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This study validates behavior development screening for toddlers (BeDevel), which utilizes a combination of short caregiver interviews (BeDevel-I) and semistructured play observations (BeDevel-P). The data of 431 toddlers (male 66.2%; mean age (SD) = 29.11 (8.59) months; ASD, n = 201; developmental delay, n = 46; typically developing, n = 184), aged 18 ~ 42 months, were included in the validation of BeDevel. The best clinical estimate diagnosis, screening rate, validity, sensitivity, and reliability of BeDevel were determined based on data cross-sectionally collected using BeDevel and existing diagnostic/screening instruments: autism diagnostic observation schedule (ADOS), autism diagnostic interview (ADI-R), Vineland adaptive behavior scales-II (VABS-II), social response scales (SRS), sequenced language scale for infants (SELSI), Korean childhood autism rating scale (K-CARS), and Korean social communication questionnaire (K-SCQ). The k values of BeDevel-I and BeDevel-P were 0.055 ~ 0.732 and 0.291 ~ 0.752, respectively. Items related to social referencing in BeDevel-P had a particularly high diagnostic validity (k = 0.483 ~ 0.684). Reliabilities of BeDevel-I and BeDevel-P were sufficient (Cronbach's alpha = 0.86 ~ 0.88 and 0.92 ~ 0.95, respectively). BeDevel-I and BeDevel-P showed high sensitivity (BeDevel-I: 85.00 ~ 89.29%; BeDevel-P: 85.00 ~ 91.75%), specificity (BeDevel-I: 77.55 ~ 89.55%; BeDevel-P: 85.09 ~ 97.01%), PPV (BeDevel-I: 70.83 ~ 88.54%; BeDevel-P: 81.52 ~ 94.68%), and NPV (BeDevel-I: 76.00 ~ 95.24%; BeDevel-P: 84.62 ~ 95.45%). The agreement between the composite BeDevel score and ADOS, ADI-R, K-CARS, and K-SCQ was >67.6% (range = 67.6 ~ 90.8%). Combining a short caregiver interview and direct play observation is a valid and reliable screening process. More studies on social referencing as an important early marker are needed. BeDevel can be utilized as a secondary screening instrument before diagnostic confirmation in clinical and community settings. LAY SUMMARY: BeDevel, which consists of a short caregiver interview and direct play observation, is a valid and reliable screening instrument for autism spectrum disorder (ASD). We suggest that BeDevel can be utilized as a secondary instrument before administering diagnostic assessments in clinical and community settings. More studies examining social referencing as a potential behavioral marker of ASD are needed.

Although early screening is critical for individuals with autism spectrum disorder (ASD) in order to receive early intervention and improve function later in life, screening is often delayed. Limitations of existing screening instruments, and the need for a culturally appropriate early screening tool in Korean children, led us to develop Behavior Development Screening for Toddlers (BeDevel). The BeDevel assessment consists of two parts: BeDevel-Interview, a structured interview measure for parents/primary caregivers; and BeDevel-Play, a play-based semi-structured observational measure in children. To examine the feasibility and validity of BeDevel, 155 children (N = 75 ASD, N = 55 typical development, N = 25 developmentally delayed) aged 18-42 months (M = 31.54 months, SD = 7.60) were examined through parent-reported screening questionnaires, BeDevel, and standard diagnostic assessments. When BeDevel items were analyzed using Cohen's kappa statistics, most items in BeDevel-Interview and all items in BeDevel-Play were reasonably consistent with diagnoses. We identified primary items, which were significantly interacted with actual diagnosis in the chi-squared test (P < 0.05, range = 0.000-0.032). Using cutoff numbers of items determined using the receiver operating characteristics curve, BeDevel showed satisfactory levels of sensitivity (83.33%-100%), specificity (81.25%-100%), positive predictive values (80.65%-100%), and negative predictive values (83.87%-100%), as well as high internal consistency (Cronbach's α = 0.866-959). The agreement between BeDevel and most other screening/diagnostic instruments was moderate (k = 0.419-1.000). These results suggest that BeDevel can be a useful instrument for early screening of ASD. Autism Res 2019, 12: 1112-1128. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Although early screening is critical for individuals with autism spectrum disorder (ASD) in order to receive early intervention and improve function later in life, screening is often delayed. Limitations of existing screening instruments and the need for a culturally appropriate early screening tool in Korean children led us to develop Behavior Development Screening for Toddlers (BeDevel). The BeDevel assessment consists of two parts: BeDevel-Interview, a structured interview measure for parents/primary caregivers; and BeDevel-Play, a play-based, semi-structured observational measure in children. In order to test the feasibility and validity of BeDevel, we analyzed preliminary data of total 155 children aged 18-42 months, examined through parent-reported screening questionnaires, BeDevel, and standard diagnostic assessments. When individual items were analyzed, responses of all BeDevel-Interview items and of most BeDevel-Play items well matched actual diagnoses, and we identified primary items, which were particularly useful in differentiating between the ASD group and the non-ASD group. With the optimal screening criteria determined, the BeDevel was able to identify individuals with a diagnosis of ASD and those without it, all at satisfactory levels. Lastly, BeDevel items were closely related as a set, and the BeDevel screening results were reasonably consistent with the results of most other screening/diagnostic instruments. These results suggest that BeDevel can be a useful instrument for early screening of ASD.