**2. Identifying children with autism in different cultures**

Children with autism have deficits in three developmental domains: communication, social‐ isation and restricted interests along with repetitive behaviours [7]. These criteria are pre‐ sumed to hold across all cultures although there is growing evidence of cultural variations in the way children may present with Autism. Indeed there are good theoretical grounds for expecting this to be so. Theories on human development propose that children develop through adapting to the multidimensional, intersecting environments within which they live and grow, the most proximate of which are their parents and families [8]. Parental influ‐ ences on their child's development may therefore vary in different cultures depending on their beliefs about normative development, the relative value their culture places on differ‐ ent behaviors and the meaning attributed to them[9;10]. For example, in Western societies the absence of direct eye contact is an early indicator of ASD yet in Chinese and Japanese societies, such eye contact is uncommon as looking directly into someone's eyes is consid‐ ered shameful in these parts of East Asia [11].

Studies done in the Western societies around early signs of autism, [12] found that the most common parental concerns were for delay in speech and language development, followed by abnormal signs of socio-emotional behaviour and medical problems or delay in reaching milestones. By contrast, Daley [13] found that with Indian parents, social difficulties - such as lack of interest in people, poor eye contact and showing no interest in playing with other children - were rated as the first parental concern with delay in speech as a secondary con‐ cern. These variations in cultural expectations are likely to exist among indigenous profes‐ sionals as well as parents.

The diagnosis of autism varies across different ethnic groups within countries. Mandell et al. [14] in a study of over 2,500 eight year-olds in the USA, reported that children from Black, Hispanic and other ethnic or racial groups were less likely than white children to have a documented autism spectrum disorder. Valicenti-McDermott et al. [15] found that children of Hispanic and African American origin, foreign-born children, and children born to for‐ eign mothers were more likely to be diagnosed at an older age than those from white Ameri‐ can parentage. Likewise in Holland, fewer children from Moroccan or Turkish immigrants than native born Dutch children were referred for assessments for ASD [16]. Moreover pae‐ diatricians (n = 81) more often referred to autism when judging clinical vignettes of Europe‐ an majority cases (Dutch) than vignettes of minority cases.

Cultural influences may also explain to some extent the variation in prevalence rate of ASD reported across different countries. A systematic review of 40 studies [17], reported rates varying from 3.8 per 10,000 in Norway, 5.4 in France and 5.6 in Finland through to a high of 60 per 10,000 in Sweden. However in London, a more thorough study reported a prevalence rate of 38 9 per 10,000 for autistic disorders and for other ASDs at 77 2 per 10,000; giving a total prevalence for all ASDs of 116 1 per 10,000 [18]. A regression analyses of the prevalence studies found that the most significant influence on ASD rates was the diagnostic criteria used, followed by the age of child when identified, the country of origin and urban/rural lo‐ cation of the sample [17].

These same factors may also account for the variation in prevalence rates that have been re‐ ported within countries even when ascertainment method, age group and reporting period are similar. In the USA, the prevalence of all ASDs in eight year old children varied across eleven sites from 42 per 10,000 in Florida to 121 per 10,000 in Arizona and Missouri [19]. Us‐ ing special education data on students with ASD, Coo at al., [20] reported a prevalence of 43.1 per 10,000 among 4–9 years school children in the British Colombia Province of Canada whereas in Quebec it is reported at less than half this, at 21.6 per 10,000 [21].

One explanation for differences in the prevalence and identification of ASD across cultures and regions is varying awareness of the criteria associated with a diagnosis of ASD [6]. More specifically, it appears that differences may be more likely to arise cross culturally due to various factors such as ''when a symptom is perceived, by whom, and what behaviour is noticed first, as well as whether it is perceived as problematic'' ([2], p. 538). Moreover cul‐ tural attitudes regarding typical behaviours and what is perceived to be normal or abnormal development for that culture would also have an impact on diagnosis of an ASD. Hence children may be more or less susceptible to a diagnosis of an ASD dependent on the cultural expectations of parents and indigenous professionals. Thus screening and other assessment tools for autism developed in Western countries may not be sufficiently sensitive to detect early signs of autism in other societies and could possibly underestimate the prevalence of the condition [3].
