Screening Autism In Middle East: Guidelines For Introduction

Researcher background and personal motivation for the study

Write an introduction chapter about screening autism in middle east country enclosed guideline on how to write introduction titled.

The present introductory chapter is in the context of the present research to be undertaken. The chapter is the discussion of the topic that is taken up for exploration and drawing clear conclusions for filling the gaps present in the past literature. The topic chosen is a screening of Autism Spectrum Disorders (ASD). The background of the searcher is presented in order to highlight the rationale behind considering the present topic. The personal motivation for undertaking a research is significant as the researchers have the knowledge on the personal interests on topics to be covered. The research problems are mentioned in an appropriate manner. The chapter’s focus is on the review of studies undertaken in the past.  This section has a highly focused review of the literature. Deficiencies in the past literature are studied carefully and presented in the chapter. The significance of the study, therefore, comes into the limelight as the next sections of the chapter. Lastly, the purpose statement of the study is laid out that enables the readers to have the understanding of the objective of the study. The chapter has a short summary at the end to provide insight into the main aspects of the chapter and to give the readers a clear concept on the background of the research.

I have completed my diploma in nursing in the year 1997 after which I had worked for three years as a nurse practitioner at many primary health care settings as well as secondary health care settings. In the year 1999, I took up further education in this field by enrolling into a bachelors degree in nursing from the United States of America. After that, I received my degree in nursing education in 2001 from the United States of America. After completing my education I have been working as a nursing tutor and have gained huge academic experience in teaching nursing students on varied subjects like pediatric nursing and child health care in clinical settings, laboratories, and theory. I have had the opportunity to be a part of the team to develop and update nursing curriculum in areas like community health, nutrition, and pediatric health. My experiences give me the ideas that nursing curriculum is not being updated as per the latest advancements, and the curriculums are not complete in aspects like child behavioral and development milestone. In spite of the fact that the curriculum is recognized to some extent, my personal opinion is that it is not sufficient to enable the nurses to fulfill the responsibilities in identifying the development and behavioral abnormalities. This is especially applicable to surveillance program and immunization program. Nurses working at EPI settings must take up the role of assessing development status of the children and immunizing children. I understand that in the present health scenario in the country related to child autism, there is a need of taking up extensive research in the field of early detection of autism for boosting up the benefits of early intervention and care. I have inbuilt a strong interest in investigating the extent to which the healthcare systems are ready for undertaking screening and identification of children having autism within the first five years of their life. Autism spectrum disorder (ASD) is the spectrum of neuro-developmental disorder that is characterized by hampered verbal as well as non-verbal communication, social interaction and repetitive and restricted behaviour (Veague 2010). The signs are usually visible in the first two years of age of the child. The signs may be developing gradually even though some children having the disorder may be reaching the developmental milestone at a usual pace (Nadesan 2013). Several screening tools have been developed that are useful for detecting children having autism. Most of the screening tools have a huge application with children of varying ages, and allow flexibility to undertake universal means of understanding developmental milestones (Schopler and Mesibov 2013). Because of their broad use, these tools often lack the sensitivity to screen specifically for autism and, therefore, need further researches (Lunsky 2016). By conducting literature search within my first year of Ph.D., I have gained the understanding that presence of autism is increasing across the world. However, the country I reside in has been reporting less number of autism patients. The reason for this is the absence of reporting, lack of professional knowledge and under diagnosis. Researchers across the globe are getting into research on different aspects of early detection of autism like examination of instruments for assisting professionals and parents for identification of autism and investigation of knowledge of parents and professionals on autism. However, most of the valuable researches have been taken up in the western countries. This gave rise to my intention of doing an investigation of the barriers and facilitators for screening autism within Middle East country. The rationale behind is that taking up such investigations would enrich the literature present on the concerned topic and give a better understanding of the part of the world view of this relation.

Research problem

Autism screening and the challenges and facilitators in doing so are the areas of concern for health practitioners, and there is an urgent need to bring improvements in these conditions. Difficulties in screening autism need to be overcome, and there are many questions that come while addressing the issues of screening of autism.

The research problem that needs to be investigated in the present research is the barriers and facilitators of screening autism.

Deb, Dhaliwal and Roy (2009) conducted a study on the usefulness of the DBC-ASA as the screening instrument for autism in children having intellectual disabilities. The investigation carried out was a pilot study. Population screening for autism is not recommended, but there is a necessity to diagnose the complication in early stages for proper intervention and management. Social Communication Questionnaire (SCQ), Gilliam Autism Rating Scale (GARS), Checklist for Autism in Toddlers (CHAT) and Childhood Autism Rating Scale (CARS) are some of the screening instruments for autism. However, there lacks validity of the use of the instruments in adults and children with intellectual disabilities. The Developmental Behaviour Checklist-Autism Screening Algorithm (DBC-ASA) is a 29-item subset from the Developmental Behaviour Checklist validated for screening autism in children. The researcher took up a preliminary study to examine the validity of DBC-ASA in children having intellectual disabilities. The researchers conducted a retrospective study of the DBC-ASA scores. Data was collected from case notes of 109 children having intellectual disabilities who attend a specialist clinic in the United Kingdom. The reason for the children having autism being a narrow group with more Kanner-type autism is that the clinic used International Classification of Diseases 10th Revision, Research Diagnostic Criteria instead of the less stringent clinic criteria for diagnosis. The diagnosis of intellectual disabilities was done by the Wessex Rating Scale. The diagnosis of intellectual disabilities was supported by the data from the child’s Statement of Special Educational Needs. One hundred and nine children were found to be fulfilling the inclusion criteria. The data was recorded in an anonymous manner and then they were entered in the statistical software program, SPSS. The collected data were double checked or preventing inaccuracies in inputting. A receiver-operating characteristics (ROC) analysis was taken up by th comparison of scores on the DBCASA. The cutoff scores having optimal level of specificity and sensitivity were considered. There was also separate analysis of the data for dissimilar age groups, a level of intellectual disability and gender. The comparison was done between scores of children with and without autism using the Mann-Whitney test and t-test.  The mean score of the DBC-ASA was statistically more significant among children having autism than those not having it. The DBC score of 20 had s sensitivity of 0.9, and the specificity was 0.6. The score of 18 yielded a sensitivity of 0.92 whereas the specificity was 0.5. The receiver–operating characteristic for the DBC-ASA score of 20 yielded a large area under the curve (AUC) (0.864) for children with intellectual disabilities against the International Classification of Diseases 10th Revision, Research Diagnostic Criteria (ICD10 DRC) diagnosis of autism. The conclusion drawn from the research is that the DBC-ASA score has the potential to discriminate between children with intellectual disabilities with and without autism.

Review of studies

Ip, Zwaigenbaum and Sharon (2015) undertook a study on the factors influencing autism spectrum disorder screening by community pediatricians. ASD is characterized by the abnormalities in the patterns of communication and social interactions and a repetitive and restricted repertoire of interests and activities. Many surveys were undertaken with pediatrics reveal that only a small section of them use standardized development screening tools. There have also been some challenges reported that they face while doing such screening for autism. These include lack of time, referral to a clinical specialist and lack of knowledge of the tools that can be used. Some of the pediatrics have reported that there lie some reservations about the evidence supporting the screening of ASD. However, recent researches have indicated that the Modified Checklist for Autism in Toddlers (M-CHAT) is capable of identifying toddlers having ASD earlier in the process and they are more consistent in the feature when compared to surveillance by community pediatrics. So is the feature of Infant-Toddler Checklist. The recommendation is that universal screening of ASD should be taken up at 18 to 24 months. There lies insufficient proof on routine ASD screening and recommendations are that careful surveillance must be taken up as an alternative strategy. Most of the recommendations for ASD screening are targeting children at risk rather than having a universal approach. As per the authors, most of the Autism Spectrum Disorders (ASD) can be effectively diagnosed at the age of two or three years. However, the Canadian data indicates that a median age of diagnosis of ASD is four years. Till date, there is a lack of evidence that examines the use of ASD screening tools among general practitioner pediatrics in Canada and the factors that relate to the practice decisions. Keeping this information in the background of the study, the researchers took up the research to examine the practices taken up by general practitioners in relation to ASD screening and identification of factors that have n impact on the decisions regarding the use of screening tools available for ASD. The participants for the study were twelve pediatrics who practice in four practice groups in an urban center in Western Canada. Half of the participants were male and the average time since medical school graduation was eighteen years. Focus group discussions were conducted at the place of their practice. One interview and four focus groups were conducted. Ethics approval was done.  The participants involved in the focus group were facilitated by principle investigator and semi-structured interviews were conducted. Open-ended questions were used, and follow-up prompts were taken up. One participant was considered for the interview at a time, and all participants were asked the same set of questions. The focus groups took place for 40 to 60 minutes, and the discussion was digitally recorded. Brief notes were also taken. The interview and focus groups were transcribed verbatim and before the initial coding, there was a thorough reading undertaken. An interpretive description approach was taken up in a qualitative manner for presenting the perspectives of the participants by remaining in a vicinity to the data. The NVivo10 software package was used for coding. After the initial discussion, themes were considered for re-examination and the determination of the themes was done. Five main broad domains of themes were identified, and these were benefits of screening autism, needs that are not addressed, elements fostering utility of screening tool, elements limiting the utility of screening tools, and lastly the procedure of function in ASD screening.  Participants were found to be having a concern regarding insufficient screening that results in un-detection and un-treatment of ASD. The participants stated that there lay many factors that can heighten the risk of missed identification of ASD. The benefit of having proper screening of ASD was the likely identification of number of children with the disorder. Many of the participants stated that they referred the children having detection of ASD to a developmental specialist without taking up an ASD screening tools. A tertiary center is usually relied on for diagnosis and formal testing. Regarding the elements fostering the utility of the tool, participants identified tool features that are significant, and they relate to validity, length, administration, language, sensitivity and reliability of the tools used. A section of the participants suggested that ASD screening must be in a more general manner. Participants had the viewpoint that their role in the screening of ASD was of much significance and they had positivity about the ability they had in relation to identification of ASD. The general argument was that pediatrics must be able to identify the children at the time of routine visits and when there is adequate time to be spent with the children. Concerns were raised by the participants on administration feasibility and scoring of a screening test. They also raised concerns regarding screening practicability in the practices. In a general it was found that recommendations came up regarding potential methods of implementation of ASD screening. Screening by routine community monitoring was suggested by them. Training of general practitioners was the alternative means suggested. Early child educators were found to be the possible detectors of early signs of risk for ASD. In the end, participants raised concerns regarding systems to be ensuring standard application and fidelity of testing and accuracy. The study identified that factors influencing perspective of Pediatrics regarding screening of ASD and the role they have in formal screening of ASD. There lies an intricate interplay of patient, family, systematic factors and physician in the ASD screening. Challenges were also identified as an important aspect of the screening and of ASD. The main conclusion was that developmental screening programs can be successfully implemented if the physicians take responsibility for the same and there are resources available for supporting so.

According to Booth et al. (2013) there is a requirement of short and specific screening tools for ASD that are useful for application by frontline healthcare professionals for taking up the decision on whether a person at risk must be referred for a complete diagnostic assessment. The adult autism spectrum quotient (AQ-50) was made for the assessment of the traits of autism in adults having intellectual functioning taking place in a normal manner. It is made up of 5 sub-scales that are effective in measuring the main traits by the vital dimensions of ASD. These dimensions are attention switching, imagination, communication and social interactions. There was an abridged version of the tool (AQ-S) that was taken up for comparison. A short version of the tool called as AQ-10 that is made to meet the requirements for a brief screening process was constructed. The aim of the study conducted by the researchers was to assess the efficiency of the AQ-10 for discriminating between people having and not having a confirmed diagnosis of ASD. For having a proper comparison, the complete AQ-50 was also evaluated and it was assessed for the important information lost in the brief version. One hundred and forty nine people participated in the study who had ASD and one hundred and thirty four controls participants were taken who had no ASD. It was found that the full AQ-50 and the AQ-10 both performed well for the screening of ASD. ROC analysis was taken up that indicated that specificity, sensitivity and area under curve were similar to cut-offs. There were not much differences in the performance of full AQ-50 and AQ-10. The clear indication is that the brief version AQ-10 can be used up as the effective tool for screening ASD. Moreover, the researchers gave a valuable suggestion on the basis of their analysis that a cut-point of 16 would be appropriate for such tools. There was not much loss of discriminative power in AQ-10 when comparison was done between it and AQ-50 and AQ-S. This result suggested that frontline professionals who do not have much time for screening of ASD can take up AQ-10 and a score of 6 would be enough to indicate that there is a need for taking up a full assessment for diagnosing individuals with ASD. The AQ-10 is thus an effective compilation of all the recommended elements for screening instruments.

Smith, Sheldrick and Perrin (2013) opined that the incidences of Autism Spectrum Disorder (ASD) has witnessed growth in a drastic manner over the last two to three years. The section of pediatrics using developmental screening tools in the United States has grown to almost 48% from 23%. However, a proportion of 8% of pediatrics working in primary care do the reporting of screening of the disease. There are some barriers that come up while screening for ASD in a routine manner and these include the cost of screening and limited time for the care providers. The instruments that are available for screening are costly and include both the professional’s and staff’s time is a challenge. Challenge also lies in making suitable referrals, as this is a very time-consuming process.  Moreover, parents may not be appropriately completing screening checklists. The aim of the researchers was to explore the internal reliability and validity of an abbreviated and new screening instrument named the Parent’s Observations of Social Interactions (POSI). The researchers took up an initial first phase study of these, followed by analysis of data taken by independent sample of parents. In the first study, two hundred and seventeen parents of children of age eighteen to forty eight months were considered as the participants who completed questionnaires including the POSI and the Modified Checklist for Autism in Toddlers (M-CHAT). The scores of these two were compared to the results of clinical evaluation for assessing the validity and the reliability. In the second study parents of two hundred and thirty two children aged sixteen to thirty six months from subspecialty settings and primary care settings were considered for the completion of the POSI and the M-CHAT. Moreover, they were to report on the diagnoses of their child. The scores of M-CHAT and POSI were compared for assessing validity and reliability. In the first study, sensitivity for POSI (89%) was significantly higher than that for the M-CHAT (71%).  No significant differences between specificities were found as it was 54% for POSI and 62% for M-CHAT. In the second study, sensitivity was more for POSI (83%) than that of M-CHAT (50%). However, the specificity for the former was less at 7% in comparison to that of the latter with 84%. In spite of fact that there were some concision, the POSI was found to be having comparable specificity and sensitivity and good internal reliability in comparison to M-CHAT in two populations that were independent. The conclusion of the study was that if more researches are taken up, there lies potential for POSI to be used up as the efficient method of screening ASD in children having the disorder. The POSI has the full potential to be the new, brief and first-level screening test for ASD and this aspect must be explored further.

The topic of child care workers contributing to early detection of Autism Spectrum Disorders was taken up by Dereu et al. (2012) as their research area that aimed at doing a comparison between screening instruments with child care workers and parents as the informants. The researchers stated that any screening instruments for ASD have been developed in the last few years. However, fewer studies take up the comparison of discriminative power of the screening instruments in the same sample. For children there are not studies on the comparison of screening instruments using different informants. The present study did the comparison of discriminant ability of the Checklist for Early signs of Developmental Disorders (CESDD) that is filled by childcare workers with that of the questionnaires used by parents.  The sample population was 357 children of which 138 were girls and 219 were boys. This sample was out of a vast screening study that was done with 7092 children and both parent questionnaires and CESDD were filled out for them. The children had an elevated risk of having ASD based on the CESDD results. The measures taken up were Checklist for Early Signs of Developmental Disorders (CESDD), Early Screening of Autistic Traits (ESAT), Modified Checklist for Autism in Toddlers (M-CHAT), Social Communication Questionnaire (SCQ), and Short-form versions of MacArthur Communicative Development Inventories (CDIs). ROC analyses of the data indicated that the discriminant power of the CESDD is similar to that of parental questionnaires. Moreover the CESDD as much efficient as parental questionnaire is discriminating children with and without ASD. This implies that the inclusion of childcare workers in the early stage detection of ASD holds much positive potential. Combination of various screening instruments having varied informants is beneficial for detecting children having risk of ASD. People may consider CESDD as the first level population screener in day-care facilities. The instrument may be used as the one for selection of children having developmental issues and the next step can be parent screener for ASD. The combination of the instruments would be done based on the age of the child and the screening setting.

Mawle and Griffiths (2006) reviewed the accuracy of screening tools that are brief for autism in pre-school children. The review was conducted for examining the evidence base for instruments that are brief and applicable for children whose age is under four years. Screening tools are to be assessed for the utility they have in primary care populations including resource implications. The study was a systematic review of diagnostic accuracy researches. The databases that were searched were Embase, Cinahl, Medline and Psychinfo. Author of one incomplete study was contacted for further information on the research. Children aged five years and less having no prior diagnosis of autism and pervasive development delays were considered as the subjects. Checklists and tools appropriate for use as screening tools in primary care settings were the interventions. Negative and positive predictive value, specificity and sensitivity of screening tools relative to diagnostic assessment by the use of ICD 10 diagnosis or DSM-III/IV diagnosis were the outcome measures. Three studies were identified that comprised of two tools. The Checklist for Autism in Toddlers (CHAT) was assessed that showed poor sensitivity but positive predictive value. Some evidence indicated that the Modified Checklist for Autism in Toddlers (M-CHAT) had good sensitivity. The high specificity of the CHAT suggests that it can be used in the secondary screening be used purposes. The M-CHAT can be used for population screening. Familiarization with the M-CHAT and CHAT would provide good opportunity for healthcare providers to recognize the manifestations of ASD. This is especially for workers who are attached to primary health care settings. The M-CHAT serves as the parent report screen and it appears that it is the more promising tool for taking up more research on the concerned topic.

The literature published in the past that are present on the concerned topic of barriers and facilitators of screening autism have certain deficiencies that have put forward the need of taking up the present research. There have been some areas that have been overlooked by researchers of the past taking up studies on the same matter. This section therefore discusses the deficiencies present in the past literature and provides a unique and specific contribution to the scholarly literature.

Sharon et al. (2015) conducted a study that emphasized on the examination of the pediatrics’ practice in relation to ASD screening and identification of factors influencing the decisions on use of screening tools. The study had the inference that further research needs to be conducted on the needs of the community practitioners regarding undertaking screening of ASD in early stages and using available interventional resources.  Allison et al. (2012) states that there lies a lack of research on the early developmental and autism screening in particular populations and few studies have addressed the examination of screening instruments and practices in diverse populations. There lies no particular studies that elaborates on the screening implementation challenges and classifies the results based on instrument characteristics. Evidence based literature are useful in providing information to pediatric providers for assessing key early developmental features that may be beneficial for avoiding screening errors and behavioral discrepancies regardless of the availability of proper screening tools (Fernell et al 2014). Khowaja, Hazzard and Robins (2015) suggested that there is a need of increased public education on the childhood  development that would facilitate the early screening and detection of autism. Bölte et al. (2013) conducted a research to conclude that autism research faces much challenges and there are many factors that together give rise to challenges in the field of autism research. Booth et al (2013) undertook a study that did not take up the examination of child versions of autism screening questionnaires and the briefer counterparts. This therefore remained as a significant direction for future studies. Almberg et al. (2015) have pointed out that not much is known about whether individuals with autism spectrum disorder (ASD) experience any specific facilitators or barriers to driving education. Moreover, sample sizes of many researches are not large enough to generalize the results to parts of the world.

The study would add valuable and rich information to the literature present in the field of barriers and facilitators of screening Autism Spectrum Disorders in children within Middle East country. The study would help in improving healthcare practices in different healthcare settings. Settings would benefit from the research in that it would be able to deliver cost-effective services wherever they are needed in relation to autism screening. Healthcare practitioners would have the clear concept on the concept of what the possible challenges and facilitators of screening autism are and the measures that can be taken up for addressing the issues so that improvement may be brought in a rapid manner in delivering healthcare practices (Veenstra-VanderWeele and McGuire 2016). Practitioners would get the foundation for further research on the same topic that can add more valuable information on the barriers and facilitators of screening autism. Researchers would be able to work together for developing, publishing and supporting the use of effective tools for assessment and screening autism. The present research would be the start of the broader effort that would serve as the means of developing culturally appropriate, valid and reliable tools for making proper diagnosis. Just as the importance of having proper tools, another challenging aspect is the training of professionals in the screening of diagnosis. The screening of autism needs healthcare practitioners to go beyond the assessment of symptoms (Rudra et al. 2014). The present study can be a guiding path for these practitioners to participate in autism screening in more elaborated manner and without any potential challenges. The research would pave the way for continued efforts from healthcare practitioners to establish and maintain high quality in diagnostic tools for autism while addressing the challenges of limited sources and cross-cultural compatibility (Hedley 2016). The study would be helpful in improving policies and decision-making in clinical practice in relation to screening of autism in children. The findings of the study would help health care organizations to take up effective and efficient decisions regarding the healthcare policies that are constructed for helping the early screening of autism. The main impact would be on the development of scenario regarding the challenges and barriers that come up in the way of screening autism and the issues that practitioner face while taking up such screening. The community would be able to take up positive and advanced changes in the healthcare settings and effectively address the imbalance in autism screening that is prevalent across the settings. Policies could be developed that would be designed for addressing autism cases found across cultures (Taylor et al. 2014).

The purpose of the research study is to bring improvements in the process of screening of autism by eliminating the barriers that come up in screening process and considering the facilitators of screening methods.

The research is undertaken as a result of the drive for gaining knowledge on the means of facilitating early detection of autism and propel the way for suitable early interventions. The particular interest is been taken up for boosting autism screening in children below five years of age. Furthermore, most of the studies present are taken up in the western countries. This particular study would be an added source of research undertaken in the middle east country. It would be helpful in making a good comparison between the scenario present in the eastern countries and the western countries. The purpose of the research study is to investigate facilitators and barriers to evidence-based screening for children with ASD. Valuable results of the study will help in the development of strategies that would eliminate such challenges and pave the way for more advance health care practices. The study would add valuable and rich information to the literature present in the field of barriers and facilitators of screening Autism Spectrum Disorders in children within Middle East country. The study would help in improving healthcare practices in different healthcare settings. The study would be helpful in improving policies and decision-making in clinical practice in relation to screening of autism in children. The present study can be a guiding path for these practitioners to participate in autism screening in more elaborated manner and without any potential challenges.

References

Allison, C., Auyeung, B. and Baron-Cohen, S., 2012. Toward brief “red flags” for autism screening: the short autism spectrum quotient and the short quantitative checklist in 1,000 cases and 3,000 controls. Journal of the American Academy of Child & Adolescent Psychiatry, 51(2), pp.202-212.

Almberg, M., Selander, H., Falkmer, M., Vaz, S., Ciccarelli, M. and Falkmer, T., 2015. Experiences of facilitators or barriers in driving education from learner and novice drivers with ADHD or ASD and their driving instructors.Developmental neurorehabilitation, pp.1-9.

Bölte, S., Marschik, P.B., Falck-Ytter, T., Charman, T., Roeyers, H. and Elsabbagh, M., 2013. Infants at risk for autism: a European perspective on current status, challenges and opportunities. European child & adolescent psychiatry, 22(6), pp.341-348.

Booth, T., Murray, A.L., McKenzie, K., Kuenssberg, R., O’Donnell, M. and Burnett, H., 2013. Brief report: An evaluation of the AQ-10 as a brief screening instrument for ASD in adults. Journal of autism and developmental disorders, 43(12), pp.2997-3000.

Deb, S., Dhaliwal, A. and Roy, M. 2009. The Usefulness of the DBC-ASA as a Screening Instrument for Autism in Children with Intellectual Disabilities: A Pilot Study. Journal of Applied Research in Intellectual Disabilities, 22(5), pp.498-501.

Dereu, M., Raymaekers, R., Warreyn, P., Schietecatte, I., Meirsschaut, M. and Roeyers, H., 2012. Can child care workers contribute to the early detection of autism spectrum disorders? A comparison between screening instruments with child care workers versus parents as informants. Journal of autism and developmental disorders, 42(5), pp.781-796.

Fernell, E., Wilson, P., Hadjikhani, N., Bourgeron, T., Neville, B., Taylor, D., Minnis, H. and Gillberg, C., 2014. Screening, intervention and outcome in autism and other developmental disorders: the role of randomized controlled trials. Journal of autism and developmental disorders, 44(8), pp.2074-2076.

Hedley, D., 2016. New rapid autism screening test. The Journal of Pediatrics, 168, pp.253-256.

Ip, A., Zwaigenbaum, L. and Sharon, R. 2015. Factors influencing autism spectrum disorder screening by community paediatricians. Paediatrics & child health, 20(5), p.E20.

Khowaja, M.K., Hazzard, A.P. and Robins, D.L., 2015. Sociodemographic barriers to early detection of autism: screening and evaluation using the M-CHAT, M-CHAT-R, and follow-up. Journal of autism and developmental disorders, 45(6), pp.1797-1808.

Lunsky, Y., 2016. Book Review: Autism Spectrum Disorders in Adolescents and Adults: Evidence Based and Promising Interventions. The Canadian Journal of Psychiatry, 61(4), pp.252-252.

Mawle, E. and Griffiths, P., 2006. Screening for autism in pre-school children in primary care: Systematic review of English Language tools. International Journal of Nursing Studies, 43(5), pp.623-636.

Nadesan, M.H., 2013. Constructing autism.

Rudra, A., Banerjee, S., Singhal, N., Barua, M., Mukerji, S. and Chakrabarti, B., 2014. Translation and usability of autism screening and diagnostic tools for autism spectrum conditions in India. Autism Research, 7(5), pp.598-607.

Schopler, E. and Mesibov, G.B. eds., 2013. Learning and cognition in autism. Springer Science & Business Media.

Smith, N.J., Sheldrick, R.C. and Perrin, E.C., 2013. An abbreviated screening instrument for autism spectrum disorders. Infant Mental Health Journal, 34(2), pp.149-155.

Taylor, C.M., Vehorn, A., Noble, H., Weitlauf, A.S. and Warren, Z.E., 2014. Brief report: can metrics of reporting bias enhance early autism screening measures?. Journal of autism and developmental disorders, 44(9), pp.2375-2380.

Veague, H. (2010). Autism. New York, NY: Chelsea House.

Veenstra-VanderWeele, J. and McGuire, K., 2016. Rigid, Inflexible Approach Results in No Recommendation for Autism Screening. JAMA psychiatry.