1. STUDY OF AUTISTIC SPECTRUM DISORDERS ON
DEFINING DATA RELATIONSHIP ON e-
HOSPITAL
Nattapong Sawettaphun and Dr.Narongrit
Waraporn
Abstract
Autism disorder is a kind of disease in patients with
three abnormalities in communication, social skill and range of
interest. Clinical in Thailand use standard criteria by ICD 10 and
DSM IV to classify of autism disorder. However researchers in
many countries try to find more criteria to classify autism patient
such as getting behavior, brain activity, and family history. Main
point of all researches tries to collect many data from many
sources, this study find best practice to sharing data by web
service method, collect data, grouping data in clinical standard.
(I) Introduction
Autistic is mostly found in children, its symptoms are the
abnormal development in communication, social skill and range of
interest[1]. Patient; have the difficulty to socialize and some
severe case patient might have in current disease such as epilepsy,
apoplexy. The preliminary analysis for the autistic uses behavior
and sociability by comparing with other children at the same age
[16].
Now, the standards of autism clinical tests in Thailand
are The American Psychiatric Association's Diagnostic and Statistic
manual of Mental Disorder - Forth Edition, 1994, DSM IV, and
International Statistical Classification of Diseases and Related
Health Problems 10th Revision Version for 2007, ICD 10[14]. They
have different strong and weak points in the method of defining
causes of the disease and its treatment. The DSM IV standard is
mostly and widely used in Thailand for Autism treatment since its
well-planed data collection and easiness of data analysis.
The analyzed data has not yet launched as the summary
report for the analysis of the overall causes. Collection data from
one hospital solely is not enough for the analysis, therefore we
suggest the data collection from several hospitals by applying web
service using xml technology for data transfer, they would provide
to a hospital connect to others on different several technologies.
Importantly, data encryption must be considered for the data
security during the data transfer.
In this study, describe definition of autism and criterion
of autism in major standard to diagnosis and classify group of
autism disorder. Then group researching to collecting data and
classify autism disorder. Finally design how to sharing data by web
service and grouping data in clinical standard format.
(II) Autism
Definition of Autism
Autism disorder, AD, is a kind of disease in patients with
three abnormalities in communication, social skill and range of
interest. Autism disorder patients are classified by level of severity
of each abnormality. National research council of America
describes about autism disorder spectrum, ADS, that it’s acute
symptom shown by age and joined by other characteristics such
as retarded and slow speaking. The distinct symptom of the
abnormality is shown once being in the society compared with
other children at the same age.
Criterion of Autism
The patient treatments in several hospitals follow the
standards reference for the certain diagnosis. In Thailand, there
are two treatment standard references; ICD 10 and DSM IV.
Both standards have the similar method to classify the
Autism disorder by analyzing of the lack of development,
communication and social skill. However, each standard has
different approaches, in ICD 10 standard; doctor classifies the
patients into what kind of Autism disorder. By studying from
their development and behavior [19], [20]. In DSM IV standard,
doctor collects and analyzes the information from patients
without classifying the type of autism disorder, but instead rates
the doctor severity of their symptom, and classifies the type of
autism disorder later for the proper treatments.
The diagnostic criteria of Autistic based on DSM IV group
autism to “Pervasive Development Disorders” means this group
lack of all development skill in communication, social skill, and
range of interest [1].
1. A total of six (or more) items from (A), (B), and (C),
with at least two from (A) and one each from (B) and (C)
(A) qualitative impairment in social interaction, as
manifested by at least two of the following:
1. Marked impairments in the use of multiple
nonverbal behaviors such as eye-to-eye gaze, facial expression,
body posture, and gestures to regulate social interaction.
2. Failure to develop peer relationships appropriate
to developmental level.
3. A lack of spontaneous seeking to share
enjoyment, interests, or achievements with other people.
4. Lack of social or emotional
(B) Qualitative impairments in communication as
manifested by at least one of the following:
1. Delay in or total lack of, the development of
spoken language (not accompanied by an attempt to compensate
through alternative modes of communication such as gesture or
mime).
2. In individuals with adequate speech, marked
impairment in the ability to initiate or sustain a conversation with
others.
3. Stereotyped and repetitive use of language or
idiosyncratic language.
4. Lack of varied, spontaneous make-believe play or
social imitative play appropriate to developmental level.
(C) Restricted repetitive and stereotyped patterns of
behavior, interests and activities, as manifested by at least two of
the following:
1. Encompassing preoccupation with one or more
stereotyped and restricted patterns of interest that is abnormal
either in intensity or focus.
2. Apparently inflexible adherence to specific,
nonfunctional routines or rituals.
3. Stereotyped and repetitive motor mannerisms.
4. Persistent preoccupation with parts of objects
2. Delays or abnormal functioning in at least one of the
following areas, with onset prior to age 3 years:
(A) Social interaction
(B) Language as used in social communication
(C) Symbolic or imaginative play

2. 3. The disturbance is not better accounted for by Rett's
disorder or childhood disintegrative disorder.
Study of Autism
Researches in autism disorder to determine the cause
and treatments; they are divided into four groups of study,
behavior, brain information, family and physical data collection
and sense of awareness and responsiveness.
1. Behavior
In this topic, researchers focus on collecting large
volume of data for the analysis. This include Carelog System, there
is support to getting data to analysis and collecting data to make a
diagnosis plan for each patient[7], [9].
2. Brain Information
Researches study brain information by collecting brain
image from Magnetic Resonance Imaging, MRI. The data is in the
form of brain diagram. Researchers normally compare the brain
diagram between the brain of autism disorder and the normal
one. Some researches compare all parts of the brain, while others
compare only the part they interested in such as Corpus Callosum
[2]. Another equipment named Electroencephalography, EEG, is
used to collect the brain information by many researches. The
data from EEG is in the form of line graph collecting the frequency
range between autism disorder and normal child. This information
would be able to analyze whether the patient have risk to be
autism or not [10].
3. Family and Physical data collection
Data collection on family and physical history is the main
concept of this analysis which is closed to the current medical
treatment, doctors question the family of ADS for the family
history and whether there are any Autistic relatives or some
resembling symptoms shown. Similar approach to the data
collection by EEG, data is compared in the frequency range among
the family members. For the physical data collection, the growth
rates of organs such as brain or face are compared on their
development between autism and normal child at the same age
[16].
4. Sense of awareness and responsiveness
The concept of this research is to test the senses of
awareness in the Autistic body such as the ability to recognize the
audio frequency compared with the normal person [15], or the
awareness of color vision.
Autism Behavior Data Collection
To collect patient information by observing their
behavior, there is the Carelog system supporting the data
collection. This system divides the data storage into checklist and
handwritten or typed notes using caregiver as collector. Carelog
system needs all behavior data from daily routine, medical
treatment from video and text resource. Carelog system makes
caregiver be able to analyze behavior data by using summary
report. Carelog system help therapist to give patient the proper
therapy by supporting report and analysis graph of children
progress.
In DSM IV criterion, require the same group of patient
behavior as same as Carelog to diagnosis autism. In Thailand,
doctors are able to classify the key information into 3 types;
communication, social skill and range of interest. From the
research of Autism clinical data collection in Thailand, there are
two steps collection by getting and filling in the form developed
by DSM IV Standard from Ramathibodi Hospital[14], which also
divides the data storages into 2 source types; Behavior
Observation and Interviewing the parent.
DSM IV divided form into two parts;
Behavior interview form
1.Communication
(A) Communication development
(B) Action
2. Social Skill (with same age children)
(A) Interaction when playing
(B) How to play
(C) Interest and strange Interaction
Behavior observation form
1. Free play
2. Imaginative play
3. Demand communication
4. Communication skill
5. Overall behavior
The obtained Information will be in the form of
checklist and handwritten or typed notes from doctor’s opinion,
which will make the data analysis easier than method from other
hospitals’, who keep the data in the form of behavior description
which collects the unstructured information from experience and
knowledge of the individual doctor
(III) Information Interchange
Web Service
Web service is the application or the program giving
service which is running by web application or application in RPC
(Remote Procedure Call) format [12]. Three major components in
web service environment SOAP, WSDL and UDDI.
Figure 1: Sample web service design
Web service components (See in figure 2)
1. SOAP (Simple Object Access Protocol) is the protocol
enabling to call components across platform, across programming
language Component developed from any programming language
such asp.net, PHP, Perl, Java, python, Delphi can communicate
between component. This protocol works with HTTP protocol and
uses XML to communicate.
2. WSDL (Web Services Description Language) is the
language to explain how to use web services. WSDL enable
description of data type in sending and receiving method. In web
services, it also includes syntax to receive, address and protocol to
call web service.
3. UDDI (Universal Description, Discovery and
Integration) is the description to publish how to use web service.
It explains; register and type of web service and their limitation.

3. Figure 2: Web service environment
Standard language for the information interchange is
Extensible Markup Language, XML. This technique of data transfer
is widely applied many practices such as in service oriented
architecture, SOA, RosettaNet e-business standard and RSS
feeding format.
XML is the standard markup language with element and
attribute names appointed as the needs of users [11].
Example
<?xml version="1.0" ?>
<Patient>
<name>Test name</name>
<HN>20091203998</HN>
<Age>12<Age>
</Patient>
verification of XML have 2 level
1. Well-Formed XML document on forms six
fundamental rules; case-sensitive, single root, proper nested tag,
version declaration, attribute vale in quotes open and close all tag
2. Valid XML document obeys the structural rules
specified as vocabulary in either DTD or XML schema
Web Service Security
To use the Web Service, the security of data transfer is
strictly considered, since the treatment information and basic
information are high confidential, therefore web service must be
secured to respect the privacy of patient.
We design two steps of security processes as
authentication and web service encryption (See in figure 3).
To create Authentication, we use feature in .net
framework, which has 3 authentication levels as follows [3];
1. Window Authentication
This level is the user name checklist by Microsoft
window active directory user to match the end-users. This level
will be effective in the organization using window server, since we
have no need to define access to multiple accounts; just the
feature in window server operation system is used in our system.
However, it could be expanded to other operating system.
2. Net Passport Authentication
This level is the checks list of window live account and able to be
used to determine the access right. The advantage of this check is
system administrator has no need to keep the user information
which makes the system maintenance easier
3. Forms Authentication is the data check using cookie
sent from the authentication of login form by developer.
Next step is web service encryption which has 2
options for the encryption is SSL (Secure Sockets Layer) and SOAP
(Sample object access protocol) extension [13], [18].
1. SSL (Secure Sockets Layer) is widely used in the
internet. The checking process is to check the server and client
whether they exist and to encrypt the connection. This will ensure
that information is the strictly kept. However, one disadvantage in
real use is the system performance will reduce because there is
the data encryption for every access; it wastes time and CPU
utilization for the decryption.
2. SOAP extension is to do the encryption at SOAP
package. The encryption can be done by several choices as
follows;
SOAP has encryption process:
 Encryption only selected messages
 Encryption only the header of the message
 Encryption only the body of the message
 Encryption only the whole message
Figure 3: web service security design
(IV) Methodology
Autism Data Collection
To study the research of Autism disorder treatment, the
interesting and practical case study in Thailand is that data
collection of patient behaviors dominates the other data that
collects during the process of EEG and MRI, since the treatment
clinic in Thailand does not have enough staffs to determine the
cause of the illness in patients. Most treatment in Thailand in
every hospital collects only behavior data while diagnosis using
medical devices is only available to patient who has the incurrent
diseases such as epilepsy, retarded. (See in figure 4)
The data we have studied has two clinical standards,
DSM IV and ICD 10. From the research of Autism disorder
treatment in Thailand, there is the developed questionnaire form
DSM IV standard which refers to the DSM IV standard. It has been
tried three years in Ramathibodi Hospital. After studying, we
found that the questionnaire has been developed for several
versions and doctors do not understand how to fill in the
questionnaire. Until the previous year, the standard and practical
questionnaire has been developed. The reference data we refer to
is the latest version questionnaire or the previous version that is
able to be adapted to the latest version.

4. Figure 4: Getting Clinical Process Data in Thailand
Questionnaire Analysis
The analysis of questionnaire for collecting behavior
data is divided into topics as per DSM IV standard and the type of
data collection; interview or observation. To import the collected
data into the electronic system instead of using document system,
including the doctors’ ability to collect the data making the
challenging to create the data collection system to support the
understanding of the doctors who collect data and the reader of
treatment report who might not have knowledge about the
treatment or the outsiders. And it must be easy for the users who
connect to the system by web service to import data into system.
Then to import data into system must not import only the
knowledge understood by doctors who collect the data, but also
we have to make sure that the users of the web service have the
same understanding in the entered data. The user must be able to
put in all information at the same standard as doctor expected the
interface must be easy to fill in the data.
Firstly, we test the data imported from document to see
how doctors fill in the data and by what procedures. After making
the interview and testing the data filling by ourselves, we found
that this form takes time to collect the data and require the
fineness in data storage. We have set the level of the analysis only
to estimate and classify t he Autism disorder level of the patients.
Database Design
Database design is divided into two important parts as
follows;
1. Patient Information
The information in this section is divided into Patient
personal information and Family history. The Patient personal
information is to distinguish the patient which includes hospital
number, HN, name, and age.
The information in this section is to identify the patient.
The main key is HN. We must consider the standard accuracy of
the patient identity. We cannot overlook that one patient might
have several HN due to repeating registering. Once we make the
system to connect with other hospitals, we might have to link the
information with the HN of other hospitals. We have to consider
the patient sorting before filling in the patient information to
register the patient in the system.
The study of family history makes the data in this range
of database design to be used further. For example, the
probability analysis of the family members must be considered if
they tend to be or used to be the Autism disorder. It will help to
specify the probability tendency or the primary treatment given by
parents or the first tendency found. This information will help
doctors estimate the type of Autism disorder and give the proper
treatment to the patients.
2. Questionnaire and Behavior Data
Information in this section is divided into two major
parts; Survey data and Behavior data from questionnaire
The questionnaire data are divided into Text section
which specifies the description and list of question, to which part
of the DSM IV Standard this questionnaire refers. This will help to
print out the report as per the type of data which will help the
analysis, estimation and giving treatment to individual patient.
Another section is Behavior data to collect behavior according to
the questionnaire. Apart from behavior data, it requires to specify
doctor and data collector for the proper storage of treatment
background. The last part is the summary data to specify the
patient characteristic or the tendency to be an Autism disorder. If
there is the tendency to be, we require the specified percentage of
possibility and the treatment details, because there is no
treatment pattern now. Doctor always indicates the medical
treatment by character of each patient. The data in this part is still
needed the further analysis for the design of treatment form.
The next section is user login and authentication which
store the authentication level of each user. The user of data access
is divided into four groups; Administrator, Questionnaire Designer,
Collector and Reporter. The important issue is when each hospital
shares the data; they might not disclose all treatment information,
so there must be database of authorized level for each hospital to
specify what level they can access to the data.
Web Service Design
To design the web service, the main concerns are the
right to access the data and the security of data transfer.
Design in the workflow of this system should make it
good performance and security. There are four main process
shows in figure 5.
1. User Authentication
To verify user right to access the system. User must send
the authentication form by cookie in web browser to be checked
from where it is sent. The information is encrypted and will be
decrypted by the server at the receiving side to verify user, check
the right level and the data level such user can access.
2. Authorizations
In each service, the user is grouped into his/her
authorized level. The requester must be checked whether they
have the right to use this service or not.
3. Retrieve Data
To extract the data, the most data are in array data
format which is in the class that has same structure as database
structure as per the feature language integrated query, LINQ, to
structured query language that Microsoft has designed. LINQ can
covert entity in database to class object in programming structure,
it help programmer to develop program.
4. Encrypt data
The data encryption as SOAP Extension by the Data
Encryption Standard, DES, is to encrypt only selected body of the
message which we have to consider the speed of data transfer
and the duration of encryption-decryption data to be fast and
save the data transfer rate

5. Figure 5: Web Service Work Flow
Information Interchange Design
The infrastructure design process to support the use of
the system is designed by the functionality as follow;
Figure 6: Infrastructure Design
1. Web Service Server
The function of this server is to retrieve and send data
via web the service to the user who connects to the system.
2. Authentication and Encryption Server
To verify the right of user once there is the request from
web service, the system must authentication with authentication
server. When the access is correct according to the system design,
this server will encrypt data before sending to web service server
and then to the requester. The function of this server is to be web
service provider as well, but only being the private web service
provider which is able to be used by client in the system only.
3. Database Server
All data are stored in SQL Server 2008 database express
edition which is convenient for the maintenance and no expenses.
(V) Conclusion, Comment and Future work
To develop the Information interchange, this system
must support standard development. Since the patients have the
right to conceal their information and treatment details, system
design must concern with security and data access authorization.
Next problem once the system can access the data is the clinical
reference standard which has many standard references. This
system is usable in many hospitals where DSM IV is the reference
standard. If any hospitals use ICD 10 standard, the data analysis
to classify the patient will be different. And the standard of
database and web service design has not yet referred to any
standard. Now the standards for the development are defined by
National Database for Autism Research, NDAR, and Health Level
Seven, HL 7. This research is able to be used in Thailand in many
places, such as in Ramathibodi Hospital already.
Next step of the development is to improve all three
parts of the system as follows;
1. Develop web service to support the data analysis
from many clinical references.
In this part, we have seen that the patient treatments
have used many reference standards and some that still has not
been referred to, include the real treatment standard such as ICD
10 and standard for Autism patient data collection such as NDAR,
HL7. Then, we will design the system to support multiple
standards for the better connection of patient analysis.
2. Develop information interchange and database to
support NDAR system which is the latest standard will be
implemented in 2010-2011.
After analyzing the design supporting multiple
treatment standards, we could implement an extended standard
for the researchers around the world to share and connect their
data according to NDAR. If we design and test together with
NDAR, this system will not only have local data but international
data for the data analysis. It may have the system design that
analyzed data in various standards.
3. Develop tool to import data from various sources
such as EEG data, Computer tomography scan, CT scan, able to
analyze data for comparison and statistic.
From the study in the international research [2],[10],
there are the other information other than behavior for diagnosis
and treatment to patient. The initial data which is easy to analyze
is EEG because it is in the line graph of brain wave. The doctor can
compare statistic of the brain activity to find the difference when
patients do an activity compared with the normal one. Once this
done successfully, the next step is to import CT scan data, which is
the brain diagram to do the image processing for the analysis on
interest parts or all part of the diagram.
Acknowledgements
This work could not be successful without helpful from
children development department team at Ramathibodi Hospital
for questionnaire especially collection sample data and Assoc.
Prof. Nichara Ruangdaraganon for valueable suggestion and
discussion.
Reference
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http://www.ieee.org
[9] Kientz J.A., Hayes G.R., Westeyn T.L., Starner T.,
and Abowd G.D., ”Pervasive Computing and Autism: Assisting
Caregivers of Children with Special Needs“, PERVASIVE
computing, JANUARY–MARCH 2007, pp. 28-35,
http://www.ieee.org
[10] Leroy G., Chuang S., Huang J., Marjorie H., Christy C.,” Digital
Libraries on Handhelds for Autistic Children “,7–11 June 2005,
http://www.ieee.org
[11] Moller A., Schwartzbach M., a Introduction to XML and Web
Technologies, Pearson Education Limited, 2006
[12] Narate N., Jirawat P., ASP.NET 2.0, Seccess Media Co.Ltd.,
2008
[13] O’Neil M., Web Service Secuirity, Mcgraw-Hill/Osborne, 2003
[14] Ruangdaraganon N., ”Autism Behavior Data Collection”,
Ramathibodi Hospital
[15] T. Lepisto, M. Kajander, R. Vanhala, P. Alku, M. Huotilainen,
R. Na¨a¨ta¨nen, T. Kujala, “The perception of invariant speech
features in children with autism”, Biological Psychology 77
(2008),pp 25–31, 31 Aug 2007, http://www.scidirect.com
[16] van Daalen E., Sophie H.N.S., Dietz C., van Engeland H., and
Buitelaar J.K., “Body Length and Head Growth in the First
Year of Life in Autism “,PEDIATRIC NEUROLOGY Vol. 37 No. 5
, pp. 324-330, http://www.sciencedirect.com
[17] Wirojanan J., Sangkool J., Limprasert P., Autism,
Songklanakarin Magazine, 4 July - August 2006, pp.325-332
[18] XML – Web Service: Economic Model,
http://pirun.ku.ac.th/~g5164187/
XML_webservice_economic_model3.doc
[19] http://www.who.int/classifications/icd/en/
[20] http://apps.who.int/classifications /apps/icd/icd10online/?
gf80.htm+f84

7. [4] Degirmenci B., Miral S., Kaya G.C., İyilikçi L., Arslan G., Baykara
A., Evren I. and Durak H.,” Technetium-99m HMPAO brain SPECT
in autistic children and their families “,Psychiatry Research:
Neuroimaging 162 (2008), pp. 236-243,
http://www.sciencedirect.com
[5] Ferrara A., MacDonald M., Programming .Net Web Service,
O’Relly & Associates Inc., 2002
[6] Hardan A.Y. , Girgis R.R. , Adams J., Gilbert A.R., Keshavan M.S.
and Minshew N.J. ,”Abnormal brain size effect on the thalamus in
autism “,Psychiatry Research: Neuroimaging 147 (2006), pp. 145-
151, http://www.sciencedirect.com
[7] Hayes G.R. and Truong K.N., ”Autism, Environmental Buffers,
and Wearable Servers“, PERVASIVE computing, APRIL–JUNE 2005,
pp. 14-17, http://www.ieee.org
[8] Joseph A.D., ” Healthcare Systems and Other Applications “,
PERVASIVE computing, JANUARY–MARCH 2007, pp. 59-63,
http://www.ieee.org
[9] Kientz J.A., Hayes G.R., Westeyn T.L., Starner T.,
and Abowd G.D., ”Pervasive Computing and Autism: Assisting
Caregivers of Children with Special Needs“, PERVASIVE
computing, JANUARY–MARCH 2007, pp. 28-35,
http://www.ieee.org
[10] Leroy G., Chuang S., Huang J., Marjorie H., Christy C.,” Digital
Libraries on Handhelds for Autistic Children “,7–11 June 2005,
http://www.ieee.org
[11] Moller A., Schwartzbach M., a Introduction to XML and Web
Technologies, Pearson Education Limited, 2006
[12] Narate N., Jirawat P., ASP.NET 2.0, Seccess Media Co.Ltd.,
2008
[13] O’Neil M., Web Service Secuirity, Mcgraw-Hill/Osborne, 2003
[14] Ruangdaraganon N., ”Autism Behavior Data Collection”,
Ramathibodi Hospital
[15] T. Lepisto, M. Kajander, R. Vanhala, P. Alku, M. Huotilainen,
R. Na¨a¨ta¨nen, T. Kujala, “The perception of invariant speech
features in children with autism”, Biological Psychology 77
(2008),pp 25–31, 31 Aug 2007, http://www.scidirect.com
[16] van Daalen E., Sophie H.N.S., Dietz C., van Engeland H., and
Buitelaar J.K., “Body Length and Head Growth in the First
Year of Life in Autism “,PEDIATRIC NEUROLOGY Vol. 37 No. 5
, pp. 324-330, http://www.sciencedirect.com
[17] Wirojanan J., Sangkool J., Limprasert P., Autism,
Songklanakarin Magazine, 4 July - August 2006, pp.325-332
[18] XML – Web Service: Economic Model,
http://pirun.ku.ac.th/~g5164187/
XML_webservice_economic_model3.doc
[19] http://www.who.int/classifications/icd/en/
[20] http://apps.who.int/classifications /apps/icd/icd10online/?
gf80.htm+f84