Autism Spectrum Disorders in Africa: Current Challenges in Identification, Assessment, and Treatment: A Report on the International Child Neurology Association Meeting on ASD in Africa, Ghana, April 3-5, 2014

Implementation of the International Classification of Diseases 11th revision behavioural indicators for disorders of intellectual development with co-occurring autism spectrum disorder

BACKGROUND

The classification of mental, behavioural and neurodevelopmental disorders in the World Health Organization's International Classification of Diseases 11th revision (ICD-11) includes a comprehensive set of behavioural indicators (BIs) within the neurodevelopmental disorders grouping. BIs can be used to assess the severity of disorders of intellectual development in situations in which standardised measures of intellectual functioning and adaptive behaviours are not available or feasible. This international study examines the implementation characteristics of the BIs and compares them to standardised measures for assessing the severity of intellectual impairment and adaptive behaviours in disorders of intellectual development and autism spectrum disorder (ASD). The clinical utility of the ICD-11 and the fidelity of its application in international clinical settings were also assessed.

METHODS

A total of 116 children and adolescents (5-18 years old) with a suspected or established diagnosis of disorders of intellectual development were included across four sites [Italy (n = 18), Sri Lanka (n = 19) and two sites in India (n = 79)]. A principal component analysis was conducted to evaluate the application of the ICD-11 guidance for combining severity levels.

RESULTS

Assessment using the BIs showed a higher proportion of individuals classified with mild severity, whereas the standardised measures indicated a higher proportion of severe ratings. Additionally, individuals with co-occurring ASD tended to have more severe impairments compared with those without ASD, as indicated by both BIs and standardised measures. Overall, the BIs were considered clinically useful, although more time and consideration were required when applying the guidelines for individuals with a co-occurring disorder of intellectual development and ASD. The principal component analysis revealed one principal component representing overall disorders of intellectual development severity levels.

CONCLUSIONS

The ICD-11 BIs can be implemented as intended in international clinical settings for a broad range of presentations of individuals with neurodevelopmental disorders. Use of the BIs results in similar severity diagnoses to those made using standardised measures. The BIs are expected to improve the reliability of severity assessments in settings where appropriate standardised measures for intellectual and adaptive behaviours are not available or feasible.

The Unmasking of Autism in South Africa and Nigeria

This review is of interest to researchers, policymakers, and healthcare professionals working in the field of autism in Africa. The review aims to describe autism in sub-Saharan Africa, focusing on South Africa and Nigeria regarding prevalence, incidence, identification, treatment, and attitudes towards autistic children. There are several challenges, such as lack of awareness, limited access to professional support and diagnostic tools, and cultural considerations in establishing the autism prevalence in the African region compared to other parts of the world. Additionally, South Africans and Nigerians exhibit diverse perspectives and attitudes that significantly influence the provision of treatment, including stigma and misconceptions held by healthcare professionals themselves. As a result, it is difficult to determine prevalence in South Africa and Nigeria. However, research has indicated that autism prevalence is rising globally, and in these contexts. Rising prevalence highlights the need to increase access to services, rehabilitation, and provide support to families of children with autism. Furthermore, research has emphasized the inequitable support and access available to families living in low-and high-income households and the need to provide contextually relevant and responsive interventions, education and training, research and policy in these countries.

Assessing Autism Knowledge Across the Global Landscape Using the ASK-Q

Substantial variability exists with regard to autism service provision around the world. Service disparities observed in many low- and middle-income countries may be driven, in part, by limited autism knowledge; however, measurement limitations have made it difficult to quantify autism knowledge across countries. The current study uses the autism stigma and knowledge questionnaire (ASK-Q) to quantify autism knowledge and stigma between different countries and demographics. The current study compiled data from 6830 participants collected using adapted versions of the ASK-Q administered in 13 different countries, representing four different continents. Structural equation modeling was used to examine how autism knowledge varied across country and individual factors. Results reveal cross country variability with a large, 17-point difference between the countries with the highest knowledge (Canada) and the lowest knowledge (Lebanon). As expected, countries with higher economies had higher levels of knowledge. We also documented differences based on country worldview, participant occupation, gender, age, and education level. These results help to identify specific regions and populations that might most need greater information about autism.

A qualitative enquiry into the challenging roles of caregivers caring for children with Autism Spectrum Disorders in Ghana

BACKGROUND

Autism Spectrum Disorder (ASD) is a condition commonly characterized by challenges with social interaction, repetitive atypical behaviour, and restricted interest. It is estimated that about 1 in 160 children has ASD. Caring for children with ASD is challenging for many parents or caregivers.

OBJECTIVES

The study aims at exploring the challenges experienced by caregivers of children with ASD.

METHODS

A qualitative phenomenological study was employed using an exploratory descriptive research design. A total of 10 participants were recruited in this study using a purposive sampling technique. Data were analysed using content analysis procedures.

RESULT

Caregivers of children with ASD face social, financial, and emotional challenges, challenges in accessing health care, education and training of their children in mainstream school settings.

CONCLUSION

The numerous challenges have implications for the quality of life of the caregivers and their children. The financial challenges and inaccessibility of specialist health services have serious implications for the continuous medical care and monitoring of children with ASD. The challenges in education and training of children with ASD has negative consequences for enrolment and retention of children with ASD in mainstream school settings.

Exploring knowledge of autism, its causes and treatment among immigrant and nonimmigrant parents in Somalia\Somaliland

BACKGROUND

The prevalence of autism spectrum disorders (ASDs) has increased over the recent years; however, little is known about the experience of parents of children with autism in Africa such as Somalia. The aim of this study is to understand the knowledge on autism of Somali parents of children with autism and their perceptions of causes and treatment of ASD.

METHODS

We conducted a qualitative study involving 22 parents of children with autism who lived in Mogadishu and Hargeisa; the two largest cities in Somalia. In-depth interviews were used to collect the data. Of the 22 participants, 9 were returned immigrants and 13 were local people (non-immigrants). Data were analysed using thematic analysis.

RESULTS

The data revealed that most of the parents hold the belief that their children's autism were caused by the measles vaccine. The findings demonstrated that parents sought diagnosis and treatment care from outside Somalia due to the lack of experience of health providers in the diagnosis and treatment of autism. The data also revealed a lack of knowledge about autism among the public with resultant stigma and discrimination against children with autism and their families.

CONCLUSIONS

Efforts to increase public knowledge on autism, its causes and treatments are of paramount importance, while a public health campaign designed to eliminate the stigma subjected to children with autism is necessary to improve the quality of life of children with autism and their caregivers. Finally, to counteract vaccine hesitancy, particularly in response to the measles vaccine, health policy makers should take steps to separate the cooccurrence of the onset of autism symptoms and the provision of the measles vaccine.

A scoping review of autism research conducted in Central Asia: Knowledge gaps and research priorities

LAY ABSTRACT

Very little is known about the status of autism research in Central Asia. Through the library databases, we identified and reviewed 11 scientific studies conducted with autistic people and their families in five Central Asian countries-Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan. Of the 11 studies, 10 were conducted in Kazakhstan and 1 in Uzbekistan. Within these limited number of research studies, different topics such as diagnosis, risk factors of autism, biology, and various service and intervention areas were addressed. We identified several knowledge gaps and research priorities to address the needs of autistic people, their families, and professionals in Central Asia.

Exploring Early Childhood Autism Spectrum Disorders: A Comprehensive Review of Diagnostic Approaches in Young Children

Autism spectrum disorders (ASD) encompass a diverse range of developmental disabilities characterized by pervasive deficiencies in socialization, communication, and the manifestation of behavioral issues. This review aims to clarify the diagnostic criteria for ASD, explore available diagnostic tools, evaluate biomedical examinations facilitating ASD diagnosis, and discuss the approach to screening assessments for ASD. ASDs are prevalent conditions, with a globally estimated prevalence of 7.6 cases per 100 (one in 132), based on a comprehensive review of epidemiological studies. The precise cause of autism and other ASDs remains unknown; however, genetic and environmental factors likely contribute. Common signs and symptoms shared among individuals with autism include restricted repetitive behaviors and learning disabilities. Standardized methods, such as the Diagnostic and Statistical Manual, Fifth Edition (DSM-5), diagnostic instruments, a thorough medical history, multiple physical examinations, laboratory investigations, neuroimaging, and screening tests, play a pivotal role in early autism diagnosis and intervention. ASD is a lifelong neurodevelopmental condition characterized by multiple deficits. Early detection is anticipated to have a positive impact on outcomes.

Impacts of Caregiving for Individuals with Autism in Low-Resource Settings, a Report from the Kurdistan Region of Iraq

Caring for children with different developmental trajectories brings various challenges, which are often exacerbated in low-resource settings. International research has shown that raising a child with autism strongly impacts family caregivers, particularly mothers. There is a dearth of information regarding caregiving for individuals with autism in the Kurdistan Region of Iraq (KRI) and for fathers as well as mothers. This study examined the similarities and differences in caregiving for mothers and fathers of a child with autism in KRI using validated rating scales to measure various aspects of their general well-being. Over two years, a sample of 118 parents of individuals with autism (81 mothers and 37 fathers) self-completed the rating scales, which were further discussed through individual interviews with service personnel mainly known to them. The findings indicated that mothers and fathers were similarly impacted. Although there were no statistically significant differences in the ratings of their general health, sources of stress, family functioning, and satisfaction with caregiving, the majority of parents had elevated ratings on all the measures. In addition, parents who rated their children higher on the Aberrant Behavior Checklist had significantly higher scores on their general health issues and were less satisfied with their caregiving role. Parents of female individuals with autism were also significantly more stressed compared to the male individuals with autism and parents of children who received a diagnosis before three years of age, reported fewer behavioral problems with their child compared to the parents who received a diagnosis when the child was older. In this sample, mothers and fathers seem to be similarly impacted by caring for a child with autism, which is contrary to findings from other countries. However, in this region, family bonds between couples and the wider family may have had an influence which further cross-cultural research in low-resource settings could help elucidate, notwithstanding the challenges this poses. The findings have policy implications for health authorities in the KRI to improve the support provided to both mothers and fathers who care for children with autism, which presently is rarely available to them.

Feeding children with autism in South Africa: The teachers' perspectives

Background

Over 80% of children diagnosed with autism spectrum disorders (autism) exhibit disruptive behaviours during mealtimes, highlighting the need for personalised care. In South Africa, teachers often take on the responsibility of feeding due to resource constraints and the time children spend at school. Moreover, children with autism have unique and individualised feeding requirements, which many teachers may not have the necessary training or skills to address adequately.

Objectives

To explore the ways in which teachers of autistic children manage feeding difficulties in the classroom.

Method

A qualitative research design was employed using semi-structured interviews. Eight teachers were interviewed on feeding autistic children between the ages of 3 years - 9 years in Johannesburg, South Africa. Data were transcribed and analysed using thematic analysis.

Results

The findings revealed that teachers encountered distinct challenges when it came to feeding autistic children in the classroom, particularly concerning the management of associated feeding difficulties. Teachers employed several strategies to encourage eating in the classroom setting including: (1) bolus modification, (2) behaviour modelling, (3) positive reinforcement and (4) offering choices and alternatives.

Conclusion

The study concludes the need for specialised support and training for teachers to address the individualised feeding needs of children with autism. Implementing targeted interventions and providing resources for teachers could enhance their abilities to effectively support children with autism during mealtimes and promote a more inclusive classroom environment.

Contribution

This study highlighted the importance of including the teacher in the multidisciplinary team when managing the feeding challenges in children with autism.

Phenotype and genetic analysis of data collected within the first year of NeuroDev

Genetic association studies have made significant contributions to our understanding of the etiology of neurodevelopmental disorders (NDDs). However, these studies rarely focused on the African continent. The NeuroDev Project aims to address this diversity gap through detailed phenotypic and genetic characterization of children with NDDs from Kenya and South Africa. We present results from NeuroDev's first year of data collection, including phenotype data from 206 cases and clinical genetic analyses of 99 parent-child trios. Most cases met criteria for global developmental delay/intellectual disability (GDD/ID, 80.3%). Approximately half of the children with GDD/ID also met criteria for autism. Analysis of exome-sequencing data identified a pathogenic or likely pathogenic variant in 13 (17%) of the 75 cases from South Africa and 9 (38%) of the 24 cases from Kenya. Data from the trio pilot are publicly available, and the NeuroDev Project will continue to develop resources for the global genetics community.

Autism in Africa: prevalence, diagnosis, treatment and the impact of social and cultural factors on families and caregivers: a review

This paper presents a narrative review of current knowledge on autism in Africa, including prevalence, diagnosis, treatment and the impact of social and cultural factors on families and caregivers. The prevalence of autism in Africa is estimated to be similar to that in other regions. However, diagnosis and treatment access remain limited due to various challenges, such as a shortage of specialised healthcare professionals and resources, a lack of awareness and understanding of autism spectrum disorder (ASD) among healthcare providers, and cultural stigma surrounding mental health and developmental disorders. Alternative therapies are commonly used with other therapies, but their effectiveness is often unproven. The impact of ASD on families and caregivers in Africa is significant, with many facing challenges in accessing support services and coping with stigma. Efforts are being made to increase awareness and reduce the stigma around ASD in African communities, but more research is needed on effective interventions and culturally appropriate treatments. Policy recommendations include increasing resources and training for healthcare professionals, improving access to evidence-based interventions and promoting community awareness and support. With improved understanding and investment, the quality of life of individuals with ASD in Africa can be significantly improved.

Parent-mediated intervention training for caregivers of children with developmental differences in Zambia

BACKGROUND

Lower- and middle-income countries (LAMICs) are under-resourced and have limited intervention services for children with developmental differences and their families. A logical method to address service gaps within resource-scarce contexts is to train caregivers as interventionists, specifically using empirically-supported parent-mediated Naturalistic Developmental Behavioral Interventions (P-M NDBIs; Kasari et al., 2010; Ingersoll & Wainer, 2013).

AIMS

The study implemented the first P-M NDBI in Zambia and aimed to train caregivers and improve children's social-communication skills.

METHODS/PROCEDURES

The current study utilized a mixed-methods, pre-post design and implemented Project ImPACT (Ingersoll & Dvortcsak, 2010, 2019). Participants included 19 Zambian caregivers of children (n = 20) with developmental differences including autism spectrum condition, Down syndrome, and cerebral palsy.

OUTCOMES/RESULTS

Findings indicated that children's language skills and pretend play skills significantly improved from pre- to post-assessment, and caregivers most frequently used intervention strategies for modeling communication and prompting communication.

CONCLUSIONS/IMPLICATIONS

The success and feasibility of implementing Project ImPACT in Zambia, and recommendations for culturally adapting and implementing P-M NDBIs in LAMICs, were discussed.

Perceptions of autism spectrum disorder among the Swahili community on the Kenyan coast

BACKGROUND

In high-income and Western societies there is great understanding and awareness of autism spectrum disorder (ASD); however, for many low-middle income countries, research and knowledge is notably lacking. In Africa, there is a growing prevalence of ASD due to increased diagnosis, yet it is still a poorly understood condition.

AIMS

Emerging literature has emphasised how cultural and societal beliefs underpin the level of understanding of ASD, and which typically results in lack of awareness and acceptance. As such it is important to investigate the cultural perceptions towards ASD within low-middle income communities of African culture, to further understand the challenges and barriers individuals with ASD face. The aim of the current study was to probe participants from the Swahili community, on the coast of Kenya, of their cultural views towards ASD.

METHOD

Semi-structured interviews were conducted with seven participants, and the data analysed using thematic analysis.

RESULTS

Three key themes developed from the data; stigma, lack of awareness, and Government responsibility.

CONCLUSION

Cultural perceptions negatively impacted awareness and are exacerbated by lack of directive from the Government in providing appropriate diagnostic and educational support.

Knowledge of developmental disabilities and referral sources among health workers in two Ghanaian hospitals

Proper treatment of developmental disabilities requires health workers to have adequate knowledge of etiology and referral procedures. There is a dearth of research on knowledge of developmental disabilities among health workers in Ghana. The purpose of this study was to document knowledge about developmental disorders, causes, and referral procedures among health workers. Researchers used a successive free-listing method to interview 37 health workers. Developmental disabilities which present with physical symptoms were the most salient disorders identified among health workers, while learning disabilities and attention deficit disorder were largely overlooked. The most commonly listed developmental disabilities were cerebral palsy, Down syndrome, and autism spectrum disorder. Respondents had limited knowledge about the causes of and referral resources for developmental disabilities. Results show the need for continuing medical education, public awareness, and enhanced resources to support the identification and care of children with developmental disabilities in Ghana.

The global prevalence of autism spectrum disorder: a comprehensive systematic review and meta-analysis

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.

Brief report: Validity and reliability of the Nigerian Autism Screening Questionnaire

Informant-report measures for screening symptoms of autism spectrum disorder (ASD) and other neurodevelopmental disorders (NDDs) are needed for low-resource settings if early identification is to be prioritized because early developmental concerns are likely to be expressed by parents and other caregivers. This paper describes the initial psychometric evaluation of the Nigeria Autism Screening Questionnaire (NASQ). Parents and other caregivers completed the NASQ on 12,311 children ages 1 to 18 in a Nigerian population sample as part of the World Bank National General Household Survey conducted in the country in 2016. Factor analyses indicated a parsimonious three-factor structure with social communication/interaction, repetitive sensory motor, and insistence on sameness dimensions. Measurement invariance was excellent across age and sex. Reliability of the subscales and total scale was good, and item response theory analyses indicated good measurement precision in the range from below average to high scores, crucial for screening, and tracking ASD symptoms. Studies with gold standard ASD diagnostic instruments and clinical confirmation are needed to evaluate screening and diagnostic accuracy. The NASQ appears to be a reliable instrument with a clear factor structure and potential for use in screening and tracking ASD symptoms in future Nigerian samples.

Experiences of siblings to children with autism spectrum disorder

Autism spectrum disorder (ASD) is prevalent globally resulting in increased awareness and understanding of the disorder internationally and to a lesser extent in Southern African countries. This understanding has predominantly been in relation to the impact of the disorder on the neurodivergent child and family relations. Internationally, limited research has explored the impact on neurotypical siblings who have been raised alongside children diagnosed with ASD, with a dearth of such studies emerging from the South African context. The importance of neurotypical siblings' developmental experiences emerging from their immediate environment is significant within the traditionally collectivist nation of South Africa. For this reason, this study aimed to explore South African neurotypical siblings' experiences of living with a brother or sister diagnosed with ASD; through a qualitative study adopting an interpretative phenomenological design. Semi-structured interviews, aimed at generating demographic data and exploring the experiences of being raised alongside a sibling diagnosed with ASD, were conducted with eight university students. The data generated were analyzed employing the five stages of interpretive phenomenological analysis approach. Themes of emotional burden, perceived family dynamics, acceptance, and identity development emerged through data analysis. The participants reported experiences of pre-mature development, unfair treatment, and feelings of being overburdened, along with reported efforts toward acceptance of their sibling's diagnosis, and support from community members. Consequently, an understanding that their neurodivergent sibling played a key role in the development of their identities and career trajectories emerged. The impact of being raised alongside a sibling diagnosed with ASD highlights the need for additional support for neurotypical individuals, supported by programs to enhance awareness about ASD in the general South African community. These interventions would be aimed at mitigating the impact of heightened childhood stress, stigmatization, and marginalization.

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

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

Validation of the Communication Profile-Adapted in Ethiopian children with neurodevelopmental disorders

BACKGROUND

Neurodevelopmental disorders (NDDs) are conditions affecting a child's cognitive, behavioural, and emotional development. Appropriate and validated outcome measures for use in children with NDDs in sub-Saharan Africa are scarce. The aim of this study was to validate the Communication Profile Adapted (CP-A), a measure developed in East Africa to assess caregivers' perception of communication among children with NDDs.

METHODS

We adapted the CP-A for use in Ethiopia, focusing on the communicative mode (CP-A-mode) and function (CP-A-function) scales. The CP-A was administered to a representative sample of caregivers of children with NDDs and clinical controls. We performed an exploratory factor analysis and determined the internal consistency, test-retest reliability, within-scale, known-group, and convergent validity of the identified factors.

RESULTS

Our analysis included N = 300 participants (N = 139 cases, N = 139 clinical controls, N = 22 who did not meet criteria for either cases or controls). Within the CP-A-mode, we identified two factors (i.e. verbal and physical communication); the CP-A-function scale was unidimensional. Combining both scales into one summary variable (the CP-A-total) resulted in a scale with excellent internal consistency and test-retest reliability (Cronbach's alpha = 0.97; Kappa = 0.60-0.95, p < 0.001; ICC = 0.97, p < 0.001). Testing known-group validity, the CP-A-total scores were significantly higher for controls than cases (Δ mean = 33.93, p < 0.001). Convergent validity assessment indicated that scores were negatively and moderately correlated with clinical severity (ρ = -0.25, p = 0.04).

CONCLUSION

The CP-A is a valid tool for the assessment of communication among children with NDDs in Ethiopia. It holds promise as a brief, quantitative, and culturally appropriate outcome measure for use in sub-Saharan Africa.

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

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

Internalization of stigma among parents of children with autism spectrum disorder in Nigeria: a mixed method study

Background

Autism Spectrum disorder (ASD) has uniquely stigmatizing aspects because children with ASD have no physical markers of their condition. Parents are usually blamed and judgment from others is often internalized (felt stigma).

Aim

This study was conducted to determine knowledge about ASD, negative experiences (enacted stigma), internalization of stigma (felt or self stigma) and its correlates among parents of children with ASD in Lagos, Nigeria.

Methods

This was a cross-sectional study of 230 parents in Lagos, Nigeria employing mixed-method data collection methods. Quantitative data were collected using a structured interviewer-administered questionnaire and analyzed with Epi- Info™ version 7.0 statistical package. Data were summarized with proportions, mean and standard deviation. Chi square and Spearman’s correlation tests were done, and the level of significance was pre-determined at 5% (p < 0.05). In-depth interviews were also conducted among six parents to further explore the topic. The interviews were analyzed narratively.

Results

The proportion of mothers and fathers were 175 (76.1%) and 55 (23.9%) respectively. The mean age of respondents was 42 ± 8.5 years. Overall knowledge of ASD was very poor as only 3(1.3%) had good knowledge. Overall, 122(53%) usually had negative experience of parenting a child with ASD (enacted stigma), mothers (17.1%) more than fathers (9.1%). Majority 192(83.5%) internalized stigma. There was a low–moderate correlation between ‘enacted’ stigma and ‘internalized’ stigma (ρ- 0.400, p < 0.001). From in-depth interviews, many parents revealed that their child’s condition had negative effects on the family. Many also recounted negative experience of stigma.

Conclusion

Overall, parents of children with ASD had poor knowledge of the condition. Majority internalized stigma and this increases with negative treatment from others. Parents should be properly educated about ASD. Community-based education to increase awareness about ASD in addition to encouraging people to show empathy and reduce stigmatizing behaviour towards parents of children with ASD are recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00687-3.

Development of a Mobile App to Improve Numeracy Skills of Children With Autism Spectrum Disorder: Participatory Design and Usability Study

BACKGROUND

The use of information and communication technologies is transforming the lives of millions of people including children with autism spectrum disorder (ASD). However, the process of developing a user-friendly and effective mobile app needs to follow a complex standard protocol and culture-sensitive customization, and involves multiple sectors. This complex work becomes even more challenging when considering children with ASD in low- and middle-income countries as the users.

OBJECTIVE

This study aimed to design and develop a more intuitive mobile app to improve numeracy skills of children with ASD in Rwanda and evaluate the usability of the app.

METHODS

A participatory design approach was utilized in this study in which 40 children with ASD, 5 teachers, and 10 parents of children with ASD participated in focus group discussions (FGDs) and usability testing. A narrative literature review was performed to explore existing mobile apps and compare previous studies to design the questions for FGD and facilitate a framework for designing the app. The agile methodology was used to develop the mobile app, and the heuristics evaluation method was used to test and evaluate the usability of the initial version of the app to improve its functionalities. The interviews were recorded, transcribed, and analyzed following the guidelines of the qualitative narrative analysis (QNA) method.

RESULTS

During the FGDs the respondents shared their need for a mobile app in teaching and learning numeracy for children with ASD and pointed to possibilities of integrating the mobile app into existing curriculum. Ten themes emerged from the FGDs and exercise of developing the mobile app. The themes were related to (1) teaching and learning numeracy for children with ASD, (2) planning and development of a mobile app for a person with ASD, (3) testing a mobile app, (4) strength of the developed app against the existing ones, (5) behavioral maintenance and relapse prevention, (6) possibilities to integrate the mobile app into the existing curriculum, (7) data protection for users, (8) social implications, (9) challenges in Rwanda, and (10) focus on future.

CONCLUSIONS

The community plays an important role in the planning, development, and evaluation of a mobile app for children with ASD. In this study, inputs from teachers and parents resulted in an optimally designed mobile app that can improve numeracy skills in children diagnosed with ASD to support the implementation of competency-based curriculum in Rwanda.

Implementing and evaluating Social Attention and Communication Surveillance (SACS) to prospectively identify autism in very young children in Nepal

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.

The Digital Divide in Technologies for Autism: Feasibility Considerations for Low- and Middle-Income Countries

Digital technologies have the potential to empower individuals with autism and their families. The COVID-19 pandemic emphasized and accelerated the drive towards technology for information, communication, training, clinical care and research, also in the autism community. However, 95% of individuals with autism live in low- and middle-income countries (LMIC) where access to electricity, internet and the ever-increasing range of digital devices may be highly limited. The World Bank coined the term ‘the digital divide’ to describe the disparities in access to digital technologies between high-income and LMIC contexts. Here we evaluated the feasibility of six emerging technologies for autism spectrum disorders, and reflected on key considerations for implementation in LMIC contexts to ensure that we do not inadvertently widen the pre-existing digital divide.

Looking at Europe's recent behavioral telehealth practices for children and families impacted by neurodevelopmental disabilities

There is a widespread lack of behavioral professionals available to support children and families affected by neurodevelopmental disabilities. As a result of limited availability, services that can be provided from a distance have developed. Telehealth is a modality that can increase access to services, lessen financial constraints, and support assessments of generalization. Using either synchronous or asynchronous components it can foster evaluation and coaching. Guidelines for usage have surfaced in North America and been integrated into the continent's existing model of behavioral care. However, in Europe where all modalities of behavioral services are fighting to receive funding, frameworks are scarce. Understanding more about telehealth in behavioral care, its various applications throughout Europe, and the local context into which it can be applicable may promote system growth. To support this cause, a scoping review of recent behavioral telehealth practices for children and families impacted by neurodevelopmental disabilities in Europe was undertaken; looking specifically to assess types of studies, their targets and outcomes, telehealth modality components, barriers, and directions for future work. Although few studies surfaced, valuable conclusions can be drawn about the model's empirical validation, creating a groundwork for sustainability, and the need for developing policy and standardized application.

Mushroom Nutrition as Preventative Healthcare in Sub-Saharan Africa

The defining characteristics of the traditional Sub-Saharan Africa (SSA) cuisine have been the richness in indigenous foods and ingredients, herbs and spices, fermented foods and beverages, and healthy and whole ingredients used. It is crucial to safeguard the recognized benefits of mainstream traditional foods and ingredients, which gradually eroded in the last decades. Notwithstanding poverty, chronic hunger, malnutrition, and undernourishment in the region, traditional eating habits have been related to positive health outcomes and sustainability. The research prevailed dealing with food availability and access rather than the health, nutrition, and diet quality dimensions of food security based on what people consume per country and on the missing data related to nutrient composition of indigenous foods. As countries become more economically developed, they shift to “modern” occidental foods rich in saturated fats, salt, sugar, fizzy beverages, and sweeteners. As a result, there are increased incidences of previously unreported ailments due to an unbalanced diet. Protein-rich foods in dietary guidelines enhance only those of animal or plant sources, while rich protein sources such as mushrooms have been absent in these charts, even in developed countries. This article considers the valorization of traditional African foodstuffs and ingredients, enhancing the importance of establishing food-based dietary guidelines per country. The crux of this review highlights the potential of mushrooms, namely some underutilized in the SSA, which is the continent’s little exploited gold mine as one of the greatest untapped resources for feeding and providing income for Africa’s growing population, which could play a role in shielding Sub-Saharan Africans against the side effects of an unhealthy stylish diet.

Changes in Knowledge on the Signs of Autism in Young Children (11-30 Months) among Female Community Health Volunteers in Nepal

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.

Assessing the Effectiveness of Professional Development Training on Autism and Culturally Responsive Practice for Educators and Practitioners in Ethiopia

This study examines the effect of professional development training on educators' and practitioners' knowledge of Autism and the use of culturally responsive practices. Using a single group, pre-post design, data was gathered from 34 educators and health professionals (i.e., teachers, counselors, psychologists, therapists, therapeutic care workers, social workers, and nurses) in Ethiopia. A week-long training covering ASDs and culturally responsive evidence-based training was provided to participants. Results showed significant improvement in participants' knowledge about ASD symptoms, nature, characteristics, as well as intervention selection. Participants' use of culturally informed approaches, in their area of professional service, showed a high level of participants' knowledge and low-level use of culturally responsive practices, policies, and procedures. Recommendations for addressing cultural factors impacting the diagnosis and treatment-seeking approaches to ASD in Africa are provided.

Children with Autism Spectrum Disorders in Low-Resource Settings: Reported Experiences and Needs of Parents in Mongolia

Although it is well-documented that families of children with autism in developed nations report hardships, few researchers have focused on families who live in less-developed, low-resource settings. Using five focus groups with 30 parents of children with autism in Mongolia, a low- resource setting, the purpose of this study was to provide detailed accounts of their experiences, challenges, and needs. Participants reported severe challenges related to raising their children with autism in their country. Parents shared barriers related to the limited availability of services and support, exacerbated financial burdens, and a lack of enforcement of relevant laws. Parents also shared their perceived needs including more services for their children, more sustainable training and coaching programs for parents, and parents' collective advocacy.

Understanding autism spectrum disorder and coping mechanism by parents: An explorative study

Objective

This study aimed to explore the perceptions of parents of children with autism spectrum disorder (ASD) and their coping strategies.

Methods

The data of the study was collected using face-to-face semi-structured interviews. The participants were purposefully selected from the three schools in Mpumalanga Province because they had children diagnosed with ASD and data was analyzed using thematic content analysis. In this study, primary caregivers were selected. In the end, 12 women were interviewed, and the data saturation was reached. Ethical considerations and measures to ensure trustworthiness were carried out throughout the study.

Results

The findings revealed two themes: caregivers' understanding and misconceptions of ASD and coping mechanisms used in dealing challenges of caring for a child with ASD; and five subthemes: lack of knowledge, cultural beliefs, prayer, strong support system, and acceptance.

Conclusion

Based on the findings, more awareness campaigns should be done on ASD to increase parents' understanding of the condition. Understanding the cultural beliefs of parents regarding ASD may assist health care professionals in developing care practices that are accepted in their culture, and may enhance parents' coping skills.

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

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

Childhood autism spectrum disorder: insights from a tertiary hospital cohort in Kenya

INTRODUCTION

Autism spectrum disorder (ASD) is characterized by impairments in behavior, social communication, and interaction. There is little data on ASD from sub-Saharan Africa (SSA) describing clinical characteristics in large cohorts of patients. Preliminary studies report a high male sex ratio, excess of nonverbal cases, possible infectious etiologies, and comorbidities e.g. epilepsy.

OBJECTIVE

To describe the clinical characteristics of children diagnosed with ASD in an African context.

METHODS

A retrospective medical chart review identified 116 children diagnosed with ASD according to DSM-5 criteria at a pediatric neurology clinic in Nairobi, Kenya.

RESULTS

The male to female ratio was 4.3:1. The median age at presentation was 3 years with speech delay as the most common reason for presentation. Expressive language delay was observed in 90% of the population. Sixty percent who obtained imaging had normal MRI brain findings. Only 44% and 34% of children had access to speech therapy and occupational therapy respectively. Epilepsy and ADHD were the most prevalent comorbidities.

CONCLUSION

An early median age at presentation and preponderance of male gender is observed. Access to speech therapy and other interventions was low. A prospective study would help determine outcomes for similar children following appropriate interventions.

The Relative Utility of Concurrent Sources of Information for Diagnosis of Autism Spectrum Disorder in Early Childhood

The development of effective screening methods for Autism Spectrum Disorder (ASD) in early childhood remains a public health priority for communities around the world. Little is known regarding the concurrence between parent concerns about ASD and formal ASD diagnostic methods. This study aimed to examine the relationships among a priori parental ASD concern, ADOS classification, and a physician specialist's diagnosis. One hundred and thirty-four toddlers (74% male; mean age = 31.8 months, SD 4.4) received an evaluation at a university center specializing in ASD and neurodevelopmental disorders. Correspondence between a priori parental ASD suspicion and physician diagnosis of ASD was 61% (p = 0.028). Correspondence between a priori parental suspicion of ASD and ADOS ASD classification was 57% (p = 0.483). Correspondence between ADOS classification and physician diagnosis of ASD was 88% (p = 0.001). Our results have implications for evaluations in low resource regions of the world where access to physician specialists may be limited; the high correspondence between ADOS classification and a physician specialist's diagnosis supports the use of trained ADOS evaluators, such as field health workers or early childhood educators, in a tiered screening process designed to identify those most in need of a specialist's evaluation. Our results also have implications for public health efforts to provide parent education to enable parents to monitor their child's development and share concerns with their providers. Parent awareness and expression of concern coupled with timely responses from providers may lead toward earlier identification of ASD, and other neurodevelopmental disorders, and hence, generate opportunities for earlier and more personalized intervention approaches, which in turn may help improve long-term outcomes. Empowering parents and community members to screen for ASD may be especially important in regions of the world where access to formal diagnosis is limited.

Implementation and effectiveness of non-specialist mediated interventions for children with Autism Spectrum Disorder: A systematic review and meta-analysis

INTRODUCTION

In recent years, several non-specialist mediated interventions have been developed and tested to address problematic symptoms associated with autism. These can be implemented with a fraction of cost required for specialist delivered interventions. This review represents a robust evidence of clinical effectiveness of these interventions in improving the social, motor and communication deficits among children with autism.

METHODS

An electronic search was conducted in eight academic databases from their inception to 31st December 2018. A total of 31 randomized controlled trials were published post-2010 while only 2 were published prior to it. Outcomes pertaining to communication, social skills and caregiver-child relationship were meta-analyzed when reported in > 2 studies.

RESULTS

A significant improvement was noted in child distress (SMD = 0.55), communication (SMD = 0.23), expressive language (SMD = 0.47), joint engagement (SMD = 0.63), motor skills (SMD = 0.25), parental distress (SMD = 0.33) parental self-efficacy (SMD = 0.42) parent-child relationship (SMD = 0.67) repetitive behaviors (SMD = 0.33), self-regulation (SMD = 0.54), social skills (SMD = 0.53) symptom severity (SMD = 0.44) and visual reception (SMD = 0.29).

CONCLUSION

Non-specialist mediated interventions for autism spectrum disorder demonstrate effectiveness across a range of outcomes for children with autism and their caregivers.

Sustainable implementation of early intervention for autism spectrum disorder through caregiver coaching: South African perspectives on barriers and facilitators

Background

A lack of specialists, and insufficient infrastructure and funding to scale early interventions for autism spectrum disorder (ASD) characterize low-resource settings. Integration of early intervention methods that utilize non-specialists, and involve caregivers, into existing systems of care, offers the best hope to address such unmet needs. In South Africa, a caregiver coaching intervention, informed by principles of the Early Start Denver Model (ESDM) was adapted for delivery by non-specialist Early Childhood Development (ECD) practitioners. This study explored perceived barriers and facilitators to sustainable implementation of this approach.

Methods

Nine stakeholders including caregivers, ECD practitioners, ECD school supervisors, and certified South African ESDM therapists involved in intervention implementation were purposively sampled, and individual in-depth interviews were conducted. Interviews were transcribed verbatim and thematically analyzed.

Results

Implementation facilitators included: ECD practitioner ASD knowledge and ongoing supervision; a positive coaching experience; and clear illustration of intervention concepts. Implementation barriers included: complexity of some intervention and coaching concepts; logistical challenges such as time constraints and internet access; and mismatch between video content and the South African context. Facilitators to sustain the intervention included perceived positive child and caregiver outcomes; and ongoing supervision. Barriers to sustain the intervention included socio-economic contextual factors.

Conclusions

In spite of the potential for positive child and caregiver outcomes from caregiver coaching, broader contextual and system-level issues such as poverty, the need for ongoing supervision, and access to local coaching materials in South African languages, may challenge sustainable implementation. Findings from this study will inform tailoring of the intervention training and supervision approach for next step evaluation.

Strategies for Autism Diagnosis and Care in Resource Deprived Settings in Africa: An Overview

Background and Goals:

Autism Spectrum Disorders (ASDs) exist in Africa as they do everywhere in the world. Historically they have been under recognized and under studied. The aim of this paper is to review the existing challenges of ASD care and diagnosis in Africa, with a view to describing workable unique strategies deployable within the continent.

Methods:

We present an overview of the existing medical literature and summarize key findings in relation to the topic of ASD in Africa. First, as a preliminary step, we highlight key findings from previous epidemiological surveys. Second, we undertook a review of relevant available evidence from the various African regions. When the authors were familiar with additional local or regional scientific works, these were also used and referenced.

Discussion:

There has been a growing awareness of the extent to which ASDs exist and have an impact on affected individuals and their families. There are many barriers to diagnosis and effective interventions. These include lack of trained personnel, stigma and cultural beliefs regarding etiology, disparities in resources between urban and rural areas, and poverty. Nonetheless, partnerships to support research and the development of culturally appropriate interventions can be developed and strengths exist in the communities that can be harnessed to improve care.

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

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

The Estimated Prevalence of Autism in School-Aged Children Living in Rural Nepal Using a Population-Based Screening Tool

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.

Early diagnosis and intervention for autism spectrum disorder in Africa: insights from a case study

Background

Globally the prevalence of autism spectrum disorder (ASD) has become more apparent. Prevalence on the African continent remains unknown. There is a call for further research into ASD in Africa as well as means to make early diagnosis and intervention possible.

Objectives

The study aimed to raise awareness about ASD in Africa and encourage dialogue on possible intervention strategies for ASD in low resource settings.

Methods

This was a qualitative mixed method case study. Literature regarding ASD in Africa was reviewed in order to provide context for the research and facilitate data reduction of the case study of Temple Grandin. The case study was conducted through a psychobiographical approach using Erikson's (1950/1973) theory of psychosocial development to interpret the life of Temple Grandin. The findings underwent further data reduction in order to focus on possible interventions for ASD.

Results

Four primary interventions were found to be useful in facilitating development in an individual with ASD. Namely; speech therapy, creative endeavours, animals (human-animal interaction), and being mentored.

Conclusion

Undiagnosed and untreated cases of ASD place undue psychosocial and economic burden on families and communities. Government support, by including ASD in health policies, is essential. Through creative adaptation of knowledge, communities may provide a valuable resource to ASD intervention strategies.

Ethiopian community health workers' beliefs and attitudes towards children with autism: Impact of a brief training intervention

There is a severe shortage of services for children with autism in Ethiopia; access to services is further impeded by negative beliefs and stigmatising attitudes towards affected children and their families. To increase access to services, care provision is decentralised through task-shifted care by community health extension workers. This study aimed to examine the impact of a brief training (Health Education and Training; HEAT) for Ethiopian rural health extension workers and comprised three groups: (1) health extension workers who completed a basic mental health training module (HEAT group, N = 104); (2) health extension workers who received enhanced training, comprising basic HEAT as well as video-based training on developmental disorders and a mental health pocket guide (HEAT+ group, N = 97); and (3) health extension workers untrained in mental health (N = 108). All participants completed a questionnaire assessing beliefs and social distance towards children with autism. Both the HEAT and HEAT+ group showed fewer negative beliefs and decreased social distance towards children with autism compared to the untrained health extension worker group, with the HEAT+ group outperforming the HEAT group. However, HEAT+ trained health extension workers were less likely to have positive expectations about children with autism than untrained health extension workers. These findings have relevance for task-sharing and scale up of autism services in low-resource settings worldwide.

Training needs and perspectives of community health workers in relation to integrating child mental health care into primary health care in a rural setting in sub-Saharan Africa: a mixed methods study

Background

Community health workers can help to address the substantial unmet need for child mental health care in low and middle income countries. However, little is known about their training needs for this potential role. The aim of this study was to examine training needs and perspectives of community health extension workers (HEWs) in relation to providing child mental health care in rural Ethiopia.

Methods

The study was conducted in the Southern Nations, Nationalities and Peoples’ Region of Ethiopia. A mixed methods approach was used. A total of 104 HEWs who had received training in child mental health using the Health Education and Training (HEAT) curriculum were interviewed using a structured survey. In-depth interviews were then conducted with 11 HEWs purposively selected on the basis of the administrative zone they had come from. A framework approach was used for qualitative data analysis.

Results

Most of the HEWs (88.5%; n = 93/104) reported that they were interested in the training provided and all respondents considered child mental health to be important. The perceived benefits of training included improved knowledge (n = 52), case identification (n = 14) and service provision (n = 22). While most of the participants had their training four months prior to the interview, over a third of them (35.6%; n = 37) had already organized mental health awareness-raising meetings. Participants in the qualitative interviews considered the problem of child mental disorders to be widespread and to cause a large burden to the family and the affected children. They reported that improving their competence and knowledge was important to address the problem and to tackle stigma and discrimination. Participants also listed some barriers for service provision, including lack of competence, stigma and institutional constraints. Opportunities mentioned included staff commitment, high levels of interest and a positive attitude towards providing the service.

Conclusions

Although the HEAT training on child mental health was brief, it appears to have had some impact in improving knowledge and care provision. If the key barriers to service provision are addressed and supported by policy guidance, community health workers may contribute substantially in addressing the treatment gap for children with mental health needs.

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

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

Challenges and opportunities to improve autism services in low-income countries: lessons from a situational analysis in Ethiopia

BACKGROUND

Little has been reported about service provision for children with autism in low-income countries. This study explored the current service provision for children with autism and their families in Ethiopia, the existing challenges and urgent needs, and stakeholders' views on the best approaches to further develop services.

METHODS

A situational analysis was conducted based on (i) qualitative interviews with existing service providers; (ii) consultation with a wider group of stakeholders through two stakeholder workshops; and (iii) information available in the public domain. Findings were triangulated where possible.

RESULTS

Existing diagnostic and educational services for children with autism are scarce and largely confined to Ethiopia's capital city, with little provision in rural areas. Families of children with autism experience practical and psychosocial challenges, including severe stigma. Informants further raised the lack of culturally and contextually appropriate autism instruments as an important problem to be addressed. The study informants and local stakeholders provided several approaches for future service provision expansion, including service decentralisation, mental health training and awareness raising initiatives.

CONCLUSIONS

Services for children with autism in Ethiopia are extremely limited; appropriate care for these children is further impeded by stigma and lack of awareness. Ethiopia's plans to scale up mental healthcare integrated into primary care provide an opportunity to expand services for children with autism and other developmental disorders. These plans, together with the additional strategies outlined in this paper can help to address the current service provision gaps and may also inform service enhancement approaches in other low-income countries.