Table 2.

Summary of main challenges and potential future directions with regards to service provision for children with autism and their families in Ethiopia

	Main challenges/unmet needs	Potential future directions
1.	Lack of knowledge and understanding about autism among the general public and health professionals	Increase/continue awareness raising activities by autism centres, community-based rehabilitation organisations and other stakeholders.
2.	Lack of culturally and contextually appropriate diagnostic and screening instruments	Translation and validation of the ADOS to Zulu in South Africa (Grinker et al. 2012) and to Kiswahili in Kenya (Petrus de Vries, personal communication) currently underway; their experiences can inform future translation and adaptation strategies. An international working group aims to develop open source screening and diagnostic instruments that can be applied globally (Durkin et al. 2015). A study to inform the cultural adaptation of an existing autism screening instrument for use in Ethiopia is currently being conducted.
3.	Inadequate mental health services in rural and urban areas	The Ethiopian National Mental Health Strategy (2012/13–2015/16) promotes a decentralised approach in which mental health services are available at local hospitals, district and regional health centres and tertiary facilities.
4.	Lack of funding for autism services; competing public health priorities	The new Sustainable Development Goals (SDGs) explicitly include mental health, generating momentum and opportunity for the scale-up of global mental health (Patel et al. 2016), including autism services. The current Ethiopian National Mental Health Strategy already mentions children as a vulnerable group; this recognition together with the momentum for sustainable global mental health development is likely to help in improving services for children with autism in future.
5.	Shortage of healthcare professionals trained in autism at all levels, including psychiatry, clinical psychology, primary healthcare workers and community-based health workers	Training of mental health specialists is being expanded, with an in-country psychiatrist training programme (Alem et al. 2010), a Ph.D. programme in mental health epidemiology, Masters programmes in clinical psychology and mental health, and psychiatric nurse training programmes. Rural community-based health workers are upgrading their training studying a 2-week module on mental healthcare including material on autism and other developmental disorders (see also www.open.ac.uk/heat).
6.	Shortage of schools for children with autism/problems of accessing education and intervention for children with autism	Expanding specialist centres for children with autism e.g. creating satellite centres in rural areas; expanding integrated services for children with autism in mainstream schools, capitalising on the plans set out in Ethiopia's fifth Education Sector Development Programme (Federal Democratic Republic of Ethiopia Ministry of Education, 2015); training caregivers about autism; training school staff on child mental health and developmental disorders. A draft parent skills training programme developed by WHO for caregivers of children with developmental disorders will be adapted and piloted in Ethiopia.
7.	Stigma, exclusion and negative attitudes/judgments against children with autism and their families	The 2 week module studied by rural community-based health workers (see under 5.) includes guidance on conducting awareness-raising and anti-stigma campaigns; continue awareness raising work by autism centres, community-based rehabilitation organisations and other stakeholders.
8.	Lack of research studies of autism in Ethiopia	The Ph.D. programme in mental health epidemiology at Addis Ababa University is training a future cohort of Ethiopian mental health research experts. Through the HEAT+ project our research team is conducting the first autism research studies in Ethiopia.