A Cross-Cultural Comparison of a Caregiver-Mediated Joint Attention Intervention for Children with Autism Spectrum Disorders (ASDs): Malaysia and the UK

Background: While there is a growing literature on interventions for children with ASDs, there is a dearth of information on the cross-cultural applicability of these interventions. Given the situation for children with ASD and their families in Malaysia, it was decided that parent-mediated interventions would be the most appropriate for the Malaysian context. Thus, an evidence-based caregiver-mediated intervention was chosen that focuses on increasing caregiver-child dyads’ joint engagement and encouraging joint attention behaviours in the children.

Objectives: The aim of this study was to compare the efficacy of a caregiver-mediated joint attention intervention for children with ASDs in Malaysia and the UK using a single-subject multiple-baselines design.

Methods: Four Malaysian and three British mother-child dyads participated in the intervention. At the start of the intervention, the children were aged between 3y 3m to 5y 5m, and the mothers were aged between 35y 5m and 43y 3m. Extensive observational data were gathered across 24-27 baseline, intervention, and follow-up sessions per dyad. These quantitative data were examined to identify any improvements in the mothers’ accurate use of intervention strategies (‘fidelity’ to intervention strategies), the children’s response to joint attention, and the dyad’s quality of interaction as a result of the intervention. The data were analysed in two ways: via visual inspection, as is traditional for single-subject designs, and via multilevel modeling. In addition, qualitative parent- and interventionist-report measures were used to gain insights into the mothers’ experiences of having participated in the intervention.

Results: As predicted, there were cross-cultural differences in the baseline levels of the mothers’ fidelity to the intervention strategies, with the Malaysian mothers scoring below the British mothers; however, the treatment effects of the intervention on the mothers’ fidelity did not differ across cultures. Thus, the Malaysian mothers started and ended the intervention at lower levels of fidelity than the British mothers (Figure 1). There were also cross-cultural differences in treatment effects with regard to the children’s joint attention skills, with the British children showing larger improvements than the Malaysian children (Figure 2). There were no cross-cultural differences in baseline levels of or treatment effects on the dyads’ joint engagement. The secondary outcome data revealed that the observed cross-cultural differences could be linked to cultural variations in parenting practices (particularly with regard to the mothers’ interaction styles within play settings) and in parents’ developmental priorities (e.g., the Malaysian mothers were more concerned than the British mothers about their children’s academic abilities). The data also indicated ways in which the length, format, and content of the intervention could be adapted to better suit the Malaysian context.

Conclusions: The findings from this study illustrate that cross-cultural differences in parenting can have an impact on the outcomes of a parent-mediated intervention for children with ASD. Thus, the findings underscore the importance of further research into cultural factors that may influence the outcomes of interventions for children with ASD, with the goal of establishing interventions that are effective within different cultural and economic settings.