The breakthroughs of caregivers in parent-implemented interventions for children with neurodevelopmental disorders: an exploratory qualitative study

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WONG, Camille K.Y. CHAN, Paul W.C. WONG This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7938870/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Parent-implemented intervention (PII) trains caregivers to be the interventionists to offer tailored learning opportunities at home and is used to promote the positive development of children with neurodevelopmental disabilities. Its effectiveness hinges not only on learning and implementing the strategies, but also on the beliefs, wellbeing and capacities of the caregivers. The existing literature focused on the acquisition and application of skills, little is known about the inner experiences and transformation of caregivers. This study explored the changing processes of caregivers and focused especially on their breakthroughs. Methods Twenty-two caregivers participated in five semi-structured focus groups in Hong Kong. They had all completed the localized version of the World Health Organization Caregiver Skills Training. Reflexive thematic analysis was adopted to analyze the qualitative data and construct codes and themes. Results There were three major breakthroughs which caregivers experienced leading to positive outcomes for themselves and for their children. The first one was the acquisition of self-care practices that helped caregivers recognize their own physical and emotional exhaustion and cultivate capacities for childcare. The second was on environmental settings, in which the caregivers learnt to adjust the home setup to promote parent-child engagement and the building of play routines. The third was on developing the discernment of the window to intervene. Caregivers learnt to adjust their pace to align with their children’s, follow into the children’s world and cultivate empathy towards the young. Being able to discern when and how to create teaching opportunities allowed caregivers to be more relaxed, and children enjoyed interacting with their caregivers more. Conclusions This study unveiled the transformation processes of caregivers in a PII and identified the key factors promoting positive outcomes in them and in their children. Through focusing on breakthroughs, it also sheds light on the inner struggles and rewards the parents experienced as the primary caregivers and interventionists. It invites clinical professionals to consider the wellbeing of caregivers as one of the key social determinants of the success of PIIs, and explore how self-care, environmental setup, and discernment to intervene shape immediate and long-term outcomes. parent-implemented early intervention neurodevelopmental disorder autism spectrum disorder caregivers training effectiveness evaluation breakthroughs autistic children developmental delay and disability wellbeing empowerment Figures Figure 1 Background Neurodevelopmental disorder is a group of disabilities characterized by disruption to brain development and has its common onset in childhood [ 1 , 2 ]. Globally, the prevalence rates stood at: intellectual disability 0.63%, attention-deficit/hyperactivity disorder 5–11%, autism spectrum disorder (ASD) 0.7-3%, specific learning disorder 3–10%, communication disorders 1-3.42%, and motor disorders 0.76-17% [ 3 ]. For children facing such challenges, a comprehensive early intervention is crucial for promoting their lifelong development as it makes use of the window of brain plasticity at an early age for maximum learning [ 4 ]. Parent-implemented intervention (PII) (or parent-mediated intervention) is an effective early intervention for children with neurodevelopmental disorders. It employs a triadic model which requires the caregivers to, first, learn the strategies from clinical professionals, and then offer training for their children at home [ 5 ]. It is not designed to replace but complement the clinician-implemented treatment so that children can have more tailored learning opportunities [ 6 – 8 ]. Research has shown that PIIs are useful in promoting children’s adaptive behaviors, social communication skills, motor skills, cognitive skills and learning abilities while reducing maladaptive behaviors [ 9 – 11 ]. With caregivers being equipped with the specialized knowledge and skills to care for their children, they too benefit from PIIs. Being empowered, their parental stress is alleviated, and their confidence is boosted [ 12 ]. PIIs can also create positive impacts on families when other caregivers are willing to learn from the trained-caregivers and put the new skills into practice [ 13 – 14 ]. Hence, PIIs have strategic values of strengthening the functioning of the children, parents as well as families. Scientific evidence reveals that although gene abnormalities and congenital brain lesions contribute to neurodevelopmental problems, environment and experience also play a role in shaping the brain development thus altering its trajectories [ 15 ]. PIIs are therefore uniquely powerful as they nurture the natural family environment which is conducive to healthy child development [ 16 ]. With the effectiveness of PIIs being validated, more qualitative studies were conducted in recent decades to explore why and how PIIs worked. In our observations, these studies were on three domains: (1) Documenting the outcomes of PIIs, (2) identifying barriers and facilitators, and (3) investigating the change processes in the interventions. On the examination of outcomes, the existing qualitative research found that PIIs were useful in helping the caregivers to make sense of and accept their children’s atypical development, equip them with new parenting strategies, strengthen parent-child relationship, promote children’s development, and support family members to acquire new caring skills [ 17 – 19 ]. On the barriers and facilitators, research showed that program design (e.g. the pace of learning, the possibility of integrating the skills into daily routines, and the match between the program and the participants), trainers’ competencies and relationship with the parents, parents’ commitment and self-efficacy, and logistics (e.g. time, location, and availability of childcare) were factors affecting caregivers’ participation in the PII training and their application of skills at home [ 17 , 19 – 22 ]. On the change mechanism, research seemed to share a similar three-step process: (1) The caregivers were empowered and experienced an increase in self-efficacy, (2) they practiced applying the skills, then (3) they witnessed the changes in their children [ 23 – 25 ]. While the existing qualitative studies have provided a rich account of lived experiences of the participants, we still have little knowledge about the changes of the caregivers in PIIs. For example, Holtrop et al. set out to examine the process of change, and they identified three steps: Attempt, Appraise, and Apply. These steps explained what the parents did to transfer their learning into practice, yet they did not describe the changes of caregivers [ 23 ]. Mejia et al. attempted to examine the changing mechanisms behind the changes in parents. They identified three sets of outcomes— (1) psychological mechanisms behind changes, (2) behavioral changes in the parent, and (3) changes in the children—and weaved them into a change model with hypothetical causal relationships. Their work encouraged researchers to investigate the relationships between changes, but it has not directly investigated the change processes [ 24 ]. Frost and Ingersoll purported to delineate the theory of change, and they offered a detailed description of how participants reacted to different ingredients of the intervention [ 25 ]. An example of the pathways they portrayed was “demonstration/modeling > visual learning > content knowledge and memory > fidelity of implementation”. Their description of the learning processes offered insights for intervention design and implementation, but this work has not offered an in-depth investigation of the inner changes of the parents. Thus far, the literature has only painted a broad stroke description that parents were likely to experience an increase in motivation, confidence and skills. In this study, we employed the qualitative research approach to explore the transformation of caregivers. We asked them to describe the changes in themselves, their children and their families, and we focused particularly on their breakthroughs that propelled the positive outcomes. This interest stemmed from our awareness that in PIIs, the caregiver-trainees were the mainly interventionists as well as the primary caregivers who had their personal and familial responsibilities, expectations and struggles. Hence, the effectiveness of PIIs was determined not only by the competencies in learning and applying of skills, but also the beliefs, habits, wellbeing and decision making of the caregivers. By zooming into their personal transformation, we could understand more about their concerns, struggles and joy in PIIs. When we joined the caregivers into their stories, we could apprehend the dilemmas they faced, and we no longer played only the spectator role to observe their performance. The insights generated will help develop PIIs that can cater the needs of the caregivers as well as the children. In our earlier paper, we found two paradigm shifts of caregivers in the PIIs: They changed from perceiving themselves as sole care providers to people with growth, and they changed from perceiving their children as mere care recipients to stakeholders [ 26 ]. In this paper, we explored what propelled these changes. Methods The intervention The World Health Organization Caregiver Skills Training (WHO-CST) was introduced in Hong Kong in 2018 through the Family Support Team of the Jockey Club Autism Support Network program (JC A-Connect) at the University of Hong Kong [ 27 – 29 ]. This course was a PII that targeted at caregivers of children aged 2–9 with developmental delays or disabilities. It aimed to equip them with skills to promote their children’s engagement, communication, positive behaviors and daily living skills, while strengthening caregivers’ confidence, psychological wellbeing and connection with their children. This intervention contained 9 group sessions and 3 individual home coaching sessions. After the initial adaptation, the local master trainers further localized the course to respond to the training and learning needs of the professionals and caregivers in Hong Kong in 2021. The PII studied in this research was this localized version. In Hong Kong, this PII was mostly open to caregivers with children aged 2–6 who were suspected or confirmed to have ASD. Research design We conducted an evaluation study in 2023 and 2024 to examine the impacts and sustainability of the localized WHO-CST in Hong Kong, and this study was part of this evaluation research. The research was approved by the Human Research Ethics Committee of the University of Hong Kong with a reference number of EA240065. Another article published from this research was on family outcomes, in which we categorized the responses from family members who did not participate in the PII training into four levels, and examined the factors promoting or discouraging their involvement [ 14 ]. Qualitative method was adopted to investigate the lived experiences of the caregiver-participants. When quantitative study is limited by the predetermined variables, qualitative approach offers room to explore the unknown territories. This study was grounded in social constructionism and social interactionism [ 30 ]. We were aware that the experiences shared by our research respondents were constructed subjectively by their sense-making and their own interpretations that were influenced by a wide range of factors such as social culture and values. Thus, having multiple accounts of stories offered us an array of perspectives that enriched our understanding. Social interactionism drew our attention to the power of social exchanges in shaping people’s understanding. We recognized that the lived experiences were shaped by the interactions during the interventions, after the interventions and even in the data collection sessions. Participants We recruited the caregiver-participants who had completed the localized WHO-CST at the time of data collection. Target-convenience sampling was used as the main method. Invitations and information sheet were sent through the organizations that offered the PII to their graduates, caregivers who were interested in participating in the research could complete a brief online survey to provide the research team their contact methods and availability. Our researchers contacted each interested party through phone to introduce the research and arrange them into focus groups. We also used the snowballing method for recruitment by asking the participants to refer their friends and families who had also completed the PII. Twenty-two caregiver-participants participated in this research. Twenty-one of them were female, and one man was the husband of one of our respondents. They were mothers (18), father (1), grandmother (1), auntie (1), and foster mother (1). Sixteen of them were in a marriage, three were singles, and three had separated with their partners. Two attained a master’s qualification or above, seven with a bachelor’s degree, and thirteen had completed secondary school or post-secondary diploma. Fourteen were homemakers, five were in a full-time job, two took up multiple jobs, and one worked in a part-time capacity. Data Collection Five focus groups were conducted, and each lasted for about 1 to 1.5 hours. Three groups were conducted virtually through ZOOM, and two were physical meet-up at the University of Hong Kong and at a social services center. Participants were asked to read an online information sheet, complete a consent form and a short profiling questionnaire prior to the focus groups; all of them consented to participate voluntarily. The discussion was semi-structured, participants were asked to share about their experiences in the PII and the changes they observed in themselves, their children and other family members. To further focus them to their breakthroughs, we asked, “What were the points which you found yourselves being “unlocked” (an expression in Cantonese)? What motivated these breakthroughs?” Given that this PII targeted mainly at Cantonese speaking Chinese in Hong Kong, this was also the profile of our respondents. As an incentive, all respondents received a supermarket voucher costing HKD100 and a set of JC A-Connect souvenirs after the data collection sessions. Data Analysis All discussion was recorded and transcribed, names were replaced by participant codes in the transcripts, and all data were stored securely to ensure confidentiality. For data analysis, we opted for reflexive thematic analysis for it encouraged us to engage deeply with the data and allowed us to immerse in the meaning creation process to generate informative themes and frameworks for the advancement of the field [ 31 – 33 ]. As an exploratory study, we applied the inductive approach to generate codes that we used as handles to follow into the respondents’ stories. The qualitative analysis software, NVivo, was used for engaging data and processing the codes. We followed the suggested procedures of conducting a reflexive thematic analysis and proceeded gradually from familiarization to code generation then theme construction [ 31 ]. We started with researchers reading the data separately to generate provisional ideas before sharing our initial notes and impressions with each other. Next, we individually applied opening coding to code the same set of data and met to share and discuss our lists. We then returned to our data to further review and refine our codes before constructing our themes. Giving researchers time to engage with the data individually allowed us room to mobilize our different expertise to make sense of the data and develop our own informed interpretations. Themes were reviewed and revised together. Results From interacting with the data, we generated three overarching themes describing the breakthroughs the caregivers experienced which propelled positive changes in themselves and in their children, they were: (1) Self-care for the wellbeing of self and the child, (2) home setup for parent-child joint engagement and routine building, and (3) discernment of the window to intervene. Each overarching theme contained two to three subthemes. Theme 1: Self-care for the wellbeing of self and the child Caregivers joined the PII expecting to acquire skills for caring for their children; many were surprised to learn about the importance and practice of self-care. They described this learning transformative as it laid a strong foundation to sustain their caregiving journeys. 1.1 Attending to one’s own needs to cultivate strengths and capacities for childcare Most caregivers who recognized the values of self-care described their transformation in a similar approach: Before the PII, they were very consumed by the needs of their children. They tended to invest all their emotional and physical energy on their children; hence they neglected their own wellbeing. In the training, the caregivers were guided to attend to their own thoughts and feelings, and they began to feel their own exhaustion. Through reflections, they realized that they needed to first take care of themselves so that they would have the strengths and capacities to care for their children. A respondent employed a tree analogy to illustrate her view. “It is good that the course taught parents to manage their own emotions. Many times, we focused entirely on our children thinking that they were the ones who had problems, and we dedicated all our attention on teaching them. We were not aware of our own emotions, focused too much on the child and neglected ourselves. Like a tree, you need to be strong so that you have plenty of leaves to provide shades for others. If you keep consuming yourself and become barren, how can you protect your child?” (C12, a mother) Some participants added that they had to attend to their own emotional needs as well as physical needs so that they could be physically strong to take care of their children, especially when the children were sick. “I didn’t think about taking care of myself so that I would have the strength to care for others. After this course, I changed my mind… At that time, Covid and flu were around, and my child just began schooling. In many occasions, when children fell ill, they spread the germs to their mothers. This was a time when I had to take good care of myself so that I could care for my child.” (C10, a mother) Self-care was particularly important for caregivers of children with special needs as these children were more vulnerable and required much care, explained by a respondent. “I agree that we have to first take care of ourselves so that we can care for our children. If we fall down, our children who have ASD or other special needs will not be able to care for themselves.” (C13, a mother) 1.2 Recognizing own influences on children’s wellbeing Self-care, as perceived by some participants, was also for the wellbeing of the children as caregivers’ emotions had direct influences on their children’s. A mother linked her own happiness to her child. In our researchers’ view, the happiness of a caregiver would open a door for their children to experience happiness. “It is tough to be a parent of a child with special educational needs. Sometimes we forget our own needs and rush to sacrifice everything for our children. What I find precious of this course is that it reminds us to care about our own emotions, because when you are happy, your child can then be happy. Your feelings directly impact your child.” (C9, a mother) While positive emotions in one could ignite the positive emotions in others, negative emotions were contagious, too. More than half of the respondents recalled how their negative feelings, expressions and actions kindled negative emotions in their children and caused a vicious cycle of emotional outbursts among them. Whereas some of them shared the stories of temporary defeats in which they were overtaken by their anger and frustration, some also shared their stories of victories. “This course talked about meditation. The trainer led us into the meditation exercises. Sometimes, I would practice on my own. Before the course, when my son had a heightened emotion, I would be frustrated and had an emotional outburst. This further stimulated my son’s emotions. After learning meditation in the course, I know how to calm my own emotions. Even when my son is very frustrated, I would remain calm to discuss with him, he will listen. If his emotions are too strong or he wants to cool down, I may hug him. Hugging him is important, too. We remain silent, hugging him makes us feel peaceful.” (C11, a mother) Taking a break (time-off) to allow all parties to calm down was a common strategy shared among the respondents. A father shared that he and his wife became more aware of their own emotions. When they found themselves getting angry, they would seek help from their partners. “Sometimes we would find ourselves at the red or yellow light, then we would take a break. Let’s say when I am at the yellow light and am not in my best condition, I would say to my wife: You take care of him! (When I am irritated,) I tend to scold him and be mad at him, so I stop teaching my son at that time. My wife does the same (when she is irritated).” (C21, a father) Some caregivers also taught their children to recognize different emotions. A caregiver shared that her daughter could recognize the anger in herself and in her mother and pointed it out. “Now when she is angry, she will say, “mom, you are angry.” I then ask if she is angry, too? When both of us recognize our anger, I will say, “let’s take a five-minute break before resuming what we are doing. This is much better than keep arguing.” (C10, a mother) One caregiver explained that as adults, we could find comfort from people and things when we were upset. However, for children, their parents constituted a large part of their worlds, hence they could find limited or no buffer to counteract the negativity from their parents. Therefore, the impacts parents have on their children were much stronger than what we experienced as adults. To help the children to build a sense of security, the caregivers realized that they needed to manage their emotions well so that they could remain emotionally stable and offer a safe haven for the young. “Only when your emotions are stable then you child’s emotions can be stable. In our worlds, we have many things—families, intimate relationship, careers and friends—that would contribute to our emotions. However, in the children’s worlds, even they have friends, the parents would have taken up eighty percent of their time, or even their whole worlds are around their parents. The emotions that the parents offered are all that affect their emotions. When you have emotional stability, your child can then have emotional stability. When you are emotionally unstable, your children won’t understand why you are mad, and they would feel unsafe. Without this stability, how can they learn other things? Especially when our children are comparatively sensitive and have less sense of security; if the parents cannot offer them safety, they will feel like a stranger to this world.” (C12, a mother) Other respondents also agreed that emotional calmness resulting from self-care was essential for promoting the children’s immediate and long-term emotional wellbeing. 1.3 Constructing new positive self-image Most caregivers cherished self-care as it allowed them to do a better job in childcare, a few owned it for themselves and expressed their joy in building a new self-image. They shared that the identity as a parent had overshadowed their own and they had failed to recognize their own values. There was a sense of hopelessness and helplessness. Nevertheless, when they practiced self-care, especially meditation, they gradually saw that they were as valuable as their children. “I am glad that the course reminds parents to praise and love ourselves and to reserve time for meditation. I find that meditation makes a big difference. When we have to handle everything and feel unsettled, we fail to see a bigger picture and forget to cherish ourselves. We are not just parents, not just tools to care for our children, we are human beings.” (C15, a mother) For some, praising one’s own efforts and celebrating for small successes in skills application became their new self-care practice. They kept practicing these after their training and used them to reinforce their positive identity. A mother demonstrated this self-appreciation at the focus group. “When I applied this skill, I found that communication with my child became a lot easier. I can do it, and I appreciate that I can. I appreciate that I spent time to learn, and I sat around like this on Saturdays to learn the skills.” (C19, a mother) Theme 2: Home Setup for parent-child joint-engagement and routine building Interestingly, another breakthrough resonated with the participants was a change of home setup. In the course, the caregivers were taught to set up a dedicated space for parent-child play sessions. For those families who did not have a small table and small chairs at home for their children before the PII, they reported that the new physical arrangement sparked instant improvement in their parent-child interactions and in their building of play routines. 2.1 Environmental setup for parent-child joint engagement Some caregivers shared that they have never considered the influences of environment on their children’s learning before the training. In the course, they learnt that they needed to have a decluttered space for the children to focus, and the seating arrangement ought to be comfortable for both adult and child to prolong the parent-child interactions. Also, the caregiver needed to come to the child’s eye level to encourage engagement and to facilitate the child’s reading of caregiver’s facial expressions and mouth movement when pronouncing a word. Before rearranging the environment, caregivers found it difficult to engage their children. The children seldom looked at the caregivers during interactions, and they would walk away quickly. After learning how environment would influence parent-child engagement, the caregivers began to pay attention to the children’s comfort level and engagement level, and they adjusted accordingly. As the children grew up, the caregivers continued to adjust the home setup to accommodate the height and preferences of their children. “I think environmental setup is very important…the child is now four years old. From two years old until now, we have kept adjusting the seating arrangement. As parents, we keep trying different setups to make the child comfortable to play. When he was younger and was unable to sit still, we let him sit in the higher chair at the adult table. Now when he can remain at his seat without walking away all the time, he sits in his own chair and parents sit on the floor. Our eye level needs to match with the child’s. Now that he is older and has his own chair, we need to find a seating arrangement that allows us to play with him and is comfortable for parents as well.” (C5, a mother) Some caregivers reported that they did not think of buying children furniture before the PII assuming the children could share adults’ furniture at home like what they had done when they were young. Now as they were trained to observe how environment affected their parent-child interactions, they added a small table and chairs for the children to match with their heights. “Before the class, I would not prepare a small table and chairs. When I was young, I thought I had a table at home, so I naturally used it for doing homework and writing. If we wanted to play, we would go to the playmat. The trainer taught us that you needed to be at the eye level of the children so that they would feel closer to you. After the class, my home has a new small table and two small chairs of the same height.” (C13, a mother). 2.2 Environmental setup as an anchor for routine and relationship building Not many caregivers were used to play with their children before the PII. In their training, some realized that they had not spent enough quality time interacting with their children as sometimes they would be occupied by their phones. Setting up a dedicated space for parent-child interactions served as an anchor to remind both parties of their playtime. A few children associated the table and small chairs with playtime with caregivers. Over time, the children conceived an impression that it was fun to play with the caregivers and became interested in interacting with them. When the adults approached the small furniture, the children would happily join in. “One advantage (of home setup) was that the child begins to form an association between the table and playtime. Even now, we may not have separate sets of toys, we could take turn to play with the same toy… With the learning from the class, the child now accepts taking turns. In his mind, I can play with my mom at the table, and playing with mom is fun.” (C9, a mother) Two caregivers shared that the joint engagement developed in the play routines at the table helped the children to get used to interacting and learning from the parents, and this opened the children up for more learning opportunities in other settings. “We need to be practical about how to transform. I think the transformation is not just around the playtime at the table or other playtime. You do not only play with your child, but you also support their doing of homework, other training and going out. These are also excellent opportunities for the child to learn. When you can synchronize with your child, you can help him to communicate with the world and promote his learning.” (C12, a mother) Theme 3: Discernment of the window to intervene In the focus groups, when the caregivers reflected on their learning and implementation of skills, they highlighted how learning when to intervene became their breakthrough points. Through the guidance from their trainers, they became aware that they could not force the learning into their children, but they needed to align with their children’s pace and follow into their worlds in order to find opportunities to teach new skills. When they practiced a child-centered parenting approach, they developed more empathy towards their children. 3.1 Aligning with the child’s pace The trainers would sometimes provide feedback on the caregivers’ videos of playtime with their children. Many caregivers reported that their trainers urged them to slow down their pace of speaking and teaching. With the advice from the trainers, the caregivers started paying attention to their own parenting styles and the impacts on their children. They found that when they were speaking fast and speaking a lot, their children would be confused about their messages, and the efforts were in vain. With practice, they learnt to slow down to align with their children’s pace. Being fast was not uncommon in this fast-paced city. A caregiver explained that it was resulted from the busyness and stress at work. Also, she shared that sometimes she would unconsciously compare her child with those of typical development, and this also propelled her to give a lot of instructions. “I think I have slowed down. Probably because I was very busy at work and the work pressure was tremendous, so I tended to speak faster than others. In this course, you learn to adjust your pace to align with your child’s… Human beings tend to compare, to compare with the children of your friends. You see that that mom has spoken a lot, and her child perfectly understands her messages. However, I know where my child is at. Even I have completed the course for two years, sometimes I would make the same mistake of speaking too fast and too much. Then I will remind myself: My child can only absorb this much. I can save my breath and speak less.” (C3, a mother) “In the beginning, we as adults thought that I had to keep teaching her, but you didn’t consider that when you used a full sentence or described the whole event, she basically could not decipher what you were talking about. Let’s say if your sentence has ten words, she will assume that you are only talking about the first word… So, teach her less, let her build a foundation. It will be easier for her to learn more.” (C20, a mother) Other than being fast, the trainers also urged the caregivers not to ask a lot of questions. “I learn not to pose many questions and not to give a lot of instructions. I need to give him room to think. Perhaps I can use a question to guide him to think about how he wants to play.” (C11, a mother) “Trainer taught me some skills and asked us not to keep raising questions. She kept reminding us not to ask questions but to let our children play in their own ways. This made the children think that it was fun to play, and they would then be willing to play with us and build relationships with us.” (C10, a mother) Through slowing down, the caregivers came to realize the importance of aligning with the child’s pace and communicating in ways which the children could understand. They learnt that when they wanted to support their children in acquiring new vocabulary, they needed to design their teaching based on the children’s current level. “You just asked us which skill was the most useful. I think of one, but I have forgotten its name. If the child always wants certain thing, you can encourage him to name the thing. Gradually, the child will build up his vocabulary. One word becomes two words. Two words become three words. This skill is very helpful. Many of his vocabularies were built slowly, one word, then add one more. Now he is speaking more and more, thank to this skill.” (C21, a father) 3.2 Following into the child’s world Many caregivers reflected that the major breakthroughs in their parent-child engagement happened when they learnt to engage the children at where they were. They reported that before the PII, they would be angry with their children from time to time because they were not willing to follow the adults’ instructions, then the two parties would compete for the control over the game. In the course, they were trained to observe their children’s responses and preferences and try to join in the children’s play. Through practice, they developed more understanding of their children’s playing styles and patterns and became more attuned to mirroring their children’s actions. They were surprised to find that by refraining from taking the control, they could discover and create more windows to help the children to learn. “The most useful skills would be waiting, observing and listening, then joining into the children’s play. We need to start from where the children are at… The course is divided the process into steps to help us apply.” (C20, a mother) “I learn that I need to observe the preferences and interests of my child, see how he plays, follows his play method and imitate. When he looks at you, you can teach him some phrases or one word, you can succeed. It is no longer like the time when we were young: ‘No, the car has to be played in this way.’ ‘Those blocks have to be stacked like this.’ ‘You cannot wear like this. You need to follow mom. You can’t do this.’ This course teaches us that if he wants to stack the blocks in this way, just let him stack, then follow his preference.” (C19, a mother) “About playing, I have some reflections. Why do you need to be so nervous during playtime? It’s not an exam, and it’s not about studying. Even when you are preparing for an exam, the more you force him, the poorer the outcomes will be. This applies more so to playing. He does not hurt himself, he does not hurt others, so why so nervous and demanding? He can play in his own ways. Two cars can go out at the same time.” (C1, a mother) A few caregivers found that following into the child’s play indeed made the playtime easier for both. A mother shared that she was happy to discover that her child could learn even from repeating the same game, as she could add small techniques at each new round. She felt more relaxed when she realized that she did not need to look for many different games to demonstrate different techniques, but one would do the work. This new understanding opened her eyes to create more small opportunities to teach new skills. “I want to share about “restarting the same game”. My impression was that I could not play with my son, even I worked very hard. I was using the adults’ perspectives to play with him. In fact, repeating the same game is good enough. Those times are important for them. I find that the pace does not need to so fast, being slow is good enough. Be repetitive and add new techniques. Those are the long struggling moments, but I find myself feeling more relaxed.” (C5, a mother) 3.3 Parenting with empathy Learning to align with the child’s pace and following the child’s play method helped the caregivers cultivate more empathy towards their children. They realized that young children were like adults who felt and thought in similar ways. To make sense of the child’s frustration, caregivers needed to think in their shoes. “Even he is young, he also has feelings. You cannot think for them and plan for them just because they are young. This is the misunderstanding of most parents.” (C1, a mother) “Indeed, putting myself into his perspective, many techniques are built upon empathy. It’s the same for adults. You have something, then I suddenly take it away from you. We wouldn’t appreciate it. We didn’t think that children would feel the same as adults. This skill is useful, empathy is important.” (C21, a father). A mother shared that she had two children. The first one was of typical development, but the second had special educational needs. She applied the same parenting approach to the second child and was disappointed to find out he could not follow her instructions, she was frustrated. After she learnt about developmental delays and disabilities in this course, she was able to see from his son’s perspective and realized his helplessness. This changed her way of teaching her son. “Joining this course helped me to understand more about children with special educational needs, and I lower my expectations. I have two children. The first one is of typical development. In many occasions, I wanted to use the same parenting method which worked for the first one, and I was disappointed that he (the younger one) failed to do what was told. ‘Why can’t you do this? You brother can, why can’t you?’ I was perplexed and frustrated. I wasn’t aware that I was rude to him and might scold him loudly. From the child’s perspective, he felt wronged. ‘What? I’m not getting it. This is it. Why is mom treating me like this?’ After joining this course, I learnt that he was using his own ways to play, and this understanding has helped improve our relationships… I can calm down; I can’t treat him like this… Now the child has a lot of improvements. I’m happier, my child is also happier. Our parent-child relationship is so much better.” (C7, a mother) Some caregivers also shared that now they would take time to reflect on their interactions with the children to see if their expressions might have hurt them. “Change? Just as this mom has shared, we would frequently reflect on our behaviors. Did I make a mistake? Was it not good enough? When I said those words, would I hurt him? The younger children might not show (their feelings).” (C2, an auntie) Discussion This qualitative study aimed to explore the transformation processes of caregivers in the PIIs, and it focused especially on their breakthroughs. From the sharing of the caregiver-participants in the focus groups, we found three major changes: (1) Self-care for the wellbeing of self and the child, (2) home set-up for parent-child joint engagement and routine building, and (3) discernment of the window to intervene. As reflected by the respondents, these breakthroughs addressed their inner hurdles and helped create positive outcomes for the caregivers and their children. The caregivers participated in the PII with the hope to acquire some strategies to care for and promote the development of their children who were experiencing developmental delays and disabilities. Many of them were suspected or diagnosed with ASD. To their surprise, they found that the course was beyond their expectations. In this PII, they also learnt about self-care. Many caregivers reported that they were completely occupied by the needs of their children, and they were unaware of the exhaustion that they were experiencing. Unlike the original WHO-CST, this localized course emphasized more on self-care with trainers teaching and practicing meditation with the caregivers in the group sessions. The caregiver-respondents found this teaching very helpful. Through paying attention to and getting in touch with their own emotions and physical conditions, they became aware of their own stress, the depletion they were feeling, and their suppressed personal identity. This realization shed light on their own psychological needs, and they became aware of the necessity of taking good care of themselves. They discovered that through attending to their own needs, they were indeed cultivating strengths and capacities to care for their children. When the caregivers attended to their own emotions, they also became more attuned to the emotional fluctuations in themselves and in their children. With this new lens, they recognized the influences of their own emotions on their children and learnt that both positive and negative emotions were contagious. The insights motivated caregivers to create more positive experiences for their children and prevent themselves from imminent emotional outbursts. Although they were not able to hold their frustration in place every time, they found that they had gradual improvement in their emotion management and they could seek help from other adults when their negative emotions were heightened. In practicing self-care, some caregivers also reclaimed their own personal identities and constructed a new positive self-image. Self-care was a breakthrough shared among the caregiver-respondents. With many PIIs aiming to teach children self-care skills, fewer were designed to teach caregivers the self-care the adults needed [ 33 , 34 ]. There were qualitative studies calling the clinical professionals and academics to attend to the self-care needs of caregivers, this study responded by documenting how the learning and practicing of self-care transformed the lives of caregivers [ 19 ]. With an emphasis on self-care, this study highlighted the need to consider the mental and physical health of caregivers in PIIs and to include self-care as an intervention component and an outcome indicator. Another breakthrough shared by the caregivers was changing the home setup. In the PII, the caregivers learnt that the seating arrangement at home would affect the parent-child interactions. When they were at the eye-level of their children, the young would have more opportunities to pay attention to the adults’ facial expressions, and this promoted parent-child engagement thus the child’s learning. The caregivers also learnt to observe the comfort level of both parties to sustain the joint engagement. They reported that after rearranging their home setup, the children became more focused, engaged and enjoyed the parent-child time more. The respondents also noticed that setting a dedicated space for parent-child interactions served as an environmental cue to remind them of the playtime, and this helped build their play routine. This cue was so effective that when some children saw their caregivers approaching the small table for playtime, they would proactively come to join in. While environmental arrangement has been a common strategy taught in PIIs, few studies had explored its effects from caregivers’ perspectives [ 35 , 36 ]. Discernment of the window for intervention was a breakthrough mentioned and cherished most by the caregiver-respondents. In the course, the caregivers were taught to observe the behaviors, emotions, interests and preferences of their children, and responded to them with a child-centered approach. Echoing other studies, the feedback from trainers were found to be conducive for caregivers’ learning [ 6 , 18 , 19 ]. With the trainers providing feedback to the caregivers’ videos of playtime with their children, the caregivers learnt to observe the effectiveness of their existing parenting approaches and gradually adjusted their pace to align with their children’s. They realized that the best teaching approach was not to inculcate ideas into their children’s mind for this might overwhelm them. Instead, they needed to identify their children’s current language and cognitive capabilities and teach in ways that matched their current levels. Given that the feedback from trainers on actual practice has been found useful across studies, we encourage PIIs to include home visitations so that the trainers could offer practical support in environmental setup and in parent-child interactions. Caregivers also learnt to follow into the children’s world by observing and mirroring the children’s play methods. They needed not find myriads play methods to teach different skills, but they could add little elements into the same activity to expose children to new learning. The caregivers felt more relaxed when they knew when to intervene and when to take a break. Shared with other studies that examined the effectiveness of the skills of imitation and mirroring, this study reaffirmed the values of synchrony in promoting parent-child interactions [ 37 , 38 ]. Through practicing this child-centered parenting approach, the caregivers found themselves having more empathy towards their children, and they developed more understanding about the children’s behaviors and emotions. When empathy was mentioned in the PII literature, it was usually in the context of the empathetic approach to engage caregivers or the cultivation of empathy in children [ 18 , 39 , 40 ]. This study documented the growing of empathy in caregivers towards their children and how this affected the caregivers’ parenting. This study offered unique values in shedding light on the critical transformation of caregivers in PII. However, it was not without limitations. Aside from the small sample size, we are aware that the sample we used was from an Asian community and the lived experiences were inevitably influenced by the local cultures. More qualitative research is to be conducted to explore the lived experiences in other settings. Conclusions This study served to explore the transformation processes of caregivers in a PII. Through focusing on their breakthroughs, it revealed their inner struggles and documented the key changes experienced and cherished by the caregivers. By zooming into the lived experiences of caregivers, it underscored the needs of considering the conditions, wellbeing and experiences of caregivers in PIIs for these factors directly affected the effectiveness and sustainability of the interventions. This study also encouraged clinical professionals to include self-care techniques for caregivers as a core component in PIIs to strengthen their capacities and promote their wellbeing. Crucially, the skills in the localized WHO-CST course appear transferable to families with typically developing children, suggesting broader generalizability, wider utility, and greater potential impact of the program beyond its original target population. Abbreviations ASD Autism Spectrum Disorder JC A-Connect Jockey Club Autism Support Network program PII Parent-implemented intervention WHO-CST World Health Organization Caregiver Skills Training Declarations Ethics approval and consent to participate An ethics approval (reference number: EA240065) was obtained from the Human Research Ethics Committee of the University of Hong Kong. All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all research participants. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Funding This work was funded by The Hong Kong Jockey club Charities Trust. Author Contribution CW spearheaded the research design and implementation, conceptualized the frameworks presented in this paper and wrote this paper. CC supported the data collection and analysis processes and contributed to improve the manuscript. PW provided directional support and clinical expertise to interpret and present the ideas. All authors read and approved the final manuscript. Acknowledgement This research was only made possible with the financial support from The Hong Kong Jockey Club Charities Trust. The Trust cares about the wellbeing of children and families, and it specially reserves resources to support the families who are being challenged by autism spectrum disorder. With JC A-Connect, a program initiated by the Trust, these children and families were receiving support at home, in schools and in communities. Initiatives were also made to educate the public on social inclusiveness. This research was conducted to support the continuous development of early interventions in Hong Kong and in other parts of the world. We are also grateful for the support from the NGO partners, master trainers, facilitators, and caregivers who participated in this research. Data Availability The data of this study are not publicly available due to the confidentiality agreement between the researchers and the participants but are available from the corresponding author on reasonable request. References APA. Diagnostic and statistical manual of mental disorders. 5th ed. Washington DC: American Psychiatric Association; 2013. Thapar AP, Cooper MM, Rutter MP. Neurodevelopmental disorders. Lancet Psychiatry. 2017;4(4):339–46. Francés L, Quintero J, Fernández A, Ruiz A, Caules J, Fillon G, et al. Current state of knowledge on the prevalence of neurodevelopmental disorders in childhood according to the DSM-5: a systematic review in accordance with the PRISMA criteria. Child Adolesc Psychiatry Ment Health. 2022;16(1):27–15. https://doi.org/10.1186/s13034-022-00462-1 . Cainelli E, Bisiacchi P. Neurodevelopmental disorders: past, present, and future. Child (Basel). 2022;10(1):31. https://doi.org/10.3390/children10010031 . Lieberman-Betz RG. A systematic review of fidelity of implementation in parent-mediated early communication intervention. Top Early Child Spec Educ. 2015;35(1):15–27. https://doi.org/10.1177/0271121414557282 . Sone BJ, Lee J, Grauzer J, Kaat A, Roberts MY. Identifying effective strategies to instruct parents during parent-implemented intervention: the role of parent practice with feedback. Early Child Res. 2023;62:394–404. https://doi.org/10.1016/j.ecresq.2022.09.010 . Meadan H, Ostrosky MM, Zaghlawan HY, Yu S. Promoting the social and communicative behavior of young children with autism spectrum disorders: a review of parent-implemented intervention studies. Top Early Child Spec Educ. 2009;29:90–104. https://doi.org/10.1177/0271121409337950 . Gerow S, Hagan-Burke S, Rispoli M, Gregori E, Mason R, Ninci J. A systematic review of parent-implemented functional communication training for children with ASD. Behav Modif. 2018;42:335–63. 10.1177/0145445517740872 . Cheng WM, Smith TB, Butler M, Taylor TM, Clayton D. Effects of parent-implemented interventions on outcomes of children with autism: a meta-analysis. J Autism Dev Disord. 2023;53(11):4147–63. https://doi.org/10.1007/s10803-022-05688-8 . Tan-MacNeill KM, Smith IM, Johnson SA, Chorney J, Corkum P. A systematic review of online parent-implemented interventions for children with neurodevelopmental disorders. Children's Health Care. 2021;50(3):239–77. https://doi.org/10.1080/02739615.2021.1886934 . Koly KN, Martin-Herz SP, Islam MS, Sharmin N, Blencowe H, Naheed A. Parent mediated intervention programmes for children and adolescents with neurodevelopmental disorders in South Asia: A systematic review. PLoS ONE. 2021;16(3):e0247432. Jhuo R-A, Chu S-Y. A review of parent-implemented early start denver model for children with autism spectrum disorder. Child (Basel). 2022;9(2):285. https://doi.org/10.1371/journal.pone.0247432 . Symon JB. Expanding interventions for children with autism: Parents as trainers. J Posit Behav Interv. 2005;7(3):159–73. Wong CHM, Chan CKY, Wong PWC. Family outcomes of a parent-implemented early intervention for neurodevelopmental disorders: an exploratory study of family dynamics. Front Public Health. 2025;13. https://doi.org/10.3389/fpubh.2025.1614089 . Cioni G, Inguaggiato E, Sgandurra G. Early intervention in neurodevelopmental disorders: underlying neural mechanisms. Dev Med Child Neurol. 2016;58(S4):61–6. https://doi.org/10.1111/dmcn.13050 . Frosch CA, Schoppe-Sullivan SJ, O’Banion DD. Parenting and child development: a relational health perspective. Am J Lifestyle Med. 2021;15(1):45–59. https://doi.org/10.1177/1559827619849028 . Leadbitter K, Macdonald W, Taylor C, Buckle KL. Parent perceptions of participation in a parent-mediated communication-focussed intervention with their young child with autism spectrum disorder. Autism. 2020;24(8):2129–41. https://doi.org/10.1177/1362361320936394 . Im-Bolter N, de la Roche L. What parents want: A qualitative analysis of a parent-implemented intervention for autistic children. Autism Dev Lang Impairments. 2023;8. https://doi.org/10.1177/23969415231189606 . Jurek L, Leadbitter K, Falissard B, Colin C, Touzet S, Geoffray MM. Parental experience of parent-mediated intervention for children with ASD: A systematic review and qualitative evidence synthesis. Autism. 2023;27(3):647–66. https://doi.org/10.1177/13623613221112204 . Furlong M, McGilloway S. Barriers and facilitators to implementing evidence-based parenting programs in disadvantaged settings: a qualitative study. J Child Fam Stud. 2015;24(6):1809–18. https://doi.org/10.1007/s10826-014-9984-6 . Carruthers S, Mleczko N, Page S, Ahuja S, Ellis C, Howlin P, Leadbitter K, Taylor L, Slonims V, Charman T. Using implementation science frameworks to explore barriers and facilitators for parents’ use of therapeutic strategies following a parent-mediated autism intervention. Autism. 2023;27(4):1011–25. https://doi.org/10.1177/13623613221125630 . Lord C, Rapley T, Marcroft C, Pearse J, Basu A. Determinants of parent-delivered therapy interventions in children with cerebral palsy: A qualitative synthesis and checklist. Child: Care Health Dev. 2018;44(5):659–69. https://doi.org/10.1111/cch.12592 . Holtrop K, Parra-Cardona JR, Forgatch MS. Examining the process of change in an evidence-based parent training intervention: a qualitative study grounded in the experiences of participants. Prev Sci. 2014;15(5):745–56. https://doi.org/10.1007/s11121-013-0401-y . Mejia A, Ulph F, Calam R. Exploration of mechanisms behind changes after participation in a parenting intervention: a qualitative study in a low-resource setting. Am J Community Psychol. 2016;57(1–2):181–9. https://doi.org/10.1002/ajcp.12020 . Frost KM, Ingersoll B. Theory of change of caregiver coaching for an early parent-mediated autism intervention. J Autism Dev Disord. 2025. https://doi.org/10.1007/s10803-025-06767-2 . Chan CKY, Wong CHM, Wong PWC. Caregiver transformation and relational growth in a parent-mediated intervention for autism in Hong Kong – A qualitative study. PloS Mental Health. (manscript accepted). World Health Organization. Training for caregivers of children with developmental disabilities, including autism. Available online at: https://www.who.int/teams/mental-health-and-substance-use/treatment-care/who-caregivers-skills-training-for-families-of-children-with-developmental-delays-and-disorders [Accessed September 11, 2025]. Salomone E, Pacione L, Shire S, Brown FL, Reichow B, Servili C. Development of the WHO caregiver skills training program for developmental disorders or delays. Front Psychiatry. 2019;10:9. https://doi.org/10.3389/fpsyt.2019.00769 . Wong PWC, Lam YY, Lau JSP, Fok HK, Servili C, Salomone E, et al. Adapting and pretesting the World Health Organization's Caregiver Skills Training Program for children with autism and developmental disorders or delays in Hong Kong. Sci Rep. 2022;12:1. https://doi.org/10.1038/s41598-022-21343-9 . Spencer R, Pryce JM, Walsh J. Philosophical approaches to qualitative research. In: Leavy P, editor. the Oxford Handbook of Qualitative Research. New York: Oxford University Press; 2014. pp. 81–98. Terry G, Hayfield N, Clarke V, Braun V. Thematic analysis. SAGE Handb Qual Res Psychol. 2017:17–37. Braun V, Clarke V. Conceptual and Design Thinking for Thematic Analysis. Qual Psychol. 2022;9(1):3–26. https://doi.org/10.1037/qup0000196 . Branjerdporn N, Benfer K, Crawford E, Ziviani J, Boyd RN, Sakzewski L. Efficacy of early interventions with active parent implementation in low-and-Middle income countries for young children with cerebral palsy to improve child development and parent mental health outcomes: a systematic review. Disabil Rehabil. 2022;44(23):6969–83. https://doi.org/10.1080/09638288.2021.1989063 . Alias NA, Kadar M, Wan Yunus F, Cremin K. A scoping review of intervention implementation for self-care skills among children with developmental delay. Malaysian J Med Sci. 2024;31(4):78–90. https://doi.org/10.21315/mjms2024.31.4.6 . Meadan H, Stoner JB, Angell ME, Daczewitz ME, Cheema J, Rugutt JK. Do you see a difference? Evaluating outcomes of a parent-implemented intervention. J Dev Phys Disabil. 2014;26(4):415–30. Akamoglu Y, Meadan H. Parent-implemented language and communication interventions for children with developmental delays and disabilities: a scoping review. Rev J Autism Dev Disord. 2018;5(3):294–309. McCabe KM, Sakamoto M, Rosas YG, Kehoe K, La R, Zerr A, et al. Keeping an I on PRIDE: Measuring imitation in parent-child interaction therapy. Behav ther. 2021;52(1):28–38. https://doi.org/10.1016/j.beth.2020.01.009 . Leclère C, Viaux S, Avril M, Achard C, Chetouani M, Missonnier S, et al. Why synchrony matters during mother-child interactions: a systematic review. PLoS ONE. 2014;9(12):e113571. https://doi.org/10.1371/journal.pone.0113571 . Sawyer BE, Hammer CS, Santoro JK, Smith JC, Feil EG. Developing Parents Plus: A Parent-Implemented Intervention for Young Children With Developmental Language Disorders. Infants Young Child. 2022;35(3):205–21. https://doi.org/10.1097/IYC.0000000000000219 . Leafe N, Pagnamenta E, Donnelly M, Taggart L, Titterington J. To know that you are a link in the chain’: a realist evaluation to explore how digital, intensive, parent-implemented interventions work for children with speech sound disorder, why, and for whom. Int J lang commun disord. 2025;60(3):e70049. https://doi.org/10.1111/1460-6984.70049 . -n/a . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7938870","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":539837358,"identity":"be1d1f6e-db69-401a-8bb7-885d9c9a2e9e","order_by":0,"name":"Cecilia H.M. 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WONG","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAm0lEQVRIiWNgGAWjYHACxgMMFQcMGBh4mInXc4DhDMlaGNtI0WLOfsbgMO+8O8YGB3gPGxClxbInB6hl2zMzgwN8yQlEaTE4ANSSu+2wjcEBHuMDxGk5/waoZQ5JWm6AbGk4bAbSQpzDLGc8Kzj859hhY8nDPMbEed+cP3njwxk1hw37jvcYSxDnMDiL6Igkzi2jYBSMglEwsgEA7HkzRZhKV0kAAAAASUVORK5CYII=","orcid":"","institution":"University of Hong Kong","correspondingAuthor":true,"prefix":"","firstName":"Paul","middleName":"W.C.","lastName":"WONG","suffix":""}],"badges":[],"createdAt":"2025-10-24 09:26:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7938870/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7938870/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95808513,"identity":"031f2bfb-a8ae-4927-b8ea-a8e759bf311f","added_by":"auto","created_at":"2025-11-13 08:49:30","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":820087,"visible":true,"origin":"","legend":"","description":"","filename":"BMCPublicHealthThebreakthroughsofcaregiversinparentimplementedinterventionsforchildrenwithneurodevelopment20251103.docx","url":"https://assets-eu.researchsquare.com/files/rs-7938870/v1/d16d8a94dd5f5df3905d3333.docx"},{"id":95808549,"identity":"a4fd7aa8-6de7-4378-91b1-51322a3fb2a2","added_by":"auto","created_at":"2025-11-13 08:49:31","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7000,"visible":true,"origin":"","legend":"","description":"","filename":"9676b9657c9045e4ac738a2f835c8c5e.json","url":"https://assets-eu.researchsquare.com/files/rs-7938870/v1/a797846cbada1017818da492.json"},{"id":95808399,"identity":"f40be1b0-0e58-4489-b38a-c67fd065e735","added_by":"auto","created_at":"2025-11-13 08:49:27","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":126477,"visible":true,"origin":"","legend":"","description":"","filename":"9676b9657c9045e4ac738a2f835c8c5e1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7938870/v1/c91585c8fc93f7bec3ae0d6f.xml"},{"id":95808597,"identity":"1be4566c-5bc8-4f7a-bde2-c9efd0e1d227","added_by":"auto","created_at":"2025-11-13 08:49:32","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":111458,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7938870/v1/63f756c46e3cdb1ed5a6d788.png"},{"id":95808725,"identity":"b1b16ae4-3eea-47e2-a950-edc8f56921a4","added_by":"auto","created_at":"2025-11-13 08:49:34","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":122301,"visible":true,"origin":"","legend":"","description":"","filename":"9676b9657c9045e4ac738a2f835c8c5e1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7938870/v1/cea49863a0ed64c9a74ec63e.xml"},{"id":95808858,"identity":"1e117269-d80c-44a3-922c-ffb48bc17aa8","added_by":"auto","created_at":"2025-11-13 08:49:39","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":137817,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7938870/v1/73ac9eddd4762ae23c673e78.html"},{"id":95808508,"identity":"b884063c-676c-443a-b990-c3ccaf263373","added_by":"auto","created_at":"2025-11-13 08:49:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":903356,"visible":true,"origin":"","legend":"\u003cp\u003esummaries the transformation of caregivers in the PII in flowcharts.\u003c/p\u003e","description":"","filename":"floatimage126.png","url":"https://assets-eu.researchsquare.com/files/rs-7938870/v1/a35be4f432ff14390914eec7.png"},{"id":96247962,"identity":"6938609f-35ff-4eb9-bb2c-3dd3efc50cdc","added_by":"auto","created_at":"2025-11-19 07:27:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1474951,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7938870/v1/8cf6acb4-5614-4959-bf64-58426d3f0fb5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The breakthroughs of caregivers in parent-implemented interventions for children with neurodevelopmental disorders: an exploratory qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eNeurodevelopmental disorder is a group of disabilities characterized by disruption to brain development and has its common onset in childhood [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Globally, the prevalence rates stood at: intellectual disability 0.63%, attention-deficit/hyperactivity disorder 5\u0026ndash;11%, autism spectrum disorder (ASD) 0.7-3%, specific learning disorder 3\u0026ndash;10%, communication disorders 1-3.42%, and motor disorders 0.76-17% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. For children facing such challenges, a comprehensive early intervention is crucial for promoting their lifelong development as it makes use of the window of brain plasticity at an early age for maximum learning [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eParent-implemented intervention (PII) (or parent-mediated intervention) is an effective early intervention for children with neurodevelopmental disorders. It employs a triadic model which requires the caregivers to, first, learn the strategies from clinical professionals, and then offer training for their children at home [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. It is not designed to replace but complement the clinician-implemented treatment so that children can have more tailored learning opportunities [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Research has shown that PIIs are useful in promoting children\u0026rsquo;s adaptive behaviors, social communication skills, motor skills, cognitive skills and learning abilities while reducing maladaptive behaviors [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. With caregivers being equipped with the specialized knowledge and skills to care for their children, they too benefit from PIIs. Being empowered, their parental stress is alleviated, and their confidence is boosted [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. PIIs can also create positive impacts on families when other caregivers are willing to learn from the trained-caregivers and put the new skills into practice [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Hence, PIIs have strategic values of strengthening the functioning of the children, parents as well as families. Scientific evidence reveals that although gene abnormalities and congenital brain lesions contribute to neurodevelopmental problems, environment and experience also play a role in shaping the brain development thus altering its trajectories [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. PIIs are therefore uniquely powerful as they nurture the natural family environment which is conducive to healthy child development [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWith the effectiveness of PIIs being validated, more qualitative studies were conducted in recent decades to explore why and how PIIs worked. In our observations, these studies were on three domains: (1) Documenting the outcomes of PIIs, (2) identifying barriers and facilitators, and (3) investigating the change processes in the interventions. On the examination of outcomes, the existing qualitative research found that PIIs were useful in helping the caregivers to make sense of and accept their children\u0026rsquo;s atypical development, equip them with new parenting strategies, strengthen parent-child relationship, promote children\u0026rsquo;s development, and support family members to acquire new caring skills [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. On the barriers and facilitators, research showed that program design (e.g. the pace of learning, the possibility of integrating the skills into daily routines, and the match between the program and the participants), trainers\u0026rsquo; competencies and relationship with the parents, parents\u0026rsquo; commitment and self-efficacy, and logistics (e.g. time, location, and availability of childcare) were factors affecting caregivers\u0026rsquo; participation in the PII training and their application of skills at home [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. On the change mechanism, research seemed to share a similar three-step process: (1) The caregivers were empowered and experienced an increase in self-efficacy, (2) they practiced applying the skills, then (3) they witnessed the changes in their children [\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile the existing qualitative studies have provided a rich account of lived experiences of the participants, we still have little knowledge about the changes of the caregivers in PIIs. For example, Holtrop et al. set out to examine the process of change, and they identified three steps: Attempt, Appraise, and Apply. These steps explained what the parents did to transfer their learning into practice, yet they did not describe the changes of caregivers [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Mejia et al. attempted to examine the changing mechanisms behind the changes in parents. They identified three sets of outcomes\u0026mdash; (1) psychological mechanisms behind changes, (2) behavioral changes in the parent, and (3) changes in the children\u0026mdash;and weaved them into a change model with hypothetical causal relationships. Their work encouraged researchers to investigate the relationships between changes, but it has not directly investigated the change processes [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Frost and Ingersoll purported to delineate the theory of change, and they offered a detailed description of how participants reacted to different ingredients of the intervention [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. An example of the pathways they portrayed was \u0026ldquo;demonstration/modeling\u0026thinsp;\u0026gt;\u0026thinsp;visual learning\u0026thinsp;\u0026gt;\u0026thinsp;content knowledge and memory\u0026thinsp;\u0026gt;\u0026thinsp;fidelity of implementation\u0026rdquo;. Their description of the learning processes offered insights for intervention design and implementation, but this work has not offered an in-depth investigation of the inner changes of the parents. Thus far, the literature has only painted a broad stroke description that parents were likely to experience an increase in motivation, confidence and skills.\u003c/p\u003e\u003cp\u003e In this study, we employed the qualitative research approach to explore the transformation of caregivers. We asked them to describe the changes in themselves, their children and their families, and we focused particularly on their breakthroughs that propelled the positive outcomes. This interest stemmed from our awareness that in PIIs, the caregiver-trainees were the mainly interventionists as well as the primary caregivers who had their personal and familial responsibilities, expectations and struggles. Hence, the effectiveness of PIIs was determined not only by the competencies in learning and applying of skills, but also the beliefs, habits, wellbeing and decision making of the caregivers. By zooming into their personal transformation, we could understand more about their concerns, struggles and joy in PIIs.\u003c/p\u003e\u003cp\u003eWhen we joined the caregivers into their stories, we could apprehend the dilemmas they faced, and we no longer played only the spectator role to observe their performance. The insights generated will help develop PIIs that can cater the needs of the caregivers as well as the children. In our earlier paper, we found two paradigm shifts of caregivers in the PIIs: They changed from perceiving themselves as sole care providers to people with growth, and they changed from perceiving their children as mere care recipients to stakeholders [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In this paper, we explored what propelled these changes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eThe intervention\u003c/h2\u003e\u003cp\u003eThe World Health Organization Caregiver Skills Training (WHO-CST) was introduced in Hong Kong in 2018 through the Family Support Team of the Jockey Club Autism Support Network program (JC A-Connect) at the University of Hong Kong [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This course was a PII that targeted at caregivers of children aged 2\u0026ndash;9 with developmental delays or disabilities. It aimed to equip them with skills to promote their children\u0026rsquo;s engagement, communication, positive behaviors and daily living skills, while strengthening caregivers\u0026rsquo; confidence, psychological wellbeing and connection with their children. This intervention contained 9 group sessions and 3 individual home coaching sessions. After the initial adaptation, the local master trainers further localized the course to respond to the training and learning needs of the professionals and caregivers in Hong Kong in 2021. The PII studied in this research was this localized version. In Hong Kong, this PII was mostly open to caregivers with children aged 2\u0026ndash;6 who were suspected or confirmed to have ASD.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eResearch design\u003c/h3\u003e\n\u003cp\u003eWe conducted an evaluation study in 2023 and 2024 to examine the impacts and sustainability of the localized WHO-CST in Hong Kong, and this study was part of this evaluation research. The research was approved by the Human Research Ethics Committee of the University of Hong Kong with a reference number of EA240065. Another article published from this research was on family outcomes, in which we categorized the responses from family members who did not participate in the PII training into four levels, and examined the factors promoting or discouraging their involvement [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eQualitative method was adopted to investigate the lived experiences of the caregiver-participants. When quantitative study is limited by the predetermined variables, qualitative approach offers room to explore the unknown territories. This study was grounded in social constructionism and social interactionism [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. We were aware that the experiences shared by our research respondents were constructed subjectively by their sense-making and their own interpretations that were influenced by a wide range of factors such as social culture and values. Thus, having multiple accounts of stories offered us an array of perspectives that enriched our understanding. Social interactionism drew our attention to the power of social exchanges in shaping people\u0026rsquo;s understanding. We recognized that the lived experiences were shaped by the interactions during the interventions, after the interventions and even in the data collection sessions.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eWe recruited the caregiver-participants who had completed the localized WHO-CST at the time of data collection. Target-convenience sampling was used as the main method. Invitations and information sheet were sent through the organizations that offered the PII to their graduates, caregivers who were interested in participating in the research could complete a brief online survey to provide the research team their contact methods and availability. Our researchers contacted each interested party through phone to introduce the research and arrange them into focus groups. We also used the snowballing method for recruitment by asking the participants to refer their friends and families who had also completed the PII.\u003c/p\u003e\u003cp\u003eTwenty-two caregiver-participants participated in this research. Twenty-one of them were female, and one man was the husband of one of our respondents. They were mothers (18), father (1), grandmother (1), auntie (1), and foster mother (1). Sixteen of them were in a marriage, three were singles, and three had separated with their partners. Two attained a master\u0026rsquo;s qualification or above, seven with a bachelor\u0026rsquo;s degree, and thirteen had completed secondary school or post-secondary diploma. Fourteen were homemakers, five were in a full-time job, two took up multiple jobs, and one worked in a part-time capacity.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eFive focus groups were conducted, and each lasted for about 1 to 1.5 hours. Three groups were conducted virtually through ZOOM, and two were physical meet-up at the University of Hong Kong and at a social services center. Participants were asked to read an online information sheet, complete a consent form and a short profiling questionnaire prior to the focus groups; all of them consented to participate voluntarily. The discussion was semi-structured, participants were asked to share about their experiences in the PII and the changes they observed in themselves, their children and other family members. To further focus them to their breakthroughs, we asked, \u0026ldquo;What were the points which you found yourselves being \u0026ldquo;unlocked\u0026rdquo; (an expression in Cantonese)? What motivated these breakthroughs?\u0026rdquo; Given that this PII targeted mainly at Cantonese speaking Chinese in Hong Kong, this was also the profile of our respondents. As an incentive, all respondents received a supermarket voucher costing HKD100 and a set of JC A-Connect souvenirs after the data collection sessions.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eAll discussion was recorded and transcribed, names were replaced by participant codes in the transcripts, and all data were stored securely to ensure confidentiality. For data analysis, we opted for reflexive thematic analysis for it encouraged us to engage deeply with the data and allowed us to immerse in the meaning creation process to generate informative themes and frameworks for the advancement of the field [\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. As an exploratory study, we applied the inductive approach to generate codes that we used as handles to follow into the respondents\u0026rsquo; stories. The qualitative analysis software, NVivo, was used for engaging data and processing the codes.\u003c/p\u003e\u003cp\u003eWe followed the suggested procedures of conducting a reflexive thematic analysis and proceeded gradually from familiarization to code generation then theme construction [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. We started with researchers reading the data separately to generate provisional ideas before sharing our initial notes and impressions with each other. Next, we individually applied opening coding to code the same set of data and met to share and discuss our lists. We then returned to our data to further review and refine our codes before constructing our themes. Giving researchers time to engage with the data individually allowed us room to mobilize our different expertise to make sense of the data and develop our own informed interpretations. Themes were reviewed and revised together.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFrom interacting with the data, we generated three overarching themes describing the breakthroughs the caregivers experienced which propelled positive changes in themselves and in their children, they were: (1) Self-care for the wellbeing of self and the child, (2) home setup for parent-child joint engagement and routine building, and (3) discernment of the window to intervene. Each overarching theme contained two to three subthemes.\u003c/p\u003e\n\u003ch3\u003eTheme 1: Self-care for the wellbeing of self and the child\u003c/h3\u003e\n\u003cp\u003eCaregivers joined the PII expecting to acquire skills for caring for their children; many were surprised to learn about the importance and practice of self-care. They described this learning transformative as it laid a strong foundation to sustain their caregiving journeys.\u003c/p\u003e\u003cp\u003e1.1 \u003cb\u003eAttending to one\u0026rsquo;s own needs to cultivate strengths and capacities for childcare\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003e Most caregivers who recognized the values of self-care described their transformation in a similar approach: Before the PII, they were very consumed by the needs of their children. They tended to invest all their emotional and physical energy on their children; hence they neglected their own wellbeing. In the training, the caregivers were guided to attend to their own thoughts and feelings, and they began to feel their own exhaustion. Through reflections, they realized that they needed to first take care of themselves so that they would have the strengths and capacities to care for their children. A respondent employed a tree analogy to illustrate her view.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;It is good that the course taught parents to manage their own emotions. Many times, we focused entirely on our children thinking that they were the ones who had problems, and we dedicated all our attention on teaching them. We were not aware of our own emotions, focused too much on the child and neglected ourselves. Like a tree, you need to be strong so that you have plenty of leaves to provide shades for others. If you keep consuming yourself and become barren, how can you protect your child?\u0026rdquo; (C12, a mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSome participants added that they had to attend to their own emotional needs as well as physical needs so that they could be physically strong to take care of their children, especially when the children were sick.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I didn\u0026rsquo;t think about taking care of myself so that I would have the strength to care for others. After this course, I changed my mind\u0026hellip; At that time, Covid and flu were around, and my child just began schooling. In many occasions, when children fell ill, they spread the germs to their mothers. This was a time when I had to take good care of myself so that I could care for my child.\u0026rdquo; (C10, a mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSelf-care was particularly important for caregivers of children with special needs as these children were more vulnerable and required much care, explained by a respondent.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I agree that we have to first take care of ourselves so that we can care for our children. If we fall down, our children who have ASD or other special needs will not be able to care for themselves.\u0026rdquo; (C13, a mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e1.2 Recognizing own influences on children\u0026rsquo;s wellbeing\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSelf-care, as perceived by some participants, was also for the wellbeing of the children as caregivers\u0026rsquo; emotions had direct influences on their children\u0026rsquo;s. A mother linked her own happiness to her child. In our researchers\u0026rsquo; view, the happiness of a caregiver would open a door for their children to experience happiness.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;It is tough to be a parent of a child with special educational needs. Sometimes we forget our own needs and rush to sacrifice everything for our children. What I find precious of this course is that it reminds us to care about our own emotions, because when you are happy, your child can then be happy. Your feelings directly impact your child.\u0026rdquo; (C9, a mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWhile positive emotions in one could ignite the positive emotions in others, negative emotions were contagious, too. More than half of the respondents recalled how their negative feelings, expressions and actions kindled negative emotions in their children and caused a vicious cycle of emotional outbursts among them. Whereas some of them shared the stories of temporary defeats in which they were overtaken by their anger and frustration, some also shared their stories of victories.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;This course talked about meditation. The trainer led us into the meditation exercises. Sometimes, I would practice on my own. Before the course, when my son had a heightened emotion, I would be frustrated and had an emotional outburst. This further stimulated my son\u0026rsquo;s emotions. After learning meditation in the course, I know how to calm my own emotions. Even when my son is very frustrated, I would remain calm to discuss with him, he will listen. If his emotions are too strong or he wants to cool down, I may hug him. Hugging him is important, too. We remain silent, hugging him makes us feel peaceful.\u0026rdquo; (C11, a mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTaking a break (time-off) to allow all parties to calm down was a common strategy shared among the respondents. A father shared that he and his wife became more aware of their own emotions. When they found themselves getting angry, they would seek help from their partners.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Sometimes we would find ourselves at the red or yellow light, then we would take a break. Let\u0026rsquo;s say when I am at the yellow light and am not in my best condition, I would say to my wife: You take care of him! (When I am irritated,) I tend to scold him and be mad at him, so I stop teaching my son at that time. My wife does the same (when she is irritated).\u0026rdquo; (C21, a father)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSome caregivers also taught their children to recognize different emotions. A caregiver shared that her daughter could recognize the anger in herself and in her mother and pointed it out.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Now when she is angry, she will say, \u0026ldquo;mom, you are angry.\u0026rdquo; I then ask if she is angry, too? When both of us recognize our anger, I will say, \u0026ldquo;let\u0026rsquo;s take a five-minute break before resuming what we are doing. This is much better than keep arguing.\u0026rdquo; (C10, a mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOne caregiver explained that as adults, we could find comfort from people and things when we were upset. However, for children, their parents constituted a large part of their worlds, hence they could find limited or no buffer to counteract the negativity from their parents. Therefore, the impacts parents have on their children were much stronger than what we experienced as adults. To help the children to build a sense of security, the caregivers realized that they needed to manage their emotions well so that they could remain emotionally stable and offer a safe haven for the young.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Only when your emotions are stable then you child\u0026rsquo;s emotions can be stable. In our worlds, we have many things\u0026mdash;families, intimate relationship, careers and friends\u0026mdash;that would contribute to our emotions. However, in the children\u0026rsquo;s worlds, even they have friends, the parents would have taken up eighty percent of their time, or even their whole worlds are around their parents. The emotions that the parents offered are all that affect their emotions. When you have emotional stability, your child can then have emotional stability. When you are emotionally unstable, your children won\u0026rsquo;t understand why you are mad, and they would feel unsafe. Without this stability, how can they learn other things? Especially when our children are comparatively sensitive and have less sense of security; if the parents cannot offer them safety, they will feel like a stranger to this world.\u0026rdquo; (C12, a mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOther respondents also agreed that emotional calmness resulting from self-care was essential for promoting the children\u0026rsquo;s immediate and long-term emotional wellbeing.\u003c/p\u003e\u003cp\u003e\u003cb\u003e1.3 Constructing new positive self-image\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMost caregivers cherished self-care as it allowed them to do a better job in childcare, a few owned it for themselves and expressed their joy in building a new self-image. They shared that the identity as a parent had overshadowed their own and they had failed to recognize their own values. There was a sense of hopelessness and helplessness. Nevertheless, when they practiced self-care, especially meditation, they gradually saw that they were as valuable as their children.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I am glad that the course reminds parents to praise and love ourselves and to reserve time for meditation. I find that meditation makes a big difference. When we have to handle everything and feel unsettled, we fail to see a bigger picture and forget to cherish ourselves. We are not just parents, not just tools to care for our children, we are human beings.\u0026rdquo; (C15, a mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFor some, praising one\u0026rsquo;s own efforts and celebrating for small successes in skills application became their new self-care practice. They kept practicing these after their training and used them to reinforce their positive identity. A mother demonstrated this self-appreciation at the focus group.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;When I applied this skill, I found that communication with my child became a lot easier. I can do it, and I appreciate that I can. I appreciate that I spent time to learn, and I sat around like this on Saturdays to learn the skills.\u0026rdquo; (C19, a mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eTheme 2: Home Setup for parent-child joint-engagement and routine building\u003c/h3\u003e\n\u003cp\u003eInterestingly, another breakthrough resonated with the participants was a change of home setup. In the course, the caregivers were taught to set up a dedicated space for parent-child play sessions. For those families who did not have a small table and small chairs at home for their children before the PII, they reported that the new physical arrangement sparked instant improvement in their parent-child interactions and in their building of play routines.\u003c/p\u003e\u003cp\u003e\u003cb\u003e2.1 Environmental setup for parent-child joint engagement\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSome caregivers shared that they have never considered the influences of environment on their children\u0026rsquo;s learning before the training. In the course, they learnt that they needed to have a decluttered space for the children to focus, and the seating arrangement ought to be comfortable for both adult and child to prolong the parent-child interactions. Also, the caregiver needed to come to the child\u0026rsquo;s eye level to encourage engagement and to facilitate the child\u0026rsquo;s reading of caregiver\u0026rsquo;s facial expressions and mouth movement when pronouncing a word.\u003c/p\u003e\u003cp\u003eBefore rearranging the environment, caregivers found it difficult to engage their children. The children seldom looked at the caregivers during interactions, and they would walk away quickly. After learning how environment would influence parent-child engagement, the caregivers began to pay attention to the children\u0026rsquo;s comfort level and engagement level, and they adjusted accordingly. As the children grew up, the caregivers continued to adjust the home setup to accommodate the height and preferences of their children.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I think environmental setup is very important\u0026hellip;the child is now four years old. From two years old until now, we have kept adjusting the seating arrangement. As parents, we keep trying different setups to make the child comfortable to play. When he was younger and was unable to sit still, we let him sit in the higher chair at the adult table. Now when he can remain at his seat without walking away all the time, he sits in his own chair and parents sit on the floor. Our eye level needs to match with the child\u0026rsquo;s. Now that he is older and has his own chair, we need to find a seating arrangement that allows us to play with him and is comfortable for parents as well.\u0026rdquo; (C5, a mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e Some caregivers reported that they did not think of buying children furniture before the PII assuming the children could share adults\u0026rsquo; furniture at home like what they had done when they were young. Now as they were trained to observe how environment affected their parent-child interactions, they added a small table and chairs for the children to match with their heights.\u003c/p\u003e\u003cp\u003e\u0026ldquo;Before the class, I would not prepare a small table and chairs. When I was young, I thought I had a table at home, so I naturally used it for doing homework and writing. If we wanted to play, we would go to the playmat. The trainer taught us that you needed to be at the eye level of the children so that they would feel closer to you. After the class, my home has a new small table and two small chairs of the same height.\u0026rdquo; (C13, a mother).\u003c/p\u003e\u003cp\u003e\u003cb\u003e2.2 Environmental setup as an anchor for routine and relationship building\u003c/b\u003e\u003c/p\u003e\u003cp\u003eNot many caregivers were used to play with their children before the PII. In their training, some realized that they had not spent enough quality time interacting with their children as sometimes they would be occupied by their phones. Setting up a dedicated space for parent-child interactions served as an anchor to remind both parties of their playtime. A few children associated the table and small chairs with playtime with caregivers. Over time, the children conceived an impression that it was fun to play with the caregivers and became interested in interacting with them. When the adults approached the small furniture, the children would happily join in.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;One advantage (of home setup) was that the child begins to form an association between the table and playtime. Even now, we may not have separate sets of toys, we could take turn to play with the same toy\u0026hellip; With the learning from the class, the child now accepts taking turns. In his mind, I can play with my mom at the table, and playing with mom is fun.\u0026rdquo; (C9, a mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTwo caregivers shared that the joint engagement developed in the play routines at the table helped the children to get used to interacting and learning from the parents, and this opened the children up for more learning opportunities in other settings.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;We need to be practical about how to transform. I think the transformation is not just around the playtime at the table or other playtime. You do not only play with your child, but you also support their doing of homework, other training and going out. These are also excellent opportunities for the child to learn. When you can synchronize with your child, you can help him to communicate with the world and promote his learning.\u0026rdquo; (C12, a mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eTheme 3: Discernment of the window to intervene\u003c/h2\u003e\u003cp\u003eIn the focus groups, when the caregivers reflected on their learning and implementation of skills, they highlighted how learning when to intervene became their breakthrough points. Through the guidance from their trainers, they became aware that they could not force the learning into their children, but they needed to align with their children\u0026rsquo;s pace and follow into their worlds in order to find opportunities to teach new skills. When they practiced a child-centered parenting approach, they developed more empathy towards their children.\u003c/p\u003e\u003cp\u003e\u003cb\u003e3.1 Aligning with the child\u0026rsquo;s pace\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe trainers would sometimes provide feedback on the caregivers\u0026rsquo; videos of playtime with their children. Many caregivers reported that their trainers urged them to slow down their pace of speaking and teaching. With the advice from the trainers, the caregivers started paying attention to their own parenting styles and the impacts on their children. They found that when they were speaking fast and speaking a lot, their children would be confused about their messages, and the efforts were in vain. With practice, they learnt to slow down to align with their children\u0026rsquo;s pace.\u003c/p\u003e\u003cp\u003eBeing fast was not uncommon in this fast-paced city. A caregiver explained that it was resulted from the busyness and stress at work. Also, she shared that sometimes she would unconsciously compare her child with those of typical development, and this also propelled her to give a lot of instructions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I think I have slowed down. Probably because I was very busy at work and the work pressure was tremendous, so I tended to speak faster than others. In this course, you learn to adjust your pace to align with your child\u0026rsquo;s\u0026hellip; Human beings tend to compare, to compare with the children of your friends. You see that that mom has spoken a lot, and her child perfectly understands her messages. However, I know where my child is at. Even I have completed the course for two years, sometimes I would make the same mistake of speaking too fast and too much. Then I will remind myself: My child can only absorb this much. I can save my breath and speak less.\u0026rdquo; (C3, a mother)\u003c/p\u003e\u003cp\u003e\u0026ldquo;In the beginning, we as adults thought that I had to keep teaching her, but you didn\u0026rsquo;t consider that when you used a full sentence or described the whole event, she basically could not decipher what you were talking about. Let\u0026rsquo;s say if your sentence has ten words, she will assume that you are only talking about the first word\u0026hellip; So, teach her less, let her build a foundation. It will be easier for her to learn more.\u0026rdquo; (C20, a mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOther than being fast, the trainers also urged the caregivers not to ask a lot of questions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I learn not to pose many questions and not to give a lot of instructions. I need to give him room to think. Perhaps I can use a question to guide him to think about how he wants to play.\u0026rdquo; (C11, a mother)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Trainer taught me some skills and asked us not to keep raising questions. She kept reminding us not to ask questions but to let our children play in their own ways. This made the children think that it was fun to play, and they would then be willing to play with us and build relationships with us.\u0026rdquo; (C10, a mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThrough slowing down, the caregivers came to realize the importance of aligning with the child\u0026rsquo;s pace and communicating in ways which the children could understand. They learnt that when they wanted to support their children in acquiring new vocabulary, they needed to design their teaching based on the children\u0026rsquo;s current level.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;You just asked us which skill was the most useful. I think of one, but I have forgotten its name. If the child always wants certain thing, you can encourage him to name the thing. Gradually, the child will build up his vocabulary. One word becomes two words. Two words become three words. This skill is very helpful. Many of his vocabularies were built slowly, one word, then add one more. Now he is speaking more and more, thank to this skill.\u0026rdquo; (C21, a father)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e3.2 Following into the child\u0026rsquo;s world\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Many caregivers reflected that the major breakthroughs in their parent-child engagement happened when they learnt to engage the children at where they were. They reported that before the PII, they would be angry with their children from time to time because they were not willing to follow the adults\u0026rsquo; instructions, then the two parties would compete for the control over the game. In the course, they were trained to observe their children\u0026rsquo;s responses and preferences and try to join in the children\u0026rsquo;s play. Through practice, they developed more understanding of their children\u0026rsquo;s playing styles and patterns and became more attuned to mirroring their children\u0026rsquo;s actions. They were surprised to find that by refraining from taking the control, they could discover and create more windows to help the children to learn.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The most useful skills would be waiting, observing and listening, then joining into the children\u0026rsquo;s play. We need to start from where the children are at\u0026hellip; The course is divided the process into steps to help us apply.\u0026rdquo; (C20, a mother)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I learn that I need to observe the preferences and interests of my child, see how he plays, follows his play method and imitate. When he looks at you, you can teach him some phrases or one word, you can succeed. It is no longer like the time when we were young: \u0026lsquo;No, the car has to be played in this way.\u0026rsquo; \u0026lsquo;Those blocks have to be stacked like this.\u0026rsquo; \u0026lsquo;You cannot wear like this. You need to follow mom. You can\u0026rsquo;t do this.\u0026rsquo; This course teaches us that if he wants to stack the blocks in this way, just let him stack, then follow his preference.\u0026rdquo; (C19, a mother)\u003c/p\u003e\u003cp\u003e\u0026ldquo;About playing, I have some reflections. Why do you need to be so nervous during playtime? It\u0026rsquo;s not an exam, and it\u0026rsquo;s not about studying. Even when you are preparing for an exam, the more you force him, the poorer the outcomes will be. This applies more so to playing. He does not hurt himself, he does not hurt others, so why so nervous and demanding? He can play in his own ways. Two cars can go out at the same time.\u0026rdquo; (C1, a mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA few caregivers found that following into the child\u0026rsquo;s play indeed made the playtime easier for both. A mother shared that she was happy to discover that her child could learn even from repeating the same game, as she could add small techniques at each new round. She felt more relaxed when she realized that she did not need to look for many different games to demonstrate different techniques, but one would do the work. This new understanding opened her eyes to create more small opportunities to teach new skills.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I want to share about \u0026ldquo;restarting the same game\u0026rdquo;. My impression was that I could not play with my son, even I worked very hard. I was using the adults\u0026rsquo; perspectives to play with him. In fact, repeating the same game is good enough. Those times are important for them. I find that the pace does not need to so fast, being slow is good enough. Be repetitive and add new techniques. Those are the long struggling moments, but I find myself feeling more relaxed.\u0026rdquo; (C5, a mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e3.3 Parenting with empathy\u003c/b\u003e\u003c/p\u003e\u003cp\u003eLearning to align with the child\u0026rsquo;s pace and following the child\u0026rsquo;s play method helped the caregivers cultivate more empathy towards their children. They realized that young children were like adults who felt and thought in similar ways. To make sense of the child\u0026rsquo;s frustration, caregivers needed to think in their shoes.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Even he is young, he also has feelings. You cannot think for them and plan for them just because they are young. This is the misunderstanding of most parents.\u0026rdquo; (C1, a mother)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Indeed, putting myself into his perspective, many techniques are built upon empathy. It\u0026rsquo;s the same for adults. You have something, then I suddenly take it away from you. We wouldn\u0026rsquo;t appreciate it. We didn\u0026rsquo;t think that children would feel the same as adults. This skill is useful, empathy is important.\u0026rdquo; (C21, a father).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA mother shared that she had two children. The first one was of typical development, but the second had special educational needs. She applied the same parenting approach to the second child and was disappointed to find out he could not follow her instructions, she was frustrated. After she learnt about developmental delays and disabilities in this course, she was able to see from his son\u0026rsquo;s perspective and realized his helplessness. This changed her way of teaching her son.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Joining this course helped me to understand more about children with special educational needs, and I lower my expectations. I have two children. The first one is of typical development. In many occasions, I wanted to use the same parenting method which worked for the first one, and I was disappointed that he (the younger one) failed to do what was told. \u0026lsquo;Why can\u0026rsquo;t you do this? You brother can, why can\u0026rsquo;t you?\u0026rsquo; I was perplexed and frustrated. I wasn\u0026rsquo;t aware that I was rude to him and might scold him loudly. From the child\u0026rsquo;s perspective, he felt wronged. \u0026lsquo;What? I\u0026rsquo;m not getting it. This is it. Why is mom treating me like this?\u0026rsquo; After joining this course, I learnt that he was using his own ways to play, and this understanding has helped improve our relationships\u0026hellip; I can calm down; I can\u0026rsquo;t treat him like this\u0026hellip; Now the child has a lot of improvements. I\u0026rsquo;m happier, my child is also happier. Our parent-child relationship is so much better.\u0026rdquo; (C7, a mother)\u003c/p\u003e\u003c/div\u003e\u003cp\u003eSome caregivers also shared that now they would take time to reflect on their interactions with the children to see if their expressions might have hurt them.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Change? Just as this mom has shared, we would frequently reflect on our behaviors. Did I make a mistake? Was it not good enough? When I said those words, would I hurt him? The younger children might not show (their feelings).\u0026rdquo; (C2, an auntie)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis qualitative study aimed to explore the transformation processes of caregivers in the PIIs, and it focused especially on their breakthroughs. From the sharing of the caregiver-participants in the focus groups, we found three major changes: (1) Self-care for the wellbeing of self and the child, (2) home set-up for parent-child joint engagement and routine building, and (3) discernment of the window to intervene. As reflected by the respondents, these breakthroughs addressed their inner hurdles and helped create positive outcomes for the caregivers and their children.\u003c/p\u003e\u003cp\u003eThe caregivers participated in the PII with the hope to acquire some strategies to care for and promote the development of their children who were experiencing developmental delays and disabilities. Many of them were suspected or diagnosed with ASD. To their surprise, they found that the course was beyond their expectations. In this PII, they also learnt about self-care. Many caregivers reported that they were completely occupied by the needs of their children, and they were unaware of the exhaustion that they were experiencing. Unlike the original WHO-CST, this localized course emphasized more on self-care with trainers teaching and practicing meditation with the caregivers in the group sessions. The caregiver-respondents found this teaching very helpful. Through paying attention to and getting in touch with their own emotions and physical conditions, they became aware of their own stress, the depletion they were feeling, and their suppressed personal identity. This realization shed light on their own psychological needs, and they became aware of the necessity of taking good care of themselves. They discovered that through attending to their own needs, they were indeed cultivating strengths and capacities to care for their children.\u003c/p\u003e\u003cp\u003eWhen the caregivers attended to their own emotions, they also became more attuned to the emotional fluctuations in themselves and in their children. With this new lens, they recognized the influences of their own emotions on their children and learnt that both positive and negative emotions were contagious. The insights motivated caregivers to create more positive experiences for their children and prevent themselves from imminent emotional outbursts. Although they were not able to hold their frustration in place every time, they found that they had gradual improvement in their emotion management and they could seek help from other adults when their negative emotions were heightened. In practicing self-care, some caregivers also reclaimed their own personal identities and constructed a new positive self-image.\u003c/p\u003e\u003cp\u003eSelf-care was a breakthrough shared among the caregiver-respondents. With many PIIs aiming to teach children self-care skills, fewer were designed to teach caregivers the self-care the adults needed [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. There were qualitative studies calling the clinical professionals and academics to attend to the self-care needs of caregivers, this study responded by documenting how the learning and practicing of self-care transformed the lives of caregivers [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. With an emphasis on self-care, this study highlighted the need to consider the mental and physical health of caregivers in PIIs and to include self-care as an intervention component and an outcome indicator.\u003c/p\u003e\u003cp\u003eAnother breakthrough shared by the caregivers was changing the home setup. In the PII, the caregivers learnt that the seating arrangement at home would affect the parent-child interactions. When they were at the eye-level of their children, the young would have more opportunities to pay attention to the adults\u0026rsquo; facial expressions, and this promoted parent-child engagement thus the child\u0026rsquo;s learning. The caregivers also learnt to observe the comfort level of both parties to sustain the joint engagement. They reported that after rearranging their home setup, the children became more focused, engaged and enjoyed the parent-child time more. The respondents also noticed that setting a dedicated space for parent-child interactions served as an environmental cue to remind them of the playtime, and this helped build their play routine. This cue was so effective that when some children saw their caregivers approaching the small table for playtime, they would proactively come to join in. While environmental arrangement has been a common strategy taught in PIIs, few studies had explored its effects from caregivers\u0026rsquo; perspectives [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDiscernment of the window for intervention was a breakthrough mentioned and cherished most by the caregiver-respondents. In the course, the caregivers were taught to observe the behaviors, emotions, interests and preferences of their children, and responded to them with a child-centered approach. Echoing other studies, the feedback from trainers were found to be conducive for caregivers\u0026rsquo; learning [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. With the trainers providing feedback to the caregivers\u0026rsquo; videos of playtime with their children, the caregivers learnt to observe the effectiveness of their existing parenting approaches and gradually adjusted their pace to align with their children\u0026rsquo;s. They realized that the best teaching approach was not to inculcate ideas into their children\u0026rsquo;s mind for this might overwhelm them. Instead, they needed to identify their children\u0026rsquo;s current language and cognitive capabilities and teach in ways that matched their current levels. Given that the feedback from trainers on actual practice has been found useful across studies, we encourage PIIs to include home visitations so that the trainers could offer practical support in environmental setup and in parent-child interactions.\u003c/p\u003e\u003cp\u003eCaregivers also learnt to follow into the children\u0026rsquo;s world by observing and mirroring the children\u0026rsquo;s play methods. They needed not find myriads play methods to teach different skills, but they could add little elements into the same activity to expose children to new learning. The caregivers felt more relaxed when they knew when to intervene and when to take a break. Shared with other studies that examined the effectiveness of the skills of imitation and mirroring, this study reaffirmed the values of synchrony in promoting parent-child interactions [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThrough practicing this child-centered parenting approach, the caregivers found themselves having more empathy towards their children, and they developed more understanding about the children\u0026rsquo;s behaviors and emotions. When empathy was mentioned in the PII literature, it was usually in the context of the empathetic approach to engage caregivers or the cultivation of empathy in children [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. This study documented the growing of empathy in caregivers towards their children and how this affected the caregivers\u0026rsquo; parenting.\u003c/p\u003e\u003cp\u003eThis study offered unique values in shedding light on the critical transformation of caregivers in PII. However, it was not without limitations. Aside from the small sample size, we are aware that the sample we used was from an Asian community and the lived experiences were inevitably influenced by the local cultures. More qualitative research is to be conducted to explore the lived experiences in other settings.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study served to explore the transformation processes of caregivers in a PII. Through focusing on their breakthroughs, it revealed their inner struggles and documented the key changes experienced and cherished by the caregivers. By zooming into the lived experiences of caregivers, it underscored the needs of considering the conditions, wellbeing and experiences of caregivers in PIIs for these factors directly affected the effectiveness and sustainability of the interventions. This study also encouraged clinical professionals to include self-care techniques for caregivers as a core component in PIIs to strengthen their capacities and promote their wellbeing. Crucially, the skills in the localized WHO-CST course appear transferable to families with typically developing children, suggesting broader generalizability, wider utility, and greater potential impact of the program beyond its original target population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eASD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAutism Spectrum Disorder\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eJC A-Connect\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eJockey Club Autism Support Network program\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePII\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eParent-implemented intervention\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO-CST\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization Caregiver Skills Training\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e An ethics approval (reference number: EA240065) was obtained from the Human Research Ethics Committee of the University of Hong Kong. All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all research participants.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis work was funded by The Hong Kong Jockey club Charities Trust.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eCW spearheaded the research design and implementation, conceptualized the frameworks presented in this paper and wrote this paper. CC supported the data collection and analysis processes and contributed to improve the manuscript. PW provided directional support and clinical expertise to interpret and present the ideas. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThis research was only made possible with the financial support from The Hong Kong Jockey Club Charities Trust. The Trust cares about the wellbeing of children and families, and it specially reserves resources to support the families who are being challenged by autism spectrum disorder. With JC A-Connect, a program initiated by the Trust, these children and families were receiving support at home, in schools and in communities. Initiatives were also made to educate the public on social inclusiveness. This research was conducted to support the continuous development of early interventions in Hong Kong and in other parts of the world. We are also grateful for the support from the NGO partners, master trainers, facilitators, and caregivers who participated in this research.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data of this study are not publicly available due to the confidentiality agreement between the researchers and the participants but are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAPA. Diagnostic and statistical manual of mental disorders. 5th ed. Washington DC: American Psychiatric Association; 2013.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThapar AP, Cooper MM, Rutter MP. Neurodevelopmental disorders. Lancet Psychiatry. 2017;4(4):339\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFranc\u0026eacute;s L, Quintero J, Fern\u0026aacute;ndez A, Ruiz A, Caules J, Fillon G, et al. Current state of knowledge on the prevalence of neurodevelopmental disorders in childhood according to the DSM-5: a systematic review in accordance with the PRISMA criteria. Child Adolesc Psychiatry Ment Health. 2022;16(1):27\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13034-022-00462-1\u003c/span\u003e\u003cspan address=\"10.1186/s13034-022-00462-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCainelli E, Bisiacchi P. Neurodevelopmental disorders: past, present, and future. Child (Basel). 2022;10(1):31. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/children10010031\u003c/span\u003e\u003cspan address=\"10.3390/children10010031\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLieberman-Betz RG. A systematic review of fidelity of implementation in parent-mediated early communication intervention. Top Early Child Spec Educ. 2015;35(1):15\u0026ndash;27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0271121414557282\u003c/span\u003e\u003cspan address=\"10.1177/0271121414557282\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSone BJ, Lee J, Grauzer J, Kaat A, Roberts MY. Identifying effective strategies to instruct parents during parent-implemented intervention: the role of parent practice with feedback. Early Child Res. 2023;62:394\u0026ndash;404. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ecresq.2022.09.010\u003c/span\u003e\u003cspan address=\"10.1016/j.ecresq.2022.09.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeadan H, Ostrosky MM, Zaghlawan HY, Yu S. Promoting the social and communicative behavior of young children with autism spectrum disorders: a review of parent-implemented intervention studies. Top Early Child Spec Educ. 2009;29:90\u0026ndash;104. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0271121409337950\u003c/span\u003e\u003cspan address=\"10.1177/0271121409337950\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGerow S, Hagan-Burke S, Rispoli M, Gregori E, Mason R, Ninci J. A systematic review of parent-implemented functional communication training for children with ASD. Behav Modif. 2018;42:335\u0026ndash;63. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0145445517740872\u003c/span\u003e\u003cspan address=\"10.1177/0145445517740872\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCheng WM, Smith TB, Butler M, Taylor TM, Clayton D. Effects of parent-implemented interventions on outcomes of children with autism: a meta-analysis. J Autism Dev Disord. 2023;53(11):4147\u0026ndash;63. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10803-022-05688-8\u003c/span\u003e\u003cspan address=\"10.1007/s10803-022-05688-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTan-MacNeill KM, Smith IM, Johnson SA, Chorney J, Corkum P. A systematic review of online parent-implemented interventions for children with neurodevelopmental disorders. Children's Health Care. 2021;50(3):239\u0026ndash;77. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/02739615.2021.1886934\u003c/span\u003e\u003cspan address=\"10.1080/02739615.2021.1886934\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKoly KN, Martin-Herz SP, Islam MS, Sharmin N, Blencowe H, Naheed A. Parent mediated intervention programmes for children and adolescents with neurodevelopmental disorders in South Asia: A systematic review. PLoS ONE. 2021;16(3):e0247432.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJhuo R-A, Chu S-Y. A review of parent-implemented early start denver model for children with autism spectrum disorder. Child (Basel). 2022;9(2):285. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0247432\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0247432\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSymon JB. Expanding interventions for children with autism: Parents as trainers. J Posit Behav Interv. 2005;7(3):159\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWong CHM, Chan CKY, Wong PWC. Family outcomes of a parent-implemented early intervention for neurodevelopmental disorders: an exploratory study of family dynamics. Front Public Health. 2025;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpubh.2025.1614089\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2025.1614089\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCioni G, Inguaggiato E, Sgandurra G. Early intervention in neurodevelopmental disorders: underlying neural mechanisms. Dev Med Child Neurol. 2016;58(S4):61\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/dmcn.13050\u003c/span\u003e\u003cspan address=\"10.1111/dmcn.13050\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFrosch CA, Schoppe-Sullivan SJ, O\u0026rsquo;Banion DD. Parenting and child development: a relational health perspective. Am J Lifestyle Med. 2021;15(1):45\u0026ndash;59. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1559827619849028\u003c/span\u003e\u003cspan address=\"10.1177/1559827619849028\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLeadbitter K, Macdonald W, Taylor C, Buckle KL. Parent perceptions of participation in a parent-mediated communication-focussed intervention with their young child with autism spectrum disorder. Autism. 2020;24(8):2129\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1362361320936394\u003c/span\u003e\u003cspan address=\"10.1177/1362361320936394\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIm-Bolter N, de la Roche L. What parents want: A qualitative analysis of a parent-implemented intervention for autistic children. Autism Dev Lang Impairments. 2023;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/23969415231189606\u003c/span\u003e\u003cspan address=\"10.1177/23969415231189606\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJurek L, Leadbitter K, Falissard B, Colin C, Touzet S, Geoffray MM. Parental experience of parent-mediated intervention for children with ASD: A systematic review and qualitative evidence synthesis. Autism. 2023;27(3):647\u0026ndash;66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/13623613221112204\u003c/span\u003e\u003cspan address=\"10.1177/13623613221112204\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFurlong M, McGilloway S. Barriers and facilitators to implementing evidence-based parenting programs in disadvantaged settings: a qualitative study. J Child Fam Stud. 2015;24(6):1809\u0026ndash;18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10826-014-9984-6\u003c/span\u003e\u003cspan address=\"10.1007/s10826-014-9984-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCarruthers S, Mleczko N, Page S, Ahuja S, Ellis C, Howlin P, Leadbitter K, Taylor L, Slonims V, Charman T. Using implementation science frameworks to explore barriers and facilitators for parents\u0026rsquo; use of therapeutic strategies following a parent-mediated autism intervention. Autism. 2023;27(4):1011\u0026ndash;25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/13623613221125630\u003c/span\u003e\u003cspan address=\"10.1177/13623613221125630\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLord C, Rapley T, Marcroft C, Pearse J, Basu A. Determinants of parent-delivered therapy interventions in children with cerebral palsy: A qualitative synthesis and checklist. Child: Care Health Dev. 2018;44(5):659\u0026ndash;69. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/cch.12592\u003c/span\u003e\u003cspan address=\"10.1111/cch.12592\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHoltrop K, Parra-Cardona JR, Forgatch MS. Examining the process of change in an evidence-based parent training intervention: a qualitative study grounded in the experiences of participants. Prev Sci. 2014;15(5):745\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11121-013-0401-y\u003c/span\u003e\u003cspan address=\"10.1007/s11121-013-0401-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMejia A, Ulph F, Calam R. Exploration of mechanisms behind changes after participation in a parenting intervention: a qualitative study in a low-resource setting. Am J Community Psychol. 2016;57(1\u0026ndash;2):181\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ajcp.12020\u003c/span\u003e\u003cspan address=\"10.1002/ajcp.12020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFrost KM, Ingersoll B. Theory of change of caregiver coaching for an early parent-mediated autism intervention. J Autism Dev Disord. 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10803-025-06767-2\u003c/span\u003e\u003cspan address=\"10.1007/s10803-025-06767-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChan CKY, Wong CHM, Wong PWC. Caregiver transformation and relational growth in a parent-mediated intervention for autism in Hong Kong \u0026ndash; A qualitative study. PloS Mental Health. (manscript accepted).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Training for caregivers of children with developmental disabilities, including autism. Available online at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/teams/mental-health-and-substance-use/treatment-care/who-caregivers-skills-training-for-families-of-children-with-developmental-delays-and-disorders\u003c/span\u003e\u003cspan address=\"https://www.who.int/teams/mental-health-and-substance-use/treatment-care/who-caregivers-skills-training-for-families-of-children-with-developmental-delays-and-disorders\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [Accessed September 11, 2025].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalomone E, Pacione L, Shire S, Brown FL, Reichow B, Servili C. Development of the WHO caregiver skills training program for developmental disorders or delays. Front Psychiatry. 2019;10:9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpsyt.2019.00769\u003c/span\u003e\u003cspan address=\"10.3389/fpsyt.2019.00769\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWong PWC, Lam YY, Lau JSP, Fok HK, Servili C, Salomone E, et al. Adapting and pretesting the World Health Organization's Caregiver Skills Training Program for children with autism and developmental disorders or delays in Hong Kong. Sci Rep. 2022;12:1. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/s41598-022-21343-9\u003c/span\u003e\u003cspan address=\"10.1038/s41598-022-21343-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSpencer R, Pryce JM, Walsh J. Philosophical approaches to qualitative research. In: Leavy P, editor. the Oxford Handbook of Qualitative Research. New York: Oxford University Press; 2014. pp. 81\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTerry G, Hayfield N, Clarke V, Braun V. Thematic analysis. SAGE Handb Qual Res Psychol. 2017:17\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Conceptual and Design Thinking for Thematic Analysis. Qual Psychol. 2022;9(1):3\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/qup0000196\u003c/span\u003e\u003cspan address=\"10.1037/qup0000196\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBranjerdporn N, Benfer K, Crawford E, Ziviani J, Boyd RN, Sakzewski L. Efficacy of early interventions with active parent implementation in low-and-Middle income countries for young children with cerebral palsy to improve child development and parent mental health outcomes: a systematic review. Disabil Rehabil. 2022;44(23):6969\u0026ndash;83. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/09638288.2021.1989063\u003c/span\u003e\u003cspan address=\"10.1080/09638288.2021.1989063\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlias NA, Kadar M, Wan Yunus F, Cremin K. A scoping review of intervention implementation for self-care skills among children with developmental delay. Malaysian J Med Sci. 2024;31(4):78\u0026ndash;90. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.21315/mjms2024.31.4.6\u003c/span\u003e\u003cspan address=\"10.21315/mjms2024.31.4.6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeadan H, Stoner JB, Angell ME, Daczewitz ME, Cheema J, Rugutt JK. Do you see a difference? Evaluating outcomes of a parent-implemented intervention. J Dev Phys Disabil. 2014;26(4):415\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAkamoglu Y, Meadan H. Parent-implemented language and communication interventions for children with developmental delays and disabilities: a scoping review. Rev J Autism Dev Disord. 2018;5(3):294\u0026ndash;309.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcCabe KM, Sakamoto M, Rosas YG, Kehoe K, La R, Zerr A, et al. Keeping an I on PRIDE: Measuring imitation in parent-child interaction therapy. Behav ther. 2021;52(1):28\u0026ndash;38. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.beth.2020.01.009\u003c/span\u003e\u003cspan address=\"10.1016/j.beth.2020.01.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLecl\u0026egrave;re C, Viaux S, Avril M, Achard C, Chetouani M, Missonnier S, et al. Why synchrony matters during mother-child interactions: a systematic review. PLoS ONE. 2014;9(12):e113571. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0113571\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0113571\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSawyer BE, Hammer CS, Santoro JK, Smith JC, Feil EG. Developing Parents Plus: A Parent-Implemented Intervention for Young Children With Developmental Language Disorders. Infants Young Child. 2022;35(3):205\u0026ndash;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/IYC.0000000000000219\u003c/span\u003e\u003cspan address=\"10.1097/IYC.0000000000000219\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLeafe N, Pagnamenta E, Donnelly M, Taggart L, Titterington J. To know that you are a link in the chain\u0026rsquo;: a realist evaluation to explore how digital, intensive, parent-implemented interventions work for children with speech sound disorder, why, and for whom. Int J lang commun disord. 2025;60(3):e70049. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/1460-6984.70049\u003c/span\u003e\u003cspan address=\"10.1111/1460-6984.70049\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e-n/a\u003c/span\u003e\u003cspan address=\"http://-n/a\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"parent-implemented early intervention, neurodevelopmental disorder, autism spectrum disorder, caregivers training, effectiveness evaluation, breakthroughs, autistic children, developmental delay and disability, wellbeing, empowerment","lastPublishedDoi":"10.21203/rs.3.rs-7938870/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7938870/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eParent-implemented intervention (PII) trains caregivers to be the interventionists to offer tailored learning opportunities at home and is used to promote the positive development of children with neurodevelopmental disabilities. Its effectiveness hinges not only on learning and implementing the strategies, but also on the beliefs, wellbeing and capacities of the caregivers. The existing literature focused on the acquisition and application of skills, little is known about the inner experiences and transformation of caregivers. This study explored the changing processes of caregivers and focused especially on their breakthroughs.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eTwenty-two caregivers participated in five semi-structured focus groups in Hong Kong. They had all completed the localized version of the World Health Organization Caregiver Skills Training. Reflexive thematic analysis was adopted to analyze the qualitative data and construct codes and themes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThere were three major breakthroughs which caregivers experienced leading to positive outcomes for themselves and for their children. The first one was the acquisition of self-care practices that helped caregivers recognize their own physical and emotional exhaustion and cultivate capacities for childcare. The second was on environmental settings, in which the caregivers learnt to adjust the home setup to promote parent-child engagement and the building of play routines. The third was on developing the discernment of the window to intervene. Caregivers learnt to adjust their pace to align with their children\u0026rsquo;s, follow into the children\u0026rsquo;s world and cultivate empathy towards the young. Being able to discern when and how to create teaching opportunities allowed caregivers to be more relaxed, and children enjoyed interacting with their caregivers more.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThis study unveiled the transformation processes of caregivers in a PII and identified the key factors promoting positive outcomes in them and in their children. Through focusing on breakthroughs, it also sheds light on the inner struggles and rewards the parents experienced as the primary caregivers and interventionists. It invites clinical professionals to consider the wellbeing of caregivers as one of the key social determinants of the success of PIIs, and explore how self-care, environmental setup, and discernment to intervene shape immediate and long-term outcomes.\u003c/p\u003e","manuscriptTitle":"The breakthroughs of caregivers in parent-implemented interventions for children with neurodevelopmental disorders: an exploratory qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-13 08:20:08","doi":"10.21203/rs.3.rs-7938870/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ce26ed75-c821-4d37-a903-019524ea4dd9","owner":[],"postedDate":"November 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T13:09:05+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-13 08:20:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7938870","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7938870","identity":"rs-7938870","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}