Authors' reply.

Sir,

We thank Al-Mendalawi MD for going through the contents[1] of our article published in the “Journal of Postgraduate Medicine” (2015;61:243-6).[2] Al-Mendalawi has raised some concerns regarding the results reported by us in our study on the prevalence of autism spectrum disorders (ASDs). We would herein like to address the concerns.

The author has based his argument on two studies published previously, one in the “Indian Journal of Pediatrics” and the other in “Indian Pediatrics.”[34] “Our response, too, the concerns raised by the author is largely based on these two studies only.

In the study published in the “Indian Journal of Pediatrics,” the authors have reported on the sensitivity, specificity, diagnostic odds ratio (DOR), and summary receiver operating characteristic curve and its area under the curve (SROC-AUC) for the overall diagnostic accuracy of Autism Diagnostic Observation Schedule (ADOS). On the basis of this very study, the author presumes that ADOS-Module 1 [ADOS (M1)] could be considered as a better alternative ASD assessment tool as its cumulative diagnostic accuracy has been evaluated by a set of Indian researchers using the original diagnostic algorithm with meta-analysis and meta-regression. However, it seems that Mr. Al-Mendalawi has overlooked the conclusion of this very study wherein the authors state that ADOSM1 with the original diagnostic algorithm lacks the overall diagnostic accuracy and pooled specificity to confirm the diagnosis of ASDs, and ADOSM1 and that the revised diagnostic algorithm should be used instead for the diagnosis of this group of disorders.[3]

In the study published in “Indian Pediatrics” and referred to by the author, the study states that the ideal Indian diagnostic tool for ASDs requires accounting for variable literacy levels and heterogeneous culture and languages.[4] The authors of this study further state that it needs to be inexpensive, accurate, valid, reliable, easy to administer, and able to fulfill multiple purposes including clinical purposes (diagnosis, grading severity, planning intervention, and monitoring), research, and certification. In this regard, therefore, a scale specifically developed and validated for the Indian population [Indian Scale for Assessment of Autism (ISAA)][5] fits the bill more than a scale that needs to be translated and validated according to culture, geography, and language. Importantly, the average time taken to administer ADOS as per its publisher is 40-60 min.[6] One should now calculate the number of working days required to conduct a population-based study on 11,000 children aged 1-10 years in different geographical locations using a module with administering duration of 40-60 min.

Lastly, the diagnosis of ASDs in our study was not entirely based on ISAA.[2] The study was conducted as a two-phase cross-sectional survey wherein ISAA was used as a screening instrument with a follow-up clinical evaluation with a revisit to the ISAA scores. The clinical evaluation included an account of the prenatal conditions, birth history, developmental and medical histories, findings from earlier evaluations (including history of hearing impairment), and intellectual and behavioral functioning.