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Differentiating Autism in a
Chinese Population
Grace Hao, M. D., Ph.D., CCC-SLP
Thomas Layton, Ph.D., CCC-SLP
ASHA
November 17, 2012
Atlanta, Georgia
Dr Hao is a Professor in the Department of
Communication Disorders at North Carolina Central
University. She has both a medical degree from China
and a Ph.D. in speech-language pathology. Dr. Layton
is currently the President/Co-owner of a private Center
in Durham NC. He, Dr. Hao, and Dr. Zou,a
developmental pediatrician in China, are standardizing
a new unpublished diagnostic test in China. We do
not have financial interests in the diagnostic tool, as it
is currently used as part of the current research.
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DSM-IV Criteria for Diagnosis
At least 6 characteristics from the following
3 domains to qualify for diagnosis of autism
1- Social skills
2- Communication
3- Behavior
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Literature Review
LFASD versus HFASD
 Bartak & Rutter (1976) found more language
delay, severe personal relationships and more
disruptive behavior than HFASD
HFASD versus Typically Developing
 Steinhausen & Metzke (2004) more disruptive
behavior
 Tsatsanis (2005) more weakness in cognitive
functions
 Baranek et al. (2005) problems in motor
development
 Tager-Flushberg (2004) problems in complex
language
 Ozonoff et al. (2004) problems in Executive
Function
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Literature Review
One study with Chinese children (Zhang &
Ji, 2005)
 LFASD versus Intellectually Disabled
 LFASD had 25% prenatal birth problems vs
62.5% of ID
 LFASD only 1 child had cerebral palsy vs 31%
had “other developmental disorders”
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Purpose of the study
To compare HFASD children to Typically
Developing children (TD)
To compare Moderate/severe ASD
(LFASD) children to Intellectually
Disabilities (ID)
To measure individual items within seven
behavior Domains
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Subjects
LFASD (n=236; mean age 46.7 m)
HFASD (n = 96; mean age 53.1 m)
Intellectual/Developmental Disabilities (n = 33;
mean age 55.7 m)
Typically Develop. (n = 103; mean age 43.9 m)
ASD groups
Previously diagnosed by developmental
pediatricians using the ADI-R, SRS, and/or
a behavioral protocol.
All subjects spoke Mandarin
Non-ASD groups
Recruited from well-baby-care clinics
throughout China
ID group administered WISC-Chinese,
scores below 70 IQ
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Research Team: Centers Involved
 Guangzhou:
 Third Affiliated Hospital & Guangzhou Center for Children with
ASD
 Shenzhen Hospital for Children and Pregnant
Woman
 Chongqing Children’s Hospital
 Hainan Children’s Hospital
 Harbin Medical University Autism Center
 Shanghai Children’s Hospital
 ShiJia-Zhuang Medical University
 Tianjin Medical University
 Nanjing Medical University
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CADS Domains used for comparisons
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(CADS)
Chinese Autism Diagnostic Scale
 First Autism Diagnostic test designed,
developed, and standardized in China for
Chinese population
 Takes into account the cultural and language
aspects
 Addresses needs and frequently asked
questions found in China
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CADS Seven Domains
Motor/Vocal Imitation
Stereotyped behaviors
Sensory behaviors
Play behaviors
Social Interaction
Receptive Language
Expressive Language
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Motor Area (3 Domains)
Motor/Vocal Imitation Domain (11 items)
Stereotyped Behavior Domain (13 items)
Sensory Domain (10 items)
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Social Area (2 Domains)
Play Domain (10 items)
Social Interaction Domain (21 items)
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Language Area (2 Domains)
Receptive Language Domain (10 items)
Expressive Language Domain (17 items)
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Supplemental Area (2 Domains)
Academic & Educational Domain (15 items)
Executive Function Domain (30 items)
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Executive Functions
 Planning
 Organizing
 Time Management
 Flexibility/Attention
 Affect
 Working Memory
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Individual Item scoring for group
comparisons
 Used group percentages due to unequal sample
sizes
 A difference of 9 percentage points or greater
between groups were required for points given
 A difference at Moderately Impaired level was
given 1 point
 A difference at Severely Impaired level was given 2
points
 Individual items required 2 or 3 total points to be
considered different
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Moderate
Severe
Total Scores
34% (1)
22% (0)
21% (2)
6% (0)
3√
0
30% (1)
3% (0)
69% (2)
0% (0)
3√
0
Squeals
LFASD
ID
Unusual interest toy
LFASD
ID
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LFASD Results
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LFASD Results
LFASD versus Intellectually Disabled
Six Domains were significantly different
The LFASD group performed less well
on all six Domains
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Individual Item contrasts
LFASD versus ID
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Play Behavior items for LFASD
No independent play skills
Tends to play alone
No interest in social play
No interest in others
Shows inappropriate play with children
Has no regular playmates
Has limited attention span
34
Stereotyped Behavior items for
LFASD
Squeals more
Unusual interest in certain part of a toy
Peculiar interests in objects
Has a particular, or unusual way of ordering
toys or things
Excessively rigid
35
Sensory Behavior items for
LFASD
Over reaction to noise
Inappropriate reaction to a pinch
Inappropriate reaction to textures
Eats restricted foods
Inappropriate reaction to visual stimuli
36
Social Interactive Behaviors
LFASD
 Does not look in faces
 Does not smile
 No understanding of
gestures
 Does not hand a toy to
adult
 Does not share food
 No empathy
 Does Not look at objects of
interest with others
 Does not point
 Reacts negatively to
familiar people who
approach him/her
 Does not help others
 Does not recognize social
errors
 Does not understand
playful remark
 Does not understand hints
or indirect remarks
 Gets upset when left at
unfamiliar places
 Does not seek parents or
others for support
37
Receptive Language items for
LFASD
Does not select objects upon command
Does not point to nose, eyes, ears
Does not point to pictures
Inappropriate response to verbal command
Inappropriately nods and responds to
speaker
Does not correctly respond to “wh” questions
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Expressive Language items for
LFASD
Echoes or repeats words
Prosody of speech not normal
Difficulty labeling or naming objects
Gets words out of order
Frequently talks to him/herself
Inappropriate use of pronouns
Inability to initiate or direct discourse
Makes socially inappropriate comments
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HFASD Results
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HFASD Results
HFASD group versus Typically
Developing children
Three Domains were
significantly different
The HFASD group performed
less well on all three Domains
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Individual Item contrasts
HFASD versus TD
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Stereotyped Behavior items for
HFASD
Stares to side
Rocks back/forth
Flaps hands/fingers
Squeals
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Sensory Interactive Behavior items
for HFASD
Over reaction to noise
Eats restricted foods
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Play Behavior items for HFASD
Plays alone
Has inappropriate play behavior with other
children
No turn taking in social play
Does not seek help from others
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Profile of Four Children
CADS profile 4 children
HFASD, LFASD, TD, ID
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Remember:
Higher the score--more severe the problem
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Future Analysis and Contrasts
Comparing three levels of ASD
Mild Functioning
Moderate Functioning
Severe Functioning
Bell Shape Curve For ASD Group
Range Of Scores
MILD GROUP
(Level I)
> 1 StD
Upper 25th
1StD
MODERATE GROUP
(Level II)
Middle 50th
SEVERE GROUP
(Level III)
< 1StD
Lower 25th
(n=66)
(n=67)
20%
21%
93 - 142 range
93 - 143
(n=210)
(n=175)
64%
54%
215 - 141 range
209 - 142
(n=50)
(n=84)
15%
26%
216 - 265 range
208 - 265
Upper number is based on Standard Deviation
*Lower number is the upper 25th percent scores, middle 50th
percent scores, and lower 25th percent scores
*Mild Group = high functioning; Moderate Group = middle
group; Severe Group = lowest functioning
*
Severity Rating of the ASD
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Conclusions
LFASD group demonstrated more difficulty
on six Domains compared to ID group
Domains:
1. Stereotyped Behaviors
2. Sensory
3. Play
4. Social
5. Receptive Language
6. Expressive Language
53
Conclusions
HFASD group demonstrated more difficulty
on three Domains compared to TD group
Domains:
1. Stereotyped Behaviors
2. Sensory
3. Play
54
Conclusions
Also, findings from preliminary data
supported significant differences, across 7
domains, between the HFASD and the
LFASD groups, which is consistent with the
DSM-V proposal for severity groupings of
children with ASD.
References
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autism and pervasive developmental disorders , Volume 2: Assessment, intervention, and policy (3rd
ed.) (New York: Wiley & Sons).
 BARTAK, L., and RUTTER, M., 1976, Differences between mentally retarded and normally intelligent
autistic children, Journal of Autism and Childhood Schizophrenia. 6(2), 109-120.
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Chinese Autism Diagnostic Scale. World Journal of Pediatrics, 2013.
 LAYTON, T., HAO, G., and ZOU, X., in progress. Chinese Autism Diagnostic Scale. (Durham, NC) for
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