Towards a culturally informed approach to implementing autism early intervention: a commentary on Ramseur II et al., 2019

Many scholars and practitioners in the field of autism spectrum disorder (ASD) agree on the importance of integrating early intervention practices into joint activity routines. This notion originates from research on typical development (1), suggesting that the predictable structure and affectively rich framework of early child-caregiver routines provide a powerful foundation for child social-communicative and cognitive development. By learning to anticipate and respond to the caregiver’s goal-directed actions and emotional-communicative cues during peek-a-boo routines, tickle games, and face-to-face interactions during bath time or mealtime, typical children become progressively more attuned, coordinated and collaborative (2,3), building a behavioral repertoire that is supported by, and supports, cooperative motives and social learning (4,5). Naturalistic Developmental Behavioral Interventions such as the Early Start Denver Model (6) are designed to support the same process in young children with ASD. Additionally, and in contrast to highly structured “therapy room” situations, joint activity routines offer the potential to embed learning in the context of culturally relevant shared experiences, naturally occurring activities, and situations where the targeted behaviors are meant to be used (7).

The research by Ramseur II and colleagues (8), however, raises a critical question—are joint activity routines a cross-cultural phenomenon, or the expression of Western child-rearing and educational practices? The question has important implications for both research and practice, given the overreliance of developmental and clinical research (including research on ASD) on the narrow and idiosyncratic populations living in Western and industrialized countries. As most individuals with ASD and their families do not live in those countries, the implementation of interventions informed by Western research in the non-Western context requires a careful consideration of their cultural fit. This is particularly important when they involve culturally determined practices such as child rearing and teaching.

Research on families of typical children in non-Western cultures has challenged long held notions in developmental literature, such as the idea that caregivers are universally inclined to scaffold learning and deliberately stimulate linguistic, social or cognitive skills in their children. For example, in many agricultural non-Western communities, caregivers appear to respond promptly to their child’s signals of hunger or distress, but less so to communicative signals such as nondistress vocalizations or eye-contact, and rarely initiate verbal or face-to-face interactions with their child during early development (9,10). Further cross-cultural research documented a reduced frequency of behaviors aimed at deliberately stimulating social engagement and learning in non-Western compared to Western contexts, such as scaffolding pretend play, contingent labelling of objects that the child is pointing to, or encouraging children’s learning efforts using praise (11-13). As argued in (9), (12) and (14), these parenting style differences do not appear to undermine the emotional or cognitive development of children raised in non-Western societies. Rather than reflecting poor parenting, this body of literature indicates that sensitive responsiveness in child caregiving is manifested differently in different cultures, and shaped by different priorities and contextual factors (15).

Parenting in the context of children with ASD, however, complicates the picture, because practices that are not necessary for fostering learning and development in typical children could play a critical role for children who have reduced ability and motivation for self-guided social learning (16,17). Against this background, and in the absence of an established cross-cultural literature on parenting practices for children with ASD, the study by Ramseur II and colleagues provides pioneering information on the cultural relevance of joint activity routines for South African caregivers (or at least those from urban Cape Town). This contribution, together with other recent research efforts (18,19), suggest that early intervention practices originating from Western contexts could be advantageously used in other cultures.

Importantly, however, this emerging body of research also indicates that adaptations are needed when interventions are implemented in contexts that are different from those where they were originally developed. For example, the recent research by Holzinger and colleagues (20) documented that caregivers and practitioners implementing the Early Start Denver Model in Austria considered one component of the model—the use of exaggerated affect (i.e., very animated and playful facial emotions and body language)—as “unnatural”. Additionally, another component of the model—collecting data every 15 minutes—was regarded as unfeasible; therefore, both components were modified when the Early Start Denver Model was implemented in Austria.

Further research is needed on understanding the trade-off between adaptations to improve cultural fit (e.g., not using exaggerated affect), including those dictated by lack of resources (e.g., making the intervention shorter or reducing training requirements), and preservation of elements that promote positive outcomes (e.g., frequent data collection and treatment intensity) (21). This requires a better understanding of the intervention components that are critical for effectiveness, versus those that can be dropped or substantially modified, so that interventions can be flexibly adapted to increase cultural fit and usability across settings without diluting effectiveness (22). Additionally, an in-depth understanding of the cultural context in which interventions are meant to be implemented is needed to drive such adaptations, and ensure that intervention strategies are consistent with expectations, goals, needs, resources as well as childrearing and educational practices of local end-users. The research study by Ramseur II and colleagues provides a seminal contribution towards such understanding. This knowledge, in turns, paves the way for the implementation of early intervention programs that hold the potential to address the unmet needs of children and families affected by ASD in under-researched settings in the African continent and globally.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Pediatric Medicine. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/pm.2019.06.01). The author has no conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Bruner J, Sherwood V. Thought, language and interaction in infancy. In: Calle JD, Tyson RL, editors. Frontiers of Infant Psychiatry. Basic Books, New York, NY, 1983:38-55.
2. Bornstein MH. Mother-infant attunement: A multilevel approach via body, brain, and behavior. In: Legerstee M, Haley DW, Bornstein MH, editors. The infant mind: Origins of the social brain. Guildford Press, New York, NY, 2013:266-98.
3. Begus K, Southgate V. Curious learners: How infants’ motivation to learn shapes and is shaped by infants’ interactions with the social world. In: Saylor M, Ganea P, editors. Active Learning from Infancy to Childhood. Springer, Cham, 2018:13-37.
4. Fantasia V, Markova G, Fasulo A, et al. Not just being lifted: Infants are sensitive to delay during a pick-up routine. Front Psychol 2016;6:2065. [Crossref] [PubMed]
5. Tomasello M. Becoming human: A theory of ontogeny. Belknap Press; 2019.
6. Rogers SJ, Dawson G. Early Start Denver Model for Young Children with Autism: Promoting Language, Learning, and Engagement. New York, NY, 2010.
7. Vivanti G, Rogers SJ. Autism and the mirror neuron system: insights from learning and teaching. Philos Trans R Soc Lond B Biol Sci 2014;369:20130184 [Crossref] [PubMed]
8. Ramseur K 2nd, de Vries PJ, Guler J, et al. Caregiver descriptions of joint activity routines with young children with autism spectrum disorder in South Africa. Pediatr Med 2019;2:6. [Crossref] [PubMed]
9. LeVine RA, Dixon S, LeVine S, et al. Child care and culture: Lessons from Africa. Cambridge University Press; 1996.
10. Mesman J, Basweti N, Misati J. Sensitive infant caregiving among the rural Gusii in Kenya. Attach Hum Dev 2018;1-9. [Epub ahead of print]. [PubMed]
11. Boyette AH, Hewlett BS. Teaching in hunter-gatherers. Rev Philos Psychol 2018;9:771-97. [Crossref]
12. Lancy DF. Teaching: natural or cultural? In: Geary DC, Berch, DB, editors. Evolutionary perspectives on child development and education. Springer, Cham: 2016;33-65.
13. Lancy DF. Learning'from nobody': The limited role of teaching in folk models of children's development. Childhood in the Past 2010;3:79-106. [Crossref]
14. LeVine RA, LeVine S. Do Parents Matter? Public Affairs; 2016.
15. Mesman J, Minter T, Angnged A, et al. Universality without uniformity: A culturally inclusive approach to sensitive responsiveness in infant caregiving. Child Dev 2018;89:837-50. [Crossref] [PubMed]
16. Vivanti G, Hocking DR, Fanning P, et al. Social affiliation motives modulate spontaneous learning in Williams syndrome but not in autism. Mol Autism 2016;7:40. [Crossref] [PubMed]
17. Vivanti G, Nuske HJ. Autism, attachment, and social learning: Three challenges and a way forward. Behav Brain Res 2017;325:251-9. [Crossref] [PubMed]
18. Divan G, Vajaratkar V, Cardozo P, et al. The Feasibility and Effectiveness of PASS Plus, A Lay Health Worker Delivered Comprehensive Intervention for Autism Spectrum Disorders: Pilot RCT in a Rural Low and Middle Income Country Setting. Autism Res 2019;12:328-39. [Crossref] [PubMed]
19. Tekola B, Girma F, Kinfe M, et al. Adapting and pre-testing the World Health Organization's Caregiver Skills Training programme for autism and other developmental disorders in a very low-resource setting: Findings from Ethiopia. Autism 2019;1362361319848532 [Epub ahead of print]. [PubMed]
20. Holzinger D, Laister D, Vivanti G, et al. Feasibility and Outcomes of the Early Start Denver Model Implemented with Low Intensity in a Community Setting in Austria. J Dev Behav Pediatr. 2019; [Epub ahead of print]. [Crossref] [PubMed]
21. Vivanti G, Stahmer A. Early intervention for autism: Are we prioritizing feasibility at the expenses of effectiveness? A cautionary note. Autism 2018;22:770-3. [Crossref] [PubMed]
22. Vivanti G, Kasari C, Green J, et al. Implementing and evaluating early intervention for children with autism: Where are the gaps and what should we do? Autism Res 2018;11:16-23. [Crossref] [PubMed]