies to evaluate the applicability and generalizability of the results. Adaptation of standardized and globally accepted instruments for use in China will allow generation of comparable autism research data between Chinese and other races and ethnicities (Matson et al., 2006; Sperber, 2004).Several recent studies have reported a rise in the prevalence of autism worldwide (Baird et al., 2006; Baron-Cohen et al., 2009; Centers for Disease Control and Prevention (CDC), 2009; Honda et al., 2005; M Posserud et al., 2009; Sun and Allison, 2010) including data from China. For example, Liu et al. (2007) reported that the prevalence of all PPDs in children aged two to six years in Beijing, China, was 0.73% and the adjusted prevalence was 1.53% (adjusted for age). Changing diagnostic criteria, heightened awareness of ASDs, as well as a true increase in incidence of ASD due to underlying risk factors (which are still unknown), are among the most commonly hypothesized explanations for this reported increase in ASD prevalence (Coo et al., 2008; Fombonne, 2009; Gillberg and Wing, 1999; Hertz-Picciotto and Delwiche, 2009; Senecky et al., 2009).International studies of ASDs require development of linguistically and culturally appropriate screening and diagnostic instruments. Several screening tools are now available in the Chinese language, including the Clancy Autism Behavior Scale (Ke et al., 2002; Liu, 2008; Liu et al., 2007), the Childhood Autism Rating Scale (Li et al., 2005) and Checklist for Autism in Toddlers (CHAT-23, Wong et al., 2004); however, no ASD screening tools are fully validated for a general population screening for school-age children. The Autism Spectrum Screening Questionnaire (ASSQ) (Ehlers and Gillberg, 1993; Ehlers et al., 1999) is a 27-item checklist originally developed in Sweden by Ehlers et al. The ASSQ was developed to screen school children for Asperger syndrome (Ehlers and Gillberg, 1993), and was later renamed as the Autism Spectrum Screening Questionnaire. This questionnaire has been shown to be both valid and reliable, with good sensitivity and specificity in clinical settings (Ehlers et al., 1999). It has further been shown to have good internal consistency (Cronbach’s alpha = 0.86 for parents) and a stable three-factor structure (social function, autism-associated problems, and third factor specific for high-functioning individuals with autism/Asperger syndrome (Posserud et al., 2008).Given the lack of brief screening instruments in Chinese language for higher-functioning ASDs, we translated the ASSQ from English and conducted a pilot study to examine its utility in a clinically diagnosed Chinese-speaking sample. Our long-term goal is to adopt ASSQ as a screening tool for a population-base epidemiologic study in China.MethodTranslation and back-translation of the questionnaireThe ASSQ was initially translated by two native-speaking experts (Y-LT and Y-QG). As part of the pilot phase, the instrument was further refined through back-translation, making minor changes that four native-speaking experts (Y-LT, L-CL, Y-QG, Y-FW) and two English-speaking experts (CR, JFC) felt would make the translation more culturally appropriate, while also maintaining the clinical meaning of the items. The Chinese version of the ASSQ is available from the corresponding author by request.Research setting and samplesWe recruited children diagnosed with ASD (n = 94), attention deficit/hyperactivity disorder (ADHD) (n = 45), and childhood-onset schizophrenia (COS, Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV diagnosis of schizophrenia with onset before age 18) (n = 26) (DSM-IV diagnoses made independently by two senior psychiatrists) from the Institute of Mental Health, Peking University. Among those diagnosed with ASD, 82 were diagnosed with childhood autism, seven with PDD-NOS, and five with Asperger syndrome. We also recruited children without a known developmental disability attending a public school in Beijing (n = 120) as unaffected controls in this study, and these children underwent a brief mental examination by a child psychiatrist (Y-QG) to exclude major mental disorders in childhood. Parents of participating children were asked to complete the CH-ASSQ. Procedures for informed consent and data collection were approved by the ethics committee of the Sixth Hospital, Peking University Health Sciences Center.Data analysisDescriptive statistics on demographics were calculated and expressed. One way analysis of variance (ANOVA) was used to examine the differences of CH-ASSQ scores and age in the four groups. The significance level was p < .05.A receiver operating characteristics (ROC) analysis (Baldessarini et al., 1983; McFall and Treat, 1999; Murphy et al., 1987) was performed to determine both the concurrent validity of the ASSQ as compared with clinical diagnosis and to find the best cutoff score for ASD. From the ROC graph, the levels of sensitivity and specificity for each possible cutoff score and an index of accuracy of discrimination provided by the scale can be determined. In this study, the goal was to find the CH-ASSQ cutoff score that best predicted which participants received an ASD diagnosis, as compared with unaffected controls.As an alternative method for determining diagnostic cutoff scores for clinical diagnoses, we used a χ2 analysis to determine the best cutoff score. Presence or absence of ASD was assigned according to each possible CH-ASSQ score, and these assignments were compared with those determined by clinical diagnosis in a two-by-two contingency table. While the choice of a cutoff score may be influenced by the specific intent of the scale and/or the characteristics of a given population, if those things are not an issue, the cutoff score with the highest χ2 value may well be the best choice (Gavin et al., 1989; Ross et al., 1990).Several aspects of the ROC analysis can be used to analyze the relationship between a scale and a criterion measure. The one most commonly used is the area under the ROC curve (AUROC curve; (Bradley et al., 1998), which is an overall measure of the relationship between the scale and the clinical diagnosis. A score of 0.5 represents a chance relationship, and 1.0 represents a perfect relationship. Scores lower than 0.5 signify a predictive ability worse than chance.We first analyzed the data for the entire dataset. In addition, to be consistent with the original age group reported by Ehlers et al. (1999), all analyses were repeated for children between 6 and 17 years old.ResultsSample characteristicsTable 1 shows the sample sizes and mean age of the four groups enrolled in this study. Of the subjects in the ASD group 62/94 (65.9%) and 74/124 (59.7%) of the unaffected group were within the age group between 6 and 17 years. All of the ADHD and COS subjects were within this age range. Statistical analysis showed that mean age of the COS group was the oldest (166 ± 36 months), followed by the ADHD group (110 ± 27 months), ASD group (81 ± 47 months) and the unaffected controls were the youngest (72 ± 16 months). The difference between any two groups was statistically significant, with the difference between ASD and the unaffected group being the least significant (p = .03).Table 1Sample sizes and age of the four groups recruited for the present studyGroupAge (months)CH-ASSQ total scoreNMeanSDMinMaxMeanSDMinMaxASD9481.847.22325425.39.2450Unaffected controls12072.016.3511315.26.6032ADHD45110.026.77517610.47.1030COS26166.135.78420112.210.6147Age comparison: Overall p < .0001, age differences between any two groups were statistical significant (p = .03 between ASD and unaffected controls). CH-ASSQ total score comparison: overall p < .0001, p< .0001 for comparison between any two groups, with only one exception for the comparison between ADHD and COS group (p = .375).ASD: autism spectrum disorder, CH-ASSQ, Chinese Autism Spectrum Screening Questionnaire, ADHD: attention deficit/hyperactivity disorder, COS: childhood-onset schizophrenia.Pearson correlations showed no significant correlations between age (in months) and the CH-ASSQ total score of the entire sample (including all clinical cases plus unaffected controls, r = .077, p = .208). Similarly, no significant correlations between age and the CH-ASSQ total score were observed in the unaffected controls (r = –.030, p = .748), ADHD group (r = .066, p = .969), or COS group (r = .295, p = .267). A marginally significant association between the CH-ASSQ total score and age was observed in the overall ASD group (r = .201, p = .055), but no significant correlations were found between age and the CH-ASSQ total score in the ASD group between ages 6 and 17 (r = .022, p = .867).Comparisons of CH-ASSQ total score of the different groupsWe performed pair-wise comparisons for the CH-ASSQ total score in the different groups (see Table 1). Children with ASDs had the highest scores (25.3), followed by COS (12.2) and ADHD (10.4), with the unaffected children having the lowest score (5.2). The overall difference of CH-ASSQ total score among all groups was highly significant (F = 112.8, p < .0001), post-hoc analysis showed that differences between any two groups were significant (p < .001), except for the difference between ADHD and COS (p = .375).Cutoff score of the CH-ASSQ versus clinical diagnosis (DSM-IV)In order to determine the optimal cutoff score for CH-ASSQ in the study sample, ROC analysis was performed with clinical diagnosis as the gold standard. We found that the optimal cutoff score for CH-ASSQ in clinically diagnosed ASD against unaffected controls was 12. We repeated the analysis for subjects between ages six and 17 and the result did not change. Table 2 shows the impact of CH-ASSQ cutoff score on sensitivity and specificity of the instrument. Based on the sum of sensitivity and specificity, as well as maximization of the χ2 value, the optimal cutoff was 12, which yielded a sensitivity of 95.7%, a specificity of 82.5%. This cutoff corresponds with an overall diagnostic accuracy of 88.3%, and positive predictive value of 81.8% and negative predictive value of 96.1%. For subjects between ages six and 17, the ROC performed even better, the cutoff of 12 yielded a sensitivity of 95.7%, and a specificity of 89.2%, which corresponds with an overall diagnostic accuracy of 92.6%, and positive predictive value of 88.2% and negative predictive value of 97.0%.Table 2Impact of CH-ASSQ cutoff score on sensitivity and specificity (ASD versus unaffected controls)Cutoff (≥)Entire sampleSensitivity (%)Specificity (%)Sensitivity + specificityχ2 valueP valuePPVNPVAccuracy (%)598.962.51.6188.9<.000167.498.678.5698.966.71.6596.4<.000169.998.780.8798.870.81.70106.7<.000172.698.883.2898.973.31.72113.3<.000174.498.884.6997.976.01.74116.5<.000176.097.885.51097.977.51.75121.3<.000177.397.986.41196.078.91.75121.5<.000180.095.786.91295.782.51.78129.3<.000181.896.188.31392.585.01.77126.9<.000182.893.588.31488.385.81.74116.3<.000183.090.386.91586.190.01.76124.4<.000187.189.288.31686.189.41.75130.6<.000186.289.488.01781.992.51.74121.4<.000189.586.787.8Overall accuracy: number of (true positives + true negatives)/number of total subjects.Repeated analyses for subjects between age six and 17 showed very similar results, with cutoff being 12.ASD: autism spectrum disorder, CH-ASSQ, Chinese Autism Spectrum Screening Questionnaire, PPV: positive predictive value, NPV: negative predictive value.To see how well the CH-ASSQ performed between ASD and other clinically mixed samples, we also tried to determine the optimal score for CH-ASSQ using the ASD cases against all other groups. The optimal cutoff score was 16, which yielded a sensitivity of 86.2, a specificity of 84.8%. The overall diagnostic accuracy is 85.3% at this cutoff.Similarly, we classified the CH-ASSQ items into three domains, based on the previous study by Hattori et al. (2006), that is, restricted and repetitive behavior (items 2, 3, 9, 10, 18, 20, 21, 22, 23, 24, 27); social interaction (items 1, 12, 14, 15, 16, 17, 19, 25, 26); and communication problem (items 4, 5, 6, 7, 8, 11, 13) and found that the pattern differentiating ASD from ADHD, COS, and unaffected controls was similar to the ASSQ total scores. In order to better provide the most useful and practical information, we also performed ROC analysis and determined the cutoff for each domain in differentiating problems among groups (see Table 3).Table 3Cutoff scores for different sub-scores of CH-ASSQ between ASD and the other groupsComparisonCutoff scoresCommunicationSocial interactionRestrictive and repetitive behaviorASD vs unaffected control453ASD vs ADHD554ASD vs COS545ASD vs all other groups556ASD: autism spectrum disorder, CH-ASSQ, Chinese Autism Spectrum Screening Questionnaire.Differentiability of CH-ASSQ between ASD and other childhood mental disordersIn order to explore if CH-ASSQ could differentiate between ASD and other childhood mental disorders, we also performed ROC analyses using the ASD group against children with clinically diagnosed ADHD and COS. The results are also shown in Figure 1. We also tried to calculate the optimal cutoff between ASD and ADHD and COS and found the optimal cutoff score between ASD and ADHD was 20, and 19 between ASD and COS.Figure 1Receiver operating characteristic (ROC) curves for autism spectrum disorder (ASD) by the CH-ASSQ, Chinese Autism Spectrum Screening Questionnaire. Comparisons were between children with (a) ASD and unaffected controls, (b) ASD and attention deficit/hyperactivity disorder (ADHD), (c) ASD and childhood-onset schizophrenia (COS), and (d) ASD and all other groups combinedDiscussionScreening instruments are important in epidemiologic studies of ASD. Unfortunately, few well-designed community epidemiologic studies of neurodevelopmental disorders in children have been conducted in China. The screening instruments used so far have mostly aimed at strictly defined cases of autistic disorder, and so are likely to miss so-called high-functioning cases such as Asperger syndrome. Though originally developed for high-functioning ASD, the ASSQ has been widely used in European populations as a screening instrument for all types of ASD (Allik et al., 2006; Hepburn et al., 2008; Indredavik et al., 2007; Mattila et al., 2009; Petersen et al., 2006; Posserud et al., 2008; M Posserud et al., 2009; MB Posserud et al., 2009; Webb et al., 2003).Using the Chinese translated ASSQ, CH-ASSQ, a group of clinically diagnosed children with ASD, ADHD and COS, and unaffected school age children from a public school were screened. We determined the cutoff score for CH-ASSQ to be 12 between ASD and unaffected controls, which was chosen to prioritize high specificity and sensitivity, but for screening purposes in a population it is more important to have high sensitivity rather than high specificity. Of note, the cutoff score 12 in our study was lower than the one recommended for further ASD evaluation established in the validation study by (Ehlers et al., 1999) (cutoff 19 when completed by parents). One possible reason for this difference could be due to the different cultural context in Chinese and Swedish.This study also indicates that the CH-ASSQ can differentiate between children with ASD and other common neurodevelopmental disorders in clinically diagnosed samples, specifically, ADHD and COS. As shown in Table 2, though children with other mental disorders had significantly higher total scores on the CH-ASSQ than that in unaffected controls, the mean CH-ASSQ scores of children with ADHD (10.4) and COS (12.2) were less than half of that in ASD group (25.3). Furthermore, we also performed ROC analysis using children with ADHD, COS, and all children without an ASD as ‘non-cases’ and calculated cut-off scores for each scenario, which yielded 19, 20, and 16 points against COS, ADHD, and all non-ASD children, respectively.With respect to the distinction between ASD and ADHD, our findings are consistent with a previous report by Hattori et al. (2006) in Japan. They collected the ASSQ assessments from parents of children with PDD, ADHD and healthy controls and found that, though the ASSQ scores of the PDD group and the ADHD group were significantly higher than the control group, the PDD group scored significantly higher than the ADHD group (21.7 versus 14.8, Mann–Whiney p = .016). They also found that the PDD and the ADHD group showed no significant difference in the domains of communication problem, and restricted and repetitive behavior (Hattori et al., 2006). The distinction between ADHD and ASD, especially PPD-NOS, has long been a topic of interest in the field and is of clinical relevance, because symptoms of ADHD are frequent among individuals with PDD (Goldstein and Schwebach, 2004; Holtmann et al., 2007). Our results showed that, although children with ADHD scored significantly higher than unaffected controls on the CH-ASSQ, they remained substantially lower overall compared with those with ASDs.Although only one score is usually derived from the ASSQ, we classified the CH-ASSQ items into three domains, restricted and repetitive behavior, social interaction, and communication problem, based on the previous study by Hattori et al. (2006). We compared each score among the four groups and found that the pattern was similar to that of the total score, with ASD group being the highest on each category, COS the second highest, ADHD the third, and the unaffected controls being the lowest (data not shown). The cutoffs in each domain for different groups are helpful since some items in the language domain and some items in both social and restricted behavior domains may fail to capture impairments or problems in those domains if the individual was nonverbal or low functioning.Several limitations of the current study need to be acknowledged. First, all the findings regarding the cutoff, overall diagnostic accuracy, PPV, and NPV were based on clinically diagnosed samples and may not be able to generalize to other populations. In particular, the clinical sample of children in ASD is likely to represent more severely affected, as indicated by the preponderance of autistic disorder diagnoses. In a community sample, it is likely that more individuals would be encountered who are on the autism spectrum but fall short of full criteria for autistic disorder (i.e., meet criteria for PDD-NOS). It seems likely that the ASSQ, or any single instrument, would be less efficient at separating such individuals from healthy controls, or possibly, other psychiatrically disordered individuals. Nonetheless, results from the current study may pave the way for a population-based epidemiologic study in the future. Second, many other factors, including the individual’s IQ, adaptive functioning, and other comorbid disorders may be related to the severity of ASD; similarly, parents’ sociodemographic factors may also affect the scores of the ASSQ, unfortunately, such data are not available for the current study. More research on the CH-ASSQ is clearly necessary to address the foregoing issues.The next step of our study will extend CH-ASSQ screening to community samples, using structured or semi-structured approaches (such as the ADI-R (Lord et al., 1997; Lord et al., 1994) and the ADOS (Lord et al., 2000)) to establish ‘gold-standard’ diagnoses. Since this study was based solely on parental report, future studies based on teacher reports are also needed to assess its utility for teachers. Previous reports have shown that agreement between parents and teachers is low to moderate in reports on child psychiatric symptoms (Achenbach et al., 1987; Kumpulainen et al., 1999), which can be interpreted as true differences in behavior between different settings (school versus. home) or informant differences in the understanding and interpretation of behavior and symptoms, or both.The separation of autism from childhood-onset psychoses, particularly schizophrenia, was an important advance for the study of childhood psychopathology (Rapoport et al., 2009). Actually, it was not until DSM-III that autism/pervasive developmental disorder (PDD) was classified as a separate category from early-onset schizophrenia (American Psychiatric Association, 1980). However, numerous systematic studies of COS have also shown high comorbidity between COS and PDD. For example, many studies found early-onset schizophrenia with findings of developmental abnormalities primarily for communication, motor abnormalities, and/or social relatedness (Alaghband-Rad et al., 1995; Watkins et al., 1988). Additionally, an early report from the University of California at Los Angeles (UCLA) COS study found that 39% of a sample of 33 patients had symptoms of autism years before onset of schizophrenia (Watkins et al., 1988). Despite these overlaps, the CH-ASSQ appeared to distinguish the diagnoses efficiently, at least in this set of clinically identified samples.One cannot establish a diagnosis based on a score on a screening instrument alone. For diagnostic assessment a full parental interview regarding current and past development and behavior, and structured observation of the child, preferably including a peer-group setting, are essential. One study (Corsello et al., 2007) has found that addition of information from the ADOS-G to information from the Social Communication Questionnaire (SCQ) significantly improved specificity to detect ASD. We would also recommend the same approach when using the CH-ASSQ for ASD screening and assessment.It should also be acknowledged that China is a large country with several major dialect regions and where a significant proportion of people (~7%) are illiterate. Our prior experiences indicated that dialect differences and illiteracy could lead to misunderstanding and confusion (L-CL, unpublished data), especially when the questionnaire is read to the parents. This will be an issue that needs to be addressed in future studies involving culturally or linguistically distinct subgroups, or persons with lower or no literacy.In conclusion, in the present study, the CH-ASSQ appeared to be an effective tool for differentiating between clinically ascertained children with ASD and unaffected controls, as well as children with ADHD and COS. Our findings suggest, based on maximized value of sensitivity, the cutoff should be ≥12 points for parents of clinically diagnosed patients.We are grateful to the children and families who participated voluntarily in the study and to the clinical teams in the Institute of Mental Health, Peking University Health Sciences Center, whose collaboration made the study possible. This study was supported by Institute of Mental Health, Peking University Health Sciences Center (subject assessment), and Emory University Global Health Institute (instrument translation and data analysis). Catherine Rice provided consultation on the instrument translation and the findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.ReferencesAchenbachTMMcConaughySHHowellCT (1987) Child/adolescent behavioral and emotional problems: implications of cross-informant correlations for situational specificity. Psychological Bulletin101(<reflink idref="bib2" id="ref1">2</reflink>): 213–32.Alaghband-RadJMcKennaKGordonCTAlbusKEHamburgerSDRumseyJM. (1995) Childhood-onset schizophrenia: the severity of premorbid course. Journal of the American Academy of Child and Adolescent Psychiatry34(<reflink idref="bib10" id="ref2">10</reflink>): 1273–83.AllikHLarssonJOSmedjeH (2006) Health-related quality of life in parents of school-age children with Asperger syndrome or high-functioning autism. Health and Quality of Life Outcomes4: 1.American Psychiatric Association, Task Force on Nomenclature and Statistics. (1980) Quick Reference to the Diagnostic Criteria From DSM-III. Washington, DC: American Psychiatric Association.American Psychiatric Association. Task Force on DSM-IV. (2000) Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th edn.Washington, DC: American Psychiatric Association.BairdGSimonoffEPicklesAChandlerSLoucasTMeldrumD. (2006) Prevalence of disorders of the autism spectrum in a population cohort of children in South Thames: the Special Needs and Autism Project (SNAP). Lancet368(9531): 210–15.BaldessariniRJFinklesteinSAranaGW (1983) The predictive power of diagnostic tests and the effect of prevalence of illness. Archives of General Psychiatry40(<reflink idref="bib5" id="ref3">5</reflink>): 569–73.Baron-CohenSScottFJAllisonCWilliamsJBoltonPMatthewsFE. (2009) Prevalence of autism-spectrum conditions: UK school-based population study. British Journal of Psychiatry194(<reflink idref="bib6" id="ref4">6</reflink>): 500–9.BradleyKABoyd-WickizerJPowellSHBurmanML (1998) Alcohol screening questionnaires in women: a critical review. Journal of the American Medical Association280(<reflink idref="bib2" id="ref5">2</reflink>): 166–71.Centers for Disease Control and Prevention (CDC) (2009) Prevalence of autism spectrum disorders – autism and developmental disabilities monitoring network, United States, 2006. MMWR Surveillance Summaries58(<reflink idref="bib10" id="ref6">10</reflink>): 1–20.CooHOuellette-KuntzHLloydJEKasmaraLHoldenJJLewisME (2008) Trends in autism prevalence: diagnostic substitution revisited. Journal of Autism and Developmental Disorders38(<reflink idref="bib6" id="ref7">6</reflink>): 1036–46.CorselloCHusVPicklesARisiSCookEHJrLeventhalBL. (2007) Between a ROC and a hard place: decision making and making decisions about using the SCQ. Journal of Child Psychology and Psychiatry48(<reflink idref="bib9" id="ref8">9</reflink>): 932–40.EhlersSGillbergC (1993) The epidemiology of Asperger syndrome. A total population study. Journal of Child Psychology and Psychiatry34(<reflink idref="bib8" id="ref9">8</reflink>): 1327–50.EhlersSGillbergCWingL (1999) A screening questionnaire for Asperger syndrome and other high-functioning autism spectrum disorders in school age children. Journal of Autism and Developmental Disorders29(<reflink idref="bib2" id="ref10">2</reflink>): 129–41.FombonneE (2009) Epidemiology of pervasive developmental disorders. Pediatric Research65(<reflink idref="bib6" id="ref11">6</reflink>): 591–8.GavinDRRossHESkinnerHA (1989) Diagnostic validity of the drug abuse screening test in the assessment of DSM-III drug disorders. British Journal of Addiction84(<reflink idref="bib3" id="ref12">3</reflink>): 301–7.GillbergCWingL (1999) Autism: not an extremely rare disorder. Acta Psychiatrica Scandinavica99(<reflink idref="bib6" id="ref13">6</reflink>): 399–406.GoldsteinSSchwebachAJ (2004) The comorbidity of pervasive developmental disorder and attention deficit hyperactivity disorder: results of a retrospective chart review. Journal of Autism and Developmental Disorders34(<reflink idref="bib3" id="ref14">3</reflink>): 329–39.HattoriJOginoTAbiruKNakanoKOkaMOhtsukaY (2006) Are pervasive developmental disorders and attention-deficit/hyperactivity disorder distinct disorders?Brain and Development28(<reflink idref="bib6" id="ref15">6</reflink>): 371–4.HepburnSLDiGuiseppiCRosenbergSKaparichKRobinsonCMillerL (2008) Use of a teacher nomination strategy to screen for autism spectrum disorders in general education classrooms: a pilot study. Journal of Autism and Developmental Disorders38(<reflink idref="bib2" id="ref16">2</reflink>): 373–82.Hertz-PicciottoIDelwicheL (2009) The rise in autism and the role of age at diagnosis. Epidemiology20(<reflink idref="bib1" id="ref17">1</reflink>): 84–90.HoltmannMBolteSPoustkaF (2007) Attention deficit hyperactivity disorder symptoms in pervasive developmental disorders: association with autistic behavior domains and coexisting psychopathology. Psychopathology40(<reflink idref="bib3" id="ref18">3</reflink>): 172–7.HondaHShimizuYImaiMNittoY (2005) Cumulative incidence of childhood autism: a total population study of better accuracy and precision. Developmental Medicine and Child Neurology47(<reflink idref="bib1" id="ref19">1</reflink>): 10–18.IndredavikMSBrubakkAMRomundstadPVikT (2007) Prenatal smoking exposure and psychiatric symptoms in adolescence. Acta Paediatrica96(<reflink idref="bib3" id="ref20">3</reflink>): 377–82.KeXYLuoSJTaoGT (2002) A study of clancy behavior scale on childhood autism (article in Chinese). Acta Academiae Medicinae Jiangxi42(<reflink idref="bib6" id="ref21">6</reflink>): 136–8.KumpulainenKRasanenEHenttonenIMoilanenIPihaJPuuraK. (1999) Children’s behavioural/emotional problems: a comparison of parents’ and teachers’ reports for elementary school-aged children. European Child and Adolescent Psychiatry8(Suppl 4): 41–7.LiJHZhongJMCaiLYChenYZhouMZ (2005) Comparison of clinical application of three autism rating scales (article in Chinese). Chinese Journal of Contemporary Pediatrics7(<reflink idref="bib1" id="ref22">1</reflink>): 67–70.LiuJ (2008) Diagnosis and assessments of autism (article in Chinese). Chinese Journal of Practical Pediatrics22(<reflink idref="bib3" id="ref23">3</reflink>): 167–70.LiuJYangXLJiaMXQuCYShiJLLiuG. (2007) Survey on pervasive developmental disorder in 2–6 year-old children in Beijing (article in Chinese). Chinese Mental Health Journal21(<reflink idref="bib5" id="ref24">5</reflink>): 290–3.LordCPicklesAMcLennanJRutterMBregmanJFolsteinS. (1997) Diagnosing autism: analyses of data from the Autism Diagnostic Interview. Journal of Autism and Developmental Disorders27(<reflink idref="bib5" id="ref25">5</reflink>): 501–17.LordCRisiSLambrechtLCookEHJrLeventhalBLDiLavorePC. (2000) The autism diagnostic observation schedule-generic: a standard measure of social and communication deficits associated with the spectrum of autism. Journal of Autism and Developmental Disorders30(<reflink idref="bib3" id="ref26">3</reflink>): 205–23.LordCRutterMLe CouteurA (1994) Autism diagnostic interview-revised: a revised version of a diagnostic interview for caregivers of individuals with possible pervasive developmental disorders. Journal of Autism and Developmental Disorders24(<reflink idref="bib5" id="ref27">5</reflink>): 659–85.MatsonJLNebel-SchwalmMMatsonML (2006) A review of methodological issues in the differential diagnosis of autism spectrum disorders in children. Research in Autism Spectrum Disorders1(<reflink idref="bib1" id="ref28">1</reflink>): 38–54.MattilaMLJussilaKKuusikkoSKielinenMLinnaSLEbelingH. (2009) When-does the Autism Spectrum Screening Questionnaire (ASSQ) predict autism spectrum disorders in primary school-aged children?European Child and Adolescent Psychiatry18(<reflink idref="bib8" id="ref29">8</reflink>): 499–509.McFallRMTreatTA (1999) Quantifying the information value of clinical assessments with signal detection theory. Annual Review of Psychology50: 215–41.MurphyJMBerwickDMWeinsteinMCBorusJFBudmanSHKlermanGL (1987) Performance of screening and diagnostic tests. Application of receiver operating characteristic analysis. Archives of General Psychiatry44(<reflink idref="bib6" id="ref30">6</reflink>): 550–5.PetersenDJBilenbergNHoerderKGillbergC (2006) The population prevalence of child psychiatric disorders in Danish 8- to 9-year-old children. European Child and Adolescent Psychiatry15(<reflink idref="bib2" id="ref31">2</reflink>): 71–8.PosserudBLundervoldAJSteijnenMCVerhoevenSStormarkKMGillbergC (2008) Factor analysis of the Autism Spectrum Screening Questionnaire. Autism12(<reflink idref="bib1" id="ref32">1</reflink>): 99–112.PosserudMLundervoldAJLieSAGillbergC (2009) The prevalence of autism spectrum disorders: impact of diagnostic instrument and non-response bias. Social Psychiatry and Psychiatric Epidemiology45: 319–27.PosserudMBLundervoldAJGillbergC (2009) Validation of the autism spectrum screening questionnaire in a total population sample. Journal of Autism and Developmental Disorders39(<reflink idref="bib1" id="ref33">1</reflink>): 126–34.RapoportJChavezAGreensteinDAddingtonAGogtayN (2009) Autism spectrum disorders and childhood-onset schizophrenia: clinical and biological contributions to a relation revisited. Journal of the American Academy of Child and Adolescent Psychiatry48(<reflink idref="bib1" id="ref34">1</reflink>): 10–18.RossHEGavinDRSkinnerHA (1990) Diagnostic validity of the MAST and the alcohol dependence scale in the assessment of DSM-III alcohol disorders. Journal of Studies on Alcohol51(<reflink idref="bib6" id="ref35">6</reflink>): 506–13.SeneckyYChodickGDiamondGLobelDDrachmanRInbarD (2009) Time trends in reported autistic spectrum disorders in Israel, 1972–2004. Israel Medical Association Journal11(<reflink idref="bib1" id="ref36">1</reflink>): 30–3.SperberAD (2004) Translation and validation of study instruments for cross-cultural research. Gastroenterology126(1 Suppl 1): S124–8.SunXAllisonC (2010) A review of the prevalence of autism spectrum disorder in Asia. Research in Autism Spectrum Disorders4: 156–67.WatkinsJMAsarnowRFTanguayPE (1988) Symptom development in childhood onset schizophrenia. Journal of Child Psychology and Psychiatry29(<reflink idref="bib6" id="ref37">6</reflink>): 865–78.WebbEMoreyJThompsenWButlerCBarberMFraserWI (2003) Prevalence of autistic spectrum disorder in children attending mainstream schools in a Welsh education authority. Developmental Medicine and Child Neurology45(<reflink idref="bib6" id="ref38">6</reflink>): 377–84.WongVHuiLHLeeWCLeungLSHoPKLauWL. (2004) A modified screening tool for autism (Checklist for Autism in Toddlers [CHAT-23]) for Chinese children. Pediatrics114(<reflink idref="bib2" id="ref39">2</reflink>): e166–76.</p> <aug> <p>By Yan-Qing Guo; Yilang Tang; Catherine Rice; Li-Ching Lee; Yu-Feng Wang and Joseph F. Cubells</p> </aug> <nolink nlid="nl1" bibid="bib2" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib10" firstref="ref2"></nolink> <nolink nlid="nl3" bibid="bib5" firstref="ref3"></nolink> <nolink nlid="nl4" bibid="bib6" firstref="ref4"></nolink> <nolink nlid="nl5" bibid="bib9" firstref="ref8"></nolink> <nolink nlid="nl6" bibid="bib8" firstref="ref9"></nolink> <nolink nlid="nl7" bibid="bib3" firstref="ref12"></nolink> <nolink nlid="nl8" bibid="bib1" firstref="ref17"></nolink>
Header DbId: eric
DbLabel: ERIC
An: EJ953857
AccessLevel: 3
PubType: Academic Journal
PubTypeId: academicJournal
PreciseRelevancyScore: 0
IllustrationInfo
Items – Name: Title
  Label: Title
  Group: Ti
  Data: Validation of the Autism Spectrum Screening Questionnaire, Mandarin Chinese Version (CH-ASSQ) in Beijing, China
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Guo%2C+Yan-Qing%22">Guo, Yan-Qing</searchLink><br /><searchLink fieldCode="AR" term="%22Tang%2C+Yilang%22">Tang, Yilang</searchLink><br /><searchLink fieldCode="AR" term="%22Rice%2C+Catherine%22">Rice, Catherine</searchLink><br /><searchLink fieldCode="AR" term="%22Lee%2C+Li-Ching%22">Lee, Li-Ching</searchLink><br /><searchLink fieldCode="AR" term="%22Wang%2C+Yu-Feng%22">Wang, Yu-Feng</searchLink><br /><searchLink fieldCode="AR" term="%22Cubells%2C+Joseph+F%2E%22">Cubells, Joseph F.</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Autism%3A+The+International+Journal+of+Research+and+Practice%22"><i>Autism: The International Journal of Research and Practice</i></searchLink>. Nov 2011 15(6):713-727.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: http://sagepub.com
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 15
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2011
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Attention+Deficit+Hyperactivity+Disorder%22">Attention Deficit Hyperactivity Disorder</searchLink><br /><searchLink fieldCode="DE" term="%22Schizophrenia%22">Schizophrenia</searchLink><br /><searchLink fieldCode="DE" term="%22Autism%22">Autism</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Mandarin+Chinese%22">Mandarin Chinese</searchLink><br /><searchLink fieldCode="DE" term="%22Screening+Tests%22">Screening Tests</searchLink><br /><searchLink fieldCode="DE" term="%22Pervasive+Developmental+Disorders%22">Pervasive Developmental Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Disorders%22">Mental Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Comparative+Analysis%22">Comparative Analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Parents%22">Parents</searchLink><br /><searchLink fieldCode="DE" term="%22Scores%22">Scores</searchLink><br /><searchLink fieldCode="DE" term="%22Urban+Schools%22">Urban Schools</searchLink><br /><searchLink fieldCode="DE" term="%22Questionnaires%22">Questionnaires</searchLink><br /><searchLink fieldCode="DE" term="%22Cutting+Scores%22">Cutting Scores</searchLink><br /><searchLink fieldCode="DE" term="%22Translation%22">Translation</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22China+%28Beijing%29%22">China (Beijing)</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1177/1362361310396383
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1362-3613
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: This study screened children in Beijing, China, in order to establish the validity of a Mandarin Chinese translation of the ASSQ. Methods: We recruited children diagnosed with autism spectrum disorders (ASDs), attention deficit/hyperactivity disorder (ADHD), childhood-onset schizophrenia (COS) (DSM-IV diagnoses made independently by two senior psychiatrists) and unaffected children attending a public school in Beijing. Their parents were asked to complete the CH-ASSQ. Results: Data from the parents of 94 children with ASD (mean age: 81 plus or minus 47 months), 45 with ADHD (106 plus or minus 27 months), 26 with COS (166 plus or minus 36 months), and 120 unaffected control (72 plus or minus 16 months) were collected. The total scores of ASSQ in children with ASD, ADHD, COS, and unaffected controls were 25.3 plus or minus 9.2, 10.4 plus or minus 7.1, 12.2 plus or minus 10.6, and 5.2 plus or minus 6.6 respectively. Total ASSQ scores of children with ASD were significantly higher than in any other group (all p less than 0.0001). ROC analysis of ASD versus unaffected control subjects showed the area under curve was 0.957, with a cutoff of 12 having the maximum sensitivity (0.957) and specificity (0.825). Conclusions: Our pilot data suggest that CH-ASSQ successfully differentiates clinically diagnosed ASD patients from unaffected controls, as well as from patients with ADHD and COS. The instrument might therefore be useful for screening for ASD in urban Mandarin Chinese-speaking populations. (Contains 1 figure and 3 tables.)
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: Ref
  Label: Number of References
  Group: RefInfo
  Data: 48
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2012
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ953857
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ953857
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1177/1362361310396383
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 15
        StartPage: 713
    Subjects:
      – SubjectFull: Attention Deficit Hyperactivity Disorder
        Type: general
      – SubjectFull: Schizophrenia
        Type: general
      – SubjectFull: Autism
        Type: general
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Mandarin Chinese
        Type: general
      – SubjectFull: Screening Tests
        Type: general
      – SubjectFull: Pervasive Developmental Disorders
        Type: general
      – SubjectFull: Mental Disorders
        Type: general
      – SubjectFull: Comparative Analysis
        Type: general
      – SubjectFull: Parents
        Type: general
      – SubjectFull: Scores
        Type: general
      – SubjectFull: Urban Schools
        Type: general
      – SubjectFull: Questionnaires
        Type: general
      – SubjectFull: Cutting Scores
        Type: general
      – SubjectFull: Translation
        Type: general
      – SubjectFull: China (Beijing)
        Type: general
    Titles:
      – TitleFull: Validation of the Autism Spectrum Screening Questionnaire, Mandarin Chinese Version (CH-ASSQ) in Beijing, China
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Guo, Yan-Qing
      – PersonEntity:
          Name:
            NameFull: Tang, Yilang
      – PersonEntity:
          Name:
            NameFull: Rice, Catherine
      – PersonEntity:
          Name:
            NameFull: Lee, Li-Ching
      – PersonEntity:
          Name:
            NameFull: Wang, Yu-Feng
      – PersonEntity:
          Name:
            NameFull: Cubells, Joseph F.
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 11
              Type: published
              Y: 2011
          Identifiers:
            – Type: issn-print
              Value: 1362-3613
          Numbering:
            – Type: volume
              Value: 15
            – Type: issue
              Value: 6
          Titles:
            – TitleFull: Autism: The International Journal of Research and Practice
              Type: main
ResultId 1