There is joint agreement among professionals internationally on the importance of diagnosing autism spectrum disorders (ASD) in the early stages of the emergence of symptoms. Criteria changes for the diagnosis of ASD need updated versions of the scale to make the diagnosis feasible. This study aimed to evaluate the level of overlap between two different versions of the Gilliam Autism Rating Scale (GARS-2 and GARS-3), which have been updated based on changes in DSM-IV and DSM-5 on a Kurdish sample of individuals at risk of having ASD and Intellectual Disability, referred to the Bahoz center in the Kurdistan Region of Iraq. A group of 148 cases with ASD and developmental disabilities (DD) was evaluated using the 2nd and 3rd versions of the GARS scale to understand the level of cases that confirm an ASD diagnosis in both scales. Ninety-six individuals (65%) scored about the cut-off score for being diagnosed with ASD based on the GARS-2, and 137 individuals (93%) scored above the cut-off score based on the GARS-3. Moreover, keeping updated and meeting the changing demand of standardization and cultural suitability of the updating scales is a challenge. This challenge is due to the shortage of infrastructure sources and lack of established professionals in low- and middle-income countries (LMICs). Findings indicated that GARS-3, updated based on the DSM-5, tends to diagnose children with accompanying diagnoses and different levels of symptoms severity of ASD at different age levels. Further studies are needed to help professionals and policymakers in low- and middle-income countries understand the updated versions of the available scales and depend on the older version, which must be considered cautiously.

There is marked variation internationally in the prevalence of children identified as having autism spectrum disorders (ASD). In part, this may reflect a shortage of screening tools for the early identification of children with ASD in many countries. This study aimed to evaluate the Kurdish translation of the Gilliam autism rating scale—third edition (GARS-3), a scale commonly used in Western countries that evaluates six domains related to the ASD definition from the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5, notably Restricted/Repetitive Behavior, deficits in Social interaction and Social Communication, as well as differences in Cognitive Style, Maladaptive Speech, and Emotional Response. GARS-3 assessments were completed through interviews with parents of 735 children, 442 (53%) of whom were diagnosed with ASD. 165 (22%) with an intellectual disability, 49 (7%) with communication disorders, and 133 (18%) typically developing children. The reliability, construct, and the predictive validity of the scale was assessed, and the scores suggestive of a child having ASD were identified. The factor structure was broadly replicated, especially on items relating to social interaction and social communication. The cutoffs for the total scores that were indicative of possible ASD had a high degree of specificity and sensitivity in distinguishing children with ASD from typically developing peers. Some children with I.D. and communication disorders may also score above the threshold, and further assessments should be sought to confirm the presence of autistic traits. Although GARS-3 could be recommended for use in Kurdistan and possibly similar cultures, further prospective research is needed to confirm a diagnosis of assessment with children who score above and below the cutoff scores identified in this study. Moreover, the development of normative data drawn from Kurdish samples of children would be advantageous, although ambitious, given the lack of diagnostic services in many low- and middle-income countries.

Screening tools for the early identification of developmental disabilities are strongly advised, yet culturally valid tools are not readily available for use in low- and middle-income countries. The present study describes the context and the processes used to develop a suitable screening procedure for use in the Kurdistan region of Iraq. This was based on an autism rating scale—GARS-3—developed in the USA for use primarily with children’s parents. It was administered to three groups of children: those with a pre-existing diagnosis of ASD; those with a confirmed diagnosis of a developmental disability; and those who were typically developing—735 participants in all. The 10 items from the 58 items in the full GARS-3 scale that best discriminated the three groups of children were identified. Subsequent analysis confirmed that the ten-item summary scores had reasonable internal reliabilities, with a good specificity and sensitivity in distinguishing children with ASD from those that were typically developing but less so for children with other developmental disabilities. The study confirms the universality of autism symptoms but also the different emphasis Kurdish parents may place on them. Nevertheless, screening procedures need to be developed in the context of support services that can undertake follow-up diagnostic assessments and provide suitable interventions for use by parents to promote their child’s development. The study provides an example of how this can be possible in low- and middle-income countries.

Job satisfaction and burnout are components of job morale. In general, and among healthcare provider personnel, these are psychological factors of the job and under the influence of different conditions and the organizational management of the healthcare systems. Both job burnout and job satisfaction among healthcare service providers have received scant attention in the literature, particularly in the healthcare systems of the Kurdistan Region of Iraq (KRI) as one low- or middle-income country (LMIC). The burnout rate and job satisfaction in a daycare center for children with autism spectrum disorders were reviewed and measured using a sample consisting of 34 employees from three different sections. The Maslach Burnout Inventory-Third Edition (MBI-3) and the Job Descriptive Index (JDI) were used. The relationships between the two scales and their consisting factors were examined using Pearson Correlation and Chi-square test to understand the correlation and levels of significant difference between the expected and the observed frequencies. There was a significant negative correlation between job burnout and satisfaction with the job and some significant correlations between the factors of the scales. Lower levels of emotional exhaustion and depersonalization factors of the burnout scale were statistically correlated. It was shown that the personnel were mainly satisfied with their jobs through their choices in the four parts of the job satisfaction scale. Further investigations are needed to understand different contributing factors to job satisfaction and burnout among healthcare providers in KRI. The current study might highlight the importance of understanding the healthcare providers’ perspectives on their careers.

The organizational strategy and environment of the healthcare systems influence the turnover rate among healthcare provider personnel. These critical factors have received scant attention in the literature and particularly in the healthcare systems of the Kurdistan Region of Iraq (KRI) as one low-income country with a lack of infrastructural health provision foundations. In this cross-sectional study with qualitative synthesis, the turnover rate of a population consisting of 115 (85 “74%” rehabilitation and training personnel) members of a daycare center for individuals with autism spectrum disorder (ASD) during eight years in the city of Erbil was considered. The aim was to understand the organizational strategy and its impacts on the personnel turnover rate, particularly among healthcare providers. The analysis was conducted utilizing collective data over an eight-year period of service provisions. A qualitative methodological approach was adopted to understand the different aspects of turnover among the staff. The finding indicated a general turnover rate of 87% for the entire personnel and 72% for the rehabilitation and training service providers. This rate imposes considerable costs on the system. Interview analysis also yields supporting evidence for the desire of the staff to change jobs and the lack of understanding of the turnover among system authoritarians resulting in unpredictable changes and staff displacement. Further investigations are needed to understand different contributing factors to imposed or desired turnover rates among healthcare providers in KRI. The turnover over the years has imposed different challenges for the center where the data was collected and imposes unwanted negative impacts on healthcare organizations.