Behavioral observation through examiner-child structured interactive play, particularly metrics related to eye contact, effectively differentiates toddlers with iASD.
Abstract
Background
Early identification of autism spectrum disorder (ASD) is crucial for improving outcomes, yet diagnosis is often delayed. Primary care faces challenges, including the limited accuracy of existing tools and scarce access to specialist assessments. This prospective cohort study evaluated the feasibility of a novel, structured examiner-child interactive play protocol as an early behavioral screening tool for ASD.
Methods
We recruited 260 toddlers aged 18-36 months. At baseline, all children participated in a structured interactive play session. Their behaviors (e.g., eye contact, turn-taking, social smiling, symbolic play) were coded from video recordings to quantify nine core indicators. After a 6-month follow-up, 217 children completed comprehensive clinical assessments. Core symptoms were evaluated using the Childhood Autism Rating Scale (CARS), and developmental level was assessed using the Bayley Scales of Infant and Toddler Development-Fourth Edition (Bayley-4). Based on clinical assessment results, participants were classified into an ASD group (n = 45) and a typically developing (TD) group (n = 165) for primary analysis. Spearman correlation analysis was used to examine the relationships between behavioral indicators, developmental levels, and symptom severity. Receiver operating characteristic (ROC) curve analysis assessed each indicator's discriminative validity for ASD.
Results
During the structured interactive play, the ASD group performed significantly worse on all behavioral indicators than the TD group. Correlation analysis revealed that several behavioral indicators, including eye contact, turn-taking, and symbolic play, showed positive correlations with cognitive (rs = 0.30-0.51) and language ability (rs = 0.34-0.43) and negative correlations with symptom severity (rs=-0.53--0.36). ROC analysis identified that eye-contact metrics were the strongest discriminators. Specifically, eye contact frequency yielded an AUC of 0.915 (sensitivity 96.36%, specificity 73.33%), and total eye contact duration achieved an AUC of 0.899 (sensitivity 86.67%, specificity 84.44%).
Conclusion
Behavioral observation through examiner-child structured interactive play, particularly metrics related to eye contact, effectively differentiates toddlers with iASD. This objective, low-cost method shows potential as a primary screening tool for enhancing early ASD detection in primary care settings.
CLINICAL TRIAL NUMBER
Not applicable.
This study aimed to develop and validate the Checklist for Chinese Toddlers with Autism, a culturally adapted early screening tool for autism spectrum disorder in children aged 12–24 months. The scale was developed by synthesizing early ASD symptom characteristics, reviewing international screening instruments, incorporating interviews with 15 medical professionals, and consulting eight experts in developmental behavioral pediatrics, child psychology, and psychometrics. The final scale comprises three dimensions (reciprocal social behaviors, social communication, interest behaviors and sensory perception) and 20 items assessed via behavioral observation. Initial validation involved 809 children (aged 12–24 months) to evaluate reliability and validity of the scale, and then determine a cutoff point to differentiate the severity levels of ASD. Further, the scale was applied in 4786 children from the neighborhood child health care clinics to test the screening value of the checklist. The results indicated that a cutoff score of 12 yielded optimal performance, with high sensitivity (0.95) and specificity (0.82). Community-based screening confirmed its efficacy in distinguishing between high likelihood and low likelihood children for ASD. Preliminary evidence indicates that the Checklist for Chinese Toddlers with Autism exhibits sound psychometric properties and may serve as an early screening tool for Chinese children with ASD aged 12–24 months, however, external validation is still required to establish its generalizability.
Zhi Shao, Lin Zhang, Yaru Zhang et al.· Frontiers in Psychiatry· 0 citations
BACKGROUND
Early language delay is a common presenting concern among toddlers with autism spectrum disorder (ASD) and developmental language disorder (DLD), creating challenges for clinical assessment and referral decisions. Although ASD and DLD differ in core social-communicative features, restricted/repetitive behaviours, and developmental mechanisms, language-focused assessment may provide complementary information about early communicative profiles. However, culturally adapted tools for assessing early language and communication in Mandarin-speaking toddlers remain limited.
METHODS
A total of 213 children aged 24-36 months (ASD = 89, DLD = 60, TD = 64) were recruited from the Child Healthcare Department of a tertiary hospital between 2020 and 2022. Clinical diagnoses were established by multidisciplinary teams based on DSM-5 and CATALISE criteria. Caregivers completed the Diagnostic Receptive and Expressive Assessment of Mandarin-Infant & Toddler (DREAM-IT), which evaluates receptive and expressive language, cognitive play, and social communication. Receiver operating characteristic (ROC) curve analyses assessed discriminative validity across diagnostic groups, logistic regression examined the contribution of DREAM-IT domains to ASD-versus-DLD classification, and concurrent validity was evaluated against GDS, ABC, CARS, and ADOS-2.
RESULTS
DREAM-IT showed strong diagnostic accuracy in distinguishing children with ASD or DLD from TD children (AUC = 0.84-0.998), but its ASD-versus-DLD discrimination was domain-specific and more limited. Receptive language provided the strongest ASD-versus-DLD discrimination (AUC = 0.81; sensitivity = 69.1%; specificity = 84.3%; optimal cutoff = 86.5), whereas expressive language, cognitive play, and social communication showed poor-to-limited standalone performance (AUC = 0.51-0.57). Logistic regression indicated that receptive language (OR = 1.10, p < 0.05) and expressive language (OR = 0.77, p = 0.015) independent contributed to ASD-versus-DLD discrimination, with an overall classification accuracy of 79.2%. DREAM-IT classifications demonstrated moderate-to-substantial agreement with established developmental and autism-related instruments, including GDS, ABC, CARS, and ADOS-2 (Cohen's κ = 0.62-0.82). Developmental age comparisons revealed domain-specific lags, with ASD characterized by greater receptive and social delays and DLD showing the largest lag in expressive language.
CONCLUSIONS
The Mandarin DREAM-IT provides clinically useful information about early language and communication development in Mandarin-speaking toddlers with ASD and DLD and shows moderate-to-strong concurrent alignment with established developmental and autism-related measures. Its primary value lies in characterizing domain-specific developmental patterns and offering useful complementary information within a broader, multi-method diagnostic framework for Mandarin-speaking populations.
WHAT THIS PAPER ADDS
What is already known on this subject Differentiating autism spectrum disorder (ASD) from developmental language disorder (DLD) in toddlers is clinically important but challenging. Both conditions may present with early language delay, while ASD is characterised by core social-communication difficulties and restricted or repetitive behaviours. Accurate interpretation therefore requires a multi-method assessment integrating language evaluation, developmental history, direct observation, and autism-specific measures. However, culturally and linguistically appropriate tools for characterising early language and communication in Mandarin-speaking toddlers remain limited. What this study adds to the existing knowledge This study evaluated the diagnostic accuracy and concurrent validity of the Mandarin DREAM-IT in 213 toddlers with ASD, DLD, or typical development. DREAMIT showed good-to-excellent accuracy in distinguishing children with ASD or DLD from typically developing children, but ASD-versus-DLD discrimination was more limited and domain-specific. Receptive language provided the clearest discriminatory signal, whereas expressive language, cognitive play, and social communication showed substantial overlap. DREAM-IT developmental age scores showed moderate correlations with corresponding GDS measures, and its descriptive rule-based patterns showed substantial agreement with autism-specific instruments. What are the potential or actual clinical implications of this study? DREAM-IT may provide useful caregiver-reported information about receptive language, expressive language, cognitive play, and social communication in Mandarin-speaking toddlers. Its main clinical value lies in characterising domain-specific developmental patterns and providing complementary information within a broader, multi-method assessment framework. It should not be used as a standalone instrument to diagnose ASD or DLD or to differentiate between them. Results should be interpreted alongside developmental history, direct clinical observation, developmental testing, and autism-specific measures.
Jinzhu Zhao, Dandan Wu, Yutong Li et al.· International journal of lan...· 0 citations
BACKGROUND
As a core diagnostic criterion for autism spectrum disorder (ASD), sensory differences may have profound implications for the quality of life among autistic individuals. However, little is known about the developmental trajectories of sensory features in toddlers at elevated likelihood (EL) for ASD. The associations between early sensory patterns and later autistic traits also remains unclear.
METHODS
A total of 127 toddlers were enrolled in a China cohort study. At 24 months, 125 toddlers were classified into three groups: EL toddlers diagnosed with ASD (EL-ASD, n = 18), EL toddlers not meeting diagnostic criteria for ASD (EL-nonASD, n = 38), and low likelihood toddlers without ASD (LL, n = 69). Prospective longitudinal assessments of sensory patterns were conducted using the Toddler Sensory Profile-2 (TSP-2). Sensory patterns were compared among groups from 12 to 24 months by Linear Mixed-effects Models and Bonferroni post-hoc comparisons. The associations between early sensory patterns and later autistic traits were also examined.
RESULTS
A significant group × time interaction for sensory sensitivity across 12-24 months (F = 9.87, p < 0.001), and a marked increase in sensory sensitivity in EL-ASD toddlers between 18 and 24 months (p < 0.001). EL-ASD toddlers exhibited significantly higher sensory registration, auditory processing and touch processing scores at 12 months compared to LL group. Elevated sensory registration scores at 12 months were positively associated with social affect (B = 0.14, p = 0.036), restricted repetitive behaviors (RRBs; B = 0.12, p = 0.003), and total scores (B = 0.25, p = 0.005) at 24 months among EL-ASD toddlers. Additionally, elevated sensory avoiding scores at 18 months were positively associated with social affect (B = 0.33, p = 0.045) and total scores (B = 0.30, p = 0.046) at 24 months.
CONCLUSIONS
Distinct sensory patterns emerge by 12 months in elevated likelihood toddlers later diagnosed with autism, with sensory sensitivity increasing significantly between 18 and 24 months. Notably, early hypo- and hyper-responsivity predict later social communication difficulties and RRBs, suggesting that sensory differences may exert a "cascading effect", thereby contributing to autistic outcomes.
CLINICAL TRIAL NUMBER
www.chictr.org.cn/; No: ChiCTR2100049811; Date:2021.08.10.
It is argued that future early ASD detection systems should be developed as clinician-supervised decision-support tools rather than autonomous diagnostic instruments.
Wenhao Luo, Z. Yin, Jianbiao Dai· Diagnostics· 0 citations
Early diagnosis of autism is crucial for timely intervention, yet existing screening tools are often limited by administration time in clinical settings. This study developed and evaluated the Screening Tool for Autism in Two-Year-Olds-Brief Form (STAT-BF) for detecting autism in toddlers aged less than 36 months. In Study 1, two independent samples of 40 toddlers each (20 autistic and 20 with developmental delays [DDs]) were analyzed using chi-square tests to identify discriminative items. Five items (Turn-taking, Bubbles, Snack, Balloon, and Bag of Toys) were retained, with a cutoff score of 3 yielding optimal sensitivity and specificity. Study 2's validation, based on a sample of 251 toddlers (81 autism, 55 mild- autism, 115 DDs), yielded high sensitivity for autism (0.91; 74/81) and mild-autism (0.91; 50/55), together with good specificity (0.81; 93/115). Administration time was reduced to 5 to 10 min while maintaining screening accuracy. These findings suggest that the STAT-BF may serve as a feasible and efficient Level 2 screening tool for early autism detection among toddlers referred for developmental concerns, particularly in resource-limited clinical settings. Further validation in diverse populations and longitudinal follow-up is warranted to establish generalizability.Lay AbstractEarly support can make a big difference in the outcomes of autistic children, but they must first be identified as early as possible. Although reliable autism screening tools exist, many are too time-consuming for high-volume clinical settings. In this study, we developed and validated a shorter version of the Screening Tool for Autism in Two-Year-Olds (STAT) that takes 5 to 10 min. This brief tool focuses on five play-based activities that assess social communication skills in toddlers aged 18 to 36 months. We conducted a two-phase study in Taiwan. The first phase identified the most discriminating items, and the validation phase included 251 toddlers with autism, mild-autism, and developmental delays (DDs). Results showed that the brief form correctly identified over 90% of autistic children, including those with milder symptoms, and correctly ruled out autism in about 80% of children with DDs. This efficient screening method could help more health care providers detect autism early, especially in high-volume clinical settings with limited resources. Because the brief form uses structured play instead of parent questionnaires, it offers direct behavioral observation and increases cultural accessibility for families from a broad range of backgrounds. This brief screening tool could help clinicians more efficiently identify autism among toddlers already referred for developmental evaluation, facilitating timely referral for formal diagnostic confirmation and subsequent access to intervention services.
Early Intensive Behavioral Intervention (EIBI) is widely recognized as an effective treatment for children with autism spectrum disorder (ASD), yet longitudinal evidence from non-Western educational settings remains limited. This study examined developmental trajectories among children with ASD participating in a school-based EIBI program in China.
Archival data from 39 children aged 2–12 enrolled in a private special education school were analyzed. Developmental functioning was assessed using the Assessment of Basic Language and Learning Skills–Revised (ABLLS-R) across three assessment points at three-month intervals.
Linear mixed-effects models showed a significant effect of time on composite scores, indicating progressive developmental improvement. Significant improvements were observed in basic learner skills, motor skills, and self-help skills. Academic skills showed moderate improvement across the intervention period. Multiple regression analysis indicated baseline composite score significantly predicted third composite scores, where age at program entry and total program hours were not significantly associated with outcomes.
These findings provide longitudinal evidence supporting the effectiveness of school-based EIBI in promoting developmental progress among children with ASD in a Chinese educational context.
Jiadong Yu, Xiao-Mei Yang, D. A. Bekerian et al.· Frontiers in Education· 0 citations
