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Volume 6 • Issue 4 • 1000188
Autism, an Open Access
ISSN: 2165-7890
Open AccessResearch Article
Autism - Open Access
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ISSN: 2165-7890
Di Renzo et al., Autism Open Access 2016, 6:4
DOI: 10.4172/2165-7890.1000188
Keywords: Autism spectrum disorder; Emotional contagion;
Understanding of intention; Leiter; Assessment
Introduction
e Autism Spectrum Disorders were included in the DSM-5 [1]
within the chapter of the neurodevelopmental disorders, that is a “group
of conditions, with onset in the development period, which typically
manifest in the early stages of development and are characterized by
developmental decits that produce impairments in personal, social,
academic, or occupational functioning”.
e dimensional approach in diagnostic classication supports the
variability of the characteristics of these disorders, for the denition of
which was in fact indicated in the DSM-5 the use of speciers of gravity
relative to the autistic symptoms, to the intellectual disability, to the
impairment of speech and to the association with known medical or
genetic conditions or environmental factors.
In children, especially preschoolers, many variables aect the
structuring of autistic-like behaviors and may be crucial to their
evolution [2]. Even the most recent epigenetic studies conrm these
ndings [3-5].
e clinical experience, the data coming from the therapeutic
ecacy and the current research guidelines support the existence of
“autisms”, or conditions that are similar between them from the point
of view of symptoms, but dierent in etiology and prognosis [6].
e identication of predictive indicators on the evolution of each
child through the application of standardized and repeatable tools gives
an important contribution in this regard, both respect to the trend of
autistic symptomatology and of intellectual functioning, on the basis of
a multidimensional and multidisciplinary assessment.
While, in fact, great attention has been and continues to be paid to
the risk recognition and early diagnosis, which are the rst and decisive
element also with respect to prognosis, to date are not yet available,
however, validated systems to identify criteria and/or prognostic
indicators.
Our research, born from years of clinical experience and careful
data analysis, would contribute to the denition of a protocol which, in
addition to the diagnosis, helps to determine the prognosis providing,
from the beginning, reliable indicators predictive of development, that
could be monitored clinically and by specic tests and that could really
individualize the therapeutic project.
Given the existence of considerable dierences within the “autism
spectrum” and the growing attention to the so-called vulnerability
indicators in the rst years of life, we think that also the therapeutic
eld should be individualized and dierentiated.
e results of a developmental approach, based on the relationship
model, especially in infancy and early childhood are now attracting
*Corresponding author: Magda Di Renzo, Institute of Ortofonologia (IdO), Via
Salaria 30, 00198, Rome, Italy, Tel: 0039-068542038; Fax: 0039-068413258;
E-mail: m.direnzo@ortofonologia.it
Received July 24, 2016; Accepted August 22, 2016; Published August 29, 2016
Citation: Di Renzo M, di Castelbianco FB, Vanadia E, Petrillo M, Racinaro L, et
al. (2016) T.U.L.I.P. Protocol (TCE, UOI, Leiter-R as Indicators of Predictivity) for
the Assessment of the Developmental Potential in Children with Autism Spectrum
Disorders. Autism Open Access 6: 188. doi:10.4172/2165-7890.1000188
Copyright: © 2016 Di Renzo M, et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
T.U.L.I.P. Protocol (TCE, UOI, Leiter-R as Indicators of Predictivity) for
the Assessment of the Developmental Potential in Children with Autism
Spectrum Disorders
Magda Di Renzo1*, Federico Bianchi di Castelbianco1, Elena Vanadia1, Massimiliano Petrillo1, Lidia Racinaro1 and Monica Rea1,2
1Institute of Ortofonologia (IdO), Via Salaria 30, 00198, Rome, Italy
2Dynamic and Clinical Psychology Department, Sapienza University of Rome, Via degli Apuli 1, 00185, Rome, Italy
Abstract
The article aims to highlight some predictive indicators of improvement in ADOS scores in a group of 49 children
with Autism Spectrum Disorders.
For this purpose we created a specic protocol named T.U.L.I.P. that, using the Fluid Reasoning of the Leiter-R,
the presence of Emotional Contagion (TCE) and the ability to understand the intentions of the others (UOI) as
predictive indicators, can identify a category of autistic children who positively respond to treatment and improves
the autistic symptomatology.
The children who at the intake had predictive indicators of Emerging or Present UOI and TCE improved their
autistic symptomatology with therapy and some of them (those with Present indicators) positively changed their
ADOS diagnosis.
In pre-school children, or in the rst year of their schooling, the assessment of cognitive and social components
shows that relational skills have a greater importance in predicting the decrease of the ADOS scores.
The presence of predictive indicators, especially on the emotional response and the ability to understand the
intentions of the others, also helps to work through a developmental- relational approach that activates in children
their existing potentialities to get improvements even in the cognitive functioning. The Social Affection component of
the Ados correlates with predictive indicators and accounts for an intervention targeted to the emotional dimension.
Citation: Di Renzo M, di Castelbianco FB, Vanadia E, Petrillo M, Racinaro L, et al. (2016) T.U.L.I.P. Protocol (TCE, UOI, Leiter-R as Indicators of
Predictivity) for the Assessment of the Developmental Potential in Children with Autism Spectrum Disorders. Autism Open Access 6: 188.
doi:10.4172/2165-7890.1000188
Page 2 of 7
Volume 6 • Issue 4 • 1000188
Autism, an Open Access
ISSN: 2165-7890
great interests. e ability to identify a category of autistic children who
responds positively to a specic developmental therapeutic program,
could have a high probability of promoting the development of children
with autism spectrum disorder (ASD) both in socio-relational and
cognitive areas. For this reason, the Institute of Ortofonologia in Rome
(IdO) has implemented the T.U.L.I.P. Protocol, with active involvement
of family and school, for the assessment of the developmental potential
in ASD children.
Being able to estimate the developmental potential in children with
autism spectrum disorders and in parallel to hold indicators related to
the most suitable treatment is, in our opinion, a further conquest and a
promising eld of research for those who deal with this disease.
Our previous research [7] investigated the cognitive area in
autistic children by evaluating the non-verbal IQ through the Leiter-R,
demonstrating the eectiveness of a treatment that favors an approach
based on the relationship and nding both the predictive value of Fluid
Reasoning on the gradual improvement of the expression of IQ both
on the decrease of the ADOS scores aer four years of treatment. Data
supported the hypothesis that an intervention based on the report
oers a cognitive improvement regardless of the severity of autism
symptomatology expressed by the ADOS score. ese recent research
indicates the importance and eectiveness of the rst two years of this
specic treatment and how the continuation of therapy in the following
years not only ensure the stability of cognitive skills but also avoid any
possible regressions in these areas of functioning.
In order to search for children’s potentialities, albeit unexpressed,
that guarantee a reliable prognostic value on the evolution of autistic
symptoms, the inductive and deductive reasoning skills represent
clinically relevant predictors, as expressions, independent from
learning, of mental exibility in a disorder characterized by rigid and
stereotyped thinking, and so represent a potential area of expression of
the social and cognitive functioning [8].
Evaluating the therapeutic ecacy of the developmental model,
estimating the results over time through the re-tests, and in parallel
searching for outcome predictors at the intake, needs to carefully
consider another decit area in autism, that is the ability to understand
the intention of the others, which is a state of mind precursor of the
theory of mind. is component is related to the level of symptoms, but
especially is relevant for the signicant predictive value at a prognostic
level, veried aer only two years of treatment, so demonstrating to
be connected only to the symptomatic severity of autistic disorder and
being independent from the cognitive level expressed [9].
A further possible predictor is the emotional responsiveness that
children may show, assessed according to the presentations of emotional
stimuli in a structured observation [10]. e lower emotional response
of children with autistic symptomatology, or with greater impairment
in the ability of Social Aection, corresponds to a greater presence of
restricted and repetitive behaviors, nding that supports the hypothesis
of the empathetic imbalance of Smith [11], for which the greater
presence of such conducts would testimony defensive behaviors.
e results of the researches, in conclusion, conrm that the
intellectual, relational and emotional skills, as well as the psycho-
physical well-being of children with autism can be improved by a
variety of non-verbal, not exclusively cognitive activities where the
therapist relates to the child and his experiences and accompanies him
to a more productive and less defensive state of activity and awareness.
ese results support the basic assumption that in a high
percentage of autistic children the primary decit is at an emotional
level even before cognitive [12] and the relational, sensorial and bodily
dimensions represent the area toward which direct the therapeutic
intervention.
e therapeutic experience with Autism, and the results of some
recent studies allowed us to integrate issues related to both clinical
practice and research, thus dening an assessment protocol that
can reliably identify capabilities that are indicative of symptomatic
impairment and at the same time can dene a developmental trajectory
for a positive evolution of the disorder and a more harmonious
development of social and cognitive skills.
e working hypothesis that guided this study was to verify
the reliability of the T.U.L.I.P. protocol in predicting the possible
evolutions of the autistic symptoms.
Methods
Participants
49 preschool children diagnosed with autism (ASD) participated
to this study. Of these, 39 males and 10 females, all aged between 24
and 88 months (M=44.35 ± 15.5). Most children are Italian (81.6%);
an African minority (4.1%), Asian (8.2%) and Eastern Europe (6.1%).
Social and cultural status of families is mostly in the average (89.8%),
while only a family (2%) has a high status and 4 families (8.2%) have
low status. At the time of the rst assessment, these children had no
phrasal language, so their cognitive level was evaluated through the
nonverbal Leiter-R scale.
Children who participated in this study came in consultation at the
Institute of Ortofonologia (Rome), with a diagnosis of autism and a
request for treatment. To these children was conrmed the diagnosis
of autism spectrum disorders according to DSM-IV criteria [13] and to
the ADOS score [14] which indicates the symptoms severity. Since the
research participants were recruited in 2011, at that time was not yet
available nor the DSM-5, nor the Italian version of the ADOS-2, that
was aer introduced in 2013. e use in the re-test of the rst version
of the ADOS responds to the need to compare the ADOS scores
obtained through the same algorithm and classication parameters,
which are dierent in the ADOS-2 [15] and that would have made not
comparable the two dierent versions.
e diagnostic assessment of the autistic children involved in
this research has been prepared by a group of experts who have at
least 10 years of experience (psychologists/psychotherapists, child
neuropsychiatrists, neurologists and other specialized gures). During
the treatment, which lasted four years, the children received three
cognitive assessments (at the intake, aer two years and aer four years
from the beginning of the treatment), three assessment focused on
autistic symptomatology (at the intake, aer two years, and aer four
years from the beginning of the treatment), an assessment concerning
the understanding of the others’ intentions and an assessment about
the emotional contagion (at the intake). Clinicians who dealt with the
assessments are not the same ones who are involved in therapy and
clinical intervention. Children with certied neurological damage,
children with sensory disabilities, children under 24 months were not
included in this research. is study was carried out in accordance with
the recommendations of the national guidelines and the APA ethic.
Parents were required informed consent according to the Declaration
of Helsinki.
Instruments
ADOS: e Autism Diagnostic Observation Schedule is
a standardized semi-structured evaluation procedure of the
Citation: Di Renzo M, di Castelbianco FB, Vanadia E, Petrillo M, Racinaro L, et al. (2016) T.U.L.I.P. Protocol (TCE, UOI, Leiter-R as Indicators of
Predictivity) for the Assessment of the Developmental Potential in Children with Autism Spectrum Disorders. Autism Open Access 6: 188.
doi:10.4172/2165-7890.1000188
Page 3 of 7
Volume 6 • Issue 4 • 1000188
Autism, an Open Access
ISSN: 2165-7890
communication and social interaction areas, including the behavioral
and symbolic play assessment, which involves a series of activities
that are evocative of conducts related to the autism spectrum disorder
diagnosis [14]. e observation and coding of these behaviors are used
to assign a score that identies social and communication decits of
the child pertinent with autism and the autistic spectrum. e ADOS
scores, included in a range that goes from 0 to 24, increase depending
on the severity of autistic symptomatology, with a cut-o of 7 for the
autistic spectrum and 11 for autism. Every child of the research sample
had an ADOS classication from the beginning to end of the 4 years
of therapy and the initial average score places the entire sample in a
diagnosis of infantile autism.
Leiter-R: e Leiter International Performance Scale-Revised [16]
is designed for the evaluation of intellectual functions of children and
adolescents aged between 2 and 20 years. e Leiter-R is formulated to
meet the clinical need to evaluate the non-verbal intelligence through
a comprehensive analysis of the strengths and weaknesses with a view
to a diagnosis that includes both neuropsychological and cognitive
aspects. Nonverbal cognitive abilities do not require the capacity to
perceive, manipulate and reason with words and numbers, so the scale
can be administered completely without the use of verbal language,
including instructions, and does not require verbal responses from
the subject. e validity coecient of the IQ score was calculated
for each age group (from alpha 0.92 to 0.93). e Leiter-R has good
evidence of validity from the studies on the content analysis, with data
coming from an extensive analysis, from the criterion related studies,
to the accuracy of classication of intellectual disability, and various
studies related to the construct. e IQ scores have a mean of 100 and
a standard deviation of 15. e intellectual disability is indicated by
a composite score that is two standard deviations or more below the
average, so that a score of 70 constitutes a borderline value.
TCE: e Test for the Emotional Contagion [17] allows estimating
the emotional contagion, both in a quantity and quality sense, that is,
the presence or absence of aective attunement in the child, through
the observation of his emotional and behavioral response during the
presentation of a structured stimulus (video). e child is presented 4
video recordings in which a girl with typical development expresses in
nonverbal ways, the four basic emotions: happiness, sadness, fear and
anger.
Each video has duration of 43 s (for 23 s the girl expresses each
single emotion and for 20 s the video gets dark). For each emotion
presented the observer writes on his encoding protocol the absence or
presence of the expressive reproductions corresponding to the emotion
stimulus and the relative bodily and behavioral responses of the child
assessed.
e encoding protocol consists of ve sections, four of which are
graphically represented from a face on which mark the expression
observed in the child for each emotion, and a check list of 16 bodily
expressions that allow a quantitative analysis of the responses. e h
section is represented by the summary of the test coding that allows
a global qualitative assessment of the emotional contagion responses.
e checklist that is present in the four sections allows to identify
if the child reproduces the motor pattern of the emotion observed in
the girl of the video, if they participate actively, if comments verbally or
vocalizes, if reproduces the intonation of emotion, if it shows postural
abnormalities, if he begins to approach the observer, if he approaches
or not the video, if he starts stereotyped movements, if he ignores the
video and so on.
Each response is considered as “absent” if the child does not
reproduce the motor pattern of the emotion and has a score of 0;
each response is considered as “present” if the child reproduces the
motor pattern of the emotion and in this case the evaluation could be
scored with 1, 2 or 3. It is scored with 1, that is “principle of emotional
contagion”, when there is one emotional contagion response and 3/4
of hints of stimulus reproduction; it is scored with 2, that is emotional
“contagion”, when there are from 2 to 4 emotional contagion responses;
it is scored with 3, “empathy”, when the child recognizes the emotions
and is able to dier from his own.
Additionally, the test allows dening, through the verbalization, if
the child shows veridical empathy or quasi-egocentric empathy [18].
e rst assumes the dierentiation between the self and the other. In
the quasi-egocentric empathy, even though there is the recognition of
each emotion, the process of separation between the self and the other
is not still completed, so the child does not dierentiate.
All the TCE evaluation procedure was videotaped and the observers
scored during the observation and also conrmed it aer, through the
video recordings.
e measures used to evaluate the TCE, were rst administered
by two experienced observers who assessed independently 20 autistic
children. e inter-observer reliability agreement was high (Cohen’s
k=0.90).
UOI: To assess the understanding of others’ intentions, we
used a modied version of the Intention condition of Behavioral
Re-enactment Procedure [19]. e original version of the Meltzo
procedure involved ve objects as test stimuli: the rst object was a
dumbbell-shaped toy that could be pulled apart and put back together
again. It consisted of two 2.5 cm wooden cubes, each with a 7.5 cm
length of plastic extending from it. One tubular piece t snugly inside
the other so that it took considerable force to pull them apart. e
second object was a small black box (16.5 × 15 × 5.5 cm) with a slightly
recessed rectangular button (3 × 2.2 cm) on the top surface. e button
activated a buzzer inside the box. e box was supported by a base that
tilted 30° o the table so that the front surface was facing the child. e
box was accompanied by a small stick tool made of a rectangular block
of wood that was used by the experimenter to push the button. e
third object consisted of a horizontal prong and nylon loop. e prong
was fashioned from an ornamental wooden piece with a bulbous end. It
protruded horizontally from a background screen made of gray plastic
(17 × 20.3 cm). e loop was made from black and yellow woven nylon
tied in a circle with a diameter of 7.5 cm. e fourth object consisted of
a yellow cylinder with a ared base (9.5 cm high with a 6.3 cm opening)
coupled with a loop of beads (19 cm long when suspended). e h
device was a transparent plastic square and wooden dowel. e square
(10 cm) had a 2.5 cm diameter round whole cut out of the center so
that if could t over the dowel. in plastic strips were glued along two
edges of the plastic square to raise it slightly from the table so that it
could be picked up by the children. e dowel (2 cm high and 1.7 cm
in diameter) was in an upright position in the center of a wooden base
plate.
In the present study the procedure involved the use of only 4 items:
we did not use the buzzer inside the box, because of oor eect: in
a preliminary study that we carried out on a sample of 40 children
with autism [20] the most part of the children with autism scored near
the bottom, because the sound characteristics of the object elicited
Citation: Di Renzo M, di Castelbianco FB, Vanadia E, Petrillo M, Racinaro L, et al. (2016) T.U.L.I.P. Protocol (TCE, UOI, Leiter-R as Indicators of
Predictivity) for the Assessment of the Developmental Potential in Children with Autism Spectrum Disorders. Autism Open Access 6: 188.
doi:10.4172/2165-7890.1000188
Page 4 of 7
Volume 6 • Issue 4 • 1000188
Autism, an Open Access
ISSN: 2165-7890
stereotypical responses of closure: whenever this specic task was
proposed, the children accentuated restricted and repetitive behaviors,
which led to attentive and relational dierences, as a result of which
they interrupted the test. is occurred regardless of the order in which
the task was proposed.
e children, in our Intention condition, look like an experimenter
(E) try to unsuccessfully perform a target action (for example, E pulls
apart the ends of a dumbbell, but his hands slip away); the children
have never seen the target action completed and well executed and
neither the object.
For each of the four items, the children are shown by E three failed
attempts to perform the action. en the object is leaved on the table
in front of the child and to him is told “now, it’s your turn”. Once the
child has touched the object, starts a time of 20 s in which the child
could respond.
is procedure was then repeated with each of the remaining
objects. In the Intention condition, children should understand what
the E intends to do, so they should perform the action-target and not
what they see him doing (for example, slide hands to the sides of the
dumbbell).
Subsequently, a score from 0 to 4 is attributed on the basis of the
number of tasks carried out, in reference to the four target actions. e
score of 0 is assigned if there is: the inability to pay attention to the
stimulus presented child; stereotyped and/or sensorial manipulation of
the object; repetition of the failed attempt as seen in the experimenter;
target action approximation.
e number of target action produced in the Intention conditions
have been coded as follows: 0=Absence of capacity (no task
performed); 1=Low capacity (1 task performed); 2=Fair capacity (2
tasks performed); 3=Good ability (3 tasks performed); 4=Excellent
capacity (4 tasks performed).
All the UOI assessment procedure was videotaped and the
observers scored during the observation and also conrmed it aer,
through the video recordings.
e measures used to evaluate the UOI, were rst administered
by two experts who observed independently 20 autistic children. e
inter-observer agreement was high (Cohen’s k=0.92).
Data Analysis
We used the Statistical Package for Social Sciences (SPSS) version
19 for data analysis. Signicance level was set at alpha 0.05 (two-tailed).
Analysis of Variance (ANOVA) was used to evaluate dierences
between groups. Analysis of Variance for repeated measures was used
to evaluate dierences between groups over time. Eect sizes were
reported as partial eta squared (η2
p), A η2
p of 0.02 was considered a
small eect size, 0.13 a medium eect size and 0.23 a large eect size.
Correlation analysis was performed to analyze the relationship between
dependent variables. e linear regression was conducted to verify the
predictors of the severity of the autistic level.
Aim
Goal 1: Verify the Fluid Reasoning reliability in predicting the
intellectual development of children with autism and in predicting
improvement in ADOS scores.
Goal 2: Verify the UOI reliability as a predictor of improvement in
ADOS scores.
Goal 3: Verify the TCE reliability as s predictor of improvement in
ADOS scores.
Results
At intake, the group of 49 children with ASD was assessed with
reference to autistic symptomatology (ADOS), cognitive skills (IQ and
FR), ability to understand the intentions of others (UOI) and presence
of emotional contagion (TCE). Table 1 describes averages and ranges
of the scores.
Goal 1: Verify the Fluid Reasoning reliability in predicting the
intellectual development of children with autism and in predicting
improvement in ADOS scores.
e IQ assessment through the Leiter-R made it possible to divide
the total group into 3 sub-groups: 15 children (mean chronological age
42.3 ± 9.3 months) cannot be evaluated (Not Ev. Group) because their
low attention levels did not allow a structured assessment; 19 children
with an IQ score between 40 and 75 (mean chronological age 45.7 ± 19.7
months); 15 children with an IQ score above 75 (mean chronological
age 44.7 ± 15.3 months). e children of the three groups did not dier
with respect to chronological age (F2,48=0.21; p=0.81).
e rst objective that we would verify was about the possibility for
the Fluid Reasoning score to act as a Target for the IQ score. As shown
in Table 2, there was a signicant eect of repeated measure variable
(F2,48=18.24; p<0.01; η2
q=0.32), so the groups improved their IQ scores
over the three assessments, at the beginning, aer 2 years, and aer 4
years, but it is important to consider that in the Not Ev. group, even
aer four years, IQ score remain in the category of severe intellectual
disabilities, corresponding to an IQ score<55 at the last Leiter-R
assessment. In this group, the Fluid Reasoning score was stable over
the years (F2,14=1.76; p=0.14), and the IQ score has not yet reached its
target score aer 4 years (given by a FR of about 62). Furthermore, in
this group, it is observed that the FR score remains signicantly higher
than the IQ score (F2,14=6.17; p <0.01; η2
q=0.13). Of these 15 children,
11 are not even evaluable aer 2 years and 4 years.
Instead, the group with IQ>76, while showing signicant IQ
improvements over time (F2,14=6.20; p<0.01; η2
q=0.16), already started
with an intellectual category in the average and remains in this category
even aer four years. In this group, even the Fluid Reasoning score is in
the average and is already high at the rst assessment and over the years
it remains lower than the IQ that has reached its Target.
Finally, the group with the IQ score between 40 and 75, is the
most clinically interesting group, because they are children with an
important cognitive impairment but actually assessable, and with
a FR signicantly higher than the IQ score, at the rst assessment
(F2,18=30.06; p<0.001; η2
q=0.26). In this group, it can be observed that,
not only the IQ score signicantly grows over time (F2,18=19.07; p<0.01;
η2
q=0.17), but that aer 4 years the IQ score reaches its Target (given
by a FR of about 74).
Mean ± SD Range
ADOS 16.3 (4.3) 7-22
IQ 62.6 (18.9) 36-102
FR 74.9 (16.8) 48-116
TCE 1.1 (0.9) 0-3
UOI 1.8 (1.5) 0-4
ADOS: Autism Diagnostic Observation Schedule; IQ: Intelligence Quotient; FR:
Fluid Reasoning; TCE: Emotional Contagion Test; UOI: Understanding of Intention
Test
Table 1: Mean (± SD) and range of ADOS scores, IQ, FR, TCE and UOI, at intake.
Citation: Di Renzo M, di Castelbianco FB, Vanadia E, Petrillo M, Racinaro L, et al. (2016) T.U.L.I.P. Protocol (TCE, UOI, Leiter-R as Indicators of
Predictivity) for the Assessment of the Developmental Potential in Children with Autism Spectrum Disorders. Autism Open Access 6: 188.
doi:10.4172/2165-7890.1000188
Page 5 of 7
Volume 6 • Issue 4 • 1000188
Autism, an Open Access
ISSN: 2165-7890
Next, as regards the possible predictability of the FR in the change
of the ADOS score, as seen in the Table 3, in the Not Ev. group a
signicant improvement of the ADOS score appeared aer four years
in ADOS category.
In the group with IQ>75 the ADOS score signicantly decreases
both aer 2 and aer 4 years (F2,14=17.21; p<0.01; η2
q=0.19), and the
children of this group change their category switching from Autism
Spectrum to No Autism.
Even in the group with the IQ score between 40 and 75 the ADOS
score signicantly decreases both aer 2 and aer 4 years (F2,18=25.14;
p<0.01; η2
q=0.21) and the children of this group changed from an
ADOS category of Autism to Autism Spectrum.
Goal 2: Verify the UOI reliability as a predictor of improvement in
ADOS scores.
We divided the UOI scores in three categories: Absent group
(N=20), Present group (N=19) and Emerging group (N=10).
In the Table 4 is shown that in children where the UOI ability
is Absent at the intake, there is a signicant improvement in ADOS
scores in the next 2 years (F2,39=4.98; p<0.01; η2
q=0.20), but then this
improvement will stop, and aer four years the ADOS scores will
remain stable (post hoc: p=0.12).
In children where the UOI ability is Emerging at the intake, there
is a signicant improvement in ADOS scores in the next 2 years
(F2,39=4.98; p<0.01; η2
q=0.20), but then this improvement will stop, and
aer four years the ADOS scores will remain stable (post hoc: p=0.21).
In children where the UOI ability is Present there is a signicant
improvement in ADOS aer 2 years of treatment (F2,39=4.98; p<0.01;
η2
q=0.20), and then this improvement continue over the next two years
(post hoc: p<0.01).
Goal 3: verify the TCE reliability as a predictor of improvement in
ADOS scores.
We divided the TCE scores in three categories: Absent group
(N=16), Present group (N=14) and Emerging group (N=19).
In the Table 5 it is shown that in children where the emotional
contagion is Absent at the intake, there is a signicant improvement in
ADOS scores in the next 2 years (F2,39=3.27; p<0.01; η2
q=0.14), but then
this improvement will stop and aer four years the ADOS scores will
stable (post hoc: p=0.11).
In children where the emotional contagion is Emerging at the
intake, there is a signicant improvement in ADOS scores in the next
2 years (F2,39=3.27; p<0.01; η2
q=0.14), but then this improvement will
stop and aer four years the ADOS scores will remain stable (post hoc:
p=0.19).
In children where the emotional contagion is Present at the intake,
there is a signicant improvement in ADOS scores aer 2 years of
treatment (F2,39=3.27; p<0.01; η2
q=0.14), and this improvement will
continue over the next two years (post hoc: p<0.01).
To see which are the best predictors of the severity of the autistic
level, we conducted the analysis of the linear regression two years aer
the beginning of the treatment (Table 6).
e ndings show that TCE and UOI are the only predictors of
ADOS scores: TCE and UOI high scores correspond to a reduction of
ADOS scores over time. Instead IQ and FR predict the decrease of the
ADOS scores only for the IQ category 40-75.
Discussion
e results of this study suggested the reliability of the T.U.L.I.P.
protocol to estimate the developmental potentialities in children
with autism spectrum disorder as well as to facilitate the dierential
diagnosis. It is extremely important to isolate a group of children with
autism spectrum disorder with positive prognosis and this responds to
the DSM-5 criteria.
e dimensional criterion introduced with the DSM-5, as
already mentioned, prompts to specify the individual symptomatic
characteristics of each child and refers to the current concept of
“autisms”, instead of autistic disorder. e protocol we used in this
research originates from the results already made by administering each
of the tests to ASD children, in order to verify the correlation with the
IQ Evolution (Mean and SD) FR Evolution (Mean and SD)
Assessment 1 Assessment 2 Assessment 3 pAssessment 1 Assessment 2 Assessment 3 p
All Groups 62.9 (1.5) 72.8 (2.7) 76.8 (3.2) 0.01 75.7 (1.6) 75.6 (2.3) 74.5 (2.6) 0.60
Condence interval 95% 59.9-65.9 67.4-78.2 70.3-83.3 72.5-79.1 70.9-80.4 69.2-79.8
Assessment 1 Assessment 2 Assessment 3 pAssessment 1 Assessment 2 Assessment 3 p
Not Ev. IQ group 46.4 (6.2) 52.1 (19.8) 54.1 (23.0) 0.56 62.8 (6.2) 61.3 (12.2) 62.3 (16.9) 0.78
Condence interval 95% 41.9-50.8 37.9-66.3 37.7-70.5 58.3-67.3 52.6-70.1 50.2-74.4
IQ>76 group 87.0 (8.6) 95.3 (14.5) 99.5 (18.5) 0.05 96.6 (11.0) 88.2 (13.2) 86.7 (15.0) 0.05
Condence interval 95% 81.8-92.2 86.6-104.1 88.3-110.6 89.3-104.0 79.3-97.1 76.6-96.8
40<IQ<75 group 55.2 (11.1) 71.1 (16.6) 76.8 (19.6) 0.01 67.9 (10.5) 77.4 (15.6) 74.4 (15.9) 0.06
Condence interval 95% 49.9-60.5 63.1-79.1 67.4-86.2 62.8-72.9 69.8-84.9 66.7-82.1
Table 2: Mean (SD) of IQ scores and FR scores, at rst, second and third assessment.
ADOS Evolution (Mean and SD)
Assessment 1 Assessment 2 Assessment 3 p
Not Ev. IQ 18.2 (3.5) 16.4 (3.2) 15.5 (3.2) 0.05
Condence interval 95% 15.7-20.7 14.1-18.7 13.2-17.8
IQ>76 13.2 (5.0) 8.8 (5.2) 6.4 (4.9) 0.01
Condence interval 95% 10.1-16.2 5.6-11.9 3.4-9.4
40<IQ<75 17.2 (2.8) 13.4 (3.9) 11.2 (5.0) 0.01
Condence interval 95% 15.8-18.5 11.5-15.3 8.7-13.6
Table 3: Mean (SD) of ADOS scores, at rst, second and third assessment, in the Not Ev. group, in the IQ>76 group and in 40<IQ<75 group.
Citation: Di Renzo M, di Castelbianco FB, Vanadia E, Petrillo M, Racinaro L, et al. (2016) T.U.L.I.P. Protocol (TCE, UOI, Leiter-R as Indicators of
Predictivity) for the Assessment of the Developmental Potential in Children with Autism Spectrum Disorders. Autism Open Access 6: 188.
doi:10.4172/2165-7890.1000188
Page 6 of 7
Volume 6 • Issue 4 • 1000188
Autism, an Open Access
ISSN: 2165-7890
not seeing an ADOS improvement. In such cases we observe a greater
adaptability of the child that, however, does not modify the severity of
the autistic symptomatology.
With regard to the second goal, that was to verify the predictive
value of the UOI on the improvement of autistic symptomatology, the
results suggested that children who at the intake had shown a Present
ability of UOI, tended to improve over time the ADOS score.
As for the third goal, that is to check the predictive value of an
improvement in autistic symptoms through the TCE, the results
conrmed that children who at the intake had shown the presence of
emotional contagion, both emergent and present, improved over time
by changing their ADOS score and maintain constant the level reached.
Despite the ADOS constitutes a gold standard for the assessment
of the Autistic Disorder, the level of severity does not allow adequate
prognosis.
In fact, although children with better ADOS score have less
problematic behaviors it is not for sure that they will have more positive
prognosis, as it seems to emerge from our ndings.
What is clear from the data is that for the children in this group,
who have all less than 7 years, when discovering cognitive and social
skills these ones have prevalence in predicting improvement in ADOS
scores.
e combination of both indexes (UOI and TCE) in case of a
positive response from the child, thus signicantly predicts the gradual
evolution of symptoms and the positive change in ADOS classication
until arriving in some cases to the “No Autism” category showing
how much emotional and social skills, more than the cognitive ones,
assessed at the intake, can aord to discriminate children that will
improve over time.
e research allowed the identication of a subgroup of children
who, even before undertaking a course of treatment, shows a greater
potential for improvement (in particular through a therapeutic
relational oriented approach, which is what we proposed for four years
to the 49 children of the sample examined).
A further interesting aspect to underline in these ndings concerns
the fact that at the rst assessment, the average ADOS score is very high
ADOS as a gold standard to assess the symptom severity. In particular,
the Leiter-R had already been administered to 90 ASD children [7],
the TCE to 46 ASD children [10] and the UOI to100 ASD children [9].
With this study we wanted to verify the predictability of the three
areas (intellectual quotient, emotional contagion and understanding of
intention) on the ADOS scores and we want to verify the correlation
among all the areas, in ASD children.
As for the rst goal, namely to verify if the FR is predictive of
future cognitive evolutions, we conrmed what already underlined in
previous studies [7,8]. In fact, in the group of children with a low IQ at
the intake, seem to be a gradual cognitive improvement in four years
of therapy up to reach the IQ score indicated by the FR. For children
who have an IQ score at least 15 points higher than the FR there is an
improvement in ADOS score.
e predictive value of the Fluid Reasoning suggests the clinical
importance of nding a potential closely linked to the exibility of the
mental strategies, such as the abstraction and deduction abilities with
discriminating prognostic value in a disease characterized by strong
behavioral rigidity of thought.
In fact, the ability of Fluid Reasoning higher than a standard
deviation (15 points) compared to IQ, in conditions of intellectual
disability, outlines developmental perspectives of progressive increase
of cognitive abilities that can be used and socially invested in the quality
and quantity of mutual communication, indicated by the improvement
in ADOS scores.
As evidence of these considerations it must be stressed that the
not assessable IQ (11 of 15 of the not assessable children at the intake
remain so even aer 4 years of therapy) is a negative index compared to
ADOS. Even in those 4 cases where there is an IQ improvement we are
ADOS Evolution (Mean and SD)
UOI Assessment 1 Assessment 2 Assessment 3 p
UOI absent 19.5 (1.5) 16.9 (1.8) 15.7 (2.3) 0.001
Condence interval 95% 18.6-20.3 15.8-17.9 14.4-16.9
UOI emerging 15.2 (3.1) 12.7 (2.9) 11.5 (3.7) 0.01
Condence interval 95% 12.9-17.4 10.6-14.7 8.8-14.2
UOI present 13.8 (4.2) 9.0 (5.1) 5.9 (4.6) 0.001
Condence interval 95% 11.4-16.2 6.3-11.6 3.5-8.3
Table 4: Mean (SD) of ADOS scores, at rst, second and third assessment, in the Absent UOI group, Emerging UOI group and present UOI group.
ADOS Evolution (Mean and SD)
TCE Assessment 1 Assessment 2 Assessment 3 p
TCE absent 18.33 (3.6) 15.3 (3.5) 13.3 (4.2) 0.001
Condence interval 95% 16.3-20.3 13.3-17.2 10.9-15.6
TCE emerging 16.7 (3.0) 14.1 (3.3) 12.9 (3.6) 0.001
Condence interval 95% 14.9-18.3 12.2-15.9 10.8-14.9
TCE present 12.8 (4.4) 7.8 (5.1) 4.8 (5.2) 0.001
Condence interval 95% 10.1-15.6 4.5-11.1 1.5-8.2
Table 5: Mean (SD) of ADOS scores, at rst, second and third assessment, in the Absent TCE group, Emerging TCE group and present TCE group.
Predictors β Coefcient SE Exp(B) t p
IQ scores -0.052 0.065 -0.202 -0.810 0.42
FR scores 0.028 0.065 0.095 0.428 0.67
TCE scores -1.300 0.529 -0.263 -2.455 0.01
UOI scores -1.704 0.446 -0.536 -3.820 0.01
Costant 18.844 2.378 7.925 0.01
Table 6: Linear Regression Model: IQ scores, FR scores, TCE and UOI scores as
predictors of reduction of ADOS scores.
Citation: Di Renzo M, di Castelbianco FB, Vanadia E, Petrillo M, Racinaro L, et al. (2016) T.U.L.I.P. Protocol (TCE, UOI, Leiter-R as Indicators of
Predictivity) for the Assessment of the Developmental Potential in Children with Autism Spectrum Disorders. Autism Open Access 6: 188.
doi:10.4172/2165-7890.1000188
Page 7 of 7
Volume 6 • Issue 4 • 1000188
Autism, an Open Access
ISSN: 2165-7890
so indicating a severe autistic condition, in all 3 groups. erefore it is
not the ADOS score that indicates the possibility of improvement over
time, but it is the presence of emotional and relational potentialities
that allows discriminating between children who will improve from
those that will improve less.
e T.U.L.I.P. Protocol enables us to identify and isolate children
with autistic symptomatology related to an emotional and relational
dimension, where the social aection area represents the therapeutic
target at which point the treatment.
e usefulness of dening, during the rst assessment, a reliable
development prole for a positive evolution of the disorder, allows
planning a specic intervention, tailored to the child’s potentialities,
which could, over time, ensure a more harmonious and integrated
development of socio-cognitive skills. is work suggests that the
T.U.L.I.P. can be a valid and repeatable protocol and, as argued by
the most part of the studies about these issues, that there is not a
“single autism” and therefore the new frontier is the identication of
autism proles, as individualized as possible. In fact, great attention is
currently directed to the denition of the pathogenetic and phenotypic
variability of autism [21], to the depth analysis of dierent elds and
levels of functioning, such as the theory of mind and executive functions
[22], but also to the quality of life and potential various therapeutic
interventions according to the principle of individualization of care
based on the denition of development proles.
e considerations reported so far should take account of a
limitation of the present study, represented by the size of the sample
(49 children); the sample was composed only by preschool children
who were assessed with all three measures (Leiter R, TCE and UOI)
in the same evaluation. However, the small sample was monitored
over four years of therapy; this gives the research a clinical value as a
longitudinal study.
Further studies will be needed, of course, to conrm our ndings. In
particular, it will be interesting to see if dierent treatment approaches
allow to achieve the same results on the basis of the potential identied
through the T.U.L.I.P. Protocol and if, conversely, this Protocol could
guide the therapeutic choice.
Another limitation is represented by the few references, but there
are still not many studies that have attempted to build one assessment
tool to investigate a combination of predictors of improvement in ASD
children.
We think that this proposal may represent a rst exploration of a
new and complex area, namely the identication of prognostic factors
and clinical dierentiation between dierent types of autism in that
unique therapeutic window represented by developmental age.
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