Training Module for AIIMS Modified INCLEN Diagnostic Tool for Autism Spectrum Disorder (INDT-ASD)

Learning Objective

  • To describe the core symptoms of autism spectrum disorder
  • To clinically evaluate a child with suspected autism spectrum disorder using AIIMS modified INDT ASD tool for autism spectrum disorder


  • Autism is a neurodevelopmental disorder characterized by impairment in
    • Reciprocal socialization
    • Qualitative impairment in communication
    • Restrictive and repetitive behaviour
  • DSM-5 diagnosis of autism spectrum disorder includes
    • Qualitative impairment of social interaction, social communication
    • Restrictive and repetitive behaviour

Symptoms of Autism Spectrum Disorder

Deficits in social emotional reciprocity

  • There may be lack of joint attention in the form of inability to share his/her interest by pointing to parents the object of interest like a dog/cat/flower/train
  • There may be lack of initiation of conversation to talk about his interests or achievements
  • There may be lack of sharing of his/her emotions, happiness or distress with parents
  • There may be lack of initiation of conversation or lack of adding significant content for the conversation to continue.
  • Child may prefer to play alone and not mix up with other children
  • There may be an impairment of  involvement in rule based games

Deficit in Nonverbal Communicative Behaviour

  • Poor integration of verbal behaviour and non verbal behaviour
  • They may have poor eye contact
  • There may be impairment of use of appropriate gestures during social interaction
  • There may be total lack of facial expression while interacting with parents or strangers

Poor Eye Contact

Deficits in developing, maintaining and understanding of relationship

  • There may be lack of enjoyment of company of other children
  • There may be lack of friends with whom he/she can chat, share or play together
  • They may play with children of younger or older age group
  • There may be lack of imaginative play

Stereotyped, Repetitive
Motor Movement or Speech

  • Child may repeat certain words or phrases regardless of the meaning that he/she has heard
  • Child may repeat few words or phrases he/she heard in television regardless of meaning or context
  • He/she may have pronoun reversal with replacement of “I for me” and “me for you”
  • He/she may speak out of context or irrelevantly
  • Child may show excitement by flapping his hands, wring his hands, rocking, spinning or making some unusual finger or hand movement

Video (Hand Stereotypies)

Video (Echolalia)

Other symptoms of Autism

  • Insistence on routines: child unreasonably insist on doing things in a particular way and/or become upset if there is any change in the daily routine
  • Highly fixed or restricted interest: Child may prefer to play with a particular part of a toy/object rather than the whole toy/object
  • Sensory symptoms:
    • Child may show indifference or exceesive reaction to pain
    • He/she may show abnormal interest in feeling the textures
    • He/she may show abnormal reaction to sounds by covering their ears
    • He/she may have excessive smelling or touching of object in unsual manner
    • He/she may have fascination with lights or moving objects

Video (Sensory Symptom)

Co morbidities of Autism
Broad category Co morbid condition
Psychiatric Anxiety (43-84%)
Depression (2-30%)
Obsessive compulsive disorder (37%)
Oppostional defiant disorder (7%)
Behavioural problems
Behavioural Disruptive
Aggressive behaviour (8-32%)
Self injurious behaviour (34%)
Sensory disturbances Tactile (80-90%)
Auditory sensitivity (5-47%)
Neurological Seizures and epilepsy (5-49%)
Tics (8-10%)
Gastrointestinal GERD (8-59%)
Constipation  (8-59%)
Sleep disturbances Sleep disruptions (52-73%)

Differentials of Autism

  • Social (pragmatic) communication disorder (SCD): children with marked deficit in social communication but whose symptoms otherwise do not meet the criteria for autism spectrum disorder must be considered for SCD
  •  Intellectual disability (ID): It is essential to differentiate intellectual disability from autism spectrum disorder (ASD) although both can co exist and the current DSM-5 gives the liberty to label “ASD with ID”
  • Landau Kleffner syndrome: children with autism spectrum disorder with later age at onset of regression must always be considered for a possibility of landau-kleffner syndrome
  • Undiagnosed hearing impairment

DSM-IV Criteria for Autistic Disorder

  • Qualitative impairment in social interaction (2 out of 4 item)
  • Qualitative impairments in communication (1 out of 4 items)
  • Restricted repetitive and stereotyped patterns of behaviour, interests and activities (1 out of 4 items)

A total of 6 out of 12 items will be called autistic disorder

DSM-5 Criteria for Autism Spectrum Disorder

  1. Persistent deficits in social communication and social interaction
  2. Restricted, repetitive patterns of behavior, interests,or activities
  3. Symptoms must be present in the early developmental period
  4. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning
  5. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay
DSM-IV versus DSM-5
Rett syndrome Rett is eliminated because it is genetic basis
Pervasive developmental disorder, asperger syndrome, childhood disintegrative disorder These three are combined to ASD
Unusual sensory symptoms are not a part of criteria Sensory symptoms are a part of diagnostic criteria
3 symptom category (social interaction, social communication, restrictive & repetitive behavior 2 symptom category (deficit in social communication and social interaction and restrictive and repetitive behavior
Co-occuring diagnosis cannot exist Co-occuring diagnosis  (ADHD, ID, fragile X) can exist  in DSM-5

Merits of DSM-5 Diagnosis for ASD

  • Single umbrella diagnosis for all ASD
  • Ensures appropriate services and insurance coverage to those who did not benefit earlier: Asperger, PDD-NOS
  • Allows co morbidities like ID, ADHD, Genetic disease (Rett, Fragile X, Tuberous sclerosis)
    • ASD with ADHD
    • ASD with ID
    • ASD with Fragile X 
  • Avoids ambiguous terms
    • PDD-NOS

Why Move from DSM-IV to DSM-5?

  • DSM-5 provides a single umbrella diagnosis of autism spectrum disorder for:
    • Autism
    • Asperger syndrome
    • Rett syndrome
    • Childhood disintegrative disorder
    • Pervasive developmental disorder-not otherwise specified (PDD-NOS).
  • Symptoms of autism spectrum disorder are specific (NOT pervasive) to impairment in social interaction and communication with presence of restrictive, repetitive behaviour
  • There are concerns of PDD-NOS being labelled as mild developmental disorder and Asperger as ‘odd’ behaviour.
  • Overuse of PDD-NOS leads to diagnostic confusion and may contribute to epidemic of autism
  • Symptoms of autism spectrum disorder are not salient among children with Rett syndrome
  • Developmental regression in autism spectrum disorder has a wide range in timing and nature of loss of skills, hence precise existence of childhood disintegrative disorder has been challenged by many author worldwide.
  • Literature has suggested that there is a considerable overlap between high functioning autism and Asperger syndrome questioning the need for separate category for the latter.

INDT-ASD Diagnostic Tool (DSM-IV Based)

  • The diagnostic accuracy [AUC=0.97 (0.93, 0.99); P<0.001]
  • Sensitivity 98%, specificity 95%, PPV 91%, NPV 99%
  • Merits:
    • High diagnostic accuracy
    • Adequate content validity
    • Good internal consistency
    • High criterion validity
    • High to moderate convergent validity
    • Easy to administer; no training required
  • Concern:
    • Use of DSM-IV as gold standard
    • Lack of severity scoring

Juneja M, Mishra D, Russell PSS, Gulati S, Deshmukh V, Tudu P, et al. INCLEN Diagnostic Tool for Autism Spectrum Disorder (INDT-ASD): development and validation. Indian Pediatr. 2014 May;51(5):359–65.

Clinical Consensus Criteria

Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following:

  • Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction
  • Deficits in nonverbal communicative behaviours used for social interaction; ranging from poorly integrated verbal  and nonverbal communication, through abnormalities in eye contact and body-language, or deficits in  understanding and use of nonverbal communication, to total lack of facial expression or gestures.
  • Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behaviour to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people

Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following:

  • Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases)
  • Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes)
  • Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
  • Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects).

Other Criteria

  • Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed  limited capacities)
  • Symptoms together limit and impair social, occupational and other areas of daily functioning.
  • These disturbances are not better explained by intellectual disability or global developmental delay.

Development of AIIMS Modified INDT
ASD Tool for Diagnosis of Autism Spectrum Disorder

Development and Validation of DSM-5 Based AIIMS Modified INDT ASD Tool

  • Aim of the study was to develop and validate AIIMS modified INDT-ASD tool for autism spectrum disorder (ASD) against gold standard DSM 5 criteria for diagnosis and categorization of severity of ASD in children aged 1-14 years

Conducted in Child Neurology Division, Department of Pediatrics, AIIMS, Delhi
(Prof Sheffali Gulati) in collabartion with INCLEN group

Development of
AIIMS Modified INDT-ASD Tool

  • A team of national experts reviewed the pool of questions (Focused group discussion) in the new tool
    • Pediatric neurologist
    • Clinical psychologist
    • Child psychiatrist
  • Pool of items were selected by investigator using modified Delphi method

*CARS: Childhood autism rating scale
*M-CHAT: Modified checklist for autism
*ABCL: Autism Behaviour Checklist

AIIMS Modified INDT ASD Tool for ASD

  • Response was marked as “yes”, “no” and “unsure”
  • “unsure” was considered “no” for statistical purpose
  • Combination of question and observation
  • Each question has been labelled as autistic or non autistic response
  • Time taken: 25-30 min

AIIMS Modified INDT ASD Tool

AIIMS Modified INDT ASD Tool
DSM-5 Section A Number of items/questions
Social communication and interaction Social emotional reciprocity 8
Non verbal communication 4
Relationships 3
Restricted, repetitive pattern of behaviour, interest and activity Stereotyped movement or speech 7
Routines 1
Fixed interests 1
Sensory symptoms 4
Total number of items 28
Section B
Analysis of section A Summary of assessment 9

Final Interpretation

  • Section A: 3 items each from A1, A2, A3
  • Presence of yes on question 3 and 4 mandatory
  • Final impression:
    • ASD present
    • No ASD

Comparison of INDT
Social interaction 4 items 3 items
Social communication 4 items
Restrictive and repetitive behaviour 4 items 4 items
Sensory symptoms Absent Present (1 item) out of 4 items in restrictive repetitive behaviour
Onset in early childhood <3 years Absent Present (1 item)
Impairment of daily functional activity Absent Present (1 item)
Total number of items 12 9
Total number of questions 29 (Section A) +12 (Section B) 28 (Section A)+7 (Section B)
Diagnosis of ASD 6 out of 12 criteria for diagnosis of autistic disorder 7 out of 9 criteria needed for diagnosis of autism spectrum disorder
Other diagnosis made using the tool Pervasive developmental disorder- Not otherwise specified, Asperger disease, Rett syndrome All clubbed under umbrella diagnosis of “Autism Spectrum Disorder”

Diagnostic Performance of AIIMS Modified INDT ASD Tool

Diagnostic Performance of AIIMS Modified INDT ASD Tool
Gold standard
DSM 5 diagnosis of ASD (n=76)
Gold standard
DSM 5 diagnosis of No ASD (n=76)
Total cases
AIIMS modified INDT ASD tool: ASD present 74 8 82
AIIMS modified INDT ASD tool: ASD absent 2 68 70
76 76 152

Sensitivity: 97.4% [90.9% to 99.3%]
Specificity: 89.5 % [80.6% to 94.6%]
Positive Predictive Value: 90.2% [81.9% to 94.9%]
Negative Predictive Value: 97.1 % [90.2% to 99.2%]
Diagnostic accuracy: 93.4% [88.3% to 96.4%]

Administration of AIIMS modified INDT ASD Tool for Autism Spectrum Disorder

Content of Tool
S. No Item Function Number of questions Interpretation
1 Section A1a Social emotional reciprocity 8 questions Mandatory item
Section A1b Non verbal communication 4 questions Mandatory item
Sections A1c Relationships 3 questions Mandatory item
2 Section A2a Stereotyped movement or speech 7 questions At least 2 items out of 4 items from A2a to A2d
Section A2b Routines 1 question
Section A2c Fixed interests 1 question
Section A2D Sensory symptoms 4 questions

AIIMS Modified
INDT-ASD Diagnostic Tool

  • The tool has two sections:
    • Section A has 28 symptoms/items
    • Section B contains 8 questions for analysis and interpretation of INDT ASD tool 
  • It takes approximately 45-60 minutes to administer the instrument and score.
  • A trichotomous endorsement choice (‘yes’, ‘no’, ‘unsure/not applicable’) is given to the assessor/ interviewer.

INDT-ASD Diagnostic Tool

  • Clinician/psychologist has to make behavioral observations on the child and score the item as well.
  • For any discrepancy in parental response and interviewer’s assessment, it is indicated for each question whether parental response or assessor’s observation should take precedence
  • Each symptom/item is given a score
    • ‘1’ for ‘Yes’
    • ‘0’ for ‘No’ or ‘unsure/not applicable’

Instructions for Evaluation

  • Primary caregiver must be present with the child
  • These behaviors are to be assessed in the context of children of same age
  • Explain to parents that the answers should be based on the child’s behavior most of the time
  • Follow the age directions given along with the question. For questions where no age cut-off is given, they should be asked for all children i.e. all ages (1-14 years)
  • Ask the questions verbatim
  • Question can be repeated if the respondent cannot understand
  •  Still, if the respondent cannot understand, give example for the particular behavior; No further elaboration is allowed
  • The questionnaire should be supplemented by observations for the suggestive behavior in the child throughout the assessment.
  • Observe the behavior of the child during the entire interview to confirm the presence or absence of a particular behavior (First ask, then observe if observation is discrepant, then re-ask the question and recheck the observation also).
  • When there is discrepancy between parental response and your observation, * indicates whether parent report or observation should take precedence, and marked accordingly
  • When parent’s response is “Unsure”, your observation of the particular behaviour will be given weightage even when asterisk (*) is on parental response. In case your are also unable to observe the behavior, then only mark the response as “Unsure”
  • Some criteria have multiple questions. While scoring, consider the criteria fulfilled even if response to any one of the questions is abnormal. For example, the criterion A1a is considered fulfilled if any one of I to viii is autisitc in the child

Tool Interpretation

Final Interpretation

  • To diagnose as autism spectrum disorder (ASD: Present) (Section B: Question 1 to 4)
  • All sections A1a, A1b, A1c must be fulfilled
  • Atleast 2 out of 4 items from section A2a, A2b, A2c, A2d must be present
  • Onset must be in early developmental period
  • These symptoms must have resulted in impaired functioning


Case Scenario

  • 3 year boy brought with complaints of poor eye contact and delayed speech.
  • He was born of non consanguineous marriage, first in birth order. His neonatal period was eventful, was born by normal delivery with birth weight of 3.2 Kg, cried immediately at birth and was discharged the next day.
  • He subsequently attained age appropriate motor milestones but his speech was delayed.
  • Parents have often observed him to be “in his own world”, often not responding to commands when called.
  • He often reacts by excessive jumping and spinning when he gets excited.
  • Mother has noticed that when offered a toy he does not play with it, rather spins its wheels and throws it away. He likes playing with toffee wrappers and threads. A pediatrician suspected autism spectrum disorder and referred the case for evaluation.

Motor Stereotypies

Fixation with Toothpaste


Case 2

  • 5 Years girl
    • Second child of non-consanguineous marriage
    • Developmentally normal till 4 years of age
  • Complaints of
    • Decline of language skills
      • Decreased verbalization
      • Not indicating basic needs
    • Behavioral problems over past 6 months
      • Absent emotional reciprocity
      • Lacks peer/ pretend play
      • Impaired sleep
      • Hyperactivity and aggressiveness
      • Motor stereotypies present
      • Gestural communication normal
      • Eye contact normal


  • AIIMS modified INDT ASD is developed and validated and based on DSM-5 based diagnosis of autism spectrum disorder
  • The tool had good psychometric properties in terms of sensitivity (97.4%), specificity (89.5%) and diagnostic accuracy (93.4%)
  • Present tool offers simple, physician administered, robust DSM 5 based diagnostic instrument for autism spectrum disorder among those with “suspected autism”

Thank You

© Copyright 2014. All Rights Reserved by Child Neurology Division