Culture as a Driver for the Design of Social Robots for Autism Spectrum Disorder Interventions in the Middle East

Abstract

In this paper, we discuss the prevalence of Autism Spectrum Disorder (ASD) in the Gulf region. We examine the importance of providing state-of-the-art ASD interventions, and highlight social robots as therapeutic tools that have gained popularity for their use in ASD therapy in the West. We also elaborate on the features of social robots that make them effective and describe how they can be used in such settings. We then emphasize the significance of taking cultural context into account in order to develop indigenous tools for ASD therapy, and explain the different ways in which social robots can be made culturally adaptive to maximize their potential impact on children with ASD.

Full text

Culture as a Driver for the Design of Social
Robots for Autism Spectrum Disorder
Interventions in the Middle East
Hifza Javed1, John-John Cabibihan1, Mohammad Aldosari2, and
Asma Al-Attiyah3
1Mechanical and Industrial Engineering Dept, Qatar University, Doha, Qatar
2Center for Autism Pediatric Institute, Cleveland Clinic
and Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
3Psychological Sciences Dept, Qatar University, Doha, Qatar
Abstract. In this paper, we discuss the prevalence of Autism Spectrum
Disorder (ASD) in the Gulf region, focusing specifically on the statis-
tics from the state of Qatar. We examine the importance of providing
state-of-the-art ASD interventions in Qatar, and highlight social robots
as therapeutic tools that have gained popularity for their use in ASD
therapy in the west. We also elaborate on the features of social robots
that make them effective and describe how they can be used in such
settings. We then emphasize the significance of taking cultural context
into account in order to develop indigenous tools for ASD therapy, and
explain the different ways in which social robots can be made culturally
adaptive to maximize their potential impact on children with ASD.
1 Introduction
Autism Spectrum disorder (ASD) is a neurodevelopment disorder [1], usually di-
agnosed during the first 3 years of life and may be accompanied by other physical
or psychological disorders [2]. It is traditionally characterized by impairments in
social communication, social interaction and imagination abilities [3], and can
be attributed to an absence of the mentalizing ability in a person diagnosed with
ASD [4][5].
Impairments in social communication include difficulties in processing lan-
guage, and in interpreting facial expressions, body language and the tone of
voice [6]. Children on the spectrum also tend only to focus on the literal mean-
ings rather than the underlying meanings of metaphors or figures of speech used
in communication.
Children diagnosed with ASD often appear withdrawn and aloof. They tend
to be uncomfortable in most social settings and have problems forming deep
social relationships. This is a direct result of their inability to process emotions
easily. They are also unable to maintain eye contact because they feel over-
loaded with information coming in simultaneously through a number of channels
(speech, body language and facial expressions). To avoid such sensory overload,

2 Javed, Cabibihan, Aldosari, and Al-Attiyah
they retreat into their own world of familiarity and clarity, thus appearing unin-
terested and rude to those around them. This marks the impairments in social
interaction.
Deficits in the ability to understand abstract ideas and imagine situations
outside the daily routine form the impairments in social imagination. These
impediments tend to confine a child to his own mind, not allowing him or her to
deal with any changes to routine. For this reason, such children tend to engage
in rigid and repetitive activities and are unable to indulge in imaginative or
interpersonal play [7].
2 Autism in the Gulf States
According to the Centers for Disease Control and Prevention (CDC) report in
2014 [8], 1% of the world’s population has autism spectrum disorder (ASD). In
the United Kingdom, one child out of 100 children has ASD [9]. In the United
States, the autism prevalence rate is 1 in 68 births [8]. In South Korea, it is 1 in
38 [10]. A large number of epidemiology studies have been conducted globally,
bringing forth a wealth of information regarding the prevalence of the condition
[11][12][13]. However, with majority of these studies being conducted in western
countries, prevalence statistics for the Gulf States and other developing countries
in the world remain largely unknown.
Table 1 lists the available statistics for some Gulf states. The overall ASD
prevalence in these countries appears to be lower than generally found in the
west. Samadi [14] reports a social stigma attached to disabilities in the Arab
culture, which may be a reason that prevents parents from fully reporting a
child’s difficulties [15]. In addition, children with such disabilities may discon-
tinue education early, preventing them from being screened during studies con-
ducted in elementary schools [16]. The differences in environmental triggers, and
in parental practices and expectations must, however, be taken into account as
well. Cannell [17] has even suggested a connection between autism and vitamin
D deficiency in pregnant women, attributing the low prevalence of autism in the
region to adequate exposure to the sun. It must also be noted that no uniform
diagnostic methodology was employed throughout the studies listed in Table 1,
making it difficult to compare their results.
Table 1. Prevalence Data for ASD in some Gulf States
Study Country No. of Cases/10,000 Subjects Ages Diagnosis
Al-Farsi (2011) Oman 1.4 Up to 14 years ASD
Naqvi (2012) Saudi Arabia 60 Up to 16 years ASD
Eapen (2007) UAE 12 3 years PDD
Alshaban (2011) Qatar 16 Up to 18 years ASD

Culture as a Driver for Social Robot Design 3
3 Importance of Intervention for the State of Qatar
The state of Qatar is currently witnessing a sharp rise in the demand for ASD
support from local and expatriate communities. Table 2 below shows all the
centres in Qatar that cater to individuals with ASD from 1992 to the present.
From only 4 centres in the 1992 to 2003 period, there has been a 250% increase
in the number of centres in the succeeding years up to the present. Furthermore,
a 2012 study from Qatar University, Shafallah Special Needs Center, and Hamad
Medical Corporation [18] showed that children with autism largely stay indoors,
spending about 17 hours a day in their own homes, with most of their time spent
sleeping or watching television.
It is important to note that a large portion of this demand comes from the
expatriate community. Qatar’s population is composed of a number of different
nationalities. This implies the same variety in the languages and cultures of
people, and hence, also in their needs. This is especially relevant to therapy and
intervention practices for ASD, which are largely child-specific in nature and can
have their efficacy affected by minute details. Therefore, in such cases, including
culturally relevant features in therapy practices can potentially improve results.
Table 2. Centers in Qatar for Special Needs Children (including Children with
ASD)
No. Years Established Name of the Center Languages
1 1992 Qatar Society for the Rehabilitation of Special Needs Arabic, English
2 1996 Awsaj Institute of Education Arabic English
3 2001 Shafallah Center for Children with Special Needs Arabic, English
4 2003 Sunbeam Center of Excellence Arabic, English
5 2005 HOPE Qatar Arabic, English
6 2007 Special Needs Center, Qatar University Arabic, English
7 2009 Al Tamakon Comprehensive School Arabic, English
8 2009 The Next Generation School Arabic, English, Urdu
9 2010 Qatar Autism Center Arabic, English
10 2011 Step by Step Center Arabic, English
11 2013 Child Development Center Arabic, English
12 2013 Hand in Hand Center Arabic, English
13 2014 Omega Center for Special Needs Education Arabic, English
14 2014 Alkhuzama Special School for Special Needs Arabic, English
4 Importance of Social Robots
Socially assistive robotics is aimed at addressing the gaps in care given to humans
by providing assistance in the form of social interaction. The large user base that
can benefit from the automated companionship, supervision, mentorship and
motivation includes stroke survivors, the elderly, patients with dementia and
children with ASD. SARs have, hence, been at the front end of ASD therapy in
developed countries for some years now [19].
The reasons for the integration of SARs in ASD therapy are manifold. Chil-
dren with ASD have been observed to show a deep interest in technology in gen-

4 Javed, Cabibihan, Aldosari, and Al-Attiyah
eral and robots in particular. The nature of their disorder inhibits their social,
emotional and interactive abilities, making human-human interaction a challenge
for them. True to their nature, humans communicate not just with words, but
also with facial expressions, body language, tone of voice and eye contact. To
complicate things further, the words are not always intended literally, such as
when humor or sarcasm is involved. Such subtleties often elude a child on the
spectrum, discouraging him from indulging in such interactions. For such a child,
interacting instead with a robot that exhibits only a small subset of the human
emotions, and does so with minimal use of complex communicative mechanisms
typical of humans is much easier to do.
In addition to this, the toy-like size and appearance of most SARs prevent
them from intimidating a child, and their abilities to repeat mundane tasks and
to indulge in interactive gameplay enable the children to view them as friendly
playmates that pass no judgment on their unconventional behavior. Their use
does not have to be limited to a session in a clinic, but can be extended to homes
and classrooms to strengthen the bond with the child.
Many previous studies [20][21][22][23][24] have reported improvements in so-
cial performances of children on the spectrum after continued interaction with
such robots. These interactions are designed especially to be simple, interactive
and enjoyable, involving gameplay and learning both. Robots take up the roles
of playmates, social actors, teaching agents and social mediators.
This robotic therapy has been used as a supplement to the conventional
therapy model involving only a therapist and the child subject. This model,
though more effective than the conventional one, may however be prevented
from attaining its true potential in multicultural environments, where the child
and the therapist may belong to different cultures. In such scenarios, it becomes
important to take the cultural context into account in order to maximize the
impact of therapeutic practices. Some of the popularly used social robots are
shown in Figure 1.
5 Importance of Cultural Context in ASD Intervention
There is no shortage of studies based on autism: prevalence and epidemiology
studies, renowned works on the nature of the disorder, and ample research on the
most advanced therapy methods. There is plenty of available published material,
case studies and surveys, discussing the role of social robots in autism therapy
as well. However, the one factor lacking in a majority such works is the lack of
social context taken in account during the course of the study.
Most of the available studies presenting statistics on the prevalence of autism
have been conducted within the developed part of the world [11][12][13]. Only
a handful of such studies have been conducted in developing countries, with
most being small-scale, and not country-wide. It is important to note that the
diagnostic and screening tools used in developing countries have been arbitrarily
adopted from the studies conducted in the developed countries, negating the
cultural differences between the two. Hence, research that addresses the cultural

Culture as a Driver for Social Robot Design 5
Fig. 1. Socially interactive robots that have been used for the therapy of chil-
dren with autism in the literatures. The 4 types of form-factors used are: (a)
humanoids, (b) human-like robots, (c) mobile or toy-like, and (d) animaloids.
context is necessary in the development of screening and therapy tools that
are sensitive to the local culture, helping also to devise new, culturally relevant
frameworks and methodologies for autism therapy.
In addition, only a few cross-cultural studies can be found on the response of
culturally different individuals towards robots in general [25][26][27][28]. To the
best of our knowledge, none, however, is focused in particular on social robots
for autism therapy. It is obvious that cultural context must be considered in
order to maximize the impact and integrity of the research efforts.
We have been unable to find any published research on equipping SARs
with the ability to become cultural mediators. Using culturally adaptive robots
for ASD therapy is truly a unique idea with potential to play a transformative
role for children with ASD. This would immensely facilitate therapists in their
struggle to mediate cultural differences when interacting with children of cultures
that are different from their own. This allows them instead to focus entirely
on therapy goals by sharing the requirement for multicultural and multilingual
competence with a robot. This enables a single robotic entity to play a critical
role in the therapy for children belonging to diverse cultural backgrounds, and
to be effective for children with varying needs. Culturally relevant interactions

6 Javed, Cabibihan, Aldosari, and Al-Attiyah
also present us with the opportunity to further our understanding of ASD, and
evaluate just how deep-rooted the impact of culture can be on the behavior of a
child with autism.
6 Design Features for Culturally Adaptive Robots for
ASD Intervention
There are a number of ways in which culturally adaptive features can be added
to social robots to maximize their effectiveness in ASD intervention. It must be
noted that a robot, as it is, is a neutral entity. It is neutral in appearance, is
independent of culture or nationality, and appeals to all children for its friendly,
toy-like appearance. Therefore, at first glance, children are not intimidated by
robots and are instead compelled to initiate interactions with them. This already
gives them an advantage over a human therapist whose unfamiliar appearance,
in some cases, may confuse or overwhelm the child.
In the Middle East region, there are many communities that are comprised
of many different nationalities, meaning that it is not uncommon for the thera-
pist and the patient to belong to different cultures. This implies a difference in
language, accents, behaviors, style of communication, gestures and many other
details that can play a significant role in helping a child feel comfortable and
understand instructions during the various activities taking place in a therapy
session.
Perhaps the most important capability that can enhance cultural relevance
of a robotic agent is the addition of multilingual features that could enable the
robot to communicate in a number of languages. This would allow one therapist
to conduct therapy with children from backgrounds dissimilar to his and who
speak a language other than with which he is familiar. The larger the number of
languages spoken by the robot, the larger the supported audience. This facilitates
the therapist in conveying instructions to the children since a major part of his
or her work is now being done by the robot.
It has been found that people belonging to some cultures have a preference
for non-anthropomorphic appearance of a robot, while others prefer anthropo-
morphic features [25][29]. Robots, as shown in Figure 1, come in a variety of
forms, including human-like, humanoid and toy-like. Therefore, the integration
of robots in ASD therapy can cater to such preferences as well, and in doing so,
make therapy more subject-specific, as needed.
Gestures form an integral part of expression in every culture. Body language
and gestures are frequently used to convey information, alongside vocal com-
munication. Robots are already being used to teach how to communicate using
gestures [30][31][32][33]. The spectrum of gestures varies widely across cultures.
Some gestures do not exist in some cultures, while it can hold drastically different
meanings in others. It is thus important to take these into account when inter-
acting with children from foreign cultures, in order to ensure that the correct
message has been conveyed. This can also help in enhancing a child’s comfort
level by offering a sense of familiarity. For example, a robot that bows to a

Culture as a Driver for Social Robot Design 7
Japanese child in the beginning of an interaction would be more welcoming than
a robot that greets in another way.
In addition, the activities can be infused with cultural relevance as well.
Many therapeutic interactions with children with ASD involve short, engaging
games such as chase and follow, imitation and turn-taking [34][35][36]. The same
activities can be modified slightly with cultural context to achieve better results.
This can be done by designing games that are local to the child’s culture and
are already familiar to him or her.
Another popular use of robots in ASD therapy is social storytelling [37][38].
This involves a social robot that narrates stories that are intended to teach
children appropriate behaviors in socially significant situations. This also offers
potential for cultural adaptation, whereby the generic stories can be replaced
with more local stories with familiar characters. This could encourage the chil-
dren to maintain interest in the storyline and also to make more sense of the
message being conveyed.
All of these measures help to provide a friendlier environment for the children
by offering more familiarity and less intimidation. In such situations, it is natural
to expect children to better understand what is being taught to them, in order
to observe long-term improvements in their behaviors. The culturally relevant
features in a robot help to strengthen the robot’s bond with the children by
making it appear to be one of their own, and not an outsider.
7 Conclusion
This paper emphasizes the importance of cultural context in ASD therapy. Most
of the available tools thus far have been developed in the west and adapted or
translated for use in other parts of the world as well. However, the many cultural
differences between the gulf and the west can prevent these tools from being as
effective as they potentially can be. There is a need to develop tools sensitive to
the local culture, so that all needs can be met and usefulness maximized.
Cultural adaptiveness also facilitates the use of socially assistive robots for
ASD therapy in culturally diverse environments, where the therapist and subject
may belong to very different cultural backgrounds. A robot that is sensitive to
the local culture of a child is able to present a more familiar and friendly environ-
ment, and encourage the child to participate in activities. This can enhance the
potential of such methods to bring about long-term behavioral improvements in
the children.
Multicultural communities in the Middle East region with rising demands
for ASD support can especially benefit from culturally adaptive methods. It is
vital that this factor be taken into account when designing therapy methods and
developing relevant tools, so that, true to the nature of the disorder, its therapy
can truly be made as case-specific as possible.
Acknowledgments The work is supported by an NPRP grant from the Qatar
National Research Fund under the grant No. NPRP 7-673-2-251. The statements
made herein are solely the responsibility of the authors.

8 Javed, Cabibihan, Aldosari, and Al-Attiyah
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