1 MASTER OF EDUCATION IN EDUCATIONAL PSYCHOLOGY Educational psychologists’ perspectives on the treatment of autism spectrum disorder (ASD) children in the South African context by Nazrana Ally 2580583 Supervisor: Dr Nicky Israel A research report submitted in partial fulfilment of the requirements for the Degree of Master of Education in Educational Psychology in the Department of Psychology, School of Human and Community Development, Faculty of Humanities, at the University of the Witwatersrand, Johannesburg. 29 March 2024 2 Plagiarism declaration I, Nazrana Ally, declare that this research project (ethics clearance number: MEDPSYC/22/03) is my own, unaided work. It has not been submitted before for this or any other degree or for examination at this or any other university. Signed: Date: 25/ 03/2024 3 Abstract This qualitative study aimed to explore a sample of South African registered educational psychologists’ perspectives on and experiences with the treatment of autism spectrum disorder (ASD) children in the South African context, including their awareness of available treatments, evaluation of treatment effectiveness, decision-making processes, level of involvement in treatment stages, and their roles in relation to other professionals. Additionally, it examined the psychologists’ perceptions of the challenges faced by ASD children and their parents in accessing treatment in South Africa, the common strategies they employed, and the difficulties they encountered when treating ASD children. An interpretive approach was used, employing semi-structured interviews conducted in English with eight South African registered educational psychologists specializing in ASD. The interviews were audio-recorded, transcribed verbatim, and analyzed using reflexive thematic analysis, informed by a self-reflexive journal to maintain awareness of potential biases. The findings highlighted the scarcity of educational psychologists in South Africa engaged in ASD cases, limited specialized ASD training, and a paucity of resources available in South Africa which encouraged participants to seek resources internationally. Participants emphasized the importance of evidence-based, individualized interventions tailored to each child's context. They also emphasized that diverse approaches were crucial for meeting the individual needs of both the child and the family. They raised concerns about applied behaviour analysis (ABA), citing its potential limitations in fostering flexibility and promoting rote learning. They recommended modifying cognitive-behavioural methods to suit specific contexts and moving away from clinical environments to foster creativity and resourcefulness. 4 Participants were actively involved in diagnosis and assessment, highlighting the importance of exposing educational psychology students to various ASD-specific assessments and emphasizing the need for addressing training gaps and cost barriers for accessing assessment tools. Educating stakeholders, including parents, teachers, and other professionals, was deemed essential for creating a supportive and informed environment for children with ASD. Significant challenges identified included limited ASD-specific training, a lack of support and awareness, long waiting periods for diagnosis, limited access to treatment, and stigmas associated with ASD. Addressing these challenges requires grassroots training initiatives and collaborative efforts among families, professionals, and policymakers to ensure quality care and support for individuals with ASD. Keywords Autism spectrum disorder (ASD), educational psychologists, treatment, South Africa, evidence- based intervention, support, training, resources 5 Acknowledgements First and foremost, I extend my gratitude to Allah the Almighty, the Most Gracious, and the Most Merciful, whose boundless mercy and blessings have guided me throughout my academic journey and enabled the completion of this thesis. I am profoundly grateful to my supervisor, Dr Nicky Israel, for her invaluable guidance, encouragement, and unwavering support for the duration of this research journey. Her expertise, insights and constructive feedback have played a pivotal role in shaping the thesis. I extend my sincere appreciation to the participants in this study, whose willingness to share their experiences and perspectives has enriched this research immeasurably. Your contributions have been invaluable in shedding light on the complexities surrounding the treatment of autism spectrum disorder (ASD) for educational psychologists in South Africa. I am indebted to my family for their unconditional love, encouragement, and patience during this journey. Their steadfast support for and belief in my abilities have served as a constant source of motivation and strength. Lastly, I acknowledge the support of the educational institution where this research was conducted. Your assistance has been instrumental in facilitating its completion. In sum, I am deeply appreciative of all those who have in their various ways contributed to this research endeavour. 6 Table of Contents Plagiarism declaration ................................................................................................................. 2 Abstract ...................................................................................................................................... 3 Acknowledgements ..................................................................................................................... 5 Chapter 1: Introduction ................................................................................................................ 9 Background and rationale ......................................................................................................... 9 Aims and objectives ............................................................................................................... 12 Structure of the report ............................................................................................................ 12 Chapter 2: Literature review ....................................................................................................... 13 Definition and brief explanation of ASD ................................................................................... 13 Types of ASD treatment .......................................................................................................... 16 Factors that affect choice of treatment ................................................................................... 29 Team-based treatment ........................................................................................................... 31 The shortage of mental health professionals for treating ASD ................................................... 34 ASD in the South African context ............................................................................................. 35 The current study ................................................................................................................... 38 Research questions ................................................................................................................ 40 Chapter 3: Methods ................................................................................................................... 41 Research design ..................................................................................................................... 41 Sample and sampling ............................................................................................................. 43 Data collection ....................................................................................................................... 47 Ethical considerations ............................................................................................................ 53 Data analysis ......................................................................................................................... 55 Trustworthiness and credibility ............................................................................................... 58 Transferability ........................................................................................................................ 59 Dependability and confirmability ............................................................................................ 59 Reflexivity and qualitative rigour .............................................................................................. 60 Chapter 4: Results and discussion of the data ............................................................................. 62 Theme 1: The level of experience of educational psychologists in the sample in treating children with ASD ................................................................................................................................ 62 Subtheme 1: Limited experience in treating children with ASD .............................................. 62 Subtheme 2: Extensive experience in treating children with ASD ........................................... 63 7 Theme 2: Forms of treatment used by educational psychologists when working with ASD children in South Africa ........................................................................................................................ 66 Subtheme 1: Social skills training and play therapy .............................................................. 66 Subtheme 2: Evidence-based interventions when treating ASD children ............................... 70 Subtheme 3: Psychoeducation, parental and family support, and tailoring interventions as part of ASD treatment ................................................................................................................ 83 Theme 3: The factors that influence educational psychologists’ decision-making for intervention or treatment ........................................................................................................................... 87 Subtheme 1: Contextual considerations .............................................................................. 87 Subtheme 2: Considering the child’s needs and interests as a part of treating a child with ASD .......................................................................................................................................... 89 Subtheme 3: Medical aid funding as a challenge .................................................................. 90 Subtheme 4: Self-directed learning and skills development .................................................. 92 Theme 4: The level of involvement of educational psychologists in each stage of the treatment process .................................................................................................................................. 93 Subtheme 1: The initial phase of treatment .......................................................................... 94 Subtheme 2: Coordinating multidisciplinary therapeutic teams ............................................ 95 Subtheme 3: Providing empowerment to others involved in the treatment process ................ 97 Subtheme 4: Engagement of educational psychologists in the assessment and diagnostic phases of treatment ............................................................................................................ 98 Subtheme 5: Therapeutic functions of educational psychologists during treatment ............ 103 Theme 5: Educational psychologists’ perspectives on their role in treatment relative to others 105 Subtheme 1: Teamwork in treating children with ASD ......................................................... 106 Subtheme 2: The role of occupational therapists ................................................................ 108 Subtheme 3: The role of speech therapists in treatment ..................................................... 110 Subtheme 4: Involvement of neurologists and paediatricians ............................................. 113 Subtheme 5: Psychiatrists’ role in the treatment process ................................................... 115 Subtheme 6: The role of teachers in the treatment process ................................................ 116 Subtheme 7: The role of the family in the treatment process ............................................... 119 Theme 6: The challenges faced by participants when offering treatment ................................. 122 Subtheme 1: Limited ASD-specific training in South Africa.................................................. 122 Subtheme 2: Demands during treatment ........................................................................... 125 Subtheme 3: A lack of support and basic awareness .......................................................... 126 Subtheme 4: Insufficient government funding .................................................................... 129 Subtheme 5: Long waiting periods for diagnosis and limited access to treatment ................ 130 8 Subtheme 6: Stigmas and labels associated with ASD ........................................................ 133 Chapter 5: Conclusion and recommendations .......................................................................... 136 Conclusions and implications of the findings ........................................................................ 136 Strengths and limitations of the study ................................................................................... 141 Recommendations and directions for future research ........................................................... 144 Conclusion .......................................................................................................................... 148 References .............................................................................................................................. 150 Appendix A: Ethics clearance certificate ................................................................................... 180 Appendix B: Invitation .............................................................................................................. 181 Appendix C: Participant information sheet ................................................................................ 183 Appendix D: Consent Form ....................................................................................................... 186 Appendix E: Demographic Questionnaire .................................................................................. 188 Appendix F: Interview Schedule ................................................................................................ 190 Appendix G: Editor’s letter ........................................................................................................ 193 9 Chapter 1: Introduction This chapter will set the stage for an in-depth exploration of educational psychologists’ perspectives on the treatment of autism spectrum disorder (ASD) in the unique context of South Africa. The chapter will explain the background and rationale for the study and provide an overview of its overall structure. Background and rationale This study explores educational psychologists’ perspectives on the treatment of autism spectrum disorder (ASD) in South Africa and aims to gain a comprehensive understanding of the approaches and interventions favoured by a sample of South African educational psychologists in addressing the diverse needs of children with ASD. Autism spectrum disorder (ASD) is a neurological and developmental condition in which the individual experiences difficulties with communication and social interaction, and engages in repetitive behaviours (Hodges et al., 2020; Robinson et al., 2017; Tsui & Rutherford, 2014). The identification and diagnosis of ASD involves consulting various professionals and having them apply a range of tests and diagnostic measures. Despite the complex diagnostic process, it is crucial to recognize ASD symptoms early to enhance management through timely intervention (Cleveland Clinic, 2023; Remington et al., 2007). As noted in numerous studies, positive outcomes have been observed with early intensive behavioural intervention in ASD (Chung et al., 2024; Guler et al., 2017; Healy & Lydon, 2013; Reichow et al., 2014; Remington et al., 2007). This approach has demonstrated effectiveness in reducing the severity of core ASD 10 symptoms, potentially leveraging neural plasticity in children (Dawson, 2008; Dawson & Zanolli, 2003; Sullivan et al., 2014). ASD poses many challenges globally, with the nature of these challenges shaped by cultural, societal and regional factors. In various regions, critical components such as timely diagnosis and intervention encounter delays and limitations, contributing to challenges to optimal development (Guler et al., 2017; Hahler & Elsabbagh, 2014; Hussain et al., 2023; Samms‐ Vaughan, 2014). Persistent stigma and misconceptions surrounding ASD result in social isolation and discriminatory practices against individuals on the autism spectrum (Guler et al., 2017; Han et al., 2021; Turnock et al., 2022). Furthermore, there are widespread difficulties associated with providing essential resources, including trained professionals, specialized educational programmes and therapeutic services; global discrepancies and research gaps further amplify these problems (Aderinto et al., 2023; Fraatz & Durand, 2021; Guler et al., 2017; Hahler & Elsabbagh, 2014). There is also a paucity of research concerning ASD and its treatment in middle- and low-income countries, with South Africa facing particular challenges because of limited resources and infrequent diagnoses (Aderinto et al., 2023; Guler et al., 2017; Rieder et al., 2023). The scarcity of research highlights the critical need to comprehend the feasibility and effectiveness of ASD interventions and treatments in South Africa (Guler et al., 2017; Samms‐ Vaughan, 2014). Within this context, educational psychologists play a pivotal role in supporting ASD children. Their responsibilities encompass enhancing the child’s functioning in the school environment; collaborating with and supporting parents in recognizing, accepting, and managing their child's difficulties; and recommending, developing, and administering strategies and therapies tailored to facilitate the optimal performance of ASD children (Donald et al., 2010; 11 Farrell, 2004). As integral members of the treatment team, educational psychologists collaborate with other professionals to identify and address barriers to learning (Donald et al., 2010; Farrell, 2004). Moreover, they contribute to breaking stigmas associated with ASD by increasing knowledge and awareness, and playing a supportive role in the lives of ASD children (Keenan & Dillenburger, 2021). While the crucial role of educational psychologists in supporting individuals with ASD is recognized, there exists a significant knowledge gap regarding the perceptions of the treatment of ASD among South African educational psychologists. Little is known about their views on working with ASD children in the complex and highly individualized South African multicultural and multilingual context. This research thus aims, at a theoretical level, to contribute to a more comprehensive understanding of ASD treatment, offering potential directions for future research. On a practical level, the study seeks to contribute to the formulation of treatment guidelines for ASD children by educational psychologists in South Africa, enhancing their training in this regard. Enhanced knowledge in this domain may play a pivotal role in refining best practices for ASD intervention and contribute to appropriate training for educational psychologists. It is hoped that exploring the perspectives of practising educational psychologists with first-hand experience of working with ASD children will provide valuable insights and important information that can augment understanding of available treatment options and their effective utilization, and of the roles played by educational psychologists in the ASD treatment process. 12 Aims and objectives The primary aim of the study was to explore a sample of South African registered educational psychologists’ perspectives on and experiences with the treatment of ASD children in the South African context. This included ascertaining how aware the educational psychologists in the sample were of available treatments, and how they determined and evaluated the effectiveness of the treatments or interventions for ASD that they did use. Additionally, the study examined the factors that influenced psychologists’ decision-making for intervention or treatment when working with ASD children, their level of involvement at each stage of the treatment process, and their roles in relation to other professionals engaged in this process. Furthermore, it explored the challenges faced by ASD children and their parents when seeking and obtaining treatment in the South African context. The research also sought to identify common strategies employed by educational psychologists when treating ASD children in South Africa and the difficulties they encountered when doing so. Structure of the report This initial chapter has thus far outlined the study’s background, rationale and aims. The next chapter offers a review of existing literature as contextualized by the research questions. The third chapter focuses on the methodology of the study, covering key aspects such as research design, sample selection, data collection methods, ethical considerations and data analysis. The fourth chapter presents and discusses the findings from the data. Chapter Five presents conclusions drawn from the findings and discusses their implications. It adumbrates the strengths and limitations of the study and suggests directions for future research. 13 Chapter 2: Literature review In this chapter, a comprehensive exploration of the literature about the treatment of autism spectrum disorder (ASD) children will be undertaken. The review will follow a structured approach to provide a thorough understanding of the multifaceted landscape of ASD treatment, both internationally and in South Africa. I will begin by providing a clear definition and concise explanation of ASD, and discuss the available treatment options as documented in the research literature. Factors guiding practitioners in selecting particular treatments will be highlighted and consideration of contextual factors and flexibility in interventions for individuals with ASD will be emphasized. The review will then discuss the global issue of the shortage of mental health professionals equipped with specialized training in ASD treatment and intervention delivery, and the various factors that impact the choice of treatments or interventions in the South African context. The role of professionals engaged in the treatment process – including the dynamics of teamwork and the parent-professional relationship that contribute to the efficacy of interventions or treatments – will then be examined. The accessibility of resources and services essential for ASD treatment in South Africa will be discussed, including the views of South African parents on the challenges they face. Finally, the focus will shift towards the rationale for the current study and how it aims to contribute to a greater understanding of South African educational psychologists’ perspectives on the treatment of ASD in South Africa. Definition and brief explanation of ASD “Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in social communication and the presence of restricted interests and repetitive behaviours” (Hodges et al., 2020, p. S55). It is an umbrella term covering autism, Asperger’s 14 syndrome, Rett’s disorder, childhood disintegrative disorder, and non-specified developmental disorders (Faras et al., 2010; Tsui & Rutherford, 2014). ASD affects the ability of children to understand and interact with their environment (Bölte et al., 2018). The symptoms usually start to appear at a young age and continue, developing and changing throughout the person’s life (Centers for Disease Control and Prevention, 2022). ASD can sometimes be identified in a child aged 18 months or younger. A diagnosis by a qualified healthcare professional can be considered to be valid after age two. Many children, however, are not given a definitive diagnosis until they are much older. In some cases, people do not receive a diagnosis until they are adolescents or adults (Centers for Disease Control and Prevention, 2022). The signs and symptoms of ASD range from mildly to severely disabling, and each child is different (Cleveland Clinic, 2023; Okoye et al., 2023; Tsui & Rutherford, 2014). However, certain signs may be indicative of a young child being on the ASD spectrum. ASD children find it difficult to make use of nonverbal types of communication such as waving or pointing; however, they also find verbal communication challenging, such as babbling or saying single words among younger children, or using single words or two-word phrases among older children (Cleveland Clinic, 2023; Tsang et al., 2019). Making or maintaining eye contact, and expressing their feelings or understanding the feelings of those around them are among the social difficulties faced by ASD children (American Academy of Pediatrics, 2023; Tsang et al., 2019). Repetitive and restrictive behaviours that are common among ASD children include rocking back and forth, flicking fingers, and hand-flapping, as well as forming routines or rituals and becoming very agitated when these routines are disrupted (American Academy of Pediatrics, 2023). Many children with ASD have unusual reactions to sound, smell, taste and sometimes even the way certain things feel; they may also react in unusual ways when engaging with others (Barthélémy 15 et al., 2019; Hyman et al., 2020). Some ASD children are extremely particular about the order of objects or toys as they line them up repetitively, and if the order changes, it makes them angry (Hyman et al., 2020). It is common for children with ASD to experience co-occurring conditions such as attention-deficit/ hyperactivity disorder (ADHD), anxiety, sleep disorders, and behavioural disorders such as self-injury and refusing food. These may well have a negative impact on both them and their family (Barthélémy et al., 2019; Hyman et al., 2020). A comprehensive examination of global practices indicates that the current diagnosis of ASD typically involves assessment by multidisciplinary teams or proficient individual specialists, such as paediatricians, developmental paediatricians, child psychiatrists and psychologists. The diagnostic process varies, depending on the healthcare systems and treatment resources available within each country (Hyassat et al., 2023; Ivanov et al., 2021). It has been estimated that in South Africa there may be over 200,000 children of school- going age who are, to some extent, on the ASD spectrum (Van der Watt, 2020), though accurate information is hard to come by. This is because ASD is under-diagnosed owing to the scarcity of available tools, especially when South Africa is compared with well-resourced countries that have multiple ‘gold-standard’ tools for screening and diagnosing ASD (Remington et al., 2007; Ruparelia et al., 2016). ASD is difficult to detect and diagnose because it requires consulting different professionals and using an array of tests and diagnostic measures. There is no definitive, objective measure and diagnosis is mainly achieved through observation. Such difficulties can make it harder for diagnoses to occur early (Lord et al., 2018). Despite this, it is extremely important to be aware of the symptoms of ASD to optimize managing the condition through early intervention programmes (Cleveland Clinic, 2023; Remington et al., 2007). Early intensive behavioural intervention has revealed positive results for 16 ASD, as reported by numerous studies (Chung et al., 2024; Guler et al., 2017; Healy & Lydon, 2013; Reichow et al., 2014; Remington et al., 2007). Early diagnosis is associated with better outcomes because it gives parents and children a chance to plan and come to terms with the diagnosis, which means that children can receive suitable treatment earlier (Cervera et al., 2011). Early intensive behavioural intervention has also been shown to decrease the level of severity of core ASD symptoms and increase language development, social skills, cognitive functioning and adaptive behaviours in young children (Chung et al., 2024; Guler et al., 2017; Healy & Lydon, 2013; Reichow et al., 2014; Remington et al., 2007). The implementation of intensive programmes provided by highly qualified professionals is the main source of evidence for the effectiveness of early ASD intervention (Guler et al., 2017). These best practices have high implementation costs and pose problems with sustainability and viability in low-resource environments, including in South Africa where ASD diagnosis and intervention are often delayed and remain a problem (Guler et al., 2017; Makombe et al., 2019; Remington et al., 2007). Types of ASD treatment ASD treatment can briefly be defined as “any medical or therapeutic intervention for children with ASD” (Wetherston et al., 2017, p. 117). Because children with ASD have many emotional, psychological, social, sensory and learning needs, it is of the utmost importance that those offering ASD treatment are acquainted with a variety of approaches, interventions and strategies to achieve optimal treatment outcomes for such children (Department of Education, 2015; Robinson et al., 2017). It is important to highlight that there is no single treatment approach for ASD, and there are many factors that need to be considered when selecting an ASD 17 treatment regime (Keenan & Dillenburger, 2021). Among the factors that determine the treatments that practitioners choose are family dynamics, the individual’s social, sensory, and physical environment, the available resources, the characteristics of the child and the practitioner’s knowledge of possible treatments (Robinson et al., 2017; Salgado-Cacho et al., 2022; Wetherston et al., 2017). There is a wide variety of treatments that can be used (Barthélémy et al., 2019). The treatment options include evidence-based interventions (EBI), which have been established through formal research as effective interventions for ASD (Robinson et al., 2017; Wetherston et al., 2017). A survey involving 146 educational psychology practitioners in the UK and Ireland explored their utilization of 31 evidence-based practices for ASD (Robinson et al., 2017). The findings revealed that, on average, approximately 30% of the psychologists’ professional workload was dedicated to implementing interventions for students with ASD. They acquired their information about ASD interventions primarily from colleagues or the internet, as well as journal articles and reports (Robinson et al., 2017). Among the commonly employed evidence-based interventions were visual supports, social stories, reinforcement, antecedent- based interventions, prompting, and social skills training. These interventions were preferred due to their ease of integration into mainstream school settings; often requiring minimal additional support or technical training, they could be implemented by class teachers or support assistants (Robinson et al., 2017). Conversely, interventions such as DTT, exercise, PRT, LEGO® therapy, technology-aided instruction, extinction, time delay, and video modelling were infrequently or never utilized by the psychologists in the sample. Such interventions typically demand a higher level of individualized support from extensively trained adults, presenting challenges in school- 18 based settings because of the specialized knowledge or resources required (Robinson et al., 2017). Many evidence-based interventions for ASD rely on the principles of behavioural therapy that focus on “modifying behaviour through positive reinforcement, repetition, and consistency, all based on learning theory principles” (Aderinto et al., 2023, p. 4412). For example, prompting (using cues and positive feedback) occurs when an individual with ASD is encouraged or taught to engage in positive behaviour that does not otherwise occur to him or her (Halbur et al., 2020). Various types of prompts can be employed, including physical assistance or gestures, verbal instructions or subtle verbal hints, and visual prompts such as photographs and checklists (Hayes, 2013). It is crucial to tailor the selection of prompts to match the individual needs of the ASD child and to gradually reduce and phase out prompts to foster the child’s independent mastery of the targeted behaviour without continual reliance on adult guidance (Hayes, 2013). Various prompt-fading techniques have been successful in teaching skills to individuals with ASD. These include prompt delay, most-to-least prompting, and least-to-most prompting (Halbur et al., 2020). Prompt-delay procedures involve gradually increasing the time between prompts (Halbur et al., 2020; Hayes, 2013). Most-to-least (MTL) prompting involves initially providing more intrusive prompts during instruction, which are gradually reduced to less intrusive prompts, to encourage independent correct responses (Halbur et al., 2020). Least-to-most (LTM) prompting involves presenting increasingly intrusive prompts within a learning opportunity if the participant does not respond to an instruction within a set time (Halbur et al., 2020). Reinforcement is the creation of a relationship between learner behaviour and the consequences of that behaviour (Malaco et al., 2020; Neitzel, 2009). Only if the consequence enhances the likelihood that a behaviour will occur in the future, or at the very least 19 be maintained, is the relationship deemed reinforcement (Dart & Melendez-Torres, 2020; Malaco et al., 2020; Neitzel, 2009). The primary objective of reinforcement is to assist learners with ASD to acquire new skills and to maintain them over time in various contexts involving various people (Malaco et al., 2020; Neitzel, 2009). Reinforcement is an essential element often employed in conjunction with other evidence-based approaches such as prompting, time delay, functional communication training and the differential reinforcement of other behaviours (Malaco et al., 2020; Neitzel, 2009). When reinforcement is personalized for a specific learner with ASD and responds to the learner’s use of a target skill or behaviour, it is most successful (Neitzel, 2009). Another technique is modelling, which occurs when skills or behaviours are demonstrated to an individual with ASD to get them to imitate this behaviour (Tsui & Rutherford, 2014). Using modelling as an intervention has been shown to be effective in instructing individuals with ASD who possess good imitative abilities and are inclined toward visual learning and thinking (Corbett & Abdullah, 2005; Tsui & Rutherford, 2014). Video modelling, a form of modelling where videos are used to demonstrate targeted skills, has demonstrated notable advantages (Ganz et al., 2011; Tsui & Rutherford, 2014). This method is particularly advantageous in instructing individuals with ASD across various skill domains, such as enhancing vocalization and communication, social and play skills, emotion processing, perspective taking, academics, and adaptive behaviour (Corbett & Abdullah, 2005; Tsui & Rutherford, 2014). Video modelling serves as a means of learning through social models without the necessity for initial face-to-face interaction (Corbett & Abdullah, 2005). Several researchers contend that interventions employing video modelling, owing to the visual medium, inherently 20 motivate and naturally reinforce individuals with ASD (Ambrose, 2017; Corbett, 2003; Corbett & Abdullah, 2005; Wahoski, 2015). Research indicates that teaching social scripts to children with ASD through modelling, prompting and reinforcement leads to improved interactions with peers and adults (Ganz et al., 2008). Social scripts present written or visual summaries of the steps that can be followed by an individual with ASD to carry out social interactions or social tasks (Scheibel et al., 2021). Social scripts that guide appropriate responses in social contexts and illustrate ongoing communication between individuals offer valuable support for children (Ganz et al., 2008; Luetkemeier, 2023; Meadan et al., 2011). Various forms of visual support have also proven beneficial for young children with ASD (Boggs, 2016; Cohen & Demchak, 2018; Meadan et al., 2011; Rutherford et al., 2019; Simmons et al., 2020). The term “visual supports” refers to a variety of concrete, reasonably inexpensive resources that are appropriate for a range of developmental levels, such as objects, pictures, and picture symbols. These resources are used to support receptive or expressive communication as well as to decrease anxiety, increase predictability, and support the understanding of routines and social expectations (Rutherford et al., 2023). Visual supports are commonly embedded in daily schedules, scripts or task analyses. Structuring the environment with visuals has been shown to enhance the independent functioning of children with ASD in their natural surroundings, reducing the need for adult prompts during routine tasks (Boggs, 2016; Cohen & Demchak, 2018; Meadan et al., 2011; Simmons et al., 2020). Visual supports are frequently incorporated into diverse interventions, whether at home or within a school setting (Rutherford et al., 2023; Simmons et al., 2020). A pilot study conducted by Rutherford et al. (2023) sought to assess the feasibility and effectiveness of a visual support intervention specifically designed for home use. The findings of the study indicated that involving parents in 21 a visual support intervention at home was not only viable but also enhanced accessibility to resources and information for families. Visual schedules serve multiple purposes, including indicating ongoing activities, predicting the next steps, signalling the conclusion of an activity, and highlighting any potential modifications to the regular schedule (Boggs, 2016; Meadan et al., 2011; Simmons et al., 2020). Visual scripts, which encompass written scenarios or skits, offer children tools to initiate conversations and engage in social interaction. For children exhibiting social avoidance, indifference or awkwardness, visual scripts may prove particularly valuable in cultivating social skills (Ganz, 2007; Ganz et al., 2008). Social stories, as a specific type of visual script, are effective in elucidating social concepts that a child may struggle to fully comprehend or may misinterpret. These narratives commonly focus on illustrating appropriate social behaviours and mitigating inappropriate ones (Ganz et al., 2008). Visual scripts have been shown to be beneficial in helping children comprehend social situations, find solutions to challenges, and prepare for conversations. To enhance children’s independence in task performance, visual task analysis can be implemented as a step-by-step support (Meadan et al., 2011). A study by Ganz et al. (2008), which focused on verbal elementary-age children with ASD, found that visual cues and scripts could enhance communicative speech while reducing perseverative speech. Furthermore, the use of visuals was noted to be less intrusive and socially stigmatizing than verbal prompts or reminders. Additionally, visual strategies proved to be less disruptive to other students in shared classrooms where prompts and cues were employed (Ganz et al., 2008). Ganz et al. (2008) argue that teachers stand to benefit from these approaches because of their ease of application and minimal resource requirements. 22 Substantial research has concentrated on devising effective instructional strategies for ASD students (Geiger et al., 2012; Odom et al., 2021; Sigafoos et al., 2019). Studies have shown that applying discrete trial teaching (DTT) can enhance language, social, academic and play skills, making it a prominent choice for individuals with ASD (Bogin, 2008; Geiger et al., 2012; Leaf et al., 2016). DTT often serves as a foundational method within applied behaviour analysis (ABA) interventions (Leaf et al., 2016; Geiger et al., 2012; Odom et al., 2021). It can be integrated with other techniques to teach various skills to individuals with ASD (Leaf et al., 2016). Each discrete trial comprises three main elements: a discriminative stimulus (typically a therapist’s instruction), the learner’s response, and a consequence (either reinforcement or punishment) determined by the therapist’s evaluation of the response. Additionally, therapists may offer prompts before the learner’s response to enhance correctness probability (Leaf et al., 2016). Traditionally, DTT follows a rigid structure, dictating actions to a therapist according to a set protocol. In contrast, a progressive DTT approach allows therapists flexibility, enabling real- time adjustments based on various factors like individual responses and past history (Leaf et al., 2016; Wong, 2019). Nevertheless, current practices typically involve a conventional approach to DTT, where therapists are constrained by strict protocols and lack the freedom or encouragement to assess and adapt to children’s unique needs and circumstances in real time (Leaf et al., 2016). Another type of intervention that supports social development for individuals with ASD is the play-based intervention, such as LEGO®-based therapy, originally introduced by LeGoff in 2004. Such approaches, applicable in both individual and group settings, are designed to create opportunities for developing social skills – under the facilitation of a therapist – in a less artificial way (Narzisi et al., 2021; Ramalho & Sarmento, 2019). Variations include diverse theoretical foundations, delivery methods, conceptualizations of play and assessment designs, 23 with some interventions adopting an instrumental approach, while others, like LEGO®-based therapy, emphasize alignment with a child’s voluntary play interests (Narzisi et al., 2021). LEGO® therapy for ASD and related disorders is grounded in two fundamental assumptions (Narzisi et al., 2021; Vegni et al., 2023). First, it recognizes that many ASD children exhibit advanced skills and interest in using Lego®. Secondly, the therapy leverages the shared outcome of collaborative LEGO® building to encourage social interaction. The structured building tasks in LEGO® therapy foster problem-solving skills, encouraging individuals with ASD to plan and create using LEGO® bricks (Narzisi et al., 2021; Vegni et al., 2023). This enhances cognitive abilities such as logical thinking and planning (Vegni et al., 2023). Notably, LEGO® therapy taps into the visual-perceptual strengths often observed in individuals with ASD and promotes the development of visual-spatial skills, including pattern recognition, understanding spatial relationships, and refining fine motor coordination (Ramalho & Sarmento, 2019; Vegni et al., 2023). It also provides a platform for practising and improving executive functions such as working memory, self-regulation and attention (Boylan, 2019; Vegni et al., 2023). Participants engage in tasks that require focused attention, memory recall and adaptability, fostering cognitive skills crucial for building tasks but also generalizable to other areas of life (Vegni et al., 2023). When conducted in small groups, the therapy encourages collaborative efforts towards a common goal. This enhances the skills required for cooperation and social interaction, as well as for communication and social cognition (Narzisi et al., 2021; Vegni et al., 2023). The cognitive skills honed through LEGO® therapy or other play-based interventions demonstrate potential generalization beyond therapy sessions. As individuals practice social interaction and cognition, the skills should transfer to real-life situations. This supports the development of adaptability and flexibility across various contexts (Narzisi et al., 24 2021; Vegni et al., 2023). Despite the potential benefits, research on play-based interventions like LEGO® therapy reports significantly variable results and this type of intervention does not always lead to positive benefits for the individual with ASD (Narzisi et al., 2021). Some ASD interventions consist of a combination of evidence-based interventions. For example, the ‘social communication, emotional regulation and transactional support’ (SCERTS) intervention concentrates on social communication, emotional regulation and transactional support, incorporating several techniques in order to develop individualized programmes to support ASD children through assisting their families, parents, and teachers to work together (Robinson et al., 2017; Walworth, 2007). Another combination intervention is the ‘treatment and education of autistic and communication-related handicapped children’ (TEACCH), which places emphasis on structured support for social communication, visual information to supplement verbal communication, and deals with problems regarding attention and executive function through external organizational support (Autism Speaks, 2022c; Robinson et al., 2017). According to Wetherston et al. (2017), evolving treatments for ASD include ‘augmentative and alternative communication’ (AAC), ‘picture exchange communication system’ (PECS), and the ‘developmental, individual differences, and relationship-based model’ (DIR)/floortime. These treatments are inexpensive but are deemed unestablished because of the absence of evidence to support their success (Wetherston et al., 2017). Augmentative and alternative communication (AAC) is a particular form of assistive technology used to increase and expand communication, independence and social interactions with others (Autism Speaks, 2022b; Crowe et al., 2021). It offers an effective communication method for individuals diagnosed with ASD, particularly those facing challenges in utilizing traditional speech because it encompasses a range of communication systems and aided methods 25 such as picture boards, speech-generating devices and picture exchange systems, as well as unaided techniques like gestures and manual signing with Makaton or Sign Language (Beukelman & Mirenda, 2013; Ganz, 2015). Some individuals on the ASD spectrum encounter challenges in using their vocal muscles for speech production, so that pointing and manual signs are more accessible (Maue, 2022). Visual aids such as pictures are beneficial for ASD individuals with auditory processing difficulties, encouraging them to leverage their visual- spatial skills (Maue, 2022). According to Brain and Mirenda (2019), augmentative and alternative communication (AAC) serves as a tool for young children to communicate with parents even before mastering verbal language. For children with delayed speech development, AAC devices can assist with learning appropriate communication methods, such as making requests or expressing wants and needs. Contrary to concerns, as indicated by Hyman et al. (2020), AAC usage does not impede speech development; rather, it may promote social interaction and enhance communication comprehension. Moreover, the integration of verbal and nonverbal communication in AAC can facilitate the initiation of speech (Hyman et al., 2020; Maue, 2022). Brain and Mirenda (2019) emphasize that the absence of a communication method in children with autism can result in frustration, behavioural challenges, and difficulties in learning and social interaction (Maue, 2022). The incorporation of AAC can contribute to the advancement of communication skills, language development, and the mitigation of frustration and challenging behaviours in children with autism (Crowe et al., 2021; Moller, 2023). These communicative means serve as tools to empower individuals to articulate thoughts, express needs, and convey emotions, thereby fostering social connections and instilling a sense of independence (Moller, 2023). 26 The picture exchange communication system (PECS) was originally developed for non- verbal ASD children as a way of teaching functional communication through pictures (Crowe et al., 2021; Thiemann-Bourque et al., 2016). PECS is a process in which the child exchanges a picture for an item the child wants and is prompted to try and say the word of the item desired. This builds on association and helps to increase communication and speech outcomes (Thiemann-Bourque et al., 2016). The user-friendly design of PECS facilitates its accessibility for children with ASD. The prerequisite skills for initiating PECS training are minimal. In comparison to other communication systems, PECS is cost-effective. Furthermore, the system is characterized by its lightweight and portable nature: it is easy to handle and transport because of the manageable nature of the cards (Murray, 2014). An investigation was carried out involving a 4-year-old boy exhibiting high levels of aggression who was introduced to the PECS system (Lund, 2016). The school staff initially faced challenges in assessing his cognitive abilities owing to his aggression during assessments. To address this, the researchers facilitated free play with the communication board in close proximity. The study revealed a reduction in aggressive behaviour during play activities following the introduction of PECS. Concurrently, there was an increase in the use of picture communication. The researchers concluded that heightened communication provided the 4-year-old with the choices and control he sought, ultimately contributing to the observed decrease in his aggressive behaviour (Lund, 2016). The developmental, individual differences and relationship-based model (DIR)/floortime encourages adults to play and interact with children on their level. The aim of this intervention is for adults to assist the child in increasing their “circles of communication” through making use of the child’s interest-based activities. The adult makes their way into the child’s games by following the child’s lead (Autism Speaks, 2022a; Thayer, 2016). Through the back-and-forth 27 play, the child’s base for engagement, shared attention, and problem solving is strengthened, while emotional thinking and two-way, complex communication is enhanced (Autism Speaks, 2022a; Divya et al., 2023). Wetherston et al. (2017) also describe various developmental approaches, naturalistic behavioural approaches and alternative treatment approaches that are sometimes used when working with ASD children. These include relationship development intervention, operant conditioning-based approaches, milieu teaching, speech-language therapy, sensory-motor therapies, vitamin therapies and diet-based interventions. The extent to which different treatments are used varies according to the extent to which the practitioner giving the treatment is familiar with the treatment, their previous experiences with the treatment, and other factors (Robinson et al., 2017). Naturalistic behavioural approaches encompass elements such as tailoring interventions to the child’s initiatives, implementing interventions in everyday settings, and employing strongly appealing incentives. Alternatively, there are treatments rooted in applied behavioural analysis (ABA), including pivotal response training and incidental teaching, which are guided by ABA principles (Wetherston et al., 2017). Applied behavioural analysis (ABA) therapies commonly address a range of developmental domains, encompassing cognition, communication, physical motor skills, adaptive skills and social skills (Gitimoghaddam et al., 2022; Tiura et al., 2017). The instructional approach involves breaking down skills into manageable tasks, providing the minimum support required for success, and utilizing a reward system to reinforce desired behaviours (Aderinto et al., 2023; Tiura et al., 2017). Grounded in behavioural and cognitive behavioural theories, these methods are implemented by trained professionals in individualized sessions with participants. Numerous studies affirm that ABA stands out as one of the most 28 extensively researched and validated approaches for effectively treating children diagnosed with ASD (Aderinto et al., 2023; Foxx, 2008; Makrygianni et al., 2018; Tiura et al., 2017). Nonetheless, there is research indicating that ABA concentrates exclusively on observable behaviour rather than internal constructs such as thoughts, emotions or pain. This emphasis has been criticized for its potential to result in psychological and physical abuse, raising concerns about the ethical imperative to prioritize the principle of “do no harm” (Shkedy et al., 2021). Moreover, studies have indicated that ABA therapy often entails significant repetition, which can be challenging for children, and the acquired skills may not necessarily transfer effectively to different situations (Lord, 2023). In the context of ASD treatments, medication is prescribed to target distressing and atypical behaviours and to help individuals respond more positively to other strategies implemented as part of their treatment (Louw et al., 2013). Although no medication is capable of curing ASD or addressing all of its symptoms, studies indicate that the efficacy of medication is maximized when it is employed in conjunction with behavioural therapies (Maniram et al., 2023). However, the accessibility of pharmacological treatments for ASD within South Africa remains limited, as highlighted by Louw et al. (2013) and Maniram et al. (2023). There is a general lack of research in Africa on the efficacy and safety of psychotropic medications used to target specific ASD symptoms (Aderinto et al., 2023; Louw et al., 2013). Accessibility to medication is also affected by a shortage of qualified healthcare professionals, poverty and certain cultural factors (Aderinto et al., 2023; Louw et al., 2013; Norris et al., 2016). Families may decide to explore changes in diet, herbal remedies, and other complementary non-conventional treatments such as acupuncture and massage therapy (Aderinto et al., 2023; Louw et al., 2013). While some attest to the benefits of these approaches, there is 29 limited scientific evidence for their effectiveness in treating ASD, certainly within the African population (Aderinto et al., 2023; Louw et al., 2013). Maniram et al. (2023), however, argue that combining vitamins, minerals, dietary supplements and other medications that manage ASD symptoms with other forms of non-medical treatment may enhance therapeutic outcomes for children diagnosed with ASD in South Africa (Maniram et al., 2023). Factors that affect choice of treatment There is a wide array of possible treatments for ASD that practitioners can use individually or in combination (Lofthouse et al., 2012). The extent to which different treatments are used varies according to the extent to which the practitioner giving the treatment is familiar with the treatment, their previous experiences with treatment, the resources that are available to support treatment, the characteristics of the child, and the role played by caregivers and other family members (Robinson et al., 2017; Salgado-Cacho et al., 2022; Wetherston et al., 2017). Previous research has shown that some of the factors that affect practitioners’ choice of treatment include the best evidence available, the characteristics, values and preferences of the client, the client’s economic and social resources and the practitioners’ experience, skills, and knowledge in determining what works best for the child (Robinson et al., 2017; Spring et al., 2008). The affordability and availability of treatments, treatment requirements, the individual needs of the child, culture, and the parents’ interpretation of symptoms are other factors that may affect treatment choice (D’Angelo, 2011; Mandell & Novak, 2005; Robinson et al., 2017). Reports from parents indicate that the availability of treatment, costs, level of trust in health-care workers and preferred parenting practices influence their choice of treatment for their child (Guler et al., 2017). Parents can be overwhelmed by all the choices of alternative treatments, and this shows the need for collaboration between parents and professionals to create a treatment plan that suits 30 the abilities of the child as well as the family environment (Bowker et al., 2010; Karst & Van Hecke, 2012; Robinson et al., 2017). The involvement of parents or caregivers during treatment is crucial for maintaining continuity in the home environment (Salgado-Cacho et al., 2022). While many ASD interventions commonly occur in a therapist’s office or at school, it is essential for families to play an active role in the treatment process and some treatments can only be successful if they also occur in the home environment (Rojas-Torres et al., 2020; Salgado-Cacho et al., 2022). Through training, families can extend speech and language therapy, occupational therapy, and physical therapy to the home setting. This includes participating in goal setting, collaborating as part of the treatment team, contributing to programme delivery, and being involved in the treatment evaluation process (Salgado-Cacho et al., 2022). Studies have indicated that the engagement of parents enhances the long-term efficacy of the treatment (Burrell & Borrego, 2012; Rojas-Torres et al., 2020; Salgado-Cacho et al., 2022; Wetherston et al., 2017). Several studies conducted in lower- to middle-income countries also advocate increased caregiver participation in delivering interventions as a cost-effective strategy for service provision and overcoming capacity limitations (Carr & Lord, 2016; Fang et al., 2022; Guler et al., 2017; McConkey, 2022). The degree to which parents and caregivers are willing to be involved in treatment and the resources they have for this therefore play a major role in the types of treatments chosen for ASD (Guler et al., 2017). Research was conducted in the eThekwini Metropolitan Municipality to explore parental perspectives and awareness concerning treatments for children with ASD (Wetherston et al., 2017). The findings revealed that over half of the parents were either unfamiliar with or had limited knowledge about the specific treatments under consideration. Additionally, 68% of the 31 participants expressed challenges in accessing ASD treatment facilities and healthcare professionals, citing perceptions of high treatment costs. One parent stated that there was so much on the internet yet so few treatments available in South Africa. Another parent expressed difficulty in finding treatment in her home language. Many parents experienced a lack of government support and funding for external (out-of-school) therapy. They mentioned that medical aid did not cover most of the costs as autism was not recognized as qualifying for primary medical benefits (Wetherston et al., 2017). Medical aid schemes in South Africa usually do not include coverage for the substantial costs of disability-related intervention services, leaving families to bear the financial responsibility on their own (Erasmus et al., 2019). Owing to all the factors that affect treatment, and owing to the fact that there are many different treatments that often need to be used together to get an effective outcome, ASD treatment tends to be team-based and to draw on different types of professionals, with each professional playing a complementary role in the team (Dillenburger et al., 2014; Karst & Van Hecke, 2012; Wetherston et al., 2017). Team-based treatment Individuals with ASD need the expertise of professionals from various disciplines – such as psychologists, speech and language therapists, physicians, occupational therapists and special educators – who can work together to provide a comprehensive intervention (Vivanti & Hamilton, 2014). Dillenburger et al. (2014) and Wetherston et al. (2017) emphasize that effective interventions for ASD require collaboration and teamwork between different types of practitioners and with the family of the ASD child. Similarly, Sinai-Gavrilov et al. (2019) found that ASD treatment was most effective when there was mutual learning and a sense of professional support among people working together from different disciplines in a 32 multidisciplinary team. Empirical evidence also suggests that team-based treatment is one of the most effective forms of treatment for ASD, and one of the best-suited treatment models for developing an individualized approach that benefits the child (Sinai-Gavrilov et al., 2019). According to the Health Professions Act, 2011 (Section 5 (a), Regulation No. 704 of 2011), the scope of practice of an educational psychologist is: “assessing, diagnosing, and intervening in order to optimize human functioning in learning and development; assessing cognitive, personality, emotional, and neuropsychological functions of people in relation to the learning and development in which they have been trained”. Educational psychologists’ role in working with ASD children is to improve their functioning within the school environment; to liaise with and support parents and caregivers to recognize, accept, and manage their child’s difficulties and impairments; to recommend, develop, and administer applicable strategies and therapies that can support ASD children to perform to the best of their potential; and to collaborate with other professionals in order to identify and address barriers to learning (Donald et al., 2010; Farrell, 2004). Educational psychologists play a supportive role in the life of an ASD child, while at the same time dispelling the stigmas attached to ASD through increasing knowledge and awareness (Keenan & Dillenburger, 2021). Although educational psychologists take on an important set of roles in treating ASD children, it is not possible for one type of practitioner to be trained in every skill needed. Working with different specializations is therefore imperative for knowledge areas to be integrated and the best possible treatment approach developed (Dillenburger et al., 2014). Because the field of ASD is constantly developing, educational psychologists, speech therapists, occupational therapists and other professionals need to work together to keep up to date while also incorporating a holistic and individualized approach to optimize treatment (Robinson et al., 33 2017; Sadreddini, 2017; Vivanti & Hamilton, 2014). Educational psychologists cannot use only formal assessment tools to create a complete view of the child – they also need to gather information from parents and the school to enable them to produce a holistic assessment. In this way, the parents, extended family, teachers and other professionals all play an important role in the treatment of the child (Sadreddini, 2017). Mental health professionals must tailor their approaches to integrate and support collaboration with parents because effectively communicating with and engaging parents in the therapeutic process is essential (Kalyva, 2013; Robinson et al., 2017; Wetherston et al., 2017). Parents who actively participate in collaboration with mental health professionals tend to enhance their abilities, knowledge and assertiveness, the better to help a child diagnosed with ASD (Catalano et al., 2018; Kalyva, 2013). Research indicates that active parental involvement in the child’s therapy not only fosters a sense of efficacy and personal control but also contributes to the parents’ becoming more effective, less stressed and less concerned (Kalyva, 2013). Fostering a positive parent-professional relationship can also significantly alleviate stress during the process of diagnosing ASD (Elder et al., 2017; Kalyva, 2013). The results of a qualitative study carried out by Ho et al. (2013) indicate that there is a connection between how well families react to a diagnosis of ASD and the value of the parent-professional partnership (Elder et al., 2017). According to Wetherston et al. (2017), almost two-thirds of parents described their families as part of the treatment process through assisting in treatment, supplying transport, support and encouragement, and, very importantly, helping with decision-making. This participation contributed positively to parents’ coping during the intervention. Research has 34 shown that optimism on the part of parents and families through the treatment process contributes positively towards the treatment outcome (Ho et al., 2013; Wetherston et al., 2017). The shortage of mental health professionals for treating ASD Although team-based treatment emphasizes the role of a range of specialists in the treatment process, international research highlights a persistent lack of mental health professionals with specialized training in ASD to deliver evidence-based services (Dückert et al., 2023; Hahler & Elsabbagh, 2014; Mathews et al., 2022). This shortage, despite the increasing prevalence of ASD over the past two decades, underscores the urgent need for training programmes to equip school psychologists effectively to address the needs of children with ASD and developmental delays. Existing resources, such as the standards set by professional and non- governmental organisations, can guide such training initiatives (Mathews et al., 2022). While most school psychology curricula adequately prepare future professionals for ASD diagnosis and assessment, there remains a knowledge gap in evidence-based treatment. A truly comprehensive curriculum should therefore cover early signs of autism, evidence-based screening and diagnostic assessment tools, treatment interventions, collaboration with families and teachers, and research methods (Mathews et al., 2022). Despite ASD research having experienced significant growth worldwide in recent times, a significant portion of this research originates from the United States and other high-income nations, and a lack of evidence emanating from lower-income and middle-income countries indicates a noteworthy gap in understanding the ASD population globally. There is a particular need for ASD research in sub-Saharan African contexts, as knowledge about the prevalence and treatment of ASD in Africa lags behind that of other continents (Aderinto et al., 2023; Bakare & 35 Münir, 2011; Guler et al., 2017). Many individuals with ASD in Africa are in urgent need of services (Bakare & Münir, 2011; Guler et al., 2017). In numerous African contexts, there is limited public education about ASD, and the healthcare approach often relies on traditional healing methods rooted in local customs (Aderinto et al., 2023; Guler et al., 2017; Zeleke et al., 2021). A lack of public education increases the risk of misinformation about ASD and exacerbates the knowledge gap among professionals responsible for diagnosing and managing ASD. Children with ASD in sub-Saharan Africa receive diagnoses later than their counterparts in the USA, particularly those from impoverished regions, due to a lack of awareness, stigma, and a shortage of professionals. The limited number of professionals available also makes it difficult to provide effective evidence-based treatment that is culturally responsive (Aderinto et al., 2023; Zeleke et al., 2021). As a result, parents or caregivers often take on the responsibility of providing interventions for ASD management. The multidisciplinary approach to treating ASD is uncommon in African countries, and there are no policies or guidelines for assessing, treating, educating and providing support for individuals with ASD (Zeleke et al., 2021). Creating awareness and providing training for educators and healthcare workers on ASD is therefore critically necessary in the region (Aderinto et al., 2023; Zeleke et al., 2021). Guler et al. (2017) note that when an intervention is transferred to a different context, it is crucial to consider contextually relevant factors and what modifications or adaptations may be needed to allow the intervention to work effectively. ASD in the South African context Although educational psychologists can take on several roles in ASD treatment, the actual roles that they perform can depend on circumstances, and, in the case of South African educational psychologists, these are very much determined by the unique context of South 36 Africa. There is a dire need for more knowledge about the prevalence and nature of ASD treatment in Africa as well as about issues specific to South Africa (Ametepee & Chitiyo, 2009; De Vries & Bölte, 2016; Franz et al., 2018; Ruparelia et al., 2016). The lack of adequately trained healthcare professionals, limited resources, and a shortage of diagnostic tools in low- income African countries contribute to constrained diagnostic capabilities, thereby impeding access to essential services and support (Aderinto et al., 2023; Kantawala et al., 2023). In South Africa, which has lower access to resources generally, the accessibility of services for ASD treatment is limited and ASD treatment options are scarce (Franz et al., 2018; Guler et al., 2017; Van Schalkwyk et al., 2016). There is limited access to specialist treatment providers and there can be long delays in diagnosis, with the average waiting period being about 18 months for a clinical diagnosis of ASD (Makombe et al., 2019; Mayosi & Benatar, 2014). This delay in clinical diagnosis has major implications for the outcomes of treatment plans, as the earlier the diagnosis, the better the treatment outcome (Erasmus et al., 2019; Guler et al., 2017). Treatment costs for ASD can be prohibitive and there are very few cost-free ASD- intervention services in South Africa (Erasmus et al., 2019; Guler et al., 2017). Another factor that can affect treatment in South Africa is language, especially if treatment is not available in the first language of the child (Wetherston et al., 2017). Guler et al. (2017) identified language as a consideration during a study they conducted exploring the perspectives of South African parents of ASD children regarding early autism intervention. Caregivers in their study noted variations in language preference for therapeutic delivery, including a preference for instruction in English or the family’s home language, and uncertainty regarding which would be most effective. Caregivers expressed a desire for therapists to be aligned with families in terms of language. They also argued for consistency in the language of instruction across educational and 37 treatment settings for children, believing that this approach would better prepare the children for school or external environments. Guler et al. (2017) also found that the following all emerged as major contextual factors in their study: stigma, culture, parenting practices, location of treatments due to scarcity of skill transfer between the clinic and home, lack of resources, disordered home settings, insufficient space for those living in informal settlements, the costs of intervention because of limited financial support from the government, low income due to poverty and/or being a single parent, and the extra financial costs of rearing an ASD child. The respondents also highlighted the tendency of extended family, teachers, health care professionals and even outsiders to label their children “naughty”. Negative labels such as this arise from the lack of knowledge about ASD among South Africans. Caregivers observed that people might think that they or their child had been bewitched, apparently referencing a South African cultural belief that children with ASD were cursed (Guler et al., 2017). One caregiver recalled how her mother and other women in her community rejected the diagnosis of her son and held the view that spirits were trapped in his throat and needed to be released through customary cutting practices in order to enable him to speak (Guler et al., 2017). These findings support other studies indicating that ASD-related stigma has negative implications for the mental health and wellbeing of families (Turnock et al., 2022). Evidence like this highlights the significant challenge posed by insufficient awareness and understanding of ASD within both the general population and healthcare profession throughout Africa (Kantawala et al., 2023). Cultural beliefs and the stigma associated with ASD in many African societies complicate the identification and diagnosis of ASD by regarding it as a spiritual ailment rather than a neurodevelopmental disability (Aderinto et al., 2023; Kwantawala 38 et al., 2023). Traditional healing practices may be favoured as quick-fix solutions in the place of specialized medical care. Combatting stigma through partnerships between local communities and national and international organisations is desirable, but resources for this are limited (Aderinto et al., 2023; Guler et al., 2017; Kantawala et al., 2023). Another problem in South Africa is finding suitable school placements, as many children with ASD wait for long periods before being able to enter formal education (Pillay et al., 2022b). To investigate this issue, Pillay et al. (2022b) conducted a qualitative study with ten ASD service providers in the Western Cape. The objective was to explore their perspectives on the issue of ASD school placement and identify possible solutions to address the educational needs of children with ASD. One participant provided a list of factors that they felt contributed to successful school placement for children with ASD, citing a coordinated approach to service provision and a consolidated and efficiently maintained database containing comprehensive information about each child (i.e. an information-rich waiting list) (Pillay et al., 2022b). The participants identified resource, competency, and contextual constraints that made placement difficult, and they emphasized the importance of building more capacity for working with children with ASD (Pillay et al., 2022b). The current study Treatment for ASD is very important and early intervention gives the best outcome for ASD children (Franz et al., 2018). International research has explored educational psychologists’ perspectives on their role in the treatment of ASD (for example, Robinson et al., 2017). Yet this research is limited, and similar work does not appear to have been carried out in South Africa. Little is known about how educational psychologists in South Africa adapt common treatment practices to their environment, how they choose different treatments for ASD children, and how 39 they engage with ASD children, their families, and other practitioners, especially in a context where the services available for ASD children fail to meet their needs in many ways (Guler et al, 2017; Tilahun et al., 2016). Additional difficulties have been associated with engaging with the healthcare system, such as inadequate support from healthcare providers (Guler et al., 2017). Due to all of this, it is very important to gain a better understanding of how educational psychologists treat ASD in South Africa and how they perceive their experience of doing so. This information can contribute to appropriate training for educational psychologists to better prepare them for working with ASD patients and their families. Although some empirical studies have been conducted, they have mainly focused on parents’ or caregivers’ perspectives or the efficacy of certain interventions or treatments (Franz et al., 2017; Guler et al., 2017; Wetherston et al., 2017). There seems to be very little if any research devoted to South African educational psychologists’ perspectives on the treatment of ASD children. The primary aim of the current study was thus to explore a sample of South African registered educational psychologists’ perspectives on and experiences of the treatment of ASD children in the South African context. This included ascertaining how the educational psychologists in the sample selected treatments or interventions for ASD and evaluated their effectiveness, as well as which other available treatments they were aware of. The study focused on the factors that they felt influenced their decision-making for intervention or treatment when working with ASD children, their level of involvement at each stage of the treatment process, and their roles in relation to other professionals engaged in the ASD treatment process. The study also explored their views of the challenges faced by themselves and the parents of ASD children in seeking and obtaining treatment in the South African context, while identifying potential mitigating factors. In sum, the research sought to identify common strategies employed by 40 educational psychologists when treating ASD children in South Africa as well as the challenges faced by these professionals when offering treatment or intervention. Research questions The broad research question for the study was: • What are educational psychologists’ perspectives on and experiences with the treatment of ASD children in the South African context? Specific research questions in the study were: • What forms of treatment/intervention do educational psychologists choose when working with ASD children in South Africa and where did they source these from? How effective are these treatments perceived to be? • What factors influence educational psychologists’ decision-making for intervention/ treatment when working with ASD children? • What level of involvement do educational psychologists have in each stage of the treatment process when working with ASD children? • How do educational psychologists understand their role in the intervention/treatment process relative to others involved in the process (for example, parents, teachers, other professionals)? • What challenges do educational psychologists feel ASD children and their parents face when seeking and/or obtaining treatment for ASD in the South African context? What factors, if any, do they feel could mitigate these? • What strategies do educational psychologists have in common when treating ASD children in South Africa and what challenges do they face when offering treatment/intervention? 41 Chapter 3: Methods In this chapter, a comprehensive methodological framework employed in this study to investigate educational psychologists’ perspectives on the treatment of ASD children within the South African context will be presented. The research design will be discussed, including the rationale behind the qualitative approach, the selection of the sample, and the sampling strategy. The data collection process will be elucidated, emphasizing ethical considerations paramount to the safeguarding of participants' rights. The method of analysis, reflexive thematic analysis, will be explained, including how a nuanced understanding of diverse viewpoints was ensured. The researcher’s commitment to producing trustworthy and credible findings, emphasizing the principles of transferability, dependability, and confirmability, will also be presented. Reflexivity and qualitative rigour were integral components throughout the research process, enriching the depth and validity of the study. Research design The primary aim of the study was to explore a sample of South African registered educational psychologists’ perspectives of and experiences with the treatment of ASD children in the South African context. The design of the study was therefore qualitative, and an interpretive approach was used (Wagner et al., 2012; Stiles, 1993). The interpretive approach focused on understanding human experience in context through the perspectives of the participants, and its philosophical underpinnings were informed by hermeneutics as well as phenomenology (Wagner et al., 2012; Terre Blanche et al., 2006). Qualitative researchers analyse language-based data by identifying and classifying themes (Stiles, 1993; Terre Blanche et al., 2006). Through qualitative methods, researchers can study particular issues in depth and openly as they recognize and try to comprehend themes that 42 arise from the data (Terre Blanche et al., 2006). Qualitative research can be utilized for exploratory reasons as well as a means of developing enriched descriptions and explanations of human phenomena (Terre Blanche et al., 2006). Qualitative research is inductive, inclusive, and naturalistic and involves immersion in the details of the data as a means to uncover categories, themes, and relationships (Terre Blanche et al., 2006). Instead of testing theoretically derived hypotheses, it starts by discovering genuinely open questions (Terre Blanche et al., 2006). Qualitative researchers who approach the world from an interpretive perspective aim to create understanding regarding experiences, situations, and events as they arise within the real world (Terre Blanche et al., 2006). In the interpretive approach, reality is a personal or social construct that depends on the individual. Reality cannot be generalized to one common reality but is instead narrowed down to context, space, time, individuals, or groups in a given situation (Wagner et al., 2012). Interpretive researchers also implement an inter-subjective epistemology. This means that knowledge is subjective due to its being socially constructed (Wagner et al., 2012). Within this research study, my interest was to explore educational psychologists’ perspectives on the treatment of ASD children in South Africa. Additionally, I wanted to find out about their experiences and the challenges they faced while working with children on the spectrum in South Africa. Thus, a qualitative research design and interpretive approach were suitable for this type of research because they allowed me to understand and interpret the different subjective perspectives and experiences of the participants. In my study, I assumed that reality is constructed through exploring shared understandings, individual meaning, and multiple interpretations of phenomena; I also assumed that knowledge is unique to each individual and that this can be co-created inter-subjectively (Alharahsheh & Pius, 2020; Terre Blanche et al., 43 2006). This allowed me to interact with my participants to gain a deep and rich understanding of their experiences and perspectives as a way to understand their reality and develop shared knowledge of my topic (Alharahsheh & Pius, 2020; Terre Blanche et al., 2006). The data was gathered using semi-structured interviews and analysed thematically, which also fit with a qualitative design and interpretive approach. Qualitative research enables problems to be assessed and dissected deeply and entirely as it uses detailed descriptions of the feelings and experiences of the participants (Terre Blanche et al., 2006). Another reason why I chose this research type, especially semi-structured interviews, was that the interviews were not narrowed down to particular questions but were guided and prompted by the researcher, and as new information arose, the research direction and structure could be revised, allowing for flexibility (Qu & Dumay, 2011). Due to this research being based on human experience, the data obtained was powerful and captivating (Terre Blanche et al., 2006). In terms of limitations, the collection and analysis of qualitative data takes a lot of time and there are times when it can be intellectually and emotionally demanding (Terre Blanche et al., 2006). Qualitative research findings are not generalizable, and it can be difficult to account for their transferability (Terre Blanche et al., 2006). Subjectivity can be another limitation but is also a strength, as the researcher’s primary role is to analyze and interpret the data; thus, the researcher chooses what is seen as significant and insignificant, and interpretations of the exact same data can differ immensely (Anderson, 2010; Rahman, 2016). Sample and sampling To obtain the sample, I used purposive and volunteer-based sampling (Jupp, 2006; Terre Blanche et al., 2006). Participants were recruited based on specific criteria. They had to be at 44 least 18 years old and registered educational psychologists involved in the treatment of autism spectrum disorder (ASD). Additionally, they needed a minimum of three years of experience working with ASD patients and/or in the field of ASD. Invitations and the participant information sheet were emailed to all potential participants, asking educational psychologists who met the criteria and were interested in participating in the study to contact me to set up a time for an interview. I also used snowball sampling, a convenience sampling method, by asking each participant and potential participant to forward or share the invitation with anyone else interested in participating who met the requirements (Shaheen et al., 2019). This method facilitated easier access to participants with the target characteristics, as educational psychologists typically work with others who share the required characteristics for the study (Naderifar et al., 2017). To contact potential participants, I made use of publicly available contact details (sourced from public forums or online) to send invitations to participate in the study. I emailed educational psychologists directly when their details were available publicly, and I emailed ASD support groups and schools to enquire if they could recommend anyone or pass on the invitation to participate to anyone who might be suitable. Approximately thirty individuals were contacted directly however most did not agree to participate in the study. Snowball sampling also yielded only one response, underscoring the challenges in recruiting participants for the study. The final sample consisted of eight participants aged 18 and above, all of whom were registered educational psychologists involved in the treatment of autism spectrum disorder (ASD). Each participant had a minimum of three years of experience working with ASD patients and/or in the field of ASD. Among the participants, one was male, and seven were female. Two participants were aged over fifty, with 19 years and 20 years of experience as registered 45 educational psychologists. Four participants fell within the age range of forty to forty-five years old, while two were in their late thirties. These participants had a wide range of experience as registered educational psychologists with registrations between 4 years and 20 years. Six of the eight participants had English as their home language, while two were bilingual, proficient in both English and Afrikaans. In terms of professional settings, six participants worked in private practice, one exclusively in a school setting, three in both private practice and school settings, and one in a provincial education department outreach team. Regarding their years of registration, six participants had been registered as educational psychologists for approximately 10-20 years, while two had less than 10 years of experience (between 4-7 years). Two participants had limited experience working with ASD clients, whereas four had extensive experience in this area. Two participants had experience working with roughly 10-15 ASD children. One participant had a considerable caseload, having provided services to about 600-700 ASD clients. Another participant worked with approximately 280 ASD clients in both their private practice and school settings, while one had experience with over 100 clients. For a full breakdown of the characteristics of each participant, please see Table A. Many participants were not located in Johannesburg, but rather in dispersed locations across South Africa. The interviews took place using the Zoom online platform. The data was collected over a five-month period, from September 2022 to January 2023. Saturation is the point at which further data collection is not needed in a qualitative study (Saunders et al., 2018). Saturation was not achieved in this study, however the eight participants represented the maximum number of participants that could be realistically obtained due to the limited pool of individuals meeting the sampling criteria and the busy schedules of potential participants. 46 Response rates were very low, making it impossible to reach saturation within the given timeframe. Despite this, the sample was considered sufficiently robust to address the research questions. Table A Participant characteristics (n = 8) Part. Age Gender Length of HPCSA registration Professional environment Duration of involvement with ASD clients Number of ASD clients worked with: A 38 Female 10 years Provincial department outreach team 14 years Hundreds B 45 Female 14 years Private practice 14 years 10 C 36 Male 7 years Private practice; specialized school 13 years 250-280 D 45 Female 20 years Private practice 20 years 600-700 E 69 Female 20 years Private practice; school setting 5 years Unknown F 41 Female 4 years Private practice 15 years 15 G 45 Female 10 years Private practice; primary and high school setting At least 3 years Unknown H 54 Female 19 years Specialized school; private practice; school setting 10-14 years Unknown 47 Data collection I first obtained ethical clearance to conduct the study from the Human Research Ethics Committee (non-medical) at the University of the Witwatersrand (protocol number: MEDPSYC/22/03). I then identified contact details for suitable possible participants and ASD schools and support groups and sent out invitations to participate in my research (please see Appendix B) with attached participant information sheets (please see Appendix C). Once potential participants contacted me, I negotiated with them to set up interviews at convenient times and places. I explained to the participants that the time frame of the interviews would be approximately one hour, and that the interviews could either be conducted in person or virtually, depending on national circumstances and the preference of the participants (both options were possible). I explained to all participants that if they opted for an in-person interview, the interview would have taken place at an agreed safe location, either at their place of work or, if they were willing to travel, at the University of Witwatersrand. Additionally, I explained to each participant that social distancing between the participant and the researcher, as well as the wearing of masks, would have been implemented. However, all participants preferred and opted for online interviews due to their demanding work schedules and their dispersed locations across South Africa. The sessions took place using the Zoom online platform, and with the participants’ consent, the interviews were recorded. I asked participants if we could turn on cameras for the introduction part of the interview; however, I gave them the option to switch off their cameras as the interview progressed, as some individuals may have felt more comfortable with their cameras off. All participants chose to leave their camera on and expressed being comfortable with this. The recording was in video 48 format. All participants had access to the Internet, a suitable device, and data. No technical issues were experienced during the interview process. The interviews were conducted individually with each participant, and with their consent, I recorded the interviews using a voice recorder. All interviews were semi-structured, creating an atmosphere of openness and trust for participants to freely express themselves (Qu & Dumay, 2011). Each interview was conducted in English. Before commencing the interviews, I provided participants with another copy of the participant information sheet (please see Appendix C), explaining the aim of the interview and assuring them that participation would be confidential, with their identities kept anonymous when reporting the results. Participants were informed that if they felt uncomfortable at any point during the interview, they had the right to express their feelings and the option to withdraw. All participants chose to participate and were then asked to sign a consent form that included permission to record the interview and to use direct quotes from the interviews (please see Appendix D). To initiate the interview, participants were asked to complete a brief demographic form (please see Appendix E). The interview was then commenced using prompts and questions from the semi-structured interview schedule (please see Appendix F). As both the researcher and interviewer, I took care to address the research questions thoroughly during the interview process to minimize the need for subsequent clarification or confirmation (Adams, 2015; Luo & Wildemuth, 2017). By presenting several open-ended questions, I directed the conversation towards the topic while allowing participants to contribute any additional pertinent details. Utilizing an interview guide facilitated the exploration and probing of relevant questions, affording me the flexibility to adjust inquiries as necessary. I centred the semi-structured 49 interview questions surrounding the experiences of the participants when treating children with ASD. Throughout the interview, I recorded and took notes while also striving to be as friendly and open as possible to encourage rapport and information sharing (DeJonckheere & Vaughn, 2019). Upon concluding the interview, the recording was stopped, and the participant was thanked. As the researcher, I served as the primary instrument in the study, subjectively interpreting and analysing the data to address the research questions (Flick, 2009). I emphasized the significance of being reflexive and vigilant concerning the potential impact of my personal perspectives on the interpretation of the data. As an educational psychology student with volunteer experience, which involved serving as a facilitator and tutor at an Autism Intervention Centre, my commitment to honing skills and comprehending the effective role of educational psychologists in both independent and multidisciplinary settings was a driving force. Acknowledging the potential impact of my passion on data interpretation, I remained conscious of this influence throughout the research process, striving for accurate representation of participants’ perspectives (Palaganas et al., 2017). My prior involvement in ASD-related initiatives and exposure to various treatment modalities in South Africa during my volunteer work facilitated the establishment of rapport with participants and enhanced engagement. This, in turn, enriched the depth of the research, fostering a conducive environment for participants to expand on their insights comfortably. The data was collected through individual semi-structured interviews with the participants. This approach proved highly beneficial as it allowed direct engagement with the participants, fostering openness and trust for them to freely express themselves. Additionally, it 50 provided a versatile means of collecting data compatible with various data analysis methods (Willig, 2008). Magaldi and Berler (2020) characterize the semi-structured interview as an exploratory method, emphasizing its reliance on a guiding framework while remaining flexible to delve into discoveries during the conversation. Despite the predefined focus, this approach permits researchers to probe deeper into emerging themes based on participants' responses (Ruslin et al., 2022). In the context of this study, the semi-structured interviews followed a thematic framework, maintaining a balance between overarching questions, follow-up inquiries, and probing for further insights. Preparation of an interview schedule in advance proved advantageous as it ensured alignment with the research objectives and facilitated comprehensive coverage of the intended questions during the interview proceedings (Ruslin et al., 2022). The interview schedule (please see Appendix F) was developed based on theory and available literature (for example, Aderinto et al., 2023; Guler et al., 2017; Robinson et al., 2017; Salgado-Cacho et al., 2022; Wetherston et al., 2017), with questions formulated to gather data for addressing the research questions. The questions prepared were open-ended, and prompts were included to enable me, as the interviewer, to seek clarification or additional information as needed. The questions were structured to provide participants with the space to bring up any topics that might arise during the interview (DeJonckheere & Vaughn, 2019). The interview schedule began with my introducing myself and expressing gratitude to the participant for meeting with me, thus setting them at ease. I explained the purpose of the interview, the approximate duration, aspects of confidentiality, and voluntary participation. I discussed the participant information sheet and asked the participant to sign the consent form. The participant was inf