Observation-Centered Approaches to ASD Assessment in Tanzania

Background: In many lower- and middle-income countries, including several African nations, there is a paucity of mental health assessment services for Autism Spectrum Disorders (ASD). Although efforts are being made to increase the availability of culturally appropriate, ASD specific diagnostic tools, at present it is necessary to promote cross-cultural assessment with available resources to ensure globally that individuals with ASD are identified and receiving treatment. 

Objectives: An observation-based assessment protocol modeled after best-practice guidelines was adapted for use in Tanzania, a region primarily without diagnostic services. The current study examined behavioral, social and adaptive differences between a group of Tanzanian children diagnosed with ASD and a comparison group of children without ASD, suspected of global delays. Based on our study, guidelines are provided for conducting cross-cultural assessments in the context of limited validated resources.

Methods: We describe the utility of a flexible, behavioral observation instrument, the Childhood Autism Rating Scales, Second Edition (CARS2), to gather diagnostic information in a culturally sensitive manner. In addition, our battery included a measure of adaptive functioning normed for use in Africa, an adapted intake interview, and a non-verbal assessment of cognitive functioning. This approach enabled us to rate DSM criteria in a culturally sensitive manner and to provide differential diagnostic evaluations for 41 children in Tanzania aged 2 to 21 years. 

Results: We observed that the ASD group was characterized by significantly higher scores on the CARS2, t = 4.41, p = .001, and demonstrated significantly more DSM symptoms, t = 6.92, p < .001, than a general delay comparison group. 

Conclusions:   Recommendations are provided for making cultural adaptations to current assessment instruments so that ASD differential diagnostic evaluations can be implemented in countries without validated diagnostic instruments, such as Tanzania. This type of assessment battery enables expedited diagnostic services to be provided to individuals in low- and middle-income countries.