Screening for autism spectrum disorder in a naturalistic home setting using the systematic observation of red flags (SORF) at 18-24 months.
Deanna Dow, Taylor N Day, Timothy J Kutta and 2 others
PMID 31643148WHAT IT FOUND
The Systematic Observation of Red Flags (SORF) screening tool accurately identified autism risk in toddlers during 1-hour home video observations.
A composite score of six specific behaviors, such as poor eye gaze and limited pointing, best distinguished children with autism from those with other delays.
Key findings
01A composite score derived from six specific items (poor eye gaze, limited showing/pointing, limited coordination of nonverbal communication, less interest in people than objects, repetitive movements of objects, and excessive interest in particular objects) showed good discrimination between children with ASD and nonspectrum groups.
02Using a cutoff score of 5 for the composite measure yielded a sensitivity of 0.77 and specificity of 0.72, while lowering the cutoff to 4 increased sensitivity to 0.88 but reduced specificity to 0.58.
03Social Communication items generally performed better than Restricted Repetitive Behaviors items in the home setting, with many RRB items showing low frequency and weak discrimination.
STILL TO COME
How it was doneWhat they foundWhat it means for SLPs
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What it does not show
The sample had higher cognitive functioning than typical clinical ASD samples, which may have inflated specificity and requires caution when generalizing to children with more severe impairments. The 1-hour observation duration is resource-intensive, and the study did not determine the minimum observation time needed for accurate screening. The unstandardized nature of the home environment means that parental behaviors (e.g., removing objects to prevent repetitive behaviors) could mask symptoms, particularly RRBs. The study was not designed to validate telehealth implementation, despite the potential for remote scoring.
Declared interests
Author A.W. is a co-author of the Communication and Symbolic Behavior Scales (CSBS) and receives royalties for its use, though not from this specific study. The research was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
The easy way to misread this
Do not assume the SORF is equally effective for detecting Restricted Repetitive Behaviors in home settings as it is for Social Communication. The study found that many RRB items had low frequency and weak discrimination in naturalistic observations, so a low RRB score does not rule out autism.