The online version of this article (https://doi.org/10.1186/s13229-018-0235-3) contains supplementary material, which is available to authorized users.
Sophie Carruthers and Emma Kinnaird are joint first authors.
Ioannis Bakolis and Rosa A. Hoekstra are joint last authors.
There is a global need for brief screening instruments that can identify key indicators for autism to support frontline professionals in their referral decision-making. Although a universal set of conditions, there may be subtle differences in expression, identification and reporting of autistic traits across cultures. In order to assess the potential for any measure for cross-cultural screening use, it is important to understand the relative performance of such measures in different cultures. Our study aimed to identify the items on the Autism Spectrum Quotient (AQ)-Child that are most predictive of an autism diagnosis among children aged 4–9 years across samples from India, Japan and the UK.
We analysed parent-reported AQ-Child data from India (73 children with an autism diagnosis and 81 neurotypical children), Japan (116 children with autism and 190 neurotypical children) and the UK (488 children with autism and 532 neurotypical children). None of the children had a reported existing diagnosis of intellectual disability. Discrimination indices (DI) and positive predictive values (PPV) were used to identify the most predictive items in each country.
Sixteen items in the Indian sample, 15 items in the Japanese sample and 28 items in the UK sample demonstrated excellent discriminatory power (DI ≥ 0.5 and PPV ≥ 0.7), suggesting these items represent the strongest indicators for predicting an autism diagnosis within these countries. Across cultures, good performing items were largely overlapping, with five key indicator items appearing across all three countries (can easily keep track of several different people’s conversations, enjoys social chit-chat, knows how to tell if someone listening to him/her is getting bored, good at social chit-chat, finds it difficult to work out people’s intentions). Four items indicated potential cultural differences. One item was highly discriminative in Japan but poorly discriminative (DI < 0.3) in the UK and India, and a further item had excellent discrimination properties in the UK but poorly discriminated in the Indian and Japanese samples. Two additional items were highly discriminative in two cultures but poor in the third.
Cross-cultural overlap in the items most predictive of an autism diagnosis supports the general notion of universality in autistic traits whilst also highlighting that there can be cultural differences associated with certain autistic traits. These findings have the potential to inform the development of a brief global screening tool for autism. Further development and evaluation work is needed.
Additional file 1: Supplementary results including breakdown of case/control response proportions by country (Tables S1-S3) and sensitivity analysis exploring influence of age in the UK sample (Table S4). (DOCX 51 kb)13229_2018_235_MOESM1_ESM.docx
American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). Washington, DC: American Psychiatric Association; 2013. CrossRef
Bishop DV. Which neurodevelopmental disorders get researched and why? PLoS One. 2010;5:e15112. CrossRef
Daley TC. The need for cross-cultural research on the pervasive developmental disorders. Transcult Psychiatry. 2002;39:531–50. CrossRef
Dyches TT, Wilder LK, Sudweeks RR, Obiakor FE, Algozzine B. Multicultural issues in autism. J Autism Dev Disord. 2004;34:211–22. CrossRef
Freeth M, Sheppard E, Ramachandran R, Milne E. A cross-cultural comparison of autistic traits in the UK, India and Malaysia. J Autism Dev Disord. 2013;43:2569–83. CrossRef
Durkin MS, Elsabbagh M, Barbaro J, Gladstone M, Happe F, Hoekstra RA, Lee LC, Rattazzi A, Stapel-Wax J, Stone WL, et al. Autism screening and diagnosis in low resource settings: challenges and opportunities to enhance research and services worldwide. Autism Res. 2015;8:473–6. CrossRef
Norbury CF, Sparks A. Difference or disorder? Cultural issues in understanding neurodevelopmental disorders. Dev Psychol. 2013;49:45–58. CrossRef
Caron KG, Schaaf RC, Benevides TW, Gal E. Cross-cultural comparison of sensory behaviors in children with autism. Am J Occup Ther. 2012;66:e77–80. CrossRef
Freeth M, Milne E, Sheppard E, Ramachandran R. Autism across cultures: perspectives from non-Western cultures and implications for research. In: Handbook of Autism and Pervasive Developmental Disorders. 4th ed; 2014.
Inada N, Koyama T, Inokuchi E, Kuroda M, Kamio Y. Reliability and validity of the Japanese version of the modified checklist for autism in toddlers (M-CHAT). Res Autism Spectr Disord. 2011;5:330–6. CrossRef
Soto S, Linas K, Jacobstein D, Biel M, Migdal T, Anthony BJ. A review of cultural adaptations of screening tools for autism spectrum disorders. Autism. 2015;19:646–61. CrossRef
Charman T, Gotham K. Measurement issues: screening and diagnostic instruments for autism spectrum disorders - lessons from research and practice. Child Adolesc Ment Health. 2013;18:52–63. CrossRef
Charman T, Baird G, Simonoff E, Chandler S, Davison-Jenkins A, Sharma A, O'Sullivan T, Pickles A. Testing two screening instruments for autism spectrum disorder in UK community child health services. Dev Med Child Neurol. 2016;58:369–75. CrossRef
Henrich J, Heine SJ, Norenzayan A. Most people are not WEIRD. Nature. 2010;466:29. CrossRef
Perera H, Wijewardena K, Aluthwelage R. Screening of 18-24-month-old children for autism in a semi-urban community in Sri Lanka. J Trop Pediatr. 2009;55:402–5. CrossRef
Seif Eldin A, Habib D, Noufal A, Farrag S, Bazaid K, Al-Sharbati M, Badr H, Moussa S, Essali A, Gaddour N. Use of M-CHAT for a multinational screening of young children with autism in the Arab countries. Int Rev Psychiatry. 2008;20:281–9. CrossRef
Srisinghasongkram P, Pruksananonda C, Chonchaiya W. Two-step screening of the modified checklist for autism in toddlers in Thai children with language delay and typically developing children. J Autism Dev Disord. 2016;46:3317–29. CrossRef
Wakabayashi A, Baron-Cohen S, Uchiyama T, Yoshida Y, Tojo Y, Kuroda M, Wheelwright S. The Autism-Spectrum Quotient (AQ) Children's Version in Japan: a cross-cultural comparison. J Autism Dev Disord. 2007;37:491–500. CrossRef
Albores-Gallo L, Roldán-Ceballos O, Villarreal-Valdes G, Betanzos-Cruz BX, Santos-Sánchez C, Martínez-Jaime MM, Lemus-Espinosa I, Hilton CL. M-CHAT Mexican version validity and reliability and some cultural considerations. ISRN Neurol. 2012;2012:408694. CrossRef
Samadi SA, McConkey R. Screening for autism in Iranian preschoolers: contrasting M-CHAT and a scale developed in Iran. J Autism Dev Disord. 2015;45:2908–16. CrossRef
Brennan L, Fein D, Como A, Rathwell IC, Chen C-M. Use of the modified checklist for autism, revised with follow up-Albanian to screen for ASD in Albania. J Autism Dev Dis. 2016;46:3392–407 Advance online publication. CrossRef
Rudra A, Banerjee S, Singhal N, Barua M, Mukerji S, Chakrabarti B. Translation and usability of autism screening and diagnostic tools for autism spectrum conditions in India. Autism Res. 2014;7:598–607. CrossRef
Robins DL, Fein D, Barton ML, Green JA. The modified checklist for autism in toddlers: an initial study investigating the early detection of autism and pervasive developmental disorders. J Autism Dev Disord. 2001;31:131–44. CrossRef
Siu A. Screening for autism spectrum disorder in young children: US Preventive Services Task Force recommendation statement. JAMA. 2016;315:691–6. CrossRef
Kamio Y, Inada N, Koyama T. A nationwide survey on quality of life and associated factors of adults with high-functioning autism spectrum disorders. Autism. 2013;17:15–26. CrossRef
Mandell DS, Novak MM, Zubritsky CD. Factors associated with age of diagnosis among children with autism spectrum disorders. Pediatrics. 2005;116:1480–6. CrossRef
Shattuck PT, Durkin M, Maenner M, Newschaffer C, Mandell DS, Wiggins L, Lee LC, Rice C, Giarelli E, Kirby R, et al. Timing of identification among children with an autism spectrum disorder: findings from a population-based surveillance study. J Am Acad Child Adolesc Psychiatry. 2009;48:474–83. CrossRef
Joshi MS, Maclean M. Maternal expectations of child development in India, Japan, and England. J Cross-Cult Psychol. 1997;28:219–34. CrossRef
Hoekstra RA, Bartels M, Cath DC, Boomsma DI. Factor structure, reliability and criterion validity of the Autism-Spectrum Quotient (AQ): a study in Dutch population and patient groups. J Autism Dev Disord. 2008;38:1555–66. CrossRef
Ruta L, Mazzone D, Mazzone L, Wheelwright S, Baron-Cohen S. The Autism-Spectrum Quotient--Italian version: a cross-cultural confirmation of the broader autism phenotype. J Autism Dev Disord. 2012;42:625–33. CrossRef
Auyeung B, Baron-Cohen S, Wheelwright S, Allison C. The Autism Spectrum Quotient: Children's Version (AQ-Child). J Autism Dev Disord. 2008;38:1230–40. CrossRef
Baron-Cohen S, Wheelwright S, Skinner R, Martin J, Clubley E. The Autism-Spectrum Quotient (AQ): evidence from Asperger syndrome/high-functioning autism, males and females, scientists and mathematicians. J Autism Dev Disord. 2001;31:5–17. CrossRef
Baron-Cohen S, Hoekstra RA, Knickmeyer R, Wheelwright S. The Autism-Spectrum Quotient (AQ)--adolescent version. J Autism Dev Disord. 2006;36:343–50. CrossRef
Murray AL, Allison C, Smith PL, Baron‐Cohen S, Booth T, Auyeung B. Investigating diagnostic bias in autism spectrum conditions: an item response theory analysis of sex bias in the AQ‐10. Autism Res. 2017;10(5)790-800. CrossRef
James RJ, Dubey I, Smith D, Ropar D, Tunney RJ. The latent structure of autistic traits: a taxometric, latent class and latent profile analysis of the adult Autism Spectrum Quotient. J Autism Dev Disord. 2016;46:3712–28. CrossRef
Ashwood KL, Gillan N, Horder J, Hayward H, Woodhouse E, McEwen FS, Findon J, Eklund H, Spain D, Wilson CE, et al. Predicting the diagnosis of autism in adults using the Autism-Spectrum Quotient (AQ) questionnaire. Psychol Med. 2016;46:2595–604. CrossRef
Allison C, Auyeung B, Baron-Cohen S. Toward brief “Red Flags” for autism screening: the short Autism Spectrum Quotient and the short Quantitative Checklist for Autism in toddlers in 1,000 cases and 3,000 controls [corrected]. J Am Acad Child Adolesc Psychiatry. 2012;51:202–12 e207. CrossRef
Glascoe FP. Parents’ concerns about children’s development: prescreening technique or screening test? Pediatrics. 1996;99:522–8. CrossRef
Gillis JM, Callahan EH, Romanczyk RG. Assessment of social behavior in children with autism: the development of the behavioral assessment of social interactions in young children. Res Autism Spectr Disord. 2011;5:351–60. CrossRef
Hofstede G. Culture's Consequences: Comparing Values, Behaviors, Institutions and Organizations Across Nations. 2nd ed. Thousand Oaks: Sage Publications; 2001.
Rose GM, Dalakas V, Kropp F. Consumer socialization and parental style across cultures: findings from Australia, Greece, and India. J Consum Psychol. 2003;13:366–76. CrossRef
Aron A, Aron EN, Tudor M, Nelson G. Close relationships as including other in the self. J Pers Soc Psychol. 1991;60:241. CrossRef
Fiske A, Kitayama S, Markus HR, Nisbett RE. The cultural matrix of social psychology. In: Gilbert SF D, Lindzey G, editors. The handbook of social psychology. 4th ed. San Francisco: McGraw-Hill; 1998. p. 915–81.
Rosenberger NR. Japanese sense of self. New York: Cambridge University Press; 1992.
Girimaji SC, Srinath S. Perspectives of intellectual disability in India: epidemiology, policy, services for children and adults. Curr Opin Psychiatry. 2010;23:441–6. CrossRef
Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang MM, Sterne JA, Bossuyt PM. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011;155:529–36. CrossRef
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th, text revision edn. Washington, DC: American Psychiatric Association; 2000.
World Health Organisation. The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organisation; 1992.
- A cross-cultural study of autistic traits across India, Japan and the UK
Rosa A Hoekstra
- BioMed Central