Translation and Cultural Appropriateness of the ADOS-2 in Afrikaans

Background:  A key need in diagnostic practice for autism spectrum disorder (ASD) in South Africa is to generate acceptable and valid diagnostic tools in the official languages of the country. The Autism Diagnostic Observation Schedule-2 (ADOS-2) is one of the “gold standard” diagnostic aids for ASD and it is increasingly used in South Africa. However, its use is limited to English-speakers, as it has not been translated into any of South Africa’s other 10 official languages. Moreover, the cultural appropriateness of this tool for the local cultures of South Africa, or the implications of low socio-economic status has not been explored.

Objectives:  Given that approximately 50% of the population of the Western Cape province of South Africa speak Afrikaans as primary language, we wanted to focus on the Afrikaans ADOS-2. The primary objective was to determine the cultural appropriateness of the tool for Afrikaans-speakers in low to middle income communities. Three components associated with method bias were examined 1) the language used in the Afrikaans-translated ADOS-2, 2) the social interactions and activities in the ADOS-2, and 3) the ADOS-2 materials.

Methods:  A mixed method and qualitative thematic approach was used to analyse the data collected through interviews and questionnaires. The ADOS-2 was translated into Afrikaans and we assessed its cultural appropriateness for the ‘coloured’ (mixed ancestry) population from low to middle socio-economic backgrounds residing in the Western Cape. An ethnographic investigation of play, social interaction, and social activities was conducted in a community sample (n = 40) and the Afrikaans ADOS-2 was pre-piloted in a clinical sample (n = 7). The ethnographic component was included given that there was no existing literature for this socio-cultural group. Community sample participants were interviewed and asked questions pertaining to what games their children played, what materials they played with, and whom they played with (on own, with peers, with adults). ADOS-2 materials were shown to community and clinical sample participants, who were asked to comment on their children’s familiarity with the materials.

Results:  The findings highlighted numerous unique aspects of the vernacular of Afrikaans spoken by this population (“Kaaps”) including the dialect spoken and use of code-switching (rapid switching between Afrikaans and English). The ethnographic exploration of play (on own, with peers, with adults) indicated that the social interaction expectations in an ADOS-2 assessment between child participant and examiner and adults seemed culturally appropriate and that most of the ADOS-2 materials and activities were familiar and appropriate. The materials raising the most concern included the frog toy (fear-inducing) and the PinArt (unfamiliarity). Gender stereotypes associated with play materials were also noted frequently.

Conclusions:   With appropriate cultural and clinical sensitivity during administration, we found the Afrikaans ADOS-2 to be useful and culturally appropriate for Afrikaans-speaking, coloured individuals from low socioeconomic backgrounds in the Western Cape. We recommend a similar parallel process when translating the ADOS-2 into other languages spoken in South Africa, as well as a similar ethnographic exploration in other communities where little is known about play, social interaction, and social activities.