Observational Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Pediatr. Feb 8, 2017; 6(1): 45-51
Published online Feb 8, 2017. doi: 10.5409/wjcp.v6.i1.45
Culturally adapted pictorial screening tool for autism spectrum disorder: A new approach
Hemamali Perera, Kamal Chandima Jeewandara, Sudarshi Seneviratne, Chandima Guruge
Hemamali Perera, Department of Psychological Medicine, Faculty of Medicine, University of Colombo and Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
Kamal Chandima Jeewandara, Department of Family Medicine, Faculty of Medical Sciences, University of Sri Jayawardenapura, Colombo, Sri Lanka
Sudarshi Seneviratne, Department of Psychological Medicine, Faculty of Medicine, University of Colombo and Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
Chandima Guruge, National Hospital of Sri Lanka, Colombo, Sri Lanka
Author contributions: Perera H contributed to research design, research performance, wrote the manuscript; Jeewandara KC contributed to research design, research performance, data entry and analysis; Seneviratne S contributed to research design, research performing, manuscript preparation; Guruge C contributed to research design, research performing, and data entry.
Institutional review board statement: Approval was granted by Ethical Review Committee, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka.
Informed consent statement: All parents participating in the study gave informed consent verbally. Identity of parents and child was accessible only to the researchers and all data were held in strict confidentiality. Informed written consent was obtained from all parents who agreed to be photographed with their children for the pictorial scale. All children photographed were typically developing children.
Conflict-of-interest statement: Authors declare no conflicts of interest.
Data sharing statement: No additional data is available on participating children, except data on clinical intervention, which are confidential and cannot be shared.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Hemamali Perera, MBBS, MD, FRCPsych, Professor Emeritus, Independent Practitioner in Child and Adolescent Psychiatry, Formally Department of Psychological Medicine, Faculty of Medicine, University of Colombo and Lady Ridgeway Hospital for Children, Colombo, Sri Lanka. hemamali_p@yahoo.com
Telephone: +94-71-8331877
Received: June 29, 2016
Peer-review started: July 1, 2016
First decision: September 28, 2016
Revised: October 26, 2016
Accepted: November 16, 2016
Article in press: November 17, 2016
Published online: February 8, 2017
Abstract
AIM

To assess the performance of a newly designed, culturally adapted screening tool for autism spectrum disorder (ASD).

METHODS

Items for the screening tool were modeled from already documented checklists and diagnostic criteria for ASD. Each item in text was paired with a photograph that illustrated the written content, which was in the 2 main local languages. The final product had 21 items and was named the pictorial autism assessment schedule (PAAS). Performance of PAAS was tested on a clinical sample of 18-48 mo old children, diagnosis naïve, presenting with developmental deficits. Mothers completed PAAS checklist. Based on clinical diagnosis, which was taken as the gold standard, children were later grouped into ASD (Group 1) and non-ASD developmental disorders (Group 2). Mothers of a control sample of typically developing children also completed PAAS (Group 3).

RESULTS

A total of 105 children (Group 1-45, Group 2-30, Group 3-30) participated in the study. Mean age of Group 1 and Group 2 were 36 and 40 mo respectively. Majority were male in all 3 groups. Performance of PAAS in discriminating between ASD and non-ASD developmental disorders was sensitivity 88.8%, specificity 60.7%, positive predictive value (PPV) 78.4%, negative predictive value (NPV) 77.2%, likelihood ratio (LR+) 2.26, and LR- 0.18. Performance of PAAS in discriminating between ASD and typical development was sensitivity 88.0%, specificity 93.3%, PPV 95.2%, NPV 84.0%, LR+ 13.3 and LR- 0.12. The results indicated that that a positive result from PAAS was 2.26 times more likely to be found in a child with ASD than in a child with non-ASD developmental disorder. A positive result from PAAS was 13.3 times more likely to be found in a child with ASD than in a child with typical development.

CONCLUSION

PAAS is an effective tool in screening for ASD. Further study is indicated to evaluate the feasibility of using this instrument for community screening for ASD.

Keywords: Autism spectrum disorder, Screening tool, Culture, Ethnicity, Parent self-assessment, Pictorial

Core tip: Two previous studies in Sri Lanka showed that mothers had difficulty in comprehending and accurately responding to symptom of autism spectrum disorder (ASD) given in written text in a screening tool. The possible reason was cultural, where mothers did not perceive social deficits. To overcome this barrier, a screening tool was designed where each item on the checklist of key features of ASD was paired with a compatible photograph to improve comprehension. The new tool was tested on children with ASD, non-ASD developmental disorders and typically developing children. The new tool showed high sensitivity in discriminating between ASD and the other 2 groups.