J Compr Ped. 2014 August; 5(3): e21730.

Published online 2014 August 25. Research Article

Early Detection of Autism Spectrum Disorders in Children With Attention

Deficit Hyperactivity Disorder by Modified Checklist for Autism in Toddlers:
a Pilot Study From India
1,* 1 1 2
Shivanand Kattimani ; Siddharth Sarkar ; Balaji Bharadwaj ; Vengadavaradan Ashvini ;
2
Subramanian Mahadevan
1Department of Psychiatry, JIPMER, Dhanvantari Nagar, Pondicherry, India
2Department of Pediatrics, JIPMER, Dhanvantari Nagar, Pondicherry, India

*Corresponding author: Shivanand Kattimani, Department of Psychiatry, JIPMER, Dhanvantari Nagar, Pondicherry, Pin 605006, India. Tel: +91-9488830078, Fax: +91-413-2272067, E-
mail: [email protected]

Received: July 2, 2014; Revised: August 2, 2014; Accepted: August 24, 2014

Background: Symptoms of autism spectrum disorders (ASD) are commonly observed in children diagnosed with Attention Deficit/
Hyperactivity Disorder (ADHD). These symptoms might underlie social and functional impairment in such children. The existing
classification systems do not allow for diagnosing both conditions in children.
Objectives: This study aimed to assess the presence of ASD in a hospital-based sample of children diagnosed with ADHD and to find the
utility of Modified Checklist for Autism in Toddlers (MCHAT) through using parent recall in predicting development of ASD.
Patients and Methods: A total of 50 children with a diagnosis of ADHD, who attended the Child Guidance Clinic of a tertiary care hospital
in Southern India, were recruited through simple random sampling from July to December 2012. These children were assessed for current
ASD using Childhood Autism Rating Scale (CARS) and MCHAT based on parents recall. To test the diagnostic accuracy of MCHAT in early
detection of ASD (index test), CARS was used as a reference test. OpenEpi 3.01 software was used for computing sensitivity, specificity,
positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy.
Results: Among 50 children, 30 (60%) had scores over the cutoff point of 33 on CARS while 38 (76%) had scored over the cutoff point
on MCHAT, qualifying for presence of ASD. Moreover, presence of ASD was associated with older age (P = 0.035), greater risk of medical
comorbidities (P = 0.022), lower social quotient on Vineland Social Maturity Scale (VSMS) (P = 0.001), and poorer global functioning
according to Children’s Global Assessment Scale (CGAS) (P = 0.002). Using CARS as Gold Standard, the sensitivity and specificity of MCHAT
in predicting ASD were 86.7% and 40.0%, respectively. The PPV and NPV of MCHAT in detecting ASD were respectively 68.4% and 66.7%.
Conclusions: ASD is present in considerable proportion of children diagnosed with ADHD. MCHAT could be a useful instrument for early
detection of children at risk of developing ASD.

Keywords:Child Development Disorders, Pervasive; Early Diagnosis; Autistic Disorder

1. Background
Attention Deficit/Hyperactivity Disorder (ADHD) is a of ASD than due to ADHD per se (7). Currently, ADHD and
common neurodevelopmental condition of childhood ASD cannot be diagnosed together in a child based on
that affects about 5% of the population (1). ADHD is as- two most commonly used classification systems such as
sociated with significant impairment in social domains, ICD-10 (13) and DSM-IV TR (14). Children with ADHD and
peer relationships, and poor quality of life (2-5). Autism comorbid ASD are at risk of more severe impairment and
spectrum disorder (ASD) is a broad umbrella term used might require different approach in care than tradition-
to refer to a group of similar conditions including au- ally given to those only with ADHD. Early recognition of
tism, atypical autism, Asperger’s syndrome, and perva- the symptoms of ASD is important as early intervention
sive developmental disorder-not otherwise specified can help such children (15). Modified Checklist for Autism
(PDD-NOS) (6, 7), which are severe developmental dis- in Toddlers (MCHAT) is a commonly used screening scale
orders characterized by deficits in language and social to identify children at risk of ASD (16). There is a lack of
communication. Clinical observation of ASD symptoms research and systematic assessing for the presence of
in children diagnosed with ADHD as well as detecting comorbid ASD in children with ADHD in the South Asia
hyperactivity and impulsivity in children with ASD is and India. Furthermore, no study has assessed the util-
common (8-12). There are reports that poor functioning ity of MCHAT in detecting children at risk of developing
in ADHD children is more likely to be due to symptoms ASD. Conducting such prospective studies in developing

Copyright © 2014, Iranian Society of Pediatrics. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0
International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided
the original work is properly cited.
 Kattimani S et al.

countries such as India is difficult due to large catchment during 16 to 30 months old to identify those who were at
areas of Government hospitals and difficulty in ensuring risk of developing ASD. The study got Institutional Ethics
follow-up. Hence, we aimed to assess the presence of ASD Committee approval and data collection lasted from July
in children with ADHD based on the recalls by parents on 1, 2012 through December 31, 2012. Data for each case was
MCHAT, which would help us to assess the future possibil- collected in a single setting. The index test and the refer-
ity of using MCHAT in early toddlerhood for predicting ence test were applied to all the 50 children. One of the
the later development of ASD. authors (SK) applied the CARS and another one (VA) ap-
plied MCHAT. The two raters were aware of the diagnosis
2. Objectives of ADHD in the children, but were blinded to the ratings
of each other. Social quotient was ascertained as per In-
Current study aimed to answer two clinical queries:
dian adaptation of Vineland Social Maturity Scale (VSMS)
(a) What proportion of children diagnosed with ADHD
(18) and children functioning was assessed on Children’s
would have ASD? (b) What was the diagnostic accuracy of
Global Assessment Scale (CGAS) (19).
MCHAT in early detection of ASD in such children?
3.2. Instruments
3. Patients and Methods
CARS (15) includes 15 symptoms of behavioral and
communication abnormalities that are typically seen in
3.1. Setting and Procedure children with ASD. First 14 symptoms are rated based on
The present exploratory study was conducted at the symptom severity over last six months as noticed by the
Child Guidance Clinic (CGC) of a tertiary-care hospital parents and on the observation of the child’s behavior
in Southern India. The CGC was run twice a week by the during the interview. The 15th item assesses global se-
Department of Pediatrics in collaboration with the De- verity of these behaviors. The items are rated on a scale
partment of Psychiatry. The hospital is situated in the of zero to four with higher scores showing more severe
semi-urban area and caters for both referred as well as abnormality. Total scores can vary from zero to 60. Vali-
nonreferred population. Children were most often ac- dation of this scale in Indian Children suggests a cutoff
companied by their parents. The treatment seekers were score of 33 (20). Children above this cutoff point are
mainly comprised of middle and lower socioeconomic termed ASD+ and the rest as ASD-. The individual items
status population in the region and the treatment was on CARS were categorized as present or absent based on
highly subsidized by the government. a cutoff score of three for this study purpose. MCHAT (21)
Children aged 12 years or younger with a range of dis- is a 23-item checklist of behaviors of toddlers who aged
orders including ASD, ADHD, and intellectual disability between 16 months to 30 months and is rated as per par-
with behavioral problems, learning disorders, and mood ent report. Presence of each of the behavior could be an-
and anxiety disorders are seen in this clinic. Diagnosis swered as yes (pass/present) or no (fail/absent). Scores
was made by the consultants through consensus clinical considered abnormal if there were overall three or more
judgment using DSM IV TR criteria (12). "No"s or two or more "No"s in six of the critical behaviors
The present study recruited children with the diagno- (items 2, 7, 9, 13, 14, and 15). Abnormal scores raised sus-
sis of ADHD according to DSM IV TR. Children were diag- picion of the presence of autism and required further
nosed with ADHD if they fulfill at least six criteria under evaluation. Children with abnormal MCHAT (MCHAT+)
inattention domain or hyperactivity-impulsivity domain were more likely to develop ASD or some other devel-
or both for at least six months with functional impair- opmental problems. For this study purpose, we asked
ment and onset of symptoms before the age of seven parents to fill the checklist from their recall of the child
years; such symptoms should not be attributable to other aged between 16 to 30 months. If there was difference of
conditions including pervasive developmental disorder. opinion on any item, both parents were asked to reach
The list of children who had been diagnosed with ADHD consensus before responding. To estimate the level of
during the two consecutive years before the study was social development, Indian adaptation of the VSMS (16)
drawn up, which included 140 children. Among them, was used to assess the level of adaptive tasks a child was
a list of 50 children was randomly selected (simple ran- capable of doing. It was used for evaluating social quo-
dom list of 50 cases was generated using Microsoft Of- tient of the child and showed a high correlation (0.80)
fice Excel). For pilot study, this number was considered with intelligence quotient. CGAS (17) is an adaptation of
adequate. These children were actively recruited and the Global Assessment of Functioning scale for children.
assessed as they came for follow-up. Informed consent It provides an estimate of child’s level of functioning ir-
was obtained from the parents. Data on sex, age, birth respective of primary diagnosis or treatment. It is rated
order, history of antenatal or postnatal complications, on a scale of one to 100 based on provided information
and medical illnesses were collected. Childhood Autism by the parents. Higher CGAS score reflects better global
Rating Scale (CARS) (17) was used to document current functioning of the child. For this study purpose, we col-
symptoms and screen for the presence of ASD. Parent re- lected the best functioning status of the child in the pre-
call ratings on MCHAT were obtained for child’s behavior ceding six months.

2 J Compr Ped. 2014;5(3):e21730

 Kattimani S et al.

3.3. Analysis 4. Results

Demographic and clinical data were presented as A total of 50 children who were diagnosed with ADHD
mean ± standard deviation for continuous data and as were recruited through random sampling from a pool
frequency (percentage) for categorical data. The data of 140 eligible children (Figure 1). The clinical and de-
were also categorized into two groups of ASD+ and mographic information of the sample is shown in Table
ASD- based on the overall score on CARS indicating cur- 1. Majority of the sample were boys, and about half of
rent presence or absence of ASD. We examined any sig- the sample reported postnatal complications. Medical
nificant difference in sex, age, antenatal and postnatal comorbidities were noted in 20 children (40%) with sei-
complications, social quotient, functioning level, and zures being the most common one (15 children). Thirty
for presence of individual symptoms of ASD using non- children had scored higher than the CARS cutoff suggest-
parametric tests. Based on MCHAT scores as recalled ing the presence of current ASD (ASD+) (Table 1). Scores
from toddlerhood, entire group was classified as be- over cutoff point on CARS was associated with older
ing abnormal or normal, represented as MCHAT+ or age (P = 0.035), higher risk of medical comorbidities (P
MCHAT-, respectively. The groups were compared with = 0.022), lower social quotient (P = 0.001), and poorer
each other using appropriate nonparametric tests due global functioning and (U = 145.5; P = 0.002). On correla-
to small sample sizes. A P value of < 0.05 on two-tailed tion analysis, it was seen that total CARS scores were in-
test was considered as statistically significant. To test versely correlated with social quotient (Spearman rho [rs]
the diagnostic accuracy of MCHAT in early detection of = - 0.466; P = 0.001) and functioning rated on CGAS (rs =
ASD (index test), CARS was used as a reference test. Ope- - 0.503; P < 0.001).
nEpi 3.01 software (www.openepi.com) for diagnostic The items on CARS, which differentiated ASD+ from ASD-
screening test was used. Sensitivity, specificity, positive , are shown in Table 2. Although most items on CARS re-
predictive value (PPV), negative predictive value (NPV), liably differentiated autistic symptoms in children with
and diagnostic accuracy were computed. We did not ADHD, “object use”, “adaptation to change”, and “taste,
use any statistical correction for the multiple tests per- smell, and touch response and use” were not helpful. The
formed. mean scores on the CARS items are shown in Figure 2.

Eligible Children
(n=140)

Excluded through simple

random sampling (n=90)

Included
(n=50)

Reference test:
CARS

CARS Abnormal CARS Normal

(n=30) (n=20)

Index test: Index test:

MCHAT MCHAT

MCHAT Abnormal MCHAT Normal MCHAT Abnormal MCHAT Normal

(n=26) (n=4) (n=8) (n=12)

Figure 1. Patient Recruitment and Screening Flowchart

J Compr Ped. 2014;5(3):e21730 3

 Kattimani S et al.

Finally, 38 children (76%) had abnormal scores on The MCHAT was associated with high sensitivity (86.7%),
MCHAT as per parent recall (Table 3). Next, a diagnos- but low specificity (40.0%). The PPV and NPV were 68.4%
tic test comparing MCHAT as a screening instrument and 66.7%, respectively, in this sample of children with
with CARS as a gold standard was conducted (Table 4). ADHD.

Figure 2. Mean Scores of Individual Items of Childhood Autism Rating Scale

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

Relating to people

Imitation

Emotional response

Body use

Object use

Adaptation to change

Visual response

Listening response

Taste, smell, and touch response and use

Fear or nervousness

Verbal communication

Nonverbal communication

Activity level

Level and consistency of intellectual response

General impression

ASD- ASD+

ASD, autism spectrum disorder.

Table 1. Comparison of Children With and Without Autism Spectrum Disorder as per CARS Cutoff Point of > 33 a,b
A B C Comparison B vs. C
(P Value)
Total Sample (n = 50) ADHD Children Over ADHD Children Below
CARS Cut-off Scores CARS Cut-off Scores
(ASD+) (n = 30) (ASD-) (n = 20)
Male Sex 43 (86.0%) 25 (83.3) 18 (90.0) χ2 = 0.443 (0.687)c
Age in Months 97.0 ± 35.8 105.7 ± 34.6 83.9 ± 34.3 U = 193.5 (0.035)d
Birth Order χ2 = 0.521 (0.470)
First 30 (60.0) 17 (56.7) 13 (65.0)
Second and Higher 20 (40.0) 13 (43.3) 7 (35.5)
Reported Antenatal Complica- 10 (20.0) 5 (16.7) 5 (25.0) χ2 = 0.521 (0.470)
tion
Reported Postnatal Complica- 22 (44.0) 13 (43.3) 9 (45.0) χ2 = 0.014 (0.907)
tions
Present Comorbid Medical 20 (40.0) 16 (53.3) 4 (20.0) χ2 = 5.556 (0.022) c,d
Conditions
Social Quotient as per VSMS 92.3 ± 18.0 86.0 ± 18.2 101.9 ± 13.2 U = 132.5 (0.001)c
CGAS score 50.4 ± 14.4 45.6 ± 15.0 57.6 ± 10.0 U = 143.5 (0.002)c
a Abbreviations: ADHD, attention deficit hyperactivity disorder; ASD, autism spectrum disorder; CARS, Childhood Autism Rating Scale; CGAS, Children’s
Global Assessment Scale; and VSMS, Vineland Social Maturity Scale.
b Data are presented as No. (%) or mean ± SD.
c P < 0.05.
d Fisher’s exact test.

4 J Compr Ped. 2014;5(3):e21730

 Kattimani S et al.

Table 2. Frequency of Individual Behaviors on Childhood Autism Rating Scale in Children With and Without Autistic Spectrum
Disorder a,b

ADHD Children
Odds Ratio (Confi-
CARS Item Over CARS Cutoff Below CARS Cutoff Scores dence Intervals)
Scores (ASD+) (n = 30) (ASD-) (n = 20), No. (%)

Relating to People 25 (83.3) 3 (15.0) 28.33 [5.96-134.61]

Imitation 17 (56.7) 3 (15.0) 7.41 [1.78-30.78]

Emotional Response 16 (53.3) 1 (5.0) 21.71 [2.57-183.63]

Body Use 14 (46.7) 2 (10.0) 7.88 [1.55-40.09]

Object Use 8 (26.7) 1 (5.0) 6.91 [0.79-60.37]

Adaptation to Change 5 (16.7) 3 (15.0) 1.13 [0.24-5.38]

Visual Response 17 (56.7) 1 (5.0) 24.85 [2.93-210.46]

Listening Response 15 (50.0) 1 (5.0) 19.00 [2.25-160.59]

Taste, Smell, and Touch Response and Use 11 (36.7) 3 (15.0) 3.28 [0.78-13.77]

Fear or Nervousness 19 (63.3) 6 (30.0) 4.03 [1.2-13.53]

Verbal Communication 21 (70.0) 5 (25.0) 7.00 [1.95-25.13]

Nonverbal Communication 13 (43.3) 1 (5.0) 14.53 [1.72-123.07]

Activity Level 17 (56.7) 4 (20.0) 5.23 [1.41-19.43]

Level and Consistency of Intellectual Response 20 (66.7) 6 (30.0) 4.67 [1.38-15.82]

General Impression 23 (76.7) 3 (15.0) 18.62 [4.19-82.67]

a Abbreviation: ADHD, attention deficit hyperactivity disorder; ASD, autism spectrum disorder; and CARS, Childhood Autism Rating Scale.
b Data are presented as No. (%).

Table 3. Comparison of Children With Normal and Abnormal Scores Using Modified Checklist for Autism in Toddlers During Tod-
dlerhood a,b

Children With Normal Children With Abnormal P Value

MCHAT Scores (MCHAT-) MCHAT Scores (MCHAT+)
(n = 12) (n = 38)

Male Sex 12 (100.0) 31 (81.6) Χ2 = 2.570 (0.174)a

Age, mo 101.8 ± 34.8 95.5 ± 36.4 U = 201 (0.540)

Birth Order Χ2 = 0.397 (0.529)

First 6 (50.0) 24 (63.2)

Second and Higher 6 (50.0) 14 (36.8)

Reported Antenatal Complication 3 (25.0) 7 (18.4) Χ2 = 0.247 (0.686) a

Reported Postnatal Complications 5 (41.7) 17 (44.7) X2 = 0.032 (0.852)

Presence of Comorbid Medical Conditions 5 (41.7) 15 (39.5) χ2 = 0.018 (0.892)

Social Quotient as per VSMS 98.3 ± 13.6 90.4 ± 19.0 U = 158 (0.112)

CGAS Score 57.0 ± 11.6 48.3 ± 14.7 U = 145 (0.058)

CARS Score 29.0 ± 7.3 35.5 ± 8.0 U = 123 (0.017)c

CARS Score Over Cutoff [ASD+] 4 (33.3) 26 (68.4) χ2 = 4.678 (0.044)cd

a Abbreviation: ADHD, attention deficit hyperactivity disorder; ASD, autism spectrum disorder; CARS, Childhood Autism Rating Scale; CGAS, Children’s
Global Assessment Scale; MCHAT, Modified Checklist for Autism in Toddlers; and VSMS, Vineland Social Maturity Scale.
b Data are presented as mean ± SD or No. (%).
c P < 0.05.
d Fisher’s exact test used.

J Compr Ped. 2014;5(3):e21730 5

 Kattimani S et al.

Table 4. Comparison of Modified Checklist for Autism in Toddlers with Childhood Autism Rating Scale Based Autism Spectrum
Disorder Status (CARS > 33) a
Current ASD+ Current ASD- Total Confidence Intervals
Recalled MCHAT +, No. 26 12 38
Recalled MCHAT -, No. 4 8 12
Total 30 20 50
Parameters, %
Sensitivity 86.7 [70.3-94.7]
Specificity 40.0 [21.9-61.3]
Positive Predictive Value 68.4 [52.5-80.9]
Negative Predictive Value 66.7 [39.1-86.2]
Diagnostic Accuracy 68.0 [54.2-79.2]
a Abbreviations: CARS, Childhood Autism Rating Scale; and MCHAT, Modified Checklist for Autism in Toddlers.

5. Discussion difference in the rates of antenatal or postnatal compli-

cations between the ASD+ and ASD- groups, suggesting
According to the present study, a large proportion
lesser role for environmental factors in the comorbid oc-
of children with the diagnosis of ADHD qualified for
currence of ADHD and ASD. The finding that higher CARS
ASD. Presence ASD was associated with increased rates
scores are associated with poor social quotient and func-
of medical illnesses, lower social quotient, and poorer
tioning were on the expected lines (27). Among the CARS
global functioning level. ASD, defined by CARS score >
items, "object use", "adaptation to change", and "taste,
33, was present in about 60% of the children with ADHD.
A study by Clark et al. (21) found that 65% to 80% of par- smell, and touch response and use" were not quite differ-
ents recalled presence of autistic symptoms in children ent between ASD+ and ASD- groups, which suggested that
with ADHD. This study used the Autism Criteria Checklist selected items were not good indicators of autistic behav-
to make the diagnosis of ASD. Two widely differing rates ior in this population of children with ADHD. Although
of comorbid ASD were found in a study by Kochhar et al. MCHAT score was related to CARS score, MCHAT score
(22); the rate of ASD among children with ADHD was 28% per se was not significantly linked with social quotient
as defined by the Social Communication Questionnaire or global functioning, which suggested that parents of
(SCQ), whereas the rate was as high as 62% when the So- children with ADHD might recollect autistic behaviors in
cial Aptitudes Scale (SAS) was used. This difference would their children even in the absence of current ASD. Criti-
be probably because of the different construct and dis- cal items on MCHAT are specifically aimed at eliciting
criminant validity of these scales. Studies that assessed deficits in imitation, joint attention, and pointing abili-
the presence of autistic symptoms among children with ties and have discriminating value in detecting autism.
ADHD have also found higher rates of autistic symptoms The age of child and recalled MCHAT score (rs = - 0.222, P
in children with ADHD than in controls. These studies = 0.121) showed poor correlation, which suggested a low
sought the presence of autistic symptoms as a dimen- likelihood of recall bias. This could explain the utility of
sion, which opposed attempts to make a categorical di- MCHAT even in a retrospective study. As the child grows
agnosis of ASD (6, 23, 24). A similar operational definition up, many of these "core" clinical features might improve
of Autistic Traits (AT) was used by Kotte et al. (9) using while some other deficits might persist. This might ex-
three subscores (withdrawn, social, and thought prob- plain the finding of MCHAT+ rate (76%) being higher than
lems) from the Child Behavior Checklist (7). The reasons ASD+ rate using CARS cutoff score (60%).
for the high rates of coincidence of the ADHD and ASD in This pilot study suggested that MCHAT had acceptable
our study would be similarities in particular phenotypic properties as screening instrument for early detection of
behavioral manifestations such as difficulty in maintain- children at risk for ASD in the Indian population. This rep-
ing social relationships. The cause of difficulties in social resentative clinical sample of children diagnosed with
relationships may be different with indifference to rela- ADHD strengthens the recent change in DSM-5 which
tionship in autism and difficulty in engaging in coopera- allows diagnosis of ADHD even in presence of autism
tive interaction in ADHD. Both of those manifestations spectrum traits (28). Same change might be required in
might be captured as similar in structured instruments. upcoming revision of mental and behavioral disorder
The second reason for the high rate could be sharing of chapter in ICD-11. Limitations of the study included re-
common vulnerability factors by these disorders. It has stricted sampling of a clinic-based population, lack of ex-
been suggested that overlap of symptoms might be at ternal control group, and lack of systematic assessment
least partly genetic (25, 26). Our study did not find any for family history of ASD. CARS score was used to define

6 J Compr Ped. 2014;5(3):e21730

 Kattimani S et al.

ASD and further structured clinical interviews were not 9. Kotte A, Joshi G, Fried R, Uchida M, Spencer A, Woodworth KY, et
al. Autistic traits in children with and without ADHD. Pediatrics.
used to confirm the diagnosis of autism. The rating on
2013;132(3):e612–22.
MCHAT was based only upon retrospective recall by the 10. Sinzig J, Walter D, Doepfner M. Attention deficit/hyperactivity
parents although other studies had also attempted to rate disorder in children and adolescents with autism spectrum dis-
scores related to autistic behaviors retrospectively (29). It order: symptom or syndrome? J Atten Disord. 2009;13(2):117–26.
11. van Steijn DJ, Richards JS, Oerlemans AM, de Ruiter SW, van
will be worthwhile to study how many children with ear- Aken MA, Franke B, et al. The co-occurrence of autism spectrum
ly detection of ASD progress into full-blown ADHD symp- disorder and attention-deficit/hyperactivity disorder symp-
toms. The findings of the study relate to a tertiary care toms in parents of children with ASD or ASD with ADHD. J Child
center with child guidance facilities and extrapolation Psychol Psychiatry. 2012;53(9):954–63.
12. Lee DO, Ousley OY. Attention-deficit hyperactivity disorder
to other situations should be done carefully. To conclude, symptoms in a clinic sample of children and adolescents with
the present study suggested that ASD is present in a large pervasive developmental disorders. J Child Adolesc Psychophar-
proportion of children with ADHD and is associated with macol. 2006;16(6):737–46.
13. World Health Organization.. The ICD-10 Classification of Mental
poor functioning. MCHAT can be a sensitive screening and Behavioural Disorders: Clinical Descriptions and Diagnostic
test for early detection of ASD in children diagnosed with Guidelines.: WHO; 1992.
ADHD. Prospective community-based screening studies 14. American Psychiatric Association.. Diagnostic And Statistical
are required to assess the usefulness of MCHAT to predict Manual Of Mental Disorders DSM-IV-TR Fourth Edition (Text Revi-
sion) Author: American Psychiatr.: American Psychiatric Publish-
the development ASD in the population. ing; 2000.
15. Harris SL, Handleman JS. Age and IQ at intake as predictors of
Acknowledgements placement for young children with autism: a four- to six-year
follow-up. J Autism Dev Disord. 2000;30(2):137–42.
We express our thanks to pediatric residents and par- 16. Robins DL, Fein D, Barton ML, Green JA. The Modified Checklist
ents of children with ADHD for their co-operation and for Autism in Toddlers: an initial study investigating the early
detection of autism and pervasive developmental disorders. J
participation. Autism Dev Disord. 2001;31(2):131–44.
17. Schopler E, Reichler RJ, DeVellis RF, Daly K. Toward objective
Authors’ Contributions classification of childhood autism: Childhood Autism Rating
Scale (CARS). J Autism Dev Disord. 1980;10(1):91–103.
Study concept and design, drafting of the manuscript, 18. Malin AJ. Indian Adaptation of Vineland Social Maturity Scale.
statistical analysis, and analysis and interpretation of Lucknow Indian Psychol Corp. 1971.
19. Shaffer D, Gould MS, Brasic J, Ambrosini P, Fisher P, Bird H, et al.
data: Shivanand Kattimani and Siddharth Sarkar. Admin-
A children's global assessment scale (CGAS). Arch Gen Psychiatry.
istrative, technical, and material support and study su- 1983;40(11):1228–31.
pervision: Subramanian Mahadevan. Acquisition, analy- 20. Russell PS, Daniel A, Russell S, Mammen P, Abel JS, Raj LE, et al.
sis, and interpretation of data: Vengadavaradan Ashvini Diagnostic accuracy, reliability and validity of Childhood Au-
tism Rating Scale in India. World J Pediatr. 2010;6(2):141–7.
and Balaji Bharadwaj. Critical revision of the manuscript 21. Clark T, Feehan C, Tinline C, Vostanis P. Autistic symptoms in
for important intellectual content: All authors. children with attention deficit-hyperactivity disorder. Eur Child
Adolesc Psychiatry. 1999;8(1):50–5.
22. Kochhar P, Batty MJ, Liddle EB, Groom MJ, Scerif G, Liddle PF,
References et al. Autistic spectrum disorder traits in children with at-
1. Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. tention deficit hyperactivity disorder. Child Care Health Dev.
The worldwide prevalence of ADHD: a systematic review and 2011;37(1):103–10.
metaregression analysis. Am J Psychiatry. 2007;164(6):942–8. 23. Reiersen AM, Constantino JN, Volk HE, Todd RD. Autistic traits in
2. Nijmeijer JS, Minderaa RB, Buitelaar JK, Mulligan A, Hartman a population-based ADHD twin sample. J Child Psychol Psychia-
CA, Hoekstra PJ. Attention-deficit/hyperactivity disorder and try. 2007;48(5):464–72.
social dysfunctioning. Clin Psychol Rev. 2008;28(4):692–708. 24. Mulligan A, Anney RJ, O'Regan M, Chen W, Butler L, Fitzgerald
3. Hoza B. Peer functioning in children with ADHD. J Pediatr Psy- M, et al. Autism symptoms in Attention-Deficit/Hyperactivity
chol. 2007;32(6):655–63. Disorder: a familial trait which correlates with conduct, op-
4. Jargin SV. Attention Deficit Hyperactivity (ADHD) and Autism positional defiant, language and motor disorders. J Autism Dev
Spectrum Disorder (ASD): on the Role of Alcohol and Societal Disord. 2009;39(2):197–209.
Factors. Int J High Risk Behav Addict. 2013;1(4):194–5. 25. Kroger A, Hanig S, Seitz C, Palmason H, Meyer J, Freitag CM. Risk
5. Hadi N, Saghebi A, Ghanizadeh A, Montazeri A, Psychitrist M. factors of autistic symptoms in children with ADHD. Eur Child
Assessment of Health-Related Quality of Life in Mothers of Chil- Adolesc Psychiatry. 2011;20(11-12):561–70.
dren with Attention-Deficit Hyperactivity Disorder (ADHD), Shi- 26. Nijmeijer JS, Arias-Vasquez A, Rommelse NN, Altink ME, Anney
raz, 2008-2009. Shiraz E Med J . 2013;14(91–101). RJ, Asherson P, et al. Identifying loci for the overlap between
6. Johnson CP, Myers SM, American Academy of Pediatrics Council attention-deficit/hyperactivity disorder and autism spectrum
on Children With D. Identification and evaluation of children disorder using a genome-wide QTL linkage approach. J Am Acad
with autism spectrum disorders. Pediatrics. 2007;120(5):1183– Child Adolesc Psychiatry. 2010;49(7):675–85.
215. 27. Nath S, Roy R, Mukherjee S. Perinatal complications associated
7. Volkmar FR, State M, Klin A. Autism and autism spectrum dis- with autism--a case control study in a neurodevelopment and
orders: diagnostic issues for the coming decade. J Child Psychol early intervention clinic. J Indian Med Assoc. 2012;110(8):526–9.
Psychiatry. 2009;50(1-2):108–15. 28. American Psychiatric Association.. Diagnostic and statistical
8. Grzadzinski R, Di Martino A, Brady E, Mairena MA, O'Neale manual of mental disorders.Arlington: American Psychiatric
M, Petkova E, et al. Examining autistic traits in children with Publishing; 2013.
ADHD: does the autism spectrum extend to ADHD? J Autism Dev 29. Singhi P, Malhi P. Clinical and neurodevelopmental profile of
Disord. 2011;41(9):1178–91. young children with autism. Indian Pediatr. 2001;38(4):384–90.

J Compr Ped. 2014;5(3):e21730 7