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09/28/2020 Conflicts of Interest None Parent-Reported Emotional and Behavioral Problems in ASD: Implications for Research and Clinic Thompson Center Annual Conference September 24 th , 2020 Integrating Clinic and Research Integrating

  1. 09/28/2020 Conflicts of Interest • None Parent-Reported Emotional and Behavioral Problems in ASD: Implications for Research and Clinic Thompson Center Annual Conference September 24 th , 2020 Integrating Clinic and Research Integrating Clinic and Research Stephen M. Kanne, PhD, ABPP 1 2 What we are going to cover: • The Research o What are Emotional Behavioral Problems (EBPs) in autism Where this s o What others have shown o Extending it to MCHAT-R/F • The Clinic happene ened o How we used this for clinic o Impact Integrating Clinic and Research Integrating Clinic and Research 3 4 The Thompson Center • Clinical o 16,000+ visits o 800 ASD evals o Numerous clinics to facilitate triage The Research ch • Research o Research core o 5,000+ research grade assessments in database • Research/Clinic o Always seems to be a Research/clinic tension o Attempt to blend o Each supports the other o Database is key (REDCap) Integrating Clinic and Research Integrating Clinic and Research 5 6 1

  2. 09/28/2020 Autism Spectrum Disorder Diagnostic Features: Emotional Social Restricted/Repetitive Communication & Behaviors Interaction Behavioral Autism Problem s & A Autism ism Spectrum Disorder Integrating Clinic and Research Integrating Clinic and Research 7 8 Emotional Behavioral Problems (EBPs) in Emotional Behavioral Problems in ASD ASD • • More than just ASD symptoms Can lead to additional diagnoses: ADHD, DBD (e.g., ODD/CD), or Anxiety o Co-occurring disorders as high as 85% (Levy, 2010) o ASD and ADHD (14-78%) (Jang et al., 2013) o Creates overlapping symptoms o ASD and DBD (25% kids with ASD) (Kaat et al., 2013) • EBPs include: o ASD and Anxiety (11-84%) (White et al., 2009) o Deficits in attention and hyperactive behaviors o Meta-analysis 40 % of ASD had at least 1 anxiety related disorder o Aggression (van Steensel et al., 2011) o Overt fearfulness o Worrying Integrating Clinic and Research Integrating Clinic and Research 9 10 Assessing risk for ASD A Quick Reminder Autism Not Autism • Questionnaires/Screeners Test Positive True Positive False Positive Positive o Population-based Predictive Value o Targeted Test Negative False Negative True Negative Negative Predictive Value o Psychometrics: e.g., Sensitivity; Specificity; PPV; NPV • Sensitivity Specificity Examples o Child Behavior Checklist (CBCL) How often a test correctly generates a o Social Responsiveness Scale, 2 nd Edition (SRS-2) positive result for people who have Sensitivity = TP/(TP+FN) the condition that’s being tested for Specificity = TN/(TN+FP) o Social Communication Questionnaire (SCQ) PPV = TP/(TP+FP) If I test positive for a disease, what o Modified Checklist for Autism in Toddlers- Revised with Follow-Up are the chances that I actually have NPV= TN/(FN+TN) the condition that I was tested for? (MCHAT-R/F) Integrating Clinic and Research Integrating Clinic and Research 11 12 2

  3. 09/28/2020 Effects of EBPs on measuring ASD Effects of EBPs on measuring ASD symptoms symptoms • Behavior problems reduced specificity in 3 questionnaires • Clinically significant CBCL subscales substantially reduced the SRS o EBPs measured by Strengths and Difficulties Questionnaire and SCQ specificity o SCQ, SRS, & CCC o EBPs measured by CBCL (Charman et al., 2007) o SRS and SCQ • High reported EBPs increase parent report of social-reciprocal abilities (Moody, et al., 2017) o EBPs measured by CBCL o SRS (Hus et al., 2013) Integrating Clinic and Research Integrating Clinic and Research 13 14 Effects of EBPs on measuring ASD symptoms • ADOS and ADI-R: o With high CBCLs, increased likelihood of false positives on ASD EBPs & M MCHAT- measures o lowered specificity on all 3 measures ─ SRS, ADOS, ADI-R R/F ─ ADOS-2 • 2 or more E codes • 27% reduction in specificity (Havdahl et al., 2016) Integrating Clinic and Research Integrating Clinic and Research 15 16 Purpose of Study MCHAT-R/F • • Replicate prior findings on impact of EBPs Population screener • Examine EBPs in a clinically-referred population of 1.5 - 5 year olds • o EBPs assessed by parent-report CBCL Recommended by APA • Assess the effects of EBPs on MCHAT-R/F • • Assess whether combining CBCL and MCHAT-R/F findings can help Many use it in tertiary clinics o Psychometrics will change o Used for ASD symptom indexing Integrating Clinic and Research Integrating Clinic and Research 17 18 3

  4. 09/28/2020 Methods: Population/Procedure Methods: Measures • Clinically referred sample – seeking ASD evaluation • 1.5 - 5 year olds • EBPs: CBCL • 3 sites • Clinicians (doctoral level- MD, DO, PsyD, PhD) • ASD symptom indexing: MCHAT-R/F – Full developmental history and clinical interview • ASD Non-ASD ASD Symptoms: ADOS-2 (Research reliable) N 339 139 • IQ: DAS-II or Mullen Mean Age (in months) (Range) 41.6 (18 – 73) 45.1 (19 -73) Gender (male%) 79.4% 74.1% ADOS-2 CS (Range) 7.7 (4 – 10) 4.6 (1 – 10) Integrating Clinic and Research Integrating Clinic and Research 19 20 Methods: Sample Do children with ASD have higher parent- reported EBPs? Total (478) ASD Non-ASD Test N Mean (SD) Range N Mean (SD) Range MCHAT-R/F 203 7.2 (4.7)* 0-17 71 4.8 (4.2) 0-17 Mullen/DAS 204 62.4 (16.9)* 49-121 71 76.2 (17.8) 49-125 CBCL 203 71 Internalizing 62.8 (11.2) 29-86 64.4 (10.7) 41-86 169 45 (80 Ext+) Externalizing 62.3 (13.1)* 35-97 68.3 (14.1) 35-97 (32 Ext+) ASD (339) Total 64.9 (12.7) 32-90 68.6 (12.8) 40-94 MCHAT-R/F+ (214) • Those with ASD are lower in each case! • Externalizing are significantly different between ASD and Non-ASD MCHAT-R/F (290) (controlled for age) Integrating Clinic and Research Integrating Clinic and Research 21 22 How good is the MCHAT-R/F in a referred What predicts MCHAT-R/F results? population? Regression • EBPs and Age were entered • Simulate only what we know prior to visit (not IQ) • Results: • Age • CBCL Ext Intended age range Extended age range AUC: .706 AUC: .613 Integrating Clinic and Research Integrating Clinic and Research 23 24 4

  5. 09/28/2020 What predicts MCHAT-R/F results? A Quick Reminder (again) Autism Not Autism Test Positive True Positive False Positive Positive Regression results: Predictive Value • Age • Test Negative False Negative True Negative Negative CBCL Ext. T-scores Predictive Value Sensitivity Specificity How often a test correctly generates a positive result for people who have Sensitivity = TP/(TP+FN) the condition that’s being tested for Specificity = TN/(TN+FP) PPV = TP/(TP+FP) If I test positive for a disease, what are the chances that I actually have NPV= TN/(FN+TN) the condition that I was tested for? Integrating Clinic and Research Integrating Clinic and Research 25 26 How do Ext. EBPs affect MCHAT-R/F? How do Ext. EBPs affect MCHAT-R/F? MCHAT-R/F 0.9 0.88 0.8 0.78 0.71 0.7 0.6 0.5 0.44 0.4 0.33 0.27 0.3 0.2 0.1 0 MCHAT TOTAL WITHOUT EBP EXT WITH EBP EXT Sensitivity Specificity Integrating Clinic and Research Integrating Clinic and Research 27 28 Positive Predictive Value Conclusions Combining MCHAT-R/F and CBCL Externalizing • 0.9 In this referred for ASD sample: 0.86 o Children with ASD have lower Externalizing EBPs compared to 0.85 non-ASD 0.8 0.78 0.75 o If Externalizing EBPs are significant, then the likelihood of a False 0.71 Positive on MCHAT-R/F is increased 0.7 0.65 o If Externalizing EBPs are not significant and the MCHAT-R/F is 0.6 positive, the PPV increases MCHAT MCHAT WITH EBP EXT MCHAT W/O EBP EXT PPV Integrating Clinic and Research Integrating Clinic and Research 29 30 5

  6. 09/28/2020 Clinic implications • These results made us think about our clinic triage Clin inic ic Triage ge • CASE clinic • How this research helped Integrating Clinic and Research Integrating Clinic and Research 31 32 Classic Autism Symptom Evaluation (CASE) CASE • • Purpose: Problem: o Chart review to determine high risk o Needed Chart Review o E.g., minimally verbal, minimal gestures, and/or pathognomonic ─ $$ and FTE symptoms o Trouble articulating what we quantified for acceptance to clinic o Patient can be referred to CASE in the interest of efficiency and o Began taking too long quickest route to care o The CASE clinic specializes in “high risk” diagnoses and thus does • Answer not involve more comprehensive testing needed for complex o Apply study findings using REDCap diagnostic differentiation o Physician led Integrating Clinic and Research Integrating Clinic and Research 33 34 CASE CASE Measure • Used regression with The behavioral response formula is: TP 212 • Algorithm developed on 1260 elements from parent- TN 369 patients report history form + OCD FP 47 • Aiming for high PPV and high o What predicted + Sensory FN 632 Specificity diagnosis Sens 0.25 - Aggression o Specificity depends on o Key: included Spec 0.89 - Depression base rates PPV 0.82 elements of EBP NPV 0.37 - Unusual/excessive fears • For the screener, MCHAT- Total 1260 R/F >= 3; SCQ >= 15 Accuracy 46.1% Integrating Clinic and Research Integrating Clinic and Research 35 36 6

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