Autism spectrum disorder (ASD) is a lifelong neurodevelopmental disorder affecting social communication and characterized by repetitive behaviors and restricted interests. Its prevalence has increased globally, placing a significant burden on children and families. Parents of children with ASD face unique challenges, including managing challenging behaviors, coping with cognitive impairments, and addressing difficulties in social interaction and bonding. These challenges often lead to parental psychological distress, including stress, anxiety, and depression. While interventions for young children with ASD can improve communication and reduce symptoms, existing interventions often cater to English-speaking, middle-class families, neglecting cultural considerations. In Tunisia, limited resources, late identification of needs, and cultural barriers hinder the delivery of parent training (PT) services. This study aimed to evaluate the effectiveness of a culturally tailored intervention, the "Blue Hope" program, designed to support Tunisian parents of preschool children with ASD, focusing on improving both child developmental outcomes and parental well-being.

The literature extensively documents the challenges faced by parents of children with ASD and the significant impact on their mental health and quality of life. Numerous studies highlight the effectiveness of parent-mediated interventions and psychoeducational programs in improving child outcomes and reducing parental stress. However, many interventions are designed for Western, middle-class families, overlooking cultural variations and resource limitations. The lack of culturally adapted interventions in Arab countries, particularly Tunisia, necessitates the development of contextually relevant programs. Previous research in Tunisia indicates a prevalence rate of ASD, but lacks studies assessing the impact of parent training programs on both children and their parents. This gap emphasizes the need for culturally sensitive interventions that address the specific challenges faced by Tunisian families.

This study employed a randomized controlled trial (RCT) design conducted in three Autism socio-educational centers in Tunisia. Sixty-two parents of children aged 3-8 years diagnosed with ASD were randomly assigned to either an intervention group (n=31) or a control group (n=31). The "Blue Hope" intervention consisted of eight 120-minute sessions delivered through a combination of face-to-face and online formats. The program integrated various early intervention and cognitive-behavioral techniques, focusing on educating parents about ASD, supporting emotional processing, managing challenging behaviors, and improving communication skills. Data collection involved three waves: pre-treatment (T0), baseline (T1), and 6-month follow-up (T2). Parental anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS). Parental quality of life was measured using the WHOQOL-BRIEF. Child outcomes were evaluated using the Aberrant Behavior Checklist (ABC) and the Social Communication Questionnaire (SCQ). Statistical analyses included Pearson's Chi-square test, Student's t-test, and Mann-Whitney U test.

At baseline, no significant differences existed between the intervention and control groups. However, at the 6-month follow-up, the intervention group showed significant improvements compared to the control group. Specifically, the "Blue Hope" program significantly reduced parental anxiety and depression scores (all p < 0.001). The intervention also led to significant improvements in the psychological domain of parental quality of life (p < 0.001). Regarding child outcomes, although no significant differences were observed at baseline or immediately post-treatment for SCQ scores, a significant improvement in autism severity was noted at 6-month follow-up (p < 0.001). Similarly, the ABC scores showed significant improvements in irritability, hyperactivity, social withdrawal, inappropriate speech, and stereotyped behavior (all p < 0.001) at 6-month follow-up in the intervention group.

The findings support the effectiveness of the "Blue Hope" parent training program in reducing parental mental health burden and improving child outcomes in a Tunisian context. The significant reduction in parental anxiety and depression underscores the program's ability to equip parents with coping mechanisms and strategies to manage the challenges of raising a child with ASD. Improvements in child communication skills and a reduction in challenging behaviors indicate the program's positive impact on children's development. The long-term effects observed at the 6-month follow-up highlight the sustainability of the intervention's positive impact. The study's results are consistent with some, but not all, previous research on parent-mediated interventions. Differences may be attributed to the program's culturally tailored approach and the inclusion of both online and face-to-face sessions.

The "Blue Hope" program demonstrates a cost-effective approach to supporting parents of preschool children with ASD in low-resource settings. Its culturally adapted design and the use of diverse delivery methods contributed to its success. Future research should focus on larger-scale studies to confirm the generalizability of findings, explore the program's effectiveness across different ASD severities, and investigate the long-term impact on family functioning and child development. Policy makers in Tunisia and other low- and middle-income countries (LMICs) should consider implementing similar culturally relevant, feasible, and community-based interventions.

The relatively small sample size and the lack of double-blinding might limit the generalizability of the findings. The study primarily included mothers, limiting the understanding of the program's impact on fathers. Participant attrition during the follow-up period may have influenced the results. Future research should address these limitations by employing larger samples, incorporating diverse parental roles, and implementing strategies to reduce attrition rates. The inclusion of objective measures from external observers would enhance the rigor of future studies.