Editorial Perspective: From schizophrenia polygenic risk score to vulnerability (endo‐)phenotypes: translational pathways in child and adolescent mental health

The Polygenic Risk Scores (PRS) approach is becoming increasingly prominent in psycho‐behavioral research, however, its translational potential is still relatively underconceptualized. Indeed, PRS paradigm (which capitalizes on the combination of multiple genetic markers into a single proxy score to predict lifetime outcomes) has the potential to unravel some of the developmental complexities leading to severe mental disorders. With respect to schizophrenia, the application of PRS approach to child–adolescent cohorts from the general population, provides a crucial vantage point for understanding how presumed genetic predisposition is manifested during developmental years. Clearly, this is essential for etiological research as well as for the timely identification of the earliest stages of those specific psychopathological trajectories leading to psychosis. Therefore, the translational import of the PRS approach could improve our etiopathogenetic understanding of schizophrenia (e.g., allowing the disentanglement of the respective contribution of genetic and environmental risk factors along neurodevelopment) and further refine current staging models for early detection of vulnerability to psychosis (e.g., providing the rationale for more developmentally oriented reformulations of clinical high‐risk criteria).     

The prodrome of autism: early behavioral and biological signs,regression, peri‐ and post‐natal development and genetics

Autism is one of the most heritable neurodevelopmental conditions and has an early onset, with symptoms being required to be present in the first 3 years of life in order to meet criteria for the ‘core’ disorder in the classification systems. As such, the focus on identifying a prodrome over the past 20 years has been on pre‐clinical signs or indicators that will be present very early in life, certainly in infancy. A number of novel lines of investigation have been used to this end, including retrospective coding of home videos, prospective population screening and ‘high risk’ sibling studies; as well as the investigation of pre‐ and peri‐natal, brain developmental and other biological factors. While no single prodromal sign is expected to be present in all cases, a picture is emerging of indicative prodromal signs in infancy and initial studies are being undertaken to attempt to ameliorate early presentation and even ‘prevent’ emergence of the full syndrome.     

Risk factors and prodromal eating pathology

Prospective studies have identified factors that increase risk for eating pathology onset, including perceived pressure for thinness, thin‐ideal internalization, body dissatisfaction, dietary restraint, and negative affect. Research also suggests that body dissatisfaction and dietary restraint may constitute prodromal stages of the development of eating disorders. Prevention trials indicate that interventions that reduce pressure to be thin, thin‐ideal internalization, body dissatisfaction, and negative affect significantly reduce eating disorder symptoms. Further, there is evidence that selective prevention programs that target young women at elevated risk for eating pathology by virtue of thin‐ideal internalization, body dissatisfaction, and negative affect produce significant larger intervention effects than do universal programs offered to unselected populations. Thus, research on risk factors and prodromal stages of eating pathology has assisted in the design of efficacious prevention programs and the identification of high‐risk individuals to target with these interventions; additional research in this area may lead to even more effective prevention programs.     

Longitudinal study of neurological soft signs in first-episode early-onset psychosis

Background: In recent decades, the assessment of neurological soft signs (NSS) in patients with psychosis has become a subject of special interest. The study of the progression of NSS during adolescence will provide valuable information about the role of NSS as endophenotypes or biomarkers and about brain development at a stage in which brain maturation has not yet been completed. Methods: Neurological soft signs were assessed in a sample of 110 first episodes of early‐onset psychosis (EOP) and 98 healthy children and adolescents at two different times in a 2‐year follow‐up period. Results: Patients with EOP showed more NSS than controls both at baseline (p < .001) and the 2‐year follow‐up (p < .001). No differences were found in the number of signs among the different diagnostic subgroups (schizophrenia, bipolar disorder, and other psychoses). When we examined the changes in NSS over the follow‐up, the reduction of NSS in the patients was greater than the controls for ‘Motor coordination’ (p = .032), ‘Others’ (p < .001), and ‘Total score’ (p < .001) of the NES. Conclusion: Despite the greater reduction of NSS in patients than in controls along the follow‐up, patients still have more neurological signs than healthy controls; therefore, these signs may be considered a trait marker. NSS do not seem to be specific to schizophrenia as they are present in different EOPs.     

Two‐year diagnostic stability in early‐onset first‐episode psychosis

Background: Only one study has used a prospective method to analyze the diagnostic stability of first psychotic episodes in children and adolescents. The Child and Adolescent First‐Episode Psychosis Study (CAFEPS) is a 2‐year, prospective longitudinal study of early‐onset first episodes of psychosis (EO‐FEP). Aim: To describe diagnostic stability and the variables related to diagnostic changes. Methods: Participants were 83 patients (aged 9–17 years) with an EO‐FEP consecutively attended. They were assessed with a structured interview (Kiddie‐Schedule for Affective Disorders and Schizophrenia, Present and Lifetime version) and clinical scales at baseline and after 2 years. Results: The global consistency for all diagnoses was 63.9%. The small group of bipolar disorder had high stability (92.31%) as did the group with schizophrenia spectrum disorders (90.00%). Depressive disorder had lower stability (37.50%) and the lowest values were for psychotic disorder not otherwise specified (11.76%) and brief psychotic disorder (0%).The most frequent diagnostic shift was to schizophrenia spectrum and bipolar disorders. One group of patients did not meet the criteria for any diagnosis at follow‐up. Independent predictors of change to schizophrenia spectrum disorders were lower scores on the Children’s Global Assessment Scale (CGAS) and the Hamilton Depression Rating Scale. Predictors of not having a diagnosis at follow‐up were the CGAS and the Strauss–Carpenter Outcome Scale. Conclusions: Global diagnostic stability was 63.9%. Bipolar and schizophrenia spectrum disorders were the most stable diagnoses, while depressive disorder and other psychosis the least stable. Psychosocial functioning at baseline was a good predictor of diagnosis at follow‐up. These data show the need for longitudinal follow‐up in EO‐FEP before a stable diagnosis is reached.     

Early breastfeeding practices contribute to exclusive breastfeeding in Bangladesh,Vietnam and Ethiopia

Limited evidence exists on the complex relationship among interventions, early initiation of breastfeeding (EIBF), prelacteal feeding and exclusive breastfeeding (EBF). We examined whether early breastfeeding practices are associated with EBF and how much improving EIBF and non‐prelacteal feeding contributes to increased prevalence of EBF. Survey data were collected in 2010 and 2014 as part of impact evaluations of Alive & Thrive (A&T) interventions to improve infant and young child feeding (IYCF) practices in Bangladesh, Vietnam and Ethiopia. Multivariable logistic regression analyses were used to examine effects of interventions and early breastfeeding practices on EBF. Structural equation modelling quantified the direct and indirect effects of interventions (via improving EIBF and non‐prelacteal feeding) on EBF. Although breastfeeding is nearly universal in all three countries (≥98%), delayed initiation of breastfeeding is prevalent (>60%) and prelacteal feeding is common. EIBF alone was not associated with EBF, whereas non‐prelacteal feeding was associated with 1.6–3.5 higher odds of EBF. Intervention exposure affected breastfeeding practices in all three countries; these impacts were amplified among those who practiced EIBF or non‐prelacteal feeding [odds ratio (OR) = 11 and 27.5 in Bangladesh and 6.5 and 11.5 in Vietnam, respectively]. The paths through EIBF and non‐prelacteal feeding explained 13%–18% of the effect of the interventions on EBF. Early breastfeeding practices influence EBF, but interventions aimed only at the initiation and early days of breastfeeding will be inadequate to promote EBF. Social and behaviour change interventions should simultaneously target EIBF, non‐prelacteal feeding and EBF to support optimal breastfeeding practices.     

Perinatal biomarkers implying ‘Developmental Origins of Health and Disease’ consequences in intrauterine growth restriction

The intrauterine-growth-restricted (IUGR) state, particularly the asymmetric one, has been associated with ‘Developmental Origins of Health and Disease’ (DOHaD) consequences later in life. Several environmental factors, acting during the phase of foetal developmental plasticity interact with genotypic variation, ‘programme’ tissue function and change the capacity of the organism to cope with its environment. They may be responsible for chronic illness risk in adulthood. Detection of possible future DOHaD consequences at a very early age, by applying relevant biomarkers, is of utmost importance. This review focuses on biomarkers possibly predicting consequences from bone, psychoneural system and lung. Although no concrete biomarker has been identified for bone disorders in adulthood, reduced brain-derived neurotrophic factor (BDNF) concentrations in cord blood and BDNF DNA methylation might predict schizophrenia and possibly depression, bipolar disorder and autism. High surfactant protein D (SP-D) concentrations in cord blood of IUGR foetuses/neonates could point to structural lung immaturity, resulting to asthma and chronic obstructive pulmonary disease in adult life.     

Neuropsychological profiles of young people with type 1 diabetes 12 yr after disease onset

Lin A, Northam EA, Rankins D, Werther GA, Cameron FJ. Neuropsychological profiles of young people with type 1 diabetes 12 yr after disease onset. Background: Lowered neuropsychological performance is evident in youth with type 1 diabetes, although evidence for associations with specific illness variables is inconsistent. This study examined the neuropsychological profiles of a cohort of youth with type 1 diabetes studied prospectively from diagnosis 12 yr previously. Methods: A total of 106 youth with type 1 diabetes and 75 healthy controls participated. There were no significant group differences on Full‐scale IQ assessed on study entry 12 yr previously, current socioeconomic status, gender distribution, or age. Neuropsychological tests assessed eight cognitive domains: verbal abilities, perceptual reasoning, new learning, working memory, non‐verbal processing speed, mental efficiency, divided attention, and sustained attention. Episodes of serious hypoglycemia and HbA_1c levels were recorded from diagnosis. Results: Youth with type 1 diabetes performed more poorly than controls on working memory (p < .05). Early onset diabetes was related to poorer sustained (p < .001) and divided attention (p = .001), new learning, and mental efficiency (both p < .05). Hypoglycemia was found to adversely effect verbal abilities, working memory, and non‐verbal processing speed (all p < .05). Poorer working memory was associated with hyperglycemia (p < .05). Youth with any combination of two or three illness risk factors (i.e., early onset diabetes, hypo‐, hyperglycemia), performed more poorly than controls and youth with no or one risk on verbal abilities, working memory, and mental efficiency. Conclusions: This study documents poorer neuropsychological performance and its association with illness risk factors in youth with type 1 diabetes. Findings suggest that early disease onset and hypoglycemia impact on the developing central nervous system, with hyperglycemia playing a lesser role.     

Exposure to potentially traumatic events in early childhood: differential links to emergent psychopathology

Objective: To examine associations between exposure to potentially traumatic events (PTEs) and clinical patterns of symptoms and disorders in preschool children. Method: Two hundred and thirteen referred and non‐referred children, ages 24 to 48 months (MN = 34.9, SD = 6.7 months) were studied. Lifetime exposure to PTEs (family violence and non‐interpersonal events) and recent stressful life events were assessed with the Preschool Age Psychiatric Assessment (PAPA) and Child Life Events Scale. Child psychiatric symptoms and disorders were assessed with parent‐reports in the PAPA, a comprehensive, developmentally sensitive interview. Sociodemographic risk, parental anxiety and depressive symptoms (Center for Epidemiologic Studies Depression, Beck Anxiety Inventory), and child developmental level (Mullen Scales of Early Learning) also were assessed. Results: Violence exposure was broadly associated with psychiatric status in the areas of depression, separation anxiety, posttraumatic stress, and conduct problems, whereas potentially traumatic non‐interpersonal exposure was associated with phobic anxiety. The majority of the associations between violence exposure and preschoolers’ symptoms were significant even when other key factors, including economic disadvantage and parental mood and anxiety symptoms, were controlled statistically. However, parental depressive/anxious symptoms may have partially or fully mediated the relationships between violence exposure and depressive and conduct symptoms. Conclusions: Evidence of robust associations between violence exposure and early childhood internalizing and externalizing disorders and symptoms highlights the need for longitudinal prospective research concerning neurodevelopmental mechanisms and pathways. Findings underscore the relevance of assessing trauma exposure, particularly interpersonal violence, to identify young children at risk.     

Dietary patterns in infancy and their associations with maternal socio‐economic and lifestyle factors among 758 Japanese mother–child pairs: the Osaka Maternal and Child Health Study

Dietary habits established in early childhood contribute to lifelong dietary pattern and the development of early risk factors for disease in adulthood. Although a large body of epidemiologic data from Western countries show that the dietary pattern of children is influenced by maternal socio‐economic and lifestyle characteristics, information on this topic in non‐Western countries is absolutely lacking. The present study identified dietary patterns among infants aged 16–24 months, and then examined the influence of maternal socio‐economic and lifestyle characteristics on identified dietary patterns. Subjects were 758 Japanese mother–child pairs. Dietary data of infants were collected from the mothers using a questionnaire. Dietary patterns were extracted from the consumption of 15 foods (times week^?1) by cluster analysis. The following two dietary patterns were identified: ‘fruits, vegetables and high‐protein foods’ (n = 483) and ‘confectionaries and sweetened beverages’ (n = 275) patterns. After adjustment for all other predictors, maternal educational level, number of infants' siblings and maternal dietary patterns were independently associated with dietary patterns of infants. Infants whose mothers had a higher educational level and the ‘rice, fish and vegetables’ dietary pattern were less likely to belong to the ‘confectionaries and sweetened beverages’ pattern, whereas infants whose mothers had a higher number of children and the ‘wheat product’ dietary pattern were more likely to belong to the ‘confectionaries and sweetened beverages’ than the ‘fruits, vegetables and high‐protein foods’ pattern. In conclusion, the mother's socio‐economic position and dietary patterns were associated with the dietary patterns of infants in the Japanese pairs as observed in the Western populations.     

Immunisation issues for Indigenous Australian children

Vaccination has provided major benefits to the health of indigenous children in the face of continuing poorer socioe‐conomic conditions but several issues have been identified for improvement. While indigenous children are vaccinated at high rates for the standard schedule vaccines, vaccination is more commonly delayed. Coverage for ‘targeted’ vaccines is substantially lower, and data on coverage for indigenous adolescents is non‐existent. Improved identification of indigenous clients by immunisation providers and the expansion of the childhood register are required. The progressive removal of early‐acting Haemophilus influenzae type b vaccines from schedules for indigenous children because of an international shortage raises the risk of disease re‐emergence and highlights the need for vigilant surveillance including carriage. The expanded use of existing vaccines (influenza) and early adoption of new vaccines (higher valency pneumococcal conjugates) are needed to maximise benefits, in particular the potential to impact on non‐invasive disease such as otitis media and non‐bacteraemic pneumonia that are so prevalent in indigenous children.     

Developmental phenotypes and causal pathways in attention deficit/hyperactivity disorder: potential targets for early intervention?

Early intervention approaches have rarely been implemented for the prevention of attention deficit/hyperactivity disorder (ADHD). In this paper we explore whether such an approach may represent an important new direction for therapeutic innovation. We propose that such an approach is most likely to be of value when grounded in and informed by developmental models of the dynamic, complex and heterogeneous nature of the condition. First, we set out a rationale for early intervention grounded in the science of ADHD viewed through developmental models. Second, we re‐examine the concept of disorder‐onset from the perspective of developmental trajectories and phenotypes. Third, we examine potential causal pathways to ADHD with regard to originating risk, pathophysiological mediators, environmental moderators and developmental continuities. Finally, we explore the potential value of strategies for identifying young children at risk for ADHD, and implementing interventions in ways that can target these underlying pathogenic processes. The utility of such an approach represents an important area for future research but still requires ‘proof of concept’. Therefore prior to widespread clinical implementation, far greater knowledge is required of (i) developmental pathways into ADHD, (ii) the value of identifying neuropsychological mediators of these pathways, and (iii) the extent to which targeting mediating mechanisms will improve treatment outcomes for children with ADHD.     

Self-assessment of pubertal Tanner stage by realistic colour images in representative Chinese obese and non-obese children and adolescents

Aim: This investigation aims to evaluate the validity of self‐assessment of pubertal Tanner stage in representative Chinese children and adolescents. Methods: The study is a nationally representative cross‐sectional survey in eight research sites in the large project entitled ‘China Puberty Research Collaboration’. Weight, height, self‐assessed pubertal Tanner stage and physical examination of pubic hair in each gender, breast development in girls and genital development in boys from were analysed. Realistic colour images of pubertal rating were used as self‐assessment of pubertal stage. Results: A large proportion of subjects aged 7.9–18.9 years old were capable of identifying their own pubertal Tanner stage accurately or close to the rater’s assessments. Obese group tends to overestimate their pubertal development compared to non‐obese peers, except for genital assessment in boys. The k values for non‐obese and obese girls were 0.619 (p < 0.0001) and 0.527 (p < 0.0001), respectively, while the k values for non‐obese and obese boys were 0.503 (p < 0.0001) and 0.352 (p < 0.0001). Conclusions: Self‐assessment of the pubertal stage by using realistic colour images could be a better alternative assessment tool for large epidemiological puberty research compared with Tanner’s original black and white pictures.     

What lessons can be learned about asthma phenotypes in children from cohort studies?

‘Phenotyping’ asthma by multivariate analyses and more recently by unsupervised analysis has been performed in children cohorts. We describe the key findings that have emerged from these cohorts. It would appear that there are three wheeze phenotypes in children of preschool age: the mild episodic viral wheeze phenotype; the multitrigger atopic wheeze; and, less often encountered, the severe non‐atopic wheeze. Early onset of allergy in asthma (more prevalent in boys) is associated with poor prognosis unlike the severe non‐atopic wheeze phenotype which has a female predominance. The prognosis of the severe non‐atopic wheeze depends on time of onset (early or late) of allergic expression. At school age, the risk of severe asthmatic exacerbations is associated with eosinophil predominant inflammation frequently related to allergic asthma, whereas neutrophil inflammation is associated with moderate‐to‐severe asthma with poorer lung function. Nevertheless, allergic asthma is also a heterogeneous disease with a severe allergic phenotype strongly associated with atopic dermatitis and very high eosinophil‐driven inflammatory markers. Further studies are required to find non‐invasive biological markers in very young children to better define wheezing phenotypes associated with an elevated risk of developing severe asthma with a view to personalizing treatment.     

Editorial: ‘What's up, (R)DoC?’ – can identifying core dimensions of early functioning help us understand,and then reduce,developmental risk for mental disorders?

In the US the National Institute of Mental Health (NIMH), the main funder of mental health research in the world, has recently changed its funding model to promote a radically new perspective for mental health science. This bold, and for some controversial, initiative, termed the Research Diagnostic Criteria (or RDoC for short), intends to shift the focus of research, and eventually clinical practice, away from existing diagnostic categories, as recently updated in the DSM‐5, towards ‘new ways of classifying psychopathology based on dimensions of observable behavior and neurobiological measures.’ This reorientation from discrete categorical disorder manifestations to underlying cross‐cutting dimensions of individual functioning has generated considerable debate across the community of mental health researchers and clinicians (with strong views voiced both pro and con). Given its pivotal role in defining the research agenda globally, there is little doubt that this US science funding initiative will also have ramifications for researchers and clinicians worldwide. In this Editorial we focus specifically on the translational potential of the dimensional RDoC approach, properly extended to developmental models of early risk, in terms of its value as a potential driver of early intervention/prevention models; in the current issue of the JCPP this is exemplified by a number of papers thata address the mapping of underlying dimensions of core functioning to disorder risk, providing evidence for their potential predictive power as early markers of later disorder processes.     

Family interaction and a supportive social network as salutogenic factors in childhood atopic illness

The role of psycho‐social factors in the development of allergy was studied prospectively in 82 infants with a family history of atopy. The family participated in a standardized family test when the children were 18 months old. The ability to adjust to demands of the situation (‘adaptability’), and the balance between emotional closeness and distance (‘cohesion’), were assessed from videotapes by independent raters. Families rated as functional in both of these aspects were classified as ‘functional’, otherwise as ‘dysfunctional’. The social network, life events, atopic symptoms (based on postal inquiries regarding symptoms answered by the parents, and on physical examinations), psychiatric symptoms, and socio‐economic circumstances of the families were evaluated when the children were 18 months and 3 years of age. The children were classified as atopic (asthmatic symptoms or eczema) or as non‐atopic. All but two children with atopic disease at 3 years of age had atopic disease before 18 months of age, while 32 of 60 children with atopic disease at 18 months of age had no problems by 3 years of age. An unbalanced family interplay at 18 months was associated with a relative risk (RR) of 1.99 for continuing atopic illness at 3 years of age (1.18 < RR < 3.37, p = 0.01). There was a weak positive confounding effect for smoking (RR reduced by 7%), eczema on three or more localizations (RR reduced by 4.5%), and the amount of cat allergen in household dust (RR reduced by 3%). Recovery from atopic illness between 18 months and 3 years of age was four times as probable in families with functional interaction and a good social supportive network when children were 18 months of age, than in dysfunctional families with a poor social network (74% versus 20% p < 0.01). Children with asthmatic symptoms showed more signs of emotional distress than did healthy children (p = 0.02). Dysfunctional family interaction patterns were more commonly observed in families of children who at 3 years of age still had atopic symptoms, than in children who had recovered. The patterns included expression of emotion and reaction to the needs of others, alternating between total disinterest and over‐involvement (p = 0.02), lack of support and rejection of offered support (p = 0.01), a greater number of individual decisions without regard to the other family members (p = 0.04), and indistinct ‘generational boundaries’ (p = 0.04). We conclude that psychosocial factors, such as family interaction and a supportive social network, play a significant role in the course of atopic illness in early childhood and that measures which enhance family interaction and the social network could influence the course of the disease favorably.     

Continuities and discontinuities in psychopathology between childhood and adult life

The possible mechanisms involved in continuities and discontinuities in psychopathology between childhood and adult life are considered in relation to the findings from systematic, prospective, long-term longitudinal studies. Findings on schizophrenia, neurodevelopmental disorders, emotional disturbances, antisocial behaviour and substance abuse are used as conditions illustrating the key issues. The overarching themes are then discussed in relation to heterotypic continuity and psychopathologic progression, early age at onset and a range of possible mediating mechanisms - including genetic mediation, 'kindling' effects, environmental influences, coping mechanisms and cognitive processing of experiences. Some of the key research challenges that remain concern the testing of competing hypotheses on mediating processes, the changes involved in adolescence, the transition from prodromal phase to overt schizophrenia and the emergence of adolescent-limited antisocial behaviour. Greater use needs to be made of genetic research strategies and of the testing of possible cognitive processing mediation effects.     

Sensory processing in internationally adopted,post‐institutionalized children

Background/Methods: Sensory processing capacities of 8–12‐year‐old internationally adopted (IA) children who experienced prolonged institutional care (> 12 months with 75% of pre‐adoption lives in institutional care) prior to adoption into family environments (PI) were compared to a group of IA children who were adopted early (< 8 months) predominantly from foster care with little or no institutional experience (EA/FC) and another group of non‐adopted (NA) children raised by their birth parents in the United States. All children had estimated IQs within the normal range and did not evidence major neurodevelopmental disorders (e.g., cerebral palsy, fetal alcohol syndrome, Down’s syndrome). Sensory processing was evaluated with a commonly used parent‐report measure and a laboratory assessment. Results: Children who had experienced prolonged institutionalization showed higher levels of reactivity to sensation and displayed both more aversion and approach to sensory stimuli than the other groups. The comparison groups (EA/FC & NA) did not differ on any of the sensory processing measures. Conclusions: These results suggest that early institutional rearing which typically involves both sensory and social deprivation is associated with problems in sensory modulation capacities.     

Extraction and Refinement Strategy for detection of autism in 18-month-olds: a guarantee of higher sensitivity and specificity in the process of mass screening

Background: For early detection of autism, it is difficult to maintain an efficient level of sensitivity and specificity based on observational data from a single screening. The Extraction and Refinement (E&R) Strategy utilizes a public children’s health surveillance program to produce maximum efficacy in early detection of autism. In the extraction stage, all cases at risk of childhood problems, including developmental abnormality, are identified; in the refinement stage, cases without problems are excluded, leaving only cases with conclusive diagnoses. Methods: The city of Yokohama, Japan, conducts a routine child health surveillance program for children at 18 months in which specialized public health nurses administer YACHT‐18 (Young Autism and other developmental disorders CHeckup Tool), a screening instrument to identify children at risk for developmental disorders. Children who screen positive undergo further observation, and those without disorders are subsequently excluded. To study the efficacy of early detection procedures for developmental disorders, including autism, 2,814 children born in 1988, examined at 18 months of age, and not already receiving treatment for diseases or disorders were selected. Results: In the extraction stage, 402 (14.3%) children were identified for follow‐up. In the refinement stage, 19 (.7%) of these were referred to the Yokohama Rehabilitation Center and diagnosed with developmental disorders. The extraction stage produced four false negatives, bringing total diagnoses of developmental disorders to 23 (.8%) – including 5 with autistic disorder and 9 with pervasive developmental disorder – not otherwise specified (PDDNOS). Sensitivity was 60% for autistic disorder and 82.6% for developmental disorders. Specificity for developmental disorders rose to 100% with the E&R Strategy. Picture cards used in YACHT‐18 provided a finer screen that excluded some false positive cases. Conclusions: An extraction and refinement methodology utilizing child health surveillance programs achieve high efficacy for early detection of autism.