Effectiveness of a training program among parents of preschool children with ASD in Tunisia: a randomized controlled trial

Autism spectrum disorder (ASD) is characterized by deficits in social communication and restricted, repetitive behaviors, with onset in early development. Global prevalence estimates suggest ASD affects approximately 0.6% of the population, and 1 in 59 children aged 8 in the U.S. ASD imposes significant burdens on children and families, including challenging behaviors and heightened parental psychological distress (stress, anxiety, depression). Parent training (PT) and psychoeducation can improve child outcomes and parental well-being, yet most interventions are designed for English-speaking, middle-class families and may not be culturally or linguistically aligned with Arab contexts. Tunisia faces limited specialized services, resources, and culturally adapted programs. This study aimed to test whether a culturally tailored parent training program would improve developmental and behavioral outcomes in preschool children with ASD and reduce parental psychological distress and enhance quality of life. Primary hypothesis: PT would improve child developmental outcomes and ASD symptom severity. Secondary hypothesis: PT would reduce parental anxiety/depression and improve quality of life.

Prior research indicates early interventions for ASD can improve communication, cognition, and ASD symptoms. Interventions range from psychoeducation focused on parental well-being to parent-mediated training targeting child outcomes; meta-analyses suggest stronger effects for parent-mediated approaches. In low-resource settings, parent groups can be cost-effective and practical. However, programs often lack cultural tailoring for Arab families, with barriers including late identification and limited awareness of PT. Evidence from Saudi Arabia, Jordan, and other LMICs shows potential benefits of culturally adapted parent education/training, but rigorous RCTs in Arab contexts are scarce. The Tunisian context has reported limited ASD services, financial constraints, and linguistic/cultural barriers (e.g., expression of emotions in Tunisian Arabic), underscoring the need for adapted parent-centered interventions.

Design: Randomized controlled trial conducted in three NGO-run Autism socio-educational centers (Les Colombes network) in Sousse, Monastir, and Mahdia, Tunisia. Study period: November 2020 to January 2022. Participants: Parents of children with ASD aged 3–8 years (N=62), randomized to intervention (n=31) or control (n=31) using a random number list and sealed envelopes. Usual care continued for all children. Eligibility: Inclusion—child aged 3–8 with ASD diagnosis per DSM-IV criteria confirmed by ADI-R and CARS-T; receiving local services as usual; parent cohabiting with child ≥6 months. Exclusion—parent with diagnosed mental health disorder; current or past enrollment in a structured parenting program. Recruitment through centers and social media; informed written consent obtained. Attrition: At 6 months, 29 families per group completed follow-up (total n=58). Intervention (Parents in Action: Blue Hope): Eight core group sessions (each 120 min) over ~20 weeks, delivered in dialectal Arabic by experienced special educators/psychologists and the researcher. Modalities included interactive training, group discussion, videos, role-play, handouts, and homework. Content: ASD education (diagnosis, characteristics, sensory issues); parental coping, grief, stress management; communication strategies (verbal and nonverbal); behavioral principles and Positive Behavior Support (identifying functions of behavior; antecedent/consequence strategies); reinforcement and skill-building (prompting, shaping, chaining); play and activity planning in home/natural environments. Two optional online booster sessions; parents were asked to complete ≥30 min daily planned practice with the child. Control: Usual local early childhood services; no PT during study period; baseline and 6‑month assessments. Assessments: Three waves—pretreatment (T0), immediate post-treatment (T1), and 6 months after baseline (T2). Parent outcomes: Hospital Anxiety and Depression Scale (HADS: Anxiety HADS-A, Depression HADS-D; cutoff≥8 for possible case; ≥11 indicates case). Quality of Life: WHOQOL-BREF (physical, psychological, social, environmental, and global). Child outcomes: Social Communication Questionnaire (SCQ; total 0–39, higher=worse; cutoff 11 for ASD risk) and Aberrant Behavior Checklist (ABC; subscales: Irritability, Social Withdrawal, Stereotypic Behavior, Hyperactivity/Noncompliance, Inappropriate Speech). Statistics: IBM SPSS v22; alpha=0.05. Normality: Kolmogorov–Smirnov. Categorical comparisons: Pearson Chi-square. Continuous comparisons: Student’s t test or Mann–Whitney U. CONSORT guidelines followed. Ethics: Approved by Faculty of Medicine of Sousse ethics committee (CEFMS 58/2020); trial registered (PACTR202212752100115).

Baseline equivalence: No significant differences between groups on demographics or outcome measures. Parent mental health (HADS): Compared to controls, the intervention group showed significant reductions in anxiety and depression at post-treatment and further improvement at 6 months (all p<10^-3). Anxiety means: T0 13.10 vs 11.94 (p=0.14), T1 8.45 vs 12.48 (p<10^-3), T2 6.97 vs 12.58 (p<10^-3). Depression means: T0 12.35 vs 11.29 (p=0.09), T1 6.74 vs 11.16 (p<10^-3), T2 5.39 vs 11.87 (p<10^-3). The total HADS score also improved significantly over time in the intervention group. Quality of life (WHOQOL-BREF): Significant improvement in the psychological domain at T1 and T2 (p<10^-3). No significant between-group differences for physical, social, or environmental domains at T1 or T2. Child communication/ASD severity (SCQ): No significant difference at T1 (p=0.38). Significant reduction at T2 favoring intervention (mean 15.77 vs 18.71; p<10^-3), indicating improved social communication/ASD symptom severity. Child behavior (ABC subscales): Significant improvements favoring intervention, particularly at 6 months. Irritability: T2 12.64 vs 15.77 (p=0.001). Hyperactivity: T2 11.70 vs 13.96 (p=0.008). Social Withdrawal: T1 9.19 vs 10.51 (p=0.035); T2 8.06 vs 10.58 (p<10^-3). Inappropriate Speech: T2 4.87 vs 6.22 (p=0.002). Stereotyped Behavior: T2 4.67 vs 5.77 (p=0.01). Immediate post-treatment differences were smaller and domain-specific, with broader and stronger effects at 6 months. Completion: 29 families per group completed 6‑month follow-up (n=58). Results support durable benefits of the PT program for both parent and child outcomes.

Findings support the primary and secondary hypotheses: a culturally tailored parent training program reduced parental anxiety and depression and improved psychological quality of life, while also improving child behavior and social communication/ASD severity, with effects strengthening by 6 months. The emphasis on practical behavioral strategies (aligned with Applied Behavior Analysis principles), communication coaching, and parental coping likely contributed to outcomes. Compared with prior literature, results align with reports that PT can reduce disruptive behaviors and improve parent mental health, and extend the evidence to an Arab, low-resource setting using group-based, hybrid delivery in dialectal Arabic. The delayed emergence of significant SCQ changes suggests cumulative gains when parents generalize techniques over time. The study demonstrates feasibility and potential cost-effectiveness of community-delivered PT in Tunisia, addressing service gaps and cultural-linguistic barriers, and highlights the role of parent empowerment in improving child trajectories and parental well-being.

The Blue Hope parent training program enhanced parents’ mastery of evidence-based strategies, leading to reduced parental anxiety/depression and improved psychological QoL, as well as improved child behavior and social communication/ASD symptom severity—effects that persisted and strengthened at 6 months. The intervention appears feasible and potentially cost-effective for low-resource contexts and can inform policy and service design in Tunisia and other LMICs. Future research should scale and adapt the program, evaluate longer-term outcomes, and integrate multi-informant and observational measures to validate and extend findings.

- Small sample size with preschool children largely presenting mild to moderate ASD, limiting generalizability. - Double-blinding not feasible due to resource constraints, introducing possible bias. - Attrition occurred over follow-up. - Outcomes relied largely on parent-reported measures, which may be influenced by parental involvement and expectations. Future studies should include teacher/professional ratings, blinded observational assessments, and physiological stress markers to strengthen objectivity.