Indian Pediatr 2014;51: 356-357
Challenges in Diagnosis of Autism and the
Struggle of Using Western Screening Tools in Different Cultures
Anjali Varma and Joseph W Iskandar
Department of Psychiatry and Behavioral Medicine,
Virginia Tech Carilion School of Medicine, Roanoke, VA 24016, USA.
Several metabolic abnormalities have been identified in
various studies (e.g. elevated 5-HT, impaired phenolic amines
metabolism) while neuroimaging has yielded inconsistent results in
evaluating autism. Thus, the diagnosis is primarily clinical and often
challenging due to frequent co-morbidities and lack of adequate
Autism spectrum disorder (ASD) and other related
conditions are estimated to affect up to 10-15 people per 10,000 in
populations worldwide . As defined in the recently published
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5), ASD encompasses the previous DSM IV TR’s autistic disorder
(autism), Asperger’s disorder, childhood disintegrative disorder, and
pervasive developmental disorder not otherwise specified. ASD manifests
in early childhood and is characterized by deficits in verbal
communication, social interaction, and restricted repetitive behaviors,
interests and activities. Although a clear etiology of ASD is unknown,
several different factors have been implicated such as genetic
predisposition, obstetric complications, exposure to toxic agents, and
perinatal exposure to medications such as valproic acid , or
infections such as maternal rubella.
With increased awareness of the potential benefits of
early interventions, there has been an increased interest and emphasis
on early identification of infants and toddlers with or at risk of ASD.
Several instruments have been developed to diagnose ASD. However,
administering these tools may need the expertise of child psychiatrists,
pediatricians and child psychologists who have extensive training and
experience with children with autism in order to use these tools and
come up with a reliable and valid evaluation. The Childhood Autism
Rating Scale (CARS) is a commonly used scale for diagnosis and measuring
the severity of autism along with others such as the Autism Diagnostic
Observation Schedule-Generic (ADOS-G) and Autism Diagnostic
Interview-Revised (ADI-R). A recent study by Kimple, et al. 
reported that Spanish-speaking toddlers in the United State of America
are twice as likely as their English-speaking peers to have abnormal
results on the Modified Checklist for Autism in Toddlers (M-CHAT), a
common parent-completed questionnaire to screen for autism. Dr. Kimple’s
study highlights the fact that children from minority and/or lower
socioeconomic status (SES) backgrounds may screen positive at higher
rates than majority and/or higher SES. Issues with translation,
interpretation, or cultural understanding of behaviors may contribute to
these false positive results.
In the current issue of Indian Pediatrics ,
the authors describe the development and validation of INCLEN diagnostic
tool for autism Spectrum disorder (INDT-ASD). The authors highlight the
current challenges involved in using the diagnostic measures developed
in the Western world in the diverse socio-cultural Indian setting
including the financial implications involved in using patented
instruments. Currently, the only other Indian scale used for diagnosing
and measuring autism is the Indian Scale for Assessment of Autism (ISAA)
, which is based on the CARS. The new tool discussed in this issue –
INDT-ASD – was tested to have specificity similar to DSM-5 (95%) and
sensitivity of 76%, that was much higher. A high Cronbach’s alpha
coefficient for internal consistency was indicative of a homogenous
symptom cluster in the Indian context. The article underscores the
importance of socio-cultural factors in the diagnosis of psychiatric
disorders, specifically ASD, and also highlights the role of language
when making diagnostic considerations in disorders involving language
and communication. Currently the INDT-ASD is available in eight
different Indian languages.
Common co-morbidities such as intellectual
impairment, subnormal intelligence quotient (IQ), Attention deficit
hyperactivity disorder (ADHD) and anxiety are common and may add to the
diagnostic challenge. Once accurate diagnosis is established, management
involves education of family members and intensive individualized
behavioral and psychosocial interventions at home and in school settings
in order for the child to achieve an optimal outcome. Applied behavior
analysis is the most influential and effective treatment for the main
core symptoms of Autism . The role of pharmacotherapy is limited to
specific target symptoms and or co-morbidities.
Continued research is needed to develop a better
means of diagnosing ASD due to inconsistencies in findings across
cultural and socioeconomic backgrounds. The development of INDT-ASD
seems to address this issue in the Indian culture.
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