Prevalence of Unrecognized Autism Spectrum Disorders in Epilepsy: A Clinic-Based Study.

Dear Editor,

In their interesting study, Juneja et al.[1] assessed the prevalence of unrecognized autism spectrum disorders (ASDs) and evaluated factors affecting it in Indian children with epilepsy using Diagnostic and Statistical Manual of Mental Disorders (Fourth edition) (DSM-IV) criteria. They found that the prevalence of unrecognized ASDs was higher than that in general population, and in cases with associated intellectual disability, co-occurrence of ASD was further increased. That risk was not related to the age of onset of epilepsy, frequency of seizures, seizure type, or intractability of epilepsy. They recommended screening all children with epilepsy, particularly those with intelligence quotient ≤50, irrespective of age of onset of epilepsy, seizure type, frequency of seizures, or intractability of epilepsy.[1] I presume that aforementioned results and recommendation ought to be cautiously interpreted. Apart from many limitations addressed by Juneja et al.,[1] which might shed some suspicions on the study results, I presume that the following methodological limitation related to ASDs assessment tool used in the study might be further contributory. It is obvious that DSM-IV tool is old, released more than a decade ago, and it is no more worthy.[2] In 2014, International Epidemiology Network (INCLEN) Diagnostic Tool for Autism Spectrum Disorder (INDT-ASD) was indigenously developed in India based on DSM-IV guidelines for the assessment of children with ASDs. The tool has been developed with regional issues of tool construction in mind, as opposed to an international context.[3] Evaluation of INDT-ASD in Indian pediatric population has revealed that INDT-ASD was superior to DSM-IV criteria in terms of having a high diagnostic accuracy (area under the curve (AUC) = 0.97, 95% confidence interval [CI]: 0.93, 0.99; P < 0.001), adequate content validity (sensitivity 98%, specificity 95%, positive predictive value 91%, and negative predictive value 99%), good internal consistency (0.96), high to moderate convergent validity with childhood autism rating scale (r = 0.73, P = 0.001), and high divergent validity with Binet–Kamat test of intelligence (r = -0.37, P = 0.004) as well as four-factor construct validity for the diagnosis of ASDs.[3] Moreover, it has been suggested that INDT-ASD could continue to be used for the diagnosis of ASDs even after the adoption of DSM-V criteria.[4] I wonder why Juneja et al.[1] did not refer to INDT-ASD instead of DSM-IV in their study. I presume that if they used INDT-ASD, more precise results might be yielded.

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