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Akhter S, Shefa J, Quader MA, Talukder K, Hussain AE, Kundu GK, Fatema K, Alam ST, Islam KA, Rahman MS, Rahman MM, Hasan Z, Mannan M. Autism spectrum disorder among 16- to 30-month-old children in Bangladesh: Observational cross-sectional study. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2024; 28:138-148. [PMID: 36373750 DOI: 10.1177/13623613221135297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
LAY ABSTRACT A nationwide survey was done in Bangladesh to assess autism spectrum disorder prevalence in 16- to 30-month-old children at urban-rural distribution and to determine the association with socioeconomic and demographic conditions. A three-stage cluster sampling method was used where districts from all divisions were selected in the first stage, census enumeration areas as blocks of households were selected in the second stage and households (within the blocks) were selected in the third stage. Thereby, it included 38,440 children from 37,982 households (71% rural, 29% urban) aged 16-30 months from 30 districts of eight divisions of Bangladesh. Screening was done with a 'Red Flag' tool and Modified Checklist for Toddlers and a final diagnosis using Diagnostic and Statistical Manual of Mental Disorders, 5th Edition for autism spectrum disorder. Autism spectrum disorder prevalence was 17 per 10,000 young children - in other words, one in 589 young children. Boys were found at higher risk of autism (one in 423 boys; one in 1026 girls). Prevalence of autism spectrum disorder was higher in urban environments than in rural ones - 25/10,000 and 14/10,000, respectively. More autism spectrum disorder children were found in advanced age groups of parents, especially mothers, and in households with a higher wealth quintile. This survey is significant as it covers both urban and rural areas and specifically targets very young children. The involvement of the Bangladesh Bureau of Statistics, as well as support from the entire healthcare system infrastructure, makes this survey more representative on a national level. Its results will form a database to support the development of an effective early intervention programme in Bangladesh. We hope it will prove useful for researchers, clinicians and frontline healthcare workers, and inform the decisions of policymakers and funders in Bangladesh.
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Affiliation(s)
- Shaheen Akhter
- Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh
| | - Jannatara Shefa
- Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh
| | - Mohammad Abdul Quader
- Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh
- University of Birmingham, UK
- University of Dhaka, Bangladesh
| | | | | | | | - Kanij Fatema
- Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh
| | | | | | | | | | - Ziaul Hasan
- A House of Survey Research (SURCH), Bangladesh
| | - Muzharul Mannan
- Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh
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Buffle P, Armijos C, Naranjo A, Gentaz E. Feasibility of an observational procedure to enhance early identification of autism spectrum disorder in paediatric settings: A mixed-methods study on an Ecuadorian sample. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2024; 28:84-94. [PMID: 37313623 PMCID: PMC10771021 DOI: 10.1177/13623613231175587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
LAY ABSTRACT In Ecuador, the low official estimate of the number of persons with autism spectrum disorder suggest that many children are not identified and are not receiving support. Screening tools are short parent-addressed questionnaires used to identify children that may be developing with autism. Their use is recommended, but their application can be perceived as challenging in paediatric routines. Some professionals prefer looking for autism-related behaviours in a child rather than using screening questionnaires. Although a short observation does not replace the use of validated screening questionnaires, tasks to guide the observation of autistic early signs can help professionals decide to screen or refer the family for assessment and early intervention. In this study, we tested observational tasks that could be adapted to the Ecuadorian paediatric contexts.
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Affiliation(s)
- Paulina Buffle
- University of Geneva, Switzerland
- Pontificia Universidad Católica del Ecuador, Ecuador
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Segre G, Cargnelutti C, Bersani C, Njogu W, Roberti E, Campi R, De Vita MV, Morino G, Canevini MP, Bonati M. Early detection of neurodevelopmental disorders in African children living in informal settlements in Nairobi. BMJ Paediatr Open 2023; 7:e002117. [PMID: 37890890 PMCID: PMC10619007 DOI: 10.1136/bmjpo-2023-002117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Children in low-income and middle-income countries (LMICs) are at a substantially increased risk of delayed physical, emotional and sociocognitive outcomes, with consequential neurodevelopmental disorders. Evidence based, cost-effective and culturally appropriate screening tools are recommended for early identification of developmental disorders. METHODS The present study aims to assess the feasibility of early screening for neurodevelopmental disorders in children living in informal settlements in Nairobi, Kenya (Korogocho). The selected tools (ie, the CDC checklist and the Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R)), widely used in high-income countries, are applied in two different populations: one from Kenya (LMIC) and one from Italy, to compare the different scores. RESULTS Of 509 children screened, 8.6% were classified at-risk based on the results of the screening tools. Significant risk factors are history of low birth weight and Apgar score, presence of neurological disorders, malnutrition and/or rickets, younger age of the child and older age of the mother. Caesarean section delivery, first pregnancy and mothers' older age were common risk factors among the Kenyan and the Italian samples. The Italian sample had a significantly greater rate of missed milestones. CONCLUSIONS Our data demonstrate the feasibility of using the CDC and M-CHAT-R tools in informal settlement dwellers. Further studies are needed to explore the opportunity for early diagnosis of developmental disorders in LMICs.
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Affiliation(s)
- Giulia Segre
- Department of Medical Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Cecilia Cargnelutti
- Department of Health Sciences, Università degli Studi di Milano, Milano, Italy
| | - Carlotta Bersani
- Department of Health Sciences, Università degli Studi di Milano, Milano, Italy
| | | | - Elisa Roberti
- Department of Medical Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Rita Campi
- Department of Medical Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | | | | | | | - Maurizio Bonati
- Department of Medical Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
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Sivayokan B, Sivayokan S, Kumanan T, Sathiadas G, Sreeharan N. Establishing a novel partnership model to deploy health services for children with autism in a low-resource setting - experience from Sri Lanka. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 17:100255. [PMID: 37849931 PMCID: PMC10577136 DOI: 10.1016/j.lansea.2023.100255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 06/28/2023] [Accepted: 07/18/2023] [Indexed: 10/19/2023]
Abstract
Sri Lanka is representative of challenges faced by low-income and middle-income countries, including the rise in the prevalence of autism and the lack of sufficient autism-specific services in the state sectors. The experience in establishing a Center to provide services for children with autism in Northern Sri Lanka is described. Funding and resourcing were accessed through an innovative partnership-based public/non-governmental organisation/charity model, where service-based outcomes were the main objectives. This model, incorporating state institutions, local and international charity organisations, and volunteers, devised a bespoke approach to care provision using the available resources under the clinical supervision of a consultant psychiatrist and the administrative purview of the Regional Director of Health Services. The evolution of this Center into a Learning Health System is described, reflecting how a minimalistic partnership approach focused on the integration of existing organisations and services could be a feasible model for the delivery of high-quality healthcare in low-resource settings.
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Affiliation(s)
- Bhavana Sivayokan
- Department of Biochemistry, University of Jaffna, Adiyapatham Road, Kokuvil West, Kokuvil, Sri Lanka
| | | | - Thirunavukarasu Kumanan
- Department of Medicine, University of Jaffna, Adiyapatham Road, Kokuvil West, Kokuvil, Sri Lanka
| | - Gitanjali Sathiadas
- Department of Paediatrics, University of Jaffna, Adiyapatham Road, Kokuvil West, Kokuvil, Sri Lanka
| | - Nadarajah Sreeharan
- Department of Medicine, University of Jaffna, Adiyapatham Road, Kokuvil West, Kokuvil, Sri Lanka
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Okoye C, Obialo-Ibeawuchi CM, Obajeun OA, Sarwar S, Tawfik C, Waleed MS, Wasim AU, Mohamoud I, Afolayan AY, Mbaezue RN. Early Diagnosis of Autism Spectrum Disorder: A Review and Analysis of the Risks and Benefits. Cureus 2023; 15:e43226. [PMID: 37692637 PMCID: PMC10491411 DOI: 10.7759/cureus.43226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/09/2023] [Indexed: 09/12/2023] Open
Abstract
Autism spectrum disorder (ASD) is a neurodevelopmental condition made up of enduring challenges in social communication and interaction and the presence of repetitive and restricted behavior patterns. Early diagnosis of autism is crucial for timely intervention and improved long-term outcomes. This review aims to explore some of its signs and symptoms, look into some diagnostic tools, and analyze the benefits and risks associated with an early diagnosis of autism. The symptoms of ASD vary from child to child, some of which are: avoidance of eye contact, lack of response to names, excessive fear, and lack of interactive and pretend play. Early identification of these symptoms by caregivers and healthcare providers facilitates the need for diagnosis and appropriate interventions. Some screening and diagnostic tools that have been found to help make the diagnosis are the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F), the Social Communication Questionnaire (SCQ), the Parents' Evaluation of Developmental Status (PEDS), and the Childhood Autism Rating Scale (CARS), amongst others. The benefits of early diagnosis include the opportunity for early intervention, which has been shown to enhance developmental outcomes and improve adaptive skills. Early identification allows for the implementation of specialized interventions tailored to the specific needs of individuals with autism, targeting social communication, language development, and behavioral challenges. Furthermore, early diagnosis enables families to access appropriate support services, educational resources, and community programs, facilitating better coping mechanisms, reducing parental stress, and increasing adult independence. However, early diagnosis of autism also entails certain risks. One significant concern is the potential for labeling and stigmatization, which can impact the child's self-esteem and social interactions. There is a risk of overdiagnosis or misdiagnosis, leading to unnecessary interventions and treatments. Additionally, the diagnostic process can be lengthy, complex, and emotionally challenging for families, requiring comprehensive assessments by multidisciplinary teams. This review highlights the importance of a balanced approach when considering the benefits and risks of early diagnosis. Early identification allows for timely interventions that significantly improve developmental outcomes and quality of life for individuals with autism. To mitigate the risks, it is crucial to ensure accurate and reliable diagnostic procedures, support families throughout the process, and promote societal awareness and acceptance. We also highlighted some future directions in the management of autism, including the use of biomarkers and the use of artificial intelligence and learning for diagnosing ASD.
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Affiliation(s)
- Chiugo Okoye
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | | | | | - Sarosh Sarwar
- Medicine and Surgery, Fazaia Medical College, Islamabad, PAK
| | - Christine Tawfik
- Pediatrics and Neonatology, October 6 University, Giza Governorate, EGY
| | | | - Asad Ullah Wasim
- Internal Medicine, Air University, Islamabad, PAK
- Internal Medicine, Fazaia Medical College, Islamabad, PAK
| | - Iman Mohamoud
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Adebola Y Afolayan
- Internal Medicine, University College of Medical Sciences, New York City, USA
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Choueiri R, Garrison WT, Tokatli V. Early Identification of Autism Spectrum Disorder (ASD): Strategies for Use in Local Communities. Indian J Pediatr 2023; 90:377-386. [PMID: 35604589 PMCID: PMC9125962 DOI: 10.1007/s12098-022-04172-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 12/16/2021] [Indexed: 11/29/2022]
Abstract
Early diagnosis of autism spectrum disorder (ASD) is essential for improved outcomes. There is a paucity of data on the prevalence of ASD in low- and middle-income countries (LMIC), but early identification may be further delayed in those communities. In this paper, recent studies on strategies for the early detection of ASD, and the prevalence of ASD in LMIC are reviewed. The limitations that can arise in the early identification of ASD in LMIC communities are discussed, and screening tools and strategies that can be helpful are identified. The goal is to recommend models that are culturally appropriate and scientifically valid, easily integrated within community settings while strengthening community systems and reducing disparities in the early identification of ASD. Starting locally by simplifying and demystifying the ASD identification process and building community connections will inform global researchers and policymakers while making a difference in the lives of the children and families affected by ASD.
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Affiliation(s)
- Roula Choueiri
- Autism Spectrum Center, Department of Neurology, Boston Children's Hospital, 2 Brookline Place, Brookline, MA, 02445, USA.
| | - William T Garrison
- Division of Developmental and Behavioral Pediatrics, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Valerie Tokatli
- Autism Spectrum Center, Department of Neurology, Boston Children's Hospital, 2 Brookline Place, Brookline, MA, 02445, USA.,Division of Developmental and Behavioral Pediatrics, University of Massachusetts Chan Medical School, Worcester, MA, USA
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Sivayokan B, Sivayokan S, Thirunavukarasu K, Sathiadas G, Sivapathamoorthy T. The Characteristics of Autistic Children Attending a Neuro-Developmental Center in Northern Sri Lanka. Cureus 2023; 15:e35970. [PMID: 37041896 PMCID: PMC10082937 DOI: 10.7759/cureus.35970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2023] [Indexed: 03/12/2023] Open
Abstract
INTRODUCTION The global prevalence of autism spectrum disorder is rising. However, the services related to autism are only slowly being developed in poor-resource nations. There is a need to understand the characteristics of autistic children in order to develop individualized, evidence-based interventions. This study aims to analyze the sociodemographic profile and initial clinical presentations of autistic children in the northern part of Sri Lanka and determine the differences in these factors between this region and the rest of the country and the globe. METHODS This retrospective descriptive study in a center for neuro-developmental disorders in Northern Sri Lanka analyzed data extracted from clinical records of 123 autistic children using a predesigned data extraction form. Descriptive analyses and chi-square tests were performed using RStudio. RESULTS Among the 123 children, 71.5% were males. The mean age of diagnosis was 3.4 years. Most children (69.9%) had mild to moderate symptoms of autism. At the time of presentation, all children had speech-related complaints, while behavioral issues, poor social interaction, and sensory issues were reported in 91.9%, 96.7%, and 78% respectively. Social stigma was found to be the prime challenge faced by caregivers. CONCLUSION The findings show that speech and language-related problems are universal among autistic children in this region, while behavioral issues, poor social interaction, and sensory issues are highly prevalent. Further, this study highlights the need for community awareness through the primary healthcare system to address delays in detecting red-flag signs of autism by parents and seeking professional help.
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Sobieski M, Sobieska A, Sekułowicz M, Bujnowska-Fedak MM. Tools for early screening of autism spectrum disorders in primary health care – a scoping review. BMC PRIMARY CARE 2022; 23:46. [PMID: 35291950 PMCID: PMC8925080 DOI: 10.1186/s12875-022-01645-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 02/21/2022] [Indexed: 12/30/2022]
Abstract
Abstract
Background
Autism spectrum disorder (ASD) is a neurodevelopmental disorder that manifests itself in early childhood. Early diagnosis of these disorders allows for the initiation of early therapy, which is crucial for the child's further functioning in society.
Objectives
This review aims to gather and present the existing ASD screening tools that can be used in primary care and adapted to different countries conditions linguistically and culturally.
Eligibility criteria
We searched for English-language publications on ASD screening tools for children aged 0–3 years suitable for use in primary care (i.e. free, requiring no additional training or qualifications).
Sources of evidence
Four databases were explored to find English studies on ASD screening tools intended for the rapid assessment of children aged 0–3.
Charting methods
The information sought (specific features of the questionnaires relevant to primary health care workers, psychometric and diagnostic values of a given cultural adaptation of screening tools, and the linguistic and cultural changes made) were extracted and collected to create profiles of these tools.
Results
We found 81 studies which met inclusion criteria and underwent full data extraction. Three additional data sources were included. These allowed to create 75 profiles of adaptations for 26 different screening tools and collect data on their psychometric values and characteristic features.
Conclusions
The results of our study indicate the availability of several diagnostic tools for early ASD screening in primary care setting concordant culturally and linguistically with a given population. They could be an effective method of accelerating the diagnostic process and starting personalized therapy faster. However, most tools have significant limitations – some are only available for research purposes, while others do not have scientific evidence to prove their effectiveness.
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Kaku SM, Sibeoni J, Basheer S, Chang JPC, Dahanayake DMA, Irarrazaval M, Lachman JM, Mapayi BM, Mejia A, Orri M, Jui-Goh T, Uddin MS, Vallance I. Global child and adolescent mental health perspectives: bringing change locally, while thinking globally. Child Adolesc Psychiatry Ment Health 2022; 16:82. [PMID: 36345001 PMCID: PMC9640779 DOI: 10.1186/s13034-022-00512-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/03/2022] [Indexed: 11/09/2022] Open
Abstract
Child and adolescent mental health (CAMH) are a global priority. Different countries across the globe face unique challenges in CAMH services that are specific to them. However, there are multiple issues that are also similar across countries. These issues have been presented in this commentary from the lens of early career CAMH professionals who are alumni of the Donald J Cohen Fellowship program of the IACAPAP. We also present recommendations that can be implemented locally, namely, how promoting mental health and development of children and adolescents can result in better awareness and interventions, the need to improve quality of care and access to care, use of technology to advance research and practices in CAMH, and how investing in research can secure and support CAMH professionals and benefit children and adolescents across the globe. As we continue to navigate significant uncertainty due to dynamic circumstances globally, bolstering collaborations by "bringing change locally, while thinking globally" are invaluable to advancing global CAMH research, clinical service provision, and advancement of the field.
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Affiliation(s)
- Sowmyashree Mayur Kaku
- Centre for Advanced Research and Excellence in Autism and Developmental Disorders (CAREADD), St. John's Medical College Hospital and St. John's Research Institute, Bangalore, India.
| | - Jordan Sibeoni
- Service Universitaire de Psychiatrie de l’Adolescent, Argenteuil Hopital Centre, Cedex, France ,grid.508487.60000 0004 7885 7602ECSTRRA Team, UMR-1153, Université de Paris, Inserm, Paris, France
| | - Salah Basheer
- grid.513003.4Department of Psychiatry, Iqraa International Hospital and Research Centre, Kozhikode, Kerala India
| | - Jane Pei-Chen Chang
- grid.411508.90000 0004 0572 9415Child Psychiatry Division, Department of Psychiatry, College of Medicine, China Medical University Hospital, Taichung, Taiwan
| | | | - Matias Irarrazaval
- Millenium Institute for Research in Depression and Personality, Santiago, Chile
| | - Jamie M Lachman
- grid.4991.50000 0004 1936 8948Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | - Boladale Moyosore Mapayi
- grid.10824.3f0000 0001 2183 9444Mental health, Obafemi Awolowo University, Ile Ife, Osun State Nigeria
| | - Anilena Mejia
- grid.5379.80000000121662407Division of Psychology of Mental Health, The University of Manchester, Manchester, UK
| | - Massimiliano Orri
- grid.412078.80000 0001 2353 5268Department of Psychiatry, McGill Group for Suicide Studies, Douglas Mental Health University Institute, McGill University, Montreal, QC Canada
| | - Tze Jui-Goh
- grid.414752.10000 0004 0469 9592Department of Developmental Psychiatry, Institute of Mental Health, Buangkok Green, Singapore
| | - Md Saleh Uddin
- grid.440425.30000 0004 1798 0746Jeffrey Cheah School of Medicine and Health Sciences, Monash University (Malaysia campus), Bandar Sunway, Malaysia
| | - Inge Vallance
- grid.4991.50000 0004 1936 8948Department of Social Policy and Intervention, University of Oxford, Oxford, UK
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Salari N, Rasoulpoor S, Rasoulpoor S, Shohaimi S, Jafarpour S, Abdoli N, Khaledi-Paveh B, Mohammadi M. The global prevalence of autism spectrum disorder: a comprehensive systematic review and meta-analysis. Ital J Pediatr 2022; 48:112. [PMID: 35804408 PMCID: PMC9270782 DOI: 10.1186/s13052-022-01310-w] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 06/24/2022] [Indexed: 01/02/2023] Open
Abstract
Background Autism spectrum disorder (ASD) is one of the serious developmental disorders that is usually diagnosed below the age of three years. Although the severity of the disease’s symptoms varies from patient to patient, the ability to communicate with others is affected in all forms of ASD. This study aimed to determine the prevalence of ASD in high-risk groups by continent. Methods The present study was conducted by systematic review and meta-analysis from 2008 to July 2021. Databases such as Science Direct, PubMed, Scopus, SID, Magiran, Web of Science (WoS), and Google Scholar from 2008 to July 2021 were searched to find related studies. Data were analysed using Comprehensive Meta-Analysis software (Version 2). Results A total of 74 studies with 30,212,757 participants were included in this study. The prevalence of ASD in the world was 0.6% (95% confidence interval: 0.4–1%). Subgroup analyses indicated that the prevalence of ASD in Asia, America, Europe, Africa and Australia was 0.4% (95% CI: 0.1–1), 1% (95% CI: 0.8–1.1), 0.5% (95% CI: 0.2–1), 1% (95% CI: 0.3–3.1), 1.7% (95% CI: 0.5–6.1) respectively. Conclusion ASD imposes a heavy health burden on communities around the world. Early detection of ASD can reduce the incidence of developmental disorders and improve patients’ communication skills. Therefore, health policymakers need to be aware of the prevalence and increasing trend of ASD to implement appropriate planning and interventions to reduce its consequences.
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Affiliation(s)
- Nader Salari
- Department of Biostatistics, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shabnam Rasoulpoor
- Department of Psychiatric Nursing, School of Nursing and Midwifery, Urmia University of Medical Sciences, Urmia, Iran
| | - Shna Rasoulpoor
- Student research committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shamarina Shohaimi
- Department of Biology, Faculty of Science, University Putra Malaysia, Serdang, Selangor, Malaysia
| | - Sima Jafarpour
- Department of Genetics and Molecular Biology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nasrin Abdoli
- Department of Psychiatry, Substance Abuse Prevention Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Behnam Khaledi-Paveh
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Masoud Mohammadi
- Cellular and Molecular Research Center, Gerash University of Medical Sciences, Gerash, Iran.
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Naithani L, Goldie C, Kaur A, Butter C, Lakhera S, Leadbitter K, Divan G. Early Autism Intervention Components Deliverable by Non-specialists in Low- and Middle-Income Countries: A Scoping Review. Front Psychiatry 2022; 13:914750. [PMID: 35845443 PMCID: PMC9277121 DOI: 10.3389/fpsyt.2022.914750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction The past decade has seen key advances in early intervention for autistic children in high-income countries, with most evidence based on specialist delivery of interventions. The care gap seen in low- and middle-income countries (LMIC) remains close to 100%. A key challenge in addressing this care gap concerns the paucity of specialists available to deliver services. Task-sharing provides an important potential solution; there is a need to identify interventions that are suitable for scaled-up delivery through task-sharing in low-resourced settings. We aimed to conduct a scoping review to identify studies which reported autism intervention delivered by non-specialists within LMIC and, using established frameworks, specify intervention components with evidence of successful non-specialist delivery. Methods A scoping literature search, conducted within four databases, generated 2,535 articles. Duplicates were removed, followed by screening of titles and abstracts, with 10% double-rated for reliability. 50 full text articles were then screened independently by two raters. Articles were included if studies: (a) were conducted in LMIC; (b) included samples of autistic children (age < 10); (c) evaluated psycho-social interventions delivered by non-specialists; (d) reported child outcomes; and (e) were peer-reviewed full-texts in English. Two established frameworks - @Practicewise and NDBI-Fi framework - were then used to ascertain the commonly delivered components of these interventions. Results Two studies met the inclusion criteria. Both studies evaluated parent-mediated interventions delivered by non-specialists in South Asia. Through the two frameworks, we identified elements and techniques that had been delivered successfully by non-specialists. Conclusion There is evidence from two acceptability and feasibility trials that non-specialists can be trained to deliver some intervention elements and techniques within parent-mediated interventions, with good fidelity and acceptability and evidence of effectiveness. The review points up the lack of a widespread evidence base in this area and need for further research in low resourced settings, including well-powered trials and mechanistic analyses to identify active ingredients. A focus on the pre-requisites for non-specialist delivery is critical to reduce inequity and provide universal health coverage within resource-constrained health systems.
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Affiliation(s)
| | - Caitlin Goldie
- Division of Neuroscience and Experimental Psychology, The University of Manchester, Manchester, United Kingdom
| | | | - Charlotte Butter
- Division of Neuroscience and Experimental Psychology, The University of Manchester, Manchester, United Kingdom
| | | | - Kathy Leadbitter
- Division of Neuroscience and Experimental Psychology, The University of Manchester, Manchester, United Kingdom
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Peiris H, Wickramarachchi DC, Samarasinghe P, Vance P, Dahanayake D, Kulasekara V, Nadeeshani M. Diagnosing autism in low-income countries: Clinical record-based analysis in Sri Lanka. Autism Res 2022; 15:1358-1367. [PMID: 35707912 DOI: 10.1002/aur.2765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 05/20/2022] [Indexed: 11/08/2022]
Abstract
Use of autism diagnosing standards in low-income countries (LICs) are restricted due to the high price and unavailability of trained health professionals. Furthermore, these standards are heavily skewed towards developed countries and LICs are underrepresented. Due to such constraints, many LICs use their own ways of assessing autism. This is the first retrospective study to analyze such local practices in Sri Lanka. The study was conducted at Ward 19B of Lady Ridgeway Hospital (LRH) using the clinical forms filled for diagnosing ASD. In this study, 356 records were analyzed, from which 79.5% were boys and the median age was 33 months. For each child, the clinical form together with the Childhood Autism Rating Scale (CARS) value were recorded. In this study, a Clinically Derived Autism Score (CDAS) is obtained from the clinical forms. Scatter plot and Pearson product moment correlation coefficient were used to benchmark CDAS with CARS, and it was found CDAS to be positively and moderately correlated with CARS. In identifying the significant variables, a logistic regression model was built based on clinically observed data and it evidenced that "Eye Contact," "Interaction with Others," "Pointing," "Flapping of Hands," "Request for Needs," "Rotate Wheels," and "Line up Things" variables as the most significant variables in diagnosing autism. Based on these significant predictors, the classification tree was built. The pruned tree depicts a set of rules, which could be used in similar clinical environments to screen for autism. LAY SUMMARY: Screening and diagnosing autism in low-income countries such as Sri Lanka has always been a challenge due to limited resources and not being able to afford global standards. Due to these challenges, locally developed clinical forms have been used. This study is the first to analyze a clinical record set for autism in Sri Lanka to benchmark the local clinic form with a global standard. Furthermore, this study identifies the most significant diagnostic symptoms for children and based on these significant features, a simple set of IF-THEN rules are derived which could be used for screening autism in a similar clinical environment by health officials in the absence of consultants.
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Affiliation(s)
- Hashan Peiris
- Department of Statistics, University of Sri Jayewardenepura, Nugegoda, Sri Lanka
| | | | - Pradeepa Samarasinghe
- Faculty of Computing, Sri Lanka Institute of Information Technology, Malabe, Sri Lanka
| | - Philip Vance
- Intelligent Systems Research Centre, University of Ulster, Londonderry, UK
| | | | - Veerandi Kulasekara
- Faculty of Computing, Sri Lanka Institute of Information Technology, Malabe, Sri Lanka
| | - Madhuka Nadeeshani
- Faculty of Computing, Sri Lanka Institute of Information Technology, Malabe, Sri Lanka
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13
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Shanmugarajah K, Rosenbaum P, Di Rezze B. Exploring Autism, Culture, and Immigrant Experiences: Lessons from Sri Lankan Tamil Mothers. Can J Occup Ther 2022; 89:170-179. [PMID: 35257593 PMCID: PMC9136378 DOI: 10.1177/00084174221085433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Canada is home to a mosaic of cultures with immigrant communities from a wide range of countries, but there are significant variations in how autism spectrum disorder (ASD) may be understood across different immigrant groups, including Sri Lankan Tamils. Such gaps in knowledge may present challenges for immigrant families that are trying to access appropriate care for their child, including occupational therapy services. Purpose: This descriptive qualitative study aimed to better understand the experiences of immigrant Sri Lankan Tamil parents of children diagnosed with ASD in Southern Ontario, Canada. Method: Interviews were analyzed using an in-depth content analysis. Findings: Results demonstrated parents' perceived supports and barriers towards ASD intervention planning, and indicated that parents were generally satisfied by the level of cultural competence in current ASD systems. However, families may still experience significant immigrant-related barriers that are not fully addressed. Implications: Recommendations to improve cultural awareness among occupational therapists utilizing ASD interventions are suggested.
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Affiliation(s)
- Kajaani Shanmugarajah
- Kajaani Shanmugarajah, School of Rehabilitation Sciences, McMaster University, Hamilton, ON L8S 1C, Canada.
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14
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Shrestha R, Dissanayake C, Barbaro J. Implementing and evaluating Social Attention and Communication Surveillance (SACS) to prospectively identify autism in very young children in Nepal. RESEARCH IN DEVELOPMENTAL DISABILITIES 2021; 115:104013. [PMID: 34144316 DOI: 10.1016/j.ridd.2021.104013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 05/31/2021] [Accepted: 06/06/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Although Autism Spectrum Disorder (ASD) can be identified as early as 12 months and diagnosed by 24 months, the mean age of diagnosis of ASD in Nepal is ∼58 months, with children missing the opportunity for early intervention. AIMS This study implemented and evaluated a Nepali version of the Social Attention and Communication Surveillance (SACS-N) tool, to identify children between 11-30 months who are at "high likelihood" of ASD in a local community in Nepal. METHODS Sixty Female Community Health Volunteers (FCHVs) were trained to monitor and identify the early signs of ASD using SACS-N. RESULTS Overall, 1926 children were monitored with the SACS-N, with 11 children (0.57 %) referred for further assessments at 11-15 months (n = 4), 16-21 months (n = 4), and 22-30 months (n = 3). Of these children, 10 children had a developmental disorder, including ASD and Global Developmental Delay; no information was available on one child who migrated. Hence, the positive predictive value (PPV) of SACS-N for all developmental disorders was 100 %. Of seven children attending a gold standard diagnostic/ developmental assessment, three had ASD (43 % PPV for ASD). The estimated prevalence of ASD ranged between 0.16 % to 0.26 %. CONCLUSION Community-based developmental monitoring of ASD and other developmental delays by FCHVs is a feasible, cost-effective and sustainable approach to promoting early identification of ASD in Nepal. Further training and awareness of autism is needed for more accurate and increased referral rates using the SACS-N, including regular supervision of FCHVs.
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Affiliation(s)
- Rena Shrestha
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Kingsbury Drive, Bundoora, Melbourne, VIC, 3086, Australia
| | - Cheryl Dissanayake
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Kingsbury Drive, Bundoora, Melbourne, VIC, 3086, Australia
| | - Josephine Barbaro
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Kingsbury Drive, Bundoora, Melbourne, VIC, 3086, Australia.
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15
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Chakraborty S, Bhatia T, Sharma V, Antony N, Das D, Sahu S, Sharma S, Shriharsh V, Brar JS, Iyengar S, Singh R, Nimgaonkar VL, Deshpande SN. Psychometric properties of a screening tool for autism in the community-The Indian Autism Screening Questionnaire (IASQ). PLoS One 2021; 16:e0249970. [PMID: 33886585 PMCID: PMC8062015 DOI: 10.1371/journal.pone.0249970] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/29/2021] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Currently available screening questionnaires for Autism spectrum disorders were tested in developed countries, but many require additional training and many are unsuitable for older individuals, thus reducing their utility in lower/ middle- income countries. We aimed to derive a simplified questionnaire that could be used to screen persons in India. METHODS We have previously validated Indian Scale for Assessment of Autism (ISAA), that is now mandated for disability assessment by the Government of India. This detailed tool requires intensive training and it is time consuming. It was used to derive a new screening questionnaire: 1) items most frequently scored as positive by participants with autism in original ISAA validation study were modified for binary scoring following expert review. 2) In a new sample, clinically diagnosed individuals with/without autism were administered the screening tool and ISAA following written informed consent. Its psychometric properties were determined. RESULTS A 10-item scale named Indian Autism Screening Questionnaire (IASQ) was prepared in Hindi and English. Thereafter 145 parents/caregivers of participants (autism, n = 90, other psychiatric disorders, n = 55) (ages 3-18), were administered IASQ and ISAA (parents/caregivers plus observation) by separate interviewers, blind to each other and to diagnosis. At a cutoff of 1, sensitivity was 99%, specificity 62%, Positive Predictive Value 81%, and Negative Predictive Value 95%. Test-retest reliability was r = 0.767 (CI = 0.62-0.86) and interrater reliability- Krippendorff"s-alpha was 0.872. The area under Receiver Operating Characteristic Curve (ROC) was 95%. There was a significant difference on IASQ-scores between participants with and without a clinical diagnosis of Autism (t = 14.57, p<0.0001). DISCUSSION The IASQ is a simple, easy to use screening tool with satisfactory reliability and validity, that can be administered to caregivers in 15 minutes and provides information about DSM 5 criteria for autism. It may be applicable outside India, following additional adaptation, for community-based studies.
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Affiliation(s)
- Satabdi Chakraborty
- Department of Psychiatric Social Work, Centre of Excellence in Mental Health, Atal Bihari Vajpayee Institute of Medical Sciences-Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Triptish Bhatia
- Indo-US Projects and NCU-ICMR, Department of Psychiatry and De-addiction, Centre of Excellence in Mental Health, Atal Bihari Vajpayee Institute of Medical Sciences-Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Vikas Sharma
- NCU-ICMR, Department of Psychiatry and De-addiction, Centre of Excellence in Mental Health Atal Bihari Vajpayee Institute of Medical Sciences-Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Nitin Antony
- Development and Validation of the Screening Version of ISAA, ICMR Project’, Dept. of Psychiatric Social Work, Centre of Excellence in Mental Health, Atal Bihari Vajpayee Institute of Medical Sciences-Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Dhritishree Das
- Development and Validation of the Screening Version of ISAA, ICMR Project’, Dept. of Psychiatric Social Work, Centre of Excellence in Mental Health, Atal Bihari Vajpayee Institute of Medical Sciences-Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Sushree Sahu
- Dyslexia Assessment for Languages of India, MoST Project, Department of Psychiatry and De-addiction, Centre of Excellence in Mental Health, Atal Bihari Vajpayee Institute of Medical Sciences-Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Satyam Sharma
- Department of Clinical Psychology, Centre of Excellence in Mental Health, Atal Bihari Vajpayee Institute of Medical Sciences-Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Vandana Shriharsh
- Department of Clinical Psychology, Centre of Excellence in Mental Health, Atal Bihari Vajpayee Institute of Medical Sciences-Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Jaspreet S. Brar
- Department of Psychiatry and Consultant, Community Care Behavioral Health Organization, Western Psychiatric Hospital of UPMC, Pittsburgh, Pennsylvania, United States of America
| | - Satish Iyengar
- Department of Statistics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Ravinder Singh
- Non Communicable Diseases, Indian Council for Medical Research, New Delhi, India
| | - Vishwajit L. Nimgaonkar
- Department of Psychiatry and Department of Human Genetics, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, Pennsylvania, United States of America
| | - Smita Neelkanth Deshpande
- Department of Psychiatry, Centre of Excellence in Mental Health, Atal Bihari Vajpayee Institute of Medical Sciences-Dr. Ram Manohar Lohia Hospital, New Delhi, India
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16
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Bong G, Kim SY, Song DY, Kim JH, Hong Y, Yoon NH, Sunwoo H, Jang JY, Oh M, Kim JM, Lee KS, Jung S, Choi CW, Ryu JS, Yoo HJ. Short caregiver interview and play observation for early screening of autism spectrum disorder: Behavior development screening for toddlers (BeDevel). Autism Res 2021; 14:1472-1483. [PMID: 33792202 DOI: 10.1002/aur.2510] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/22/2020] [Accepted: 03/15/2021] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Guiyoung Bong
- Department of Psychiatry, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - So Yoon Kim
- Department in Teacher Education, Duksung Women's University, Seoul, South Korea
| | - Da-Yea Song
- Department of Psychiatry, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jeong-Heun Kim
- Department of Psychology, University of Alabama Birmingham, Birmingham, Alabama, USA
| | | | - Nan-He Yoon
- Department of Health Administration, Hanyang Cyber University, South Korea
| | - Hyunjung Sunwoo
- Department of Clinical Psychology, Junior mind clinic Didim, Hwaseong, South Korea
| | - Jeong Yun Jang
- Department of Psychiatry, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Miae Oh
- Department of Psychiatry, Kyung Hee University Hospital, Seoul, South Korea
| | - Jong Myeong Kim
- Department of Psychiatry, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Kyung-Sook Lee
- Department of Rehabilitation, Hanshin University, Kyeonggi, South Korea.,Sewon Infant Child Development Center, Seoul, South Korea
| | - Seokjin Jung
- Sewon Infant Child Development Center, Seoul, South Korea
| | - Chang Won Choi
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Ju Seok Ryu
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Hee Jeong Yoo
- Department of Psychiatry, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Psychiatry, Seoul National University College of Medicine, Seoul, South Korea
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17
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Shrestha R, Barbaro J, Dissanayake C. Changes in Knowledge on the Signs of Autism in Young Children (11-30 Months) among Female Community Health Volunteers in Nepal. J Autism Dev Disord 2021; 52:219-239. [PMID: 33709379 DOI: 10.1007/s10803-021-04944-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2021] [Indexed: 10/21/2022]
Abstract
Nepalese Female Community Health Volunteers' (FCHVs) knowledge on social attention and communication development and the early signs of autism was evaluated before, immediately after, and 12-months following training on typical and atypical social-communicative development in infants/toddlers, early signs of autism, and monitoring of key "markers" of autism using Social Attention and Communication Surveillance. FCHVs (N = 60) significantly improved their knowledge about autism and reported increased perceived confidence in monitoring and referring young children at high likelihood of autism following training, which was sustained one year later. FCHVs also reported a positive impact of training on their work. These findings indicate the effectiveness of training in improving FCHVs' knowledge and perceived confidence to monitor and refer young children at high likelihood of autism.
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Affiliation(s)
- Rena Shrestha
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Kingsbury Drive, Bundoora, Melbourne, VIC, 3086, Australia
| | - Josephine Barbaro
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Kingsbury Drive, Bundoora, Melbourne, VIC, 3086, Australia
| | - Cheryl Dissanayake
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Kingsbury Drive, Bundoora, Melbourne, VIC, 3086, Australia.
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18
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Scarlytt de Oliveira Holanda N, Delgado Oliveira da Costa L, Suelen Santos Sampaio S, Gomes da Fonseca Filho G, Batista Bezerra R, Guerra Azevedo I, Alves Pereira S. Screening for Autism Spectrum Disorder in Premature Subjects Hospitalized in a Neonatal Intensive Care Unit. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17207675. [PMID: 33096698 PMCID: PMC7589640 DOI: 10.3390/ijerph17207675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/13/2020] [Accepted: 10/16/2020] [Indexed: 02/06/2023]
Abstract
Considering that the average age for diagnosis of autism spectrum disorder (ASD) is 4–5 years, testing screening methods for ASD risk in early infancy is a public health priority. This study aims to identify the risks for development of ASD in children born prematurely and hospitalized in a neonatal intensive care unit (NICU) and explore the association with pre-, peri- and postnatal factors. Methods: The children’s families were contacted by telephone when their child was between 18 and 24 months of age, to apply the Modified Checklist for Autism in Toddlers (M-CHAT). The sample consisted of 40 children (57.5% boys). M-CHAT screening revealed that 50% of the sample showed early signs of ASD. Although the frequency of delayed development was higher in boys, this difference was not statistically significant between the sexes (p = 0.11). Assessment of the association between perinatal conditions and early signs of autism in children hospitalized in an NICU exhibited no correlation between the factors analyzed (birth weight and type of delivery). The findings indicate a high risk of ASD in premature children, demonstrating no associations with gestational and neonatal variables or the hospitalization conditions of the NICUs investigated.
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Affiliation(s)
- Norrara Scarlytt de Oliveira Holanda
- Physiotherapy Course, Universidade Federal do Rio Grande do Norte (UFRN), Natal 59078-970, Rio Grande do Norte, Brazil; (N.S.d.O.H.); (L.D.O.d.C.); (S.A.P.)
| | - Lidiane Delgado Oliveira da Costa
- Physiotherapy Course, Universidade Federal do Rio Grande do Norte (UFRN), Natal 59078-970, Rio Grande do Norte, Brazil; (N.S.d.O.H.); (L.D.O.d.C.); (S.A.P.)
| | - Sabrinne Suelen Santos Sampaio
- Post-graduation Program of Physiotherapy, Universidade Federal do Rio Grande do Norte (UFRN), Natal 59078-970, Rio Grande do Norte, Brazil; (S.S.S.S.); (G.G.d.F.F.)
| | - Gentil Gomes da Fonseca Filho
- Post-graduation Program of Physiotherapy, Universidade Federal do Rio Grande do Norte (UFRN), Natal 59078-970, Rio Grande do Norte, Brazil; (S.S.S.S.); (G.G.d.F.F.)
- Instituto Santos Dumont, Macaíba 59280-000, Rio Grande do Norte, Brazil
| | - Ruth Batista Bezerra
- Rehabilitation Sciences Graduate Program, Faculty of Health Sciences of Trairi/ Universidade Federal do Rio Grande do Norte (FACISA/UFRN), Santa Cruz 59200-000, Rio Grande do Norte, Brazil;
| | - Ingrid Guerra Azevedo
- Department of Therapeutic Processes, Universidad Católica de Temuco, Temuco 4813302, La Araucania, Chile
- Correspondence:
| | - Silvana Alves Pereira
- Physiotherapy Course, Universidade Federal do Rio Grande do Norte (UFRN), Natal 59078-970, Rio Grande do Norte, Brazil; (N.S.d.O.H.); (L.D.O.d.C.); (S.A.P.)
- Rehabilitation Sciences Graduate Program, Faculty of Health Sciences of Trairi/ Universidade Federal do Rio Grande do Norte (FACISA/UFRN), Santa Cruz 59200-000, Rio Grande do Norte, Brazil;
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19
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Rohanachandra YM, Prathapan S, Amarabandu HGI. The knowledge of Public Health Midwives on Autism Spectrum Disorder in two selected districts of the Western Province of Sri Lanka. Asian J Psychiatr 2020; 52:102094. [PMID: 32334398 DOI: 10.1016/j.ajp.2020.102094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/27/2020] [Accepted: 04/07/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Early interventions are important for improving outcome in autism. However, the diagnosis of autism is often delayed for 3-4 years, which leads to missed opportunities to initiate early intensive behavioural interventions, thus jeopardizing its prognosis. The lack of knowledge among healthcare workers about the features of autism is postulated to be the main reason for this delay. METHODOLOGY A descriptive cross-sectional study was carried out among the PHMs in the Colombo and Kalutara districts of the Western Province, Sri Lanka. A specifically designed self-administered questionnaire was used to obtain information about the socio-demographic details. The knowledge about the signs and symptoms and common comorbidities of ASD were assessed using the "Knowledge about Childhood Autism among Health Workers (KCAHW) Questionnaire". RESULTS Out of 406 participants, 56.9 % (n = 231) were from the Colombo District. The mean knowledge of the participants on the "Knowledge about Childhood Autism among Health Workers (KCAHW) Questionnaire" was 13.23/19 (SD = 2.647). The knowledge was significantly higher in those who had participated in training programmes on autism (p < 0.01) and in those who have had contact with a child with autism (p < 0.05). Of the participants, 17.2 % (n = 70) believed that autism could be completely cured. 43.6 % and 42.2 % believed that poor attention from parents and parental conflicts during pregnancy and early childhood caused autism in children respectively. CONCLUSION The knowledge of PHMs on autism is inadequate, with regard to the comorbidities, aetiology and treatment options. In service programmes are useful in improving the knowledge of PHMs on autism.
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Affiliation(s)
| | - Shamini Prathapan
- Department of Community Medicine, University of Sri Jayewardenepura, Sri Soratha Mawatha, Nugegoda, Sri Lanka.
| | - H G Irosha Amarabandu
- Department of Psychiatry, University of Sri Jayewardenepura, Sri Soratha Mawatha, Nugegoda, Sri Lanka.
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20
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Mahmood HM, Aldhalaan HM, Alshammari TK, Alqasem MA, Alshammari MA, Albekairi NA, AlSharari SD. The Role of Nicotinic Receptors in the Attenuation of Autism-Related Behaviors in a Murine BTBR T + tf/J Autistic Model. Autism Res 2020; 13:1311-1334. [PMID: 32691528 DOI: 10.1002/aur.2342] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 04/28/2020] [Accepted: 05/31/2020] [Indexed: 12/15/2022]
Abstract
Nicotinic receptors are distributed throughout the central and peripheral nervous system. Postmortem studies have reported that some nicotinic receptor subtypes are altered in the brains of autistic people. Recent studies have demonstrated the importance of nicotinic acetylcholine receptors (nAChRs) in the autistic behavior of BTBR T + tf/J mouse model of autism. This study was undertaken to examine the behavioral effects of targeted nAChRs using pharmacological ligands, including nicotine and mecamylamine in BTBR T + tf/J and C57BL/6J mice in a panel of behavioral tests relating to autism. These behavioral tests included the three-chamber social interaction, self-grooming, marble burying, locomotor activity, and rotarod test. We examined the effect of various oral doses of nicotine (50, 100, and 400 mcg/mL; po) over a period of 2 weeks in BTBR T + tf/J mouse model. The results indicated that the chronic administration of nicotine modulated sociability and repetitive behavior in BTBR T + tf/J mice while no effects observed in C57BL/6J mice. Furthermore, the nonselective nAChR antagonist, mecamylamine, reversed nicotine effects on sociability and increased repetitive behaviors in BTBR T + tf/J mice. Overall, the findings indicate that the pharmacological modulation of nicotinic receptors is involved in modulating core behavioral phenotypes in the BTBR T + tf/J mouse model. LAY SUMMARY: The involvement of brain nicotinic neurotransmission system plays a crucial role in regulating autism-related behavioral features. In addition, the brain of the autistic-like mouse model has a low acetylcholine level. Here, we report that nicotine, at certain doses, improved sociability and reduced repetitive behaviors in a mouse model of autism, implicating the potential therapeutic values of a pharmacological intervention targeting nicotinic receptors for autism therapy. Autism Res 2020, 13: 1311-1334. © 2020 International Society for Autism Research, Wiley Periodicals, Inc.
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Affiliation(s)
- Hafiz M Mahmood
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Hesham M Aldhalaan
- Department of Neuroscience, Center for Autism Research, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Tahani K Alshammari
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mashael A Alqasem
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Musaad A Alshammari
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Norah A Albekairi
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Shakir D AlSharari
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.,Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia, USA
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21
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de Leeuw A, Happé F, Hoekstra RA. A Conceptual Framework for Understanding the Cultural and Contextual Factors on Autism Across the Globe. Autism Res 2020; 13:1029-1050. [PMID: 32083402 PMCID: PMC7614360 DOI: 10.1002/aur.2276] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 01/02/2020] [Accepted: 01/24/2020] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Anne de Leeuw
- Amsterdam University Medical Centre, location VUmc, Amsterdam, The Netherlands
| | - Francesca Happé
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK
| | - Rosa A Hoekstra
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK
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Wingfield B, Miller S, Yogarajah P, Kerr D, Gardiner B, Seneviratne S, Samarasinghe P, Coleman S. A predictive model for paediatric autism screening. Health Informatics J 2020; 26:2538-2553. [PMID: 32191164 DOI: 10.1177/1460458219887823] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Autism spectrum disorder is an umbrella term for a group of neurodevelopmental disorders that is associated with impairments to social interaction, communication, and behaviour. Typically, autism spectrum disorder is first detected with a screening tool (e.g. modified checklist for autism in toddlers). However, the interpretation of autism spectrum disorder behavioural symptoms varies across cultures: the sensitivity of modified checklist for autism in toddlers is as low as 25 per cent in Sri Lanka. A culturally sensitive screening tool called pictorial autism assessment schedule has overcome this problem. Low- and middle-income countries have a shortage of mental health specialists, which is a key barrier for obtaining an early autism spectrum disorder diagnosis. Early identification of autism spectrum disorder enables intervention before atypical patterns of behaviour and brain function become established. This article proposes a culturally sensitive autism spectrum disorder screening mobile application. The proposed application embeds an intelligent machine learning model and uses a clinically validated symptom checklist to monitor and detect autism spectrum disorder in low- and middle-income countries for the first time. Machine learning models were trained on clinical pictorial autism assessment schedule data and their predictive performance was evaluated, which demonstrated that the random forest was the optimal classifier (area under the receiver operating characteristic (0.98)) for embedding into the mobile screening tool. In addition, feature selection demonstrated that many pictorial autism assessment schedule questions are redundant and can be removed to optimise the screening process.
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Qiu S, Lu Y, Li Y, Shi J, Cui H, Gu Y, Li Y, Zhong W, Zhu X, Liu Y, Cheng Y, Liu Y, Qiao Y. Prevalence of autism spectrum disorder in Asia: A systematic review and meta-analysis. Psychiatry Res 2020; 284:112679. [PMID: 31735373 DOI: 10.1016/j.psychres.2019.112679] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 11/04/2019] [Accepted: 11/04/2019] [Indexed: 12/18/2022]
Abstract
There has been an increased prevalence of the diagnosis of Autism Spectrum Disorder (ASD) globally during the last decade. An updated and overall estimate of ASD prevalence in Asia would assist health professionals to develop relevant public health strategies. We performed a systematic review by searching English databases (Medline, Embase, Web of Science, and Cochran Library) from inception date to August 6, 2018. Subgroup, sensitivity, and meta-regression analyses were performed to address heterogeneity. Publication bias was evaluated using Egger's test. A total of 2,195,497 subjects in Asia from 12 eligible studies were included in this meta-analysis. The pooled estimate of ASD prevalence among the included subjects was 0.36% (95% CI: 0.16-0.79%). The pooled ASD prevalence in males (0.45%, 95% CI: 0.19-1.04%) was higher than that in females (0.18%, 95% CI: 0.079-0.49%). ASD prevalence in East Asia, South Asia, and West Asia was 0.51% (95% CI: 0.06-4.22%), 0.31% (95% CI: 0.14-0.65%), and 0.35% (95% CI: 0.07-1.80%) respectively. The prevalence of ASD is increasing in Asia. Universal and standardized diagnostic processes for ASD should be adopted for the prevention and control programs of ASD in future.
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Affiliation(s)
- Shuang Qiu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin 130021, China
| | - Yuping Lu
- Centers for Disease Control and Prevention, Changchun, Jilin 130033, China
| | - Yan Li
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin 130021, China
| | - Jikang Shi
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin 130021, China
| | - Heran Cui
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin 130021, China
| | - Yulu Gu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin 130021, China
| | - Yong Li
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin 130021, China
| | - Weijing Zhong
- Chunguang Rehabilitation Hospital, Changchun, Jilin 130012, China
| | - Xiaojuan Zhu
- The Key Laboratory of Molecular Epigenetics of Ministry of Education, Institute of Cytology and Genetics, Northeast Normal University, Changchun, Jilin 130021, China
| | - Yunkai Liu
- Department of Cardiovascular Diseases, the First Hospital of Jilin University, Changchun, Jilin 130021, China; Key laboratory for Cardiovascular Mechanism of Traditional Chinese Medicine, Changchun, Jilin 130021, China; Institute of Translational Medicine, the First Hospital of Jilin University, Changchun, Jilin 130021, China
| | - Yi Cheng
- Department of Cardiovascular Diseases, the First Hospital of Jilin University, Changchun, Jilin 130021, China; Key laboratory for Cardiovascular Mechanism of Traditional Chinese Medicine, Changchun, Jilin 130021, China; Institute of Translational Medicine, the First Hospital of Jilin University, Changchun, Jilin 130021, China
| | - Yawen Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin 130021, China
| | - Yichun Qiao
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin 130021, China.
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Patterns of psychiatric morbidity among children and adolescents presenting to an outpatient child and adolescent mental health service (CAMHS) in a Teaching Hospital in Colombo, Sri Lanka-Challenges and implications for service development. Asian J Psychiatr 2019; 46:44-48. [PMID: 31590009 DOI: 10.1016/j.ajp.2019.09.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 09/17/2019] [Accepted: 09/21/2019] [Indexed: 11/22/2022]
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Chandradasa M, Champika L. Subspecialisation in Postgraduate Psychiatry and Implications for a Resource-Limited Specialised Child and Adolescent Mental Health Service. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2019; 43:135-139. [PMID: 29671220 DOI: 10.1007/s40596-018-0920-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 04/04/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Miyuru Chandradasa
- University of Kelaniya, Kelaniya, Sri Lanka.
- Monash University, Melbourne, Australia.
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26
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Marlow M, Servili C, Tomlinson M. A review of screening tools for the identification of autism spectrum disorders and developmental delay in infants and young children: recommendations for use in low- and middle-income countries. Autism Res 2019; 12:176-199. [DOI: 10.1002/aur.2033] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 06/08/2018] [Accepted: 06/27/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Marguerite Marlow
- Department of Psychology; Stellenbosch University; Stellenbosch South Africa
| | - Chiara Servili
- Department of Mental Health and Substance Abuse; World Health Organization; Geneva Switzerland
| | - Mark Tomlinson
- Department of Psychology; Stellenbosch University; Stellenbosch South Africa
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Tsai JM, Lu L, Jeng SF, Cheong PL, Gau SSF, Huang YH, Wu YT. Validation of the modified checklist for autism in toddlers, revised with follow-up in Taiwanese toddlers. RESEARCH IN DEVELOPMENTAL DISABILITIES 2019; 85:205-216. [PMID: 30579261 DOI: 10.1016/j.ridd.2018.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 11/17/2018] [Accepted: 11/24/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND The Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) is a two-stage screening scale for determining the risk of autism spectrum disorder (ASD) in toddlers. However, the validity of the M-CHAT-R/F for Asian populations has not yet been established. AIMS This study investigated the psychometric properties of the M-CHAT-R/F, Taiwan version (M-CHAT-R/F-T), among low- and high-risk Taiwanese toddlers aged 16-30 months. The associations among M-CHAT-R/F-T scores, developmental performance at 24 and 30 months, and ASD diagnosis prediction at 36 months were examined. METHODS AND PROCEDURES A two-stage screening of the M-CHAT-R/F-T was applied to a study sample comprising 25 toddlers with ASD and 71 atypically developing (ATD) and 221 typically developing (TD) toddlers. OUTCOMES AND RESULTS The M-CHAT-R/F-T exhibited acceptable internal consistency and test-retest reliability. The M-CHAT-R/F-T scores were significantly correlated with several syndrome scores of the Child Behavior Checklist for Ages 1.5-5 and were significantly higher among toddlers with ASD than among ATD or TD toddlers. Furthermore, M-CHAT-R/F-T scores were negatively correlated with developmental scores in the Mullen Scales of Early Learning at 24 and 30 months. Moreover, the screening exhibited acceptable predictive validity (sensitivity = 0.86; specificity = 0.96) for ASD diagnosis at 36 months. CONCLUSIONS AND IMPLICATIONS The findings indicate that the M-CHAT-R/F-T is a valid and reliable tool for the developmental screening of low- and high-risk Taiwanese toddlers in community and clinical settings.
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Affiliation(s)
- Jung-Mei Tsai
- School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Lu Lu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Suh-Fang Jeng
- School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Pou-Leng Cheong
- Department of Pediatrics, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Susan Shur-Fen Gau
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Hsun Huang
- Department of Child and Adolescent Psychiatry, Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan
| | - Yen-Tzu Wu
- School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan.
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Carruthers S, Kinnaird E, Rudra A, Smith P, Allison C, Auyeung B, Chakrabarti B, Wakabayashi A, Baron-Cohen S, Bakolis I, Hoekstra RA. A cross-cultural study of autistic traits across India, Japan and the UK. Mol Autism 2018; 9:52. [PMID: 30410715 PMCID: PMC6217788 DOI: 10.1186/s13229-018-0235-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 09/21/2018] [Indexed: 11/10/2022] Open
Abstract
Background There is a global need for brief screening instruments that can identify key indicators for autism to support frontline professionals in their referral decision-making. Although a universal set of conditions, there may be subtle differences in expression, identification and reporting of autistic traits across cultures. In order to assess the potential for any measure for cross-cultural screening use, it is important to understand the relative performance of such measures in different cultures. Our study aimed to identify the items on the Autism Spectrum Quotient (AQ)-Child that are most predictive of an autism diagnosis among children aged 4-9 years across samples from India, Japan and the UK. Methods We analysed parent-reported AQ-Child data from India (73 children with an autism diagnosis and 81 neurotypical children), Japan (116 children with autism and 190 neurotypical children) and the UK (488 children with autism and 532 neurotypical children). None of the children had a reported existing diagnosis of intellectual disability. Discrimination indices (DI) and positive predictive values (PPV) were used to identify the most predictive items in each country. Results Sixteen items in the Indian sample, 15 items in the Japanese sample and 28 items in the UK sample demonstrated excellent discriminatory power (DI ≥ 0.5 and PPV ≥ 0.7), suggesting these items represent the strongest indicators for predicting an autism diagnosis within these countries. Across cultures, good performing items were largely overlapping, with five key indicator items appearing across all three countries (can easily keep track of several different people's conversations, enjoys social chit-chat, knows how to tell if someone listening to him/her is getting bored, good at social chit-chat, finds it difficult to work out people's intentions). Four items indicated potential cultural differences. One item was highly discriminative in Japan but poorly discriminative (DI < 0.3) in the UK and India, and a further item had excellent discrimination properties in the UK but poorly discriminated in the Indian and Japanese samples. Two additional items were highly discriminative in two cultures but poor in the third. Conclusions Cross-cultural overlap in the items most predictive of an autism diagnosis supports the general notion of universality in autistic traits whilst also highlighting that there can be cultural differences associated with certain autistic traits. These findings have the potential to inform the development of a brief global screening tool for autism. Further development and evaluation work is needed.
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Affiliation(s)
- Sophie Carruthers
- 1Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Emma Kinnaird
- 1Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Alokananda Rudra
- 2Psychology, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Paula Smith
- 3Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Carrie Allison
- 3Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Bonnie Auyeung
- 4Department of Psychology, School of Philosophy, Psychology and Language Sciences, University of Edinburgh, Edinburgh, UK
| | - Bhismadev Chakrabarti
- 5Centre for Autism, School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | | | - Simon Baron-Cohen
- 3Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Ioannis Bakolis
- 1Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Rosa A Hoekstra
- 1Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Heys M, Gibbons F, Haworth E, Medeiros E, Tumbahangphe KM, Wickenden M, Shrestha M, Costello A, Manandhar D, Pellicano E. The Estimated Prevalence of Autism in School-Aged Children Living in Rural Nepal Using a Population-Based Screening Tool. J Autism Dev Disord 2018; 48:3483-3498. [PMID: 29855757 PMCID: PMC6153945 DOI: 10.1007/s10803-018-3610-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Few data exist on the prevalence of autism in low-income countries. We translated, adapted and tested the acceptability of a Nepali-language version of a screening tool for autism (Autism Quotient-10). Using this tool, we estimated autism prevalence in 4098 rural Nepali children aged 9-13 years. Fourteen children scored > 6 out of 10, indicative of elevated autistic symptomatology, of which 13 also screened positive for disability. If the AQ-10 screening tool is as sensitive and specific in the Nepali population as it is in the UK, this would yield an estimated true prevalence of 3 in 1000 (95% confidence interval 2-5 in 1000). Future research is required to validate this tool through in-depth assessments of high-scoring children.
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Affiliation(s)
- Michelle Heys
- UCL Institute for Global Health, University College London, London, UK.
- Great Ormond Street Institute of Child Global Health, University College London, London, UK.
| | | | - Ed Haworth
- Great Ormond Street Institute of Child Global Health, University College London, London, UK
| | - Emilie Medeiros
- UCL Institute for Global Health, University College London, London, UK
| | | | - Mary Wickenden
- UCL Institute for Global Health, University College London, London, UK
| | - Merina Shrestha
- Autism Care Society, Kathmandu, Nepal
- Tribhuvan University Teaching Hospital, Department of Child Health, Kathmandu, Nepal
| | - Anthony Costello
- UCL Institute for Global Health, University College London, London, UK
- Department of Maternal, Newborn, Child and Adolescent Health (MCA), World Health Organization, Geneva, Switzerland
| | | | - Elizabeth Pellicano
- Centre for Research in Autism and Education (CRAE), UCL Institute of Education, University College London, London, UK
- Department of Educational Studies, Macquarie University, Sydney, Australia
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Systematic review: cultural adaptation and feasibility of screening for autism in non-English speaking countries. Int J Ment Health Syst 2018; 12:22. [PMID: 29760771 PMCID: PMC5941599 DOI: 10.1186/s13033-018-0200-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 04/12/2018] [Indexed: 01/30/2023] Open
Abstract
Background Screening children for autism has gained wider acceptance within clinical practice, and early intervention has improved outcomes. Increasingly, adapting an existing screening instrument is a common, fast method to create a usable screening tool, especially for countries with limited resources and/or expertise. However, concerns have been raised regarding adaptation adequacy and the feasibility of screening across cultural groups. This study systematically examined the levels of cultural adaptation and feasibility aspects considered when screening for autism in non-English speaking countries to build upon the sparse knowledge that exists on this topic in the literature. Methods Nineteen studies, obtained from five electronic databases, were examined. PRISMA guidance was used for this review. The Ecological Validity Framework model, and Bowen Recommendations for Feasibility were adopted to extract relevant data, which was synthesised narratively. Results Cultural adaptation within the included studies mostly involved language translation with little information offered to enable conclusions on how the processes were guided and maintained. Few cultural adjustments involved modifying screening methods; clarifying difficult concepts and changing instrument content were employed to address the core values, competence, beliefs, and norms of the adapted culture. However, less attention was given to adapt the screening goals within the context of cultural values, and customs or to consider interactional match between the clients and assessors. The review also highlighted an acceptable level of practicality to screen for autism but did not encourage integrating autism screening within routine practice or beyond the study context for different cultures. Conclusion Concurring with previous literature, we agree that knowledge on cultural adaptation for autism screening instruments is limited and not sufficiently documented to establish adaptation levels (process and/or contents), and prove adequacy. However, this review provides an infrastructure to improve future adaptation processes. Integrating autism screening as routine medical practice is not encouraged and warrants further feasibility studies to minimize wasted resources and improve screening effectiveness in various health care systems.
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Bitta M, Kariuki SM, Abubakar A, Newton CR. Burden of neurodevelopmental disorders in low and middle-income countries: A systematic review and meta-analysis. Wellcome Open Res 2018. [DOI: 10.12688/wellcomeopenres.13540.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Childhood mortality from infectious diseases has declined steadily in many low and middle-income (LAMIC) countries, with increased recognition of non-communicable diseases such as neurodevelopmental disorders (NDD). There is lack of data on the burden of NDD in LAMIC. Current global burden of these disorders are largely extrapolated from high-income countries. The main objective of the study was therefore to estimate the burden of NDD in LAMIC using meta-analytic techniques. Methods: We systematically searched online databases including Medline/PubMed, PsychoInfo, and Embase for studies that reported prevalence or incidence of NDD. Pooled prevalence, heterogeneity and risk factors for prevalence were determined using meta-analytic techniques. Results: We identified 4,802 records, but only 51 studies met the eligibility criteria. Most studies were from Asia-Pacific (52.2%) and most were on neurological disorders (63.1%). The median pooled prevalence per 1,000 for any NDD was 7.6 (95%CI 7.5-7.7), being 11.3 (11.7-12.0) for neurological disorders and 3.2 (95%CI 3.1-3.3) for mental conditions such as attention-deficit hyperactivity disorder (ADHD). The type of NDD was significantly associated with the greatest prevalence ratio in the multivariable model (PR=2.6(95%CI 0.6-11.6) (P>0.05). Incidence was only reported for epilepsy (mean of 447.7 (95%CI 415.3-481.9) per 100,000). Perinatal complications were the commonest risk factor for NDD. Conclusion: The burden of NDD in LAMIC is considerable. Epidemiological surveys on NDD should screen all types of NDD to provide reliable estimates.
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Bitta M, Kariuki SM, Abubakar A, Newton CRJC. Burden of neurodevelopmental disorders in low and middle-income countries: A systematic review and meta-analysis. Wellcome Open Res 2017. [PMID: 29881784 DOI: 10.12688/wellcomeopenres.13540.1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Childhood mortality from infectious diseases has declined steadily in many low and middle-income (LAMIC) countries, with increased recognition of non-communicable diseases such as neurodevelopmental disorders (NDD). There is lack of data on the burden of NDD in LAMIC. Current global burden of these disorders are largely extrapolated from high-income countries. The main objective of the study was therefore to estimate the burden of NDD in LAMIC using meta-analytic techniques. Methods: We systematically searched online databases including Medline/PubMed, PsychoInfo, and Embase for studies that reported prevalence or incidence of NDD. Pooled prevalence, heterogeneity and risk factors for prevalence were determined using meta-analytic techniques. Results: We identified 4,802 records, but only 51 studies met the eligibility criteria. Most studies were from Asia (52.2%) and most were on neurological disorders (63.1%). The median pooled prevalence per 1,000 for all NDD was 7.6 (95%CI 7.5-7.7), being 11.3 (11.7-12.0) for neurological disorders and 3.2 (95%CI 3.1-3.3) for mental conditions such as attention-deficit hyperactivity disorder (ADHD). The type of NDD was significantly associated with the greatest prevalence ratio in the multivariable model (PR=2.6(95%CI 0.6-11.6) (P>0.05). Incidence was only reported for epilepsy (mean of 447.7 (95%CI 415.3-481.9) per 100,000). Perinatal complications were the commonest risk factor for NDD. Conclusion: The burden of NDD in LAMIC is considerable. Epidemiological surveys on NDD should screen all types of NDD to provide reliable estimates.
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Affiliation(s)
- Mary Bitta
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research , (Coast), Kilifi, Kenya
| | - Symon M Kariuki
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research , (Coast), Kilifi, Kenya
| | - Amina Abubakar
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research , (Coast), Kilifi, Kenya.,Department of Public Health, Pwani University, Kilifi, Kenya.,Department of Psychiatry, University of Oxford, Oxford, UK
| | - Charles R J C Newton
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research , (Coast), Kilifi, Kenya.,Department of Public Health, Pwani University, Kilifi, Kenya.,Department of Psychiatry, University of Oxford, Oxford, UK
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Hossain MD, Ahmed HU, Jalal Uddin MM, Chowdhury WA, Iqbal MS, Kabir RI, Chowdhury IA, Aftab A, Datta PG, Rabbani G, Hossain SW, Sarker M. Autism Spectrum disorders (ASD) in South Asia: a systematic review. BMC Psychiatry 2017; 17:281. [PMID: 28826398 PMCID: PMC5563911 DOI: 10.1186/s12888-017-1440-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/23/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Autism spectrum disorders (ASD) are a group of complex neurodevelopmental disorders. The prevalence of ASD in many South Asian countries is still unknown. The aim of this study was to systematically review available epidemiological studies of ASD in this region to identify gaps in our current knowledge. METHODS We searched, collected and evaluated articles published between January 1962 and July 2016 which reported the prevalence of ASD in eight South Asian countries. The search was conducted in line with the PRISMA guidelines. RESULTS We identified six articles from Bangladesh, India, and Sri Lanka which met our predefined inclusion criteria. The reported prevalence of ASD in South Asia ranged from 0.09% in India to 1.07% in Sri Lanka that indicates up to one in 93 children have ASD in this region. Alarmingly high prevalence (3%) was reported in Dhaka city. Study sample sizes ranged from 374 in Sri Lanka to 18,480 in India. The age range varied between 1 and 30 years. No studies were found which reported the prevalence of ASD in Pakistan, Nepal, Bhutan, Maldives and Afghanistan. This review identifies methodological differences in case definition, screening instruments and diagnostic criteria among reported three countries which make it very difficult to compare the studies. CONCLUSIONS Our study is an attempt at understanding the scale of the problem and scarcity of information regarding ASD in the South Asia. This study will contribute to the evidence base needed to design further research and make policy decisions on addressing this issue in this region. Knowing the prevalence of ASD in South Asia is vital to ensure the effective allocation of resources and services.
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Affiliation(s)
- Mohammad Didar Hossain
- James P. Grant School of Public Health, BRAC University, 68 Shahid Tajuddin Ahmed Sharani, Dhaka, Bangladesh
- Foundation for Advancement of Innovations in Technology and Health (faith), Bangladesh, Iqbal Road, Mohammadpur, Dhaka, 1207 Bangladesh
| | - Helal Uddin Ahmed
- National Institute of Mental Health, Bangladesh (NIMH,B), Sher-E-Bangla Nagar, Dhaka, 1207 Bangladesh
| | - M M Jalal Uddin
- National Institute of Neurosciences & Hospital, Bangladesh (NINS,B), Sher-E-Bangla Nagar, Dhaka, 1207 Bangladesh
| | - Waziul Alam Chowdhury
- Bangladesh Association of psychiatrists, National Institute of Mental Health, Bangladesh (NIMH,B), Sher-E-Bangla Nagar, Dhaka, 1207 Bangladesh
| | - Mohd S Iqbal
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212 Bangladesh
| | - Razin Iqbal Kabir
- James P. Grant School of Public Health, BRAC University, 68 Shahid Tajuddin Ahmed Sharani, Dhaka, Bangladesh
| | - Imran Ahmed Chowdhury
- James P. Grant School of Public Health, BRAC University, 68 Shahid Tajuddin Ahmed Sharani, Dhaka, Bangladesh
| | - Afzal Aftab
- James P. Grant School of Public Health, BRAC University, 68 Shahid Tajuddin Ahmed Sharani, Dhaka, Bangladesh
- Foundation for Advancement of Innovations in Technology and Health (faith), Bangladesh, Iqbal Road, Mohammadpur, Dhaka, 1207 Bangladesh
| | - Pran Gopal Datta
- Shuchona Foundation, Bangabandhu Memorial Trust Building, 2nd floor, 8 Rd No 11, Dhaka, 1209 Bangladesh
- Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, 1000 Bangladesh
| | - Golam Rabbani
- Neuro-Developmental Disability Protection Trust, Department of Social Services Building, Agargaon, Sher-e-Bangla Nagar, Dhaka, 1207 Bangladesh
| | - Saima Wazed Hossain
- Shuchona Foundation, Bangabandhu Memorial Trust Building, 2nd floor, 8 Rd No 11, Dhaka, 1209 Bangladesh
- Expert Advisory Panel on Mental Health; Global Autism Advocate, World Health Organization, Dhaka, Bangladesh
- National Advisory Committee for Autism and Neurodevelopmental Disorders, Ministry of Health and Family Welfare, Government of Bangladesh, Dhaka, Bangladesh
| | - Malabika Sarker
- James P. Grant School of Public Health, BRAC University, 68 Shahid Tajuddin Ahmed Sharani, Dhaka, Bangladesh
- Institute of Public Health, University of Heidelberg, Im Neuenheimer Feld, Heidelberg, 69120 Germany
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Blake JM, Rubenstein E, Tsai PC, Rahman H, Rieth SR, Ali H, Lee LC. Lessons learned while developing, adapting and implementing a pilot parent-mediated behavioural intervention for children with autism spectrum disorder in rural Bangladesh. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2017; 21:611-621. [PMID: 28366007 DOI: 10.1177/1362361316683890] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Low- and middle-income countries often have limited resources, underdeveloped health systems and scarce knowledge of autism spectrum disorder. The objectives of this preliminary study were to develop and adapt intervention materials and to train a native clinician to implement a community-based parent-mediated behavioural intervention in rural Gaibandha, Bangladesh. Intervention materials to support parents' use of behavioural strategies were developed and refined by US behavioural intervention experts and Bangladesh field experts. Study investigators trained a native child psychologist in developmental milestones and behavioural intervention techniques. The native clinician delivered a 1-day group education session attended by 10 families of children aged 7-9 years with autism spectrum disorder, followed by two one-on-one training sessions with each family to train and practice individualized strategies for targeted challenging behaviours. Preliminary qualitative results indicate the importance of materials that are culturally appropriate and at an adequate literacy level. All families expressed strong desires to have learned the behavioural strategies when their child was younger and vocalized their need for further support and tools to help their children. This study is a preliminary step to creating sustainable and low-cost autism spectrum disorder interventions in rural Bangladesh, and possibly for families in regions with similar cultural and socioeconomic status backgrounds.
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Affiliation(s)
- Jasmine M Blake
- 1 Johns Hopkins Bloomberg School of Public Health, USA.,2 University of Maryland School of Medicine, USA
| | | | | | | | - Sarah R Rieth
- 5 San Diego State University, USA.,6 Child and Adolescent Services Research Center, USA
| | - Hasmot Ali
- 1 Johns Hopkins Bloomberg School of Public Health, USA.,4 Johns Hopkins University - Bangladesh, Bangladesh
| | - Li-Ching Lee
- 1 Johns Hopkins Bloomberg School of Public Health, USA
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Seize MDM, Borsa JC. Instrumentos para Rastreamento de Sinais Precoces do Autismo: Revisão Sistemática. PSICO-USF 2017. [DOI: 10.1590/1413-82712017220114] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo O rastreamento dos sinais precoces do autismo é crucial para um diagnóstico também precoce, viabilizando uma intervenção efetiva que possibilite a melhora no desenvolvimento e na qualidade de vida do indivíduo com autismo. O objetivo deste estudo foi identificar os instrumentos disponíveis para rastreamento dos sinais do autismo em crianças com até 36 meses de idade. Para tanto, foi conduzida uma revisão de artigos publicados entre 2004 e 2015 nas bases de dados eletrônicas SciELO, PubMed, PsycINFO e Lilacs. Foram encontrados 11 instrumentos em 34 artigos analisados, sendo que apenas um instrumento foi traduzido para o português, o que indica uma escassez desses instrumentos no Brasil. Considerando a relevância da identificação e do diagnóstico precoce do autismo para a melhoria da qualidade de vida do sujeito, acredita-se que é essencial que estudos sobre instrumentos para rastreamento precoce sejam conduzidos no país.
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Stewart LA, Lee LC. Screening for autism spectrum disorder in low- and middle-income countries: A systematic review. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2017; 21:527-539. [DOI: 10.1177/1362361316677025] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This review contributes to the growing body of global autism spectrum disorder literature by examining the use of screening instruments in low- and middle-income countries with respect to study design and methodology, instrument adaptation and performance, and collaboration with community stakeholders in research. A systematic review was conducted to understand the use of autism spectrum disorder screening instruments in low- and middle-income countries from studies published between 1992 and 2015. This review found that 18 different autism spectrum disorder screeners have been used in low- and middle-income settings with wide ranges of sensitivities and specificities. The significant variation in study design, screening methodology, and population characteristics limits the ability of this review to make robust recommendations about optimal screening tool selection. Clinical-based screening for autism spectrum disorder was the most widely reported method. However, community-based screening was shown to be an effective method for identifying autism spectrum disorder in communities with limited clinical resources. Only a few studies included in this review reported cultural adaptation of screening tools and collaboration with local stakeholders. Establishing guidelines for the reporting of cultural adaptation and community collaboration procedures as well as screening instrument psychometrics and screening methodology will enable the field to develop best practices for autism spectrum disorder screening in low-resource settings.
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Affiliation(s)
| | - Li-Ching Lee
- Johns Hopkins Bloomberg School of Public Health, USA
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Perera H, Jeewandara KC, Seneviratne S, Guruge C. Culturally adapted pictorial screening tool for autism spectrum disorder: A new approach. World J Clin Pediatr 2017; 6:45-51. [PMID: 28224095 PMCID: PMC5296629 DOI: 10.5409/wjcp.v6.i1.45] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/22/2016] [Accepted: 11/17/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the performance of a newly designed, culturally adapted screening tool for autism spectrum disorder (ASD).
METHODS Items for the screening tool were modeled from already documented checklists and diagnostic criteria for ASD. Each item in text was paired with a photograph that illustrated the written content, which was in the 2 main local languages. The final product had 21 items and was named the pictorial autism assessment schedule (PAAS). Performance of PAAS was tested on a clinical sample of 18-48 mo old children, diagnosis naïve, presenting with developmental deficits. Mothers completed PAAS checklist. Based on clinical diagnosis, which was taken as the gold standard, children were later grouped into ASD (Group 1) and non-ASD developmental disorders (Group 2). Mothers of a control sample of typically developing children also completed PAAS (Group 3).
RESULTS A total of 105 children (Group 1-45, Group 2-30, Group 3-30) participated in the study. Mean age of Group 1 and Group 2 were 36 and 40 mo respectively. Majority were male in all 3 groups. Performance of PAAS in discriminating between ASD and non-ASD developmental disorders was sensitivity 88.8%, specificity 60.7%, positive predictive value (PPV) 78.4%, negative predictive value (NPV) 77.2%, likelihood ratio (LR+) 2.26, and LR- 0.18. Performance of PAAS in discriminating between ASD and typical development was sensitivity 88.0%, specificity 93.3%, PPV 95.2%, NPV 84.0%, LR+ 13.3 and LR- 0.12. The results indicated that that a positive result from PAAS was 2.26 times more likely to be found in a child with ASD than in a child with non-ASD developmental disorder. A positive result from PAAS was 13.3 times more likely to be found in a child with ASD than in a child with typical development.
CONCLUSION PAAS is an effective tool in screening for ASD. Further study is indicated to evaluate the feasibility of using this instrument for community screening for ASD.
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Bitta M, Kariuki SM, Abubakar A, Newton CRJC. Burden of neurodevelopmental disorders in low and middle-income countries: A systematic review and meta-analysis. Wellcome Open Res 2017; 2:121. [PMID: 29881784 PMCID: PMC5964629 DOI: 10.12688/wellcomeopenres.13540.3] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2017] [Indexed: 12/23/2022] Open
Abstract
Background: Childhood mortality from infectious diseases has declined steadily in many low and middle-income (LAMIC) countries, with increased recognition of non-communicable diseases such as neurodevelopmental disorders (NDD). There is lack of data on the burden of NDD in LAMIC. Current global burden of these disorders are largely extrapolated from high-income countries. The main objective of the study was therefore to estimate the burden of NDD in LAMIC using meta-analytic techniques. Methods: We systematically searched online databases including Medline/PubMed, PsychoInfo, and Embase for studies that reported prevalence or incidence of NDD. Pooled prevalence, heterogeneity and risk factors for prevalence were determined using meta-analytic techniques. Results: We identified 4,802 records, but only 51 studies met the eligibility criteria. Most studies were from Asia (52.2%) and most were on neurological disorders (63.1%). The median pooled prevalence per 1,000 for all NDD was 7.6 (95%CI 7.5-7.7), being 11.3 (11.7-12.0) for neurological disorders and 3.2 (95%CI 3.1-3.3) for mental conditions such as attention-deficit hyperactivity disorder (ADHD). The type of NDD was significantly associated with the greatest prevalence ratio in the multivariable model (PR=2.6(95%CI 0.6-11.6) (P>0.05). Incidence was only reported for epilepsy (mean of 447.7 (95%CI 415.3-481.9) per 100,000). Perinatal complications were the commonest risk factor for NDD. Conclusion: The burden of NDD in LAMIC is considerable. Epidemiological surveys on NDD should screen all types of NDD to provide reliable estimates.
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Affiliation(s)
- Mary Bitta
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research , (Coast), Kilifi, Kenya
| | - Symon M Kariuki
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research , (Coast), Kilifi, Kenya
| | - Amina Abubakar
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research , (Coast), Kilifi, Kenya.,Department of Public Health, Pwani University, Kilifi, Kenya.,Department of Psychiatry, University of Oxford, Oxford, UK
| | - Charles R J C Newton
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research , (Coast), Kilifi, Kenya.,Department of Public Health, Pwani University, Kilifi, Kenya.,Department of Psychiatry, University of Oxford, Oxford, UK
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Brennan L, Fein D, Como A, Rathwell IC, Chen CM. Use of the Modified Checklist for Autism, Revised with Follow Up-Albanian to Screen for ASD in Albania. J Autism Dev Disord 2016; 46:3392-3407. [PMID: 27491423 PMCID: PMC5074853 DOI: 10.1007/s10803-016-2875-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The Modified Checklist for Autism in Toddlers Revised-Albanian screener (M-CHAT-R-A) was used to screen 2594 toddlers, aged 16-30 months, at well-child visits. Two hundred fifty-three (9.75 %) screened positive; follow up on failed items were conducted by phone with 127 (50 %); the remainder were lost to follow-up. Twenty-six toddlers (21 %) continued to screen positive; 19 received full evaluations, which assessed for ASD with the Autism Diagnostic Observation Schedule and developmental delays with the Parents Assessment of Developmental Status-Developmental Milestones. All evaluated children had significant delays; 17 of the 19 met criteria for Autism/ASD. Removal of three items improved performance. Although Albania and the US are quite different in culture and language, key features of ASD appeared very similar.
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Affiliation(s)
- Laura Brennan
- Dept. of Psychology, University of Connecticut, Storrs, CT
| | - Deborah Fein
- Depts. of Psychology and Pediatrics, University of Connecticut, Storrs, CT, tel: 413-519-1324, fax: 860-486-2760
| | - Ariel Como
- Tirana Medical University, Medical Director, “Domenick Scaglione” Regional Center for Autism, Tirana, Albania
| | | | - Chi-Ming Chen
- Department of Psychology, University of Connecticut, Storrs, CT
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Outcome of Home-Based Early Intervention for Autism in Sri Lanka: Follow-Up of a Cohort and Comparison with a Nonintervention Group. BIOMED RESEARCH INTERNATIONAL 2016; 2016:3284087. [PMID: 27419131 PMCID: PMC4933858 DOI: 10.1155/2016/3284087] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 03/15/2016] [Accepted: 05/24/2016] [Indexed: 11/30/2022]
Abstract
This paper presents the outcome of a home-based autism intervention program (HBAIP) in 18- to 40-month-old children newly diagnosed and treatment naïve. Intervention was exclusively implemented at home. Outcome was measured at 3 months and 6 months after intervention and compared with a group of newly diagnosed children with autism who were >40 months at intake but had not received any autism specific clinical management. Aim was also to estimate whether natural development would contribute to gain in skills and compare with the effect of intervention. Five selected parameters of behavior representing social interaction and social communication were used to assess outcome. Results showed a statistically significant improvement between preintervention and postintervention in all the measured parameters. The effect size was large when compared to preintervention and gains were indicated by changes in mean scores and p values within a narrow confidence interval. Highest gains were in first 3 months of postintervention which continued up to 6 months. Although the comparison group was more advanced in the measured skills at intake, they were significantly below the level reached by experimental group at 3 months and 6 months after intervention. This study was registered in the Sri Lanka Clinical Trials Registry (SLCTR/2009/011).
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Skonieczna-Żydecka K, Gorzkowska I, Pierzak-Sominka J, Adler G. The Prevalence of Autism Spectrum Disorders in West Pomeranian and Pomeranian Regions of Poland. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2016; 30:283-289. [PMID: 26771078 DOI: 10.1111/jar.12238] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND The prevalence of autism spectrum disorders (ASD) varies worldwide from 1.4/10 000 children in the Arabian Peninsula to 185/10 000 children of Asian population. In Europe, the highest prevalence has been observed in Sweden, while the lowest in Croatia (115/10 000 and 2-3/10 000, respectively). There have been no epidemiological studies on the prevalence of ASD in Polish population. The aim of our study was to assess the prevalence of ASD in children aged 0-16 years, inhabitants of West Pomeranian and Pomeranian regions. MATERIAL AND METHODS In total, 2514 children (2038 males, 81.1%) were included. The estimates were based on the government registries, whereas data were obtained from Provincial Disability Services Commissions. RESULTS The prevalence of ASD in children aged 0-16 years varies between two regions of Poland - 32/10 000 in West Pomeranian and 38/10 000 in Pomeranian region. CONCLUSIONS The average prevalence of ASD was 35/10 000 children and was about 4-fold higher in males (P < 0.05). More studies are necessary.
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Affiliation(s)
| | - Izabela Gorzkowska
- Department of Psychiatry, Pomeranian Medical University, Szczecin, Poland
| | | | - Grażyna Adler
- Department of Gerontobiology, Pomeranian Medical University, Szczecin, Poland
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Garg P, Lillystone D, Dossetor D, Wilkinson H, Kefford C, Eastwood J, Liaw ST. A Framework for Developing a Curriculum Regarding Autism Spectrum Disorders for Primary Care Providers. J Clin Diagn Res 2015; 9:SC01-6. [PMID: 26557583 DOI: 10.7860/jcdr/2015/13248.6651] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 05/21/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The prevalence of Autism Spectrum Disorders (ASDs) has increased and varies across age groups. Thus there is an increasing need for educational opportunities for General Practitioners (GPs) and other Primary Care providers to help in early identification and referral to specialist services. An earlier survey of GPs in New South Wales (Australia) demonstrated two broad domains for educational activities: (1) a general knowledge (important for early identification and referral) and (2) surveillance (important for ongoing management). AIM To seek further evidence to these domains and synthesize the important contents for educational programs for GPs. MATERIALS AND METHODS We conducted a (1) Confirmatory Factor Analysis (CFA) on our original survey data and (2) systematic review of the literature to identify important educational topics, using a life cycle approach. RESULTS CFA and literature review support theoretical framework of two domains. Alerts and red flags for ASDs, knowledge of simple surveillance tools, communication of diagnosis with parents, referral pathways particularly to speech pathologists before a formal diagnosis is confirmed, and appreciation of vulnerabilities for identifying supports were important in the general knowledge domain, while supporting the families through transition points such as from pre-school to school entry, secondary school and adolescence, role of psychopharmacology such as medications for sleep issues, and for common co-morbidities of anxiety were important in the surveillance dimension. CONCLUSION GP supervisors and medical and nursing educators can use findings from this paper for developing structured learning activities for training primary health care workforce regarding ASD's.
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Affiliation(s)
- Pankaj Garg
- School of Women's and Children's Health, UNSW, Discipline of Paediatrics, Central Clinical School, University of Sydney, Ingham Health Research Institute , Liverpool, NSW
| | - David Lillystone
- Senior Community Paediatrician, Hornsby Ku-Ring Hospital and Hornsby Community Child Health Centre, Hornsby, Northern Clinical School, University of Sydney
| | - David Dossetor
- Senior Child Psychiatrist with an interest in Autism and Intellectual Disability, Department of Psychological Medicine, Sydney Children's Hospital Network (Westmead), Clinical Associate Professor, University of Sydney
| | - Helen Wilkinson
- Senior Career Medical Officer in Community Paediatrics, Hornsby Child health , 59, Florence street, Hornsby, NSW 2077
| | - Carolyn Kefford
- Senior Academic General Practitioner, Northern Clinical School, University of Sydney
| | - John Eastwood
- Conjoint Associate Professor School of Women's and Children's Health and School of Public Health and Community Medicine, UNSW and Sydney School of Public Health, University of Sydney, Ingham Health Research Institute , Liverpool, NSW, Community Paediatrics, Sydney Local Health District
| | - Siaw Teng Liaw
- Professor of General Practice, School of Public Health and Community Medicine, UNSW, Centre for Primary Health Care and Equity, UNSW and Academic General practice Unit, Fairfield Hospital , Fairfield
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The clinical utility of the modified checklist for autism in toddlers with high risk 18-48 month old children in Singapore. J Autism Dev Disord 2014; 44:405-16. [PMID: 23812662 DOI: 10.1007/s10803-013-1880-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The modified checklist for autism in toddlers (M-CHAT) is a tool developed for 16-30 month old children to screen for autism spectrum disorders (ASD). It is a well-researched tool, but little is known about its utility with Singaporean toddlers and with older children referred for developmental concerns. This study investigated the M-CHAT's performance with 18-30 month old (N = 173) and >30-48 month old (N = 407) developmentally at-risk Singaporean children, when used with three recommended scoring methods i.e., the total, critical and Best7 scoring methods. The results indicate that the critical and Best7 scoring methods detected most true cases of ASD without inflating the false positive rates in toddlers, and that only the total scoring method performed acceptably for the older children.
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Windham GC, Smith KS, Rosen N, Anderson MC, Grether JK, Coolman RB, Harris S. Autism and developmental screening in a public, primary care setting primarily serving Hispanics: challenges and results. J Autism Dev Disord 2014; 44:1621-32. [PMID: 24408091 DOI: 10.1007/s10803-014-2032-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We implemented screening of children 16-30 months of age (n = 1,760) from a typically under-served, primarily Hispanic, population, at routine pediatric appointments using the modified checklist for autism in toddlers (M-CHAT) and Ages and Stages Questionnaire. Screen positive rates of 26 and 39%, respectively, were higher than previous reports. Hispanics were more likely to score M-CHAT positive than non-Hispanics (adjusted OR 1.7, 95% CI 1.2-2.4), as were those screened in Spanish. About 30% of screen-positive children were referred for further assessment, but only half were seen. Thus screening in this population is feasible, but may require additional resources. Attention to the cultural applicability of screening instruments, as well as to explaining the results or need for additional services to parents, is critical to serve the growing Hispanic population.
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Affiliation(s)
- Gayle C Windham
- Division of Environmental and Occupational Disease Control, California Department of Public Health, 850 Marina Bay Parkway, Building P, Richmond, CA, 94804, USA,
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Kimple KS, Bartelt EA, Wysocki KL, Steiner MJ. Performance of the Modified Checklist for Autism in Toddlers in Spanish-speaking patients. Clin Pediatr (Phila) 2014; 53:632-8. [PMID: 24550559 DOI: 10.1177/0009922814522346] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To compare abnormal screening rates of 2 different Spanish versions of the Modified Checklist for Autism in Toddlers (M-CHAT) in US Spanish-speaking patients. METHOD Quasi-experimental design was used with historical and English language controls. Abnormal screening rates were compared between Spain and Western-hemisphere Spanish versions, as well as to English controls during the same time periods using chi square analysis. RESULTS M-CHAT questionnaires were scored from 589 subjects (English n = 415, Spanish n = 174). There was little difference between Spanish versions. Overall, the Spanish abnormal screening rate was double that of English (23.6% vs 11.3%, P < .001). CONCLUSIONS Spanish M-CHAT questionnaires are abnormal more often than those in English even after changing to appropriate translation, despite lower prevalence of autism in Latinos. Issues with translation, interpretation, or cultural understanding of behaviors may contribute. Given abnormal screening rates for Latinos, the use of the M-CHAT follow-up interview in Spanish-speaking patients is beneficial but may be more time-consuming.
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Affiliation(s)
- Kelly S Kimple
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Erica A Bartelt
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Karen L Wysocki
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Peiris-John RJ, Attanayake S, Daskon L, Wickremasinghe AR, Ameratunga S. Disability studies in Sri Lanka: priorities for action. Disabil Rehabil 2013; 36:1742-8. [DOI: 10.3109/09638288.2013.864714] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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47
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Daley TC, Singhal N, Krishnamurthy V. Ethical Considerations in Conducting Research on Autism Spectrum Disorders in Low and Middle Income Countries. J Autism Dev Disord 2013; 43:2002-14. [DOI: 10.1007/s10803-012-1750-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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48
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Kara B, Mukaddes NM, Altınkaya I, Güntepe D, Gökçay G, Özmen M. Using the modified checklist for autism in toddlers in a well-child clinic in Turkey: adapting the screening method based on culture and setting. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2012; 18:331-8. [PMID: 23175752 DOI: 10.1177/1362361312467864] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We aimed to adapt the Modified Checklist for Autism in Toddlers to Turkish culture. The Modified Checklist for Autism in Toddlers was filled out independently by 191 parents while they were waiting for the well-child examination of their child. A high screen-positive rate was found. Because of this high false-positive rate, a second study was done in which the Modified Checklist for Autism in Toddlers was administered by health-care staff in a short interview with two groups of parents. The first group (the high-risk group) comprised 80 children aged 18-36 months, who were initially diagnosed with pervasive developmental disorders. The second group (the low-risk group) comprised 538 children of the same age, who were followed regularly by the well-child clinic. Two screen positives were found in the low-risk group. These two children, a random sample of 120 children from the low-risk group, and all the high-risk group were invited to a clinical evaluation. The diagnostic power of the Modified Checklist for Autism in Toddlers was assessed against clinical diagnosis and the Childhood Autism Rating Scale. The positive predictive value of the Modified Checklist for Autism in Toddlers was found to be 75%. Our findings led us to conclude that the Modified Checklist for Autism in Toddlers is a useful tool in Turkey for screening of pervasive developmental disorders in primary care, but in our culture, it is completed more accurately when health-care personnel ask the parents the questions. This study shows that Modified Checklist for Autism in Toddlers screening should be adapted based on culture and setting.
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Albores-Gallo L, Roldán-Ceballos O, Villarreal-Valdes G, Betanzos-Cruz BX, Santos-Sánchez C, Martínez-Jaime MM, Lemus-Espinosa I, Hilton CL. M-CHAT Mexican Version Validity and Reliability and Some Cultural Considerations. ISRN NEUROLOGY 2012; 2012:408694. [PMID: 22811934 PMCID: PMC3395208 DOI: 10.5402/2012/408694] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 03/18/2012] [Indexed: 02/02/2023]
Abstract
The Modified Checklist for Autism in Toddlers (M-CHAT) questionnaire is a brief measure available in Spanish which needs to be validated for the Mexican population. Parents of children from (1) community with typical development (TD) and (2) psychiatric outpatient unit completed the CBCL/1.5–5 and the Mexican/MM-CHAT-version. The study sample consisted of 456 children (age M = 4.46, SD = 1.12), 74.34% TD children and 26.65% with Autism Spectrum Disorders (ASD). The MM-CHAT mean score for failed key items was higher for the ASD group compared with the TD group. Internal consistency for the Mexican/M-CHAT version was .76 for total score and .70 for the 6 critical items. Correlations between the MM-CHAT and the CBCL/1.5: PDD and Withdrawn subscales and with ADI-R dimensions: B non verbal) and A were high, and were moderate with ADI-R dimensions B1 (verbal) and C The failure rate of the MM-CHAT between the groups did not reproduce all the critical items found in other studies. Although the instrument has good psychometric properties and can be used for screening purposes in primary settings or busy specialized psychiatric clinics, these results support evidence for cultural differences in item responses, making it difficult to compare M-CHAT results internationally.
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Affiliation(s)
- Lilia Albores-Gallo
- Research Division, Hospital Psiquiátrico Infantil "Dr. Juan N. Navarro," Secretaría de Salud, Mexico
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Elsabbagh M, Divan G, Koh YJ, Kim YS, Kauchali S, Marcín C, Montiel-Nava C, Patel V, Paula CS, Wang C, Yasamy MT, Fombonne E. Global prevalence of autism and other pervasive developmental disorders. Autism Res 2012; 5:160-79. [PMID: 22495912 PMCID: PMC3763210 DOI: 10.1002/aur.239] [Citation(s) in RCA: 1341] [Impact Index Per Article: 111.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 11/11/2011] [Indexed: 01/09/2023]
Abstract
We provide a systematic review of epidemiological surveys of autistic disorder and pervasive developmental disorders (PDDs) worldwide. A secondary aim was to consider the possible impact of geographic, cultural/ethnic, and socioeconomic factors on prevalence estimates and on clinical presentation of PDD. Based on the evidence reviewed, the median of prevalence estimates of autism spectrum disorders was 62/10 000. While existing estimates are variable, the evidence reviewed does not support differences in PDD prevalence by geographic region nor of a strong impact of ethnic/cultural or socioeconomic factors. However, power to detect such effects is seriously limited in existing data sets, particularly in low-income countries. While it is clear that prevalence estimates have increased over time and these vary in different neighboring and distant regions, these findings most likely represent broadening of the diagnostic concets, diagnostic switching from other developmental disabilities to PDD, service availability, and awareness of autistic spectrum disorders in both the lay and professional public. The lack of evidence from the majority of the world's population suggests a critical need for further research and capacity building in low- and middle-income countries.
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Affiliation(s)
- Mayada Elsabbagh
- Department of Psychiatry, Montreal Children's HospitalMontrealCanada and Birkbeck, University of LondonLondon, UK
| | | | - Yun-Joo Koh
- The Korea Institute for Children's Social DevelopmentSeoul, South Korea
| | - Young Shin Kim
- Child Study Center, Yale University School of MedicineNew Haven, USA
| | - Shuaib Kauchali
- Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa and Mailman School of Public Health, Columbia UniversityNew York, NY, USA
| | | | | | - Vikram Patel
- Centre for Global Mental Health, London School of Hygiene and Tropical MedicineLondon, UK and Sangath CentreGoa, India
| | - Cristiane S Paula
- Developmental Disorders Program, Mackenzie Presbyterian UniversitySão Paulo, Brazil
| | - Chongying Wang
- Center for Behavioural Science and School of Medicine, Nankai UniversityTianjin, China
| | | | - Eric Fombonne
- Department of Psychiatry, Montreal Children's HospitalMontreal, Canada
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