**3. Screening and assessing children for autism**

tistic traits [6]. Nevertheless the implementation of tools for the identification of children with autism has to be located within wider considerations; notably the education of parents and professionals around indicators of atypical child development and the possible environ‐

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‐

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‐

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‐

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

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

mental influences on children's behaviours.

30 Recent Advances in Autism Spectrum Disorders - Volume I

ered shameful in these parts of East Asia [11].

an majority cases (Dutch) than vignettes of minority cases.

sionals as well as parents.

A two-stage process for identifying children with autism is operational in many countries [22]. The first stage involves a universal screening of all children and various tools have been developed for use with children at different ages. They consist of a series of items indi‐ cative of autism and use parents as the primary informants. For example the CHAT (Check‐ list for Autism in Toddlers) is a screening tool developed for use with infants aged 18 months developed in the UK [23] that has also been adapted for use in the USA (M-CHAT: [24]) and which has shown promise for use in Arab countries [25]. More recently, ten item screening tools have been developed for use with children, adolescents and adults based on the Autism Quotient developed in the UK [26]. Those individuals who screen positive – their scores exceed a designated cut-off point - are then referred for more detailed diagnostic assessment.

A range of diagnostic tools for autism also have been developed [27]. These are based on DSM-IV/ICD-10 criteria for autism and information about the child is usually obtained through a detailed, structured interview with parents. However a multi-disciplinary as‐ sessment by experienced clinicians is also recommended including a physical examination along with developmental and/or psychometric evaluations. These will enable a differen‐ tial diagnosis to be made for autism from other conditions in which there is overlap of symptomology [28].

affluent families. Provision for adult services is mostly through private or voluntary organi‐

Indicators of Autism in Iranian Children http://dx.doi.org/10.5772/52853 33

Iran is one of the few countries that has a national screening programme for autism prior to children's entry to compulsory education at age 6. An analysis of data obtained on over 1.32 million children aged 5 years of age screened over a three-year period, yielded an overall Iranian prevalence of 6.26 per 10,000 [1]. Although this rate is similar to that previously re‐ ported for certain European countries and for Hong Kong, it is much lower than those re‐

The main aim of the two studies reported in this chapter was to identify the most common indicators of autism for Iranian parents whose children had been given a diagnosis of au‐ tism. As argued above, this investigation would identify items for use in screening tests that would be culturally sensitive for an Iranian culture. However the initial pool of items would be drawn from those behaviours that define autism internationally according to DSM-IV [7] and ICHD-10 [30]. These were taken from two commonly used scales for autism – the Gil‐ liam Rating Scale for Autism (GARS) and the Autism Diagnostic Interview – revised (ADI-R). Although developed in the USA and the UK respectively, they have been translated for

The most common indicators of autism would be chosen as those that best discriminated children with a diagnosis of autism from age peers who were normally developing; from those who were considered to have an intellectual disability and from those who were ini‐ tially suspected of having autism but were not diagnosed as such following assessment.

The resulting set of indicators would have particular relevance for the development of fur‐ ther screening tools in Iran but these findings might have wider applicability to other Mus‐

The Gilliam Autism Rating Scale - Second edition GARS ll [4] was developed in the United States of America and is based on DSM-IV diagnostic criteria for autism. It is widely used in hospitals, school and clinics across the USA with good psychometric properties which sub‐ sequent evaluation studies have confirmed [40]. The main reservations concerning its use, centre on the cut-off points that are taken to be indicative of autism. The consensus is that

This tool takes the form of a behaviour checklist developed for use with children and youth aged 3 to 22 years. It consists of 42 items grouped into three subscales: Stereotyped Behav‐ iours, Communication, and Social Interaction which are combined into a standard score called the "Autism Index" with higher scores indicative of ASD. A further 14 items contrib‐ ute data about the child's development during the first three years of life which are used to supplement information about the child's current level of functioning. Reliability and validi‐

these should be set at a lower level than recommended in the test manual [41].

sations that also rely heavily on parental fees.

ported for Sweden, USA and England [29].

**4.1. Indicators of autism in Iran**

use in other countries.

lim cultures and non-Western societies.

**4.2. Study 1: Screening for autism**

Such assessments can be time-consuming and costly. Their efficiency is determined by the referrals from the screening tests. If individuals are screened as positive for autism but are not subsequently diagnosed as having autism (false positives) this can mean wasted efforts by the diagnostic team. The converse is also concerning. Children may screen as negative for autism but had they been assessed, they might have been given a diagnosis of autism (false negatives). Thus the effectiveness of the screening test needs to be assessed in terms of its sensitivity (true positives are identified) and its specificity (false negatives are avoided). Thus the choice of items that are included in the screening test is crucial. To date, the screen‐ ing tools have been developed within Western societies and given the earlier comments about cultural influences, it is conceivable that at least some of these items may not be suited for use in other cultures. The risk then is that the efficiency of the screening tool is diminish‐ ed within that society [11]. Indeed the same argument may apply when screening individu‐ als from immigrant communities in Western countries.
