A cross-cultural study of autistic traits across India, Japan and the UK

Autism spectrum disorders (ASD), henceforth ‘autism’, are neurodevelopmental conditions, characterised by difficulties with social interaction and communication, unusually repetitive and restricted behaviours and interests and sensory hyper-sensitivity [1]. Despite a considerable amount of research into autism [2], the majority of studies have been conducted in Western, higher income countries [3‐6]. Consequently, assumptions surrounding the epidemiology, diagnosis and treatment of autism have not been adequately tested across different cultures and socioeconomic settings.

A diagnosis of autism is based on the behavioural characteristics of an individual. Though core autism characteristics are believed to be universal, there is preliminary evidence to suggest that cultural differences may exert subtle influence over the expression, identification and/or reporting of symptomatology [5, 7‐9]. Culturally specific stigmas, norms and priorities may mask or emphasise relative distinctions between autistic traits and typically developing behaviours [3, 7, 9]. For example, previous work validating screening measures in Japan reported that parent judgements of whether their child is interested in their peers do not correlate with autism in Japanese communities as it does in the US [10]. If this example reflects a true cultural difference, such disparities could reflect a relative higher peer interest for Japanese children with autism, a relative lower peer interest for the Japanese typically developing children or that the salience of these symptoms is weaker for Japanese parents. Consequently, the profile of autism symptoms as measured by parent report may not be globally consistent [5, 7].

Tools developed for screening autism are increasingly being used outside their original cultural context [11, 12], with the majority developed in Europe and North America [13, 14]. Due to the emphasis on behavioural symptoms of such tools, if the presentation, salience and reporting of autistic characteristics are not globally consistent, this could impact the ability to use tools developed in one culture (typically the West) in other countries [15]. Developing new screening tools requires extensive resources and effort that may not be feasible for lower income countries. Existing Western screening tools have been translated into other languages [10, 16‐20] but not always without difficulties [6, 21, 22], and validation studies of these screening tools in other cultures have typically examined overall mean group differences, rather than item-level analyses [16, 18‐20, 23]. Moreover, the previous literature has often focused on toddlers [21, 24, 25]. However, children with autism without intellectual disability are less likely to exhibit salient symptoms at the preschool age and often only receive a diagnosis in mid-late childhood [26‐28]. This is particularly problematic since behavioural expectations of children in different countries may differ according to age [29], suggesting that findings on toddler screening measures may neither be translatable to school-aged children, nor necessarily be equivalent across cultures.

There is thus a need for cross-cultural research exploring screening tools for this age group. An important consideration, particularly when aiming to develop a short screening tool, is whether the autistic traits that best predict an autism diagnosis are similar across different cultures. Initial research exploring such ‘key indicators’ has been conducted using the Autism Spectrum Quotient (AQ), a 50-item open-access and free to use questionnaire developed in the UK, adapted for different ages and validated in several languages [19, 24, 30‐37]. Researchers developed shorter versions for different age groups (AQ-10) by examining which items best discriminate between cases and controls in UK samples, identifying ten highly predictive items [38]. The AQ-10 exhibited high test accuracy properties and internal consistency and is as effective as the original questionnaire in identifying high-risk autism cases across a range of different ages [38]. However, this analysis has so far only been conducted within a UK sample.

This study aimed to contribute towards a greater understanding of expression and recognition of childhood autism symptoms across cultures by identifying key indicator items across three distinct cultural settings: the UK, Japan and India.

Children’s demographic characteristics are summarised in Table 2. There were no age differences between cases and controls in the Japanese and Indian samples; in the UK, the autism group was younger than the control group (p < .001) (Table 2).

DI and PPV analyses for each item are summarised in Table 3, with a summary of case/control responses per country for each item included in Additional file 1. Inspection of the DI and PPV values revealed 16 items for the Indian sample with DI ≥ 0.5 and PPV ≥ 0.7 (cells labelled with ‘a’ in Table 3), indicating that these items provided excellent differentiation between autism cases and controls. Similarly, 15 AQ-Child items for the Japanese sample and 28 items for the UK sample surpassed the excellent item performance thresholds (in the middle and right-hand columns of Table 3).

This study aimed to identify which items on the AQ-Child were most predictive of an autism diagnosis among children from India, Japan and the UK. Sixteen items in the Indian sample, 15 in the Japanese sample and 28 items in the UK sample demonstrated high discriminant and predictive ability of ASD cases, excellent psychometric properties and similar sensitivity and specificity values to the original AQ-50. This suggests that at least within cultures, it is possible to adapt existing measures into psychometrically sound brief tools that successfully differentiate children with and without autism.

When comparing the ‘key indicator’ items across cultures, our findings suggest that there is substantial overlap in the items most predictive of an autism diagnosis cross-culturally. Overall, 28 items were found to have acceptable or excellent discrimination properties in all three countries. This suggests that a number of autistic traits are consistently expressed, salient for parents and thus reliably identified and reported across different countries. This provides support for the position that screening measures developed in one country can indeed be used in different cultures. Five items were identified to be consistently excellent at discriminating between children with autism and controls in all three countries and identified as universal key indicators. However, it should be noted that two of these universal items (item 17; s/he enjoys social chit-chat and item 38; s/he is good at social chit-chat) are similarly worded and therefore may be overlapping measurements of the same aspect of behaviour.

The present study also identified four autistic traits that may represent cultural differences. Item 34 (s/he enjoys doing things spontaneously) was a highly predictive item in the UK sample, but not in Japan or India. In the UK, two-thirds of the autism children in the derivation sample were reported to not enjoy spontaneity (in line with autism symptomatology). This ratio was much reduced in the Indian and Japanese samples, where only around 30% of the children with autism were reported to not enjoy spontaneity. By contrast, control children across all three countries were reported to enjoy spontaneity at similar levels (91–97%), suggesting that this difference is specific to the autism group. Cross-cultural studies show that societies differ in their tolerance for uncertainty. For instance, Japan is characterised as a highly uncertainty avoidant society, whereas India and the UK score much lower on uncertainty avoidance [41]. It is possible that as a result of Japanese society’s tendency towards reducing uncertainty, any spontaneous activity is more structured in Japan than in the other cultures, resulting in relatively few children objecting to spontaneous activities. Indian children with autism also appear more accepting of spontaneity that could reflect the prevalence of an authoritarian parenting style in India, resulting in a general reduction in spontaneity across diagnostic groups and so accounting for the reduced predictive power of this item [42]. Alternatively, these differences may be due to linguistic variation rather than a cultural difference: in the Japanese translation of the AQ-Child, the meaning of item 34 was perceived ambiguously by parents and so had to be clarified with a supplemental explanation in addition to the original question [19]. In the supplemental explanation, more emphasis was placed on the meaning of spontaneous as ‘doing something on your own initiative, without suggestions from others’, rather than on ‘doing something without much prior planning’. Similarly, the terms used in the Bengali and Hindi translations of the AQ-Child for ‘spontaneous’ are more common in written than in spoken language. Therefore, these differences in response patterns may reflect a lack of familiarity or ambiguity for parents interpreting the question.

Item 18 (when s/he talks, it is not always easy for others to get a word in edgeways) has strong predictive properties in the Japan sample but not in India or the UK. As expected from a highly predictive item, this item is endorsed (suggesting the presence of the autistic trait) in a larger proportion of the cases (64%) and very few controls (3%) in Japan. In contrast, although endorsed for a large proportion of UK cases (70%), it is also reported in a large proportion of UK controls (53%). For India, the proportion of children for whom it is reported are very similar for both cases (61%) and controls (63%). While lack of qualitative research or cognitive interviewing data prevents us from drawing strong inferences on the causes of these differences, we speculate that parents in the UK and India may have interpreted the item to mean their child was very chatty. While excessive chatting by children is culturally acceptable in the UK and India, the stronger emphasis in Japanese society on social conformity [9, 43‐45], politeness and respect for elders may make this characteristic much less acceptable and/or more salient to the reporting parents in Japan.

Items 35 (s/he is often the last to understand the point of a joke) and 44 (s/he enjoys social occasions) were both highly discriminative in the UK and Japan samples but not in India. Although these may be indicative of cultural differences, the smaller size of the Indian sample leads us to interpret these with caution. Moreover, these questions may represent a translation issue: in the versions for India, both ‘joke’ and ‘social occasion’ were translated using more formal language.

Our analyses have demonstrated that taking the most discriminating items from the AQ-Child from three countries results in psychometrically sound brief measures that correctly classify children with autism and typically developing controls. Items with good discriminating power were, to a large extent, universal across the UK, Japan and India samples, but there were also some potential cultural differences. These findings suggest that five items included in the AQ-50 have consistent excellent power to discriminate autism from control children across three distinct cultures and thus hold promise as cross-cultural key indicators for autism. Additional research is needed to further advance our understanding of the cross-cultural nature of autism symptomatology before a ‘universal’ screening instrument for autism can be derived.