Autism isn’t like chicken pox. No symptom or test unequivocally says, “This is autism.” Instead, diagnosing the condition often hinges on confirming difficulties in social function. One way to address these difficulties is to provide classes that help people with autism navigate a complex social world.
But different societies have different social cues. As a result, translating social skills programs for use in different cultures is a tricky task.
One success story is the Program for the Education and Enrichment of Relational Skills (PEERS). The 14- to 16-week program improves the social skills of adolescents and young adults with autism bybreaking down social interactions into small steps.
The PEERS curriculum has reached at least 20 countries and been translated into more than a dozen languages, according to its chief developer, Elizabeth Laugeson, assistant clinical professor of psychiatry and biobehavioral sciences at the University of California, Los Angeles (UCLA).
“It’s not just enough for us to develop these interventions at UCLA and test them,” Laugeson says. “We are very passionate about disseminating these interventions to other people, and we have trained professionals and educators across the globe.”
Through practice and role-play, PEERS students learn the discrete moves that add up to social give and take, such as the steps involved in approaching and joining a group. Their caregivers — usually parents — also learn the lessons so that they can guide practice between the sessions and after the program ends.
Translating the curriculum is more than a matter of capturing a linguistic idiom. It also requires adapting to cultural differences in the way that young adults socialize and spend their time.
Hee Jeong Yoo, professor of psychiatry at Seoul National University in South Korea, has set the standard for this process. She learned about PEERS as a visiting scholar at UCLA in 2010. She then took on the daunting task of translating it for use in her country.
Yoo first translated the PEERS manual into her native tongue. She then distributed it to two dozen mental health professionals in South Korea and asked them to flag anything that seemed culturally off the mark. Based on this feedback, Yoo edited the manual.
Yoo then surveyed a group of typically developing adolescents about how the curriculum reflected their experiences. The survey revealed several culture gaps that ultimately led to some important adjustments.
One big difference between American and South Korean adolescents is how they spend their after-school hours, for example. This is the period during which PEERS participants practice what they’re learning in the program. Whereas American teens often play sports and engage in social activities during that time, Korean teens tend to study and receive tutoring.
The U.S. version of PEERS helps teens build relationships by shaping interactions around common interests, such as a sport. Because South Korean teens are less likely to participate in sports and other extracurricular activities, the translated curriculum uses role-play to encourage conversations that help teens identify common interests.
Another difference between the cultures is where teens gather. In the U.S., teens often meet in homes, with a parent present. This allows parents to help guide social interactions. But in South Korea, where homes are often much smaller, most get-togethers happen in public places.
“And it’s usually independent of parents, so that creates challenges for parents to provide coaching around these get-togethers,” Laugeson says. Coaching from parents in South Korea focuses on preparing teens for social interactions instead of guiding them as they take place.
PEERS also addresses how to manage bullying. Yoo says that bullying can look different in the U.S. than in South Korea, where ostracism — both in the real world and in cyberspace — is the predominant tactic.
“Social exclusion, or ‘wang-tta,’ is more common and problematic than physical violence in Korea,” Yoo says. “It is very important for the social skills program to reflect this reality and how to deal with it.”
With these adjustments, the translated curriculum worked beautifully. Yoo and her colleagues tested it on 47 adolescents with autism, assigning them to a group that received the program either immediately or after a delay. They found that the teens in the first group improved significantly in their ability to interact with others and to establish personal relationships compared with those who had not yet completed the program1.
“She basically got almost identical findings to what we get in North American samples,” says Laugeson.
Teens who participated in PEERS also had fewer depressive symptoms than teens who didn’t get the training, and their mothers were less likely to have symptoms of anxiety.
Researchers elsewhere in the world are taking a cue from Yoo, trying to carefully hone the PEERS curriculum for teens in their countries. Lourdes Lam, an educational psychologist at SAHK, a rehabilitation service center in Hong Kong, heard about PEERS at a conference and has begun the tedious translation process.
As with South Korea, one key adjustment for the Hong Kong curriculum reflects how adolescents — and their parents — spend their time. Many families consider the standard number of sessions for PEERS “too demanding,” says Lam, because of their already packed schedules. As a result, parents needed a little extra prodding during the program.
“They needed more encouragement to complete all of the sessions and assignments,” she says.
Misconceptions about autism pose another challenge in Hong Kong, where Lam says many parents and teachers think of people with autism as “‘Rain Man’ geniuses” who lack empathy. Getting past this perception to implement a program such as PEERS requires first accepting that people with autism are interested in socializing.
These cultural nuances underscore the importance of collaborating with people who understand local cultures when trying to translate an intervention. The approach Yoo used in South Korea sets the bar, Laugeson says.
“She has set the gold standard for how to do cross-cultural validation trials,” says Laugeson of Yoo’s lengthy process. “All of our colleagues are following this formula.”