**6. Discussion**

**Items common to GARS and ADI-R**

situations

him or her

to self)

more

least 5 secs

people)

humoured or entertained

**GARS Items ADI-R items**

Lack of interest in other children; may watch them but

Uncertain, odd or occasional use of gaze in social

Little or no coordination of eye gaze and vocalisations or

Mis-uses pronoun 'I' and refers to self by name rather than

Little or no smiling at people though may smile at things;

Does not attempt or limited attempt to express

Stereotyped, inappropriate, very limited or no

responses to people except parents.

Special or circumscribed interests that can interfere

Play is linked to highly stereotypic use of objects or attention; interested in infant toys such as music

almost never tries to approach them. No spontaneous sharing or no sharing.

interactions

weakly integrated.

major amount of time.

no reciprocal smiling.

interest by pointing

with social activities

boxes and rattles.

with pronoun.

Flaps hands or fingers in front of face or at sides Marked mannerisms of hands and fingers that may or may

Smells or sniffs objects (e.g. toys, person's hand, hair) Has one to two unusual sensory interests that may take

Whirls, turns in circles Complex and stereotyped bodily movements

**Table 6.** Items common to GARS and ADI-R that best discriminated Iranian children with autism

**Table 7.** Items particular to GARS and ADI-R that best discriminated Iranian children with autism

**Items on GARS only Items ADI-R only**

not interfere with social activities Flicks fingers rapidly in front of eyes for periods of 5 secs or

Withdraws, remains aloof or acts stand-offish in group

42 Recent Advances in Autism Spectrum Disorders - Volume I

Avoids eye contact, looks away when someone looks at

Uses the word I inappropriately e.g. does not say I to refer

Stares at hands, objects or items in the environment for at

Stares or looks unhappy or unexcited when praised

Does not initiate conversations with peers or adults

desirable such as in games or learning activities Makes high-pitched sounds (e.g. eee-eee-eee) or other

vocalizations for self-stimulation Laughs, giggles, cries inappropriately

Uses gestures instead of speech or uses signs to obtain objects

Shows no recognition that a person is present (i.e. looks through

Does not imitate other people when imitation is required or

Behaves in a unreasonably fearful or frightened manner

These two studies had a number of strengths. Sizeable samples of children with autism were recruited alongside those who were normally developing and those who had intellectual disability or another form of developmental disorder. In both studies, the selected items dis‐ criminated effectively the children with autism. Also the studies were located in Iran; a country on which relatively little published research exists. Equally there are some limita‐ tions that need to be acknowledged. No independent verification of the child's diagnosis of autism was possible and reliance was placed on either parental reports or data held by the ISEO. This issue may be of relevance also to children with ID in that some of them may have undiagnosed autism. However even within developed countries, it would have been a cost‐ ly, not to say difficult undertaking, to obtain independent verification of diagnoses and even more improbable in a country such as Iran.

A further limitation is that the first study was retrospective for parents in that their child had already been diagnosed and hence their ratings on GARS may have been influenced by the increased awareness they had about the indicators of autism which they may not have had prior to the diagnosis. Hence it would be important to replicate the study on a prospec‐ tive basis especially with parents who had limited contact with professionals or with parents who had lower levels of education. The latter recommendation arises from the finding in Study 1 that parents from two provinces had significantly lower scores on the 16 items. In these two provinces professional services are more limited with fewer parents availing of higher education. These factors were also proposed as reasons for the variations in preva‐ lence rates of autism across Iran that has been previously reported [1].

Nevertheless it would be a major undertaking to repeat the study with an unselected popu‐ lation of children although the existence of the Iranian national screening programme for autism on school entry makes this a possibility for five year olds. An alternative approach is to consider the items identified in these studies as the basis for a referral tool [26]. For exam‐ ple, when concern is expressed about a child by parents or preschool educators, or if a child is already experiencing problems, then these items might serve as a guide for primary health or social care personnel to help them decide as to whether a referral should be made for more specialist assessment for autism.

However the issue of identifying children with autism in other cultures has to be set within a broader context than screening. First increased opportunities need to be provided to pa‐ rents - and to mothers especially – for them to become more knowledgeable about child de‐ velopment and indicators of potential problems particularly those of relevance to their culture. The desire for increased information about autism is a common request of parents in different cultures [34]. Modern technology provides a cost-effective means for doing this.

Second, the beliefs, knowledge and skills of professions involved in diagnosing develop‐ mental problems will need to be expanded in relation to autism so that they can undertake appropriate and thorough assessments of the children and devise relevant intervention pro‐ gramme for them and their families [35]. The development of an indigenous knowledge base in relation to autism is especially pertinent as reliance on assessment and intervention tools from other cultures may prove inadequate. Equally there is an onus on professionals in Western countries to become better attuned to the cultural issues they may face with immi‐ grant communities [9] as part of the endeavour to find more effective and efficient tools for the diagnosis of autism spectrum disorders [42].

Finally cross-cultural research in autism has much to contribute to our wider understanding of this condition and of the factors that may ameliorate its impact on children and families. An essential starting point is to have a common tool for use across countries that not only defines the similarities in children who have the condition but is also sensitive to the cultur‐ al variations that may be inherent in its manifestation in varying cultures. These studies in Iran are a contribution to that endeavour and provide a model as to how it could be realised.

Indicators of Autism in Iranian Children http://dx.doi.org/10.5772/52853 45

Our sincere thanks to Miss Ameneh Mahmoodizadeh from the Iranian Special Education

Centre for Intellectual and Developmental Disabilities, Institute of Nursing Research, Uni‐

[1] Samadi SA, Mahmoodizadeh A & McConkey R. A national study of the prevalence of autism among five-year-old children in Iran. Autism: The International Journal of

[2] Daley, TC. The need for cross-cultural research on the pervasive developmental dis‐

[3] Greenfield PM, Ward M & Jacobs J. You can't take it with you: why ability assess‐ ments don't cross cultures. American Psychologist, 1997; 52(10) 1115–1124.

[4] Gilliam JE. Gilliam Autism Rating Scale-Second edition. Austin, Texas: Pro-Ed; 2006. [5] Lord C, Rutter M & Le Couteur A. Autism Diagnostic Interview-Revised: A revised version of a diagnostic interview for caregivers of individuals with possible perva‐ sive developmental disorders. Journal of Autism and Developmental Disorders 1994;

[6] Matson JL, Worley JA, Fodstad JC, Chung K-M, Suh D, Jhin HK, Ben-Itzchak E, Za‐ chor DA, Furniss F. A multinational study examining the cross cultural differences in

**Acknowledgement**

**Author details**

**References**

24(5) 659-685.

Organisation for her assistance with Study 2.

Sayyed Ali Samadi and Roy McConkey

\*Address all correspondence to: r.mcconkey@ulster.ac.uk.

versity of Ulster, Newtownabbey, N. Ireland, UK

Research and Practice 2012; 16 (1), 4-15.

orders. Transcultural Psychiatry, 2002; 39 531–550.

A third aspect arises from the previous two; namely the relationships between parents and professionals. Recent guidance in relation to autism in the UK, emphases the need for pro‐ fessionals to take seriously parental concerns [36]. Also diagnostic information often has to be obtained through sensitive and careful questioning about the child's typical behaviours in natural settings as well as observations of the child in clinic or school contexts. This is best done through a trusted relationship between parents and professionals. Moreover parents may experience elevated levels of stress and poorer health because of their child's behaviour and will personally benefit from support offered by professional advisers [37]. Thus profes‐ sionals may need to acquire wider communication and inter-personal skills in order to effec‐ tively support families.

These broader issues relating to the identification and diagnosis of autism are not peculiar to Iran and future cross-cultural research would help to identify practical means of addressing them, especially when health, social care and educational resources are limited [38].

The findings also have international application in another sense. They confirm the uni‐ versality of certain indicators of autism in children; most notably in Iranian culture of re‐ petitive and stereotyped behaviours and atypical social interactions. Items relating to communication and language were apparently less indicative of autism. As yet there is no directly comparable data with that obtained from other cultures although future re‐ search might provide this. However studies that have directly compared children in the UK and USA with those from South Korea and Israel [6] found significant differences in the extent to which items relating to socialisation, verbal communication and restricted interests were reported although all were present across the four countries. It is likely that this cultural variation in parental perceptions of autistic traits reflects the behaviours in children that parents value or perceive as being unusual within their particular cul‐ ture. Future research could usefully explore this proposition further as it may also ac‐ count for differences between the perceptions of parents from different socio-economic backgrounds.

It is possible though that some of the inter-cultural differences and perhaps the intra-coun‐ try variation may arise from other environmental factors. Walker et al [39] have identified from international epidemiological studies the key risks that prevent children from attaining their developmental potential, such as lack of cognitive stimulation, intrauterine growth re‐ striction, maternal stress and exposure to societal violence. It is possible that some of these environmental factors could trigger particular behaviour patterns within children that fall within the broad category of autism. To date much energy has been expended on identify‐ ing the genetic bases for autism and even if these were to be found, there may well be envi‐ ronmental factors that mediate the genetic disposition for autistic traits.

Finally cross-cultural research in autism has much to contribute to our wider understanding of this condition and of the factors that may ameliorate its impact on children and families. An essential starting point is to have a common tool for use across countries that not only defines the similarities in children who have the condition but is also sensitive to the cultur‐ al variations that may be inherent in its manifestation in varying cultures. These studies in Iran are a contribution to that endeavour and provide a model as to how it could be realised.
