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The Effectiveness of RAADS-R as a Screening Tool for Adult ASD Populations

The Effectiveness of RAADS-R as a Screening Tool for Adult ASD Populations Hindawi Autism Research and Treatment Volume 2021, Article ID 9974791, 6 pages https://doi.org/10.1155/2021/9974791 Research Article The Effectiveness of RAADS-R as a Screening Tool for Adult ASD Populations 1 1 1 2 Sarah L Jones , Maria Johnson, Bronwen Alty, and Marios Adamou South West Yorkshire Partnership NHS Foundation Trust, Wakefield, UK University of Hudderfield, Huddersfield, UK Correspondence should be addressed to Sarah L Jones; sarah.jones1@swyt.nhs.uk Received 15 March 2021; Accepted 31 August 2021; Published 13 September 2021 Academic Editor: Salam Salloum-Asfar Copyright © 2021 Sarah L Jones et al. +is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Adult referrals to specialist autism spectrum disorder diagnostic services have increased in recent years, placing strain on existing services. It was proposed that the Ritvo Autism Asperger’s Diagnostic Scale could be used as a screening tool, in order to identify and prioritise patients most likely to receive an ASD diagnosis. +is study evaluates the validity of the RAADS-R as a screening tool for ASD in an adult population. Retrospective case note analysis was used to evaluate the efficacy of the RAADS-R as a screening tool to predict ASD diagnostic outcomes in 50 service users of a NHS specialist autism service. Results indicate no association between RAADS-R scores and clinical diagnostic outcome, suggesting the RAADS-R is not an effective screening tool for identifying service users most likely to receive an ASD diagnosis. In conclusion, used as a self-report measure pre-full diagnostic assessment, the RAADS-R lacks predictive validity and is not a suitable screening tool for adults awaiting autism assessments. Future research should aim to identify reliable screening tools for this purpose. from learned behaviour or compensation strategies, other 1. Introduction conditions, or mental health disorders which may lead to Autism spectrum disorders (ASD) are lifelong neuro- misdiagnosis [5–12]. developmental conditions characterised by a clinically sig- +ere have been a number of key pieces of legislation nificant impairment in reciprocal social interaction and which have focused on improving services for adults with communication, alongside restricted interest and repetitive ASD. “+e Autism Act” [13] and subsequent “Strategy for behaviours [1]. Although ASD is typically diagnosed in Adults with Autism” [14] have been instrumental in setting childhood, there has been a marked increase in the number out strategies for improved diagnostic provision and sup- of adults referred for assessment over recent years [2], which port. However, despite this, waiting times for diagnostic has placed greater demand on local services and resources. assessments of ASD in adults are still lengthy. +erefore, there is a clear necessity to alleviate the pressures on di- Because of this demand, the time for diagnosis is rather long and one report found 29% of adults with autism and 46% of agnostic services by screening the waiting lists to identify and prioritise those at a greater probability of receiving a those with Asperger’s disorder did not receive a diagnosis until adulthood [3]. ASD diagnosis for adults is often ex- diagnosis using standardised methods [15]. pensive in both time and resources; assessments are lengthy Currently, NICE guidelines recommend the use of the and subjective in nature. Adding to the complexity, the Autism Quotient (AQ) [16] for screening purposes [4]. +e diagnostic procedure should be based on multidisciplinary AQ is a 50-item self-report questionnaire, which was observations which include evaluation of current func- originally developed as a means to quantify ASD symptoms. tioning and behaviours, together with a detailed history It is commonly used in research studies for participant taking [4]. +is process can sometimes be further compli- inclusion and exclusion purposes [17] and reports high cated in adult populations due to difficulties obtaining an sensitivity and specificity [16, 18]. Clinically, it has been noted to be useful in the screening process by identifying the accurate early history, in differentiating autistic symptoms 2 Autism Research and Treatment extent of autistic symptoms an individual demonstrates [19], functioning individuals of adult age. It consists of 80 questions although there is good evidence to suggest it has weaknesses in total, divided into four subscales measuring as follows: social relatedness (39 items), circumscribed interest (14 [20–22]. Similarly, the Ritvo Autism Asperger’s Diagnostic Scale- items), language (4 items), and sensory-motor symptoms (20 Revised (RAADS-R) is an 80-item self-report questionnaire, items) and is designed to be delivered by a trained clinician. based on the ICD-10 and DSM-5 diagnostic criteria [2]. It is Participants are asked to rate the degree to which the pre- designed to be used in ASD diagnostic assessments for adults ceding statements, measuring both autistic and normative and has proven good specificity and sensitivity in previous behaviours, are present in their life on a Likert scale ranging studies [23]. +e RAADS-R is recommended by NICE for from “True now and when I was young” � 3; “only true use in the assessment of ASD in adult populations [4]. now” � 2; “true only when I was young” � 1; or “never However, it is not clear how effective the RAADS-R is as a true” � 0. +reshold score of 65 has to be met to determine tool for screening purposes. that ASD is likely to be present. +e questionnaire has been Although various screening tools are available for found to have a sensitivity of 97%, specificity of 100% (at a cutoff of >65), and test-retest reliability of r � 0.987 [2]. identifying ASD in adult populations, few have been eval- uated for use in outpatient settings [17]. Considering that diagnostic services are bound by long and lengthy waiting 2.4. Procedure. Following referral, the RAADS-R and AQ lists, this study aims to evaluate the predictive validity of the was sent to service users to complete at home and return by RAADS-R as a self-report screening tool for patients referred post as a part of the first step in the clinical evaluation. Upon for an ASD assessment to the Adult ADHD and Autism return, scores were entered into the secure electronic patient Service, South West Yorkshire Partnership NHS Foundation record system, RiO, by health care professionals who were Trust. +e implications of which could aid with informing familiar with the scoring procedure. +e results of the the pathway to diagnosis for patients, thus contributing to RAADS-R were used by clinicians in the diagnostic screening more effective service. process (and were made available to researchers retrospec- tively). +e researchers compared the RAADS-R score with 2. Methods the clinical diagnostic outcome of the service user, which was 2.1. Participants. +e sample consisted of fifty adults, 70% of also made available through RiO. +is information enabled the researchers to categorise service users into two groups: the sample identified as male (n � 35), 28% as female (n � 14), those who received an ASD diagnosis and those who did not. and 2% as transgender (n � 1), with a mean age of 32.8 years (SD± � 10.3). Patients were assessed between May 2013 and To reach a positive diagnosis of ASD, the participant has to be screened as likely to have ASD using the AAA [19], classified April 2016, and none had a confirmed ASD diagnosis upon referral. +e adult ADHD and autism service are specialists in having autism spectrum or autism using ADOS-2 [24] and their full psychiatric history discussed at an multidisaplinary diagnosing ADHD and autism in adulthood. Patients are referred to the service by health care professionals, who deem team meeting (MDT) consisting of experts in ASD. Data were analysed using SPSS version 27; analysis was it appropriate based on patient history and current difficulties. Inclusion criteria dictated that participants did not have performed to establish any significant differences between the RAADS-R scores of those who received a clinically learning disability, were over the age of 18 years (no upper cut off), had good comprehension of the English language, and determined diagnosis, compared to those who did not. A had IQ within normal range, i.e., >70. receiver operating characteristic (ROC) curve was then calculated to establish the quality of the RAADS-R for predicting the diagnostic outcome amongst adults referred 2.2. Design. Data were gathered retrospectively from records for an ASD assessment. of the adult Autism Service, South West Yorkshire Part- nership NHS Foundation Trust. As a part of the referral 3. Results process, each participant completed a RAADS-R ques- tionnaire. For the purposes of the adult autism service, the +e sample consisted of 50 service users, all of whom were RAADS-R was used as a self-report measure. +e study referred to the service for diagnostic assessment of ASD. required access to sensitive information and the compu- +ere were no differences found for age or sex between ASD terised health records of patients who had been discharged and non-ASD outcome groups (ns). 70% of the sample was from the service. +erefore, ethical approval was sought identified as male (n � 35), 28% as female (n � 14), and 2% as from Leeds Beckett University. +e study was also registered transgender (n � 1), with a mean age of 32.8 years as a service evaluation within South West Yorkshire Part- (SD± � 10.3). Overall, 17 patients (34%) received a final nership NHS Foundation Trust, in accordance with trust diagnostic outcome of ASD by clinical consensus of a protocol. Service user’s data were taken from RiO (electronic specialist multidisciplinary team. For those who were medical records system) and anonymised prior to analysis. identified as males, the diagnostic rate was 37.1%; for fe- males, it was 28.6%; and for transgender, it was 0%. In terms 2.3. Measures. +e RAADS-R [2] is designed to contribute to of meeting the threshold score for RAADS-R, 49 patients the diagnostic assessment of ASD in adults during the (98%) scored above the diagnostic threshold (>65) screening process. It is designed for use with higher- (median � 146, range � 214). Subgroup analysis showed that Autism Research and Treatment 3 males tended to score lower on the RAADS-R ROC Curve 1.0 (median � 138, range � 209) than females (median � 154, range � 146), but not at a significant level U � 309.5, p � 0.55. +ere was no difference between RAADS-R scores for patients who received an ASD diagnosis (median � 138, 0.8 range � 123) and those who did not (median � 154, range � 214). 0.6 3.1. Sensitivity, Specificity, and Predictive Values. +e RAADS-R demonstrated 100% sensitivity in detecting the presence of ASD in those who received a clinical diagnosis, 0.4 alongside 3.03% specificity in detecting the absence of ASD in those who did not receive a clinical diagnosis. Positive predictive value (PPV) determined that if a patient scored above the RAADS-R cutoff (>65), they have a 34.7% chance 0.2 of receiving a clinical diagnosis. Negative predictive value (NPV) determined that 100% of those who did not score above the threshold did not receive a clinical diagnosis. 0.0 0.0 0.2 0.4 0.6 0.8 1.0 3.2. Receiver Operating Characteristic. +e validity of the 1 – specificity RAADS-R in predicting an ASD diagnosis in this adult Figure 1: ROC curve showing the predictive validity of the sample was calculated using an ROC curve (Figure 1). +e RAADS-R-R. area under the curve (AUC) can be interpreted as a measure of predictive validity by indicating the predictive value of a ASD clinical practice, including the AQ and RAADS-R. +ey diagnostic test. +e AUC was an unacceptable level of concluded poor predictive validity in both questionnaires, discriminaative ability (AUC � 0.45; 95% CI, 0.285 to 0.612), noting that they were unable to predict diagnostic outcomes in line with the null hypothesis. amongst adults referred for ASD assessments, where the mean score for neurotypical controls sat 27 points higher 4. Discussion than the cutoff score [17], which is similar to the finding here +e use of evidence-based assessment is crucial in providing that, descriptively, the non-ASD outcome group scored effective and efficient health services; thus, it is imperative greater on average than the ASD outcome group. Fur- that the credibility of screening assessments is explored. +e thermore, Kember and Williams [28] explored the validity of implementation of screening tools which can accurately the RAADS-14 [29] (a shortened version of the RAADS-R) in a population of New Zealand adults, finding high levels of identify those who are most likely to be diagnosed with ASD would facilitate efficient use of resources and reduced sensitivity alongside low levels of specificity, concluding that the RAADS-14 is not a reliable measure of self-reported ASD waiting times, which produce quicker diagnostic outcomes and access to interventions. as the assessment results in a very high rate of false positives, +e aim of the study was to evaluate the effectiveness of which is in line with our results. Also, in a study exploring the RAADS-R as a screening tool for predicting the presence the validity of popular ASD measures in 93 adults who of ASD in an adult population of service users referred to a received an ASD assessment at a specialist service, Conner specialist ASD diagnostic service. +e results suggest that et al. [30] found those who received a clinical diagnosis, when used as a self-report screening tool, the RAADS-R was scored higher on the ADOS than those who did not receive a unable to discriminate between ASD and non-ASD cohorts. diagnosis. However, no differences between outcome groups Troublingly, scores on the RAADS-R only had a 3.03% were evident on the AQ or the RAADS-R assessment. All three assessments showed poor sensitivity and specificity chance of detecting the absence of ASD in our sample, rendering the assessment futile. +e results here are dis- levels. A recent systematic review explored structured questionnaires as diagnostic measures recommended by appointing given the recommendation by NICE for the inclusion of the RAADS-R assessment in the diagnostic NICE guidelines [31]. +e authors found sensitivity and pathway [4]. specificity of assessments are reduced in those referred to Whilst there is some support for the use of the RAADS-R services for diagnostic assessment compared to populations in terms of test-retest reliability [25] and facilitating referrals who have a previously confirmed diagnosis, with discrim- in psychiatric and psychology services (albeit not in isola- ination between ASD and other mental health conditions tion) [26], as well as evidence of its ability to differentiate particularly limited. between ASD and eating disorder cohorts [27], other re- Confounds such as inappropriate referrals or comorbid search supports what we have found here. For instance, conditions could have contributed to findings here and those of similar studies. It is likely that high levels of comorbidity Sizoo and Horwitz [17] examined the predictive validity of several assessments commonly used as screening tools in in ASD exist within these cohorts, and it has been suggested Sensitivity 4 Autism Research and Treatment be diagnostic. Indeed, they are used to aid and guide cli- that due to high levels of comorbidity in referrals, assess- ments such as the RAADS-R, which are consistently dem- nicians in diagnosis, and ideally, they should always be validated against the “gold standard” assessments for that onstrating low specificity, are not reliable indicators of which patients should receive a full diagnostic assessment as a population [43]. +e idea of concurrent validity is relevant as priority [31], and we would concur. Evidence strongly the RAADS-R and RAADS-14 have shown a strong positive suggests that ASD often exists alongside symptoms of other correlation with scores on the AQ and AQ-10 [25, 28] and a conditions or disorders [32–38]. Anxiety and depression, in strong negative correlation with the empathy quotient (EQ) particular, may “mimic” some ASD symptoms, thereby [28]. In general, this should be deemed supportive of the resulting in an increased false positive rate on the ASD effectiveness of the RAADS-R. However, there are serious questions surrounding the validity of the AQ as a screening assessments [39, 40]. Due to an increased awareness of ASD, these cofounding symptoms may contribute to inappro- measure for ASD populations [20, 22, 39] which is of considerable concern for tools measuring against the AQ. priate referrals from health care professionals; as ASD is considered in advance of other conditions such as OCD or Due to the lengthy waiting lists, expert screening of service users prior to assessments is a logical solution. Future attachment disorders. +ese symptoms, in turn, could be interpreted by the RAADS-R as autistic in nature, thereby research should aim to identify reliable and robust ASD leading to false positive outcomes. +is is evident in previous screening methods for use in an adult outpatient population. studies, for example Sizoo et al. [17] suggested that referred Not only could these be used by specialist services to reduce adults with nonautistic psychiatric problems scored higher waiting list times and to prioritise those identified as most in the autism spectrum, but not as high as patients with ASD. likely to receive an ASD diagnoses but also the screening Eriksson et al. [29] found good sensitivity and specificity of tools could be used by GP’s to assist them with referral decisions and reduce the number of inappropriate referrals the RAADS in an ASD cohort compared to a general population control group. However, specificity reduced to to diagnostic services. Some suggest that future screening questionnaires used in outpatient services could aim to 46% when differentiating between ASD and a clinical control group (ADHD). Also, in a study exploring the validity of the include an element of qualitative data, whereby after each question, there could be a prompt for the service user to French version of the RAADS-R, Picot et al. [41] found limited support for the RAADS-R, suggesting that it is useful provide “additional information.” Ritvo et al. [2] noted that, in helping clinicians discriminate between ASD and non- during the assessment, the clinician would note down any ASD groups. However the RAADS-R had a high false additional information provided by the respondent, which positive rate in a psychiatric disorder group (inclusion contributed to the eventual diagnostic prediction. +e criteria: diagnosis of either mood disorder, schizophrenia, spontaneous information provided by the service user could bipolar disorder, or anxiety disorder confirmed by a clinician prove a valuable addition to the screening and may bridge the gap between a self-report and clinical-led assessment, consensus opinion according to ICD-10 or DSM-IV crite- ria). Furthermore, in a large study exploring the use of thereby resulting in more realistic results. It must be highlighted that one possible factor in de- questionnaires for social and communication disorders in 738 service users of various disorders, over half of the sample termining results here is the way the RAADS-R was ad- met the recommended threshold for ASD as determined by ministered in this cohort. +e RAADS-R was not designed to the RAADS-R assessment, resulting in a high false positive be completed without face-to-face support; indeed, the rate. +is leads the authors to advice that the cutoff score of authors recommend it should be completed as a self-report >65 is too low and should not be used. Alternatively, they measure, but within the presence of a trained clinician [2]. In recommend a higher threshold score of >120 [26]. Also, the current study, however, the questionnaire was used in a there is an argument that the RAADS-R is not a sensitive self-report format, completed by the service user alone. +is enough measure to detect milder variations of ASD. Horwitz may have led to service users to provide misleading answers due to not fully understanding the questions or lack of clarity and Schoevers [42] suggest that this is because the RAADS-R assessment fails to cover a whole range of behavioural issues on how to use the rating scale. We recognise that it is likely that the clinician would be able to respond to service user that may be relevant to milder forms of ASD, and therefore, it is not robust enough to capture the autism spectrum. +is questions or elaborate more on the question details, which is an important issue considering the clinical picture of ASD could have been reflected in the results. However, whilst this is complex and is varied in presentation. should be considered, a recent study found only 6% of Health services are under exceeding pressure to deliver patients were unable to complete the RAADS-R and AQ efficient care for service users. By administering screening questionnaire by themselves and required assistance [26]. tools, services can facilitate effective systems by identifying Further research would be required to investigate this possibility. In general, it is pertinent to mention here that those who are more likely to receive a clinical diagnosis, using a standardised method [15]. Our findings and those self-report measures in general may be particularly prob- lematic in ASD populations as self-insight from self-report discussed above, confirm that symptoms of ASD can only be reliably identified or differentiated from other conditions measures may not be reliable [44]. A particular strength of our study is that it was carried out in a setting that the following specialist clinical assessment from an ASD prac- titioner. Yet, guidelines advocate using screening assess- RAADS-R assessment was intended for. As Brugha et al. [26] ments to build a clear picture of the clinical need. 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The Effectiveness of RAADS-R as a Screening Tool for Adult ASD Populations

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Copyright © 2021 Sarah L Jones et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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2090-1933
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10.1155/2021/9974791
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Hindawi Autism Research and Treatment Volume 2021, Article ID 9974791, 6 pages https://doi.org/10.1155/2021/9974791 Research Article The Effectiveness of RAADS-R as a Screening Tool for Adult ASD Populations 1 1 1 2 Sarah L Jones , Maria Johnson, Bronwen Alty, and Marios Adamou South West Yorkshire Partnership NHS Foundation Trust, Wakefield, UK University of Hudderfield, Huddersfield, UK Correspondence should be addressed to Sarah L Jones; sarah.jones1@swyt.nhs.uk Received 15 March 2021; Accepted 31 August 2021; Published 13 September 2021 Academic Editor: Salam Salloum-Asfar Copyright © 2021 Sarah L Jones et al. +is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Adult referrals to specialist autism spectrum disorder diagnostic services have increased in recent years, placing strain on existing services. It was proposed that the Ritvo Autism Asperger’s Diagnostic Scale could be used as a screening tool, in order to identify and prioritise patients most likely to receive an ASD diagnosis. +is study evaluates the validity of the RAADS-R as a screening tool for ASD in an adult population. Retrospective case note analysis was used to evaluate the efficacy of the RAADS-R as a screening tool to predict ASD diagnostic outcomes in 50 service users of a NHS specialist autism service. Results indicate no association between RAADS-R scores and clinical diagnostic outcome, suggesting the RAADS-R is not an effective screening tool for identifying service users most likely to receive an ASD diagnosis. In conclusion, used as a self-report measure pre-full diagnostic assessment, the RAADS-R lacks predictive validity and is not a suitable screening tool for adults awaiting autism assessments. Future research should aim to identify reliable screening tools for this purpose. from learned behaviour or compensation strategies, other 1. Introduction conditions, or mental health disorders which may lead to Autism spectrum disorders (ASD) are lifelong neuro- misdiagnosis [5–12]. developmental conditions characterised by a clinically sig- +ere have been a number of key pieces of legislation nificant impairment in reciprocal social interaction and which have focused on improving services for adults with communication, alongside restricted interest and repetitive ASD. “+e Autism Act” [13] and subsequent “Strategy for behaviours [1]. Although ASD is typically diagnosed in Adults with Autism” [14] have been instrumental in setting childhood, there has been a marked increase in the number out strategies for improved diagnostic provision and sup- of adults referred for assessment over recent years [2], which port. However, despite this, waiting times for diagnostic has placed greater demand on local services and resources. assessments of ASD in adults are still lengthy. +erefore, there is a clear necessity to alleviate the pressures on di- Because of this demand, the time for diagnosis is rather long and one report found 29% of adults with autism and 46% of agnostic services by screening the waiting lists to identify and prioritise those at a greater probability of receiving a those with Asperger’s disorder did not receive a diagnosis until adulthood [3]. ASD diagnosis for adults is often ex- diagnosis using standardised methods [15]. pensive in both time and resources; assessments are lengthy Currently, NICE guidelines recommend the use of the and subjective in nature. Adding to the complexity, the Autism Quotient (AQ) [16] for screening purposes [4]. +e diagnostic procedure should be based on multidisciplinary AQ is a 50-item self-report questionnaire, which was observations which include evaluation of current func- originally developed as a means to quantify ASD symptoms. tioning and behaviours, together with a detailed history It is commonly used in research studies for participant taking [4]. +is process can sometimes be further compli- inclusion and exclusion purposes [17] and reports high cated in adult populations due to difficulties obtaining an sensitivity and specificity [16, 18]. Clinically, it has been noted to be useful in the screening process by identifying the accurate early history, in differentiating autistic symptoms 2 Autism Research and Treatment extent of autistic symptoms an individual demonstrates [19], functioning individuals of adult age. It consists of 80 questions although there is good evidence to suggest it has weaknesses in total, divided into four subscales measuring as follows: social relatedness (39 items), circumscribed interest (14 [20–22]. Similarly, the Ritvo Autism Asperger’s Diagnostic Scale- items), language (4 items), and sensory-motor symptoms (20 Revised (RAADS-R) is an 80-item self-report questionnaire, items) and is designed to be delivered by a trained clinician. based on the ICD-10 and DSM-5 diagnostic criteria [2]. It is Participants are asked to rate the degree to which the pre- designed to be used in ASD diagnostic assessments for adults ceding statements, measuring both autistic and normative and has proven good specificity and sensitivity in previous behaviours, are present in their life on a Likert scale ranging studies [23]. +e RAADS-R is recommended by NICE for from “True now and when I was young” � 3; “only true use in the assessment of ASD in adult populations [4]. now” � 2; “true only when I was young” � 1; or “never However, it is not clear how effective the RAADS-R is as a true” � 0. +reshold score of 65 has to be met to determine tool for screening purposes. that ASD is likely to be present. +e questionnaire has been Although various screening tools are available for found to have a sensitivity of 97%, specificity of 100% (at a cutoff of >65), and test-retest reliability of r � 0.987 [2]. identifying ASD in adult populations, few have been eval- uated for use in outpatient settings [17]. Considering that diagnostic services are bound by long and lengthy waiting 2.4. Procedure. Following referral, the RAADS-R and AQ lists, this study aims to evaluate the predictive validity of the was sent to service users to complete at home and return by RAADS-R as a self-report screening tool for patients referred post as a part of the first step in the clinical evaluation. Upon for an ASD assessment to the Adult ADHD and Autism return, scores were entered into the secure electronic patient Service, South West Yorkshire Partnership NHS Foundation record system, RiO, by health care professionals who were Trust. +e implications of which could aid with informing familiar with the scoring procedure. +e results of the the pathway to diagnosis for patients, thus contributing to RAADS-R were used by clinicians in the diagnostic screening more effective service. process (and were made available to researchers retrospec- tively). +e researchers compared the RAADS-R score with 2. Methods the clinical diagnostic outcome of the service user, which was 2.1. Participants. +e sample consisted of fifty adults, 70% of also made available through RiO. +is information enabled the researchers to categorise service users into two groups: the sample identified as male (n � 35), 28% as female (n � 14), those who received an ASD diagnosis and those who did not. and 2% as transgender (n � 1), with a mean age of 32.8 years (SD± � 10.3). Patients were assessed between May 2013 and To reach a positive diagnosis of ASD, the participant has to be screened as likely to have ASD using the AAA [19], classified April 2016, and none had a confirmed ASD diagnosis upon referral. +e adult ADHD and autism service are specialists in having autism spectrum or autism using ADOS-2 [24] and their full psychiatric history discussed at an multidisaplinary diagnosing ADHD and autism in adulthood. Patients are referred to the service by health care professionals, who deem team meeting (MDT) consisting of experts in ASD. Data were analysed using SPSS version 27; analysis was it appropriate based on patient history and current difficulties. Inclusion criteria dictated that participants did not have performed to establish any significant differences between the RAADS-R scores of those who received a clinically learning disability, were over the age of 18 years (no upper cut off), had good comprehension of the English language, and determined diagnosis, compared to those who did not. A had IQ within normal range, i.e., >70. receiver operating characteristic (ROC) curve was then calculated to establish the quality of the RAADS-R for predicting the diagnostic outcome amongst adults referred 2.2. Design. Data were gathered retrospectively from records for an ASD assessment. of the adult Autism Service, South West Yorkshire Part- nership NHS Foundation Trust. As a part of the referral 3. Results process, each participant completed a RAADS-R ques- tionnaire. For the purposes of the adult autism service, the +e sample consisted of 50 service users, all of whom were RAADS-R was used as a self-report measure. +e study referred to the service for diagnostic assessment of ASD. required access to sensitive information and the compu- +ere were no differences found for age or sex between ASD terised health records of patients who had been discharged and non-ASD outcome groups (ns). 70% of the sample was from the service. +erefore, ethical approval was sought identified as male (n � 35), 28% as female (n � 14), and 2% as from Leeds Beckett University. +e study was also registered transgender (n � 1), with a mean age of 32.8 years as a service evaluation within South West Yorkshire Part- (SD± � 10.3). Overall, 17 patients (34%) received a final nership NHS Foundation Trust, in accordance with trust diagnostic outcome of ASD by clinical consensus of a protocol. Service user’s data were taken from RiO (electronic specialist multidisciplinary team. For those who were medical records system) and anonymised prior to analysis. identified as males, the diagnostic rate was 37.1%; for fe- males, it was 28.6%; and for transgender, it was 0%. In terms 2.3. Measures. +e RAADS-R [2] is designed to contribute to of meeting the threshold score for RAADS-R, 49 patients the diagnostic assessment of ASD in adults during the (98%) scored above the diagnostic threshold (>65) screening process. It is designed for use with higher- (median � 146, range � 214). Subgroup analysis showed that Autism Research and Treatment 3 males tended to score lower on the RAADS-R ROC Curve 1.0 (median � 138, range � 209) than females (median � 154, range � 146), but not at a significant level U � 309.5, p � 0.55. +ere was no difference between RAADS-R scores for patients who received an ASD diagnosis (median � 138, 0.8 range � 123) and those who did not (median � 154, range � 214). 0.6 3.1. Sensitivity, Specificity, and Predictive Values. +e RAADS-R demonstrated 100% sensitivity in detecting the presence of ASD in those who received a clinical diagnosis, 0.4 alongside 3.03% specificity in detecting the absence of ASD in those who did not receive a clinical diagnosis. Positive predictive value (PPV) determined that if a patient scored above the RAADS-R cutoff (>65), they have a 34.7% chance 0.2 of receiving a clinical diagnosis. Negative predictive value (NPV) determined that 100% of those who did not score above the threshold did not receive a clinical diagnosis. 0.0 0.0 0.2 0.4 0.6 0.8 1.0 3.2. Receiver Operating Characteristic. +e validity of the 1 – specificity RAADS-R in predicting an ASD diagnosis in this adult Figure 1: ROC curve showing the predictive validity of the sample was calculated using an ROC curve (Figure 1). +e RAADS-R-R. area under the curve (AUC) can be interpreted as a measure of predictive validity by indicating the predictive value of a ASD clinical practice, including the AQ and RAADS-R. +ey diagnostic test. +e AUC was an unacceptable level of concluded poor predictive validity in both questionnaires, discriminaative ability (AUC � 0.45; 95% CI, 0.285 to 0.612), noting that they were unable to predict diagnostic outcomes in line with the null hypothesis. amongst adults referred for ASD assessments, where the mean score for neurotypical controls sat 27 points higher 4. Discussion than the cutoff score [17], which is similar to the finding here +e use of evidence-based assessment is crucial in providing that, descriptively, the non-ASD outcome group scored effective and efficient health services; thus, it is imperative greater on average than the ASD outcome group. Fur- that the credibility of screening assessments is explored. +e thermore, Kember and Williams [28] explored the validity of implementation of screening tools which can accurately the RAADS-14 [29] (a shortened version of the RAADS-R) in a population of New Zealand adults, finding high levels of identify those who are most likely to be diagnosed with ASD would facilitate efficient use of resources and reduced sensitivity alongside low levels of specificity, concluding that the RAADS-14 is not a reliable measure of self-reported ASD waiting times, which produce quicker diagnostic outcomes and access to interventions. as the assessment results in a very high rate of false positives, +e aim of the study was to evaluate the effectiveness of which is in line with our results. Also, in a study exploring the RAADS-R as a screening tool for predicting the presence the validity of popular ASD measures in 93 adults who of ASD in an adult population of service users referred to a received an ASD assessment at a specialist service, Conner specialist ASD diagnostic service. +e results suggest that et al. [30] found those who received a clinical diagnosis, when used as a self-report screening tool, the RAADS-R was scored higher on the ADOS than those who did not receive a unable to discriminate between ASD and non-ASD cohorts. diagnosis. However, no differences between outcome groups Troublingly, scores on the RAADS-R only had a 3.03% were evident on the AQ or the RAADS-R assessment. All three assessments showed poor sensitivity and specificity chance of detecting the absence of ASD in our sample, rendering the assessment futile. +e results here are dis- levels. A recent systematic review explored structured questionnaires as diagnostic measures recommended by appointing given the recommendation by NICE for the inclusion of the RAADS-R assessment in the diagnostic NICE guidelines [31]. +e authors found sensitivity and pathway [4]. specificity of assessments are reduced in those referred to Whilst there is some support for the use of the RAADS-R services for diagnostic assessment compared to populations in terms of test-retest reliability [25] and facilitating referrals who have a previously confirmed diagnosis, with discrim- in psychiatric and psychology services (albeit not in isola- ination between ASD and other mental health conditions tion) [26], as well as evidence of its ability to differentiate particularly limited. between ASD and eating disorder cohorts [27], other re- Confounds such as inappropriate referrals or comorbid search supports what we have found here. For instance, conditions could have contributed to findings here and those of similar studies. It is likely that high levels of comorbidity Sizoo and Horwitz [17] examined the predictive validity of several assessments commonly used as screening tools in in ASD exist within these cohorts, and it has been suggested Sensitivity 4 Autism Research and Treatment be diagnostic. Indeed, they are used to aid and guide cli- that due to high levels of comorbidity in referrals, assess- ments such as the RAADS-R, which are consistently dem- nicians in diagnosis, and ideally, they should always be validated against the “gold standard” assessments for that onstrating low specificity, are not reliable indicators of which patients should receive a full diagnostic assessment as a population [43]. +e idea of concurrent validity is relevant as priority [31], and we would concur. Evidence strongly the RAADS-R and RAADS-14 have shown a strong positive suggests that ASD often exists alongside symptoms of other correlation with scores on the AQ and AQ-10 [25, 28] and a conditions or disorders [32–38]. Anxiety and depression, in strong negative correlation with the empathy quotient (EQ) particular, may “mimic” some ASD symptoms, thereby [28]. In general, this should be deemed supportive of the resulting in an increased false positive rate on the ASD effectiveness of the RAADS-R. However, there are serious questions surrounding the validity of the AQ as a screening assessments [39, 40]. Due to an increased awareness of ASD, these cofounding symptoms may contribute to inappro- measure for ASD populations [20, 22, 39] which is of considerable concern for tools measuring against the AQ. priate referrals from health care professionals; as ASD is considered in advance of other conditions such as OCD or Due to the lengthy waiting lists, expert screening of service users prior to assessments is a logical solution. Future attachment disorders. +ese symptoms, in turn, could be interpreted by the RAADS-R as autistic in nature, thereby research should aim to identify reliable and robust ASD leading to false positive outcomes. +is is evident in previous screening methods for use in an adult outpatient population. studies, for example Sizoo et al. [17] suggested that referred Not only could these be used by specialist services to reduce adults with nonautistic psychiatric problems scored higher waiting list times and to prioritise those identified as most in the autism spectrum, but not as high as patients with ASD. likely to receive an ASD diagnoses but also the screening Eriksson et al. [29] found good sensitivity and specificity of tools could be used by GP’s to assist them with referral decisions and reduce the number of inappropriate referrals the RAADS in an ASD cohort compared to a general population control group. However, specificity reduced to to diagnostic services. Some suggest that future screening questionnaires used in outpatient services could aim to 46% when differentiating between ASD and a clinical control group (ADHD). Also, in a study exploring the validity of the include an element of qualitative data, whereby after each question, there could be a prompt for the service user to French version of the RAADS-R, Picot et al. [41] found limited support for the RAADS-R, suggesting that it is useful provide “additional information.” Ritvo et al. [2] noted that, in helping clinicians discriminate between ASD and non- during the assessment, the clinician would note down any ASD groups. However the RAADS-R had a high false additional information provided by the respondent, which positive rate in a psychiatric disorder group (inclusion contributed to the eventual diagnostic prediction. +e criteria: diagnosis of either mood disorder, schizophrenia, spontaneous information provided by the service user could bipolar disorder, or anxiety disorder confirmed by a clinician prove a valuable addition to the screening and may bridge the gap between a self-report and clinical-led assessment, consensus opinion according to ICD-10 or DSM-IV crite- ria). Furthermore, in a large study exploring the use of thereby resulting in more realistic results. It must be highlighted that one possible factor in de- questionnaires for social and communication disorders in 738 service users of various disorders, over half of the sample termining results here is the way the RAADS-R was ad- met the recommended threshold for ASD as determined by ministered in this cohort. +e RAADS-R was not designed to the RAADS-R assessment, resulting in a high false positive be completed without face-to-face support; indeed, the rate. +is leads the authors to advice that the cutoff score of authors recommend it should be completed as a self-report >65 is too low and should not be used. Alternatively, they measure, but within the presence of a trained clinician [2]. In recommend a higher threshold score of >120 [26]. Also, the current study, however, the questionnaire was used in a there is an argument that the RAADS-R is not a sensitive self-report format, completed by the service user alone. +is enough measure to detect milder variations of ASD. Horwitz may have led to service users to provide misleading answers due to not fully understanding the questions or lack of clarity and Schoevers [42] suggest that this is because the RAADS-R assessment fails to cover a whole range of behavioural issues on how to use the rating scale. We recognise that it is likely that the clinician would be able to respond to service user that may be relevant to milder forms of ASD, and therefore, it is not robust enough to capture the autism spectrum. +is questions or elaborate more on the question details, which is an important issue considering the clinical picture of ASD could have been reflected in the results. However, whilst this is complex and is varied in presentation. should be considered, a recent study found only 6% of Health services are under exceeding pressure to deliver patients were unable to complete the RAADS-R and AQ efficient care for service users. By administering screening questionnaire by themselves and required assistance [26]. tools, services can facilitate effective systems by identifying Further research would be required to investigate this possibility. In general, it is pertinent to mention here that those who are more likely to receive a clinical diagnosis, using a standardised method [15]. Our findings and those self-report measures in general may be particularly prob- lematic in ASD populations as self-insight from self-report discussed above, confirm that symptoms of ASD can only be reliably identified or differentiated from other conditions measures may not be reliable [44]. A particular strength of our study is that it was carried out in a setting that the following specialist clinical assessment from an ASD prac- titioner. Yet, guidelines advocate using screening assess- RAADS-R assessment was intended for. As Brugha et al. [26] ments to build a clear picture of the clinical need. 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References