title: Culturally adapted pictorial screening tool for autism spectrum disorder: A new approach.
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Hemamali Perera, Department of Psychological Medicine, Faculty of Medicine, University of Colombo and Lady Ridgeway Hospital for Children, Colombo, Sri Lanka.
authors.forename: Hemamali
authors.initials: H
authors.lastname: Perera
authors.affiliation: Hemamali Perera, Department of Psychological Medicine, Faculty of Medicine, University of Colombo and Lady Ridgeway Hospital for Children, Colombo, Sri Lanka.
authors.forename: Kamal Chandima
authors.initials: KC
authors.lastname: Jeewandara
authors.affiliation: Hemamali Perera, Department of Psychological Medicine, Faculty of Medicine, University of Colombo and Lady Ridgeway Hospital for Children, Colombo, Sri Lanka.
authors.forename: Sudarshi
authors.initials: S
authors.lastname: Seneviratne
authors.affiliation: Hemamali Perera, Department of Psychological Medicine, Faculty of Medicine, University of Colombo and Lady Ridgeway Hospital for Children, Colombo, Sri Lanka.
authors.forename: Chandima
authors.initials: C
authors.lastname: Guruge
keywords: Autism spectrum disorder; Culture; Ethnicity; Parent self-assessment; Pictorial; Screening tool