CHAPTER 2: LITERATURE REVIEW
2.5 Autism Diagnostic Observation Schedule (ADOS)
2.5.3 A Western tool within the South African Context
The ADOS is a Western tool and this study primarily aimed to explore the diagnostic ability of it in the South African context. As mentioned, cultures and related behaviours are variable.
In conducting the assessments in South African schools where the majority of the participants are Black, one needed to try to reduce behavioural variances related to culture.
Assessment tools such as the ADOS are subject to cultural biases (Norbury & Sparks, 2012).
Hence, every effort was made to standardise the ADOS to the South African context without changing the assessment procedure. Some adaptations were however necessary. For example, the pictures on the original ADOS kit are Americanised and represent activities many South African children are unfamiliar with Due to concern regarding un-relatedness and lack of understanding, the Westernised pictures were substituted for scenes that are more African.
Namely, a picture including activities such as water skiing, paragliding, playing tennis and sailing, were replaced with illustrations of a rural home environment with people flying home-made kites, corn growing in the garden and chickens running around with a pet dog on the scene, since these are features that were more likely to be familiar to most Black African families.
Similarly, dolls in the form of a Caucasian family with children and grandparents, were substituted for an African family with brown skins. Likewise the doll used in the birthday party task was replaced with a brown-skinned doll.
The reason for these minor adjustments was to ensure equivalence across races in
administration of the ADOS and thus avoiding bias. According to Van deVijver and Leung (1997) attaining equivalence is the most central issue in cross cultural research.
Further, the demonstration task was simplified to a dish and the soap, without too much focus on hot and cold taps. If children were unable to perform the demonstration gestures
simultaneously with verbal comments, they were provided a bar piece of soap and a face cloth with which to demonstrate the task. If this task was unsuccessful, the child was asked to show and describe how they brush their teeth, using imaginary tooth paste and tooth brush.
Although the ‘birthday party’ routine was not problematic, a more culturally accepted alternative of ‘bathing the baby’ is provided in the manual.
Further, the frog was also not used as a toy in the ADOS subtest as many Black children fear frogs. This was noted in the Azenze study which forms part of the larger K-ASD study. Here researchers tested normal developing African children’s responses to the ADOS subtests. It was found as a general rule, that Black children were culturally scared of frogs. The DSM IV acknowledges specific phobias associated with frogs, termed Ranidae phobia. Frogs also superstitiously represent bad omens in the Zulu culture (Gordon, n.d.; Psychiatry speciality board review for the DSM IV, 1996). The ‘Tuesday’ book tells the story of flying frogs.
Attempts were made to introduce a more culturally appropriate book for storytelling and the children were given the choice of which book they wanted to read.
Changing the tasks to be more culture fair was relatively simple. The larger challenge lies in recognising the culturally embedded verbal and non-verbal behaviours that relate to the spontaneity in play, use of gestures, and in the asking and showing of objects in an interactive way with adults. Especially, adults who are unfamiliar white adults, namely the researchers.
Finding appropriate translations of ADOS instructions and commands can also be challenging. The translation and back-translation processes were conducted under the
auspices of Western Psychology, the distributors of the ADOS, in conjunction with members of the K-AD research team.
Thus, an attempt was made to make the ADOS more culture-fair. Allowing the participants to identify more with the objects and elicit free conversation and imaginative play more easily.
The adaptations made included:
1. Translation, back-translation and re-translation of the ADOS prompts into isiZulu.
2. Substituting the Americanised pictures for ones that portray scenes more familiar to South African children.
3. Dark-skinned dolls were added to modules 1, 2 & 3 of the ADOS for both task two and the birthday party.
These adaptations aided in bridging the obvious cultural and social gaps that existed in using the ADOS in a Western context as opposed to the South African context. The aim was to aid the children who were being assessed to more easily identify with the tasks of the ADOS in order to facilitate an accurate diagnosis. These adaptations were not done independently by the researcher, rather an expert panel of psychologists (across race), and paediatricians on the larger K-ASD study made adjustments relative to their findings in the broader study.
Since ASDs affect multiple domains of a person’s life and are a very under researched field in South Africa, it was hoped that this study might contribute to our understanding and management of this disorder. Hopefully, changes at a national policy level could improve the provision of services and needs to children with disabilities in our country.