Assessing autism spectrum disorder and other neurodevelopmental conditions in preschoolers through the Strengths and Difficulties Questionnaire (SDQ) with remote data collection

Assessing autism spectrum disorder and other neurodevelopmental conditions in preschoolers through the Strengths and Difficulties Questionnaire (SDQ) with remote data collection | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessing autism spectrum disorder and other neurodevelopmental conditions in preschoolers through the Strengths and Difficulties Questionnaire (SDQ) with remote data collection Nicole Viganò, Lisa Stucchi, Ginevra Winters, Noemi Buo, Silvia Busti, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8079551/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract BACKGROUND Screening is now worldwide recognised as essential for early detection of neurodevelopmental divergences, and telemedicine is increasingly proving to be a valuable resource in this area. Our retrospective observational study aimed to assess the ability of the Strengths and Difficulties Questionnaire (SDQ 2–4) as a measure to distinguish autism spectrum disorder from other neurodevelopmental disorders in clinical and typically developing populations of preschoolers by remote data collection. METHODS Data from 343 preschoolers, including 93 children with autism spectrum disorder (ASD), 28 neurotypical children (NT), 167 children with developmental language disorder (DLD), and 55 children with developmental delay (DD), were collected through the MEDea Information and Clinical Assessment on-Line (MedicalBIT) platform. RESULTS Our results showed higher scores on all SDQ 2–4 scales for the ASD group vs the NT group, except for a scale scored in reverse (Prosocial Behaviour Scales) that had lower scores in children with ASD than NT children. Total Problems, Peer Problems, Hyperactivity, and Prosocial Behaviour Scales could more significantly differentiate the ASD group from the NT group. When comparing ASD group with other neurodevelopmental conditions (DLD, DD), the most significant results were found for the Total Problems, Peer Problems and Prosocial Behaviour Scales. CONCLUSIONS We concluded that these scales were more effective in differentiating children with autism spectrum disorder from children with developmental language disorder and from children with developmental delay, as well as from neurotypical children. We proved the SDQ 2–4 to be a valid short screening tool for use in preschoolers, to differentiate between ASD and other conditions by remote data collection. Autism spectrum disorder Early screening Telemedicine Preschoolers SDQ 2–4 Neurodevelopmental conditions Figures Figure 1 Figure 2 Figure 3 Introduction Early childhood is a critical period for the psycho-physical, social, and emotional development of infants. Developmental neurodivergences, such as developmental delay (DD), autism spectrum disorder (ASD) and developmental language disorder (DLD), are conditions that typically emerge early in development and result in atypicalities across the cognitive, linguistic, socio-emotional, behavioural, and neuro-motor domains, leading to functional impairments [ 1 , 2 ]. Despite the early emergence of signs indicative of neurodevelopmental conditions, diagnosis is often delayed [ 3 , 4 ]. A recent meta-analysis reported that the average age of diagnosis of ASD is over 3 years, with a mean of 43 months [ 5 ]. According to the World Health Organization (2011), recognizing infants at increased likelihood of neurodevelopmental conditions is a critical first step in fostering a strong partnership between parents and healthcare providers, as well as in providing early intervention [ 6 ]. In a 2006 policy statement, the American Psychiatric Association (APA) recommended that primary care physicians conduct structured developmental screening using a standardized tool at a specified age [ 7 ]. Early screening identifies children at increased likelihood of neurodevelopmental conditions, enabling early intervention that improves long-term outcomes as supported by a growing body of evidence [ 8 – 13 ]. Globally, the estimated prevalence rates across children and adolescents aged < 18 years are as follows: 0.63% for DD, 5–11% for ADHD, 0.70-3% for ASD, 3–10% for Specific learning disorders (SLDs), 1–3.42% for Communication disorders (CDs) and 0.76-17% for Motor disorders (MDs) [ 14 , 15 ]. Neuropsychiatric conditions are frequently identified as a primary source of disability among youths globally, imposing considerable burdens on families, individuals, and national healthcare systems [ 16 , 17 ] while also leading to effects during developmental stages [ 18 – 21 ]. Screening has become an increasingly common practice among pediatricians, with an increase from 23% in 2002 to 45% in 2009, and up to 63% in 2016. However, there are still barriers, such as lack of time, inadequate reimbursement, and difficulty with scoring, which must be overcome to promote early access to services for children in need [ 22 ]. A response to this challenge is provided by technology, which today offers a number of tools that can be integrated into healthcare practice [ 23 ]. Web-based tools for developmental screening offer a potential solution to the complex logistical challenges of this process, leading to an increase in screening rates [ 24 ] and monitoring at various time points [ 25 ], as recommended by the APA (2006) [ 7 ]. Telemedicine has proven to be useful for directly reaching patients, even prior to the COVID-19 pandemic [ 26 ]. Furthermore, the acceptability and effectiveness of web-based developmental surveillance programs for preschoolers have been demonstrated by both parents and healthcare providers, although further studies on this topic are needed [ 27 ]. Despite the increased screening [ 28 ] and the substantial evidence supporting telemedicine as an effective means to facilitate this process [ 29 – 31 ], only a smaller proportion of practitioners have so far used a standardized tool for this purpose [ 32 ], relying solely on clinical judgment, which may lead to underreporting of neurodevelopmental disorders [ 33 , 34 ]. Among the most widely used screening tools [ 35 ], the Infant Toddler Checklist (ITC) [ 36 , 37 ] and the Checklist for Autism in Toddlers (CHAT) [ 38 , 39 ] are however designed for general population screening in children under 2 years of age. Few screening tools are available for use with preschool-aged children, particularly in the 2–4-year age range. One of them is the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) [ 40 ], which can only be used up to 30 months of age and – although highly sensitive – has low specificity leading to a high risk of false positives. The Pervasive Developmental Disorder Screening Test-II (PDDST-II) [ 41 ] is yet another tool but it is not freely accessible and is offered in a limited number of languages. The Child Behavior Checklist 1½–5 (CBCL 1½–5) [ 42 ] is a parent-report measure; however, owing to its length it requires a substantial time commitment for completion, and trained professionals are needed for accurate interpretation. Based on the above, there is a critical need for screening tools with strong psychometric properties specifically designed for preschool children (age 2–4 years) that are easily accessible and widely accepted. The Strengths and Difficulties Questionnaire (SDQ) is a brief screening tool designed to assess emotional and behavioural problems in children aged 2 to 17 years [ 43 – 45 ]. Developed by Goodman in the United Kingdom in 1997 [ 43 ], it is now available for free in multiple languages on the website www.sdq.info.org . A specific version of the SDQ for children aged 2–4 years, the SDQ 2–4, is available and can be quickly completed by parents. It is widely used internationally and its strong psychometric properties have been confirmed by several studies, confirming its validity for early identification of children with emotional and behavioural difficulties, thereby increasing the likelihood of access to effective interventions [ 46 – 51 ]. Although a substantial body of research has examined the effectiveness of the SDQ as a screening tool for predicting childhood psychiatric disorders [ 45 , 52 ], to our knowledge, few studies have focused on the predictive validity of the SDQ 2–4 for neurodevelopmental disorders, which are often associated with emotional and behavioural challenges [ 53 , 54 ], while several studies have focused on the SDQ 4–17 specifically for conditions such as ASD and ADHD. Goodman himself demonstrated that the SDQ identifies approximately two-thirds of children with psychiatric disorders, in particular conduct and hyperactivity disorders [ 45 ]. Later studies [ 55 – 57 ] found significant score differences between clinical groups (ASD, ADHD) and comparison groups on all SDQ scales. Russell et al. (2013) observed higher hyperactivity scores and lower prosocial behaviour scores in clinical groups, while Iizuka et al. (2010) highlighted differences between ADHD and ASD, with the latter being associated with higher emotional symptoms and peer problems [ 55 , 56 ]. Salayev e Sanne (2017) confirmed that emotional problems and prosocial behaviour are key in differentiating ASD, with the Prosocial Behaviour Scale being the most predictive of this neurodevelopmental condition [ 57 ]. Further studies [ 58 ] supported these findings, with additional measures enhancing the prediction of ASD in children aged 4–12. The only studies known to have used the SDQ 2–4 to predict neurodevelopmental conditions were conducted by Croft et al. (2015) – Croft’s being the first longitudinal study in this area – and by Grasso et al. (2022) who evaluated the SDQ 2–4 predictive validity across a broader age range [ 46 , 59 ]. Croft et al. (2015) identified the Hyperactivity scale as a predictor of ASD [ 46 ]. In contrast, Grasso et al. (2022) found the Peer Problems and Prosocial Behaviour scales to be the most effective in capturing the core symptoms of ASD [ 59 ]. Their findings highlight the potential of the SDQ 2–4 to specifically differentiate and identify behavioural and emotional profiles associated with clinical diagnoses. Our retrospective observational study aims to examine the validity of the SDQ 2–4 as a tool for distinguishing between different neurodevelopmental conditions in both clinical and typically developing populations, with a specific focus on its ability to differentiate ASD from other neurodevelopmental disorders. Previous research has demonstrated the equivalence between paper-based and digital versions of assessment tools. In particular, Tanaka et al. (2021) found that the web-based versions of the SDQ – used for developmental health monitoring in preschoolers– showed comparable levels of internal consistency, inter-rater reliability, and overall equivalence to their paper-based counterparts, thereby supporting the use of digital questionnaires for neurodevelopmental conditions assessment [ 60 ]. In accordance with this, our study aims to achieve its objective by utilizing the SDQ 2–4 in a digital format through access to a clinical web-based platform. Methods In this retrospective observational study, we considered the demographic and clinical data of children referred to the Developmental Psychopathology Unit of the Scientific Institute “IRCCS Eugenio Medea –Associazione La Nostra Famiglia” in Bosisio Parini (Lecco, Italy). The study was approved by the Institute’s Ethical Review Board (Prot. N. 42/23, “Comitato Etico IRCCS E. Medea—Sezione Scientifica Associazione La Nostra Famiglia”) and all the participants’ parents/legal guardians gave their written informed consent to the children’s participation. Participants A sample of 335 children aged between 2 and 4 years were referred to the Child Neuropsychiatry Service of our Institute for suspected neurodevelopmental conditions between January 2019 and July 2024. All participants’ parents, before accessing the Institute, are asked to complete remotely a socio-anamnestic questionnaire and some screening questionnaires (for example, SDQ) using the MedicalBIT internet-based platform (MEDea Information and Clinical Assessment on-Line - www.medicalbit.com), which is currently the first Italian internet-based screening platform for child and adolescent neuropsychiatric conditions [61, 62]. The participating children underwent a comprehensive clinical evaluation by experienced developmental neuropsychiatrists and received one (or more) clinical diagnoses based on the International Classification of Diseases, 10th Revision (ICD-10) [63]. Fifteen children did not meet the criteria for a neurodevelopmental disorder diagnosis at the time of the assessment; however, they are still being followed-up by our service as they exhibit subclinical traits. Four of them do not have neurodevelopmental disorders but were diagnosed with syndromes or neurological conditions, so they were excluded. One child with emotional disorders was not included in our analysis due to the small sample size. The remaining 315 participants were divided into three groups based on the ICD-10 clinical diagnosis. Our study also included 28 neurotypical children (NT) aged from 2 to 4 years who were recruited through local advertisements from two hospitals in northern Italy for participation in a larger ongoing longitudinal study [64]. The final sample included a total of 343 participants (M = 38,73 months; SD = 5,34; Males = 66,8%; Female = 33,2%), divided into four groups: children with autistic spectrum disorder (ASD - N=93), neurotypical children (NT - N=28), children with developmental language disorder (DLD - N=167), and children with developmental delay (DD - N=55). The sample characteristics are presented in Table 1. All children were between 2 and 4 years of age but there was some difference across groups: the ASD group had a mean age which was slightly lower than that of the DLD and DD groups and higher than that of the NT group. In all groups, except for the NT group, there was a majority of male participants, with the biggest difference in ASD and DD. The developmental quotient was significantly higher in the neurotypical group vs the other groups, with the DD and ASD groups showing the lowest quotient which significantly differed from that of the NT and DLD groups. All participant-related data were obtained remotely by parents using the MedicalBIT platform, except for the diagnosis which was recorded onto the platform by the neuropsychiatrists. Table 1. Descriptive statistics and group comparisons on individual, clinical and demographic characteristics Group Characteristics ASD NT DLD DD N 93 28 167 55 Age in months - Mean (SD) 37.12 (5.34) a,b,c 32.00 (5.95) a,b,d 40.26 (4.30) c,d 40.22 (4.47) c,d Sex - n (%) Male 68 (73.10) 13 (46.40) 106 (63.50) 42 (76.40) Female 25 (26.90) 15 (53.60) 61 (36.50) 13 (23.60) DQ - Mean (SD) 68.21 (19.38) b,c 109.81 (6.25) a,b,d 89.03 (12.33) a,c,d 66.27 (7.81) b,c ASD, autism spectrum disorder; DD, developmental delay; DLD, developmental language disorder; NT, neurotypical children; DQ, developmental quotient [65]; a Significant difference with DD group. b Significant difference with DLD group. c Significant difference with NT group. d Significant difference with ASD group. Materials The parent-report SDQ 2-4 (Strengths and Difficulties Questionnaire for children from 2 to 4 years old - www.sdqinfo.org) contains 25 items forming 5 scales, 4 difficulties scales (Conduct Problems, Hyperactivity, Emotional Problems and Peer Problems) and a Prosocial Behaviour Scale. A Total Problems score provides a global score for all the difficulties scale. Parents are asked to rate items as either 0 (not true), 1 (somewhat true), or 2 (certainly true). Every scale has a minimum score of 0 and a maximum score of 10 and the total scale has a minimum score of 0 and a maximum score of 40. The higher the scores on the difficulty scales, the greater the impairment, while a higher score on the Prosocial Behaviour Scale indicates greater strengths. The SDQ 2-4 version is quite similar to the SDQ 4-17 version, the only differences being 3 items adjusted to reflect age-appropriate behaviours and contexts: item 18 “often lies or cheats” and item 22 “steals from home, school or elsewhere” of the Conduct Problems Scale became “argumentative with adults” and “can be spiteful”; item 21 “thinks things out before acting” of the Hyperactivity Scale became “can stop and think before acting”. For this study, raw scores from the scales and the total scale were used to assess the strengths and difficulties in the selected samples. Statistical Analysis One-way ANOVAs were used to assess whether the 4 groups (i.e., ASD, DD, DLD, NT) showed statistically significant differences on the SDQ scales (i.e., Emotional Problems, Conduct Problems, Hyperactivity Problems, Peer Problems, and Prosocial Behaviour) and the SDQ total scale (i.e., Total Difficulties). Post-hoc pairwise comparisons (Tukey-HSD) were conducted to further explore the differences between specific groups when a significant main effect was found. Receiver Operating Characteristic (ROC) curve analyses were conducted, and Area Under the Curve (AUC) scores were calculated to show the strength of discrimination between children with ASD and NT children, as well as between children with ASD and children with other neurodevelopmental disorders (i.e., ASD vs. DD, ASD vs. DLD). An AUC of 0.50 indicates that the classifier (i.e., SDQ scales and total score) cannot distinguish between the two groups, while an AUC of 1 indicates that the classifier (i.e., SDQ scales and total score) can perfectly distinguish between the selected groups. Published cut-off scores [43, 66, 67] were used to calculate sensitivity (proportion of children with ASD correctly identified), specificity (proportion of children without ASD correctly identified), Positive Predictive Values (PPVs), and Negative Predictive Values (NPVs). We decided to use a published cut-off as it is widely recognized and validated in the scientific literature [43, 66, 67]. Also, pre-established cut-offs allow us to compare our results with those of previous studies. This approach was chosen to promote replicability and comparability of our findings. Results Group comparison First, we used a one-way ANOVA to assess the group differences between all the 5 scales of the SDQ, and post-hoc pairwise comparisons (Tukey-HSD) were computed. Overall significant differences emerged between groups for all the scales (see Table 2). The Emotional Problems Scale (F (3, 339) = 5.83, p< .01) and the Conduct Problems Scale (F (3, 339) = 3.56, p< .01) were the least significant in the group comparisons, highlighting a lower difference between the groups on these scales. All 3 diagnostic groups differed on the Emotional Problems Scale from the NT (M = 0.46, SD = 0.51), with the higher score obtained by ASD (M = 1.65, SD = 1.63). On the Conduct Problems Scale, the ASD group obtained significantly higher scores (M = 1.89, SD = 1.45) compared to NT (M = 1.89, SD= 1.45). On the Total Problems Scale (F (3, 339) = 25.39, p< .001), differences emerged between all 4 groups, with the ASD group reporting the highest scores (M = 13.88, SD = 5.65). The Hyperactivity Scale showed a significant difference (F (3, 339) = 23.88, p< .001) between ASD (M = 5.37, SD = 2.39) and DD (M = 4.64, SD = 2.55) groups, with scores higher than the other groups (NT (M = 2.21, SD = 1.45); DLD (M = 3.31, SD= 2.81)). On the Emotional Problems Scale all groups significantly differed from the NT (F (3, 339) = 5.63, p< .01) group, who had a lower score (M = 0.46, SD = 0.51). The ASD group also differed from the other groups on the Peer Problems (F (3, 339) = 29.97, p < .001) and Prosocial Behaviour (F (3, 339) = 33.19, p < .001) scales, obtaining a significantly higher score on Peer Problems compared to all the other groups (M = 3.76, SD = 1.83). On the Prosocial Behaviour Scale –this being an inversely scored measure, the ASD group differed significantly from all the others as it obtained the lowest score (M = 4.80, SD = 2.36). In sum, a significant difference emerged for the ASD group vs the NT group on all the scales, and the ASD group was the only one with a significantly higher score on Conduct Problems. The highest statistical differences were found for the Total Difficulties, Hyperactivity, Peer Problems and Prosocial Behaviour scales. Table 2. Descriptive statistics and group comparisons on SDQ Scores ASD (n= 93) Mean (SD) DD (n=55) Mean (SD) DLD (n=167) Mean (SD) NT (n=28) Mean (SD) F Group differences Total Difficulties 13.88 (5.65) 11.56 (5.51) 9.11 (5.22) 5.75 (2.40) 25.39*** ASD > DD > DLD>NT Emotional Problems 1.65 (1.63) 1.71 (1.75) 1.34 (1.31) 0.46 (0.51) 5.83** ASD > NT; DD > NT; DLD > NT Conduct Problems 3.11 (2.00) 2.91 (1.87) 2.60 (1.85) 1.89 (1.45) 3.56** ASD > NT Hyperactivity 5.37 (2.39) 4.64 (2.55) 3.31 (2.18) 2.21 (1.45) 23.88*** ASD > DLD; ASD > NT; DD > DLD; DD > NT Peer Problems 3.76 (1.86) 2.31 (1.55) 1.86 (1.76) 1.18 (1.16) 29.97*** ASD > DD > NT; ASD > DLD Prosocial Behaviour 4.80 (2.36) 6.69 (2.04) 7.34 (1.79) 6.75 (1.53) 33.19*** ASD < DD; ASD < DLD; ASD < NT ASD, autism spectrum disorder; DD, developmental delay; DLD, developmental language disorder; NT, neurotypical children; SDQ, Strengths and Difficulties Questionnaire. *P < .05, **P < .01, ***P < .001 ROC curve analysis based on group differences ROC curve analysis was used to assess how well the SDQ discriminates between the ASD group and the other three groups. In this analysis, we used a previously published cut-off to ensure the replicability and comparability of our findings. Table 3. Summary score for the ROC curve analysis based on diagnostic classification ASD (93) VS NT (28) ASD (93) VS DLD (167) ASD (93) VS DD (55) AUC (SE) 95% CI Sens/Spec PPV/NPV AUC (SE) 95% CI Sens/Spec PPV/NPV AUC (SE) 95% CI Sens/Spec PPV/NPV Total Difficulties .92*** (.026) [0.87 - 0.97] .387/1.000 1.000/.329 .74***(.031) [0.68 - 0.80] .387/.850 .590/.714 .62** (.049) [0.52 - 0.72] .387/.727 .706/.412 Emotional Problems .71*** (.047) [0.62 - 0.81] .161/1.000 1.000/.264 .54 (0.28) [0.47 - 0.62] .49 (.049) [0.40 - 0.59] Conduct Problems .68*** (.056) [0.57 - 0.79] .226/.964 .955/.273 .57* (.037) [0.50 - 0.64] .226/.844 .447/662 .52 (.049) [0.42 - 0.62] Hyperactivity .86*** (.033) [0.80 - 0.93] .301/1.000 1.000/.301 .74*** (.032) [0.68 - 0.80] .301/.910 .651/.700 .59 (.049) [0.49 - 0.68] Peer Problems .87*** (.036) [0.80 - 0.94] .591/.964 .982/.416 .77*** (.030) [0.71 - 0.83] .591/.826 .655/.784 .72*** (.042) [0.64 - 0.80] .591/.782 .820/.531 Prosocial Behaviour .75*** (.045) [0.66 - 0.83] .462/.929 .921/.397 .80*** (.030) [0.74 - 0.86] .462/.946 .690/.801 .73*** (.042) [0.64 - 0.81] .462/.873 .794/.534 ASD, autism spectrum disorder; DD, developmental delay; DLD, developmental language disorder; NT, neurotypical children. CI, Confidence interval. *p < .05, **p< .01, ***p< .001 ASD versus NT The area under the curve (AUC) showed a good capacity of the SDQ to distinguish between ASD and NT (all ps< .001; see Table 3). Total Difficulties (0.92, p< .001), Peer Problems (0.87, p< .001) and Hyperactivity (0.86, p< .001) scales showed the higher values (Fig.1). As can be seen in Table 3, there are high levels of specificity for all the scales, specifically for the Hyperactivity, Total Problems and Emotional Problems Scales. This shows an optimal discrimination ability of these questionnaires, with no risk of false positives for ASD. Fig. 1 shows the ROC curves for the SDQ 2-4 in the ASD and NT groups. ASD versus others neurodevelopmental conditions When comparing the ASD group vs. the DLD group, the AUC values remained significant across all scales, except for the Emotional Problems Scale (AUC = 0.54) which did not reach statistical significance. The Conduct Problems Scale yielded a marginally significant result (AUC = 0.57, p < .05). Here, too, high levels of specificity were seen, with all the values above .83, and the highest value being reported for the Hyperactivity (0.91) and Prosocial Behaviour (0.95) scales. The ASD-DD comparison yielded results consistent with the ASD vs. DLD analysis, with these three scales showing the higher value (Peer Problems (0.72, p< .001); Prosocial Behaviour (0.73, p< .001); Total Problems (0.62, p<.001). In this case, a high specificity emerged for the Prosocial Behaviour (0.87) and Peer Problems (0.78) scales; a notable increase was also observed on the Total Problems (0.73). We can thus conclude that Total Problems, Prosocial Behaviour and Peer Problems can more effectively differentiate ASD from the other diagnoses and a NT group. The high specificity observed, particularly on these three scales, supports the strong discriminative capacity of the SDQ, indicating a low risk of false positives in identifying ASD. Fig. 2 shows the ROC curves for the SDQ 2-4 in the ASD and DLD groups, and Fig. 3 shows the ROC curves for the SDQ 2-4 in the ASD and DD groups. Discussion Since 2006, the APA has strongly recommended early screening as it plays a crucial role in identifying children at increased likelihood of neurodevelopmental conditions and facilitating timely referrals for comprehensive developmental assessments and early interventions, which are often linked to improved long-term outcomes [ 7 , 10 , 13 ]. However, the lack of accessible, time-efficient, and psychometrically sound screening tools remains a significant barrier to the widespread implementation of early screening practices in both primary care and specialized clinical settings. The Strengths and Difficulties Questionnaire (SDQ 2–4), which is freely available online, offers a brief and straightforward assessment that can help both professionals and parents identify areas of developmental concern based on parental observations. This study aimed to evaluate the ability of the SDQ 2–4, when administered completely in digital form through a clinical web-based platform, to differentiate between typical and atypical developmental conditions, especially focusing on its effectiveness in distinguishing ASD from neurotypical development and from other neurodevelopmental conditions. Our findings suggest that the SDQ 2–4 is effective in differentiating between typically developing children from children with autism spectrum disorder. Firstly, children with ASD showed higher scores on all SDQ scales compared to NT children, including lower scores on the Prosocial Behaviour Scale. This is consistent with previous studies [ 55 – 57 ] that have found the same pattern using the school-age children and adolescents questionnaire (SDQ 4–17) [ 43 ]. To our knowledge, no study has been performed on preschool-aged children using the SDQ 2–4 specifically focusing on ASD and including a neurotypical group as a comparison group. Using the validated cut-offs [ 43 , 66 , 67 ], we found that all SDQ 2–4 scales enable to differentiate between children with ASD and NT children. The most significant results concern the Total Problems (AUC 0.92, p < .001), Peer Problems (AUC 0.87, p < .001), Hyperactivity (AUC 0.86, p < .001), and Prosocial Behaviour Scales (AUC 0.75, p < .001). These scales are the most effective in distinguishing between NT and ASD. A previous study [ 50 ] using the SDQ 2–4 in preschool-aged children found similar results, showing that the Total Difficulties scale effectively differentiates between preschoolers with and without psychosocial issues. However, to our knowledge, none of these studies on preschoolers has specifically focused on ASD as the primary subject of investigation as these studies were conducted on children older than 4 years [ 56 , 68 ]. They found that the Hyperactivity Scale yielded higher scores in children with ASD compared to typically developing children, while children with ASD obtained lower scores on the Prosocial Behaviour Scale. Consistent with the previously described results, we found that all SDQ 2–4 scales show good validity parameters (specificity), with values either equal to or close to one across all scales. Its strong psychometric properties and its ease of use make it a valuable tool for early developmental surveillance within primary care settings. Our study also explored the SDQ 2–4 performance in the context of neurodevelopmental conditions. Specifically, we evaluated its effectiveness in distinguishing ASD from other neurodevelopmental conditions, including DLD and DD. Our findings suggest that the SDQ 2–4 can effectively differentiate ASD from both clinical groups. Consistent with previous results by Croft et al. [ 46 ], higher scores on the Hyperactivity Scale were seen in children with ASD; however, this was only seen in comparison with children with DLD. In contrast, children with ASD showed higher scores on the Total Problems and Peer Problems Scales than children with either DLD or DD. Regarding social functioning, lower scores on the Prosocial Behaviour scale emerged for the ASD group compared to the DLD and DD groups. These findings suggest that children with ASD experience greater difficulties in peer relationships and prosocial behaviour not only in comparison with typically developing children (as previously described) but also in comparison to DLD and DD children. This is in line with Grasso et al. (2022), who found higher Peer Problems scores in ASD vs. DLD and DD and reported similar results on the Prosocial Behaviour Scale for ASD vs. DLD [ 59 ]. We found that specific SDQ 2–4 scales effectively differentiate between ASD and DLD as well as between ASD and DD. All scales, except for the Emotional Problems scale, distinguished between children with ASD and those with DLD. The most significant results emerged for the Total Difficulties, Hyperactivity, Peer Problems, and Prosocial Behaviour Scales, suggesting that these scales are particularly effective in discriminating between these two neurodevelopmental conditions. Instead, only the Peer Problems and Prosocial Behaviour Scales, besides the Total Difficulties scale, were able to differentiate between ASD and DD. This suggests that the Peer Problems, Prosocial Behaviour, and Total Difficulties scales are the most effective in distinguishing ASD from both DLD and DD. These findings are in line with the core features of ASD, namely significant impairments in communication and social interaction. As such, they appear to be the most effective in distinguishing ASD from all other clinical and non-clinical conditions examined. This is in line with previous studies on school-aged populations which identified the Prosocial Behaviour Scale as the strongest predictor of ASD [ 56 , 68 ]. Saleyev & Sanne [ 57 ] investigated the trajectory of the Prosocial Behaviour Scale in populations with ASD incorporating an additional measure, the Autism Screening Score [ 69 ], which is the difference between Prosocial Behaviour and Peer Problems scores. This measure emerged as one of the strongest predictors of ASD in children aged 4–12 years – a finding later supported by Aydin et al. [ 58 ]. Consistent with the findings described above, we found that these SDQ 2–4 scales exhibit a high level of specificity, with values approaching one. This further supports our conclusion that the SDQ 2–4 is a valuable tool for distinguishing ASD from a range of conditions, including both typical development and other neurodevelopmental conditions. Conclusions To our knowledge, this is the first study to use the SDQ 2–4 in preschool-aged children within the context of neurodevelopmental conditions focusing on ASD. Furthermore, it is the first study to rely exclusively on the SDQ 2–4 in a population with a narrow and homogeneous age range (preschoolers aged 2–4 years) while also including a rather large sample size (N = 343). It also leverages the potential benefits of telemedicine, being the first study to use SDQ 2–4 exclusively in a fully digitalized remotely accessible format. In conclusion, our results show that the SDQ 2–4 is a short, easy-to-use, and freely available tool with good psychometric properties, supporting its use as an early screening instrument. Future studies should further investigate its use, especially in digital format, as a screening tool for neurodevelopmental conditions in preschoolers using larger and more sociodemographically homogeneous samples. Abbreviations ASD Autism Spectrum Disorder DD Developmental Delay DLD Developmental Language Delay SDQ Strengths and Difficulties Questionnaire MedicalBIT MEDea Information and Clinical Assessment on-Line ROC Receiver Operating Characteristic AUC Area Under the Curve Declarations Ethics approval and consent to participate The study was approved by the Institute’s Ethical Review Board (protocol number 42/23, “Comitato Etico IRCCS E. Medea—Sezione Scientifica Associazione La Nostra Famiglia”). All procedures performed in studies involving human participants were in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards and have been approved by the Scientific and Ethics Committee. Informed Consent was obtained from all individual participants included in the study. Participants were assured of the confidentiality and privacy of their data. Clinical trial number Not applicable. Consent for publication Not applicable. Availability of data and materials The data that support the findings of this study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no conflict of interest. Funding This work has been supported by the Italian Ministry of Health (Ricerca Corrente 2025) and by “Fondo Nazionale Autismo anno 2021” of the Italian Ministry of Health, through Regione Lombardia AUTINCA Project [Deliberazione N° XII/277, 15/05/2023]. The authors acknowledge all partners and collaborators of the project. Authors’ Contributions NV, MM and PC designed the study and SB and NB contributed to the development of the telemedicine platform. SA, LV and MM contributed clinical knowledge regarding neurodevelopmental and psychopathological conditions. NV, LS, GW, SB and NB conducted literature searches. NV, LS, VR and PC performed the statistical analyses and data interpretation. NV, LS, GW, wrote the first draft. Writing revision and editing were performed by PC, VR, and MM. All authors revised and approved the final manuscript. References Bellman M, Byrne O, Sege R. Developmental assessment of children. BMJ. 2013;346:e8687. 10.1136/bmj.e8687 . Hansen BH, Oerbeck B, Skirbekk B, Petrovski BÉ, Kristensen H. Neurodevelopmental disorders: prevalence and comorbidity in children referred to mental health services. Nord J Psychiatry. 2018;72(4):285–91. 10.1080/08039488.2018.1444087 . Santocchi E, Tancredi R, Narzisi A, Igliozzi R, Apicella F. Stabilità della diagnosi di autismo in età prescolare. Psichiatr Infanz Adolesc. 2010;77(3):489–501. World Health Organization; United Nations Children’s Fund. 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J Abnorm Child Psychol. 2010;38(8):1179–91. 10.1007/s10802-010-9434-x . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 08 Jan, 2026 Editor invited by journal 11 Dec, 2025 Editor assigned by journal 13 Nov, 2025 Submission checks completed at journal 13 Nov, 2025 First submitted to journal 10 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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09:22:37","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":195437,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8079551/v1/dab5d65cef3d8920aee001b6.html"},{"id":100365703,"identity":"f50305f0-8555-410c-82c7-218a9acc7d7b","added_by":"auto","created_at":"2026-01-16 07:55:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":51868,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eReceiver operating curve (ROC) for SDQ 2-4 scales in children with autistic spectrum disorder (ASD) and children with neurotypical children (NT)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8079551/v1/77ba96fed05ca71cc9f142c2.png"},{"id":100367101,"identity":"53b8490f-75ec-4da3-8ac0-b0f07a1c002a","added_by":"auto","created_at":"2026-01-16 07:56:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":53232,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eReceiver operating curve (ROC) for SDQ 2-4 scales in children with autistic spectrum disorder (ASD) and children with developmental language disorder (DLD)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8079551/v1/1a6a9cd1a8245a53cc25bd07.png"},{"id":100125463,"identity":"913a4d4c-acd6-497f-95fe-eac53b1236c7","added_by":"auto","created_at":"2026-01-13 09:22:37","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":52158,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eReceiver operating curve (ROC) for SDQ 2-4 scales children with autistic spectrum disorder (ASD) and children with developmental delay (DD)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8079551/v1/82b48bd8dca8cd1f751670e4.png"},{"id":100382335,"identity":"26cbce3a-aa44-4a64-89fa-157b9b5f3fa4","added_by":"auto","created_at":"2026-01-16 10:42:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":904756,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8079551/v1/fa741f77-2c97-4143-a2dd-820777847e24.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing autism spectrum disorder and other neurodevelopmental conditions in preschoolers through the Strengths and Difficulties Questionnaire (SDQ) with remote data collection","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEarly childhood is a critical period for the psycho-physical, social, and emotional development of infants. Developmental neurodivergences, such as developmental delay (DD), autism spectrum disorder (ASD) and developmental language disorder (DLD), are conditions that typically emerge early in development and result in atypicalities across the cognitive, linguistic, socio-emotional, behavioural, and neuro-motor domains, leading to functional impairments [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Despite the early emergence of signs indicative of neurodevelopmental conditions, diagnosis is often delayed [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. A recent meta-analysis reported that the average age of diagnosis of ASD is over 3 years, with a mean of 43 months [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. According to the World Health Organization (2011), recognizing infants at increased likelihood of neurodevelopmental conditions is a critical first step in fostering a strong partnership between parents and healthcare providers, as well as in providing early intervention [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In a 2006 policy statement, the American Psychiatric Association (APA) recommended that primary care physicians conduct structured developmental screening using a standardized tool at a specified age [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Early screening identifies children at increased likelihood of neurodevelopmental conditions, enabling early intervention that improves long-term outcomes as supported by a growing body of evidence [\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Globally, the estimated prevalence rates across children and adolescents aged\u0026thinsp;\u0026lt;\u0026thinsp;18 years are as follows: 0.63% for DD, 5\u0026ndash;11% for ADHD, 0.70-3% for ASD, 3\u0026ndash;10% for Specific learning disorders (SLDs), 1\u0026ndash;3.42% for Communication disorders (CDs) and 0.76-17% for Motor disorders (MDs) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNeuropsychiatric conditions are frequently identified as a primary source of disability among youths globally, imposing considerable burdens on families, individuals, and national healthcare systems [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] while also leading to effects during developmental stages [\u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Screening has become an increasingly common practice among pediatricians, with an increase from 23% in 2002 to 45% in 2009, and up to 63% in 2016. However, there are still barriers, such as lack of time, inadequate reimbursement, and difficulty with scoring, which must be overcome to promote early access to services for children in need [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA response to this challenge is provided by technology, which today offers a number of tools that can be integrated into healthcare practice [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Web-based tools for developmental screening offer a potential solution to the complex logistical challenges of this process, leading to an increase in screening rates [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and monitoring at various time points [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], as recommended by the APA (2006) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Telemedicine has proven to be useful for directly reaching patients, even prior to the COVID-19 pandemic [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Furthermore, the acceptability and effectiveness of web-based developmental surveillance programs for preschoolers have been demonstrated by both parents and healthcare providers, although further studies on this topic are needed [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Despite the increased screening [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and the substantial evidence supporting telemedicine as an effective means to facilitate this process [\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], only a smaller proportion of practitioners have so far used a standardized tool for this purpose [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], relying solely on clinical judgment, which may lead to underreporting of neurodevelopmental disorders [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong the most widely used screening tools [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], the Infant Toddler Checklist (ITC) [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] and the Checklist for Autism in Toddlers (CHAT) [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] are however designed for general population screening in children under 2 years of age. Few screening tools are available for use with preschool-aged children, particularly in the 2\u0026ndash;4-year age range. One of them is the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], which can only be used up to 30 months of age and \u0026ndash; although highly sensitive \u0026ndash; has low specificity leading to a high risk of false positives. The Pervasive Developmental Disorder Screening Test-II (PDDST-II) [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] is yet another tool but it is not freely accessible and is offered in a limited number of languages. The Child Behavior Checklist 1\u0026frac12;\u0026ndash;5 (CBCL 1\u0026frac12;\u0026ndash;5) [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] is a parent-report measure; however, owing to its length it requires a substantial time commitment for completion, and trained professionals are needed for accurate interpretation. Based on the above, there is a critical need for screening tools with strong psychometric properties specifically designed for preschool children (age 2\u0026ndash;4 years) that are easily accessible and widely accepted. The Strengths and Difficulties Questionnaire (SDQ) is a brief screening tool designed to assess emotional and behavioural problems in children aged 2 to 17 years [\u003cspan additionalcitationids=\"CR44\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Developed by Goodman in the United Kingdom in 1997 [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], it is now available for free in multiple languages on the website \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.sdq.info.org\u003c/span\u003e\u003cspan address=\"http://www.sdq.info.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eA specific version of the SDQ for children aged 2\u0026ndash;4 years, the SDQ 2\u0026ndash;4, is available and can be quickly completed by parents. It is widely used internationally and its strong psychometric properties have been confirmed by several studies, confirming its validity for early identification of children with emotional and behavioural difficulties, thereby increasing the likelihood of access to effective interventions [\u003cspan additionalcitationids=\"CR47 CR48 CR49 CR50\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Although a substantial body of research has examined the effectiveness of the SDQ as a screening tool for predicting childhood psychiatric disorders [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], to our knowledge, few studies have focused on the predictive validity of the SDQ 2\u0026ndash;4 for neurodevelopmental disorders, which are often associated with emotional and behavioural challenges [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e], while several studies have focused on the SDQ 4\u0026ndash;17 specifically for conditions such as ASD and ADHD. Goodman himself demonstrated that the SDQ identifies approximately two-thirds of children with psychiatric disorders, in particular conduct and hyperactivity disorders [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Later studies [\u003cspan additionalcitationids=\"CR56\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] found significant score differences between clinical groups (ASD, ADHD) and comparison groups on all SDQ scales. Russell et al. (2013) observed higher hyperactivity scores and lower prosocial behaviour scores in clinical groups, while Iizuka et al. (2010) highlighted differences between ADHD and ASD, with the latter being associated with higher emotional symptoms and peer problems [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Salayev e Sanne (2017) confirmed that emotional problems and prosocial behaviour are key in differentiating ASD, with the Prosocial Behaviour Scale being the most predictive of this neurodevelopmental condition [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Further studies [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e] supported these findings, with additional measures enhancing the prediction of ASD in children aged 4\u0026ndash;12. The only studies known to have used the SDQ 2\u0026ndash;4 to predict neurodevelopmental conditions were conducted by Croft et al. (2015) \u0026ndash; Croft\u0026rsquo;s being the first longitudinal study in this area \u0026ndash; and by Grasso et al. (2022) who evaluated the SDQ 2\u0026ndash;4 predictive validity across a broader age range [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Croft et al. (2015) identified the Hyperactivity scale as a predictor of ASD [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. In contrast, Grasso et al. (2022) found the Peer Problems and Prosocial Behaviour scales to be the most effective in capturing the core symptoms of ASD [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Their findings highlight the potential of the SDQ 2\u0026ndash;4 to specifically differentiate and identify behavioural and emotional profiles associated with clinical diagnoses.\u003c/p\u003e \u003cp\u003eOur retrospective observational study aims to examine the validity of the SDQ 2\u0026ndash;4 as a tool for distinguishing between different neurodevelopmental conditions in both clinical and typically developing populations, with a specific focus on its ability to differentiate ASD from other neurodevelopmental disorders. Previous research has demonstrated the equivalence between paper-based and digital versions of assessment tools. In particular, Tanaka et al. (2021) found that the web-based versions of the SDQ \u0026ndash; used for developmental health monitoring in preschoolers\u0026ndash; showed comparable levels of internal consistency, inter-rater reliability, and overall equivalence to their paper-based counterparts, thereby supporting the use of digital questionnaires for neurodevelopmental conditions assessment [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. In accordance with this, our study aims to achieve its objective by utilizing the SDQ 2\u0026ndash;4 in a digital format through access to a clinical web-based platform.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eIn this retrospective observational study, we considered the demographic and clinical data of children referred to the Developmental Psychopathology Unit of the Scientific Institute \u0026ldquo;IRCCS Eugenio Medea \u0026ndash;Associazione La Nostra Famiglia\u0026rdquo; in Bosisio Parini (Lecco, Italy). The study was approved by the Institute\u0026rsquo;s Ethical Review Board (Prot. N. 42/23, \u0026ldquo;Comitato Etico IRCCS E. Medea\u0026mdash;Sezione Scientifica Associazione La Nostra Famiglia\u0026rdquo;) and all the participants\u0026rsquo; parents/legal guardians gave their written informed consent to the children\u0026rsquo;s participation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipants\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA sample of 335 children aged between 2 and 4 years were referred to the Child Neuropsychiatry Service of our Institute for suspected neurodevelopmental conditions between January 2019 and July 2024. All participants\u0026rsquo; parents, before accessing the Institute, are asked to complete remotely a socio-anamnestic questionnaire and some screening questionnaires (for example, SDQ) using the MedicalBIT internet-based platform (MEDea Information and Clinical Assessment on-Line - www.medicalbit.com), which is currently the first Italian internet-based screening platform for child and adolescent neuropsychiatric conditions [61, 62]. The participating children underwent a comprehensive clinical evaluation by experienced developmental neuropsychiatrists and received one (or more) clinical diagnoses based on the International Classification of Diseases, 10th Revision (ICD-10) [63]. Fifteen children did not meet the criteria for a neurodevelopmental disorder diagnosis at the time of the assessment; however, they are still being followed-up by our service as they exhibit subclinical traits. Four of them do not have neurodevelopmental disorders but were diagnosed with syndromes or neurological conditions, so they were excluded. One child with emotional disorders was not included in our analysis due to the small sample size. The remaining 315 participants were divided into three groups based on the ICD-10 clinical diagnosis. Our study also included 28 neurotypical children (NT) aged from 2 to 4 years who were recruited through local advertisements from two hospitals in northern Italy for participation in a larger ongoing longitudinal study [64].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe final sample included a total of 343 participants (M = 38,73 months; SD = 5,34; Males = 66,8%; Female = 33,2%), divided into four groups: children with autistic spectrum disorder (ASD - N=93), neurotypical children (NT - N=28), children with developmental language disorder (DLD - N=167), and children with developmental delay (DD - N=55). The sample characteristics are presented in Table 1.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAll children were between 2 and 4 years of age but there was some difference across groups: the ASD group had a mean age which was slightly lower than that of the DLD and DD groups and higher than that of the NT group. In all groups, except for the NT group, there was a majority of male participants, with the biggest difference in ASD and DD. The developmental quotient was significantly higher in the neurotypical group vs the other groups, with the DD and ASD groups showing the lowest quotient which significantly differed from that of the NT and DLD groups. All participant-related data were obtained remotely by parents using the MedicalBIT platform, except for the diagnosis which was recorded onto the platform by the neuropsychiatrists.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 602px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1. Descriptive statistics and group comparisons on individual, clinical and demographic characteristics\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eASD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eNT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eDLD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eDD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e167\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eAge in months - \u003cem\u003eMean\u003c/em\u003e \u003cem\u003e(SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e37.12 (5.34) \u003csup\u003ea,b,c\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e32.00 (5.95)\u003csup\u003e\u0026nbsp;a,b,d\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e40.26 (4.30) \u003csup\u003ec,d\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e40.22 (4.47) \u003csup\u003ec,d\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eSex - \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e68 (73.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e13 (46.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e106 (63.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e42 (76.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e25 (26.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e15 (53.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e61 (36.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e13 (23.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eDQ - \u003cem\u003eMean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e68.21 (19.38) \u003csup\u003eb,c\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e109.81 (6.25) \u003csup\u003ea,b,d\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e89.03 (12.33) \u003csup\u003ea,c,d\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e66.27 (7.81) \u003csup\u003eb,c\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eASD, autism spectrum disorder; DD, developmental delay; DLD, developmental language disorder; NT, neurotypical children; DQ, developmental quotient [65];\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eSignificant difference with DD group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003eSignificant difference with DLD group.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ec\u003c/sup\u003eSignificant difference with NT group.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ed\u003c/sup\u003eSignificant difference with ASD group.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMaterials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe parent-report SDQ 2-4 (Strengths and Difficulties Questionnaire for children from 2 to 4 years old - www.sdqinfo.org) contains 25 items forming 5 scales, 4 difficulties scales (Conduct Problems, Hyperactivity, Emotional Problems and Peer Problems) and a Prosocial Behaviour Scale. A Total Problems score provides a global score for all the difficulties scale. Parents are asked to rate items as either 0 (not true), 1 (somewhat true), or 2 (certainly true). Every scale has a minimum score of 0 and a maximum score of 10 and the total scale has a minimum score of 0 and a maximum score of 40. The higher the scores on the difficulty scales, the greater the impairment, while a higher score on the Prosocial Behaviour Scale indicates greater strengths. The SDQ 2-4 version is quite similar to the SDQ 4-17 version, the only differences being 3 items adjusted to reflect age-appropriate behaviours and contexts: item 18 \u0026ldquo;often lies or cheats\u0026rdquo; and item 22 \u0026ldquo;steals from home, school or elsewhere\u0026rdquo; of the Conduct Problems Scale became \u0026ldquo;argumentative with adults\u0026rdquo; and \u0026ldquo;can be spiteful\u0026rdquo;; item 21 \u0026ldquo;thinks things out before acting\u0026rdquo; of the Hyperactivity Scale became \u0026ldquo;can stop and think before acting\u0026rdquo;. For this study, raw scores from the scales and the total scale were used to assess the strengths and difficulties in the selected samples.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOne-way ANOVAs were used to assess whether the 4 groups (i.e., ASD, DD, DLD, NT) showed statistically significant differences on the SDQ scales (i.e., Emotional Problems, Conduct Problems, Hyperactivity Problems, Peer Problems, and Prosocial Behaviour) and the SDQ total scale (i.e., Total Difficulties). Post-hoc pairwise comparisons (Tukey-HSD) were conducted to further explore the differences between specific groups when a significant main effect was found.\u003c/p\u003e\n\u003cp\u003eReceiver Operating Characteristic (ROC) curve analyses were conducted, and Area Under the Curve (AUC) scores were calculated to show the strength of discrimination between children with ASD and NT children, as well as between children with ASD and children with other neurodevelopmental disorders (i.e., ASD vs. DD, ASD vs. DLD). An AUC of 0.50 indicates that the classifier (i.e., SDQ scales and total score) cannot distinguish between the two groups, while an AUC of 1 indicates that the classifier (i.e., SDQ scales and total score) can perfectly distinguish between the selected groups. Published cut-off scores [43, 66, 67] were used to calculate sensitivity (proportion of children with ASD correctly identified), specificity (proportion of children without ASD correctly identified), Positive Predictive Values (PPVs), and Negative Predictive Values (NPVs). We decided to use a published cut-off as it is widely recognized and validated in the scientific literature [43, 66, 67]. Also, pre-established cut-offs allow us to compare our results with those of previous studies. This approach was chosen to promote replicability and comparability of our findings.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eGroup comparison\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFirst, we used a one-way ANOVA to assess the group differences between all the 5 scales of the SDQ, and post-hoc pairwise comparisons (Tukey-HSD) were computed. Overall significant differences emerged between groups for all the scales (see Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Emotional Problems Scale (F (3, 339) = 5.83, p\u0026lt; .01) and the Conduct Problems Scale (F (3, 339) = 3.56, p\u0026lt; .01) were the least significant in the group comparisons, highlighting a lower difference between the groups on these scales. All 3 diagnostic groups differed on the Emotional Problems Scale from the NT (M = 0.46, SD = 0.51), with the higher score obtained by ASD (M = 1.65, SD = 1.63). On the Conduct Problems Scale, the ASD group obtained significantly higher scores (M = 1.89, SD = 1.45) compared to NT (M = 1.89, SD= 1.45).\u003c/p\u003e\n\u003cp\u003eOn the Total Problems Scale (F (3, 339) = 25.39, p\u0026lt; .001), differences emerged between all 4 groups, with the ASD group reporting the highest scores (M = 13.88, SD = 5.65). The Hyperactivity Scale showed a significant difference (F (3, 339) = 23.88, p\u0026lt; .001) between ASD (M = 5.37, SD = 2.39) and DD (M = 4.64, SD = 2.55) groups, with scores higher than the other groups (NT (M = 2.21, SD = 1.45); DLD (M = 3.31, SD= 2.81)). On the Emotional Problems Scale all groups significantly differed from the NT (F (3, 339) = 5.63, p\u0026lt; .01) group, who had a lower score (M = 0.46, SD = 0.51). The ASD group also differed from the other groups on the Peer Problems (F (3, 339) = 29.97, p \u0026lt; .001) and Prosocial Behaviour (F (3, 339) = 33.19, p \u0026lt; .001) scales, obtaining a significantly higher score on Peer Problems compared to all the other groups (M = 3.76, SD = 1.83). On the Prosocial Behaviour Scale \u0026ndash;this being an inversely scored measure, the ASD group differed significantly from all the others as it obtained the lowest score (M = 4.80, SD = 2.36). In sum, a significant difference emerged for the ASD group vs the NT group on all the scales, and the ASD group was the only one with a significantly higher score on Conduct Problems. The highest statistical differences were found for the Total Difficulties, Hyperactivity, Peer Problems and Prosocial Behaviour scales.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"620\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"bottom\" style=\"width: 620px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2. Descriptive statistics and group comparisons on SDQ Scores\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eASD \u003cem\u003e(n= 93) Mean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eDD \u003cem\u003e(n=55) Mean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eDLD \u003cem\u003e(n=167) Mean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003eNT \u003cem\u003e(n=28) Mean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eGroup differences\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003eTotal Difficulties\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e13.88 (5.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e11.56 (5.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e9.11 (5.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e5.75 (2.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e25.39***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eASD \u0026gt; DD \u0026gt; DLD\u0026gt;NT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003eEmotional Problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e1.65 (1.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e1.71 (1.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e1.34 (1.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e0.46 (0.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e5.83**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eASD \u0026gt; NT;\u0026nbsp;\u003cbr\u003e\u0026nbsp;DD \u0026gt; NT;\u0026nbsp;\u003cbr\u003e\u0026nbsp;DLD \u0026gt; NT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003eConduct Problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e3.11 (2.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e2.91 (1.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e2.60 (1.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e1.89 (1.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e3.56**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eASD \u0026gt; NT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003eHyperactivity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e5.37 (2.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e4.64 (2.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e3.31 (2.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e2.21 (1.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e23.88***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eASD \u0026gt; DLD;\u0026nbsp;\u003cbr\u003e\u0026nbsp;ASD \u0026gt; NT;\u0026nbsp;\u003cbr\u003e\u0026nbsp;DD \u0026gt; DLD;\u0026nbsp;\u003cbr\u003e\u0026nbsp;DD \u0026gt; NT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003ePeer Problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e3.76 (1.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e2.31 (1.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e1.86 (1.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e1.18 (1.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e29.97***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eASD \u0026gt; DD \u0026gt; NT;\u0026nbsp;\u003cbr\u003e\u0026nbsp;ASD \u0026gt; DLD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003eProsocial Behaviour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e4.80 (2.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e6.69 (2.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e7.34 (1.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e6.75 (1.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e33.19***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eASD \u0026lt; DD;\u0026nbsp;\u003cbr\u003e\u0026nbsp;ASD \u0026lt; DLD;\u0026nbsp;\u003cbr\u003e\u0026nbsp;ASD \u0026lt; NT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eASD, autism spectrum disorder; DD, developmental delay; DLD, developmental language disorder; NT, neurotypical children; SDQ, Strengths and Difficulties Questionnaire.\u003c/p\u003e\n\u003cp\u003e*P \u0026lt; .05, **P \u0026lt; .01, ***P \u0026lt; .001 \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eROC curve analysis based on group differences\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eROC curve analysis was used to assess how well the SDQ discriminates between the ASD group and the other three groups. In this analysis, we used a previously published cut-off to ensure the replicability and comparability of our findings.\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"1029\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"15\" valign=\"top\" style=\"width: 1029px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3. Summary score for the ROC curve analysis based on diagnostic classification\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 320px;\"\u003e\n \u003cp\u003eASD (93) VS NT (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 296px;\"\u003e\n \u003cp\u003eASD (93) VS DLD (167)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 300px;\"\u003e\n \u003cp\u003eASD (93) VS DD (55)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eAUC (SE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eSens/Spec\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003ePPV/NPV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eAUC (SE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eSens/Spec\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003ePPV/NPV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eAUC (SE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003eSens/Spec\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003ePPV/NPV\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eTotal Difficulties\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e.92*** (.026)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e[0.87 - 0.97]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e.387/1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e1.000/.329\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e.74***(.031)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e[0.68 - 0.80]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e.387/.850\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e.590/.714\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e.62** (.049)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e[0.52 - 0.72]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e.387/.727\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e.706/.412\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eEmotional Problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e.71*** (.047)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e[0.62 - 0.81]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e.161/1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e1.000/.264\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e.54 \u0026nbsp; \u0026nbsp;(0.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e[0.47 - 0.62]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e.49 \u0026nbsp; (.049)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e[0.40 - 0.59]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eConduct Problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e.68*** (.056)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e[0.57 - 0.79]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e.226/.964\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e.955/.273\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e.57* \u0026nbsp; (.037)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e[0.50 - 0.64]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e.226/.844\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e.447/662\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e.52 \u0026nbsp; \u0026nbsp;(.049)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e[0.42 - 0.62]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eHyperactivity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e.86*** (.033)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e[0.80 - 0.93]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e.301/1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e1.000/.301\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e.74*** (.032)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e[0.68 - 0.80]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e.301/.910\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e.651/.700\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e.59 \u0026nbsp; \u0026nbsp;(.049)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e[0.49 - 0.68]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003ePeer Problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e.87*** (.036)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e[0.80 - 0.94]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e.591/.964\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e.982/.416\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e.77*** (.030)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e[0.71 - 0.83]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e.591/.826\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e.655/.784\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e.72*** (.042)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e[0.64 - 0.80]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e.591/.782\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e.820/.531\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eProsocial Behaviour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e.75*** (.045)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e[0.66 - 0.83]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e.462/.929\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e.921/.397\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e.80*** (.030)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e[0.74 - 0.86]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e.462/.946\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e.690/.801\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e.73*** (.042)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e[0.64 - 0.81]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e.462/.873\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e.794/.534\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eASD, autism spectrum disorder; DD, developmental delay; DLD, developmental language disorder; NT, neurotypical children.\u003c/p\u003e\n\u003cp\u003eCI, Confidence interval.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e*p \u0026lt; .05, **p\u0026lt; .01, ***p\u0026lt; .001\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eASD versus NT\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe area under the curve (AUC) showed a good capacity of the SDQ to distinguish between ASD and NT (all ps\u0026lt; .001; see Table 3). Total Difficulties (0.92, p\u0026lt; .001), Peer Problems (0.87, p\u0026lt; .001) and Hyperactivity (0.86, p\u0026lt; .001) scales showed the higher values (Fig.1). As can be seen in Table 3, there are high levels of specificity for all the scales, specifically for the Hyperactivity, Total Problems and Emotional Problems Scales. This shows an optimal discrimination ability of these questionnaires, with no risk of false positives for ASD. Fig. \u003ca href=\"https://pmc.ncbi.nlm.nih.gov/articles/PMC9946866/#Fig1\"\u003e1\u003c/a\u003e shows the ROC curves for the SDQ 2-4 in the ASD and NT groups.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eASD versus others neurodevelopmental conditions\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhen comparing the ASD group vs. the DLD group, the AUC values remained significant across all scales, except for the Emotional Problems Scale (AUC = 0.54) which did not reach statistical significance. The Conduct Problems Scale yielded a marginally significant result (AUC = 0.57, \u003cem\u003ep\u003c/em\u003e \u0026lt; .05). Here, too, high levels of specificity were seen, with all the values above .83, and the highest value being reported for the Hyperactivity (0.91) and Prosocial Behaviour (0.95) scales.\u003c/p\u003e\n\u003cp\u003eThe ASD-DD comparison yielded results consistent with the ASD vs. DLD analysis, with these three scales showing the higher value (Peer Problems (0.72, p\u0026lt; .001); Prosocial Behaviour (0.73, p\u0026lt; .001); Total Problems (0.62, p\u0026lt;.001). In this case, a high specificity emerged for the Prosocial Behaviour (0.87) and Peer Problems (0.78) scales; a notable increase was also observed on the Total Problems (0.73). We can thus conclude that Total Problems, Prosocial Behaviour and Peer Problems can more effectively differentiate ASD from the other diagnoses and a NT group. The high specificity observed, particularly on these three scales, supports the strong discriminative capacity of the SDQ, indicating a low risk of false positives in identifying ASD. Fig. 2 shows the ROC curves for the SDQ 2-4 in the ASD and DLD groups, and Fig. 3 shows the ROC curves for the SDQ 2-4 in the ASD and DD groups.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSince 2006, the APA has strongly recommended early screening as it plays a crucial role in identifying children at increased likelihood of neurodevelopmental conditions and facilitating timely referrals for comprehensive developmental assessments and early interventions, which are often linked to improved long-term outcomes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, the lack of accessible, time-efficient, and psychometrically sound screening tools remains a significant barrier to the widespread implementation of early screening practices in both primary care and specialized clinical settings.\u003c/p\u003e \u003cp\u003e The Strengths and Difficulties Questionnaire (SDQ 2\u0026ndash;4), which is freely available online, offers a brief and straightforward assessment that can help both professionals and parents identify areas of developmental concern based on parental observations. This study aimed to evaluate the ability of the SDQ 2\u0026ndash;4, when administered completely in digital form through a clinical web-based platform, to differentiate between typical and atypical developmental conditions, especially focusing on its effectiveness in distinguishing ASD from neurotypical development and from other neurodevelopmental conditions. Our findings suggest that the SDQ 2\u0026ndash;4 is effective in differentiating between typically developing children from children with autism spectrum disorder.\u003c/p\u003e \u003cp\u003eFirstly, children with ASD showed higher scores on all SDQ scales compared to NT children, including lower scores on the Prosocial Behaviour Scale. This is consistent with previous studies [\u003cspan additionalcitationids=\"CR56\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] that have found the same pattern using the school-age children and adolescents questionnaire (SDQ 4\u0026ndash;17) [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. To our knowledge, no study has been performed on preschool-aged children using the SDQ 2\u0026ndash;4 specifically focusing on ASD and including a neurotypical group as a comparison group. Using the validated cut-offs [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e], we found that all SDQ 2\u0026ndash;4 scales enable to differentiate between children with ASD and NT children. The most significant results concern the Total Problems (AUC 0.92, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), Peer Problems (AUC 0.87, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), Hyperactivity (AUC 0.86, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), and Prosocial Behaviour Scales (AUC 0.75, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). These scales are the most effective in distinguishing between NT and ASD. A previous study [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] using the SDQ 2\u0026ndash;4 in preschool-aged children found similar results, showing that the Total Difficulties scale effectively differentiates between preschoolers with and without psychosocial issues. However, to our knowledge, none of these studies on preschoolers has specifically focused on ASD as the primary subject of investigation as these studies were conducted on children older than 4 years [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. They found that the Hyperactivity Scale yielded higher scores in children with ASD compared to typically developing children, while children with ASD obtained lower scores on the Prosocial Behaviour Scale. Consistent with the previously described results, we found that all SDQ 2\u0026ndash;4 scales show good validity parameters (specificity), with values either equal to or close to one across all scales. Its strong psychometric properties and its ease of use make it a valuable tool for early developmental surveillance within primary care settings.\u003c/p\u003e \u003cp\u003eOur study also explored the SDQ 2\u0026ndash;4 performance in the context of neurodevelopmental conditions. Specifically, we evaluated its effectiveness in distinguishing ASD from other neurodevelopmental conditions, including DLD and DD. Our findings suggest that the SDQ 2\u0026ndash;4 can effectively differentiate ASD from both clinical groups. Consistent with previous results by Croft et al. [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], higher scores on the Hyperactivity Scale were seen in children with ASD; however, this was only seen in comparison with children with DLD. In contrast, children with ASD showed higher scores on the Total Problems and Peer Problems Scales than children with either DLD or DD. Regarding social functioning, lower scores on the Prosocial Behaviour scale emerged for the ASD group compared to the DLD and DD groups. These findings suggest that children with ASD experience greater difficulties in peer relationships and prosocial behaviour not only in comparison with typically developing children (as previously described) but also in comparison to DLD and DD children. This is in line with Grasso et al. (2022), who found higher Peer Problems scores in ASD vs. DLD and DD and reported similar results on the Prosocial Behaviour Scale for ASD vs. DLD [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe found that specific SDQ 2\u0026ndash;4 scales effectively differentiate between ASD and DLD as well as between ASD and DD. All scales, except for the Emotional Problems scale, distinguished between children with ASD and those with DLD. The most significant results emerged for the Total Difficulties, Hyperactivity, Peer Problems, and Prosocial Behaviour Scales, suggesting that these scales are particularly effective in discriminating between these two neurodevelopmental conditions. Instead, only the Peer Problems and Prosocial Behaviour Scales, besides the Total Difficulties scale, were able to differentiate between ASD and DD. This suggests that the Peer Problems, Prosocial Behaviour, and Total Difficulties scales are the most effective in distinguishing ASD from both DLD and DD. These findings are in line with the core features of ASD, namely significant impairments in communication and social interaction. As such, they appear to be the most effective in distinguishing ASD from all other clinical and non-clinical conditions examined. This is in line with previous studies on school-aged populations which identified the Prosocial Behaviour Scale as the strongest predictor of ASD [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. Saleyev \u0026amp; Sanne [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] investigated the trajectory of the Prosocial Behaviour Scale in populations with ASD incorporating an additional measure, the Autism Screening Score [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e], which is the difference between Prosocial Behaviour and Peer Problems scores. This measure emerged as one of the strongest predictors of ASD in children aged 4\u0026ndash;12 years \u0026ndash; a finding later supported by Aydin et al. [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConsistent with the findings described above, we found that these SDQ 2\u0026ndash;4 scales exhibit a high level of specificity, with values approaching one. This further supports our conclusion that the SDQ 2\u0026ndash;4 is a valuable tool for distinguishing ASD from a range of conditions, including both typical development and other neurodevelopmental conditions.\u003c/p\u003e \u003c/p\u003e "},{"header":"Conclusions","content":"\u003cp\u003eTo our knowledge, this is the first study to use the SDQ 2\u0026ndash;4 in preschool-aged children within the context of neurodevelopmental conditions focusing on ASD. Furthermore, it is the first study to rely exclusively on the SDQ 2\u0026ndash;4 in a population with a narrow and homogeneous age range (preschoolers aged 2\u0026ndash;4 years) while also including a rather large sample size (N\u0026thinsp;=\u0026thinsp;343). It also leverages the potential benefits of telemedicine, being the first study to use SDQ 2\u0026ndash;4 exclusively in a fully digitalized remotely accessible format. In conclusion, our results show that the SDQ 2\u0026ndash;4 is a short, easy-to-use, and freely available tool with good psychometric properties, supporting its use as an early screening instrument. Future studies should further investigate its use, especially in digital format, as a screening tool for neurodevelopmental conditions in preschoolers using larger and more sociodemographically homogeneous samples.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAutism Spectrum Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDevelopmental Delay\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDLD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDevelopmental Language Delay\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSDQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStrengths and Difficulties Questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMedicalBIT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMEDea Information and Clinical Assessment on-Line\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eROC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eReceiver Operating Characteristic\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAUC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eArea Under the Curve\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Institute’s Ethical Review Board (protocol number 42/23, “Comitato Etico IRCCS E. Medea—Sezione Scientifica Associazione La Nostra Famiglia”).\u0026nbsp;All procedures performed in studies involving human participants were in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards and have been approved by the Scientific and Ethics Committee. Informed Consent was obtained from all individual participants included in the study. Participants were assured of the confidentiality and privacy of their data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work has been supported by the Italian Ministry of Health (Ricerca Corrente 2025) and by “Fondo Nazionale Autismo anno 2021” of the Italian Ministry of Health, through Regione Lombardia AUTINCA Project [Deliberazione N° XII/277, 15/05/2023]. The authors acknowledge all partners and collaborators of the project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNV, MM and PC designed the study and SB and NB contributed to the development of the telemedicine platform. SA, LV and MM contributed clinical knowledge regarding neurodevelopmental and psychopathological conditions. NV, LS, GW, SB and NB conducted literature searches. NV, LS, VR and PC performed the statistical analyses and data interpretation. NV, LS, GW, wrote the first draft. Writing revision and editing were performed by PC, VR, and MM. All authors revised and approved the final manuscript.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBellman M, Byrne O, Sege R. Developmental assessment of children. 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J Abnorm Child Psychol. 2010;38(8):1179\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10802-010-9434-x\u003c/span\u003e\u003cspan address=\"10.1007/s10802-010-9434-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Autism spectrum disorder, Early screening, Telemedicine, Preschoolers, SDQ 2–4, Neurodevelopmental conditions","lastPublishedDoi":"10.21203/rs.3.rs-8079551/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8079551/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBACKGROUND\u003c/h2\u003e \u003cp\u003eScreening is now worldwide recognised as essential for early detection of neurodevelopmental divergences, and telemedicine is increasingly proving to be a valuable resource in this area. Our retrospective observational study aimed to assess the ability of the Strengths and Difficulties Questionnaire (SDQ 2\u0026ndash;4) as a measure to distinguish autism spectrum disorder from other neurodevelopmental disorders in clinical and typically developing populations of preschoolers by remote data collection.\u003c/p\u003e\u003ch2\u003eMETHODS\u003c/h2\u003e \u003cp\u003eData from 343 preschoolers, including 93 children with autism spectrum disorder (ASD), 28 neurotypical children (NT), 167 children with developmental language disorder (DLD), and 55 children with developmental delay (DD), were collected through the MEDea Information and Clinical Assessment on-Line (MedicalBIT) platform.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e \u003cp\u003eOur results showed higher scores on all SDQ 2\u0026ndash;4 scales for the ASD group vs the NT group, except for a scale scored in reverse (Prosocial Behaviour Scales) that had lower scores in children with ASD than NT children. Total Problems, Peer Problems, Hyperactivity, and Prosocial Behaviour Scales could more significantly differentiate the ASD group from the NT group. When comparing ASD group with other neurodevelopmental conditions (DLD, DD), the most significant results were found for the Total Problems, Peer Problems and Prosocial Behaviour Scales.\u003c/p\u003e\u003ch2\u003eCONCLUSIONS\u003c/h2\u003e \u003cp\u003eWe concluded that these scales were more effective in differentiating children with autism spectrum disorder from children with developmental language disorder and from children with developmental delay, as well as from neurotypical children. We proved the SDQ 2\u0026ndash;4 to be a valid short screening tool for use in preschoolers, to differentiate between ASD and other conditions by remote data collection.\u003c/p\u003e","manuscriptTitle":"Assessing autism spectrum disorder and other neurodevelopmental conditions in preschoolers through the Strengths and Difficulties Questionnaire (SDQ) with remote data collection","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-13 09:22:32","doi":"10.21203/rs.3.rs-8079551/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-01-08T10:46:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-12T04:38:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-13T08:58:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-13T08:56:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2025-11-10T17:23:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0772c286-2148-48b2-9956-0c8f9216635e","owner":[],"postedDate":"January 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-13T09:22:32+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-13 09:22:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8079551","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8079551","identity":"rs-8079551","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}