Conner Caitlin M, Cramer Ryan D, McGonigle John J
Western Regional Autism Services, Education, Resources, Training (ASERT) Collaborative, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Autism Adulthood. 2019 Mar 1;1(1):60-68. doi: 10.1089/aut.2018.0023. Epub 2019 Mar 11.
Previous research has questioned the validity of diagnostic measures for autism spectrum disorder (ASD) among adults. This study examined the correspondence between several measures and clinician diagnosis.
We conducted a retrospective chart review for 93 adults (18-61 years; 72% male) who received an ASD evaluation at a specialty outpatient clinic. Thirty-one individuals (33%) in the sample were diagnosed with ASD. We compared participant scores on the Autism Spectrum Quotient (AQ), the Ritvo Autism Asperger's Diagnostic Scale-Revised (RAADS-R), and the Autism Diagnostic Observation Schedule (ADOS) to clinician diagnosis of ASD. We calculated sensitivity, specificity, and area under the curve (AUC) for each measure.
Participants diagnosed with ASD scored significantly higher, on average, on the ADOS than those who were not diagnosed with ASD, but not on the RAADS-R or AQ. The AUC was relatively low for each measure: ADOS = 0.69 (95% confidence interval [CI] 0.58-0.81), RAADS-R = 0.58 (95% CI 0.46-0.72), and AQ = 0.40 (95% CI 0.28-0.52). Sensitivity and specificity of all three measures were in the poor to fair range. When dichotomized at the optimal cutoffs for this sample, the ADOS had a sensitivity of 0.65 and a specificity of 0.76; the RAADS-R had a sensitivity of 0.52 and a specificity of 0.73; and the AQ had a sensitivity of 0.45 and a specificity of 0.52.
Results of the study suggest that clinicians should not rely solely on self-report measures or the ADOS when diagnosing adults on the spectrum. Further development of measures is needed, including self-report measures with higher diagnostic validity, that are sensitive across age, gender, and cognitive functioning, and that differentiate autism from psychiatric diagnoses.
Diagnosing adults with autism spectrum disorder (ASD) is difficult. Other research has suggested that the few measures that exist for autistic adults may not be very effective for accurate diagnoses. We wanted to see how closely the results of commonly used ASD assessment tools compared with clinical diagnoses in a real-life outpatient setting. This study looked at adults who went to an adult ASD outpatient clinic for an initial ASD diagnosis over 3 years. Of these 93 adults, one-third were diagnosed as autistic. As part of the evaluation, all participants completed two commonly used autism screening surveys-the Autism Spectrum Quotient (AQ) and the Ritvo Autism Asperger's Diagnostic Scale-Revised (RAADS-R)-and took part in a semistructured diagnostic interview called the Autism Diagnostic Observation Schedule (ADOS). The clinicians also collected additional information and, when possible, spoke to family members before jointly making a diagnosis. The researchers compared how those diagnosed with ASD and those who were not diagnosed with ASD scored on the AQ, the RAADS-R, and the ADOS. Although adults on the spectrum scored higher on average on the ADOS clinical interview than those who did not receive an autism diagnosis, they did not score higher on the AQ and RAADS-R self-report measures. All three of the measures were only moderately effective at showing who would be diagnosed with ASD and who was not. These results confirm and expand on findings from other prior studies. The findings suggest that ASD diagnostic measures should not be used alone or considered the only source of information when making an initial autism diagnosis in adulthood. When studying the accuracy of diagnostic tests, it is best to compare the results of the tests being studied with an "independent gold standard," that is, a test that we know is very good and that is totally separate from the tests being studied. In this case, there is no clear "gold standard," so we had to compare the tests with the next best thing-the clinicians' final decision about whether or not a client has a diagnosis of ASD. It is possible that the clinicians did not make the right diagnosis. Also, the diagnosis was not "independent" of the tests being studied, since the clinicians used the results of the tests to help make the diagnosis. Clinicians only diagnosed about one-third of adults in this study with ASD, whereas previous studies in community clinics have had a higher percentage of adults diagnosed; this factor may have influenced the measures' accuracy. Lastly, clinicians in this study did not assess clients for any other mental health conditions, which may have provided more information about the clients who were not diagnosed with ASD. The findings from this study suggest that none of these measures are very accurate on their own. Thus, we recommend multiple measures (interviews and questionnaires) should be used together when clinicians diagnose ASD in adulthood. Results of this study also suggest that measures for adults with ASD should be tested in real-world community clinics, so that clinicians and researchers see how the measures perform when used for initial diagnosis in adulthood.
先前的研究对成人自闭症谱系障碍（ASD）诊断方法的有效性提出了质疑。本研究考察了几种测评方法与临床医生诊断结果之间的一致性。
我们对93名在专科门诊接受ASD评估的成人（年龄18 - 61岁；72%为男性）进行了回顾性病历审查。样本中有31人（33%）被诊断为ASD。我们将参与者在自闭症谱系商数（AQ）、修订版里特沃自闭症阿斯伯格诊断量表（RAADS - R）和自闭症诊断观察量表（ADOS）上的得分与临床医生对ASD的诊断进行了比较。我们计算了每种测评方法的敏感性、特异性和曲线下面积（AUC）。
被诊断为ASD的参与者在ADOS上的平均得分显著高于未被诊断为ASD的参与者，但在RAADS - R或AQ上并非如此。每种测评方法的AUC相对较低：ADOS = 0.69（95%置信区间[CI] 0.58 - 0.81），RAADS - R = 0.58（95% CI 0.46 - 0.72），AQ = 0.40（95% CI 0.28 - 0.52）。所有三种测评方法的敏感性和特异性都处于较差到中等的范围。在为本样本设定的最佳临界值处进行二分法划分时，ADOS的敏感性为0.65，特异性为0.76；RAADS - R的敏感性为0.52，特异性为0.73；AQ的敏感性为0.45，特异性为0.52。
研究结果表明，临床医生在诊断谱系中的成年人时，不应仅依赖自我报告测评方法或ADOS。需要进一步开发测评方法，包括具有更高诊断效度、对年龄、性别和认知功能敏感且能区分自闭症与精神疾病诊断的自我报告测评方法。
诊断患有自闭症谱系障碍（ASD）的成年人很困难。其他研究表明，现有的针对成年自闭症患者的少数测评方法可能对准确诊断不是很有效。我们想看看在现实生活中的门诊环境中，常用的ASD评估工具的结果与临床诊断的契合程度。本研究观察了在三年时间里前往成人ASD门诊进行初次ASD诊断的成年人。在这93名成年人中，三分之一被诊断为自闭症。作为评估的一部分，所有参与者都完成了两项常用的自闭症筛查调查问卷——自闭症谱系商数（AQ）和修订版里特沃自闭症阿斯伯格诊断量表（RAADS - R）——并参加了一项名为自闭症诊断观察量表（ADOS）的半结构化诊断访谈。临床医生还收集了其他信息，并在可能的情况下与家庭成员交谈，然后共同做出诊断。研究人员比较了被诊断为ASD的人和未被诊断为ASD的人在AQ、RAADS - R和ADOS上的得分。虽然谱系中的成年人在ADOS临床访谈中的平均得分高于未被诊断为自闭症的人，但他们在AQ和RAADS - R自我报告测评中的得分并没有更高。所有这三种测评方法在显示谁会被诊断为ASD以及谁不会被诊断为ASD方面，效果都只是中等。这些结果证实并扩展了其他先前研究的发现。研究结果表明，在进行成年期的初次自闭症诊断时，ASD诊断测评方法不应单独使用或被视为唯一的信息来源。在研究诊断测试的准确性时，最好将所研究测试的结果与“独立金标准”进行比较，也就是说，一种我们知道非常好且与所研究测试完全独立的测试。在这种情况下，没有明确的“金标准”，所以我们不得不将这些测试与次优选择——临床医生关于患者是否被诊断为ASD的最终决定进行比较。临床医生有可能没有做出正确的诊断。此外，该诊断并非与所研究的测试“独立”，因为临床医生使用了测试结果来辅助做出诊断。在本研究中，临床医生仅诊断出约三分之一的成年人患有ASD，而社区诊所先前的研究中被诊断为ASD的成年人比例更高；这个因素可能影响了测评方法的准确性。最后，本研究中的临床医生没有对患者进行任何其他心理健康状况的评估，而这可能会提供更多关于未被诊断为ASD的患者的信息。本研究的结果表明，这些测评方法单独使用时都不是非常准确。因此，我们建议临床医生在诊断成年期的ASD时，应同时使用多种测评方法（访谈和问卷）。本研究的结果还表明，针对成年ASD患者的测评方法应在现实世界的社区诊所中进行测试，以便临床医生和研究人员了解这些测评方法在用于成年期初次诊断时的表现。
