EstablishmentandclinicalapplicationoftheRapidInterventionScreeningTestforAutismin

Toddlers(RITA-T)Roula Choueiri, MD

NeurodevelopmentalDisabilitiesPediatricianAssociateProfessorofPediatrics

Chief,DivisionofDevelopmentalandBehavioralPediatricsCDCActearlyCampaignAmbassadortoMAUniversityofMassachusettsMedicalSchool

NewTwoLevelScreeningModel

CurrentScreeningMethodsforASD• Level1oruniversalscreensuchastheMCHAT-R:

• Verygoodatpickingupchildrenwhoneedmoreworkup• HighfalsepositiveforASD

• Level2– Disorder-specificscreener• DifferentiatesbetweenASDandotherdelays

• ReferralsforASDevaluationsmoreappropriate

vInteractiveLevel2ASDscreenerspreferredtoquestionnaires

èTriggersatypicalbehaviors

Two-LevelASDScreeningModel

RiskASD+++

RiskforDevelopmentalDelays/ASD

WellChildVisitsorhighrisk(ex:EarlyIntervention)

Level1

Level2

IdealASDLevel2screenerThismodelwouldallowimprovedaccess

ToddlerswithhighriskofASDwouldnotbedelayedfordiagnosticconfirmation

EarlyIntervention,EarlyChildhoodeducators,Pediatricians,nurses,NP,canbetrainedonit

Reliablein18-36monthsold

Easytotrainandlearn

DiscriminateswellbetweentoddlerswithASDandthosewithDelaysthatarenonASD

Andmostimportantly:FITSWELLINTOBUSYPRACTICEFLOW

CurrentInteractiveLevel2ASDscreenersSTAT:ScreeningforAutismin

Toddlers• 20minutestoadminister• Difficulttraining• Goodpsychometricsfor2-3y

old• Lessgoodfor<2y• Missesmildtomoderate

formsofASD• HighCosts

RITA-T:RapidInteractiveScreeningTestforAutisminToddlers

• 5-10minutestoadminister• Reliabletrainingin3hours• Goodpsychometricsfor18-39

months• Trainingandaccesstobe

accessible

DESCRIPTIONoftheRITA-T@UMassMed

DescriptionoftheRITA-T(JournalofPediatrics,August2015)

• 9interactivepresses• Assessesdevelopmental

constructsdelayedinearlyASDsuchas:• JointAttention(JA)• ReactiontoEmotions• AwarenessofHumanAgency

• Eachitemcodedfrom0to2,3or4(typicaltoatypical)

• Totalscoregenerated;maximum:30

• Thelower thescore,themoretypicalthereaction

vAdministrationandscoringtime:10minutes

RITA-T- Description

• Scoringalgorithm,Manualandtrainingdevelopedandtested.

• Resultsofvalidationstudies

• CorrelatesverywellwithAutismDiagnostictests

EyeContactandJA

“Checking in” to share interest/surprise to a magical change in colors or to disappearing ball

HumanAgency&preferenceforfaces

Child aware of person blocking object not just “the hand”

Preference for faces

TheRITA-TActivitiesItem Constructs Materials Administration Score

*A-Blockedexplorationofatoy(TL:11s)

SA;JA;HA Toyphone Childexplorestoy.Examinerblocksit,3times.ObserveECandlatencytoECfor11s.

0-4 forEC;timetoEC;orgivingup

B-ObjectTease SA;JA;HA ToyPhone Examinerpretendstogivetoytochildthenpullsback,3times.ObserveECtoexaminerorparent.

0-2forECtoparent,examinerorboth

*C-BlockedVision(TL:11s)

SA;JA;HA ToyOpaquescreen

Childexplorestoy;examinerblockstoyfrombehind thechildusingascreenfor11s.ObserveEC,JA.

0-3forEC;TimetoEC

D-MagicBall CogJA

“Magic”cup&ball

Ballinmagiccupshowntochildthenexaminermakesitdisappear,3times.Observesurprise;JAtoexaminer&parent.

0-3forreactionofsurprise;ECtoparentand/orexaminer

E-ColorConstancy

CogJA

“Magic”scarf Examinershowsdouble-sidedmagicscarfononesideinitiallythenexaminerchangescolorabruptly.Observesurprise;JAtoexaminerorparent.

0-2forreactionofsurprise;JAtoparentorexaminer

F-*Objectvs.Face

(TL:15s)

SA Picturesoftrain&baby

Picturesofababyandofatrainoneithersidearepresentedtothechild5seachside.Observepicturepreferencefor5s.

0-2forpreferencetobaby(0),trainpictures(1),ornointerestatall(2)

G-RapidJA JA Ceilinglight Examinercallschildsuddenlyandpointsatceilinglight.ObserveJA.

0-1forJA

H*-SadFace,StillFace

(TL:10seach)

SA Caregiver Caregiverisaskedtopretend tocry:Observe:distress,EC,proximityseekingorno interestfor10s.Thencaregiverisaskedtohaveaneutralexpression;Observesamefor10s.

0-4each:0-1scoreprovided toeachreactionobserved.

I-Recognition CogSR

MarkerMirror Areddotismarkedonforeheadwithremovablenon-allergenicmarker.Examinerholdssmallmirrortochild.Observereactiontorecognizingdotandtakingitaway.

0-2forrecognizesthereddot;attemptstoremoveit

RITA-TScoringSheet

InitialvalidationSample(JofPediatrics,2015)

• 74 toddlerswereenrolled• 13 wereexcluded

»61 continuedthestudy

• 23 hadASD

• 19hadDD(DevelopmentalDelay)/Non-ASDdiagnoses

• LanguageDelay(LD)in12• GlobalDevelopmentalDelay(GDD)in7

• 19 were“TD”(NCR:NoConcernsRaised)

Results- Demographics

ASD(N=23)

NonASD(N=19)

NCR(N=19)

P-value

FemaleN(%) 1(4) 8(36) 12(63) <0.001AgemonthsMean(SD)

27.77(5.7) 29.46(6) 21.7(6.5) 0.001

RaceN(%) 0.07WhiteN(%) 11(47.8) 15(79) 8(42.1)

Hispanic 8(34.7) 3(15.8) 4(21)Other 4(17.3) 1(5.2) 7(36.8)

IncomeN(%) NS>$50,000 7(30.4) 8(42.1) 6(31.5)<$50,000 16(69.5) 11(58) 13(68.4)

P-valuesforgroupdifferencesarebasedonANOVAforcontinuousvariablesandchi-squaretestsforcategoricalvariables.

Results- MeanScores(SD)byDiagnoses

ASD DD/NON-ASD NCR P-VALUERITA-T 20.8(3.6) 13(2.5) 10.9(2.12) <0.0001M-CHAT

TotalItemsfailed(SD) 8.7(4.9) 4(3.6) 1.3(1.6) <0.0001M-CHAT

Meancriticalfailed(SD) 2.87(2.3) 1.42(1.6) 0.11(0.31) <0.0001DSMIV 8.96(1.99) 0.89(1.15) N/A <0.0001DSM5 6.04(0.88) 0.75(1.15) N/A <0.0001

MULLENReceptiveLanguage 29.7(12.3) 33.8(15.2) N/A NS

MULLENExpressiveLanguage 28.4(13.2) 29.6(13.4) N/A NS

MULLENVisual Reception 32.8(10.7) 40(14.65) N/A NS

Results- CorrelationsofRITA-TwithAutismmeasures

CorrelationsDSMIVcriteria

checkedDSM5criteria

checkedADOS

CompositeScore

r= 0.78 0.76 0.79

N= 42 42 25

t= 7.81 7.37 6.14

p=(two-tailed) <0.0001 <0.0001 <0.0001

Discriminant Validation: Results DD/NonASD group

GDD(N=7)

LD(N=12) p-value

RITA-TMean total score (SD)

12.9 (3.6) 12.6 (2.7)NS

M-CHAT Mean total items (SD)

4.6(4.1) 4.5(3.8) NS

DSM IVMean total symptoms (SD)

2.4 (2.4) 2.3(1.5) NS

DSM 5 Mean total symptoms (SD)

1.0 (1.7) 1.2 (1.9) NS

Mullen RL-T*Mean (SD)

29.8 (9.7) 42.7 (7.3) 0.01

Mullen EL-T**Mean (SD)

31.75 (8.2) 35.6 (8.2) NS

Mullen VR-T***Mean (SD)

27.0 (9.3) 49.8 (12.4) 0.004

DISCRIMINANT VALIDATION: RESULTS

•RITA-T & MCHAT total score: Positive Correlation

– Spearman Rho: 0.65; p < 0.001

•RITA-T mean total score BY ADOS classification (t-test)

MeanRITA-TScorep<0.01

ADOS(Autism) ADOS(ASD)22(SD:3.3) 16.25(SD:3.8)

Measures of test validity

•Sensitivity:– Positivesaretruepositives

•Specificity:• Negativesaretrulynegatives

•PPV:PositivePredictiveValue– Proportionofpatientswithpositivetestresultswhoarecorrectlydiagnosed

•NPV:NegativePredictiveValue– Proportionofpatientswithnegativetestresultswhoarecorrectlyexcluded

RITA-TTotalscore Sensitivity Specificity PPV NPV

8 1 0.05 0.56 19 1 0.11 0.58 110 1 0.16 0.59 111 1 0.26 0.62 112 1 0.37 0.66 113 1 0.53 0.72 114 1 0.84 0.88 115 0.96 0.84 0.88 0.9416 0.83 0.89 0.90 0.8117 0.74 0.95 0.94 0.7518 0.65 1 1 0.7019 0.61 1 1 0.6821 0.48 1 1 0.6122 0.35 1 1 0.5623 0.30 1 1 0.5424 0.13 1 1 0.4925 0.09 1 1 0.4826 0.04 1 1 0.4627 0 1 1 0.45

Sensitivity&Specificityforallcut-offscores

SUMMARY– CorrelateswellwiththeADOS– Reliability inadministrationandscoringiseasilyobtained– Differentiateswellbetween“TD”&toddlerswithASD– Discriminatessensitivelyandspecificallybetween

toddlerswithDD/NonASD&toddlerswithASDatcutoffscoreof14

– At5-10minutes,itfitsverywell intoclinicflow

ØTheRITA-Tisareliable,valid,Level2interactiveASDscreeningtestfortoddlers

18-36months

OtherValidationStudiesGeneralization&Newmodels

• DivisionofDevelopmentalandBehavioralPediatrics:teamtrainedontheRITA-T(JeanFrancoisLemay,MDFRCPC;twospeechtherapists,andapsychologist)

• Goal:Reducepatientwait-listtimefortoddlers18- 39monthsreferredfordiagnosticevaluationsforpossibleASD

• October,2013:waittobeevaluatedfora0-3ywas12months

• NewmodelandtriagewithRITA-T:– Parentmeeting– MCHAT&RITA-Tadministrationthentriagetospecifictestinggroup(Lowrisk,moderateriskandhighrisk)withdiagnosticevaluations,

treatmentandfollowupprovided.

a- CalgaryAlbertaChildren’sHospitalReplicationStudy-Results

ResultsofNewTriageProtocolContinuesafterstudycompletion

DATE WAITTIMETODIAGNOSTICVISIT

OCT,2013 12-13MONTHS

MAY,2014 6MONTHS

SEPT,2014 2MONTHS

JAN,2016 28days

• This quality improvement (QI) project incorporated evidence-based practice with process improvement methodology.

• The model included: – a) an initial mandatory parent education session followed one week later by – b) a child visit using the face-to-face level II screening tool (RITA-T) + completion

of M-CHAT questionnaire by parents followed in 7-21 days by – c) an ASD diagnostic evaluation appointment (type dependent on score obtained

in screening appointment) and finally the opportunity to attend in the next 2-3 weeks

– d) an “After the ASD Diagnosis” parent group session with a positive diagnosis of ASD.

TriageGroupsBasedonRITA–TScore

LowRisk: score<under12

MediumRisk: scoreisbetween12-16

HighRisk: score>above16

Results• A total of 173 patients were assessed (81% male; mean age 30.74

months +/- 5.53 months, interval 15.4-39.0). Of those 143 children (82.7%) were diagnosed with ASD

• The diagnostic process was completed within a max 30-day cycle (previously >4 months with high variation) and required less hours/child (12 vs 20 hours – overall 40% net gain)

• Waitlist was reduced to <1 month by August 2014 compared to >12 months in October 2013

• The discriminative properties of RITA-T at a cut off score of 12 were calculated: Sensitivity 0.99; Specificity 0.67; Positive Predictive Value 0.91; Negative Predictive Value 0.94.

RESULTS:

ASD NON-ASD

N=133 N=20

MEAN S.D MEAN S.Dp-

VALUE

RITA-TTOTAL 22.3 4.3 10.9 2.9 <.0001

#OFDSM-5CRITERIAHITS 6.2 1.4 3.2 4 <.0001

M-CHATTOTAL 8.81 4.88 3.7 3.83 <.0001

AGE 29.5 4 30.1 5 0.56

CORRELATIONS(CALGARY)

• RITA-TIsuncorrelatedwithageacrossallagegroups

• ModeratelycorrelatedwithM-CHAThits(r=.53)

• ModeratelycorrelatedwithtotalDSM-5criteriaendorsedbyclinician(r=.6)

• WithfemalesRITA-ThighercorrelationwithDSM-5hits(r=.8)

RITA-TSCORESbyDx(0%False-Negatives,2.6%False-Positives)

SummaryCalgaryProject

•Our ASD diagnostic approach of toddlers [12-39 months], a blend of quality improvement and evidence-based practice, has led to innovation in developing an efficient ASD diagnostic assessment process

•Reduced the wait times from 12+ months to 1 month and decreased capacity hours by 40%

•The RITA-T was very useful in the overall process and showed very good discriminative properties comparable to previous results

•This sustainable diagnostic approach promoted practice innovation

•Patients are now able to access critical community supports and resources in a timely manner.

b- OngoingStudiesatUMassinWorcester(DevelopmentalandBehavioralPediatrics- DBP)

a- EarlyInterventionReplicationStudy

TheTHOMEarlyInterventionprograminWorcester:- EIprovidersalltrainedontheMCHAT-R/F- FourEIprovidersfromAutismteamtrainedreliablyontheRITA-T

- Pediatricclinicsinformedaboutstudy.MCHATR/Fcompletedbypediatricians.

- AlltoddlersenrolledinEIprogramreceiveMCHAT-R/F- ThosewithconcernsonMCHATR/ForconcernsclinicallyareadministeredtheRITA-T

- TheyarethenreferredtodiagnosticteaminDBPatUMassinWorcester

36

-DBPUMassWorcesterDiagnosticTeamandTesting

DiagnosticevaluationteamatUMass(phase1)andinEI(Phase2):- TheAutismDiagnosticObservationSchedule(ADOS)-2- TheMullenScalesofEarlyLearning

- Diagnosesdiscussedwithfamilies

- StudyapprovedbyIRB

- Followupprovided

RESULTS• Pilot:BetweenFebruary2016andJune2016:(otherongoingJanuary2017-December2017- noresultsyet)

– 68toddlersenrolled:NonASDin13;ASDin55– Waittime:within4weeks

• Females:15andMales:53• Averageage:29.91months(19-36months)• Ethnicity:

– White:29– Hispanic:15– Other:12– Multiple:3– NA:9

C.RESULTSFROMUMASSEISAMPLE:

ASD Non-ASD

MEASURE N MEAN S.D. N MEAN S.D. P-valueRITATOTAL 55 17.6 5.4 13 12.0 4.0 0.0004MCHATScore 55 3.6 4.4 13 2.3 3.2 NS

MULLENScales earlyLearning(MSEL)

VisualReception(T) 55 29.5 14.3 13 42.3 18.9 0.004ReceptiveLanguage(T) 55 31.2 13.4 13 40.1 15.2 0.03ExpressiveLanguage(T) 55 34.0 13.3 13 38.1 14.1 NSEarlyLearningComp.(SS) 55 65.3 25.3 13 80.9 27.9 0.04

EICORRELATIONS

ASD NON-ASD

WITHASDRITATOTAL CORRELATION WITHNON-ASDRITATOTAL CORRELATION

MCHATScore 0.34 MCHATScore 0.64

MULLEN VR(T) -0.31 MULLEN VR(T) 0.01

Receptive Language(T) -0.36 Receptive Language(T) -0.19

ExpressiveLanguage (T) -0.46 ExpressiveLanguage (T) 0.09

CognitiveTScoreSum -0.11 CognitiveTScoreSum -0.06

ELCompositeSS -0.28 ELCompositeSS -0.08

MullenPercentileRank -0.30 MullenPercentileRank -0.18

ADOSMod1TOTAL(SA+RRB) 0.63 ADOSMod1TOTAL(SA+RRB) 0.67

EISAMPLE:CORRELATIONSCORRELATIONS(WHOLESAMPLE) WithRITA-TTotalScoreMCHATSCORE 0.5AGE -0.24MULLENVR(T) -0.35RECEPTIVELANGUAGE(T) -0.39COGNITIVETSCORESUM -0.11EXPRESSIVELANGUAGE(T) -0.40EARLYLEARNINGCOMP.STANDARDSCORE -0.31MULLENPERCENTILERANK -0.33ADOS-2ToddlerandMOD1TOTAL 0.7

CharacteristicsoftheRITAinthePilotEIsample

• Acutoffscoreof13(18-36months)seemedagooddiscriminatorbetweenASDandnonASDbut

• Sensitivity:0.8• Specificity:0.7• PPV:0.9

b- FurtherEIreplicationandnewmodels

• PediatricpracticestobetrainedontheRITA-T

• OtherEIprograms

• Generalizetoothersettingsandothercultures

SUMMARY:TheRITA-T• CorrelateswellwithAutismdiagnosticmeasures

• Reliabletrainingiseasilyobtained

• DiscriminateswellbetweentoddlerswithDD/NonASD&ASDatcutoffscoreof12(greyarea12-14)

• At5-10minutes,itfitsverywell intoclinicflow

• TheRITA-TisareliableandreasonablyvalidLevel2interactiveASDscreeningtestfortoddlers

• Facilitatesearlierdetectionandtwo-levelscreeningmodels

Futuresteps• Validationpapers• ContinuingtocollectdatafromEIprojectandotherpractices• TwopediatricpracticeswilltrainontheRITA-Tand

establishingaclinicatUMassforfasttrackdiagnosis• PhysiciantrainerinChinaandstudyimplementationofRITA-T

inscreeninganddiagnosticclinicsin2areasinChina• Generalizeitsuseindifferentsettingsandculturesandby

differentproviders.• Forinformationorquestions:

• Roula.choueiri@umassmemorial.org

Futuresteps:RITA-Thttp://www.umassmed.edu/AutismRITA-T/rita-t/

AcknowledgementsRITA-TResearchTeams

TuftsTeam:SheldonWagner,PhD;SusanParsons,MD;

KarenMiller,MD;NicolaSmith,MD;KathleenReilly,CCC-SLP;KrishnaBanerjee,MD;SherylLevy,MD;NaomiSteiner,MD;ChristinaSakai,MD;CarminaErdei,MD;SusanMangan,MS;EricStern,BS;LaurenBrodsky,MS;

Calgaryteam:• JeanFrancoisLemay,MDChinateam:JuneKong,MDUMassteam:• AsherLindenbaum,MS;RoksanaSasanfar,

MD;MargaretManning,PhD;RyanShafer,BS.

• THOMWorcesterEarlyInterventionprogram(JeanineMindrum;ChantalRoyer-Haig;KellyBrennan)

• ITdepartmentandCMEdepartment

Grants1- PlanningGrantTuftsClinical andTranslationalScienceInstitute(CTSI)20102- CVScharitabletrademark(Autismoutcomeresearchproject)3- TuftsSusanSaltonstallPilotGrant20124- UMassPediatricDepartmentSeedgrant5- UMassScholaraward6- WorcesterFairlawnFoundation

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