title: Developing a social skills intervention for adolescents with Autism Spectrum Disorders (ASD) in Thailand
Creators: name: Tawankanjanachot, Nadlada
Publisher: name: University of Glasgow
Year: 2024

description: Background: The global prevalence of autism spectrum disorders (ASD) is 0.6%, similar to the prevalence of ASD in Thailand. In 2022, approximately 2.2 million Thai children were diagnosed with ASD, but only 1.16 percent obtained healthcare services through the health system. Adolescents with ASD have challenges with social communication, lack social cognition to understand or predict the behaviour of others, and lack emotional recognition to recognise the emotions of others, which negatively impacts their relationships and daily life. A number of systematic reviews have concluded that the Western-originated social skills interventions is effective in improving social skills and quality of life in adolescents with ASD. However, these interventions may not be applicable to Thailand, whose culture is different and may have different needs in, and preferences for, engaging with social skills interventions. It is essential to develop a culturally adapted social skills intervention for Thai adolescents with ASD. 

Aim: The aim of this thesis was to inform the development of a culturally adapted social skills intervention for adolescents with ASD (aged 10–19 years) and their families in Thailand. 

Methodology: To achieve this aim, three studies followed the initial phase of the Heuristic Cultural Adaptation framework for intervention development. A second cultural adaptation framework, the Ecological Validity Model (EVM) framework was used for evaluating the cultural domain of an evidence-based intervention and identifying the cultural needs of the stakeholders. The first study was a systematic review and meta-analysis to determine the efficacy and cultural adaptability of a social skills intervention for adolescents with ASD in Asian countries. The second study was a qualitative study which included focus groups of healthcare professionals and paired-depth interviews with adolescents with ASD and their caregivers to understand needs and perspectives towards the components and delivery formats of and necessary cultural adaptations to, a social skills programme for Thai adolescents. Lastly, given that the research was conducted during the COVID-19 pandemic, the third study was an online survey of caregivers of adolescents with ASD that investigated the impact of the COVID-19 pandemic on the experiences of Thai adolescents and their families across Thailand. This study was important to understand how the pandemic had impacted on, and provided a context for, the current landscape of social skills development in adolescents with ASD and the recommendations emerging from this PhD study for the development of a social skills programme for Thai adolescents and future research. 

Results: The findings from the three studies presented in this thesis provide an understanding of the role, needs for, and cultural adaptation required in developing a social skills programme for adolescents with ASD in Thailand. The systematic review and metaanalysis (n = 15) highlighted that social skills interventions in Asian countries significantly improved social skills in adolescents with ASD. It also demonstrated that the adaptation of these interventions was crucial when adapting western intervention concepts to the local population.

The qualitative data reinforced that there is a need for social skill interventions among Thai adolescents with ASD. The data identified that the provision of a programme should assess the social skills of adolescents before giving them social skills training, teach the specific social skills, cooperate with the various learning strategies, involve parents in the programme, and encourage parents’ knowledge and skills. Furthermore, adolescents with ASD and parents were required to comprehend and practise Thai social knowledge (e.g., respect for the elderly, morality, generosity, responsibility, and Buddhism) as well as communication and behaviour techniques (e.g., assertiveness and praising) with which Thai parents were unfamiliar. Staff workload, staff competence, the impact of the COVID-19 pandemic, and stigma were identified by health professionals as potential barriers to implementing the intervention. 

The online survey results confirmed that the COVID-19 pandemic, school closings, decline in outdoor activities, and postponement of treatments influenced the social skill development of Thai adolescents with ASD. However, adolescents' regular access to services, caregivers' sufficient support from the hospital, and the older age of adolescents may have helped to prevent the worsening of social skills during this time. To support the development of social skills, caregivers and adolescents with ASD required additional medical support, such as social skills training, telehealth, and home medication delivery. 

Conclusion: Social skills interventions are essential for improving the ASD adolescent's social skills and quality of life. To ensure that social skills interventions appropriately engage and meet the needs of Thai adolescents with ASD and their families, current social skills interventions developed in Westernised countries need to be culturally adapted. The results from the three studies conducted here provide recommendations for informing the aims, cultural adaptation, and delivery of a social skills intervention for Thai adolescents and their families. The outcome of a culturally adapted intervention may help to increase engagement with and participation in the programme and improve outcomes for adolescents with ASD in Thailand. It is recommended that future research involves the testing of an adapted social skills intervention with regards to these outcomes.