Parent-implemented interventions in Chinese families of children with autism spectrum disorder

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by persistent social communication deficits and restricted, repetitive behaviors, with lifelong impact. The global prevalence of ASD is rising and families face substantial psychosocial and financial burdens. Intensive, clinic-based rehabilitation (e.g., 25–40 hours/week) is often inaccessible or unaffordable, particularly in China where costs are largely borne by families. Parent-implemented interventions (PIIs) offer a potentially cost-effective alternative by training caregivers to deliver evidence-based strategies within daily routines. Prior work suggests PIIs improve children’s communication and social functioning, but Chinese evidence is limited and effects on family quality of life (FQOL) are understudied. This study therefore asks: (i) What are the effects of PIIs on the abilities (social communication and related domains) of children with ASD in China? (ii) Do PIIs affect the family quality of life of families of children with ASD in China, and in what ways?

Evidence indicates parents of children with ASD experience higher stress and financial strain than parents of children with other disabilities. Clinic recommendations for intensive therapy create barriers to access. PIIs (also termed parent training or parent-mediated interventions) train caregivers to embed individualized strategies into everyday settings to improve children’s communication, social engagement, behavior, and daily living skills. Multiple studies report positive effects of PIIs on motor, communication, and adaptive behaviors and emphasize strengthened caregiver–professional partnerships. In China, most research is theoretical or review-based, with limited empirical studies showing benefits for joint attention and social interaction. Social support theory posits that emotional, informational, appraisal, and instrumental supports enhance family well-being; PIIs may function as such support, potentially improving FQOL. There remains a gap in Chinese empirical evidence, particularly regarding PIIs’ effects on family-level outcomes, justifying a replication and extension in the Chinese context.

Design: Randomized controlled trial with pre-test, post-test, and 3-month follow-up assessments over 7 months total. Setting and participants: Recruited from the Fifth Hospital of Yulin City (Shaanxi, China), a neurodevelopmental specialty hospital conducting PII training. Participants were 70 children with ASD (diagnosis confirmed by qualified institutions) and 70 parents (one per family; junior high education or above; biological parent; complete parenting experience since diagnosis). Parents aged 25–45 years; children predominantly preschool age (2–5 years). Groups were balanced on demographics (no significant differences in parent gender, age, education, employment; child gender, age, ASD severity; p > 0.05). Groups: Intervention group (N parents = 35, age M ± SD = 35.69 ± 3.45; N children = 35, age M ± SD = 5.49 ± 2.74). Control group (N parents = 35, age M ± SD = 36.06 ± 4.28; N children = 35, age M ± SD = 5.71 ± 3.25). Intervention: Parents in the intervention group received Caregiver Skills Training (CST; WHO) delivered by hospital trainers in 15 modules (engagement, communication, behavior understanding and support, teaching new skills, problem-solving, and self-care). Each module lasted 40–60 minutes, delivered twice weekly (Wednesday and Friday) over two months. From the end of the first training, parents implemented daily home-based interventions (90–120 minutes/day), with audio/video recordings for monitoring, over 5 months (from first family intervention to follow-up). All children in both groups continued usual hospital-based rehabilitation. Measures: Children’s ASD symptom severity via CARS-2 Standard Version (CARS2-ST; 15 items, 4-point scale; strong reliability α ≈ 0.93 and validity). Family Quality of Life via the Beach Center FQOL Scale (25 items; five domains: family interaction, parenting, emotional well-being, physical/material well-being, disability-related support; satisfaction rated 1–5; strong reliability and validity). Procedure: Phases included pre-test (trainer ratings on CARS2-ST using parent reports, diagnostic records, and observation; parents completed FQOL), training, home implementation, post-test (CARS2-ST and FQOL), and 3-month follow-up (CARS2-ST and FQOL). Data were analyzed in SPSS 27.0 using 2 (group: intervention, control) × 3 (time: pre, post, follow-up) repeated measures ANOVA and paired-samples t-tests within the intervention group. Ethics approval was obtained; informed consent was secured; data were anonymized and securely stored.

- Sample and data completeness: 140 scales collected at each time point (70 children, 70 parents) with all valid. - Children’s outcomes (CARS2-ST): Repeated measures ANOVA showed a significant main effect of time, F(2,67) = 101.85, p < 0.001; nonsignificant main effect of group, F(1,68) = 3.69, p > 0.05; significant time × group interaction, F(2,67) = 49.61, p < 0.001. Group comparisons: no pre-test difference, F(1,68) = 0.176, p > 0.05; significant post-test difference, F(1,68) = 5.63, p < 0.05; significant follow-up difference, F(1,68) = 8.78, p < 0.05. Intervention group improved significantly from pre to post and post to follow-up (all p < 0.001); control showed no significant change from pre to post or post to follow-up (p > 0.05), with a smaller pre to follow-up change (p < 0.05). • Mean CARS2-ST (Intervention): pre 38.89 ± 2.63; post 37.31 ± 2.65; follow-up 36.69 ± 2.68. Control: pre 39.17 ± 3.05; post 38.97 ± 3.17; follow-up 38.71 ± 2.89. • Within-intervention paired t-tests (selected subscales): significant improvements from pre to post in imitation (p < 0.05), emotional response (p < 0.001), fear and nervousness (p < 0.05), non-verbal communication (p < 0.05). Maintenance/enhancement from post to follow-up in emotional response (p < 0.05), fear and nervousness (p < 0.05), and activity level (p < 0.05). Total score t-values: pre vs post t = 12.58, p < 0.001; post vs follow-up t = 5.76, p < 0.001. - Family Quality of Life (FQOL): Repeated measures ANOVA on total score showed significant main effect of time, F(2,67) = 91.87, p < 0.001; significant main effect of group, F(1,68) = 35.04, p < 0.001; significant time × group interaction, F(2,67) = 53.92, p < 0.001. No group difference at pre-test; significant differences at post-test and follow-up favoring intervention (p < 0.001). • FQOL total means (Intervention): pre 60.54 ± 3.09; post 65.11 ± 3.01; follow-up 66.46 ± 3.09. Control: pre 59.86 ± 2.44; post 60.57 ± 2.59; follow-up 60.54 ± 2.57. • Intervention group paired t-tests: Pre to post significant increases in all five domains—family interaction (t = 6.39, p < 0.001), parenting (t = 13.52, p < 0.001), emotional well-being (t = 5.45, p < 0.001), physical/material well-being (t = 2.76, p < 0.05), disability-related support (t = 5.76, p < 0.001). Post to follow-up significant increases in family interaction (t = 6.42, p < 0.001), parenting (t = 3.51, p < 0.05), emotional well-being (t = 2.24, p < 0.05), physical/material well-being (t = 3.43, p < 0.05). Total score improved from pre to post (t = 12.15, p < 0.001) and post to follow-up (t = 8.20, p < 0.001). - Interpretation: PIIs significantly enhanced children’s social communication-related abilities (e.g., imitation, emotional regulation, non-verbal communication) and improved multiple dimensions of family quality of life, with effects maintained or further improved at 3-month follow-up. Combining institutional and family interventions was more effective and faster-acting than institutional rehabilitation alone.

The RCT demonstrates that parent-implemented interventions, delivered via WHO’s CST framework and embedded in daily home routines, significantly improve children’s ASD-related behaviors tied to social communication and reduce symptom severity over time. Concurrently, these interventions increase parental satisfaction across key FQOL domains, indicating broader family-level benefits consistent with social support theory (emotional, informational, and instrumental support). The results directly answer the research questions: PIIs benefit children’s abilities and have substantial positive effects on family quality of life in the Chinese context. Importantly, the combination of clinic-based rehabilitation and structured home implementation yields greater and quicker gains than clinic-only approaches, suggesting a cost-effective model that can alleviate family burden while maintaining therapeutic impact.

Parent-implemented interventions in China, structured around WHO’s CST, effectively enhance the social communication abilities of children with ASD and improve family quality of life across family interaction, parenting, emotional well-being, physical/material well-being, and disability-related support. PIIs serve as a cost-effective complement to institutional rehabilitation and have positive implications for the well-being and sustainability of children with ASD and their families. Future research should broaden sampling across diverse Chinese regions and cultures, examine determinants of family quality of life in local contexts, evaluate lifelong support models that balance cost and feasibility, and identify optimal family intervention strategies across different developmental stages.

The sample was drawn from a single hospital, limiting generalizability; broader, more diverse samples across China are needed. The study calls for deeper investigation of factors influencing family quality of life in the Chinese context. Lifelong intervention demands impose significant time, financial, and labor burdens, indicating a need to study supportive social policies, welfare, and services. Finally, while positive effects were observed for children and families at the studied life stage, the appropriate family intervention strategies for other developmental stages remain to be determined.