Effectiveness and feasibility of a joint attention (JA)-based parent-mediated intervention (PMI) for Malaysian children with autism spectrum disorder (ASD): cultural considerations

Background Social interaction and social cognition models underpinning joint attention (JA)-based parent-mediated interventions (PMIs), advocate family-centred practices and child-directed interactions as current best practices for autism spectrum disorder (ASD) early language intervention. PMIs place emphasis on Speech-language Therapist (SLT)-parents partnership. Parents are coached to become co-therapist by learning and applying a series of interaction and language facilitation strategies, aimed to enhance parent-child interactions and support their children’s JA, language, and social communication development. While the effectiveness of PMIs is mainly grounded on evidence from Western and high-resource countries, the effectiveness of PMIs in other cultures is unknown. Objective This study aimed to investigate (a) the effects of the Malay-based Hanen More Than Words (M-HMTW), a PMI, on mothers’ beliefs in family-centred intervention and practices of mother-child interactions; (b) the effects of the M-HMTW on the following child outcomes, i.e. JA, language, and social communication; and (c) the feasibility of implementing the M-HMTW among the Malay mothers of preschool children with ASD in Malaysia. Method Participants included 59 dyads of Malay mothers and their preschool children aged two to five years old with a provisional and/or diagnosis of ASD. 31 dyads were randomly assigned to the M-HMTW group, and 28 dyads were randomly assigned to a treatment-as-usual (TAU) group (i.e. conventional one-to-one therapist-mediated language intervention). The interventions were provided in four months. Mothers’ beliefs in family-centred intervention and practices of mother-child interactions were measured through the Parental Beliefs and Practices Questionnaire (Pappas et al., 2008; Simmons & Johnston, 2007). Pre- (T1) and post- (T2) intervention child measures in joint engagement (JE), total vocabulary, and social communication skills were measured via the Joint Engagement Rating Inventory (JERI; Adamson et al., 2016), the Trilingual MacArthur-Bates Communicative Development Inventories (Trilingual MCDI; Low, 2009), and the Language Use Inventory (LUI; O’Neill, 2009), respectively. The feasibility of the M-HMTW was examined through attrition rates and Gadke et al.’s (2021) ten dimensions of feasibility protocol. Results Only 32 dyads (n M-HMTW = 14; n TAU = 18) completed the four months intervention. They were included in the per-protocol and gain scores to analyse the effectiveness of the M-HMTW. The study found only a medium effect of the M-HMTW intervention on mothers’ beliefs in family-centred intervention. A lack of intervention effects was found on the gain scores in the practices of mother-child interactions and all child outcomes between the two groups. Within the M-HMTW group, from T1 to T2, the children showed significant increases in their total expressive vocabulary and social communication skills. Within the TAU, the only significant increase observed from T1 to T2 was the children’s social communication skills. Following Gadke et al.’s (2021) feasibility protocol, this M-HMTW study showed adequate feasibility in the dimensions of practicality, adaptability, and implementation; partial feasibility in the dimensions of data collection, design procedure, social validity, integration, and effectiveness; and poor feasibility in the dimensions of recruitment capability and generalisability. Conclusions This study preliminary shows the impact of the M-HMTW intervention in changing the Malay mothers’ beliefs in family-centred intervention. Issues such as attrition rates, assessment time points, and sensitivity of instruments that limited the feasibility of the study were discussed