How can we better engage culturally and linguistically diverse parents of autistic children in online parent-led therapy? An Interpretative Phenomenological Analysis

How can we better engage culturally and linguistically diverse parents of autistic children in online parent-led therapy? 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An Interpretative Phenomenological Analysis Sarah Oudet, Katie Howard, Napoleon Katsos, Stephanie Durrleman This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7757342/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 Purpose : This study aims to understand the lived experiences of culturally and linguistically diverse (CaLD) parents of autistic children who participated in a longitudinal self-directed (without clinical coaching) parent-led therapy (PLT) program targeting social-communication skills, or who were unable to complete participation in the longitudinal study coached group sessions. This work explores how each participant’s specific context impacted their engagement with online PLT. Methodology : Five mothers from a range of CaLD backgrounds participated in this study from different countries. Semi-structured online interviews were conducted. Interpretative Phenomenological Analysis (IPA) was used to analyse data, focusing on understanding each participant’s lived experience. Findings : Two superordinate themes were developed; 1) Cultural differences amplify barriers to online PLT; 2) Linguistic adaptations of therapeutic strategies need to be contextualised for each CaLD environment. Originality : PLT is emerging as a useful support approach for parents of autistic children in bilingual environments. This study explores perspectives of CaLD parents who struggled to complete group PLT programs to better understand the specific barriers and facilitators to their engagement with online PLT. Research imitations/implications : Participants had high English proficiency and academic backgrounds, which may not represent the CaLD population struggling most with PLT engagement. Further investigation amongst non-WEIRD (Western, Educated, Industrialised, Rich, Democratic) populations is warranted. Practical implications : Specific considerations for socio-cultural adaptations to monolingually-designed PLT programs are needed beyond linguistic translations. Social implications : CaLD minorities without heritage links to their country of residence face amplified challenges in supporting their autistic children. Such families need more contextualised support to enhance PLT engagement. Special Education Autism early years young children parent-led therapy parent coaching bilingual bicultural culturally and linguistically diverse telehealth telepractice barriers to specific support interpretative phenomenological analysis Figures Figure 1 Figure 1 Introduction Autism 1 is a developmental condition characterised by difficulties in social interactions and restricted and repetitive behaviours (APA, 2013 ). Current estimates place the proportion of bilingual 2 individuals at more than half of the world population (Grosjean, 2024 ), and global prevalence of diagnosed children on the autism spectrum at 1/100 (Zeidan et al., 2022 ). Emerging consensus indicates that bilingualism does not impede, and indeed, can boost various areas of development of young autistic children (Reetzke et al., 2015 ; Uljarević et al., 2016 ; Lund, Kohlmeier and Durán, 2017 ; Dai et al., 2018 ; Vanegas, 2019 ; Zhou et al., 2019 ; Peristeri et al., 2021 ; Montgomery et al., 2022 ; Hastedt et al., 2023 ; Wolfer et al., 2025 ). Bilingual exposure also improves the development of multicultural identities and preservation of heritage (Jegatheesan, 2011 ; Yu, 2013 ), and enriches family and social relationships (Kay-Raining Bird, Genesee and Verhoeven, 2016 ; Howard, Gibson and Katsos, 2020 ; Davis and Crompton, 2021 ). However, parents still report hesitancy, concerns, and conflicting advice on whether to maintain bilingualism for their autistic children (Yu, 2016 ; Hampton et al., 2017 ; Oudet, Howard and Durrleman, 2022 ). Similarly, practitioners continue to convey unease regarding the feasibility of bilingualism for some autistic children and express uncertainties about providing advice to parents, despite a desire to move towards more inclusive and culturally diverse practice (Davis, Zaki and Sargent, 2024 ). While there is a considerable body of literature focusing on the impact of PLT on developing social-communication skills in monolingual populations, the same cannot be said for bilingual families (Davis et al., 2021 ; Oudet et al., 2024 ). Parent-child interactions are critically important for autistic children, for whom social-communication is more difficult and limited, particularly during the early years, when children are likely to spend more time in their homes and neighbourhoods than other settings (Zwaigenbaum, Brian and Ip, 2019 ; Hyman et al., 2020 ). A growing body of research indicates a promising evidence base for the use of parent-led therapy (PLT) 3 to improve social-communication development of autistic children (Oono, Honey and Mcconachie, 2013 ; Nevill, Lecavalier and Stratis, 2018 ; Glenn et al., 2022 ). By learning and using therapeutic strategies and techniques over long time-periods through PLT, parents may enhance learning success by providing a large “dose” of support, such as, more learning opportunities across varied settings and specific support in naturally occurring teachable moments, leading to stronger durability and generalisation of acquired skills (Carruthers et al., 2023 ; Derosier et al., 2011; Reichow & Volkmar, 2010; Te Kaat-van den Os et al., 2017; Zlomke & Jeter, 2019 ). However, recent evidence suggests that some parents may lack confidence in their ability to implement PLT strategies and may feel that direct sessions relieve pressure of having to deliver support themselves (Estes, Swain and MacDuffie, 2019 ; Oudet, Howard and Durrleman, 2022 ; Bent et al., 2023 ). Additionally, parents of autistic children are more likely to experience higher levels of stress than parents of non-autistic children, and report higher levels of adaptive coping strategies, including emotional support (McStay et al., 2014 ; Costa, Steffgen and Ferring, 2017 ; Padden and James, 2017 ). The efficacy of PLT beyond English-speaking environments has begun to attract more study (Sokmum, Joginder Singh and Vandort, 2017; Lok, Qi and To, 2021 ; Senent-Capuz, Baixauli-Fortea and Moret-Tatay, 2021 ; Khamis et al., 2023 ; Dubay et al., 2024 ). However, the evidence remains rooted in the monolingual context, and culturally and linguistically diverse (CaLD) families with varied socio-economic backgrounds continue to be under-represented. It will be important to base careful investigation on a nuanced model moving away from the traditional ladder of power, using a variety of involvement methods that flexibly cater to a highly heterogenous and diverse population (Tritter and McCallum, 2006 ). Early findings indicate that telehealth 4 services are acceptable to parents of autistic children and online teaching methods can enable their learning and skill acquisition (Sutherland, Trembath and Roberts, 2018 ; Blackman, Jimenez-Gomez and Shvarts, 2020 ; Glenn et al., 2022 ; Li, Wu, et al. , 2022; Qu et al., 2022 ). PLT delivered via telehealth is particularly relevant for addressing some of the barriers to accessing support, which include long waitlists, proficiency of community language, availability of bilingual clinicians, time required to attend appointments, and cost (Byford et al., 2015 ; Tilmont Pittala et al., 2018 ; Li, Xu, et al. , 2022). However, telehealth requires access to stable internet connections and connected devices, raising a resource barrier that is likely to disproportionately impact families in low- to middle-income environments. Context of the current study This study is part of a project that aims to explore the ways in which CaLD parents engage in PLT to support the development of their young autistic children’s social-communication skills. The conditions examined are displayed in Table 1. The coached groups received synchronous clinical coaching with the More Than Words program (The Hanen Centre, 2016 ). The self-directed groups received weekly materials via emails, with which they engaged asynchronously and individually. The groups that received language adaptations (LA) received PLT content in English and another language of their choice (French, Spanish), as well as guidance on implementing strategies bilingually. French and Spanish MTW official handout translations are provided by the Hanen Centre for their coached programs (The Hanen Centre, 2016 ). Groups that did not have LA received standard English content. All participants were offered a copy of the More Than Words parent guidebook (The Hanen Centre, 2016 ). The data analysis plan for this project is registered with Open Science Framework (OSF, https://doi.org/10.17605/OSF.IO/8QNGX ). In this project, an environment was considered bilingual if the home language (L1) was different to the societal language (L2), and/or if there was more than one dominant language spoken in the household. Thirty-eight parents initially provided written informed consent for the project. Twenty-three participants completed at least one measure pre- and post-test. Eighteen of those were retained in the coached groups (originally 25), and five participants were retained in the self-directed groups (originally 13). Of the 15 participants who withdrew participation, five identified “home” cultures in high-income countries (France, Germany, Switzerland, United Kingdom) and 10 identified “home” cultures in low-/middle-income countries (Congo, India, Morocco). Given the level of attrition experienced over the course of this data collection, particularly within the self-directed groups and those born in non-WEIRD (Western, Educated, Industrialised, Rich, Democratic) countries, questions about how parents were able or unable to complete the PLT programs are warranted. A phenomenological approach was considered most suitable to fully understand nuances affecting families who engaged with self-directed PLT or who were unable to complete their allocated PLT. Aim and research questions This study explores the factors that influenced participation of parents from CaLD backgrounds in a PLT program delivered online to support social-communication skills in autistic children. It aims to understand the unique context of individual families and how these shaped their engagement with the service. The main research question was: What are the specific barriers and facilitators to participating in online PLT among CaLD families with autistic children? Methods Design Interpretative Phenomenological Analysis (IPA) is concerned with understanding lived experiences of a unique phenomenon. This study aims to understand what hinders and helps CaLD parents of autistic children complete online PLT. Smith et al. ( 2022 ) provided a methodological framework for this study, which is well-suited to small highly heterogenous sample groups and increasingly applied in autism research (Howard, Katsos and Gibson, 2019 ; Oudet, Howard and Durrleman, 2022 ). This study draws on data collected from four semi-structured synchronous interviews, and one email interview. Participants Participants were recruited through Swiss-based clinical and family support organisations who distributed recruitment information via their online platforms (mailing lists, websites, social media groups). Inclusion criteria were a) parents/key caregiver of an autistic child; b) child in question is seven years or younger; c) child lives in a bilingual environment; d) ability to participate independently in written and verbal activities with the researcher in English or French; e) access to stable internet connection. Geographic location was neither an inclusion nor exclusion criterion. Following individual information meetings held via Teams, interested parents were invited to download a copy of the written information form and provide written consent via REDCap (Harris et al., 2019 ). An adapted version of the Questionnaire for Parents of Bilingual Children (PABIQ) (COST Action IS0804, 2011 ) was completed independently by participants to collect demographic and background information. Participants were then allocated to one of the four group conditions. The participants included in this analysis are a subset (n = 5) of the total number of participants (n = 38) who provided informed written consent and 1) were part of a self-directed group, or 2) did not complete their allocated PLT. Participants in this IPA study were mothers living in France, India, Germany, and USA. All participants were married to men and held tertiary education degrees. Four households had one child and one household had two children. The autistic children in discussion were sons aged between 2;0 years and 5;0 years. Exchanges between participant and researcher were conducted in English. Three participants lived outside their self-identified home country. A summary of participant information is displayed in Table 2. Procedure Ethical approval for this project was provided by the Canton Research Ethics Committee (Commission cantonale (VD) d’éthique de la recherche sur l’être humain) (CER-VD): Project ID 2023 − 00562. Individual semi-structured interviews were conducted by the first author via Microsoft Teams with four participants. Remote modes of interview have been shown to have no significant impact on quality of data collected with adult participants when compared with in-person interviews (Sturges and Hanrahan, 2004 ; Novick, 2008 ). One participant provided responses via email as she was unable to complete a synchronous interview. Email interviews have been shown to be an effective online tool for phenomenological research (Jones, Bowden and Galindo-Gonzalez, 2015 ). Synchronous interviews were audio recorded and transcribed verbatim in Microsoft Word based on Conversation Analysis conventions (Wilkinson, 1999 ). The email interview was transferred to the same transcription template. Information and themes extracted from each interview were reviewed with each participant to verify that what had been interpreted from their statements was what they had intended to express. To increase reliability and validity, this study engaged with five trustworthiness criteria (credibility, transferability, dependability, confirmability, audit trails (Nowell et al., 2017 ) and subscribes to the principles of high-quality IPA (Smith, Flowers and Larkin, 2022 ). Data analysis Interview data were analysed following guidelines of IPA methodology (Smith, Flowers and Larkin, 2022 ). Transcripts were initially analysed in Word and then transferred to NVivo15 (Lumivero, 2024 ). Initial analysis involved inductive coding. Emergent themes were identified in each account as an individual case-study-style analysis. Super-ordinate themes were then developed deductively for each account to progress from the general ideas expressed by participants to emergent themes extracted across accounts, to precise super-ordinate themes ultimately generated. Themes were developed by the first author and reviewed and further refined with the second author to increase confirmability and validity of findings. In the case of coding disagreement, relevant interview data were analysed in their original form and discussed until consensus was reached Three review meetings were held. Final superordinate themes were reviewed with all named authors to confirm interpretation and ensure agreement. Positionality of the researchers The first author is a doctoral researcher from a clinical perspective (speech-language therapy) with a CaLD background and environment. The second author is an experienced qualitative researcher in the field of autism and bilingualism from an education perspective. The third and fourth authors are experienced researchers in the field of autism and bilingualism from linguistic perspectives, and are of CaLD backgrounds and environments. Each researcher actively bracketed their specific areas of expertise and experiences that may have impacted their approach to the data. Results Two final super-ordinate themes and their respective subthemes were generated from the data. These are displayed in Fig. 1. Theme A: Cultural differences amplify barriers to online PLT. A1. Navigating foreign social communication codes is hard . All parents expressed that time was a dominant factor in their ability to participate in PLT regardless of the service delivery mode. Other factors that influenced their engagement with their allocated program included prioritising clinician-led (direct) therapy sessions, distance from clinical centres and effort required to travel, and financial cost. However, the three parents who lived in foreign cultures shared that their resources felt even more limited than when they were supporting their children in their home environments because integrating into their new environments was harder than expected. One mother reported that she was uncomfortable in her allocated group because: “ … too big group became awkward and the group had diversity. If the group had same region people it would have been easier .” While the participant does not specify what she meant by “diversity,” this may reflect a preference for groups with more shared regional or cultural backgrounds, in addition to a shared common language. While her group of seven parents was significantly smaller than the recommended 12–16 members, it is notable that this parent was connecting with her mobile phone, which may have added to her participation difficulties. One parent spoke about moving internationally: “ I did not anticipate that settling in was going to be so difficult. Like right now, seven months down the line, I am going to view a house. Like literally, we don’t even have like, a house yet, like… I also did underestimate… my son being settling into school, has been a nightmare… I just wasn’t, I think, prepared, mentally. ” Views converged on the reflection that despite preparing as best they could for an international transition, the difficulties they encountered were unexpectedly greater than what they had been living with, which left them even less time, space, or energy to engage with PLT. The cost of care was also reported as a concern for parents transitioning between countries, as their families were not yet part of public administration systems. One parent reported, “ … the idea is to get into the care. The government care system. Because, what I am doing right now, I am using the private sector, to get those needs met. And it’s very steep. Very costly… It’s super costly .” The need to access support in the private sector can be useful for families moving between countries to ensure continuity of care for their autistic children, but presents an additional cost that may not be necessary in their home countries. Parents shared corresponding notions of additional difficulty when supporting their autistic children in spaces that were culturally unfamiliar to them. One parent remarked, “ I would say that it’s, easier [in your own country]… the challenges are different, right? Because you’re in your culture. You have that off your plate. Even if it’s difficult situation you’re in, even if what you have to fix is a bigger problem… you have that reassurance that you’re in your culture and you can do things that you already know, that you’re already familiar with .” Notions of “reassurance” from the “familiar” suggest that living in the foreign CaLD context adds intangible burden for parents trying to implement PLT. Another parent spoke about the culture shock she experienced that made supporting her autistic child more difficult in the new foreign environment: “ I come from a place where we have community… you know, kids are brought up in a community by the community. And I realise very quickly that here it’s just about the hours… the billable hours. For me that was a big shock… because in the world that we worked in, especially for my son’s support, it was quite easy… I’m so tired of this, come on .” This participant clearly expresses frustration with the cultural “shock” of more individualistic and transactional models of support. While not an explicitly identified as a reason she was not able to complete her assigned PLT program, it may be that the added challenge of navigating such unexpected cultural differences left even fewer social-emotional resources with which to engage in PLT. Overall, the process and practical realities of acculturation may increase strain that parents feel when supporting their autistic children, thus adding to the intangible and concrete challenges they face when trying to engage with and implement PLT regardless of service delivery mode and common languages shared. A2. Maintaining courage to implement PLT is harder. All parents reported feeling alone in supporting their autistic children. Tensions were reported about being far from heritage families and friends. There was strong agreement among the three parents who lived in unfamiliar cultures that more resilience was needed to engage with PLT when abroad: “ … the determination to go through it… I would say that, uh, in in a different culture, it’s a lonelier road, but it’s not an impossible one.” Another parent shared, “I think it’s just to be intentional. To be honest. About it. I was initially being intentional and being very open-minded, going into it .” One parent, who completed a self-directed program living outside her familiar home culture, indicated that she did not feel confident in her understanding and implementation of strategies: “ I[t] will help in the, initial meeting, the reassurance that, you’re gonna feel that you’re failing. You’re gonna feel that you’re doing it all wrong… That would be helpful because then you will, recall to that moment, ah yes, she told me this will happen and it’s okay. It’s part of the process .” This is a clear expression of uncertainty and a lack of confidence during her program related to the aloneness she felt without clinical coaching in the unfamiliar culture. A parent, who had been allocated to a coached group, shared that she needed both direct and indirect (PLT) sessions to feel empowered in her unfamiliar cultural context: “ …at the end of the day when the child is with a specialist, it’s for a certain number of billable hours… so I mean, as a parent I felt a need to also be empowered, as well. Once I’m able to do that, to do the family, at home, once I will be able to do that with the carer at home, and also for the whole family, of course they must be taught as well .” This desire for empowerment was reasserted: “ … it means that, okay, I’m doing the training not just for myself, but also how to talk to the carer, I am more empowered and I can challenge some of their approaches that, that they apply .” These expressions of empowerment can be associated with the notion of reassurance that parents need to feel more substantially when raising autistic children and interacting with practitioners and caregivers in culturally unfamiliar spaces. The three mothers who lived far from their homes of origin shared tensions of how they felt about this distance. One parent shared, “ I came with one family member. I don’t think if there were many it would have helped because the more is never the merrier in this thing .” Another parent agreed with this notion, disclosing that, “ The family will be hard, because they will be sometimes too… pushy or too… they can be very opinionated at times. So it will be hard to have that… They’re always, all try to help by putting their own opinions. And sometimes it’s not what you need .” Such remarks suggest that these parents have found a silver lining in being far, namely, distance from the weight of their relatives’ good intentions, allowing them to be connected enough to feel loved, and far enough to not be overwhelmed as they navigate the challenges of supporting their autistic children in an unfamiliar environment. Overall, parents found it harder to maintain their social-emotional well-being when living abroad, expressing more need for determination and empowerment than when they were in their home cultures. Theme B: Linguistic adaptations need to be contextualised for each CaLD environment. B1. Translated materials alone are not enough. Four parents, who demonstrated adequate English proficiency to engage with the interviewing researcher without the need for an interpreter, three of whom lived abroad, reported that the translations they received during the intervention were not helpful. One parent reported: “ I don’t think the translated materials are useful. To be honest. I mean, because it’s a lot. You just need someone, hold your hand… Who understands that it’s a nightmare, trying to navigate this system .” This indicates that providing translated materials alone may add more burden than benefit, if provided without individual follow-up. Similarly, another parent reported that the translations she received in her dominant language did not add value: “… it made no difference… having it in the English and Spanish, sometimes, was just part of the same, a little, just part of the same .” This parent also reported that her son did not like when adults translated information for him: “ … they [school teachers] try to translate one thing, I don’t know… it just doesn’t go, he just hates it .” This aligns with the views that linguistic translations can sometimes be more hindrance than help. However, linguistic translation was essential for one parent, living in her home community, who reported a higher level of English proficiency than she was able to demonstrate: “ I don’t uh… understand everything. Uh… yeah… I think… yeah… Hindi yeah… English also but uh, mm simple language this time. Okay? ” This reveals the necessity of translations for those who lack proficiency in the language of service delivery, which is a clear barrier for parents accessing online PLT from a practitioner with whom they do not share a strong common language. Overall, the parents living abroad from their home cultures reported that the non-English linguistic adaptation of PLT materials did not meet their prioritised needs. B2. Language attitudes and perceived prestige should inform adaptations needed . All parents reported valuing English as a priority language for their children to be exposed to regardless of their heritage and country of residence. The parents who remained in their home communities indicated lower priority for their “mother” languages. One parent reported speaking the nationally and globally dominant languages to her child, rather than her regional language, which was spoken in her community: “ … we talk to him in uh, Hindi. Hindi, okay? A little bit English also. He talk to, English, uh English. And little bit Teluga also. Okay? First, first, Hindi. Second, English. And third is Teluga. Because Teluga… from friend or woman, actually, from neighbours .” This indicates the value this parent places on the respective languages in her son’s CaLD environment, possibly based on the perceived lack of status that her regional language has. Notably, this parent seems to highly value English, preferring to speak it to her son despite her level of proficiency. One parent remarked that regardless of her cultural and linguistic environment, she would like her son to remain in a bilingual or English education structure: “ I would not put him into single language, because I think it helps to broaden… it’s helping their brain to grow… parents are going to be talking in Hindi. He knows the language. And in school he’s being spoken to in English... I think this is helping him. We cannot see it, it right now, but I know that is helping him .” While this belief in bilingualism was based in ideas of cognitive benefit, there was also a sense of English specifically considered as valuable in the future. Another parent described four languages in her son’s environment, and that she prioritised English above her heritage national and regional languages, as well as her current community language: ‘ I tend to stick with English and Swahili. And sometimes my mother tongue… the people surrounding my child are mostly speaking English and then… Yeah, so I stick with one .’ For this parent, who lived abroad from her home culture and accessed online specific support for her son with practitioners in different countries, English was the most important language for her to foster with her son because of its value as a globally accessible language. Overall, parents revealed the high value placed on English language environments and in some cases, low value on exposure of their L1s for their autistic children, regardless of their CaLD heritage and own English-language proficiency. B3. Cultural adaptation supports implementation of strategies. Parents aligned in their report of cultural differences being more challenging than linguistic differences in their foreign CaLD environments. A greater need to affirm the parent’s home culture was expressed. The difference in parenting styles across cultures can be enormously varied, and one mother shared her experience of navigating these differences in her new community: “ I mean… just manoeuvring the situation. What to do and what not to do at the park and the parties .” While social norms and diversities are specific to each CaLD families’ foreign environment, this parent did not complete her allocated PLT program and it remains unknown how understood, implemented, and, ultimately, effective the strategies may have been in her setting. However, it is likely that implementing PLT strategies to support her autistic child’s social-communication skills in an unfamiliar socio-cultural context would have been challenging. One parent spoke of the difficulties supporting her child in an unfamiliar cultural environment: “ We all have games that translate to all of us. But… it’s not the same if I teach him to play here at home with his father and I. Then he goes out there, he tries to play the same things with the kids, they would, they just won’t understand. They won’t. Then they see like it’s a little bit weird, what are you trying to do? ” This exemplifies this parent’s struggle to support her autistic son’s pragmatic skills, because she needed culturally adapted aid to meet the social-communication needs in her foreign CaLD context. One parent suggested that LA she received include more contextualised examples of how strategies can be culturally nuanced: “ Not everybody is going to… want to go through, or have the time to go through, how do I do this in this cultural setting. Or maybe some don’t even understand that it’s different. The cultural setting, the cultural rules, the cultural games. It’s different environment, with their own set of rules. Not necessarily the ones we have. In our household. ” The desire to maintain cultural heritage through language may be greater because it is the minority when a family lives in a new society. One parent remarked that she consciously affirmed this while abroad: “ I keep saying it all the time… I am very intentional about… on how I’m raising my child on how to be aligned to my own culture. Than any other, and, I know language is part of culture for sure. ” Overall, these comments indicate that specific cultural adaptations within the PLT program would have been useful to these parents beyond linguistic adaptations. CaLD parents may benefit from more individually contextualised support with an understanding of both the culture that they’re coming from and the one they’re living in. Discussion Within the CaLD context, recognition that PLT is an appropriate specific support approach for autistic children is growing, which could aid in the support of heritage language and cultural maintenance for families who live abroad from their home communities (Oudet et al., 2024 ). However, there are distinctive CaLD needs related to transitioning to unfamiliar CaLD spaces that require distinct consideration for such parents to successfully engage with PLT. All parents in this study confirmed the acceptability of online service delivery, both in coached and self-directed formats. This aligns with contemporary research recognising the benefit and efficacy of telehealth service provision (Blackman, Jimenez-Gomez and Shvarts, 2020 ; Li, Wu, et al. , 2022; Qu et al., 2022 ). However, one parent remarked that the group size and diversity were factors in her PLT engagement. This indicates that, possibly more so in telepractice, group size and member diversity may be potential barriers for CaLD parents. Despite the advantages of online service delivery in addressing the accessibility barrier of physical proximity to clinical centres, it will be valuable to consider the cultural values and social norms of potential group members regarding interactions with those from unfamiliar backgrounds, different genders, and group sizes. For coached programs, it may be important for PLT practitioners to consider that matching parents for groups based on common language(s) spoken may need to also include matching for common cultural heritage. However, as Carruthers et al ( 2023 ) identified that individual parent characteristics are a key factor in PLT implementation success, care must be taken to avoid homogenising experiences and expectations of certain cultural or ethnic groups when designing and implementing PLT to remain attentive to the uniqueness of each family and parents’ situation and specific needs. Parents raised issues of external dependency and financial cost that is created by relying on clinician-led therapy, particularly for families moving internationally on temporary or permanent bases. Resource availability must also be considered regarding quality of internet access and device(s) being used to connect to sessions, which will likely impact parents’ ability to adequately learn skills required to support their autistic children. The degree of unfamiliarity that a parent feels with the cultural and linguistic norms of their community could impact their confidence and ability to support their children’s social-communication skills. Aligning with current evidence identifying significant factors of stress for parents of autistic children as perceptions of parenting skills and reliance on social-emotional adaptive coping strategies (McStay et al., 2014 ; Costa, Steffgen and Ferring, 2017 ; Padden and James, 2017 ), parents in this study reported that the cultural shock of integrating into foreign environments magnified the challenges they faced, notably, they felt they had fewer resources at their disposal, including ability to navigate unfamiliar societal norms, and had more difficulty maintaining social-emotional well-being. Reflection on specific needs of populations in which neither parent has heritage in their community of residence is warranted, for whom challenges of supporting their autistic children’s social-communication skills are exacerbated. Parents spoke about empowerment and determination being more necessary than when in their “home” contexts, which is consistent with findings that parent motivation is key to effective implementors of specific support (Zlomke and Jeter, 2019 ; Carruthers et al., 2023 ). It is possible that parents in such situations have greater need for clinical reassurance, which may account for the level of participant withdrawal in the self-directed groups who did not receive coaching. This aligns with findings that parents may feel pressure in implementing strategies themselves and lack confidence in their ability to deliver support strategies to their autistic children (Estes, Swain and MacDuffie, 2019 ; Bent et al., 2023 ), which is likely to be amplified in foreign CaLD environments. LA that were provided were considered less helpful than expected. Instead, parents would have preferred nuanced cultural adaptations to support their autistic child’s social-communication skills, particularly with local peers. It is possible that this is a more critical consideration for autistic children who have more advanced social-communication skills for whom peer play is an immediate goal. Parents who are supporting children at more foundational stages of communication may be less immediately focused on cultural adaptations for peer play. In any case, PLT programs should be sensitive to families’ cultural heritage and current CaLD context for which translated strategies must be adapted for successful implementation. Ultimately, CaLD parents, particularly those in unfamiliar and/or minority communities, may need more individualised support from PLT practitioners to contextualise, integrate, and implement social-communication support strategies successfully. These results underscore the need for PLT programs to flexibly allow parents to participate in ways in which they feel most comfortable to improve engagement and boost outcomes of the social-communication specific support strategies they deliver to their autistic children. This finding is in line with Tritter and McCallum’s ( 2006 ) call for models of engagement that use a variety of involvement methods to flexibly cater for a diverse community of “users” to engage at the level of participation they choose. Reflections and limitations A key limitation of this study is the low number of participants, which limits the robustness and transferability of findings. However, IPA is concerned with understanding lived experiences of a particular phenomenon and not necessarily to generalise further. Given the convergent themes generated and analysed regarding parents’ challenges allocating resources of time, budget, and personal energy, as well as issues of stable internet connection, adequate device availability, and desire for individual reassurance and culturally contextualised support, it is possible that other parents who did not participate in this study were deterred by similar barriers. It is essential that PLT practitioners take such considerations into account when proving PLT in CaLD environments, particularly when families are CaLD minorities. All participants in this study were mothers. Perspectives may have been more balanced had fathers, grandparents, and other key carers participated, whose views are typically underrepresented in qualitative research regarding children and childcare (Davies and Hanna, 2021 ). This is likely to be of greater import when working with cultures in which multigenerational and extended-family households are more common. However, most of the participants in the wider project from which this study is based were mostly mothers, so it was proportionately expected that mothers would be more represented in this work too. Participants who lived abroad from their home culture and language communities were expatriates (who relocated for a job for a fixed amount of time and remain tax residents in their home countries) and not migrants (who intend to relocate indefinitely). This may not represent the CaLD populations struggling most with PLT engagement. This may also have influenced the finding that translated materials were not helpful to them as they were already highly proficient in English within their international careers and did not require LA from the original English material. This was juxtaposed with the participants who lived in their home communities, who professed certain levels of English proficiency but may have struggled with the program content and interviews where no translations were provided. This strengthens the finding that implementation of PLT to CaLD families must be contextualised to each family’s unique environment and practitioners must make specific adaptations to best support autistic children in various CaLD situations. Implications and future research Given the paucity of evidence in the field of PLT provided to families of autistic children in bilingual environments, it is imperative that PLT programs are validated in a variety of formats, including online, self-directed, and hybrid modes, and with bilingual and bicultural adaptions. It continues to be crucial that PLT practitioners and researchers actively consider the nuanced and contextualised challenges faced by families of autistic children when supporting social-communication skills in unfamiliar CaLD contexts, and how these factors may impact parents’ abilities to implement PLT strategies in unfamiliar CaLD communities, Future research beyond WEIRD environments should include factors of group size, gender mixing, length of sessions and program period, and providing more contextualised adaptations for peer-targeted social-communication specific support. Overall, this study highlights the need for further investigation of PLT to support social-communication development of autistic children in a greater diversity of CaLD families to move beyond WEIRD communities, particularly where they reside as CaLD minorities. The design of any such investigation should include key stakeholders (parents, clinicians) from specific populations in question to better understand the nuances of cultural adaptations required to increase efficacy and impact of study. References APA (2013) Diagnostic and Statistical Manual of Mental Disorders . 5th edition. Washington, DC: American Psychiatric Association Bent CA et al (2023) Perspectives from parents of autistic children on participating in early intervention and associated research, Autism , 27(5), pp. 1295–1306. Available at: https://doi.org/10.1177/13623613221141540 Blackman AL, Jimenez-Gomez C, Shvarts S (2020) Comparison of the efficacy of online versus in-vivo behavior analytic training for parents of children with autism spectrum disorder, Behavior Analysis: Research and Practice , 20(1), pp. 13–23. Available at: https://doi.org/10.1037/bar0000163 Bury SM et al (2020) ‘It Defines Who I Am’ or ‘It’s Something I Have’: What Language Do [Autistic] Australian Adults [on the Autism Spectrum] Prefer? Journal of autism and developmental disorders [Preprint]. Available at: https://doi.org/10.1007/s10803-020-04425-3 Byford S et al (2015) Cost-effectiveness analysis of a communication-focused therapy for pre-school children with autism: Results from a randomised controlled trial, BMC Psychiatry , 15. Available at: https://doi.org/10.1186/s12888-015-0700-x Carruthers S et al (2023) Using implementation science frameworks to explore barriers and facilitators for parents’ use of therapeutic strategies following a parent-mediated autism intervention, Autism , 27(4), pp. 1011–1025. Available at: https://doi.org/10.1177/13623613221125630 COST Action IS0804 (2011) Questionnaire for Parents of Bilingual Children (PaBIQ) . Available at: http://www.bi-sli.org Costa AP, Steffgen G, Ferring D (2017) Contributors to well-being and stress in parents of children with autism spectrum disorder, Research in Autism Spectrum Disorders , 37, pp. 61–72. Available at: https://doi.org/10.1016/j.rasd.2017.01.007 Dai YG et al (2018) Language abilities in monolingual- and bilingual- exposed children with autism or other developmental disorders, Research in Autism Spectrum Disorders , 55, pp. 38–49. Available at: https://doi.org/10.1016/j.rasd.2018.08.001 Davies L, Hanna E (2021) The experience of qualitative research with young fathers: Considerations of gender, class and reflexive practice, Families, Relationships and Societies , 10(3), pp. 479–496. Available at: https://doi.org/10.1332/204674320X15919851992841 Davis R, Crompton CJ (2021) What Do New Findings About Social Interaction in Autistic Adults Mean for Neurodevelopmental Research? Perspectives on Psychological Science , 16(3), pp. 649–653. Available at: https://doi.org/10.1177/1745691620958010 Davis R, Fletcher-Watson S, Digard BG (2021) Autistic People’s Access to Bilingualism and Additional Language Learning: Identifying the Barriers and Facilitators for Equal Opportunities, Frontiers in Psychology , 12. Available at: https://doi.org/10.3389/fpsyg.2021.741182 Davis R, Zaki FBM, Sargent L (2024) Autism and bilingualism: A thematic analysis of practitioner perspectives in the United Kingdom, International Journal of Language & Communication Disorders , 59(1), pp. 205–222. Available at: https://doi.org/10.1111/1460-6984.12939 Dubay M et al (2024) Exploring the Experiences of Latina Mothers in a Culturally Tailored Early Parent-Mediated Neurodevelopmental Intervention, Infants and Young Children , 37(4), pp. 273–293. Available at: https://doi.org/10.1097/IYC.0000000000000273 Estes A, Swain DM, MacDuffie KE (2019) The effects of early autism intervention on parents and family adaptive functioning, Pediatric Medicine . AME Publishing Company. Available at: https://doi.org/10.21037/pm.2019.05.05 Glenn E et al (2022) Self-Directed Web-Based Parent-Mediated Interventions for Autistic Children: A systematic review, Review Journal of Autism and Developmental Disorders [Preprint]. Springer. Available at: https://doi.org/10.1007/s40489-022-00307-9 Grosjean F (2010) Bilingual . Cambridge (MA): Harvard University Press. Available at: https://doi.org/ https://doi.org/10.4159/9780674056459 Grosjean F (2015) Bicultural bilinguals, International Journal of Bilingualism , 19(5), pp. 572–586. Available at: https://doi.org/10.1177/1367006914526297 Grosjean F (2024) On bilinguals and bilingualism. Cambridge University Press Hampton S et al (2017) Autism and bilingualism: A qualitative interview study of parents’ perspectives and experiences, Journal of Speech, Language, and Hearing Research [Preprint]. Available at: https://doi.org/10.1044/2016_JSLHR-L-15-0348 Harris PA et al (2019) The REDCap consortium: Building an international community of software platform partners, Journal of Biomedical Informatics . Academic Press Inc. Available at: https://doi.org/10.1016/j.jbi.2019.103208 Hastedt I et al (2023) Bilingual and Monolingual Autistic Toddlers: Language and Social Communication Skills, Journal of Autism and Developmental Disorders , 53(6), pp. 2185–2202. Available at: https://doi.org/10.1007/s10803-022-05504-3 Howard K, Gibson J, Katsos N (2020) Parental Perceptions and Decisions Regarding Maintaining Bilingualism in Autism, Journal of Autism and Developmental Disorders [Preprint], (0123456789). Available at: https://doi.org/10.1007/s10803-020-04528-x Howard K, Katsos N, Gibson J (2019) Using interpretative phenomenological analysis in autism research, Autism : the international journal of research and practice , 23(7), pp. 1871–1876. Available at: https://doi.org/10.1177/1362361318823902 Hyman SL et al (2020) Identification, evaluation, and management of children with autism spectrum disorder, Pediatrics , 145(1). Available at: https://doi.org/10.1542/PEDS.2019-3447 Jegatheesan B (2011) Multilingual development in children with autism: Perspectives of South Asian Muslim immigrant parents on raising a child with a communicative disorder in multilingual contexts, Bilingual Research Journal , 34(2), pp. 185–200. Available at: https://doi.org/10.1080/15235882.2011.597824 Jones M, Bowden C, Galindo-Gonzalez S (2015) Interviewing When You’re Not Face-To-Face: The Use of Email Interviews in a Phenomenological Study , International Journal of Doctoral Studies . Available at: http://ijds.org/Volume10/IJDSv10p079-092Bowden0684.pdf Kay-Raining Bird E, Genesee F, Verhoeven L (2016) Bilingualism in children with developmental disorders: A narrative review, Journal of Communication Disorders , 63. Available at: https://doi.org/10.1016/j.jcomdis.2016.07.003 Kenny L et al (2016) Which terms should be used to describe autism? Perspectives from the UK autism community, Autism , 20(4), pp. 442–462. Available at: https://doi.org/10.1177/1362361315588200 Khamis R et al (2023) Perceptions and Lived Experiences of Arab American Parent Participants in LENA Start: Lessons for Parent Education Programs in Minoritized Communities, American Journal of Speech-Language Pathology , 32(3), pp. 999–1015. Available at: https://doi.org/10.1044/2023_AJSLP-22-00112 Li Fēi, Wu D et al (2022) Effectiveness of Online-Delivered Project ImPACT for Children With ASD and Their Parents: A Pilot Study During the COVID-19 Pandemic, Frontiers in Psychiatry , 13. Available at: https://doi.org/10.3389/fpsyt.2022.806149 Li Fēi, Xu M et al (2022) From child social impairment to parenting stress in mothers of children with ASD: The role of parental self-efficacy and social support., Frontiers in psychiatry , 13, p. 1005748. Available at: https://doi.org/10.3389/fpsyt.2022.1005748 Lok JSY, Qi X, To CKS (2021) Using the More Than Words Program with Chinese Families: A Case-Control Study, Frontiers in Communication , 6. Available at: https://doi.org/10.3389/fcomm.2021.792758 Lumivero (2024) NVivo, Version 15 [Preprint]. www.lumivero.com Lund EM, Kohlmeier TL, Durán LK (2017) Comparative Language Development in Bilingual and Monolingual Children With Autism Spectrum Disorder: A Systematic Review, Journal of Early Intervention , 39(2), pp. 106–124. Available at: https://doi.org/10.1177/1053815117690871 McStay RL et al (2014) Parenting stress and autism: The role of age, autism severity, quality of life and problem behaviour of children and adolescents with autism, Autism , 18(5), pp. 502–510. Available at: https://doi.org/10.1177/1362361313485163 Monk R, Whitehouse AJO, Waddington H (2022) The use of language in autism research, Trends in Neurosciences [Preprint]. Available at: https://doi.org/10.1016/j.tins.2022.08.009 Montgomery L et al (2022) Measuring the Impact of Bilingualism on Executive Functioning Via Inhibitory Control Abilities in Autistic Children, Journal of Autism and Developmental Disorders , 52(8), pp. 3560–3573. Available at: https://doi.org/10.1007/S10803-021-05234-Y/TABLES/6 Nevill RE, Lecavalier L, Stratis EA (2018) Meta-analysis of parent-mediated interventions for young children with autism spectrum disorder, Autism , 22(2), pp. 84–98. Available at: https://doi.org/10.1177/1362361316677838 Novick G (2008) Is there a bias against telephone interviews in qualitative research? Research in nursing & health , 31(4), pp. 391–398. Available at: https://doi.org/10.1002/nur.20259 Nowell LS et al (2017) Thematic Analysis, International journal of qualitative methods , 16(1), pp. 1–13. Available at: https://doi.org/10.1177/1609406917733847 Oono IP, Honey EJ, Mcconachie H (2013) Parent-mediated early intervention for young children with autism spectrum disorders (ASD), Cochrane Database of Systematic Reviews , 2013(4). Available at: https://doi.org/10.1002/14651858.CD009774.pub2 Oudet S et al (2024) Parent-led Communication Therapy for Young Bilingual Autistic Children: A Scoping Review, Journal of Autism and Developmental Disorders [Preprint]. Available at: https://doi.org/10.1007/s10803-024-06478-0 Oudet S, Howard K, Durrleman S (2022) Early years autism and bilingualism: An interpretative phenomenological analysis of parent perceptions during lockdown, Autism and Developmental Language Impairments , 7. Available at: https://doi.org/10.1177/23969415221138704/FORMAT/EPUB Padden C, James JE (2017) Stress among Parents of Children with and without Autism Spectrum Disorder: A Comparison Involving Physiological Indicators and Parent Self-Reports, Journal of Developmental and Physical Disabilities , 29(4), pp. 567–586. Available at: https://doi.org/10.1007/s10882-017-9547-z Peristeri E et al (2021) The cognitive benefits of bilingualism in autism spectrum disorder: Is theory of mind boosted and by which underlying factors? Autism Research , 14(8), pp. 1695–1709. Available at: https://doi.org/10.1002/aur.2542 Qu L et al (2022) Assessing the Satisfaction and Acceptability of an Online Parent Coaching Intervention: A Mixed-Methods Approach, Frontiers in Psychology , 13. Available at: https://doi.org/10.3389/fpsyg.2022.859145 Reetzke R et al (2015) Communicative Development in Bilingually Exposed Chinese Children with Autism Spectrum Disorders, Journal of Speech, Language, and Hearing Research , 58(June), pp. 813–825. Available at: https://doi.org/10.1044/2015_JSLHR-L-13-0258 Senent-Capuz N, Baixauli-Fortea I, Moret-Tatay C (2021) Parent-Implemented Hanen Program It Takes Two to Talk®: An Exploratory Study in Spain, International Journal of Environmental Research and Public Health 2021, Vol. 18, Page 8214 , 18(15), p. 8214. Available at: https://doi.org/10.3390/IJERPH18158214 Smith JA, Flowers P, Larkin M (2022) Interpretative phenomenological analysis : theory, method and research, p. 225 Sokmum S, Singh J, S. and, Vandort S (2017) The Impact of Hanen More Than Words Programme on Parents of Children with ASD in Malaysia, Jurnal Sains Kesihatan Malaysia , 15(02), pp. 43–51. Available at: https://doi.org/10.17576/jskm-2017-1502-06 Sturges JE, Hanrahan KJ (2004) Comparing Telephone and Face-to-Face Qualitative Interviewing: a Research Note, Qualitative research : QR , 4(1), pp. 107–118. Available at: https://doi.org/10.1177/1468794104041110 Sutherland R, Trembath D, Roberts J (2018) Telehealth and autism: A systematic search and review of the literature, International Journal of Speech-Language Pathology , 20(3), pp. 324–336. Available at: https://doi.org/10.1080/17549507.2018.1465123 ;REQUESTEDJOURNAL:JOURNAL:IASL20;WGROUP:STRING:PUBLICATION The Hanen Centre (2016) More Than Words – Hanen Program for Parents of Children on the Autism Spectrum or who have Social Communication Difficulties . Available at: http://www.hanen.org/Programs/For-Parents/More-Than-Words.aspx (Accessed: November 14, 2022) Tilmont Pittala E et al (2018) Clinical outcomes of interactive, intensive and individual (3i) play therapy for children with ASD: A two-year follow-up study, BMC Pediatrics , 18(1). Available at: https://doi.org/10.1186/s12887-018-1126-7 Tritter JQ, McCallum A (2006) The snakes and ladders of user involvement: Moving beyond Arnstein, Health policy (Amsterdam, Netherlands) , 76(2), pp. 156–168. Available at: https://doi.org/10.1016/J.HEALTHPOL.2005.05.008 Uljarević M et al (2016) Practitioner Review: Multilingualism and neurodevelopmental disorders – an overview of recent research and discussion of clinical implications, Journal of Child Psychology and Psychiatry and Allied Disciplines , 57(11), pp. 1205–1217. Available at: https://doi.org/10.1111/JCPP.12596 Vanegas SB (2019) Academic skills in children with autism spectrum disorders with monolingual or bilingual experience, Autism and Developmental Language Impairments , 4. Available at: https://doi.org/10.1177/2396941519888170/ASSET/IMAGES/LARGE/10.1177_2396941519888170-FIG1.JPEG Wilkinson R (1999) Introduction, Aphasiology , 13(4–5), pp. 251–258. Available at: https://doi.org/10.1080/026870399402082 Wolfer P et al (2025) Co-speech gesture comprehension in autistic children, Journal of Child Language , pp. 1–22. Available at: https://doi.org/10.1017/S0305000925000157 Yu B (2013) Issues in bilingualism and heritage language maintenance: Perspectives of minority-language mothers of children with autism spectrum disorders, American Journal of Speech-Language Pathology , 22(1), pp. 10–24. Available at: https://doi.org/10.1044/1058-0360(2012/10-0078 ) Yu B (2016) Bilingualism as Conceptualized and Bilingualism as Lived: A Critical Examination of the Monolingual Socialization of a Child with Autism in a Bilingual Family, Journal of Autism and Developmental Disorders , 46(2), pp. 424–435. Available at: https://doi.org/10.1007/s10803-015-2625-0 Zeidan J et al (2022) Global prevalence of autism: A systematic review update, Autism Research , 15(5), pp. 778–790. Available at: https://doi.org/10.1002/AUR.2696 Zhou V et al (2019) An exploratory longitudinal study of social and language outcomes in children with autism in bilingual home environments, Autism : the international journal of research and practice , 23(2), pp. 394–404. Available at: https://doi.org/10.1177/1362361317743251 Zlomke KR, Jeter K (2019) Comparative Effectiveness of Parent–Child Interaction Therapy for Children with and Without Autism Spectrum Disorder, Journal of Autism and Developmental Disorders , 50(6), pp. 2041–2052. Available at: https://doi.org/10.1007/s10803-019-03960-y Zwaigenbaum L, Brian JA, Ip A (2019) Early detection for autism spectrum disorder in young children., Paediatrics & child health , 24(7), pp. 424–443. Available at: https://doi.org/10.1093/pch/pxz119 Footnotes This study will use terms “on the autism spectrum”, “autistic”, and “specific support” in accordance with preferences expressed by the autism community (Kenny et al. , 2016; Bury et al. , 2020; Monk, Whitehouse and Waddington, 2022). The term “bilingual” will be used in this study to refer to those who use, receptively and/or expressively, two or more languages in their everyday life (Grosjean, 2010, 2015). This focus on functional use rather than levels of proficiency is considered most appropriate when examining social-communication skills, and particularly relevant when exploring such skills among young autistic children. Sometimes referred to as parent self-directed, parent-mediated, coached, or indirect therapy/specific support. Sometimes referred to as telepractice or online healthcare. Tables Table 1 and 2 are available in the Supplementary Files section. Additional Declarations The authors declare no competing interests. Supplementary Files PreprintABPLTIPATablesandFigures.docx Tables and Figures Table2.png Table 2. Participant demographic and involvement summary 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. 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for figure legend.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7757342/v1/fbb297b64068f6200ce9daad.png"},{"id":92803306,"identity":"6d2fe3e4-e411-44f8-8b86-12f2c214f634","added_by":"auto","created_at":"2025-10-05 11:55:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":805214,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7757342/v1/1e873046-9570-4f9c-9355-fd6fa23b3a70.pdf"},{"id":92801761,"identity":"0b268053-535b-4a72-bf3b-a73f6968ae73","added_by":"auto","created_at":"2025-10-05 11:39:24","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":34467,"visible":true,"origin":"","legend":"\u003cp\u003eTables and Figures\u003c/p\u003e","description":"","filename":"PreprintABPLTIPATablesandFigures.docx","url":"https://assets-eu.researchsquare.com/files/rs-7757342/v1/88e22c4abdc9be0f9e0fd4f5.docx"},{"id":92801764,"identity":"eb2dea76-7eba-40e2-8b87-720575271b8c","added_by":"auto","created_at":"2025-10-05 11:39:24","extension":"png","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":210058,"visible":true,"origin":"","legend":"\u003cp\u003eTable 2. Participant demographic and involvement summary\u003c/p\u003e","description":"","filename":"Table2.png","url":"https://assets-eu.researchsquare.com/files/rs-7757342/v1/ee1b7ad0aef50e6212cfa317.png"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eHow can we better engage culturally and linguistically diverse parents of autistic children in online parent-led therapy? An Interpretative Phenomenological Analysis\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAutism\u003csup\u003e1\u003c/sup\u003e is a developmental condition characterised by difficulties in social interactions and restricted and repetitive behaviours (APA, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Current estimates place the proportion of bilingual\u003csup\u003e2\u003c/sup\u003e individuals at more than half of the world population (Grosjean, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), and global prevalence of diagnosed children on the autism spectrum at 1/100 (Zeidan et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Emerging consensus indicates that bilingualism does not impede, and indeed, can boost various areas of development of young autistic children (Reetzke et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Uljarević et al., \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Lund, Kohlmeier and Dur\u0026aacute;n, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Dai et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Vanegas, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Zhou et al., \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Peristeri et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Montgomery et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Hastedt et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Wolfer et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Bilingual exposure also improves the development of multicultural identities and preservation of heritage (Jegatheesan, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Yu, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2013\u003c/span\u003e), and enriches family and social relationships (Kay-Raining Bird, Genesee and Verhoeven, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Howard, Gibson and Katsos, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Davis and Crompton, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). However, parents still report hesitancy, concerns, and conflicting advice on whether to maintain bilingualism for their autistic children (Yu, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Hampton et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Oudet, Howard and Durrleman, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Similarly, practitioners continue to convey unease regarding the feasibility of bilingualism for some autistic children and express uncertainties about providing advice to parents, despite a desire to move towards more inclusive and culturally diverse practice (Davis, Zaki and Sargent, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). While there is a considerable body of literature focusing on the impact of PLT on developing social-communication skills in monolingual populations, the same cannot be said for bilingual families (Davis et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Oudet et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eParent-child interactions are critically important for autistic children, for whom social-communication is more difficult and limited, particularly during the early years, when children are likely to spend more time in their homes and neighbourhoods than other settings (Zwaigenbaum, Brian and Ip, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Hyman et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). A growing body of research indicates a promising evidence base for the use of parent-led therapy (PLT)\u003csup\u003e3\u003c/sup\u003e to improve social-communication development of autistic children (Oono, Honey and Mcconachie, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Nevill, Lecavalier and Stratis, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Glenn et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). By learning and using therapeutic strategies and techniques over long time-periods through PLT, parents may enhance learning success by providing a large \u0026ldquo;dose\u0026rdquo; of support, such as, more learning opportunities across varied settings and specific support in naturally occurring teachable moments, leading to stronger durability and generalisation of acquired skills (Carruthers et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Derosier et al., 2011; Reichow \u0026amp; Volkmar, 2010; Te Kaat-van den Os et al., 2017; Zlomke \u0026amp; Jeter, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHowever, recent evidence suggests that some parents may lack confidence in their ability to implement PLT strategies and may feel that direct sessions relieve pressure of having to deliver support themselves (Estes, Swain and MacDuffie, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Oudet, Howard and Durrleman, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Bent et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Additionally, parents of autistic children are more likely to experience higher levels of stress than parents of non-autistic children, and report higher levels of adaptive coping strategies, including emotional support (McStay et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Costa, Steffgen and Ferring, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Padden and James, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe efficacy of PLT beyond English-speaking environments has begun to attract more study (Sokmum, Joginder Singh and Vandort, 2017; Lok, Qi and To, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Senent-Capuz, Baixauli-Fortea and Moret-Tatay, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Khamis et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Dubay et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). However, the evidence remains rooted in the monolingual context, and culturally and linguistically diverse (CaLD) families with varied socio-economic backgrounds continue to be under-represented. It will be important to base careful investigation on a nuanced model moving away from the traditional ladder of power, using a variety of involvement methods that flexibly cater to a highly heterogenous and diverse population (Tritter and McCallum, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2006\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEarly findings indicate that telehealth\u003csup\u003e4\u003c/sup\u003e services are acceptable to parents of autistic children and online teaching methods can enable their learning and skill acquisition (Sutherland, Trembath and Roberts, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Blackman, Jimenez-Gomez and Shvarts, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Glenn et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Li, Wu, \u003cem\u003eet al.\u003c/em\u003e, 2022; Qu et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). PLT delivered via telehealth is particularly relevant for addressing some of the barriers to accessing support, which include long waitlists, proficiency of community language, availability of bilingual clinicians, time required to attend appointments, and cost (Byford et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Tilmont Pittala et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Li, Xu, \u003cem\u003eet al.\u003c/em\u003e, 2022). However, telehealth requires access to stable internet connections and connected devices, raising a resource barrier that is likely to disproportionately impact families in low- to middle-income environments.\u003c/p\u003e\n\u003ch3\u003eContext of the current study\u003c/h3\u003e\n\u003cp\u003eThis study is part of a project that aims to explore the ways in which CaLD parents engage in PLT to support the development of their young autistic children\u0026rsquo;s social-communication skills. The conditions examined are displayed in Table\u0026nbsp;1. The coached groups received synchronous clinical coaching with the More Than Words program (The Hanen Centre, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). The self-directed groups received weekly materials via emails, with which they engaged asynchronously and individually. The groups that received language adaptations (LA) received PLT content in English and another language of their choice (French, Spanish), as well as guidance on implementing strategies bilingually. French and Spanish MTW official handout translations are provided by the Hanen Centre for their coached programs (The Hanen Centre, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Groups that did not have LA received standard English content. All participants were offered a copy of the More Than Words parent guidebook (The Hanen Centre, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). The data analysis plan for this project is registered with Open Science Framework (OSF, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.17605/OSF.IO/8QNGX\u003c/span\u003e\u003cspan address=\"10.17605/OSF.IO/8QNGX\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn this project, an environment was considered bilingual if the home language (L1) was different to the societal language (L2), and/or if there was more than one dominant language spoken in the household. Thirty-eight parents initially provided written informed consent for the project. Twenty-three participants completed at least one measure pre- and post-test. Eighteen of those were retained in the coached groups (originally 25), and five participants were retained in the self-directed groups (originally 13). Of the 15 participants who withdrew participation, five identified \u0026ldquo;home\u0026rdquo; cultures in high-income countries (France, Germany, Switzerland, United Kingdom) and 10 identified \u0026ldquo;home\u0026rdquo; cultures in low-/middle-income countries (Congo, India, Morocco). Given the level of attrition experienced over the course of this data collection, particularly within the self-directed groups and those born in non-WEIRD (Western, Educated, Industrialised, Rich, Democratic) countries, questions about how parents were able or unable to complete the PLT programs are warranted. A phenomenological approach was considered most suitable to fully understand nuances affecting families who engaged with self-directed PLT or who were unable to complete their allocated PLT.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eAim and research questions\u003c/h2\u003e\u003cp\u003eThis study explores the factors that influenced participation of parents from CaLD backgrounds in a PLT program delivered online to support social-communication skills in autistic children. It aims to understand the unique context of individual families and how these shaped their engagement with the service.\u003c/p\u003e\u003cp\u003eThe main research question was: What are the specific barriers and facilitators to participating in online PLT among CaLD families with autistic children?\u003c/p\u003e\u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eDesign\u003c/h2\u003e\u003cp\u003eInterpretative Phenomenological Analysis (IPA) is concerned with understanding lived experiences of a unique phenomenon. This study aims to understand what hinders and helps CaLD parents of autistic children complete online PLT. Smith et al. (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) provided a methodological framework for this study, which is well-suited to small highly heterogenous sample groups and increasingly applied in autism research (Howard, Katsos and Gibson, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Oudet, Howard and Durrleman, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This study draws on data collected from four semi-structured synchronous interviews, and one email interview.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eParticipants were recruited through Swiss-based clinical and family support organisations who distributed recruitment information via their online platforms (mailing lists, websites, social media groups). Inclusion criteria were a) parents/key caregiver of an autistic child; b) child in question is seven years or younger; c) child lives in a bilingual environment; d) ability to participate independently in written and verbal activities with the researcher in English or French; e) access to stable internet connection. Geographic location was neither an inclusion nor exclusion criterion.\u003c/p\u003e\u003cp\u003eFollowing individual information meetings held via Teams, interested parents were invited to download a copy of the written information form and provide written consent via REDCap (Harris et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). An adapted version of the Questionnaire for Parents of Bilingual Children (PABIQ) (COST Action IS0804, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) was completed independently by participants to collect demographic and background information. Participants were then allocated to one of the four group conditions. The participants included in this analysis are a subset (n\u0026thinsp;=\u0026thinsp;5) of the total number of participants (n\u0026thinsp;=\u0026thinsp;38) who provided informed written consent and 1) were part of a self-directed group, or 2) did not complete their allocated PLT.\u003c/p\u003e\u003cp\u003eParticipants in this IPA study were mothers living in France, India, Germany, and USA. All participants were married to men and held tertiary education degrees. Four households had one child and one household had two children. The autistic children in discussion were sons aged between 2;0 years and 5;0 years. Exchanges between participant and researcher were conducted in English. Three participants lived outside their self-identified home country. A summary of participant information is displayed in Table\u0026nbsp;2.\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eEthical approval for this project was provided by the Canton Research Ethics Committee (Commission cantonale (VD) d\u0026rsquo;\u0026eacute;thique de la recherche sur l\u0026rsquo;\u0026ecirc;tre humain) (CER-VD): Project ID 2023\u0026thinsp;\u0026minus;\u0026thinsp;00562.\u003c/p\u003e\u003c/p\u003e\u003cp\u003eIndividual semi-structured interviews were conducted by the first author via Microsoft Teams with four participants. Remote modes of interview have been shown to have no significant impact on quality of data collected with adult participants when compared with in-person interviews (Sturges and Hanrahan, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Novick, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). One participant provided responses via email as she was unable to complete a synchronous interview. Email interviews have been shown to be an effective online tool for phenomenological research (Jones, Bowden and Galindo-Gonzalez, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSynchronous interviews were audio recorded and transcribed verbatim in Microsoft Word based on Conversation Analysis conventions (Wilkinson, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e1999\u003c/span\u003e). The email interview was transferred to the same transcription template. Information and themes extracted from each interview were reviewed with each participant to verify that what had been interpreted from their statements was what they had intended to express.\u003c/p\u003e\u003cp\u003eTo increase reliability and validity, this study engaged with five trustworthiness criteria (credibility, transferability, dependability, confirmability, audit trails (Nowell et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) and subscribes to the principles of high-quality IPA (Smith, Flowers and Larkin, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eInterview data were analysed following guidelines of IPA methodology (Smith, Flowers and Larkin, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Transcripts were initially analysed in Word and then transferred to NVivo15 (Lumivero, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Initial analysis involved inductive coding. Emergent themes were identified in each account as an individual case-study-style analysis. Super-ordinate themes were then developed deductively for each account to progress from the general ideas expressed by participants to emergent themes extracted across accounts, to precise super-ordinate themes ultimately generated.\u003c/p\u003e\u003cp\u003eThemes were developed by the first author and reviewed and further refined with the second author to increase confirmability and validity of findings. In the case of coding disagreement, relevant interview data were analysed in their original form and discussed until consensus was reached Three review meetings were held. Final superordinate themes were reviewed with all named authors to confirm interpretation and ensure agreement.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePositionality of the researchers\u003c/h3\u003e\n\u003cp\u003eThe first author is a doctoral researcher from a clinical perspective (speech-language therapy) with a CaLD background and environment. The second author is an experienced qualitative researcher in the field of autism and bilingualism from an education perspective. The third and fourth authors are experienced researchers in the field of autism and bilingualism from linguistic perspectives, and are of CaLD backgrounds and environments. Each researcher actively bracketed their specific areas of expertise and experiences that may have impacted their approach to the data.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTwo final super-ordinate themes and their respective subthemes were generated from the data. These are displayed in Fig.\u0026nbsp;1.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eTheme A: Cultural differences amplify barriers to online PLT.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eA1. Navigating foreign social communication codes is hard\u003c/b\u003e. All parents expressed that time was a dominant factor in their ability to participate in PLT regardless of the service delivery mode. Other factors that influenced their engagement with their allocated program included prioritising clinician-led (direct) therapy sessions, distance from clinical centres and effort required to travel, and financial cost. However, the three parents who lived in foreign cultures shared that their resources felt even more limited than when they were supporting their children in their home environments because integrating into their new environments was harder than expected.\u003c/p\u003e\u003cp\u003eOne mother reported that she was uncomfortable in her allocated group because: \u0026ldquo;\u003cem\u003e\u0026hellip; too big group became awkward and the group had diversity. If the group had same region people it would have been easier\u003c/em\u003e.\u0026rdquo; While the participant does not specify what she meant by \u0026ldquo;diversity,\u0026rdquo; this may reflect a preference for groups with more shared regional or cultural backgrounds, in addition to a shared common language. While her group of seven parents was significantly smaller than the recommended 12\u0026ndash;16 members, it is notable that this parent was connecting with her mobile phone, which may have added to her participation difficulties.\u003c/p\u003e\u003cp\u003eOne parent spoke about moving internationally: \u0026ldquo;\u003cem\u003eI did not anticipate that settling in was going to be so difficult. Like right now, seven months down the line, I am going to view a house. Like literally, we don\u0026rsquo;t even have like, a house yet, like\u0026hellip; I also did underestimate\u0026hellip; my son being settling into school, has been a nightmare\u0026hellip; I just wasn\u0026rsquo;t, I think, prepared, mentally.\u003c/em\u003e\u0026rdquo; Views converged on the reflection that despite preparing as best they could for an international transition, the difficulties they encountered were unexpectedly greater than what they had been living with, which left them even less time, space, or energy to engage with PLT.\u003c/p\u003e\u003cp\u003eThe cost of care was also reported as a concern for parents transitioning between countries, as their families were not yet part of public administration systems. One parent reported, \u0026ldquo;\u003cem\u003e\u0026hellip; the idea is to get into the care. The government care system. Because, what I am doing right now, I am using the private sector, to get those needs met. And it\u0026rsquo;s very steep. Very costly\u0026hellip; It\u0026rsquo;s super costly\u003c/em\u003e.\u0026rdquo; The need to access support in the private sector can be useful for families moving between countries to ensure continuity of care for their autistic children, but presents an additional cost that may not be necessary in their home countries.\u003c/p\u003e\u003cp\u003e Parents shared corresponding notions of additional difficulty when supporting their autistic children in spaces that were culturally unfamiliar to them. One parent remarked, \u0026ldquo;\u003cem\u003eI would say that it\u0026rsquo;s, easier [in your own country]\u0026hellip; the challenges are different, right? Because you\u0026rsquo;re in your culture. You have that off your plate. Even if it\u0026rsquo;s difficult situation you\u0026rsquo;re in, even if what you have to fix is a bigger problem\u0026hellip; you have that reassurance that you\u0026rsquo;re in your culture and you can do things that you already know, that you\u0026rsquo;re already familiar with\u003c/em\u003e.\u0026rdquo; Notions of \u0026ldquo;reassurance\u0026rdquo; from the \u0026ldquo;familiar\u0026rdquo; suggest that living in the foreign CaLD context adds intangible burden for parents trying to implement PLT.\u003c/p\u003e\u003cp\u003eAnother parent spoke about the culture shock she experienced that made supporting her autistic child more difficult in the new foreign environment: \u0026ldquo;\u003cem\u003eI come from a place where we have community\u0026hellip; you know, kids are brought up in a community by the community. And I realise very quickly that here it\u0026rsquo;s just about the hours\u0026hellip; the billable hours. For me that was a big shock\u0026hellip; because in the world that we worked in, especially for my son\u0026rsquo;s support, it was quite easy\u0026hellip; I\u0026rsquo;m so tired of this, come on\u003c/em\u003e.\u0026rdquo; This participant clearly expresses frustration with the cultural \u0026ldquo;shock\u0026rdquo; of more individualistic and transactional models of support. While not an explicitly identified as a reason she was not able to complete her assigned PLT program, it may be that the added challenge of navigating such unexpected cultural differences left even fewer social-emotional resources with which to engage in PLT.\u003c/p\u003e\u003cp\u003eOverall, the process and practical realities of acculturation may increase strain that parents feel when supporting their autistic children, thus adding to the intangible and concrete challenges they face when trying to engage with and implement PLT regardless of service delivery mode and common languages shared.\u003c/p\u003e\u003cp\u003e\u003cb\u003eA2. Maintaining courage to implement PLT is harder.\u003c/b\u003e All parents reported feeling alone in supporting their autistic children. Tensions were reported about being far from heritage families and friends.\u003c/p\u003e\u003cp\u003eThere was strong agreement among the three parents who lived in unfamiliar cultures that more resilience was needed to engage with PLT when abroad: \u0026ldquo;\u003cem\u003e\u0026hellip; the determination to go through it\u0026hellip; I would say that, uh, in in a different culture, it\u0026rsquo;s a lonelier road, but it\u0026rsquo;s not an impossible one.\u0026rdquo; Another parent shared, \u0026ldquo;I think it\u0026rsquo;s just to be intentional. To be honest. About it. I was initially being intentional and being very open-minded, going into it\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\u003cp\u003eOne parent, who completed a self-directed program living outside her familiar home culture, indicated that she did not feel confident in her understanding and implementation of strategies: \u0026ldquo;\u003cem\u003eI[t] will help in the, initial meeting, the reassurance that, you\u0026rsquo;re gonna feel that you\u0026rsquo;re failing. You\u0026rsquo;re gonna feel that you\u0026rsquo;re doing it all wrong\u0026hellip; That would be helpful because then you will, recall to that moment, ah yes, she told me this will happen and it\u0026rsquo;s okay. It\u0026rsquo;s part of the process\u003c/em\u003e.\u0026rdquo; This is a clear expression of uncertainty and a lack of confidence during her program related to the aloneness she felt without clinical coaching in the unfamiliar culture.\u003c/p\u003e\u003cp\u003eA parent, who had been allocated to a coached group, shared that she needed both direct and indirect (PLT) sessions to feel empowered in her unfamiliar cultural context: \u0026ldquo;\u003cem\u003e\u0026hellip;at the end of the day when the child is with a specialist, it\u0026rsquo;s for a certain number of billable hours\u0026hellip; so I mean, as a parent I felt a need to also be empowered, as well. Once I\u0026rsquo;m able to do that, to do the family, at home, once I will be able to do that with the carer at home, and also for the whole family, of course they must be taught as well\u003c/em\u003e.\u0026rdquo; This desire for empowerment was reasserted: \u0026ldquo;\u003cem\u003e\u0026hellip; it means that, okay, I\u0026rsquo;m doing the training not just for myself, but also how to talk to the carer, I am more empowered and I can challenge some of their approaches that, that they apply\u003c/em\u003e.\u0026rdquo; These expressions of empowerment can be associated with the notion of reassurance that parents need to feel more substantially when raising autistic children and interacting with practitioners and caregivers in culturally unfamiliar spaces.\u003c/p\u003e\u003cp\u003eThe three mothers who lived far from their homes of origin shared tensions of how they felt about this distance. One parent shared, \u0026ldquo;\u003cem\u003eI came with one family member. I don\u0026rsquo;t think if there were many it would have helped because the more is never the merrier in this thing\u003c/em\u003e.\u0026rdquo; Another parent agreed with this notion, disclosing that, \u0026ldquo;\u003cem\u003eThe family will be hard, because they will be sometimes too\u0026hellip; pushy or too\u0026hellip; they can be very opinionated at times. So it will be hard to have that\u0026hellip; They\u0026rsquo;re always, all try to help by putting their own opinions. And sometimes it\u0026rsquo;s not what you need\u003c/em\u003e.\u0026rdquo; Such remarks suggest that these parents have found a silver lining in being far, namely, distance from the weight of their relatives\u0026rsquo; good intentions, allowing them to be connected enough to feel loved, and far enough to not be overwhelmed as they navigate the challenges of supporting their autistic children in an unfamiliar environment.\u003c/p\u003e\u003cp\u003e Overall, parents found it harder to maintain their social-emotional well-being when living abroad, expressing more need for determination and empowerment than when they were in their home cultures.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eTheme B: Linguistic adaptations need to be contextualised for each CaLD environment.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eB1. Translated materials alone are not enough.\u003c/b\u003e Four parents, who demonstrated adequate English proficiency to engage with the interviewing researcher without the need for an interpreter, three of whom lived abroad, reported that the translations they received during the intervention were not helpful.\u003c/p\u003e\u003cp\u003eOne parent reported: \u0026ldquo;\u003cem\u003eI don\u0026rsquo;t think the translated materials are useful. To be honest. I mean, because it\u0026rsquo;s a lot. You just need someone, hold your hand\u0026hellip; Who understands that it\u0026rsquo;s a nightmare, trying to navigate this system\u003c/em\u003e.\u0026rdquo; This indicates that providing translated materials alone may add more burden than benefit, if provided without individual follow-up.\u003c/p\u003e\u003cp\u003eSimilarly, another parent reported that the translations she received in her dominant language did not add value: \u003cem\u003e\u0026ldquo;\u0026hellip; it made no difference\u0026hellip; having it in the English and Spanish, sometimes, was just part of the same, a little, just part of the same\u003c/em\u003e.\u0026rdquo; This parent also reported that her son did not like when adults translated information for him: \u0026ldquo;\u003cem\u003e\u0026hellip; they [school teachers] try to translate one thing, I don\u0026rsquo;t know\u0026hellip; it just doesn\u0026rsquo;t go, he just hates it\u003c/em\u003e.\u0026rdquo; This aligns with the views that linguistic translations can sometimes be more hindrance than help.\u003c/p\u003e\u003cp\u003eHowever, linguistic translation was essential for one parent, living in her home community, who reported a higher level of English proficiency than she was able to demonstrate: \u0026ldquo;\u003cem\u003eI don\u0026rsquo;t uh\u0026hellip; understand everything. Uh\u0026hellip; yeah\u0026hellip; I think\u0026hellip; yeah\u0026hellip; Hindi yeah\u0026hellip; English also but uh, mm simple language this time. Okay?\u003c/em\u003e\u0026rdquo; This reveals the necessity of translations for those who lack proficiency in the language of service delivery, which is a clear barrier for parents accessing online PLT from a practitioner with whom they do not share a strong common language.\u003c/p\u003e\u003cp\u003eOverall, the parents living abroad from their home cultures reported that the non-English linguistic adaptation of PLT materials did not meet their prioritised needs.\u003c/p\u003e\u003cp\u003e\u003cb\u003eB2. Language attitudes and perceived prestige should inform adaptations needed\u003c/b\u003e. All parents reported valuing English as a priority language for their children to be exposed to regardless of their heritage and country of residence.\u003c/p\u003e\u003cp\u003eThe parents who remained in their home communities indicated lower priority for their \u0026ldquo;mother\u0026rdquo; languages. One parent reported speaking the nationally and globally dominant languages to her child, rather than her regional language, which was spoken in her community: \u0026ldquo;\u003cem\u003e\u0026hellip; we talk to him in uh, Hindi. Hindi, okay? A little bit English also. He talk to, English, uh English. And little bit Teluga also. Okay? First, first, Hindi. Second, English. And third is Teluga. Because Teluga\u0026hellip; from friend or woman, actually, from neighbours\u003c/em\u003e.\u0026rdquo; This indicates the value this parent places on the respective languages in her son\u0026rsquo;s CaLD environment, possibly based on the perceived lack of status that her regional language has. Notably, this parent seems to highly value English, preferring to speak it to her son despite her level of proficiency.\u003c/p\u003e\u003cp\u003eOne parent remarked that regardless of her cultural and linguistic environment, she would like her son to remain in a bilingual or English education structure: \u0026ldquo;\u003cem\u003eI would not put him into single language, because I think it helps to broaden\u0026hellip; it\u0026rsquo;s helping their brain to grow\u0026hellip; parents are going to be talking in Hindi. He knows the language. And in school he\u0026rsquo;s being spoken to in English... I think this is helping him. We cannot see it, it right now, but I know that is helping him\u003c/em\u003e.\u0026rdquo; While this belief in bilingualism was based in ideas of cognitive benefit, there was also a sense of English specifically considered as valuable in the future.\u003c/p\u003e\u003cp\u003eAnother parent described four languages in her son\u0026rsquo;s environment, and that she prioritised English above her heritage national and regional languages, as well as her current community language: \u0026lsquo;\u003cem\u003eI tend to stick with English and Swahili. And sometimes my mother tongue\u0026hellip; the people surrounding my child are mostly speaking English and then\u0026hellip; Yeah, so I stick with one\u003c/em\u003e.\u0026rsquo; For this parent, who lived abroad from her home culture and accessed online specific support for her son with practitioners in different countries, English was the most important language for her to foster with her son because of its value as a globally accessible language.\u003c/p\u003e\u003cp\u003eOverall, parents revealed the high value placed on English language environments and in some cases, low value on exposure of their L1s for their autistic children, regardless of their CaLD heritage and own English-language proficiency.\u003c/p\u003e\u003cp\u003e\u003cb\u003eB3. Cultural adaptation supports implementation of strategies.\u003c/b\u003e Parents aligned in their report of cultural differences being more challenging than linguistic differences in their foreign CaLD environments. A greater need to affirm the parent\u0026rsquo;s home culture was expressed.\u003c/p\u003e\u003cp\u003eThe difference in parenting styles across cultures can be enormously varied, and one mother shared her experience of navigating these differences in her new community: \u0026ldquo;\u003cem\u003eI mean\u0026hellip; just manoeuvring the situation. What to do and what not to do at the park and the parties\u003c/em\u003e.\u0026rdquo; While social norms and diversities are specific to each CaLD families\u0026rsquo; foreign environment, this parent did not complete her allocated PLT program and it remains unknown how understood, implemented, and, ultimately, effective the strategies may have been in her setting. However, it is likely that implementing PLT strategies to support her autistic child\u0026rsquo;s social-communication skills in an unfamiliar socio-cultural context would have been challenging.\u003c/p\u003e\u003cp\u003eOne parent spoke of the difficulties supporting her child in an unfamiliar cultural environment: \u0026ldquo;\u003cem\u003eWe all have games that translate to all of us. But\u0026hellip; it\u0026rsquo;s not the same if I teach him to play here at home with his father and I. Then he goes out there, he tries to play the same things with the kids, they would, they just won\u0026rsquo;t understand. They won\u0026rsquo;t. Then they see like it\u0026rsquo;s a little bit weird, what are you trying to do?\u003c/em\u003e\u0026rdquo; This exemplifies this parent\u0026rsquo;s struggle to support her autistic son\u0026rsquo;s pragmatic skills, because she needed culturally adapted aid to meet the social-communication needs in her foreign CaLD context.\u003c/p\u003e\u003cp\u003eOne parent suggested that LA she received include more contextualised examples of how strategies can be culturally nuanced: \u0026ldquo;\u003cem\u003eNot everybody is going to\u0026hellip; want to go through, or have the time to go through, how do I do this in this cultural setting. Or maybe some don\u0026rsquo;t even understand that it\u0026rsquo;s different. The cultural setting, the cultural rules, the cultural games. It\u0026rsquo;s different environment, with their own set of rules. Not necessarily the ones we have. In our household.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\u003cp\u003eThe desire to maintain cultural heritage through language may be greater because it is the minority when a family lives in a new society. One parent remarked that she consciously affirmed this while abroad: \u0026ldquo;\u003cem\u003eI keep saying it all the time\u0026hellip; I am very intentional about\u0026hellip; on how I\u0026rsquo;m raising my child on how to be aligned to my own culture. Than any other, and, I know language is part of culture for sure.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\u003cp\u003eOverall, these comments indicate that specific cultural adaptations within the PLT program would have been useful to these parents beyond linguistic adaptations. CaLD parents may benefit from more individually contextualised support with an understanding of both the culture that they\u0026rsquo;re coming from and the one they\u0026rsquo;re living in.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWithin the CaLD context, recognition that PLT is an appropriate specific support approach for autistic children is growing, which could aid in the support of heritage language and cultural maintenance for families who live abroad from their home communities (Oudet et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). However, there are distinctive CaLD needs related to transitioning to unfamiliar CaLD spaces that require distinct consideration for such parents to successfully engage with PLT.\u003c/p\u003e\u003cp\u003eAll parents in this study confirmed the acceptability of online service delivery, both in coached and self-directed formats. This aligns with contemporary research recognising the benefit and efficacy of telehealth service provision (Blackman, Jimenez-Gomez and Shvarts, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Li, Wu, \u003cem\u003eet al.\u003c/em\u003e, 2022; Qu et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). However, one parent remarked that the group size and diversity were factors in her PLT engagement. This indicates that, possibly more so in telepractice, group size and member diversity may be potential barriers for CaLD parents. Despite the advantages of online service delivery in addressing the accessibility barrier of physical proximity to clinical centres, it will be valuable to consider the cultural values and social norms of potential group members regarding interactions with those from unfamiliar backgrounds, different genders, and group sizes. For coached programs, it may be important for PLT practitioners to consider that matching parents for groups based on common language(s) spoken may need to also include matching for common cultural heritage. However, as Carruthers et al (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) identified that individual parent characteristics are a key factor in PLT implementation success, care must be taken to avoid homogenising experiences and expectations of certain cultural or ethnic groups when designing and implementing PLT to remain attentive to the uniqueness of each family and parents\u0026rsquo; situation and specific needs.\u003c/p\u003e\u003cp\u003e Parents raised issues of external dependency and financial cost that is created by relying on clinician-led therapy, particularly for families moving internationally on temporary or permanent bases. Resource availability must also be considered regarding quality of internet access and device(s) being used to connect to sessions, which will likely impact parents\u0026rsquo; ability to adequately learn skills required to support their autistic children.\u003c/p\u003e\u003cp\u003eThe degree of unfamiliarity that a parent feels with the cultural and linguistic norms of their community could impact their confidence and ability to support their children\u0026rsquo;s social-communication skills. Aligning with current evidence identifying significant factors of stress for parents of autistic children as perceptions of parenting skills and reliance on social-emotional adaptive coping strategies (McStay et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Costa, Steffgen and Ferring, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Padden and James, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), parents in this study reported that the cultural shock of integrating into foreign environments magnified the challenges they faced, notably, they felt they had fewer resources at their disposal, including ability to navigate unfamiliar societal norms, and had more difficulty maintaining social-emotional well-being. Reflection on specific needs of populations in which neither parent has heritage in their community of residence is warranted, for whom challenges of supporting their autistic children\u0026rsquo;s social-communication skills are exacerbated.\u003c/p\u003e\u003cp\u003eParents spoke about empowerment and determination being more necessary than when in their \u0026ldquo;home\u0026rdquo; contexts, which is consistent with findings that parent motivation is key to effective implementors of specific support (Zlomke and Jeter, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Carruthers et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). It is possible that parents in such situations have greater need for clinical reassurance, which may account for the level of participant withdrawal in the self-directed groups who did not receive coaching. This aligns with findings that parents may feel pressure in implementing strategies themselves and lack confidence in their ability to deliver support strategies to their autistic children (Estes, Swain and MacDuffie, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Bent et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), which is likely to be amplified in foreign CaLD environments.\u003c/p\u003e\u003cp\u003e LA that were provided were considered less helpful than expected. Instead, parents would have preferred nuanced cultural adaptations to support their autistic child\u0026rsquo;s social-communication skills, particularly with local peers. It is possible that this is a more critical consideration for autistic children who have more advanced social-communication skills for whom peer play is an immediate goal. Parents who are supporting children at more foundational stages of communication may be less immediately focused on cultural adaptations for peer play. In any case, PLT programs should be sensitive to families\u0026rsquo; cultural heritage and current CaLD context for which translated strategies must be adapted for successful implementation.\u003c/p\u003e\u003cp\u003eUltimately, CaLD parents, particularly those in unfamiliar and/or minority communities, may need more individualised support from PLT practitioners to contextualise, integrate, and implement social-communication support strategies successfully. These results underscore the need for PLT programs to flexibly allow parents to participate in ways in which they feel most comfortable to improve engagement and boost outcomes of the social-communication specific support strategies they deliver to their autistic children. This finding is in line with Tritter and McCallum\u0026rsquo;s (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) call for models of engagement that use a variety of involvement methods to flexibly cater for a diverse community of \u0026ldquo;users\u0026rdquo; to engage at the level of participation they choose.\u003c/p\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eReflections and limitations\u003c/h2\u003e\u003cp\u003eA key limitation of this study is the low number of participants, which limits the robustness and transferability of findings. However, IPA is concerned with understanding lived experiences of a particular phenomenon and not necessarily to generalise further. Given the convergent themes generated and analysed regarding parents\u0026rsquo; challenges allocating resources of time, budget, and personal energy, as well as issues of stable internet connection, adequate device availability, and desire for individual reassurance and culturally contextualised support, it is possible that other parents who did not participate in this study were deterred by similar barriers. It is essential that PLT practitioners take such considerations into account when proving PLT in CaLD environments, particularly when families are CaLD minorities.\u003c/p\u003e\u003cp\u003eAll participants in this study were mothers. Perspectives may have been more balanced had fathers, grandparents, and other key carers participated, whose views are typically underrepresented in qualitative research regarding children and childcare (Davies and Hanna, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This is likely to be of greater import when working with cultures in which multigenerational and extended-family households are more common. However, most of the participants in the wider project from which this study is based were mostly mothers, so it was proportionately expected that mothers would be more represented in this work too.\u003c/p\u003e\u003cp\u003eParticipants who lived abroad from their home culture and language communities were expatriates (who relocated for a job for a fixed amount of time and remain tax residents in their home countries) and not migrants (who intend to relocate indefinitely). This may not represent the CaLD populations struggling most with PLT engagement. This may also have influenced the finding that translated materials were not helpful to them as they were already highly proficient in English within their international careers and did not require LA from the original English material. This was juxtaposed with the participants who lived in their home communities, who professed certain levels of English proficiency but may have struggled with the program content and interviews where no translations were provided. This strengthens the finding that implementation of PLT to CaLD families must be contextualised to each family\u0026rsquo;s unique environment and practitioners must make specific adaptations to best support autistic children in various CaLD situations.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eImplications and future research\u003c/h2\u003e\u003cp\u003eGiven the paucity of evidence in the field of PLT provided to families of autistic children in bilingual environments, it is imperative that PLT programs are validated in a variety of formats, including online, self-directed, and hybrid modes, and with bilingual and bicultural adaptions.\u003c/p\u003e\u003cp\u003eIt continues to be crucial that PLT practitioners and researchers actively consider the nuanced and contextualised challenges faced by families of autistic children when supporting social-communication skills in unfamiliar CaLD contexts, and how these factors may impact parents\u0026rsquo; abilities to implement PLT strategies in unfamiliar CaLD communities, Future research beyond WEIRD environments should include factors of group size, gender mixing, length of sessions and program period, and providing more contextualised adaptations for peer-targeted social-communication specific support.\u003c/p\u003e\u003cp\u003eOverall, this study highlights the need for further investigation of PLT to support social-communication development of autistic children in a greater diversity of CaLD families to move beyond WEIRD communities, particularly where they reside as CaLD minorities. The design of any such investigation should include key stakeholders (parents, clinicians) from specific populations in question to better understand the nuances of cultural adaptations required to increase efficacy and impact of study.\u003c/p\u003e\u003c/div\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAPA (2013) \u003cem\u003eDiagnostic and Statistical Manual of Mental Disorders\u003c/em\u003e. 5th edition. Washington, DC: American Psychiatric Association\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBent CA et al (2023) Perspectives from parents of autistic children on participating in early intervention and associated research, \u003cem\u003eAutism\u003c/em\u003e, 27(5), pp. 1295\u0026ndash;1306. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/13623613221141540\u003c/span\u003e\u003cspan address=\"10.1177/13623613221141540\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBlackman AL, Jimenez-Gomez C, Shvarts S (2020) Comparison of the efficacy of online versus in-vivo behavior analytic training for parents of children with autism spectrum disorder, \u003cem\u003eBehavior Analysis: Research and Practice\u003c/em\u003e, 20(1), pp. 13\u0026ndash;23. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/bar0000163\u003c/span\u003e\u003cspan address=\"10.1037/bar0000163\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBury SM et al (2020) \u0026lsquo;It Defines Who I Am\u0026rsquo; or \u0026lsquo;It\u0026rsquo;s Something I Have\u0026rsquo;: What Language Do [Autistic] Australian Adults [on the Autism Spectrum] Prefer? \u003cem\u003eJournal of autism and developmental disorders\u003c/em\u003e [Preprint]. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10803-020-04425-3\u003c/span\u003e\u003cspan address=\"10.1007/s10803-020-04425-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eByford S et al (2015) Cost-effectiveness analysis of a communication-focused therapy for pre-school children with autism: Results from a randomised controlled trial, \u003cem\u003eBMC Psychiatry\u003c/em\u003e, 15. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12888-015-0700-x\u003c/span\u003e\u003cspan address=\"10.1186/s12888-015-0700-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCarruthers S et al (2023) Using implementation science frameworks to explore barriers and facilitators for parents\u0026rsquo; use of therapeutic strategies following a parent-mediated autism intervention, \u003cem\u003eAutism\u003c/em\u003e, 27(4), pp. 1011\u0026ndash;1025. Available at: \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\u003eCOST Action IS0804 (2011) \u003cem\u003eQuestionnaire for Parents of Bilingual Children (PaBIQ)\u003c/em\u003e. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.bi-sli.org\u003c/span\u003e\u003cspan address=\"http://www.bi-sli.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCosta AP, Steffgen G, Ferring D (2017) Contributors to well-being and stress in parents of children with autism spectrum disorder, \u003cem\u003eResearch in Autism Spectrum Disorders\u003c/em\u003e, 37, pp. 61\u0026ndash;72. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.rasd.2017.01.007\u003c/span\u003e\u003cspan address=\"10.1016/j.rasd.2017.01.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDai YG et al (2018) Language abilities in monolingual- and bilingual- exposed children with autism or other developmental disorders, \u003cem\u003eResearch in Autism Spectrum Disorders\u003c/em\u003e, 55, pp. 38\u0026ndash;49. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.rasd.2018.08.001\u003c/span\u003e\u003cspan address=\"10.1016/j.rasd.2018.08.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDavies L, Hanna E (2021) The experience of qualitative research with young fathers: Considerations of gender, class and reflexive practice, \u003cem\u003eFamilies, Relationships and Societies\u003c/em\u003e, 10(3), pp. 479\u0026ndash;496. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1332/204674320X15919851992841\u003c/span\u003e\u003cspan address=\"10.1332/204674320X15919851992841\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDavis R, Crompton CJ (2021) What Do New Findings About Social Interaction in Autistic Adults Mean for Neurodevelopmental Research? \u003cem\u003ePerspectives on Psychological Science\u003c/em\u003e, 16(3), pp. 649\u0026ndash;653. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1745691620958010\u003c/span\u003e\u003cspan address=\"10.1177/1745691620958010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDavis R, Fletcher-Watson S, Digard BG (2021) Autistic People\u0026rsquo;s Access to Bilingualism and Additional Language Learning: Identifying the Barriers and Facilitators for Equal Opportunities, \u003cem\u003eFrontiers in Psychology\u003c/em\u003e, 12. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpsyg.2021.741182\u003c/span\u003e\u003cspan address=\"10.3389/fpsyg.2021.741182\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDavis R, Zaki FBM, Sargent L (2024) Autism and bilingualism: A thematic analysis of practitioner perspectives in the United Kingdom, \u003cem\u003eInternational Journal of Language \u0026amp; Communication Disorders\u003c/em\u003e, 59(1), pp. 205\u0026ndash;222. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/1460-6984.12939\u003c/span\u003e\u003cspan address=\"10.1111/1460-6984.12939\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDubay M et al (2024) Exploring the Experiences of Latina Mothers in a Culturally Tailored Early Parent-Mediated Neurodevelopmental Intervention, \u003cem\u003eInfants and Young Children\u003c/em\u003e, 37(4), pp. 273\u0026ndash;293. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/IYC.0000000000000273\u003c/span\u003e\u003cspan address=\"10.1097/IYC.0000000000000273\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEstes A, Swain DM, MacDuffie KE (2019) The effects of early autism intervention on parents and family adaptive functioning, \u003cem\u003ePediatric Medicine\u003c/em\u003e. AME Publishing Company. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.21037/pm.2019.05.05\u003c/span\u003e\u003cspan address=\"10.21037/pm.2019.05.05\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGlenn E et al (2022) Self-Directed Web-Based Parent-Mediated Interventions for Autistic Children: A systematic review, \u003cem\u003eReview Journal of Autism and Developmental Disorders\u003c/em\u003e [Preprint]. Springer. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s40489-022-00307-9\u003c/span\u003e\u003cspan address=\"10.1007/s40489-022-00307-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrosjean F (2010) \u003cem\u003eBilingual\u003c/em\u003e. Cambridge (MA): Harvard University Press. Available at: https://doi.org/\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4159/9780674056459\u003c/span\u003e\u003cspan address=\"10.4159/9780674056459\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrosjean F (2015) Bicultural bilinguals, \u003cem\u003eInternational Journal of Bilingualism\u003c/em\u003e, 19(5), pp. 572\u0026ndash;586. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1367006914526297\u003c/span\u003e\u003cspan address=\"10.1177/1367006914526297\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrosjean F (2024) On bilinguals and bilingualism. Cambridge University Press\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHampton S et al (2017) Autism and bilingualism: A qualitative interview study of parents\u0026rsquo; perspectives and experiences, \u003cem\u003eJournal of Speech, Language, and Hearing Research\u003c/em\u003e [Preprint]. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1044/2016_JSLHR-L-15-0348\u003c/span\u003e\u003cspan address=\"10.1044/2016_JSLHR-L-15-0348\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHarris PA et al (2019) The REDCap consortium: Building an international community of software platform partners, \u003cem\u003eJournal of Biomedical Informatics\u003c/em\u003e. Academic Press Inc. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jbi.2019.103208\u003c/span\u003e\u003cspan address=\"10.1016/j.jbi.2019.103208\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHastedt I et al (2023) Bilingual and Monolingual Autistic Toddlers: Language and Social Communication Skills, \u003cem\u003eJournal of Autism and Developmental Disorders\u003c/em\u003e, 53(6), pp. 2185\u0026ndash;2202. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10803-022-05504-3\u003c/span\u003e\u003cspan address=\"10.1007/s10803-022-05504-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHoward K, Gibson J, Katsos N (2020) Parental Perceptions and Decisions Regarding Maintaining Bilingualism in Autism, \u003cem\u003eJournal of Autism and Developmental Disorders\u003c/em\u003e [Preprint], (0123456789). Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10803-020-04528-x\u003c/span\u003e\u003cspan address=\"10.1007/s10803-020-04528-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHoward K, Katsos N, Gibson J (2019) Using interpretative phenomenological analysis in autism research, \u003cem\u003eAutism : the international journal of research and practice\u003c/em\u003e, 23(7), pp. 1871\u0026ndash;1876. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1362361318823902\u003c/span\u003e\u003cspan address=\"10.1177/1362361318823902\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHyman SL et al (2020) Identification, evaluation, and management of children with autism spectrum disorder, \u003cem\u003ePediatrics\u003c/em\u003e, 145(1). Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1542/PEDS.2019-3447\u003c/span\u003e\u003cspan address=\"10.1542/PEDS.2019-3447\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJegatheesan B (2011) Multilingual development in children with autism: Perspectives of South Asian Muslim immigrant parents on raising a child with a communicative disorder in multilingual contexts, \u003cem\u003eBilingual Research Journal\u003c/em\u003e, 34(2), pp. 185\u0026ndash;200. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/15235882.2011.597824\u003c/span\u003e\u003cspan address=\"10.1080/15235882.2011.597824\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJones M, Bowden C, Galindo-Gonzalez S (2015) \u003cem\u003eInterviewing When You\u0026rsquo;re Not Face-To-Face: The Use of Email Interviews in a Phenomenological Study\u003c/em\u003e, \u003cem\u003eInternational Journal of Doctoral Studies\u003c/em\u003e. Available at: http://ijds.org/Volume10/IJDSv10p079-092Bowden0684.pdf\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKay-Raining Bird E, Genesee F, Verhoeven L (2016) Bilingualism in children with developmental disorders: A narrative review, \u003cem\u003eJournal of Communication Disorders\u003c/em\u003e, 63. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jcomdis.2016.07.003\u003c/span\u003e\u003cspan address=\"10.1016/j.jcomdis.2016.07.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKenny L et al (2016) Which terms should be used to describe autism? Perspectives from the UK autism community, \u003cem\u003eAutism\u003c/em\u003e, 20(4), pp. 442\u0026ndash;462. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1362361315588200\u003c/span\u003e\u003cspan address=\"10.1177/1362361315588200\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhamis R et al (2023) Perceptions and Lived Experiences of Arab American Parent Participants in LENA Start: Lessons for Parent Education Programs in Minoritized Communities, \u003cem\u003eAmerican Journal of Speech-Language Pathology\u003c/em\u003e, 32(3), pp. 999\u0026ndash;1015. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1044/2023_AJSLP-22-00112\u003c/span\u003e\u003cspan address=\"10.1044/2023_AJSLP-22-00112\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi Fēi, Wu D et al (2022) Effectiveness of Online-Delivered Project ImPACT for Children With ASD and Their Parents: A Pilot Study During the COVID-19 Pandemic, \u003cem\u003eFrontiers in Psychiatry\u003c/em\u003e, 13. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpsyt.2022.806149\u003c/span\u003e\u003cspan address=\"10.3389/fpsyt.2022.806149\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi Fēi, Xu M et al (2022) From child social impairment to parenting stress in mothers of children with ASD: The role of parental self-efficacy and social support., \u003cem\u003eFrontiers in psychiatry\u003c/em\u003e, 13, p. 1005748. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpsyt.2022.1005748\u003c/span\u003e\u003cspan address=\"10.3389/fpsyt.2022.1005748\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLok JSY, Qi X, To CKS (2021) Using the More Than Words Program with Chinese Families: A Case-Control Study, \u003cem\u003eFrontiers in Communication\u003c/em\u003e, 6. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fcomm.2021.792758\u003c/span\u003e\u003cspan address=\"10.3389/fcomm.2021.792758\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLumivero (2024) NVivo, \u003cem\u003eVersion 15\u003c/em\u003e [Preprint]. www.lumivero.com\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLund EM, Kohlmeier TL, Dur\u0026aacute;n LK (2017) Comparative Language Development in Bilingual and Monolingual Children With Autism Spectrum Disorder: A Systematic Review, \u003cem\u003eJournal of Early Intervention\u003c/em\u003e, 39(2), pp. 106\u0026ndash;124. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1053815117690871\u003c/span\u003e\u003cspan address=\"10.1177/1053815117690871\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcStay RL et al (2014) Parenting stress and autism: The role of age, autism severity, quality of life and problem behaviour of children and adolescents with autism, \u003cem\u003eAutism\u003c/em\u003e, 18(5), pp. 502\u0026ndash;510. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1362361313485163\u003c/span\u003e\u003cspan address=\"10.1177/1362361313485163\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMonk R, Whitehouse AJO, Waddington H (2022) The use of language in autism research, \u003cem\u003eTrends in Neurosciences\u003c/em\u003e [Preprint]. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.tins.2022.08.009\u003c/span\u003e\u003cspan address=\"10.1016/j.tins.2022.08.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMontgomery L et al (2022) Measuring the Impact of Bilingualism on Executive Functioning Via Inhibitory Control Abilities in Autistic Children, \u003cem\u003eJournal of Autism and Developmental Disorders\u003c/em\u003e, 52(8), pp. 3560\u0026ndash;3573. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/S10803-021-05234-Y/TABLES/6\u003c/span\u003e\u003cspan address=\"10.1007/S10803-021-05234-Y/TABLES/6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNevill RE, Lecavalier L, Stratis EA (2018) Meta-analysis of parent-mediated interventions for young children with autism spectrum disorder, \u003cem\u003eAutism\u003c/em\u003e, 22(2), pp. 84\u0026ndash;98. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1362361316677838\u003c/span\u003e\u003cspan address=\"10.1177/1362361316677838\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNovick G (2008) Is there a bias against telephone interviews in qualitative research? \u003cem\u003eResearch in nursing \u0026amp; health\u003c/em\u003e, 31(4), pp. 391\u0026ndash;398. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/nur.20259\u003c/span\u003e\u003cspan address=\"10.1002/nur.20259\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNowell LS et al (2017) Thematic Analysis, \u003cem\u003eInternational journal of qualitative methods\u003c/em\u003e, 16(1), pp. 1\u0026ndash;13. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1609406917733847\u003c/span\u003e\u003cspan address=\"10.1177/1609406917733847\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOono IP, Honey EJ, Mcconachie H (2013) Parent-mediated early intervention for young children with autism spectrum disorders (ASD), \u003cem\u003eCochrane Database of Systematic Reviews\u003c/em\u003e, 2013(4). Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/14651858.CD009774.pub2\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD009774.pub2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOudet S et al (2024) Parent-led Communication Therapy for Young Bilingual Autistic Children: A Scoping Review, \u003cem\u003eJournal of Autism and Developmental Disorders\u003c/em\u003e [Preprint]. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10803-024-06478-0\u003c/span\u003e\u003cspan address=\"10.1007/s10803-024-06478-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOudet S, Howard K, Durrleman S (2022) Early years autism and bilingualism: An interpretative phenomenological analysis of parent perceptions during lockdown, \u003cem\u003eAutism and Developmental Language Impairments\u003c/em\u003e, 7. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/23969415221138704/FORMAT/EPUB\u003c/span\u003e\u003cspan address=\"10.1177/23969415221138704/FORMAT/EPUB\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePadden C, James JE (2017) Stress among Parents of Children with and without Autism Spectrum Disorder: A Comparison Involving Physiological Indicators and Parent Self-Reports, \u003cem\u003eJournal of Developmental and Physical Disabilities\u003c/em\u003e, 29(4), pp. 567\u0026ndash;586. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10882-017-9547-z\u003c/span\u003e\u003cspan address=\"10.1007/s10882-017-9547-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePeristeri E et al (2021) The cognitive benefits of bilingualism in autism spectrum disorder: Is theory of mind boosted and by which underlying factors? \u003cem\u003eAutism Research\u003c/em\u003e, 14(8), pp. 1695\u0026ndash;1709. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/aur.2542\u003c/span\u003e\u003cspan address=\"10.1002/aur.2542\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eQu L et al (2022) Assessing the Satisfaction and Acceptability of an Online Parent Coaching Intervention: A Mixed-Methods Approach, \u003cem\u003eFrontiers in Psychology\u003c/em\u003e, 13. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpsyg.2022.859145\u003c/span\u003e\u003cspan address=\"10.3389/fpsyg.2022.859145\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eReetzke R et al (2015) Communicative Development in Bilingually Exposed Chinese Children with Autism Spectrum Disorders, \u003cem\u003eJournal of Speech, Language, and Hearing Research\u003c/em\u003e, 58(June), pp. 813\u0026ndash;825. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1044/2015_JSLHR-L-13-0258\u003c/span\u003e\u003cspan address=\"10.1044/2015_JSLHR-L-13-0258\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSenent-Capuz N, Baixauli-Fortea I, Moret-Tatay C (2021) Parent-Implemented Hanen Program It Takes Two to Talk\u0026reg;: An Exploratory Study in Spain, \u003cem\u003eInternational Journal of Environmental Research and Public Health 2021, Vol. 18, Page 8214\u003c/em\u003e, 18(15), p. 8214. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/IJERPH18158214\u003c/span\u003e\u003cspan address=\"10.3390/IJERPH18158214\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSmith JA, Flowers P, Larkin M (2022) Interpretative phenomenological analysis : theory, method and research, p. 225\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSokmum S, Singh J, S. and, Vandort S (2017) The Impact of Hanen More Than Words Programme on Parents of Children with ASD in Malaysia, \u003cem\u003eJurnal Sains Kesihatan Malaysia\u003c/em\u003e, 15(02), pp. 43\u0026ndash;51. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.17576/jskm-2017-1502-06\u003c/span\u003e\u003cspan address=\"10.17576/jskm-2017-1502-06\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSturges JE, Hanrahan KJ (2004) Comparing Telephone and Face-to-Face Qualitative Interviewing: a Research Note, \u003cem\u003eQualitative research : QR\u003c/em\u003e, 4(1), pp. 107\u0026ndash;118. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1468794104041110\u003c/span\u003e\u003cspan address=\"10.1177/1468794104041110\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSutherland R, Trembath D, Roberts J (2018) Telehealth and autism: A systematic search and review of the literature, \u003cem\u003eInternational Journal of Speech-Language Pathology\u003c/em\u003e, 20(3), pp. 324\u0026ndash;336. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/17549507.2018.1465123\u003c/span\u003e\u003cspan address=\"10.1080/17549507.2018.1465123\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e;REQUESTEDJOURNAL:JOURNAL:IASL20;WGROUP:STRING:PUBLICATION\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThe Hanen Centre (2016) \u003cem\u003eMore Than Words \u0026ndash; Hanen Program for Parents of Children on the Autism Spectrum or who have Social Communication Difficulties\u003c/em\u003e. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.hanen.org/Programs/For-Parents/More-Than-Words.aspx\u003c/span\u003e\u003cspan address=\"http://www.hanen.org/Programs/For-Parents/More-Than-Words.aspx\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (Accessed: November 14, 2022)\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTilmont Pittala E et al (2018) Clinical outcomes of interactive, intensive and individual (3i) play therapy for children with ASD: A two-year follow-up study, \u003cem\u003eBMC Pediatrics\u003c/em\u003e, 18(1). Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12887-018-1126-7\u003c/span\u003e\u003cspan address=\"10.1186/s12887-018-1126-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTritter JQ, McCallum A (2006) The snakes and ladders of user involvement: Moving beyond Arnstein, \u003cem\u003eHealth policy (Amsterdam, Netherlands)\u003c/em\u003e, 76(2), pp. 156\u0026ndash;168. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/J.HEALTHPOL.2005.05.008\u003c/span\u003e\u003cspan address=\"10.1016/J.HEALTHPOL.2005.05.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUljarević M et al (2016) Practitioner Review: Multilingualism and neurodevelopmental disorders \u0026ndash; an overview of recent research and discussion of clinical implications, \u003cem\u003eJournal of Child Psychology and Psychiatry and Allied Disciplines\u003c/em\u003e, 57(11), pp. 1205\u0026ndash;1217. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/JCPP.12596\u003c/span\u003e\u003cspan address=\"10.1111/JCPP.12596\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVanegas SB (2019) Academic skills in children with autism spectrum disorders with monolingual or bilingual experience, \u003cem\u003eAutism and Developmental Language Impairments\u003c/em\u003e, 4. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/2396941519888170/ASSET/IMAGES/LARGE/10.1177_2396941519888170-FIG1.JPEG\u003c/span\u003e\u003cspan address=\"10.1177/2396941519888170/ASSET/IMAGES/LARGE/10.1177_2396941519888170-FIG1.JPEG\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWilkinson R (1999) Introduction, \u003cem\u003eAphasiology\u003c/em\u003e, 13(4\u0026ndash;5), pp. 251\u0026ndash;258. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/026870399402082\u003c/span\u003e\u003cspan address=\"10.1080/026870399402082\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWolfer P et al (2025) Co-speech gesture comprehension in autistic children, \u003cem\u003eJournal of Child Language\u003c/em\u003e, pp. 1\u0026ndash;22. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S0305000925000157\u003c/span\u003e\u003cspan address=\"10.1017/S0305000925000157\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYu B (2013) Issues in bilingualism and heritage language maintenance: Perspectives of minority-language mothers of children with autism spectrum disorders, \u003cem\u003eAmerican Journal of Speech-Language Pathology\u003c/em\u003e, 22(1), pp. 10\u0026ndash;24. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1044/1058-0360(2012/10-0078\u003c/span\u003e\u003cspan address=\"10.1044/1058-0360(2012/10-0078\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e)\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYu B (2016) Bilingualism as Conceptualized and Bilingualism as Lived: A Critical Examination of the Monolingual Socialization of a Child with Autism in a Bilingual Family, \u003cem\u003eJournal of Autism and Developmental Disorders\u003c/em\u003e, 46(2), pp. 424\u0026ndash;435. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10803-015-2625-0\u003c/span\u003e\u003cspan address=\"10.1007/s10803-015-2625-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZeidan J et al (2022) Global prevalence of autism: A systematic review update, \u003cem\u003eAutism Research\u003c/em\u003e, 15(5), pp. 778\u0026ndash;790. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/AUR.2696\u003c/span\u003e\u003cspan address=\"10.1002/AUR.2696\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhou V et al (2019) An exploratory longitudinal study of social and language outcomes in children with autism in bilingual home environments, \u003cem\u003eAutism : the international journal of research and practice\u003c/em\u003e, 23(2), pp. 394\u0026ndash;404. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1362361317743251\u003c/span\u003e\u003cspan address=\"10.1177/1362361317743251\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZlomke KR, Jeter K (2019) Comparative Effectiveness of Parent\u0026ndash;Child Interaction Therapy for Children with and Without Autism Spectrum Disorder, \u003cem\u003eJournal of Autism and Developmental Disorders\u003c/em\u003e, 50(6), pp. 2041\u0026ndash;2052. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10803-019-03960-y\u003c/span\u003e\u003cspan address=\"10.1007/s10803-019-03960-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZwaigenbaum L, Brian JA, Ip A (2019) Early detection for autism spectrum disorder in young children., \u003cem\u003ePaediatrics \u0026amp; child health\u003c/em\u003e, 24(7), pp. 424\u0026ndash;443. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/pch/pxz119\u003c/span\u003e\u003cspan address=\"10.1093/pch/pxz119\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e This study will use terms \u0026ldquo;on the autism spectrum\u0026rdquo;, \u0026ldquo;autistic\u0026rdquo;, and \u0026ldquo;specific support\u0026rdquo; in accordance with preferences expressed by the autism community (Kenny \u003cem\u003eet al.\u003c/em\u003e, 2016; Bury \u003cem\u003eet al.\u003c/em\u003e, 2020; Monk, Whitehouse and Waddington, 2022).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e The term \u0026ldquo;bilingual\u0026rdquo; will be used in this study to refer to those who use, receptively and/or expressively, two or more languages in their everyday life (Grosjean, 2010, 2015). This focus on functional use rather than levels of proficiency is considered most appropriate when examining social-communication skills, and particularly relevant when exploring such skills among young autistic children.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Sometimes referred to as parent self-directed, parent-mediated, coached, or indirect therapy/specific support.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Sometimes referred to as telepractice or online healthcare.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"83c8d8e0-5af0-4cb4-936c-7d79cccc451c","identifier":"10.13039/501100001711","name":"Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung","awardNumber":"P000PS_219038 / 1 FNS 50070108","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Fribourg","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":"Autism, early years, young children, parent-led therapy, parent coaching, bilingual, bicultural, culturally and linguistically diverse, telehealth, telepractice, barriers to specific support, interpretative phenomenological analysis","lastPublishedDoi":"10.21203/rs.3.rs-7757342/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7757342/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003ePurpose\u003c/u\u003e: This study aims to understand the lived experiences of culturally and linguistically diverse (CaLD) parents of autistic children who participated in a longitudinal self-directed (without clinical coaching) parent-led therapy (PLT) program targeting social-communication skills, or who were unable to complete participation in the longitudinal study coached group sessions. This work explores how each participant’s specific context impacted their engagement with online PLT.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMethodology\u003c/u\u003e: Five mothers from a range of CaLD backgrounds participated in this study from different countries. Semi-structured online interviews were conducted. Interpretative Phenomenological Analysis (IPA) was used to analyse data, focusing on understanding each participant’s lived experience.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFindings\u003c/u\u003e: Two superordinate themes were developed; 1) Cultural differences amplify barriers to online PLT; 2) Linguistic adaptations of therapeutic strategies need to be contextualised for each CaLD environment.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eOriginality\u003c/u\u003e: PLT is emerging as a useful support approach for parents of autistic children in bilingual environments. This study explores perspectives of CaLD parents who struggled to complete group PLT programs to better understand the specific barriers and facilitators to their engagement with online PLT.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eResearch imitations/implications\u003c/u\u003e: Participants had high English proficiency and academic backgrounds, which may not represent the CaLD population struggling most with PLT engagement. Further investigation amongst non-WEIRD (Western, Educated, Industrialised, Rich, Democratic) populations is warranted.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003ePractical implications\u003c/u\u003e: Specific considerations for socio-cultural adaptations to monolingually-designed PLT programs are needed beyond linguistic translations.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eSocial implications\u003c/u\u003e: CaLD minorities without heritage links to their country of residence face amplified challenges in supporting their autistic children. Such families need more contextualised support to enhance PLT engagement.\u003c/p\u003e","manuscriptTitle":"How can we better engage culturally and linguistically diverse parents of autistic children in online parent-led therapy? An Interpretative Phenomenological Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-05 11:39:20","doi":"10.21203/rs.3.rs-7757342/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":"409215cd-2c7f-4106-b5f7-26b9dd622fbb","owner":[],"postedDate":"October 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":55615818,"name":"Special Education"}],"tags":[],"updatedAt":"2025-10-05T11:39:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-05 11:39:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7757342","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7757342","identity":"rs-7757342","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}