Abstract
We are pleased to see discussion of innovative strategies for introducing autism detection and intervention in Bangladesh, as mentioned in a Letter to the Editor published in Autism in May 2018: “Managing autism spectrum disorder in developing countries by utilizing existing resources: A perspective from Bangladesh” by Nova Ahmed et al.
However, the information provided on a tool which we have developed is incorrect. We quote from paragraph 2 of the letter: In this context, a non-expert based rapid screening tool, Rapid Neuro Developmental Assessment (RNDA) showed promising results for early screening of ASD in resource constrained countries like Bangladesh (Khan et al., 2010; The Directorate General of Health Services (DGHS), 2013). This tool was developed for countries with limited expertise to screen neurodevelopmental disorders based on 10 questions covering motor development, vision, hearing, speech, cognition, and behavior at a basic level. Even non-professionals like trained college graduates, school teachers, and community health workers can easily administer it (DGHS, 2013).
The authors have unfortunately conflated screening with direct child assessment. First, the Rapid Neurodevelopmental Assessment (RNDA) is not a screening tool. It is a hands-on assessment of a child which requires training and certification for its application (Khan and Muslima, 2016). It is best used by professionals and para-professionals who have experience in working with children, such as teachers, therapists, doctors, and experienced community health care workers. It was developed by a team of multidisciplinary professionals from the Bangladesh Protibondhi Foundation (BPF) in conjunction with the Department of Pediatric Neurosciences, Dhaka Shishu (Children’s) Hospital and an international team of experts; it is copyrighted to the BPF. Second, the authors mention the “10 questions” and the developmental functions it screens. The authors appear to have confused the Ten Questions (TQ) screening tool (Durkin et al., 1994; Zaman et al., 1990), or Ten Questions Plus (TQP) (Wu et al., 2012), with the RNDA. In the Bangladesh national DGHS survey (2013) which the letter quotes, both tools (i.e. TQP and RNDA) were used in a three-stage survey: the TQP for home-based screening for neurodevelopmental disorders (NDDs) in stage 1; the RNDA in stage 2 for assessment of all children within community clinics who screened positive on the TQP and a percentage of controls; and in stage 3, a comprehensive diagnosis of specific NDDs by a multidisciplinary team of professionals of children identified to have developmental problems. This final stage of diagnosis includes processes, where appropriate, to assess children with regard to autism spectrum disorder.
Thus, the screening strategy laid out in Figure 1 of the letter is incorrect, for the same reasons as mentioned above. We raise this issue so that readers of the journal may understand how screening, assessment, and diagnosis can be addressed in low-resource countries such as Bangladesh. Accurate diagnosis and innovative approaches to intervention must proceed together.