Translation and cultural appropriateness of the Autism Diagnostic Observation Schedule-2 in Afrikaans

Item-Based Analysis of Some ADOS-2 Items with Typically Developing Participants Might help Improve Cross-Cultural Validity of ADOS-2

Most internationally recognized instruments for the screening and diagnosis of autism spectrum disorder have been developed in the USA, which calls into question the degree of their cultural adaptation to diverse populations. The aim of this study is to examine the characteristics of social communication in typically developing Croatian-speaking participants (N = 220) using ADOS-2-defined item-level normative values. Croatian subjects showed the expected ("typical") results in the domain of verbal communication, slightly atpical results in nonverbal communication (primarily gesture use), and more significant deviations in pragmatics (offering and asking for information), relative to the expectations of the ADOS-2. As ADOS-2 has become an important component of thorough ASD diagnostic evaluations worldwide, identifying methods for increasing the cross-cultural validity is essential.

'We are doing damage control': Government stakeholder perspectives of educational and other services for children with autism spectrum disorder in South Africa

LAY ABSTRACT

Autism spectrum disorder is a growing public health concern in low- and middle-income countries like South Africa where there are no plans or policies in place for autism spectrum disorder management. Many children with autism spectrum disorder in South Africa are out of schools and waiting for school placement to become available. This study explored the perspectives of key government stakeholders on educational and other services for children with autism spectrum disorder in the Western Cape Province of South Africa and their suggestion for improving services for these children and their families. Semi-structured interviews were conducted with government stakeholders from the Western Cape Department of Education, Department of Health and the Department of Social development. The main theme that emerged was 'We are doing damage control'. Government stakeholders acknowledged that autism spectrum disorder services were being overlooked because of other demands on government resources. Finding from this study highlighted the need for government departments to work together to develop a strategy for autism spectrum disorder management. Engagement between government and civil society to break down barriers, strengthen systems and develop solutions to improving access to services for children with autism spectrum disorder and their families is recommended.

Psychosocial interventions for autistic children and adolescents delivered by non-specialists in low- and middle-income countries: a scoping review

Background

Most autistic individuals reside in low- and middle-income countries (LMIC) and have limited access to medical providers and specialists. Support for delivery of psychosocial interventions by non-specialists is growing to address this mental health care gap. This scoping review involved a systematic analysis of studies of non-specialist delivered psychosocial interventions for children and adolescents diagnosed with autism and living in low- and middle-income countries.

Methods

The primary objective of this review was to identify psychosocial interventions for autistic children and adolescents in LMIC delivered by non-specialists (parent, teacher, peer, community, multi-level) and to summarize resulting effects on targeted outcomes. The search strategy was completed in four databases with predetermined inclusion and exclusion criteria. The systematic search generated 3,601 articles. A total of 18 studies met inclusion/exclusion criteria. Data extraction was completed, and results summarized by; (1) participant sample; (2) intervention procedures; (3) implementation by non-specialists; (4) effect on evaluated outcomes; and (5) assessment of risk of bias. Studies examined a range of child and adolescent outcomes including assessment of communication skills, social skills, motor skills, functional and adaptive behaviors, emotional regulation, attention and engagement, sensory challenges, depression, anxiety, and quality of life. Several studies also evaluated intervention effects on family relationships, parent/caregiver stress and parent/caregiver mental health.

Results

Collectively, the 18 studies included a total of 952 ASC participants ranging in age from 2 to 16 years. Of the included studies, 8 studies were parent/caregiver-mediated, 1 study was peer-mediated, 2 studies were teacher-mediated, and 7 studies included multi-level non-specialist mediated components. Effects on evaluated outcomes are reported.

Conclusion

Non-specialist delivered interventions for autistic children and adolescents are effective for an array of outcomes and are particularly well suited for low- and middle-income countries. Implications for future research are discussed.

Duration of untreated autism in rural America: emerging public health crisis

The rural areas have been at the receiving end amidst mental health disparity across the USA. There is a serious and concerning divide among ones with autism spectrum disorders (ASDs) living in underserved areas as compared to urban residents. With the higher than ever prevalence of ASD as per the recent reports of the Centers for Disease Control and Prevention; there is a need for a closer look at the prevailing issues. The trends are reflecting marked underdiagnosis, late diagnosis, lack of evidence-based diagnostic measures and interventions. These factors interplay in worsening the mental health crisis and there is an urgent need for corrective measures to address these highly modifiable problems.

The Bidirectional Social-Cognitive Mechanisms of the Social-Attention Symptoms of Autism

Differences in social attention development begin to be apparent in the 6th to 12th month of development in children with Autism Spectrum Disorder (ASD) and theoretically reflect important elements of its neurodevelopmental endophenotype. This paper examines alternative conceptual views of these early social attention symptoms and hypotheses about the mechanisms involved in their development. One model emphasizes mechanism involved in the spontaneous allocation of attention to faces, or social orienting. Alternatively, another model emphasizes mechanisms involved in the coordination of attention with other people, or joint attention, and the socially bi-directional nature of its development. This model raises the possibility that atypical responses of children to the attention or the gaze of a social partner directed toward themselves may be as important in the development of social attention symptoms as differences in the development of social orienting. Another model holds that symptoms of social attention may be important to early development, but may not impact older individuals with ASD. The alterative model is that the social attention symptoms in infancy (social orienting and joint attention), and social cognitive symptoms in childhood and adulthood share common neurodevelopmental substrates. Therefore, differences in early social attention and later social cognition constitute a developmentally continuous axis of symptom presentation in ASD. However, symptoms in older individuals may be best measured with in vivo measures of efficiency of social attention and social cognition in social interactions rather than the accuracy of response on analog tests used in measures with younger children. Finally, a third model suggests that the social attention symptoms may not truly be a symptom of ASD. Rather, they may be best conceptualized as stemming from differences domain general attention and motivation mechanisms. The alternative argued for here that infant social attention symptoms meet all the criteria of a unique dimension of the phenotype of ASD and the bi-directional phenomena involved in social attention cannot be fully explained in terms of domain general aspects of attention development.

Cultural differences in social communication and interaction: A gap in autism research

Social communication and interaction deficits are a diagnostic criteria of autism and integral to practitioner and researcher conceptualization. Culture is an influential factor in expectations for, and demonstration of, social communication and interaction skills, but there is limited research published in autism journals on this topic. This paucity of autism research examining cultural factors related to social communication and interaction may contribute to known identification disparities for racial and ethnic populations minoritized by systemic factors and research bias. We call for increased commitment from researchers to recruit racially and ethnically minoritized participants, prioritize investigating cultural expectations and perceptions of social communication and interaction, and evaluate measures related to social communication for cultural and linguistic responsivity. LAY SUMMARY: A diagnosis of autism requires the presence of deficits in social communication and interaction. Examples of these behaviors and skills include holding a back-and-forth conversation, the use of nonverbal communicative behaviors (e.g., gestures), and developing and maintaining social relationships. Culture influences the expectations for, and presentation of, these behaviors. However, research on this topic is lacking. Conducting more research related to culture and social communication could help reduce the disparities in autism identification across racially and ethnically minoritized populations.

Adaptation and validation of two autism-related measures of skills and quality of life in Ethiopia

Although most children with autism and other neurodevelopmental disorders live in low- and middle-income countries, assessment tools are lacking in these settings. This study aims to culturally adapt and validate two questionnaires for use in Ethiopia: the Autism Treatment Evaluation Checklist and the Pediatric Quality of Life Inventory™ Family Impact Module. Both questionnaires were adapted to be suitable for administration in low-literate caregivers and translated using the backward translation procedure. The factor structure, reliability and validity were investigated using caregiver-reports on 300 children with neurodevelopmental disorders or physical health conditions. Confirmatory factor analysis of the Pediatric Quality of Life Inventory™ Family Impact Module data indicated an acceptable fit of the hypothesised eight-factor structure. Internal consistency was high for both measures. Test–retest reliability was excellent for the Autism Treatment Evaluation Checklist and moderate to excellent for the Pediatric Quality of Life Inventory™ Family Impact Module. Both questionnaires demonstrated adequate known-group validity, with moderate to very large effect size group differences between case and control groups. The questionnaires correlated moderately with each other. In conclusion, the Ethiopian adaptations of the Autism Treatment Evaluation Checklist and the Pediatric Quality of Life Inventory™ Family Impact Module are valid and reliable tools for use in parents of children with neurodevelopmental disorders including autism. These adapted measures may also be valuable for use in other low-income settings.

The Diagnosis of Autism: From Kanner to DSM-III to DSM-5 and Beyond

In this paper we review the impact of DSM-III and its successors on the field of autism-both in terms of clinical work and research. We summarize the events leading up to the inclusion of autism as a "new" official diagnostic category in DSM-III, the subsequent revisions of the DSM, and the impact of the official recognition of autism on research. We discuss the uses of categorical vs. dimensional approaches and the continuing tensions around broad vs. narrow views of autism. We also note some areas of current controversy and directions for the future.

Social Skills Instruments for Children with Autism Spectrum Disorder: A Critical Interpretive Synthesis

Identifying and critically analyzing the most frequently used social skills psychometric instruments (SSPI) for children with autism spectrum disorder (ASD) can inform future music therapy research and clinical practice. Therefore, the initial purpose of this critical interpretive synthesis was to identify the SSPI most frequently used as dependent measures in the Journal of Autism and Developmental Disorders (JADD) for children with ASD from 2012 to 2018. Results indicated that the Social Responsiveness Scale (n = 35), Autism Diagnostic Observation Schedule (n = 19), and Vineland Adaptive Behavior Scales (n = 15) were the most frequently used instruments. Congruent with critical interpretive synthesis methodology, we then identified the psychometric properties and advantages and disadvantages of the 9 most commonly used instruments. To compare these results with the existing music therapy literature, we also identified nonmusical SSPI used as dependent measures in music therapy research for children with ASD in studies published between 2012 and 2018. In comparing the data sets, music therapy researchers used 5 of the 9 SSPI we identified from our JADD review. Understanding frequently used SSPI has applications for consultation and communication with other professionals as well as how future music therapy research is conducted. Implications for clinical practice, limitations of the study, and suggestions for future research are provided.

A Conceptual Framework for Understanding the Cultural and Contextual Factors on Autism Across the Globe

Autism research is heavily skewed toward western high-income countries. Culturally appropriate screening and diagnostic instruments for autism are lacking in most low- and middle-income settings where the majority of the global autism population lives. To date, a clear overview of the possible cultural and contextual factors that may affect the process of identifying and diagnosing individuals with autism spectrum disorders (ASD) is missing. This study aims to outline these factors by proposing a conceptual framework. A multidisciplinary review approach was applied to inform the development of the conceptual framework, combining a systematic review of the relevant autism research literature with a wider literature search spanning key texts in global mental health, cultural psychiatry, cross-cultural psychology, and intellectual disability research. The resulting conceptual framework considers the identification, help-seeking, and diagnostic process at four interrelated levels: (a) the expression; (b) recognition; (c) interpretation; and (d) reporting of autism symptoms, and describes the cultural and contextual factors associated with each of these levels, including cultural norms of typical and atypical behavior, culture-specific approaches to parenting, mental health literacy, cultural beliefs, attitudes and stigma, as well as the affordability, availability, accessibility, and acceptability of services. This framework, mapping out the cultural and contextual factors that can affect the identification, help-seeking, and diagnosis of ASD may function as a springboard for the development of culturally appropriate autism screening and diagnostic instruments, and inform future cross-cultural autism research directions. The framework also has relevance for clinicians and policy makers aiming to improve support for underserved autism populations worldwide. Autism Res 2020, 13: 1029-1050. © 2020 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: The vast majority of autism research is conducted in western high-income settings. We therefore know relatively little of how culture and context can affect the identification, help-seeking, and diagnosis of autism across the globe. This study synthesizes what is known from the autism research literature and a broader literature and maps out how culture and context may affect (a) the expression, (b) recognition, (c) interpretation, and (d) reporting of autism symptoms.

Awareness and Knowledge Associated with Autism Spectrum Disorders Among University Students in Zambia

Experiences with Autism Spectrum Disorders (ASDs) in sub-Saharan Africa are characterized with lots of uncertainty, including lack of awareness and knowledge. This study examined ASD awareness and knowledge among 488 University of Zambia undergraduate students using an autism awareness and knowledge survey. Study findings on awareness revealed a high proportion of students-seventy-nine percent (79%) had never heard of ASD before the survey. Significant variation in aspects of ASD knowledge was explained by gender, having children, internet use and school of study. Implications of low levels of ASD awareness and knowledge is a call to invest in ASD awareness campaigns through different platforms in order to promote ASD knowledge that translates into increased ASD understanding for better service provision in Zambia.

Caregiver descriptions of joint activity routines with young children with autism spectrum disorder in South Africa

BACKGROUND

Coaching caregivers to deliver Naturalistic Developmental Behavioral Intervention (NDBI) strategies to their young child with autism spectrum disorder (ASD) could help address the provider capacity barrier in sub-Saharan Africa. However, the behavioral and developmental research that underpins NDBIs is overwhelmingly drawn from high resource settings. Therefore, our understanding of joint activity routines, including play and family routines in which NDBI strategies are embedded, may have limited applicability in low resource, culturally diverse environments. Important questions remain on how to adapt NDBIs to be relevant in the family lives in these settings. This study aimed to elicit descriptions of joint activity routines from caregivers of young children with ASD in South Africa, to understand whether an NDBI-informed caregiver coaching could 'fit' within the multicultural, multilingual South African context.

METHODS

Four focus groups were conducted with 22 caregivers of young children with ASD who were recruited from the Western Cape Education Department autism waiting list. Data were analyzed through directed content analysis, which uses inductive methods to determine salient themes and subthemes. The predetermined initial coding classifications were based on joint activity routine categories of object-based play, sensory social routines, and family routines.

RESULTS

Participants' descriptions of caregiver-child interactions aligned with a-priori joint activity routine categories. During object-based play, caregivers engaged in turn-taking, taught developmental skills (for example cognitive, language, and fine motor skills), and participated in child-directed activities. During sensory social routines, caregivers described active, physical play, awareness of child affect, increased child expressive language, and willingness to engage with different play partners. During family routines, caregivers detailed child participation in mealtime and bath time.

CONCLUSIONS

These data suggest that South African caregivers of young children with ASD use joint activity routines to engage their children and teach them new skills, thus suggesting a degree of 'fit' between South African caregiver-child interactions and an NDBI-informed caregiver coaching approach. However, more information on family routines and which caregiver interacts with the young child with ASD during these routines would help tailor these interventions for low-resource African settings.

Providing early detection and early intervention for autism spectrum disorder in South Africa: stakeholder perspectives from the Western Cape province

We set out to examine key stakeholder perspectives on early detection and intervention for autism spectrum disorder (ASD) in South Africa. Early detection and intervention improves child and family outcomes and lessens long-term costs. We focused on stakeholders in the Western Cape province, one of the better-resourced in terms of healthcare. Eight senior management level stakeholders, two each from government's Health, Education, and Social Development, and the non-profit sector were identified using purposive sampling. In-depth interviews focused on key implementation- related themes. The National Integrated Early Childhood Development Policy was the most relevant to early detection and intervention. This policy, however, is not ASD specific. This lack of specificity is in keeping with an emerging theme: ASD was only seen within the context of other developmental disabilities, particularly by Health and Social Development. Specific ASD early detection and intervention may not currently align with Health and Social Development departmental goals. These departments are primarily responsible for identifying and providing services and financial support to young children with ASD. Increased ASD knowledge and local South African statistics on prevalence, burden and associated costs may alter this approach. At this time, ASD early intervention may be more closely aligned with Education department goals.

Autism spectrum disorder in sub-saharan africa: A comprehensive scoping review

Autism spectrum disorder (ASD) is recognized as a global public health concern, yet almost everything we know about ASD comes from high-income countries. Here we performed a scoping review of all research on ASD ever published in sub-Saharan Africa (SSA) in order to identify ASD knowledge gaps in this part of the world. Fifty-three publications met inclusion criteria. Themes included the phenotype, genetics and risk factors for ASD in SSA, screening and diagnosis, professional knowledge, interventions for ASD, parental perceptions, and social-cognitive neuroscience. No epidemiological, early intervention, school-based or adult studies were identified. For each identified theme, we aimed to summarize results and make recommendations to fill the knowledge gaps. The quality of study methodologies was generally not high. Few studies used standardized diagnostic instruments, and intervention studies were typically small-scale. Overall, findings suggest a substantial need for large-scale clinical, training, and research programmes to improve the lives of people who live with ASD in SSA. However, SSA also has the potential to make unique and globally-significant contributions to the etiology and treatments of ASD through implementation, interventional, and comparative genomic science. Autism Res 2017, 10: 723-749. © 2017 International Society for Autism Research, Wiley Periodicals, Inc.

The diagnosis of autism and autism spectrum disorder in low- and middle-income countries: Experience from Jamaica

The administration requirements of the Autism Diagnostic Observation Schedule and the Autism Diagnostic Interview-Revised, widely used in high-income countries, make them less feasible for diagnosis of autism spectrum disorder in low- and middle-income countries. The flexible administration requirements of the Childhood Autism Rating Scale have resulted in its use in both high-income countries and low- and middle-income countries. This study examines the agreement between assessments using the Childhood Autism Rating Scale with those using the Autism Diagnostic Observation Schedule or Autism Diagnostic Observation Schedule, Second Edition and Autism Diagnostic Interview-Revised in Jamaica. Children aged 2-8 years (n = 149) diagnosed with autism by an experienced clinician using the Childhood Autism Rating Scale were re-evaluated using the Autism Diagnostic Observation Schedule and Autism Diagnostic Interview-Revised. The proportion diagnosed with autism spectrum disorder using the Autism Diagnostic Observation Schedule, Autism Diagnostic Observation Schedule, Second Edition, and Autism Diagnostic Interview-Revised was determined and mean domain scores compared using analysis of variance (ANOVA). The mean age was 64.4 (standard deviation = 21.6) months; the male:female ratio was 6:1. The diagnostic agreement of the Childhood Autism Rating Scale with the Autism Diagnostic Observation Schedule and Autism Diagnostic Observation Schedule, Second Edition was 100.0% and 98.0%, respectively. Agreement with the Autism Diagnostic Interview-Revised was 94.6%. Domain scores were highest for children with more severe symptoms (p < 0.01). Despite a high level of agreement of the Childhood Autism Rating Scale with the Autism Diagnostic Observation Schedule, Autism Diagnostic Observation Schedule, Second Edition, and Autism Diagnostic Interview-Revised, the Childhood Autism Rating Scale should be evaluated further with a broader range of autism spectrum disorder symptomatology, and by clinicians with varying experience before recommendation for use in low- and middle-income countries.

A Systematic Review of Research on Autism Spectrum Disorders in Sub-Saharan Africa

The burden of autism spectrum disorders (ASDs) in sub-Saharan Africa (SSA) is not well known. We carried out a systematic review of the literature to identify published work from SSA. We have systematically searched four databases, namely, Medline, PsycINFO, CINAHL, and Child Development & Adolescent Studies, through EBSCO and identified studies from across SSA. Based on predefined inclusion criteria, 47 studies were included in this review. Most of the identified studies (74%) were conducted in only 2 African countries, that is, South Africa and Nigeria. Additionally, most of these studies (83%) were carried out in the last decade. These studies had four major themes: development of measurement tools of ASD in Africa, examining the prevalence of ASD, identifying risk factors and risk markers, and examining psychosocial issues. We identified only a single population level study aimed at documenting the prevalence of ASD and could not identify a single case-control study aimed at examining a comprehensive set of potential risk factors. All intervention studies were based on very small sample sizes. Put together, our findings suggest that current evidence base is too scanty to provide the required information to plan adequately for effective intervention strategies for children with ASD in Africa.