Repenser les representations corporelles dans l'autisme a travers les cultures

Titre original en anglais : Rethinking body representations in autism across cultures

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Mourad, J., Grosjean, B., Perroud, N., Bogaerts, K., Desseilles, M., & Bonnechère, B. (2025). Rethinking body representations in autism across cultures. Frontiers in Psychiatry, 16, 1612219-1612219. https://doi.org/10.3389/fpsyt.2025.1612219

Date de publication: 04/08/2025 Ajout dans AutiHub: 05/07/2026 Type: Article Langue de l’article: Anglais
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Auteurs

Auteur·ices des publications
6
Auteur·ices de la publication identifié·es comme autistes
1 / 6 (16,7 %)
  1. Joanna Mourad
  2. Bernadette Grosjean *
  3. Nader Perroud
  1. Katleen Bogaerts
  2. Martin Desseilles
  3. Bruno Bonnechère

Résumé

Les questionnaires et les evaluations ont principalement ete developpes dans un ensemble limite de pays developpes, notamment la France (10,11), l'Arabie saoudite (15,19), le Japon (13), les Etats-Unis (14), le Royaume-Uni (15), la Suede (16) et l'Autriche (17). Cette concentration dans les pays developpes limite l'applicabilite de ces outils. Malgre des similitudes culturelles, des evaluations biaisees ne tiennent pas compte de la diversite mondiale des representations corporelles (BR), negligeant de nombreuses cultures et entravant le diagnostic et le soutien relatifs a l'autisme dans le monde entier. Par consequent, les recherches futures doivent prioriser le developpement d'evaluations universellement adaptables qui tiennent compte de la diversite culturelle et linguistique, en ameliorant a la fois l'exactitude et l'accessibilite. Puisque les normes culturelles faconnent de maniere significative la facon dont les BR se manifestent et dont l'autisme est percu, par exemple les normes variables concernant le contact visuel et l'engagement social (18)(19)(20), il est essentiel d'evaluer les BR dans ces contextes. Cette necessite s'etend bien au-dela de l'autisme, car les croyances et les pratiques culturelles faconnent les comportements de recours aux soins et l'interpretation des symptomes dans differentes populations. Des adaptations culturellement ancrees des interventions relatives a l'autisme ameliorent l'efficacite, comme le souligne Keehn (21), et les croyances culturelles influencent les pratiques de soins et les resultats des traitements (21,22). Une approche unique pour tous de l'evaluation de l'autisme peut donc ne pas tenir compte de nuances culturelles critiques, conduisant potentiellement a des erreurs de diagnostic ou a des interventions inefficaces. Par consequent, cette opinion souligne l'importance d'integrer des facteurs culturels dans l'evaluation des BR dans l'autisme. Actuellement, la vaste majorite des etudes sont menees dans des pays a revenu eleve (HIC), ce qui conduit a des conceptions biaisees de l'autisme (23), limitant la generalisabilite des resultats aux populations non occidentales. Bien que 80 % de la population vive dans des LMIC (23), la recherche sur l'autisme dans les pays a revenu faible et intermediaire (LMIC) reste tres limitee, et de nombreuses personnes restent non diagnostiquees en raison du manque d'outils diagnostiques culturellement appropries (24)(25)(26)(27). Par exemple, en Chine, les services diagnostiques sont encore en cours de developpement, ce qui se traduit par des taux de prevalence plus faibles, de 39,23 pour 10 000, par rapport a des pays a revenu plus eleve tels que les Etats-Unis et l'Europe du Nord (1 % a 2,21 %) ; cet ecart peut etre attribue a des outils diagnostiques qui ne tiennent pas compte des differences culturelles, des barrieres linguistiques et des niveaux variables de sensibilisation a l'autisme (23)(24)(25)(26)(27)(28)(29). Cette disparite est evidente dans les etudes epidemiologiques, ou 26 des 37 enquetes provenaient de pays a revenu eleve et seulement 11 de pays a revenu intermediaire (prevalence moyenne de 0,47 %), sans aucune etude provenant de pays a faible revenu (19). Au Nigeria et en Afrique du Sud, les chercheurs soulignent des obstacles persistants tels qu'une faible sensibilisation au diagnostic, la stigmatisation culturelle et le manque d'outils de depistage adaptes regionalement (24,25). De meme, en Inde, Dey et al. ont mene une enquete en ligne suivie d'une conversation approfondie avec des parents d'enfants autistes et des adultes autistes, soulignant la necessite de priorites et d'outils relatifs a l'autisme culturellement ancres (26). Ces etudes demontrent que le sous-diagnostic dans les LMIC n'est pas uniquement du a des contraintes economiques, mais aussi a des discordances fondamentales entre les modeles diagnostiques fondes sur l'Occident et les cadres socioculturels locaux. Afin de mieux evaluer la recherche specifiquement menee sur les BR dans les TSA, nous avons realise une analyse bibliometrique. L'analyse bibliometrique est une methode quantitative de cartographie de la litterature scientifique, permettant aux chercheurs d'identifier les tendances, les reseaux de collaboration, les lacunes dans les connaissances et les orientations potentielles de recherche future en analysant les metadonnees des publications (30). Les donnees de la presente etude ont ete obtenues a partir de WoS (consulte le 15 avril 2025), en utilisant des mots-cles MeSH et de titre/resume lies au trouble du spectre de l'autisme (par exemple, "ASD", "autism", "Asperger's syndrome") et aux representations corporelles (par exemple, "body awareness", "interoception", "body schema", "proprioception", "sensorimotor integration", "embodiment", "motor imagery"). Un total de 4 024 documents, comprenant des articles de recherche, des articles de revue et des chapitres de livres, constituait l'ensemble de donnees final, les donnees ayant ete traitees a l'aide de VOSviewer afin de visualiser et de cartographier les reseaux de collaboration (31). Avant 2000, nous avons observe que ce concept etait peu etudie, mais il a depuis connu une croissance exponentielle. (Figure 1B). En ce qui concerne les etudes sur la prevalence des TSA, nous avons observe que la plupart, sinon la totalite, des etudes sont menees dans des HIC (les 20 contributeurs les plus importants sont presentes dans la Figure 1C). Une autre constatation importante, limitant potentiellement la validite externe de ces etudes d'un point de vue culturel, est que la plupart des etudes sont menees dans un seul pays et que, comme le montre la Figure 1A, il n'existe presque aucune collaboration avec les LMIC. Les principaux defis de l'evaluation des BR dans diverses cultures 3.1 Contexte culturel : entre similitudes et differences dans les profils regionaux. Un aspect crucial a prendre en compte est que les similitudes culturelles entre certaines regions ou certains pays peuvent entrainer des profils similaires dans la manifestation des BR et d'autres caracteristiques liees a l'autisme. Les pays partageant des contextes culturels, historiques ou linguistiques sont plus susceptibles de presenter des normes societales et des attitudes comparables a l'egard de la perception corporelle. Cette base culturelle commune peut conduire a des similitudes dans les resultats de recherche au sein de ces regions. Par exemple, les etudes menees dans des pays qui partagent des ressemblances culturelles et linguistiques montrent souvent des resultats analogues en termes d'evaluations des BR et de prevalence de l'autisme (23). Les pays du Moyen-Orient, tels que l'Arabie saoudite et l'Egypte, peuvent presenter des resultats paralleles en raison de normes culturelles et religieuses partagees (32)(33)(34)(35)(36). De meme, les pays influences par les traditions biomedicales europeennes latines et occidentales partagent des cadres culturels et scientifiques, des systemes de sante publique et d'education, conduisant finalement a des attitudes societales similaires envers les perceptions corporelles. Dans les cultures occidentalisees, en particulier chez les femmes, l'insatisfaction a l'egard du poids et de l'apparence corporels est frequente et a ete associee aux troubles alimentaires, a la depression et a l'anxiete (18,37). En revanche, d'autres cultures peuvent mettre l'accent sur des ideaux physiques differents ou interpreter les differences corporelles differemment ; par exemple, le surpoids peut etre associe a la norme de beaute ou meme considere comme un signe de sante et de richesse (18,19,38). Les outils diagnostiques occidentaux, tels que ceux fondes sur l'insatisfaction liee a l'image corporelle, peuvent ne pas etre applicables ou pertinents dans des contextes non occidentaux. En outre, des comportements consideres comme socialement deviant dans une culture peuvent etre normalises, voire valorises, dans une autre. Bien qu'il soit reconnu que les normes culturelles faconnent la representation corporelle (BR) (18,39), les mecanismes par lesquels ces influences operent, en particulier dans l'autisme, meritent une exploration plus approfondie. Les environnements culturels structurent les experiences sensori-motrices precoces (40,41), y compris les normes relatives au toucher physique, a la posture, a l'autonomie corporelle et a l'usage social du corps. Chez les personnes autistes, qui presentent souvent un traitement sensoriel atypique, incluant une proprioception, une interoception et une perception tactile alterees (42)(43)(44), les entrees sensorielles mediees culturellement peuvent exercer des effets developpementaux amplifies ou divergents. Par exemple, des etudes ont montre que l'auto-representation et l'integration multisensorielle sont modulees par les experiences culturelles par l'intermediaire de la plasticite de regions telles que l'insula et la jonction temporoparietale (45,46), des zones qui sont egalement impliquees dans les BR et dont le fonctionnement est connu pour etre atypique chez les personnes autistes (47). Pris ensemble, ces resultats suggerent que des experiences culturellement specifiques faconnent dynamiquement le neurodeveloppement des BR en influencant l'integration multisensorielle et la conscience corporelle de soi, en particulier dans les populations neurodivergentes. Par consequent, une approche sensible a la culture est essentielle pour une evaluation exacte chez les personnes autistes. Il est egalement important de prendre en compte l'equilibre nature-environnement dans les troubles du developpement. Cette distinction souligne la necessite d'adapter les outils d'evaluation non seulement aux contextes culturels regionaux, mais aussi au profil sous-jacent nature contre environnement de l'affection evaluee. La reconnaissance des similitudes et des differences culturelles peut ainsi faciliter le developpement d'outils diagnostiques plus exacts et universellement adaptables (35,48,49). Les barrieres linguistiques et de communication peuvent egalement jouer un role important dans l'evaluation des BR, en particulier dans des contextes multilingues et culturellement diversifies (50). Le langage corporel et la communication sociale, tous deux faconnes par les normes culturelles et linguistiques, peuvent presenter des defis particuliers pour les personnes autistes (51). Les variations culturelles de la communication non verbale peuvent compliquer davantage l'interpretation des expressions physiques des personnes autistes. Par exemple, tandis que les enfants au developpement typique ont tendance a presenter des mouvements ouverts, diriges vers l'exterieur, les enfants autistes presentent souvent des postures tournees vers l'interieur, fermees, et des mouvements plus legers. Cependant, ces differences ne devraient pas etre considerees uniquement comme des deficits, mais plutot comme des aspects intrinseques de leur identite. Comme le suggerent Gowen et ses collaborateurs, il ne s'agit plus d'"un grand desordre maladroit" mais d'"une partie fondamentale de [leur] caractere" (52). Les recherches futures devraient examiner comment les attentes culturelles relatives au langage corporel influencent la perception et l'interpretation des mouvements des personnes autistes, plutot que de traiter ces differences comme des obstacles. Plusieurs modeles sensibles a la culture ont ete developpes pour traiter ces questions et ameliorer les soins centres sur le patient (53). En reponse a une diversite croissante, les professionnels de sante et les decideurs politiques developpent des services culturellement competents qui alignent la communication et les soins sur les valeurs des patients (54). Par exemple, le Patient-Centered Culturally Sensitive Health Care Model a montre que lorsque les prestataires de soins de sante font preuve de sensibilite culturelle, l'adhesion des patients au traitement s'ameliore chez des patients ethniquement diversifies, en particulier des Afro-Americains a faible revenu et des Americains blancs non hispaniques, vus dans des cliniques communautaires de soins primaires. Toutefois, une recente revue de cadrage souligne une heterogeneite importante des modeles et interventions de competence culturelle, la plupart se concentrant sur la diversite raciale et ethnique, en particulier dans les populations minoritaires, tout en negligeant la diversite culturelle. Cela souligne la necessite de modeles plus inclusifs adaptes aux populations superdiverses de l'Europe et au-dela (55). Une autre initiative cruciale est le ACT Cultural Model, qui fournit des principes directeurs pour des soins culturellement competents, en soulignant l'integration d'une formation a la sensibilite culturelle dans l'enseignement des soins de sante, tant au premier cycle qu'au cycle superieur. Une revue meta-ethnographique souligne en outre l'importance de la conscience de soi, de la sensibilite culturelle et d'une collaboration efficace avec les patients et les familles (56,57). Keehn et al. (21) ont applique l'Ecological Validity Framework au Kenya afin de co-developper un programme de formation des aidants, en soulignant l'importance du partenariat communautaire et d'une conception culturellement ancree. Leur approche illustre comment des interventions peuvent etre significatives et extensibles lorsqu'elles sont co-creees avec des acteurs locaux. De plus, Kang-Yi et al. (22) ont examine comment les croyances culturelles au niveau communautaire faconnent profondement a la fois les comportements de recours a l'aide des aidants et les parcours diagnostiques professionnels. Malgre la reconnaissance generalisee de la competence culturelle, la recherche sur son impact reste limitee, en particulier dans des domaines specialises tels que l'evaluation et l'intervention relatives a l'autisme (58). En outre, les defis associes au diagnostic de l'autisme dans les contextes a faibles ressources soulignent le besoin urgent d'outils d'evaluation sensibles a la culture. L'absence d'outils diagnostiques culturellement appropries et la penurie de professionnels formes peuvent gravement entraver le diagnostic et le traitement de l'autisme, en particulier dans des contextes culturellement diversifies (59). De meme, il a ete montre que les outils de depistage de l'autisme sont souvent indisponibles ou mal compris dans certains contextes culturels, entrainant des retards dans le diagnostic et l'intervention (60). Il convient de noter que ces problemes ne sont pas propres a l'autisme ; ils s'etendent a d'autres affections de sante mentale et physique, dans lesquelles les facteurs culturels influencent de maniere significative l'accessibilite et l'efficacite des outils diagnostiques et des traitements, ce qui souligne davantage la necessite absolue de developper des outils d'evaluation plus adaptes culturellement et moins dependants du langage. Au-dela du diagnostic, les experiences des personnes autistes et de leurs familles illustrent davantage le role critique des facteurs culturels dans la formation des resultats cliniques comme des experiences vecues. Par exemple, la recherche souligne comment les politiques sociales et les recits culturels influencent les identites des personnes autistes, mettant en evidence la necessite de politiques qui reduisent la stigmatisation et favorisent la comprehension (61). Les perceptions culturelles n'affectent pas seulement le processus diagnostique, mais faconnent egalement les attitudes societales, l'acces au soutien et le bien-etre des personnes autistes et de leurs familles. Ces defis sont paralleles a ceux auxquels sont confrontees les personnes atteintes d'autres affections de sante, ou la stigmatisation culturelle peut affecter l'adhesion au traitement et les resultats pour les patients. Il est imperatif de combler les ecarts culturels et geographiques importants dans notre comprehension des BR. La recherche actuelle provient principalement de pays developpes, conduisant a des connaissances faussees et a des outils d'evaluation culturellement limites. Cette orientation centree sur l'Occident ne tient pas compte des manifestations diverses de l'autisme qui se produisent dans les differentes cultures mondiales, ce qui peut entrainer des erreurs de diagnostic et des interventions inefficaces. Pour ameliorer cela, des outils diagnostiques plus inclusifs et adaptables, refletant une multitude de contextes culturels, doivent etre developpes. Les chercheurs et les praticiens devraient prioriser les collaborations entre les HIC et les LMIC afin d'assurer une comprehension plus large et plus complete des BR et de l'autisme. Cependant, cette collaboration doit prendre en compte les contraintes economiques et infrastructurelles dans les LMIC. Les lacunes de financement, de personnel et de technologie demeurent des obstacles majeurs. Pour repondre a la faisabilite, nous proposons plusieurs approches rentables et extensibles. Les outils de sante mobile (mHealth), tels que le depistage par applications et les evaluations sur tablette, peuvent etre proposes dans les langues locales et administres par des agents de sante non specialises formes. Ces outils peuvent etre integres aux programmes de sante communautaires existants et aux systemes de sante publique, tels que ceux soutenus par le Programme d'action Combler les lacunes en sante mentale (mhGAP) de l'OMS. Une co-conception participative impliquant des cliniciens locaux, des familles et des personnes autistes est essentielle afin d'assurer la pertinence culturelle et l'adoption. Des protocoles diagnostiques en acces libre et des partenariats public-prive peuvent aider a attenuer les contraintes financieres et a reduire la dependance a l'egard d'outils occidentaux couteux et proprietaires. Investir dans la recherche locale au sein des LMIC et favoriser les partenariats interculturels ouvrira la voie a des progres diagnostiques qui soient a la fois exacts et accessibles dans le monde entier. En outre, l'integration de la sensibilite culturelle dans les evaluations de l'autisme ameliorera leur pertinence et leur efficacite. Cela implique d'adapter les interventions afin de les aligner sur les normes regionales, les competences linguistiques et les styles de communication, en veillant a ce que toutes les personnes recoivent des soins et un soutien equitables. De plus, l'adaptation et la validation interculturelles des outils diagnostiques sont cruciales pour garantir qu'ils prennent en compte les langues locales, les normes culturelles et les contextes ecologiques. Les methodes emergentes, non supervisees et fondees sur la technologie pour l'evaluation longitudinale, telles que le phenotypage numerique, offrent des solutions prometteuses, en particulier dans les regions ou l'acces aux professionnels de sante est limite (62). Ces innovations pourraient aider a integrer les evaluations des BR dans des environnements naturels, rendant le diagnostic et l'intervention plus accessibles et plus ecologiques. Pris ensemble, ces solutions representent des strategies faisables et extensibles pour traiter les limites centrees sur l'Occident et promouvoir des diagnostics de l'autisme eclaires par la culture dans des contextes mondiaux diversifies. En conclusion, l'integration de facteurs culturels dans l'evaluation de l'autisme constitue une necessite plus large dans les soins de sante, car les contextes culturels faconnent la comprehension, le diagnostic et le traitement de diverses affections de sante mentale et physique. Ne pas tenir compte de ces facteurs presente des defis ethiques et pratiques, en particulier lors de l'evaluation des representations corporelles, une fonction psychomotrice centrale liee a l'autonomie et a la qualite de vie. La recherche sur l'autisme a historiquement ete centree sur l'Occident, surrepresentant les personnes blanches, cisgenres et instruites tout en sous-representant celles issues de contextes ethniques, culturels, religieux et socioeconomiques diversifies, en particulier dans les LMIC. Ce biais de representativite a fausse la comprehension mondiale de l'autisme, conduisant a des erreurs de diagnostic et a un soutien inadequat. Pour traiter ces disparites, il est essentiel d'investir dans des outils diagnostiques adaptes culturellement et dans le phenotypage numerique permettant des evaluations longitudinales non supervisees. La collaboration interculturelle entre les chercheurs garantira des evaluations de l'autisme plus exactes, inclusives et sensibles au contexte.

questionnaires and evaluations have primarily been developed in a limited set of developed nations, including France (10,11), Saudi Arabia (15,19), Japan (13), the USA (14), the UK (15), Sweden (16) and Austria (17). This concentration in developed countries restricts the applicability of these tools. Despite cultural commonalities, biased assessments overlook global BR diversity, neglecting many cultures and hindering autism diagnosis and support worldwide. Consequently, future research must prioritize developing universally adaptable assessments that accommodate cultural and linguistic diversity, enhancing both accuracy and accessibility. Because cultural norms significantly shape how BR manifest and how autism is perceived, e.g., varying norms around eye contact and social engagement (18)(19)(20), it is essential to assess BR within these contexts. This necessity extends well beyond autism, as cultural beliefs and practices shape health-seeking behaviors and the interpretation of symptoms across different populations. Culturally grounded adaptations in autism interventions improve effectiveness, as emphasized by Keehn (21), and cultural beliefs influence care practices and treatment outcomes (21,22). A one-size-fits-all approach to autism assessment may therefore overlook critical cultural nuances, potentially leading to misdiagnosis or ineffective interventions.Therefore, this opinion highlights the importance of integrating cultural factors in the assessment of BRs in autism.Currently, the vast majority of the studies are being conducted in high-income countries (HIC), which leads to biased understandings of autism (23), limiting the generalizability of findings to non-Western populations. While 80% of the population lives in LMICs (23), research on autism in lowand middle income countries (LMICs) is still very limited, and many individuals remain undiagnosed due to the lack of culturally appropriate diagnostic tools (24)(25)(26)(27). For example in China, diagnostic services are still developing, resulting in lower prevalence rates 39.23 per 10,000 compared to higher-income countries like the USA and Northern Europe (1% to 2.21%); this gap can be attributed to diagnostic tools that overlook cultural differences, language barriers, and varying levels of autism awareness (23)(24)(25)(26)(27)(28)(29). This disparity is evident in epidemiological studies, where 26 of 37 surveys were from high-income countries and only 11 from middle-income countries (average prevalence 0.47%), with no studies from low-income countries (19). In Nigeria and South Africa, researchers highlight persistent barriers such as low diagnostic awareness, cultural stigma, and a lack of regionally adapted screening tools (24,25). Similarly, in India, Dey et al. conducted an online survey followed by an indepth conversation with parents of autistic children and autistic adults emphasizing the need for culturally grounded autism priorities and tools (26). These studies demonstrate that underdiagnosis in LMICs is not solely due to economic constraints, but also to fundamental mismatches between Western-based diagnostic models and local sociocultural frameworks.To better evaluate the research specifically performed around BR in ASD we performed a bibliometric analysis. Bibliometric analysis is a quantitative method for mapping scientific literature, allowing researchers to identify trends, collaboration networks, knowledge gaps and potential future research direction by analyzing publication metadata (30). Data for the present study was obtained from the WoS (accessed on 15 April 2025), using MeSH and title/abstract keywords related to autism spectrum disorder (e.g., "ASD," "autism," "Asperger's syndrome") and body representations (e.g., "body awareness," "interoception," "body schema," "proprioception," "sensorimotor integration," "embodiment," "motor imagery"). A total of 4,024 documents including research articles, review articles and book chapters formed the final dataset, with data processed using VOSviewer to visualize and map collaboration networks (31).Before 2000 we observed that this concept was scarcely studied, but it has since experienced exponential growth. (Figure 1B). As for studies about the prevalence of ASD we observed that most, if not all the studies, are being performed in HIC (the 20 most significant contributor are presented in Figure 1C). Another important finding, potentially limiting the external validity of these studies, from a cultural point of view, is that most of the studies are being performed in one single country and that, as depicted in Figure 1A, there are almost no collaborations with LMICs.The main challenges in assessing BRs in various cultures 3.1 Cultural background: between similarities and differences in regional patternsOne crucial aspect to consider is that cultural similarities across certain regions or countries can result in similar patterns in the manifestation of BR and other autism-related characteristics. Countries with shared cultural, historical, or linguistic backgrounds are more likely to exhibit comparable societal norms and attitudes towards body perception. This common cultural foundation can lead to similarities in research outcomes within these regions. For example, studies conducted in countries which share cultural and linguistic resemblances, often show analogous results in terms of BRs assessments and autism prevalence (23). Countries in the Middle East, like Saudi Arabia and Egypt, may exhibit parallel outcomes due to shared cultural and religious norms (32)(33)(34)(35)(36). Similarly, countries influenced by Latin European and Western biomedical traditions share cultural and scientific framework, public health and educational systems, ultimately leading to alike societal attitudes toward body perceptions. In Westernized cultures, particularly among women, dissatisfaction with body weight and appearance is common and has been linked to eating disorders, depression, and anxiety (18,37). In contrast, other cultures may emphasize different physical ideals or interpret bodily differences, for instance overweight can be associated with the norm of beauty or even considered as healthy and wealth (18,19,38). Western diagnostic tools, such as those based on body image dissatisfaction, may not be applicable or relevant in non-Western contexts. Moreover, behaviors seen as socially deviant in one culture may be normalized or even valued in another.While cultural norms are acknowledged to shape body representation (BR) (18,39) the mechanisms by which these influences operate, particularly in autism, deserve a deeper exploration. Cultural environments structure early sensorimotor experiences (40,41), including norms around physical touch, posture, bodily autonomy, and social body use. In autistic individuals, who often show atypical sensory processing, including altered proprioception, interoception, and tactile perception (42)(43)(44), culturally mediated sensory input may exert amplified or divergent developmental effects.For example, studies have shown that self-representation and multisensory integration are modulated by cultural experiences through plasticity in regions such as the insula and temporoparietal junction (45,46), areas that are also implicated in BR and are known to function atypically in autistic individuals (47). Taken together, these findings suggest that culturally specific experiences dynamically shape BR neurodevelopment by influencing multisensory integration and bodily selfawareness, particularly in neurodivergent populations. Therefore, a culturally sensitive approach is critical for accurate assessment in autistic individuals. It is also important to consider the naturenurture balance in developmental disorders. This distinction underscores the need to tailor assessment tools not only to regional cultural contexts but also to the underlying nature vs nurture profile of the condition being evaluated. Acknowledging cultural similarities and differences can thus facilitate the development of more accurate and universally adaptable diagnostic tools (35,48,49). Language and communication barriers can also play a significant role in assessing BR, especially in multilingual and culturally diverse contexts (50). Body language and social communication, both shaped by cultural and linguistic norms, can present unique challenges for autistic individuals (51). Cultural variations in non-verbal communication may further complicate the interpretation of autistic individuals' physical expressions. For example, while typically developing children tend to display open, outward-directed movements, autistic children often exhibit inward, closed postures and lighter movements. However, these differences should not be seen merely as deficits but rather as intrinsic aspects of their identity. As Gowen and collaborators suggest, it is no longer "one big clumsy mess" but "a fundamental part of [their] character" (52). Future research should explore how cultural expectations around body language influence the perception and interpretation of autistic individuals' movements, rather than treating these differences as barriers.Several culturally sensitive models have been developed to address these issues and enhance patientcentered care (53). In response to increasing diversity, healthcare professionals, and policymakers are developing culturally competent services that align communication and care with patients' values (54). For example, the Patient-Centered Culturally Sensitive Health Care Model has demonstrated that when healthcare providers exhibit cultural sensitivity, patient adherence to treatment improves among ethnically diverse patients, particularly low-income African American and non-Hispanic White Americans, seen in community-based primary care clinics. However, a recent scoping review highlights significant heterogeneity in cultural competence models and interventions, with most focusing on racial and ethnic diversity, particularly in minority populations, overlooking cultural diversity. This underscores the need for more inclusive models suited to Europe's superdiverse populations and beyond (55).Another crucial initiative is the ACT Cultural Model, which provides guiding principles for culturally competent care, emphasizing the integration of cultural sensitivity training into both undergraduate and postgraduate healthcare education. A meta-ethnographic review further underscores the importance of self-awareness, cultural sensitivity, and effective collaboration with patients and families (56,57). Keehn et al. (21) applied the Ecological Validity Framework in Kenya to codevelop a caregiver training program, emphasizing the importance of community partnership and culturally grounded design. Their approach illustrates how interventions can be meaningful and scalable when co-created with local stakeholders. Additionally, Kang-Yi et al. (22) examined how community-level cultural beliefs profoundly shape both caregiver help-seeking behaviors and professional diagnostic pathways. Despite the widespread recognition of cultural competence, research on its impact remains limited, particularly in specialized areas such as autism assessment and intervention (58). Moreover, the challenges associated with autism diagnosis in low-resource settings highlight the urgent need for culturally sensitive assessment tools. The absence of culturally appropriate diagnostic tools and a shortage of trained professionals can severely hinder autism diagnosis and treatment, especially in diverse cultural contexts (59). Similarly, it has been shown that screening tools for autism are often unavailable or poorly understood in certain cultural settings, resulting in delays in diagnosis and intervention (60). Note that these issues are not unique to autism; they extend to other mental and physical health conditions, where cultural factors significantly impact the accessibility and effectiveness of diagnostic tools and treatments, this further highlights the absolute necessity of developing more culturally adapted and less language dependent assessment tools.Beyond diagnosis, the experiences of individuals with autism and their families further illustrate the critical role of cultural factors in shaping both clinical outcomes and lived experiences. For instance, research highlights how social policies and cultural narratives influence the identities of individuals with autism, underscoring the need for policies that reduce stigma and promote understanding (61). Cultural perceptions do not only affect the diagnostic process but also shape societal attitudes, access to support, and the well-being of autistic individuals and their families. These challenges parallel those faced by individuals with other health conditions, where cultural stigma may impact treatment adherence and patient outcomes.It is imperative that we address the significant cultural and geographical gaps in our understanding of BR. Current research predominantly hails from developed countries, leading to skewed insights and culturally limited assessment tools. This Western-centric focus neglects the diverse manifestations of autism that occur across different global cultures, potentially resulting in misdiagnoses and ineffective interventions.To improve this, more inclusive and adaptable diagnostic tools that reflect a multitude of cultural contexts need to be developed. Researchers and practitioners should prioritize collaborations between HICs and LMICs to ensure a broader, more comprehensive understanding of BRs and autism. However, such collaboration must consider the economic and infrastructural constraints in LMICs. Funding, staffing, and technological gaps remain key barriers. To address feasibility, we propose several cost-effective and scalable approaches. Mobile health (mHealth) tools, such as app-based screening and tablet assessments, can be delivered in local languages and administered by trained lay health workers. These tools can be integrated into existing community-based health programs and public health systems, such as those supported by the WHO's Mental Health Gap Action Programme (mhGAP). Participatory co-design involving local clinicians, families, and autistic individuals is essential to ensure cultural relevance and uptake. Open-access diagnostic protocols and publicprivate partnerships can help mitigate financial constraints and reduce dependency on expensive, proprietary Western tools.Investing in local research within LMICs and fostering cross-cultural partnerships will pave the way for diagnostic advancements that are both accurate and accessible worldwide.Furthermore, integrating cultural sensitivity into autism assessments will improve their relevance and effectiveness. This involves tailoring interventions to align with regional norms, language proficiencies, and communication styles, ensuring that all individuals receive equitable care and support.Additionally, cross-cultural adaptation and validation of diagnostic tools are crucial to ensure they account for local languages, cultural norms, and ecological contexts. Emerging technology-based, unsupervised methods for longitudinal assessment, such as digital phenotyping, offer promising solutions, particularly in regions with limited access to healthcare professionals (62). These innovations could help integrate BR assessments into natural environments, making diagnosis and intervention more accessible and ecologic.Taken together, these solutions represent feasible, scalable strategies to address Western-centric limitations and promote culturally informed autism diagnostics in diverse global settings. In conclusion, integrating cultural factors into autism assessment is a broader necessity in healthcare, as cultural contexts shape the understanding, diagnosis, and treatment of various mental and physical health conditions. Failing to consider these factors presents ethical and practical challenges, particularly in evaluating body representations, a core psychomotor function linked to autonomy and quality of life.Autism research has historically been Western-centric, overrepresenting white, cisgender, and educated individuals while underrepresenting those from diverse ethnic, cultural, religious, and socioeconomic backgrounds, particularly in LMICs. This representativity bias has distorted the global understanding of autism, leading to misdiagnosis and inadequate support.To address these disparities, investing in culturally adapted diagnostic tools and digital phenotyping enabling unsupervised, longitudinal assessments is essential. Cross-cultural collaboration among researchers will ensure more accurate, inclusive, and context-sensitive autism assessments.

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Ces indicateurs décrivent la bibliographie citée importée pour cette publication. Les métriques de références citées utilisent le total des références citées comme dénominateur. Les métriques d’auteurices cité·es indiquent si elles utilisent toutes les occurrences d’auteurices cité·es ou seulement les occurrences rattachées à des auteurices déjà intégré·es à la base de données AutiHub. Ils utilisent les rattachements mis en cache entre les auteurices cité·es et les auteurices intégré·es à la base de données AutiHub. Dernier calcul : 16/08/2026 11:30.

Références citées
64
Nombre total de références citées intégrées pour cette publication.
Références citées avec un·e auteur·ice identifié·e comme autiste
1 / 64 (1,6 %)
Occurrences d’auteur·ices cité·es identifié·es comme autistes
1 / 304 (0,3 %)
Parmi les occurrences rattachées à des auteurices intégré·es à la base de données AutiHub : 1 / 35 (2,9 %). Auteurices cité·es distinct·es identifié·es comme autistes : 1 / 295 (0,3 %).
Occurrences citées rattachées à la base AutiHub
35 / 304 (11,5 %)
Auteurices cité·es distinct·es rattaché·es : 29 / 295 (9,8 %)
Occurrences rattachées, non identifiées comme autistes
34 / 35 (97,1 %)
Parmi les seules occurrences rattachées. Sur l’ensemble des occurrences d’auteurices cité·es : 34 / 304 (11,2 %). Auteurices cité·es distinct·es rattaché·es, non identifié·es comme autistes : 28 / 29 (96,6 %).
2 entrées de bibliographie citée n’ont pas pu être entièrement enrichies à partir des métadonnées DOI.
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