Original articleAges and Stages Questionnaires: Adaptation to an Arabic speaking population and cultural sensitivity
Introduction
Early child development is a crucial determinant of an individual's potentials namely health, education and economic status throughout the life span. Detection of developmental delay leading to early intervention and special education1 is important for a better outcome. Since formal screening for developmental delay is essential to initiate early intervention, the American Academy of Pediatrics published guidelines for pediatricians promoting early screening to identify developmental delay.2
Early detection is completed by either the physician or parents, using clinical impression and/or standardized screening tools. The latter method is usually recommended, as physicians' clinical impressions alone are ineffective in detecting developmental delay.3 In addition, studies have shown that parents' completed standardized questionnaires are at least equal or superior to the physicians' formal screening4, 5, 6 irrespective of parental socioeconomic categories, geographical locations or parental conditions.7 Despite clear guidelines and recommendations, compliance with screening is hindered by many factors such as cost, lack of time and training on screening tools.8, 9 These factors are particularly true in developing countries, where there is a pressing need to apply simple screening tools at low cost to help ensure early detection and referral. To our knowledge there is no screening tool available in Arabic for the Middle-Eastern countries with the exception of the Denver II10 which is administered by physicians and as such is not being widely used.
Ages and Stages Questionnaires 2nd edition (ASQ-II), is a standardized parent completed screening instrument that includes questionnaires for different age groups addressing all five development domains (communication, gross motor, fine motor, problem solving, and personal-social skills).11 ASQ has been shown to be reliable and cost effective as well as to correlate well with physicians' assessment.12, 13 In addition, although ASQ was found to have poor positive predictive value (40%) in a sample of premature infants, its negative predictive value was excellent (98%) and it had good agreement (79%) with formal psychometric assessments.14 Furthermore, its sensitivity is 90% and specificity 77% as shown by Skellern et al.14
ASQ has been translated into many languages and standardized with different populations,15, 16, 17, 18, 19, 20, 21, 22, 23 though most of the adaptations did not require major changes. Given these positive findings we speculated that, accounting for the specificities of the Middle-Eastern culture, the adaptation and standardization of ASQ to Arabic would be successful and very useful in this region. Since there are no validated screening tools available for the Arabic speaking population the aim of this study was not to validate but to test the adequacy of administering ASQ in Arabic and to assess its reliability and its cultural acceptance in a sample of Arabic speaking population.
Section snippets
Population
Parents and children were recruited from health care centers (private and public sectors) and day care centers located in all Lebanese provinces. Inclusion criteria were healthy children between 4 and 60 months of age and whose parents were Arabic speaking. Children were recruited if their age was in the range of either one month younger or older than the age category specified on the ASQ questionnaires, as per the user manual guidelines.11 Since the aim of this study was cultural adaptability,
Translation and adaptation
During translation of the ASQ, few changes were required. Results of the field-testing showed that most questionnaires were easily understood and feasible to administer with the exception of 48 and 60 month intervals. Increased variability in types of schooling and learning experiences among 4–5 years old children precluded testing; almost all children in Lebanon enroll in a preschool system at the age of 3 years, and these preschools differ in terms of which language is taught first. For
Discussion
This study shows that the Arabic translated ASQ was feasible for certain age groups but not all. Although it was easily administered in a clinical setting and appreciated by parents as screening for development, it was culturally sensitive. The answers to some questions were found to be culturally sensitive and were therefore adjusted to render the questionnaire more culturally appropriate to Arabic speaking national groups. Adequacy of translation to Arabic and back translation was ensured by
Conclusion
To our knowledge, this is the first study to show reliability results of an Arabic adapted ASQ. Our results indicate that special care and consideration should be taken into account when adapting ASQ to a different culture or language, mainly non-Western ones. Questions pertaining to certain skills should be assessed and modified accordingly. The current study may constitute an asset for future research in standardization and validation of A-ASQ in the Arabic speaking children.
Funding source
American University of Beirut Medical Center Medical Practice Plan and University Research Board, Lebanese National Council for Scientific Research.
Contributors statement
Lama Charafeddine: conceptualized and designed the study, designed the data collection instruments, coordinated and supervised data collection, drafted the initial manuscript, critically reviewed it and approved the final manuscript as submitted.
Durriyah Sinno: conceptualized and designed the study, designed the data collection instruments, coordinated and supervised data collection drafted the initial manuscript, critically reviewed it and approved the final manuscript as submitted.
Farah
Conflict of interest
The authors have no conflict of interest to disclose.
Abstract accepted for poster presentation at the Pediatric Academic Societies meeting April 2012 (E-PAS2012:3806.56).
Acknowledgments
We are grateful for the contribution of Jane Squires for her valuable comments and feedback. We are also in debt to Mrs. Sawsan Maktabi who translated the questionnaires to Arabic, and to the panel expert of pediatricians who reviewed the back translated questionnaires in addition to all the pediatricians, health care facilities, day care centers and parents for their participation in this study.
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Factors affecting child development assessed by the Ages and Stages Questionnaire (ASQ) in an Arabic speaking population
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Ages and Stages Questionnaire: a global screening scale
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Reliability and acceptability of web-based administration of Spanish ages and stages questionnaires third edition®
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