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Published: 15 November 2024 ,
Received: 08 May 2023 ,
Revised: 27 September 2023
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孤独症谱系障碍(ASD)儿童的适应行为能力普遍受到损害,然而其与早期发展水平之间的关系尚不明确。深入开展二者间关系的研究,将有助于了解ASD儿童能力的发展规律,促进ASD儿童早期个体化干预的实施。本文回顾性选取了1656例在2019年1月至2022年3月期间在浙江大学医学院附属儿童医院发育行为科被诊断为ASD的儿童,汇总了《婴儿-初中学生社会生活能力量表》和《Gesell发育诊断量表》(GDS)的结果,并进行统计学分析。结果表明,年龄会影响ASD儿童的适应行为以及GDS中各能区的早期发展;同时,适应行为也会显著影响GDS各能区的发育商数,且呈正相关关系。综上所述,ASD儿童的适应行为和各方面能力相互影响,因此有必要对不同ASD个体能力进行全面评估,并采取个体化的综合干预模式。
The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) (
Contemporary developmental theory holds that development in all domains depends on the interaction between developmental domains, and different developmental domains do not develop in isolation (
This study included 1656 children with ASD. The youngest participant was 1.5 years old, the oldest was 5.6 years old, and the average age was (2.67±0.59) years. Among the participants, 86.78% had abnormal adaptive behavior and 43.90% had mild or more severe impairment. These children all lagged behind to varying degrees in the five domains assessed by the Gesell Developmental Schedules (GDS), among which the language lagged behind the most (
Variable | Number(percentage) | Adaptability | Gross motor | Fine motor | Language | Personal-social activity | |||||
---|---|---|---|---|---|---|---|---|---|---|---|
Mean±SD | P-value | Mean±SD | P-value | Mean±SD | P-value | Mean±SD | P-value | Mean±SD | P-value | ||
Gender | |||||||||||
Male | 1297 (78.32%) | 67.81±16.92 | 0.046 | 77.88±14.33 | <0.001 | 71.66±17.83 | 0.105 | 47.57±16.51 | 0.164 | 60.80±13.83 | 0.731 |
Female | 359 (21.68%) | 65.80±16.60 | 75.09±13.88 | 73.40±18.34 | 46.19±17.23 | 61.09±14.09 | |||||
Premature | |||||||||||
No | 1572 (94.93%) | 67.53±16.80 | 0.094 | 77.20±14.03 | 0.339 | 72.23±17.95 | 0.061 | 47.35±16.57 | 0.402 | 60.98±13.66 | 0.154 |
Yes | 84 (5.07%) | 64.37±17.90 | 78.73±18.37 | 68.46±17.60 | 45.79±18.53 | 58.76±17.54 | |||||
Age (years) | |||||||||||
1.5‒2.0 | 158 (9.54%) | 73.49±14.83 | <0.001 | 90.15±13.80 | <0.001 | 79.15±16.34 | <0.001 | 50.94±14.65 | 0.005 | 72.71±14.53 | <0.001 |
2.0‒3.0 | 1085 (65.52%) | 69.22±16.58 | 78.80±12.39 | 74.07±17.28 | 47.27±16.37 | 61.30±12.14 | |||||
≥3.0 | 413 (24.94%) | 60.18±16.16 | 68.33±13.86 | 63.98±17.64 | 45.87±17.95 | 55.20±14.80 | |||||
Adaptive function | |||||||||||
Normal and high normal | 219 (13.22%) | 80.45±14.09 | <0.001 | 88.47±13.41 | <0.001 | 84.60±17.05 | <0.001 | 65.09±17.42 | <0.001 | 75.20±12.45 | <0.001 |
Borderline impairment | 710 (42.87%) | 70.72±13.84 | 80.59±12.33 | 74.81±15.22 | 51.85±13.33 | 64.59±10.91 | |||||
Mild impairment | 569 (34.36%) | 63.22±15.63 | 72.98±11.92 | 68.21±16.70 | 39.74±12.33 | 55.39±10.31 | |||||
Moderate impairment and above | 158 (9.54%) | 49.15±17.02 | 62.31±13.49 | 55.97±19.21 | 29.11±8.95 | 44.01±12.27 | |||||
Sum | 1656 (100.00%) | 67.37±16.87 | 77.27±14.28 | 72.04±17.95 | 47.27±16.67 | 60.87±13.88 |
SD: standard deviation.
Age significantly affected the developmental quotient (DQ) of each domain (P<0.05) (
Variable | Adaptive function | Sum | P-value | |||
---|---|---|---|---|---|---|
Normal and high normal | Borderline impairment | Mild impairment | Moderate impairment and above | |||
Gender | ||||||
Male | 173 | 575 | 432 | 117 | 1297 | 0.083 |
Female | 46 | 135 | 137 | 41 | 359 | |
Premature | ||||||
No | 210 | 675 | 540 | 147 | 1572 | 0.653 |
Yes | 9 | 35 | 29 | 11 | 84 | |
Age (years) | ||||||
1.5‒2.0 | 49 | 99 | 10 | 0 | 158 | <0.001 |
2.0‒3.0 | 123 | 428 | 427 | 107 | 1085 | |
≥3.0 | 47 | 183 | 132 | 51 | 413 | |
Sum | 219 | 710 | 569 | 158 | 1656 |
Comparison group | P-value | ||||
---|---|---|---|---|---|
Adaptability | Gross motor | Fine motor | Language | Personal-social activity | |
Age groups | |||||
1.5‒2.0 vs. 2.0‒3.0 years | 0.006 | <0.001 | 0.002 | 0.029 | <0.001 |
1.5‒2.0 vs. ≥3.0 years | <0.001 | <0.001 | <0.001 | 0.003 | <0.001 |
2.0‒3.0 vs. ≥3.0 years | <0.001 | <0.001 | <0.001 | 0.436 | <0.001 |
Adaptive function groups | |||||
Normal and high normal vs. borderline impairment | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 |
Normal and high normal vs. mild impairment | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 |
Normal and high normal vs. moderate impairment and above | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 |
Borderline impairment vs. mild impairment | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 |
Borderline impairment vs. moderate impairment and above | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 |
Mild impairment vs. moderate impairment and above | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 |
The above P-value is the Bonferroni method-adjusted P-value and should be compared with 0.05.
The adaptability DQ and gross motor DQ of ASD boys were higher than those of girls, and the difference was statistically significant (P<0.05). The effect of premature or full-term delivery on the developmental level of each domain was not significant (
Children’s adaptive behavior significantly affected the DQ of all five developmental domains (P<0.05;
Factor/developmental level | Gender | Premature | Age | Impairment of adaptive function | Adaptability | Gross motor | Fine motor | Language | Personal-social activity |
---|---|---|---|---|---|---|---|---|---|
Gender | 1 | – | – | 1.27*a | -0.05*c | -0.08*c | 0.04c | -0.03c | -0.01c |
Premature | 1 | – | 1.24a | -0.04c | 0.02c | -0.05c | -0.02c | -0.04c | |
Age | 1 | 0.14*b | -0.23*b | -0.42*b | -0.25*b | -0.08*b | -0.33*b | ||
Impairment of adaptive function | 1 | -0.45*b | -0.46*b | -0.38*b | -0.62*b | -0.59*b | |||
Adaptability | 1 | 0.58*d | 0.74*d | 0.58*d | 0.61*d | ||||
Gross motor | 1 | 0.54*d | 0.49*d | 0.62*d | |||||
Fine motor | 1 | 0.43*d | 0.53*d | ||||||
Language | 1 | 0.61*d | |||||||
Personal-social activity | 1 |
a Represents the odds ratio (OR) calculated by multivariate logistic regression. b Represents the r calculated by Spearman's rank correlation coefficient. c Represents the r calculated by Point-biserial. d Represents the r calculated by the Pearson's correlation. *P≤0.05.
In this retrospective study, we found that as children with ASD get older, their abilities become more delayed compared with those of children of the same age, and they exhibit more serious impairment to their adaptive behavior. We divided the age of the study subjects into three groups. Children in the ≥3-year-old group had the lowest DQ scores in all areas of competence. As is well known, the younger the child, the more their adaptive behaviors depend on parental assistance to manifest. Most Chinese children with ASD are raised at home until the age of 3 years; therefore, parents are fully aware of their children’s habits. Even when a child has social deficits, most parents are able to sensibly identify and meet their child’s needs. With the active assistance of parents, many children with ASD seem to be doing relatively well. However, most Chinese children begin kindergarten life after the age of 3 years. In group life, children with ASD lose the assistance of their parents and their adaptive behavior abnormalities begin to come to the fore. This finding is similar to the result of VABS in the European Autism Interventions (EU-AIMS) Longitudinal European Autism Project cohort, which reported that with age, the gap between the adaptive behavior ability of ASD individuals and their peers may widen (
Research on gender and ASD continues to gain attention, and recent data show the ratio of males to females as 4.2 ∶1 among children with ASD, with similar proportions of boys and girls meeting a diagnosis of intellectual disability (35.1% for boys and 35.6% for girls) (
In China, GDS is one of the most commonly used tools for evaluating the abilities of children with ASD. We found that in the early development of children with ASD, the average DQ of the adaptability, gross motor, fine motor, language, and personal-social activity domains did not reach the normal level. Children with ASD may have developmental delays, among which language lag is the most common. “Language disorder” is listed as the first chief complaint in the initial diagnosis of many children with ASD. The timely assessment of the abilities of children with ASD is helpful to understand their ability development, provide a reference for the formulation of intervention plans, and supply baseline data for the longitudinal evaluation of intervention effects. While discovering the law of groupings, we must also identify differences in the ability development of ASD, which is manifested in the different levels of ability development among different ASD individuals and in the uneven development of different domains in the same individual, both being important reasons for the heterogeneity of clinical phenotypes of ASD (
We found that adaptive behavior ability can significantly affect and positively correlate with the DQ of each domain of the GDS. Based on this, we speculate that the adaptive behavior ability of children with ASD will be the “hub” of all abilities, and we wonder if we can further improve the level of other abilities by focusing on adaptive behavior interventions. Intervention trials are needed to test this hypothesis. At present, some intervention strategies exist to address the adaptive behavior of adolescents with ASD, such as the improvement of daily living skills, while such interventions are not yet systematic (
There is evidence that early intervention may improve the adaptive behavior ability of children with ASD (
This study has the following limitations. Because the six aspects of the S-M scale, especially communication and socialization (which are closely related to ASD), were not scored separately, only the total rough score and standard score of the full scale could be presented, which is not conducive to understanding the internal characteristics of adaptive behavior. Only the DQ of the personal-social activity domain in the GDS can reflect the social level of autistic children to a certain extent, and data directly reflecting the social level of children with ASD (such as Autism Behavior Checklist Scale scores, Childhood Autism Rating Scale scores, or ADOS results) were not available. This shortcoming makes the analysis of children’s social ability and its influence on and correlation with the development of other domains less robust. This study focused on a description and analysis of the phenomenon, but the mechanism by which adaptive behavior affects the developmental domains requires further elucidation. In addition, this study may have some bias in the observation aspect, which is an inevitable weakness in this field and could make the conclusion weak. Therefore, the limitations of further inference and quality assessments of this study will be completed in the subsequent cohort study we are currently preparing.
Detailed methods are provided in the electronic supplementary materials of this paper.
The data are available from the corresponding author on reasonable request.
Chao SONG and Ting HAN performed the data analysis, and wrote and edited the manuscript. Ning SHAO and Zepeng WANG contributed to the study design and data analysis. Yan JIN, Tingting CHEN, and Lifei HU contributed to the writing and editing of the manuscript. Zhiwei ZHU revised and edited the final version. All authors have read and approved the final manuscript, and therefore, have full access to all the data in the study and take responsibility for the integrity and security of the data.
This work was supported by the Zhejiang Provincial Natural Science Foundation of China (No. LTGY24H090005) and the Autism Research Special Fund of Zhejiang Foundation for Disabled Persons (No.2023006). The authors thank all the participants and all the investigators.
Chao SONG, Ting HAN, Ning SHAO, Zepeng WANG, Yan JIN, Tingting CHEN, Lifei HU, and Zhiwei ZHU declare that they have no conflict of interest.
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013. The ethical approval institution is the Ethics Committee of Children's Hospital, Zhejiang University School of Medicine (No. 2022-IRB-014-A1). Informed consent was obtained from all patients for being included in the study.
The data are available from the corresponding author onreasonable request.
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