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Outcomes of the World Health Organization's Caregiver Skills Training Program for Eritrean and Ethiopian Parents of Autistic Children in the United States

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Title: Outcomes of the World Health Organization's Caregiver Skills Training Program for Eritrean and Ethiopian Parents of Autistic Children in the United States
Language: English
Authors: Sarah Dababnah (ORCID 0000-0001-8298-1639), Waganesh A. Zeleke (ORCID 0000-0002-4604-336X), Yoonzie Chung (ORCID 0000-0001-5528-6577), Rachel Antwi Adjei, Pamela Dixon, Erica Salomone (ORCID 0000-0002-8083-5942), WHO CST Team
Source: Autism: The International Journal of Research and Practice. 2025 29(12):2941-2954.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
Peer Reviewed: Y
Page Count: 14
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Education Level: Adult Education
Descriptors: Autism Spectrum Disorders, Skill Development, Parent Education, Immigrants, Foreign Countries, Mothers, Anxiety, Stress Variables, Coping, Stress Management, Intervention, Program Effectiveness, Neurodevelopmental Disorders
Geographic Terms: Eritrea, Ethiopia, Maryland, District of Columbia, Virginia
DOI: 10.1177/13623613251351345
ISSN: 1362-3613
1461-7005
Abstract: Autism intervention research has not adequately addressed the needs of Black autistic children and their families, particularly those who are also immigrants to the United States. The World Health Organization designed Caregiver Skills Training (CST), a parent-mediated intervention intended to improve child social communication and behavior, to fill in the global gap of services for caregivers of young children with autism and other neurodevelopmental conditions. While CST has been implemented in Ethiopia, it has not been evaluated for Ethiopian and Eritrean immigrant families in the United States. This single-arm pilot study of CST investigated pre- and post-intervention changes in parent and child outcomes within a sample of 25 mothers of autistic children (ages 2-9 years) in Maryland, Washington, DC, and Virginia. Eritrean and Ethiopian facilitators delivered CST remotely to five parent groups. We used Wilcoxon signed-rank tests and found statistically significant improvements in parents' knowledge, skills, self-efficacy, depression, and empowerment, as well as child communication, sociability, and sensory/ cognitive awareness. There were no statistically significant changes in parents' anxiety, stress, and coping, nor some subscales of the empowerment and child outcome measures. We conclude CST is a promising intervention for Ethiopian and Eritrean immigrant families in the United States. Randomized controlled trials are needed to confirm study findings.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1489391
Database: ERIC
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  Value: <anid>AN0189325690;f9d01dec.25;2025Nov18.00:28;v2.2.500</anid> <title id="AN0189325690-1">Outcomes of the World Health Organization's Caregiver Skills Training Program for Eritrean and Ethiopian parents of autistic children in the United States </title> <p>Autism intervention research has not adequately addressed the needs of Black autistic children and their families, particularly those who are also immigrants to the United States. The World Health Organization designed Caregiver Skills Training (CST), a parent-mediated intervention intended to improve child social communication and behavior, to fill in the global gap of services for caregivers of young children with autism and other neurodevelopmental conditions. While CST has been implemented in Ethiopia, it has not been evaluated for Ethiopian and Eritrean immigrant families in the United States. This single-arm pilot study of CST investigated pre- and post-intervention changes in parent and child outcomes within a sample of 25 mothers of autistic children (ages 2–9 years) in Maryland, Washington, DC, and Virginia. Eritrean and Ethiopian facilitators delivered CST remotely to five parent groups. We used Wilcoxon signed-rank tests and found statistically significant improvements in parents' knowledge, skills, self-efficacy, depression, and empowerment, as well as child communication, sociability, and sensory/cognitive awareness. There were no statistically significant changes in parents' anxiety, stress, and coping, nor some subscales of the empowerment and child outcome measures. We conclude CST is a promising intervention for Ethiopian and Eritrean immigrant families in the United States. Randomized controlled trials are needed to confirm study findings. Autism intervention research has often not included Black autistic children and families, including those who are also immigrants to the United States. The World Health Organization designed Caregiver Skills Training (CST) because there are not enough services for caregivers of young children with autism and other neurodevelopmental conditions. CST is an intervention in which parents receive information on how to support their own and their children's needs in nine group and three individual sessions. While CST has been adapted and piloted in Ethiopia, it has not been evaluated for Ethiopian and Eritrean immigrant families in the United States. In this study, five groups with a total of 25 mothers of autistic children (ages 2–9 years) all received CST from Eritrean and Ethiopian facilitators on Zoom. The participants completed surveys about themselves and their autistic children before and after they completed CST. We found that parents' knowledge, skills, self-efficacy, depression, and empowerment, as well as their children's communication, sociability, and sensory/cognitive awareness improved after they completed CST. We did not find changes in some areas we measured, such as parents' anxiety, stress, and coping. We believe that CST might be a promising intervention for Ethiopian and Eritrean immigrant families in the United States. We recommend that more research should be done to confirm what we found in this study.</p> <p>Keywords: autism; Caregiver Skills Training; early intervention; Eritrea; Ethiopia; immigrants; parent-mediated autism intervention; telehealth; World Health Organization; neurodevelopmental conditions; developmental delays; developmental disabilities</p> <p>As the prevalence of autism in the United States (US) has increased over the past two decades ([<reflink idref="bib30" id="ref1">30</reflink>]), so too has the availability of early intervention strategies, programs, and resources for families of autistic children. Rigorous trials of parent-mediated autism interventions (i.e. interventions in which parents learn child therapeutic approaches from professionals to use with their children) have reported a vast array of developmental and behavioral improvements for autistic children ([<reflink idref="bib2" id="ref2">2</reflink>]; [<reflink idref="bib13" id="ref3">13</reflink>]; [<reflink idref="bib36" id="ref4">36</reflink>]; [<reflink idref="bib37" id="ref5">37</reflink>]; [<reflink idref="bib39" id="ref6">39</reflink>]; [<reflink idref="bib40" id="ref7">40</reflink>]; [<reflink idref="bib41" id="ref8">41</reflink>]; [<reflink idref="bib53" id="ref9">53</reflink>]). These interventions aim to target child social communication, challenging behaviors, and other common concerns for autistic children. To a lesser extent, existing parent-mediated interventions address the high, persistent levels of stress and depression disproportionately experienced by parents raising autistic children ([<reflink idref="bib7" id="ref10">7</reflink>]; [<reflink idref="bib10" id="ref11">10</reflink>]; [<reflink idref="bib41" id="ref12">41</reflink>]). Indeed, despite the correlation between child and parent outcomes ([<reflink idref="bib7" id="ref13">7</reflink>]; [<reflink idref="bib59" id="ref14">59</reflink>]), autism interventions have only more recently begun to focus on parent needs such as parent mental health or self-efficacy ([<reflink idref="bib13" id="ref15">13</reflink>]; [<reflink idref="bib19" id="ref16">19</reflink>]; [<reflink idref="bib49" id="ref17">49</reflink>]; [<reflink idref="bib53" id="ref18">53</reflink>]).</p> <p>Despite recent advances in autism intervention research, there remain considerable gaps in knowledge regarding the availability, relevance, and access of autism-related interventions to racially, ethnically, and other minoritized communities. Only a small number of interventions have specifically focused on the needs of parents in low- and middle-income countries ([<reflink idref="bib41" id="ref19">41</reflink>]) or racially or ethnically minoritized communities in high-income countries (e.g. <emph>Parents Taking Action</emph>; [<reflink idref="bib31" id="ref20">31</reflink>]). The dearth of such interventions is concerning given the widely reported geographic, racial, ethnic, and socioeconomic disparities in autism service use (e.g. low-income and racially and ethnically minoritized autistic children in the US are less likely to receive early intervention; [<reflink idref="bib4" id="ref21">4</reflink>]; [<reflink idref="bib28" id="ref22">28</reflink>]; [<reflink idref="bib35" id="ref23">35</reflink>]; [<reflink idref="bib50" id="ref24">50</reflink>]) and the unique needs of culturally diverse parents of autistic children (e.g. necessity of culturally and linguistically relevant information on the autism diagnosis; [<reflink idref="bib38" id="ref25">38</reflink>]). Indeed, the preponderance of autism intervention studies have been conducted primarily with white, upper-/middle-class families or do not report demographic characteristics at all ([<reflink idref="bib16" id="ref26">16</reflink>]; [<reflink idref="bib20" id="ref27">20</reflink>]; [<reflink idref="bib48" id="ref28">48</reflink>]; [<reflink idref="bib52" id="ref29">52</reflink>]).</p> <p>Amid the emerging body of research focused on racially and ethnically minoritized autistic children and their families, there is little known about the experiences of immigrant families of autistic children. Broadly, research has noted that immigrants underutilize healthcare and social services for a variety of reasons, including limited English skills, poverty, fear, stigma, high mobility, lack of healthcare insurance coverage, or difficulties navigating the US healthcare system ([<reflink idref="bib18" id="ref30">18</reflink>]; [<reflink idref="bib22" id="ref31">22</reflink>]; [<reflink idref="bib63" id="ref32">63</reflink>]). However, even when immigrant parents of autistic children overcome access barriers, they are faced with a service system that often provides interventions that are not culturally and contextually modified to address the distinct challenges faced by immigrant families ([<reflink idref="bib38" id="ref33">38</reflink>]).</p> <p>Ethiopians compose the second-largest African population in the US ([<reflink idref="bib32" id="ref34">32</reflink>]). Yet, the literature on Ethiopian and Eritrean American families raising autistic children is almost nonexistent, despite their intersectional identities as racially minoritized and immigrant people in the US ([<reflink idref="bib1" id="ref35">1</reflink>]; [<reflink idref="bib62" id="ref36">62</reflink>]). In this research, we consider Eritreans and Ethiopians together due to their shared history. Eritrea gained independence from Ethiopia in the early 1990s, and it was not until the 2000s that the US Census Bureau counted them separately ([<reflink idref="bib1" id="ref37">1</reflink>]). Both countries are multilingual and share many cultural values. They also have similar experiences as immigrants in the US, such as relying on spiritual practices and family and community support as coping mechanisms ([<reflink idref="bib1" id="ref38">1</reflink>]). One study found that language barriers, distrust in the healthcare system, and lack of understanding of the signs and symptoms of autism can lead to delays in diagnosis, treatment, and school support ([<reflink idref="bib62" id="ref39">62</reflink>]). The study also found that Ethiopian immigrant parents in the US reported a lack of information about available services or care coordination for their autistic children ([<reflink idref="bib62" id="ref40">62</reflink>]). The parents also expressed that formal support systems needed to help them cope with autism-related stigma were limited ([<reflink idref="bib62" id="ref41">62</reflink>]). A recent study focused on the perspectives of Eritrean and Ethiopian families of autistic children confirmed findings from [<reflink idref="bib62" id="ref42">62</reflink>], including the need for culturally relevant supports for parents ([<reflink idref="bib1" id="ref43">1</reflink>]).</p> <p>Despite the lack of autism research on Ethiopian and Eritrean immigrant parents raising autistic children in the US, some studies have been conducted in Ethiopia. They have noted a shortage of child mental health and disability specialists, as well as a severely limited service array, particularly services that are evidence-informed and delivered by qualified professionals ([<reflink idref="bib60" id="ref44">60</reflink>]; [<reflink idref="bib64" id="ref45">64</reflink>]). In response to the significant needs for care related to children with autism and other neurodevelopmental conditions in Ethiopia, [<reflink idref="bib54" id="ref46">54</reflink>] adapted and implemented the World Health Organization's Caregiver Skills Training (CST) program in the country.</p> <p>The World Health Organization developed CST to address the needs of families of children with autism and other neurodevelopmental conditions ([<reflink idref="bib43" id="ref47">43</reflink>]; [<reflink idref="bib58" id="ref48">58</reflink>]). This parent-mediated intervention is specifically designed for implementation in low-resource settings by non-specialists, with protocols to culturally and contextually adapt the intervention to ensure its relevance for target users ([<reflink idref="bib43" id="ref49">43</reflink>]; [<reflink idref="bib57" id="ref50">57</reflink>]). CST focuses on enhancing the parent-child relationship; improving parent well-being, knowledge, coping abilities, and self-efficacy; increasing child adaptive and communication skills; and decreasing challenging behavior ([<reflink idref="bib43" id="ref51">43</reflink>]). Ethiopia was one of the first countries globally to adapt and evaluate CST, which found high acceptability and feasibility ([<reflink idref="bib54" id="ref52">54</reflink>]), as well as the need for additional cultural and contextual modifications to improve implementation ([<reflink idref="bib64" id="ref53">64</reflink>]). An ongoing multisite trial in Ethiopia and Kenya will rigorously test CST outcomes in these settings ([<reflink idref="bib55" id="ref54">55</reflink>]).</p> <p>Given the successful implementation of CST for parents of autistic children in Ethiopia, the intervention holds promise to fill in the gap of culturally relevant programs for Ethiopians and Eritreans in the diaspora. Thus, we aimed to adapt and pilot CST for Eritrean and Ethiopian immigrant parents of autistic children in the US. We have described our rigorous adaptation process of CST to the US context elsewhere ([<reflink idref="bib61" id="ref55">61</reflink>]). The purpose of this article is to report changes in parent and child outcomes following participation in CST.</p> <hd id="AN0189325690-2">Method</hd> <p></p> <hd id="AN0189325690-3">Intervention description and training procedures</hd> <p>A university-based institutional review board approved this single-arm pilot study. The CST package, which is free and publicly accessible, includes guides for planning, adaptation, implementation, monitoring, and evaluation; booklets for facilitators and participants; and training and supervision materials ([<reflink idref="bib58" id="ref56">58</reflink>]). CST is the result of a rigorous scientific process undertaken by the World Health Organization, leading early intervention experts, and community stakeholders ([<reflink idref="bib43" id="ref57">43</reflink>]). It incorporates common elements of evidence-based autism interventions while responding to unique cultural needs and limited resources. CST can be adapted to different local needs and possible mechanisms to reach parents and other caregivers and implement training in communities. Its acceptability and feasibility have been tested in multiple contexts, across high-income ([<reflink idref="bib33" id="ref58">33</reflink>]; [<reflink idref="bib42" id="ref59">42</reflink>]; [<reflink idref="bib56" id="ref60">56</reflink>]) and low- and middle-income countries ([<reflink idref="bib46" id="ref61">46</reflink>]; [<reflink idref="bib54" id="ref62">54</reflink>]).</p> <p>As we describe in a separate article ([<reflink idref="bib61" id="ref63">61</reflink>]), we adapted the Amharic language materials from the Ethiopian CST site ([<reflink idref="bib54" id="ref64">54</reflink>]; [<reflink idref="bib64" id="ref65">64</reflink>]) to the US context using an intensive community-engaged process guided by [<reflink idref="bib3" id="ref66">3</reflink>] Ecological Validity Framework. In short, aside from linguistic (e.g. reducing technical language) and contextual (e.g. anticipating differences in educational levels and acculturation across participants) changes we made using [<reflink idref="bib57" id="ref67">57</reflink>] protocols, we also prepared to deliver CST remotely via Zoom. We made this decision collectively with our community partners given the COVID-19 pandemic, the geographic dispersal of participants across the region, and generally high Internet access levels. We also considered our telehealth experience, plus the growing evidence of the feasibility and acceptability of CST delivered remotely in high-income countries ([<reflink idref="bib17" id="ref68">17</reflink>]; [<reflink idref="bib26" id="ref69">26</reflink>]; [<reflink idref="bib33" id="ref70">33</reflink>]). Thus, we incorporated additional time to train Master Trainers (in the context of this study, individuals with specialized experience to deliver autism interventions who train and support non-specialist intervention facilitators) to strengthen participant engagement on Zoom (e.g. developing virtual group norms related to privacy and confidentiality; demonstrating and practicing child-parent interactions using role-plays and breakout rooms).</p> <p>The course was delivered entirely in Amharic. While we did not use any English materials directly during the sessions, as a bilingual community, there was mixing with English in some sessions. All participants received a PDF copy of the participant manual. For those participants who intended to join with their phone, we also mailed a hard copy.</p> <p>Master Trainers support non-specialist facilitators (i.e. those without professional training to deliver autism interventions), such as parents, teachers, or workers in community-based facilities, to deliver CST in pairs. The intervention consists of a combination of nine group sessions and three individual sessions. Each group session has a specific focus: (<reflink idref="bib1" id="ref71">1</reflink>) introduction and psychoeducation, (<reflink idref="bib2" id="ref72">2</reflink>) child-directed play/engagement, (<reflink idref="bib3" id="ref73">3</reflink>) helping children share engagement, (<reflink idref="bib4" id="ref74">4</reflink>) understanding social communication, (<reflink idref="bib5" id="ref75">5</reflink>) promoting communication, (<reflink idref="bib6" id="ref76">6</reflink>) preventing challenging behavior, (<reflink idref="bib7" id="ref77">7</reflink>) responding to challenging behavior and promoting positive behavior, (<reflink idref="bib8" id="ref78">8</reflink>) learning new skills, and (<reflink idref="bib9" id="ref79">9</reflink>) emotion regulation and caregiver well-being. The group sessions used various learning techniques: modeling, role-play, demonstrations, group discussions, and case vignettes. The first individual session (prior to the first group session) is intended to define specific goals and targets for each family, explore the presence of additional health problems, and inform and engage other caregivers. The two subsequent individual sessions (midway and at the end of the intervention) focus on coaching the parent, providing tailored support, evaluating progress, troubleshooting, and identifying possible additional support needs. The group sessions last 2–2.5 hours on a weekly or biweekly basis.</p> <p>CST uses a cascade training model to train interventionists to deliver CST, in which a small number of autism intervention specialists train and support non-specialists to deliver the program (Figure 1). First, with the support of a nonprofit autism advocacy organization, we organized six weekly 4-hour trainings for six individuals with professional backgrounds in education, psychology, or other helping professions and prior autism intervention experience. These individuals also spoke Amharic and had lived experiences as Ethiopian or Eritrean parents (five mothers and one father) of autistic individuals. CST Master Trainers were chosen based not only on their professional autism experience but also on their willingness to incorporate CST into their routine services and to train and supervise non-specialists to carry out the intervention. Four experienced Master Trainers (three from Ethiopia and one from the US) led the "Master Trainer" training over Zoom. After the new Master Trainers had delivered CST once, with support from the nonprofit autism advocacy organization, they led a CST training for four non-specialist facilitators, who all identified as Ethiopian mothers of autistic individuals. The non-specialist facilitators received 7 days of training to prepare them to deliver their first CST course. This extended training included additional practice and feedback sessions to build facilitators' confidence and ensure effective delivery and cultural relevance of sessions, consistent with the cascade training model recommended in the WHO CST guidelines ([<reflink idref="bib57" id="ref80">57</reflink>]). Each non-specialist facilitator was paired with a Master Trainer in their first CST course and received direct supervision and coaching each time they delivered the program.</p> <p>Graph: Figure 1. Cascade training model.</p> <hd id="AN0189325690-4">Sample selection and recruitment</hd> <p>We predominantly recruited participants in Amharic and English in partnership with a community-based organization that serves Eritrean and Ethiopian parents of children with disabilities. However, we did not exclusively limit our recruitment to this group. Our partner organization facilitated recruitment by disseminating informational flyers through their organizational members and networks. The partner organization either obtained the family's permission to share contact information with the study team or provided the family with the necessary information to directly contact the study team. After obtaining a participant's contact information, a study team member directly contacted them to explain the study, including sending a study flyer and a copy of the electronic consent form which described study details. After allowing potential participants to ask questions, a study team member sent them a link to the electronic consent form via email. Participants provided consent by reading the full consent document and clicking the "I agree to consent" option.</p> <p>As Figure 2 shows, we recruited 41 caregivers and assessed them for the following eligibility criteria: (<reflink idref="bib1" id="ref81">1</reflink>) parents or other primary caregivers of an autistic child aged 2–9 years old; (<reflink idref="bib2" id="ref82">2</reflink>) Ethiopian or Eritrean, and (<reflink idref="bib3" id="ref83">3</reflink>) residence in Maryland, Washington, DC, or Virginia. Among them, five declined to participate, and two were excluded because of their child's age. Thus, we non-randomly assigned 34 participants to one of five CST groups based on their schedules. One individual did not complete the baseline measures, a pre-condition for participation, and three dropped out prior to the first session. Of the remaining 30 people, five caregivers did not complete the post-intervention measures for unknown reasons and were excluded from the analysis, resulting in a total of 25 people being analyzed.</p> <p>Graph: Figure 2. Intervention flowchart.</p> <hd id="AN0189325690-5">Intervention delivery and data-collection procedures</hd> <p>As recommended by the [<reflink idref="bib57" id="ref84">57</reflink>], Master Trainers and non-specialist facilitators piloted CST in two phases. First, the Master Trainers delivered CST to two groups of 11 participants meeting study recruitment criteria (5–6 per group). Then, once the non-specialist facilitators completed training, three Master Trainers paired with three non-specialist facilitators to deliver the intervention to three additional groups of 19 participants (6–7 per group). This phased approach enabled Master Trainers to document any issues with the program's comprehensibility, cultural relevance, timing/pacing, educational setting, or any other concerns raised by participants in the first groups they delivered. Based on participant and Master Trainer feedback in these groups, we simplified how we presented role-play scenarios to better reflect daily routines, shifted session times to late evening to accommodate participants' schedules, and added session reminders to enhance engagement during remote sessions in the subsequent three groups. As noted in our companion article ([<reflink idref="bib61" id="ref85">61</reflink>]), we shared our progress with the advisory board and other stakeholders to obtain feedback once the initial groups were complete.</p> <p>We collected data using Qualtrics, a secure survey software, between January and June 2022. At baseline (pre-intervention), we collected demographic information. Given the extensive nature of our feasibility and acceptability data, these results will be reported separately to allow for a more thorough analysis and inform replication. In this article, we focus on the pre- and post-intervention measures that participants completed approximately 3 months after baseline, covering parent outcomes (knowledge, self-efficacy, coping, depression, anxiety, and stress), family empowerment, and child outcomes (communication, sociability, sensory/cognitive awareness, and health/physical/behavioral problems). If parents had more than one autistic child, we asked them to report on their youngest autistic child within the 2- to 9-year-old age range. The estimated time required to complete the pre- and post-intervention measures was 2 hours in total. Participants completed the measures online on their own, but our team was available for questions or clarifications as needed. Participants received a $50 gift card to compensate for their time to complete the post-intervention measures.</p> <hd id="AN0189325690-6">Measures</hd> <p>We utilized measures recommended by the [<reflink idref="bib57" id="ref86">57</reflink>] in English. As noted earlier, we offered assistance to any participants needing help to complete the forms, although only one participant requested any clarification. We describe our measures below, along with their reliability in our current study. We considered Cronbach's α ⩾ 0.9 as very high/excellent; 0.7 ⩽ α < 0.9 as high/good; 0.6 ⩽ α < 0.7 as moderate/acceptable; 0.5 ⩽ α < 0.6 as poor/low; and α < 0.5 as unacceptable ([<reflink idref="bib11" id="ref87">11</reflink>]).</p> <hd id="AN0189325690-7">CST knowledge and skills</hd> <p>This CST-specific survey includes 24 items regarding caregivers' knowledge and skills (WHO CST Team, unpublished). Example items include: "Taking my child with me to social events can offer opportunities to improve my child's way of communicating," "Caregivers should take time to care for themselves and take part in social or family events," and "It is important to praise children during play time." The response options range from "1 = <emph>I strongly disagree</emph>" to "5 = <emph>I strongly agree</emph>." Some items were reverse-coded, such as "Caregivers should continue focusing all their effort and energy on their child even when they are very tired and worn out." We calculated mean scores, with higher scores representing elevated levels of caregivers' knowledge and skills. Cronbach's alpha coefficients at pre- and post-intervention were 0.78–0.81.</p> <hd id="AN0189325690-8">Caregiver Self-Efficacy Questionnaire</hd> <p>This 13-item measure assesses a caregiver's confidence in applying the skills and knowledge caregivers have learned in CST (WHO CST Team, unpublished). Examples of these items are "I feel confident in using everyday activities to create opportunities for my child to communicate" and "I feel confident in engaging my child in play activities." Responses range from "1 = <emph>not at all confident</emph>" to "5 = <emph>very confident</emph>." Responses were mean-scored. Higher scores indicated greater caregiver self-efficacy. The range of Cronbach's alpha coefficients at pre- and post-intervention was 0.88–0.91.</p> <hd id="AN0189325690-9">Depression, Anxiety, and Stress Scale</hd> <p>We used the Depression, Anxiety, and Stress Scale (DASS)-21 to measure how distressed respondents had felt over the past week ([<reflink idref="bib29" id="ref88">29</reflink>]). It is divided into three subscales: depression (seven items; e.g. "I couldn't seem to experience any positive feeling at all"), anxiety (seven items; e.g. "I was aware of dryness of my mouth"), and stress (seven items; e.g. "I found it hard to wind down"). The response options range from "0 = <emph>did not apply to me at all</emph>" to "3 = <emph>applied to me very much, or most of the time.</emph>" Higher mean scores represent elevated levels of depression, anxiety, and stress. The range of Cronbach's alpha coefficients at pre- and post-intervention were as follows: depression (0.87–0.88), anxiety (0.84–0.88), and stress (0.73–0.83).</p> <hd id="AN0189325690-10">Brief Coping Orientation to Problems Experienced Inventory (Brief COPE)</hd> <p>The Brief COPE measures the use of coping strategies ([<reflink idref="bib8" id="ref89">8</reflink>]). In this study, we asked parents to focus specifically on coping with stress related to raising an autistic child. The three overarching coping strategies were as follows: problem-focused coping (8 items; e.g. "I have been concentrating my efforts on doing something about the situation I am in"), emotion-focused coping (12 items; e.g. "I have been getting emotional support from others"), and avoidant coping (8 items; e.g. "I have been turning to work or other activities to take my mind off things"). The response options ranged from "1 = <emph>I have not been doing this at all</emph>" to "4 = <emph>I have been doing this a lot.</emph>" The range of Cronbach's alpha coefficients at pre-and post-intervention were as follows: problem-focused coping (0.91), emotion-focused coping (0.67–0.75), and avoidant coping (0.73–0.80). Higher problem-focused coping scores were associated with adaptive coping, whereas elevated avoidant coping scores were related to maladaptive coping. Higher emotion-focused coping scores indicated the use of emotions to manage stress.</p> <hd id="AN0189325690-11">Family Empowerment Scale</hd> <p>The Family Empowerment Scale (FES) measures empowerment of parents or other caregivers of children with disabilities ([<reflink idref="bib24" id="ref90">24</reflink>]). The current study used a shortened version of the original version (34 items) from the CST monitoring and evaluation guidelines (WHO CST Team, unpublished), with three subscales regarding family needs (six items; e.g. "I feel confident in my ability to help my child grow and develop"), child's services (six items; e.g. "I know the steps to take when I am concerned my child is receiving poor services"), and community involvement (five items; e.g. "I get in touch with my legislators when important bills or issues concerning children are pending"). The responses are on a 5-point scale ranging from "1 = <emph>never</emph>" to "5 = <emph>very often</emph>." The range of Cronbach's alpha coefficients at pre- and post-intervention were as follows: family (0.72–0.79), child services (0.67–0.88), and community involvement (0.65–0.78).</p> <hd id="AN0189325690-12">Autism Treatment Evaluation Checklist</hd> <p>The Autism Treatment Evaluation Checklist (ATEC) was developed for autistic children to measure the impact of interventions ([<reflink idref="bib14" id="ref91">14</reflink>]). It consists of 77 items and is classified into four domains: (<reflink idref="bib1" id="ref92">1</reflink>) speech/language/communication, 14 items; (<reflink idref="bib2" id="ref93">2</reflink>) sociability, 20 items; (<reflink idref="bib3" id="ref94">3</reflink>) sensory/cognitive awareness, 18 items; and 4) health/physical/behavioral problems, 25 items. Example items from the speech/language/communication domain are "knows own name" and "can follow some commands," with three response options ranging from "0 = <emph>very true</emph>" to "2 = <emph>not true</emph>." The range of Cronbach's alpha coefficients at pre- and post-intervention was 0.88–0.90. Example items from the sociability domain include "seems to be in a shell-you cannot reach him or her" and "ignores other people," with three response options ranging from "0 = <emph>not descriptive</emph>" to "2 = <emph>very descriptive</emph>." The range of Cronbach's alpha coefficients at pre- and post-intervention was 0.84–0.91. Example items from the sensory/cognitive awareness domain include "responds to own name" and "responds to praise," with three response options ranging from "0 = <emph>very descriptive</emph>" to "2 = <emph>not descriptive</emph>." Cronbach's alpha coefficients at pre- and post-intervention were 0.90–0.92. Finally, example items from the health/physical/behavior challenges domain include "bed-wetting," "hits or injures self," and "shouts or screams," with response options ranging from "0 = <emph>not a problem</emph>" to "3 = <emph>serious problem</emph>." The range of Cronbach's alpha coefficients at pre- and post-intervention was 0.76–0.85. Each domain's items were mean-scored, and the total score was summed. Higher scores indicate more challenges.</p> <hd id="AN0189325690-13">Data analysis</hd> <p>We used STATA Version 15.0 for data management, cleaning, and analyses. We used two-tailed Wilcoxon signed-rank tests to examine changes in the outcomes pre- and post-intervention. This non-parametric method is used to compare two matched samples and does not require a normal distribution. We considered <emph>p</emph> < 0.05 statistically significant. Multiple tests may lead to an increase in type 1 errors. Therefore, we utilized the Benjamini-Hochberg adjustment of significance level based on the ordered <emph>p</emph>-value and the ratio (rank divided by the total number of measures) with the chosen False Discovery Rate (0.5). We calculated effect sizes using <emph>r</emph> (z statistic/square root of the number of observations; range −1 to 1) and interpreted the|<emph>r</emph>| as small (0.1), medium (0.3), or large (0.5; [<reflink idref="bib9" id="ref95">9</reflink>]).</p> <hd id="AN0189325690-14">Community involvement</hd> <p>Our research team, led by an Ethiopian principal investigator, worked closely with individuals with lived experience related to this study: Ethiopian and Eritrean immigrant parents of autistic children in the US. As described throughout this article, Eritrean and Ethiopian parents and advocates led the adaptation, recruitment, and delivery of CST to other parents. We shared regular study updates with stakeholders through newsletters and meetings. A companion article, co-authored with parents and other community stakeholders involved in this research, describes their involvement in more detail ([<reflink idref="bib61" id="ref96">61</reflink>]).</p> <hd id="AN0189325690-15">Results</hd> <p></p> <hd id="AN0189325690-16">Sample characteristics</hd> <p>Descriptive statistics of the 25 participants are in Table 1. Caregivers' ages ranged from 26 to 47 years (<emph>M</emph> = 38.76, <emph>SD</emph> = 4.95). All participants identified themselves as mothers to an autistic child. Nearly two-thirds (64.0%) of caregivers had a university degree. Most caregivers (88.0%) were from Ethiopia, whereas 12.0% were from Eritrea. Most participants were married or living with a partner (84.0%). Most participants lived in urban (58.3%) or suburban (37.5%) areas and were unemployed (64.0%). The number of children at home ranged from 1 to 4 (<emph>M</emph> = 1.84, <emph>SD</emph> = 0.75). Participants reported their autistic children's ages ranged from 2 to 9 years (<emph>M</emph> = 5.16, <emph>SD</emph> = 2.37) and were mostly boys (72%). Some caregivers (16%) had another child with autism or other neurodevelopmental conditions.</p> <p>Table 1. Sample description (n = 25)* [<reflink idref="bib1" id="ref97">1</reflink>].</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="left">Frequency (%)</th><th align="left"><italic>M</italic> (<italic>SD</italic>) [range]</th></tr></thead><tbody><tr><td>Caregiver age</td><td /><td>38.76 (4.95) [26, 47]</td></tr><tr><td colspan="3">Caregiver highest education level</td></tr><tr><td> No formal education</td><td>1 (4.0%)</td><td /></tr><tr><td> Secondary education</td><td>8 (32.0%)</td><td /></tr><tr><td> University</td><td>16 (64.0%)</td><td /></tr><tr><td colspan="3">Caregiver country of origin</td></tr><tr><td> Ethiopia</td><td>22 (88.0%)</td><td /></tr><tr><td> Eritrea</td><td>3 (12.0%)</td><td /></tr><tr><td colspan="3">Caregiver marital status</td></tr><tr><td> Single</td><td>3 (12.0%)</td><td /></tr><tr><td> Married or living with partner</td><td>21 (84.0%)</td><td /></tr><tr><td> Separated/divorced</td><td>1 (4.0%)</td><td /></tr><tr><td colspan="3">Caregiver area of residence</td></tr><tr><td> Urban</td><td>14 (58.3%)</td><td /></tr><tr><td> Suburban</td><td>9 (37.5%)</td><td /></tr><tr><td> Rural</td><td>1 (4.2%)</td><td /></tr><tr><td colspan="3">Caregiver employment status</td></tr><tr><td> Unemployed</td><td>16 (64.0%)</td><td /></tr><tr><td> Full-time</td><td>5 (20.0%)</td><td /></tr><tr><td> Part-time</td><td>4 (16.0%)</td><td /></tr><tr><td>Number of children in household</td><td /><td>1.84 (0.75) [1, 4]</td></tr><tr><td>Autistic child's age</td><td /><td>5.16 (2.37) [2, 9]</td></tr><tr><td colspan="3">Autistic child's gender</td></tr><tr><td> Boy</td><td>18 (72.0%)</td><td /></tr><tr><td> Girl</td><td>7 (28.0%)</td><td /></tr><tr><td colspan="3">Caregiver has another child with autism or other neurodevelopmental conditions</td></tr><tr><td> No</td><td>21 (84.0%)</td><td /></tr><tr><td> Yes</td><td>4 (16.0%)</td><td /></tr></tbody></table> </ephtml> </p> <p>1 *All caregivers identified themselves as women and mothers to an autistic child. For those with more than one autistic child, they reported on their youngest child between the ages of 2–9 years.</p> <hd id="AN0189325690-17">Intervention outcomes</hd> <p>Table 2 displays the Wilcoxon signed-rank test of the difference between pre- and post-intervention scores. Caregivers' knowledge and skills increased significantly on average, with a medium effect size (<emph>z</emph> = −2.91; <emph>p</emph> < 0.01; <emph>r</emph> = −0.41). Likewise, mean caregiver self-efficacy increased after the intervention, which was statistically significant and showed a large effect size (<emph>z</emph> = −3.51; <emph>p</emph> < 0.001, <emph>r</emph> = −0.50). While anxiety and stress scores did not improve significantly, we found a statistically significant reduction in depression with a small effect size (<emph>z</emph> = 2.04; <emph>p</emph> < 0.05; <emph>r</emph> = 0.29). We did not find any statistically significant changes in any coping subscale. Regarding the family empowerment measure, our analyses only found statistically significant improvements and medium effect sizes in community involvement (<emph>z</emph> = −2.79, <emph>p</emph> < 0.01; <emph>r</emph> = −0.39) and the total family empowerment score (<emph>z</emph> = −2.96, <emph>p</emph> < 0.001, <emph>r</emph> = −0.42). The total ATEC score significantly decreased (<emph>z</emph> = 3.14; <emph>p</emph> < 0.01), with a medium effect size <emph>(r</emph> = −0.44). With the exception of the health/physical/behavior challenges subscale of the ATEC, we found statistically significant improvements and small-to-medium effect sizes on the remaining subscales: speech/language/communication (<emph>z</emph> = 2.52; <emph>p</emph> < 0.05; <emph>r</emph> = 0.36), sociability (<emph>z</emph> = 3.40, <emph>p</emph> < 0.001; <emph>r</emph> = 0.48), and sensory/cognitive awareness (<emph>z</emph> = 2.73, <emph>p</emph> < 0.01; <emph>r</emph> = 0.39).</p> <p>Table 2. Wilcoxon signed-rank test of difference between pre- and post-intervention scores.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="left">Pre-intervention</th><th align="left">Post-intervention</th><th align="left">Difference</th><th /><th /><th /></tr><tr><th align="left">Outcomes</th><th align="left"><italic>M</italic> (<italic>SD</italic>)</th><th align="left"><italic>M</italic> (<italic>SD</italic>)</th><th align="left"><italic>M</italic> (<italic>SD</italic>)</th><th align="left">z</th><th align="left"><italic>p</italic>-value</th><th align="left"><italic>r</italic></th></tr></thead><tbody><tr><td>Knowledge and skills</td><td>3.85 (0.30)</td><td>4.09 (0.39)</td><td>−0.24 (0.40)</td><td>−2.91</td><td>0.0036<xref ref-type="table-fn" rid="tfn3">**</xref></td><td>−0.41</td></tr><tr><td>Self-efficacy</td><td>3.67 (0.86)</td><td>4.41 (0.56)</td><td>−0.74 (0.83)</td><td>−3.51</td><td>0.00<xref ref-type="table-fn" rid="tfn3">***</xref></td><td>−0.50</td></tr><tr><td colspan="7">DASS</td></tr><tr><td> Depression</td><td>0.47 (0.50)</td><td>0.35 (0.47)</td><td>0.12 (0.63)</td><td>2.04</td><td>0.042<xref ref-type="table-fn" rid="tfn3">*</xref></td><td>0.29</td></tr><tr><td> Anxiety</td><td>0.69 (0.57)</td><td>0.53 (0.54)</td><td>0.17 (0.70)</td><td>1.39</td><td>0.17</td><td>0.20</td></tr><tr><td> Stress</td><td>0.35 (0.40)</td><td>0.33 (0.49)</td><td>0.02 (0.60)</td><td>0.58</td><td>0.56</td><td>0.08</td></tr><tr><td colspan="7">Brief COPE</td></tr><tr><td> Problem-focused</td><td>2.92 (0.84)</td><td>2.92 (0.81)</td><td>0 (1.09)</td><td>−0.14</td><td>0.89</td><td>−0.02</td></tr><tr><td> Emotion-focused</td><td>2.31 (0.52)</td><td>2.41 (0.48)</td><td>−0.10 (0.70)</td><td>−0.14</td><td>0.89</td><td>−0.02</td></tr><tr><td> Avoidant</td><td>1.62 (0.55)</td><td>1.54 (0.51)</td><td>0.08 (0.66)</td><td>1.60</td><td>0.11</td><td>0.23</td></tr><tr><td colspan="7">FES</td></tr><tr><td> Family</td><td>4.05 (0.60)</td><td>4.13 (0.65)</td><td>−0.08 (0.57)</td><td>−0.78</td><td>0.434</td><td>−0.11</td></tr><tr><td> Service</td><td>3.87 (0.78)</td><td>4.01 (0.59)</td><td>−0.14 (0.57)</td><td>−1.08</td><td>0.281</td><td>−0.15</td></tr><tr><td> Community</td><td>2.61 (0.82)</td><td>3.10 (0.77)</td><td>−0.50 (0.75)</td><td>−2.79</td><td>0.005<xref ref-type="table-fn" rid="tfn3">**</xref></td><td>−0.39</td></tr><tr><td> Total score</td><td>10.53 (1.72)</td><td>11.24 (1.63)</td><td>−0.72 (0.95)</td><td>−2.96</td><td>0.003<xref ref-type="table-fn" rid="tfn3">**</xref></td><td>−0.42</td></tr><tr><td colspan="7">ATEC</td></tr><tr><td> Communication</td><td>1.17 (0.44)</td><td>0.97 (0.51)</td><td>0.20 (0.35)</td><td>2.52</td><td>0.01<xref ref-type="table-fn" rid="tfn3">*</xref></td><td>0.36</td></tr><tr><td> Sociability</td><td>1.88 (0.45)</td><td>1.53 (0.31)</td><td>0.35 (0.46)</td><td>3.40</td><td>0.001<xref ref-type="table-fn" rid="tfn3">***</xref></td><td>0.48</td></tr><tr><td> Sensory/Cognitive awareness</td><td>1.00 (0.43)</td><td>0.83 (0.46)</td><td>0.16 (0.27)</td><td>2.73</td><td>0.006<xref ref-type="table-fn" rid="tfn3">**</xref></td><td>0.39</td></tr><tr><td>Health/Physical/Behavior challenges</td><td>1.72 (0.30)</td><td>1.68 (0.41)</td><td>0.04 (0.37)</td><td>1.13</td><td>0.26</td><td>0.15</td></tr><tr><td> Total score</td><td>5.69 (1.14)</td><td>5.03 (1.28)</td><td>0.66 (0.98)</td><td>3.14</td><td>0.002<xref ref-type="table-fn" rid="tfn3">**</xref></td><td>0.44</td></tr></tbody></table> </ephtml> </p> <ulist> <item>2 DASS, Depression, Anxiety, and Stress Scale; Brief COPE, Brief Coping Orientation to Problems Experienced Inventory; FES, Family Empowerment Scale; ATEC, Autism Treatment Evaluation Checklist.</item> <item>3 <emph>p</emph> < 0.05. **<emph>p</emph> < 0.01. ***<emph>p</emph> < 0.001.</item> </ulist> <hd id="AN0189325690-18">Discussion</hd> <p>This research investigated the preliminary outcomes of the World Health Organization's CST program adapted for remote delivery to Ethiopian and Eritrean immigrant parents raising autistic children (ages 2–9 years) in one region of the US. This pilot study begins to fill in a large gap in the extant literature regarding autism interventions for culturally diverse populations ([<reflink idref="bib38" id="ref98">38</reflink>]). The limited literature available on Eritrean and Ethiopian immigrant parents of autistic children in the US has identified multiple challenges, including barriers to access culturally relevant services and supports ([<reflink idref="bib1" id="ref99">1</reflink>]). In another article ([<reflink idref="bib61" id="ref100">61</reflink>]), we described our efforts to adapt CST, which the World Health Organization specifically developed to address limited services for autism and other neurodevelopmental conditions worldwide ([<reflink idref="bib43" id="ref101">43</reflink>]). CST has already been adapted in the Ethiopian context ([<reflink idref="bib54" id="ref102">54</reflink>]; [<reflink idref="bib64" id="ref103">64</reflink>]); however, we made considerable efforts to adapt the intervention to the US context, including a shift to remote delivery. Thus, this article presents preliminary parent and child outcomes for Ethiopian and Eritrean communities in the US after participating in CST, which adds to the growing body of studies reporting promising outcomes of telehealth-delivered CST ([<reflink idref="bib17" id="ref104">17</reflink>]; [<reflink idref="bib26" id="ref105">26</reflink>]; [<reflink idref="bib33" id="ref106">33</reflink>]).</p> <p>While the study was open to all parents and other caregivers, all 25 participants identified themselves as mothers. Most participants had a university education but were not working outside of the home. While little has been published about Ethiopian and Eritrean communities in the US, [<reflink idref="bib1" id="ref107">1</reflink>] found that a sizable number of Ethiopian and Eritrean parents in their US-based study reported a negative impact on their workforce participation related to raising an autistic child. More research is needed to explore immigrant families' experiences navigating employment, education, and other obligations so that interventions can be better tailored to meet diverse needs.</p> <p>Our pilot study explored a range of parent and child outcomes before and after parents completed CST. We found statistically significant improvements in parent-reported knowledge, skills, and self-efficacy. Improvements in knowledge are important given past research that Eritrean and Ethiopian immigrant parents of autistic children report gaps in autism-related knowledge within their communities ([<reflink idref="bib1" id="ref108">1</reflink>]), a finding echoed in research in other immigrant communities in the US ([<reflink idref="bib23" id="ref109">23</reflink>]) as well as CST research in India ([<reflink idref="bib46" id="ref110">46</reflink>]). Like CST research in countries across income levels ([<reflink idref="bib33" id="ref111">33</reflink>]; [<reflink idref="bib44" id="ref112">44</reflink>]; [<reflink idref="bib45" id="ref113">45</reflink>]; [<reflink idref="bib46" id="ref114">46</reflink>]), we found improvements in parent self-efficacy. In Italy, a randomized controlled trial of CST delivered in public health settings showed significant improvement in the masked-rated primary outcomes assessing the quality of the parent/child interaction and caregiver skills ([<reflink idref="bib42" id="ref115">42</reflink>]), and a mediation analysis showed that changes in caregiver skills significantly mediated the treatment effect at follow-up on the dyad and child outcomes ([<reflink idref="bib47" id="ref116">47</reflink>]). Therefore our finding of improved self-efficacy with a large effect size (<emph>r</emph> = −0.50) is a hopeful indication of possible improvements of caregiver use of intervention strategies. It is particularly notable in light of the correlation between individuals' perceived self-efficacy to manage their parenting demands and participation in and satisfaction of their child's therapeutic services ([<reflink idref="bib25" id="ref117">25</reflink>]). Thus, it is crucial that interventions such as CST support learning, skill development, and confidence in ways that are culturally relevant and accessible to immigrant communities.</p> <p>Our findings related to parent well-being (as measured by the DASS-21) and coping were more mixed, given the lack of any statistically significant improvements in parent coping, stress, or anxiety after CST completion. Non-statistically significant reductions in parenting stress in our study diverged from CST studies in Italy and India ([<reflink idref="bib44" id="ref118">44</reflink>]; [<reflink idref="bib46" id="ref119">46</reflink>]), although these studies used different measures and were in person. Nonetheless, the need to address parent stress in particular is urgent, given its prevalence among parents raising autistic children and its correlation with parent and child well-being ([<reflink idref="bib5" id="ref120">5</reflink>]; [<reflink idref="bib7" id="ref121">7</reflink>]; [<reflink idref="bib10" id="ref122">10</reflink>]). Studies with longer follow-up periods, larger samples, and control groups can ascertain if there are delayed impacts on these outcomes related to CST participation and/or if elements related to in-person delivery (e.g. more time to build peer support) impact parent coping, stress, and/or anxiety.</p> <p>However, in the present study, we found a significant decrease in parent-reported depression, which is important due to the persistent levels of depression experienced by parents raising autistic children ([<reflink idref="bib5" id="ref123">5</reflink>]; [<reflink idref="bib7" id="ref124">7</reflink>]; [<reflink idref="bib10" id="ref125">10</reflink>]). It is possible that CST addressed different predictors of parent depression, anxiety, and stress, which led to differential outcomes. [<reflink idref="bib15" id="ref126">15</reflink>] reported that child aggressive behavior, parental locus of control, and social support predicted depression using the DASS-21, whereas a mix of malleable and less malleable variables (e.g. maternal age, autism symptom severity) predicted anxiety and stress. Future studies should examine the impact of CST on parent well-being in more detail.</p> <p>We found statistically significant improvement in the family empowerment total score, as well as the community involvement subscale (e.g. legislative advocacy). Previous research has not only emphasized the importance of parent advocacy in order to obtain needed autism services for their children ([<reflink idref="bib6" id="ref127">6</reflink>]) but also the challenges and emotional burden that Black parents of autistic children encounter in their advocacy efforts ([<reflink idref="bib27" id="ref128">27</reflink>]; [<reflink idref="bib34" id="ref129">34</reflink>]). Nonetheless, we did not find significant increases in the subscales that focused on empowerment related to family (organizing daily child and family needs) and services (accessing needed child services). Other parent-mediated interventions that utilized peers (i.e. other parents) as interventionists have found significant improvements in empowerment and advocacy skills ([<reflink idref="bib12" id="ref130">12</reflink>]; [<reflink idref="bib21" id="ref131">21</reflink>]). While CST is not reliant only on peer interventionists, future research should consider if peers and/or other methods can support parents to build their advocacy and related skills.</p> <p>Finally, we used the ATEC to understand if CST indirectly impacted the autistic children of participants. A central focus of CST is identifying and responding to children's communication cues and needs. Similar to other CST studies that identified improvements in aspects of child communication and social interaction ([<reflink idref="bib33" id="ref132">33</reflink>]; [<reflink idref="bib44" id="ref133">44</reflink>]; [<reflink idref="bib45" id="ref134">45</reflink>]; [<reflink idref="bib46" id="ref135">46</reflink>]), we found a statistically significant improvement in the total score, as well as three of the four subscales (communication, sociability, and sensory/cognitive awareness). [<reflink idref="bib45" id="ref136">45</reflink>] research with CST in Taiwan found ATEC total score improvements, as well as those in communication and sociability, were maintained at 3-month follow-up. While more research is needed, including studies that include other sources of data (e.g. clinical observation of children) and longer-term follow-up, the initial findings that parents perceived some aspects of children's communication, sociability, and sensory/cognitive awareness had improved after CST are favorable.</p> <hd id="AN0189325690-19">Limitations</hd> <p>It is important to consider the limitations of this study. As with any single-arm study, the results should be viewed with some caution due to the absence of control or comparison groups. In addition, due to our sample size, we were unable to compare potential differences by interventionist (e.g. Master Trainer versus non-specialist). Nonetheless, this study can inform future research with more rigorous methods, including those with longer-term follow-up and that examine potential differences in outcomes during phased adaptation processes. Furthermore, despite our attempts to include fathers and other caregivers in CST (including hiring one interventionist who was a father to an autistic child), our sample was only composed of mothers, potentially due to Ethiopian gender norms related to caregiving ([<reflink idref="bib51" id="ref137">51</reflink>]). We will continue to seek the advice of community advisors on this issue. Furthermore, consistent with national statistics finding that male children are diagnosed with autism at higher rates that females ([<reflink idref="bib30" id="ref138">30</reflink>]), participants in this study reported mostly on boys. While we did not analyze boys and girls separately in this study due to sample size, we encourage future research to consider the potentially different experiences of autistic girls when designing and delivering services. Furthermore, we used measures exclusively in English due to the lack of validated translations available to us at the time. However, we mitigated potential comprehension challenges by offering clarifications and ensuring that participants could seek assistance as needed. Future research will focus on the adaptation and validation of translated versions to enhance accessibility and cultural responsiveness. Finally, given that some of our sample did not complete the intervention or post-intervention surveys, we recommend future studies investigate potential barriers to participation, which could include some of the same reasons that immigrant families underutilize needed services (e.g. Internet access, language skills, high mobility; [<reflink idref="bib62" id="ref139">62</reflink>]). For example, subsequent research should adapt measures and intervention materials in other languages spoken in Ethiopia and Eritrea.</p> <hd id="AN0189325690-20">Conclusion</hd> <p>Autism intervention research has been grappling to right the wrongs of a long history of studies that have focused primarily on middle-/upper-class white children and families in high-income countries ([<reflink idref="bib16" id="ref140">16</reflink>]; [<reflink idref="bib20" id="ref141">20</reflink>]; [<reflink idref="bib48" id="ref142">48</reflink>]; [<reflink idref="bib52" id="ref143">52</reflink>]). The minoritized intersectional identities of Eritrean and Ethiopian immigrant families of autistic children place them at higher risk of discrimination and marginalization due to racism, nativism, ableism, and other forms of oppression. Thus, interventions such as CST, which rely on the input of people from the target communities, hold promise to deliver the culturally and contextually relevant resources that all children and their families deserve. Randomized controlled trials of CST, along with comparative studies with other parent-mediated interventions, are needed to validate this study's results and explore potential differences in outcomes across interventions.</p> <p>We appreciate the contributions of participating families and our community partners and advocates, particularly the Ethiopian Eritean Special Needs Community (EESNC), without whom this work would not be possible. We also acknowledge members of the World Health Organization's CST Team who developed the CST contents and monitoring and evaluation framework. The CST Team is led by Dr. Chiara Servili and comprises Dr. Felicity Brown, Dr. Laura Pacione, Dr. Erica Salomone, and Dr. Stephanie Shire.</p> <ref id="AN0189325690-21"> <title> References </title> <blist> <bibl id="bib1" idref="ref35" type="bt">1</bibl> <bibtext> Adere A. A., Dababnah S., Habayeb S. (2023). Identifying needs of Ethiopian and Eritrean American parents of autistic children. Journal of Autism and Developmental Disorders. https://doi.org/10.1007/s10803-023-06102-7</bibtext> </blist> <blist> <bibl id="bib2" idref="ref2" type="bt">2</bibl> <bibtext> Bearss K., Johnson C., Smith T., Lecavalier L., Swiezy N., Aman M., McAdam D. B., Butter E., Stillitano C., Minshawi N., Sukhodolsky D. G., Mruzek D. W., Turner K., Neal T., Hallett V., Mulick J. A., Green B., Handen B., Deng Y...Scahill L. (2015). Effect of parent training vs parent education on behavioral problems in children with autism spectrum disorder: A randomized clinical trial. JAMA, 313(15), 1524–1533. https://doi.org/10.1001/jama.2015.3150</bibtext> </blist> <blist> <bibl id="bib3" idref="ref66" type="bt">3</bibl> <bibtext> Bernal G., Sáez-Santiago E. (2006). Culturally centered psychosocial interventions. Journal of Community Psychology, 34(2), 121–132. https://doi.org/10.1002/jcop.20096</bibtext> </blist> <blist> <bibl id="bib4" idref="ref21" type="bt">4</bibl> <bibtext> Bilaver L. A., Havlicek J. (2019). Racial and ethnic disparities in autism-related health and educational services. Journal of Developmental & Behavioral Pediatrics, 40(7), 501–510. https://doi.org/10.1097/DBP.0000000000000700</bibtext> </blist> <blist> <bibl id="bib5" idref="ref75" type="bt">5</bibl> <bibtext> Bonis S. (2016). Stress and parents of children with autism: A review of literature. Issues in Mental Health Nursing, 37(3), 153–163. https://doi.org/10.3109/01612840.2015.1116030</bibtext> </blist> <blist> <bibl id="bib6" idref="ref76" type="bt">6</bibl> <bibtext> Boshoff K., Gibbs D., Phillips R. L., Wiles L., Porter L. (2018). Parents' voices: "Our process of advocating for our child with autism." A meta-synthesis of parents' perspectives. Child: Care, Health and Development, 44(1), 147–160. https://doi.org/10.1111/cch.12504</bibtext> </blist> <blist> <bibl id="bib7" idref="ref10" type="bt">7</bibl> <bibtext> Carter A. S., Martínez-Pedraza F., de L., Gray S. A. O. (2009). Stability and individual change in depressive symptoms among mothers raising young children with ASD: Maternal and child correlates. Journal of Clinical Psychology, 65(12), 1270–1280. https://doi.org/10.1002/jclp.20634</bibtext> </blist> <blist> <bibl id="bib8" idref="ref78" type="bt">8</bibl> <bibtext> Carver C. S. (1997). You want to measure coping but your protocol's too long: Consider the brief COPE. International Journal of Behavioral Medicine, 4(1), 92–100. https://doi.org/10.1207/s15327558ijbm0401_6</bibtext> </blist> <blist> <bibl id="bib9" idref="ref79" type="bt">9</bibl> <bibtext> Cohen J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Routledge. https://doi.org/10.4324/9780203771587</bibtext> </blist> <blist> <bibtext> Cohrs A. C., Leslie D. L. (2017). Depression in parents of children diagnosed with autism spectrum disorder: A claims-based analysis. Journal of Autism and Developmental Disorders, 47(5), 1416–1422. https://doi.org/10.1007/s10803-017-3063-y</bibtext> </blist> <blist> <bibtext> Cooper D. R., Schindler P. S. (2003). Business research methods (8th ed.). McGraw-Hill.</bibtext> </blist> <blist> <bibtext> Dababnah S., Reyes C., Kim I., Badawi D. G., Chung Y., Shaia W. E. (2023). Pilot trial of a peer-to-peer psychoeducational intervention for parents of Black children awaiting a developmental evaluation. Journal of Developmental and Behavioral Pediatrics, 44(5), e370–e378. https://doi.org/10.1097/DBP.0000000000001182</bibtext> </blist> <blist> <bibtext> Deb S., Retzer A., Roy M., Acharya R., Limbu B., Roy A. (2020). The effectiveness of parent training for children with autism spectrum disorder: A systematic review and meta-analyses. BMC Psychiatry, 20(1), Article 583. https://doi.org/10.1186/s12888-020-02973-7</bibtext> </blist> <blist> <bibtext> Edelson S. M., Rimland B. (1999). Autism treatment evaluation checklist. Autism Research Institute. https://<ulink href="http://www.autism.org/autism-treatment-evaluation-checklist/">www.autism.org/autism-treatment-evaluation-checklist/</ulink></bibtext> </blist> <blist> <bibtext> Falk N. H., Norris K., Quinn M. G. (2014). The factors predicting stress, anxiety and depression in the parents of children with autism. Journal of Autism and Developmental Disorders, 44(12), 3185–3203. https://doi.org/10.1007/s10803-014-2189-4</bibtext> </blist> <blist> <bibtext> Fannin D. K. (2017). Reporting of underrepresented populations in autism treatment studies across 25 years. Clinical Archives of Communication Disorders, 2(3), 250–263. https://doi.org/10.21849/cacd.2017.00129</bibtext> </blist> <blist> <bibtext> Ferrante C., Sorgato P., Fioravanti M., Pacione L., Arduino G. M., Ghersi S., Scattoni M. L., Chiesa C., Elia D., Gonella E., Rizzo S., Salandin A., Brown F. L., Shire S., Servili C., Salomone E., &CST Italy Team, WHO CST Team. (2024). Supporting caregivers remotely during a pandemic: Comparison of WHO caregiver skills training delivered online versus in person in public health settings in Italy. Journal of Autism and Developmental Disorders, 54(2), 765–784. https://doi.org/10.1007/s10803-022-05800-y</bibtext> </blist> <blist> <bibtext> Fortuny K., Chaudry A. (2011). A comprehensive review of immigrant access to health and human services. https://<ulink href="http://www.urban.org/research/publication/comprehensive-review-immigrant-access-health-and-human-services">www.urban.org/research/publication/comprehensive-review-immigrant-access-health-and-human-services</ulink></bibtext> </blist> <blist> <bibtext> Frantz R., Hansen S. G., Machalicek W. (2018). Interventions to promote well-being in parents of children with autism: A systematic review. Review Journal of Autism and Developmental Disorders, 5(1), 58–77. https://doi.org/10.1007/s40489-017-0123-3</bibtext> </blist> <blist> <bibtext> Girolamo T., Shen L., Monroe-Gulick A., Rice M. L., Eigsti I.-M. (2023). Studies pertaining to language impairment in school-age autistic individuals underreport participant socio-demographics: A systematic review. Autism: The International Journal of Research and Practice, 27(8), 2218–2240. https://doi.org/10.1177/13623613231166749</bibtext> </blist> <blist> <bibtext> Hamdani S. U., Minhas F. A., Iqbal Z., Rahman A. (2015). Model for service delivery for developmental disorders in low-income countries. Pediatrics, 136(6), 1166–1172. https://doi.org/10.1542/peds.2015-0861</bibtext> </blist> <blist> <bibtext> Huang Z. J., Yu S. M., Ledsky R. (2006). Health status and health service access and use among children in U.S. immigrant families. American Journal of Public Health, 96(4), 634–640. https://doi.org/10.2105/AJPH.2004.049791</bibtext> </blist> <blist> <bibtext> Kim I., Dababnah S., Wang Y., Reyes C. (2022). Diagnostic process and barriers among Chinese-American and Korean-American parents of children with autism. Journal of Developmental & Behavioral Pediatrics, 43(6), 327–334. https://doi.org/10.1097/DBP.0000000000001070</bibtext> </blist> <blist> <bibtext> Koren P. E., DeChillo N., Friesen B. J. (1992). Measuring empowerment in families whose children have emotional disabilities: A brief questionnaire. Rehabilitation Psychology, 37(4), 305–321. https://doi.org/10.1037/h0079106</bibtext> </blist> <blist> <bibtext> Kurzrok J., McBride E., Grossman R. B. (2021). Autism-specific parenting self-efficacy: An examination of the role of parent-reported intervention involvement, satisfaction with intervention-related training, and caregiver burden. Autism: The International Journal of Research and Practice, 25(5), 1395–1408. https://doi.org/10.1177/1362361321990931</bibtext> </blist> <blist> <bibtext> Lau J. S.-P., Lai S. M.-K., Ip F. T.-S., Wong P. W.-C., Team W. C., Servili C., Salomone E., Pacione L., Shire S., Brown F. L. (2022). Acceptability and feasibility of the World Health Organization's Caregiver Skills Training Programme (WHO CST) delivered via eLearning, videoconferencing, and in-person hybrid modalities in Hong Kong. Frontiers in Psychiatry, 13, Article 915263. https://doi.org/10.3389/fpsyt.2022.915263</bibtext> </blist> <blist> <bibtext> Lewis E. M., Dababnah S., Hollie K. R., Kim I., Wang Y., Shaia W. E. (2022). The creator did not give me more than I can handle: Exploring coping in parents of Black autistic children. Autism. https://doi.org/10.1177/13623613211070865</bibtext> </blist> <blist> <bibtext> Liu B. M., Paskov K., Kent J., McNealis M., Sutaria S., Dods O., Harjadi C., Stockham N., Ostrovsky A., Wall D. P. (2023). Racial and ethnic disparities in geographic access to autism resources across the US. JAMA Network Open, 6(1), Article e2251182. https://doi.org/10.1001/jamanetworkopen.2022.51182</bibtext> </blist> <blist> <bibtext> Lovibond P. F., Lovibond S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy, 33(3), 335–343.</bibtext> </blist> <blist> <bibtext> Maenner M. J., Warren Z., Williams A. R., Amoakohene E., Bakian A. V., Bilder D. A., Durkin M. S., Fitzgerald R. T., Furnier S. M., Hughes M. M., Ladd-Acosta C. M., McArthur D., Pas E. T., Salinas A., Vehorn A., Williams S., Esler A., Grzybowski A., Hall-Lande J., Nguyen R. H. N., Shaw K. A. (2023). Prevalence and Characteristics of Autism Spectrum Disorder Among Children Aged 8 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2020. Morbidity and mortality weekly report. Surveillance summaries (Washington, D.C.: 2002), 72(2), 1–14. https://doi.org/10.15585/mmwr.ss7202a1</bibtext> </blist> <blist> <bibtext> Magaña S., Dababnah S., Xu Y., Garcia Torres M., Rieth S. R., Corsello C., Rangel E., Brookman-Frazee L., Vanegas S. B. (2021). Chapter Nine—Cultural adaptations of a parent training program for families of children with ASD/IDD: Parents Taking Action. In Riggs N. R., Rigles B. (Eds.), International Review of Research in Developmental Disabilities (Vol. 61, pp. 263–300). https://doi.org/10.1016/bs.irrdd.2021.07.005</bibtext> </blist> <blist> <bibtext> Migration Policy Institute. (2014). The Ethiopian diaspora in the United States. https://<ulink href="http://www.migrationpolicy.org/sites/default/files/publications/RAD-Ethiopia.pdf">www.migrationpolicy.org/sites/default/files/publications/RAD-Ethiopia.pdf</ulink></bibtext> </blist> <blist> <bibtext> Montiel-Nava C., Tregnago M., Marshall J., Sohl K., Curran A. B., Mahurin M., Warne-Griggs M.WHO CST Team, & Dixon, P. (2022). Implementing the WHO caregivers skills training program with caregivers of autistic children via telehealth in rural communities. Frontiers in Psychiatry, 13, 909947. https://doi.org/10.3389/fpsyt.2022.909947</bibtext> </blist> <blist> <bibtext> Morgan E. H., Stahmer A. C. (2020). Narratives of single, Black mothers using cultural capital to access autism interventions in schools. British Journal of Sociology of Education, 42(1), 48–65. https://doi.org/10.1080/01425692.2020.1861927</bibtext> </blist> <blist> <bibtext> Nguyen C. T., Krakowiak P., Hansen R., Hertz-Picciotto I., Angkustsiri K. (2016). Sociodemographic disparities in intervention service utilization in families of children with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders, 46(12), 3729–3738. https://doi.org/10.1007/s10803-016-2913-3</bibtext> </blist> <blist> <bibtext> Oono I. P., Honey E. J., McConachie H. (2016). Parent-mediated early intervention for young children with autism spectrum disorders (ASD). BJPsych Advances, 22(3), 146–146. https://doi.org/10.1192/apt.22.3.146</bibtext> </blist> <blist> <bibtext> Pacia C., Holloway J., Gunning C., Lee H. (2022). A systematic review of family-mediated social communication interventions for young children with autism. Review Journal of Autism and Developmental Disorders, 9(2), 208–234. https://doi.org/10.1007/s40489-021-00249-8</bibtext> </blist> <blist> <bibtext> Papoudi D., Jørgensen C. R., Guldberg K., Meadan H. (2021). Perceptions, experiences, and needs of parents of culturally and linguistically diverse children with autism: A scoping review. Review Journal of Autism and Developmental Disorders, 8(2), 195–212. https://doi.org/10.1007/s40489-020-00210-1</bibtext> </blist> <blist> <bibtext> Parsons D., Cordier R., Vaz S., Lee H. C. (2017). Parent-mediated intervention training delivered remotely for children with autism spectrum disorder living outside of urban areas: Systematic review. Journal of Medical Internet Research, 19(8), Article e6651. https://doi.org/10.2196/jmir.6651</bibtext> </blist> <blist> <bibtext> Pickles A., Le Couteur A., Leadbitter K., Salomone E., Cole-Fletcher R., Tobin H., Gammer I., Lowry J., Vamvakas G., Byford S., Aldred C., Slonims V., McConachie H., Howlin P., Parr J. R., Charman T., Green J. (2016). Parent-mediated social communication therapy for young children with autism (PACT): Long-term follow-up of a randomised controlled trial. The Lancet, 388(10059), 2501–2509. https://doi.org/10.1016/S0140-6736(16)31229-6</bibtext> </blist> <blist> <bibtext> Reichow B., Kogan C., Barbui C., Maggin D., Salomone E., Smith I. C., Yasamy M. T., Servili C. (2024). Caregiver skills training for caregivers of individuals with neurodevelopmental disorders: A systematic review and meta-analysis. Developmental Medicine & Child Neurology, 66(6), 713–724. https://doi.org/10.1111/dmcn.15764</bibtext> </blist> <blist> <bibtext> Salomone E., Ferrante C., Salandin A., Ferrara F., Torchio E., Foletti G., Ghersi S.CST Italy Team, WHO CST Team, Pacione L., Servili C. (2022). Acceptability and feasibility of the World Health Organization's Caregiver Skills Training implemented in the Italian National Health System. Autism: The International Journal of Research and Practice, 26(4), 859–874. https://doi.org/10.1177/13623613211035228</bibtext> </blist> <blist> <bibtext> Salomone E., Pacione L., Shire S., Brown F. L., Reichow B., Servili C. (2019). Development of the WHO Caregiver Skills Training Program for Developmental Disorders or Delays. Frontiers in Psychiatry, 10, Article 769. https://doi.org/10.3389/fpsyt.2019.00769</bibtext> </blist> <blist> <bibtext> Salomone E., Settanni M., McConachie H., Suma K., Ferrara F., Foletti G., Salandin A., Brown F. L., Pacione L., Shire S., Servili C., Adamson L. B., &WHO CST Team. (2022). Pilot randomized controlled trial of the WHO Caregiver Skills Training in public health services in Italy. Journal of Autism and Developmental Disorders, 52(10), 4286–4300. https://doi.org/10.1007/s10803-021-05297-x</bibtext> </blist> <blist> <bibtext> Seng G.-J., Chiu Y.-N., Tsai W.-C., Lin H.-Y., Li S.-C., Hsiao M.-N., Liu T.-J., Chen H.-M., Shih A., Chang Y.-C.Who CST Team, Soong W.-T. (2022). Promotion and implementation effectiveness of World Health Organization's Caregiver Skills Training program in Taiwan. Frontiers in Psychiatry, 13, 904380. https://doi.org/10.3389/fpsyt.2022.904380</bibtext> </blist> <blist> <bibtext> Sengupta K., Shah H., Ghosh S., Sanghvi D., Mahadik S., Dani A., Deshmukh O., Pacione L., Dixon P., Salomone E.WHO CST Team, &Servili C. (2023). World Health Organisation-Caregiver Skills Training (WHO CST) Program: Feasibility of delivery by non-specialist providers in real-world urban settings in India. Journal of Autism and Developmental Disorders, 53(4), 1444–1461. https://doi.org/10.1007/s10803-021-05367-0</bibtext> </blist> <blist> <bibtext> Settanni M., Suma K., Adamson L. B., McConachie H., Servili C., Salomone E. (2024). Treatment mechanism of the WHO caregiver skills training intervention for autism delivered in community settings. Autism Research: Official Journal of the International Society for Autism Research, 17(1), 182–194. https://doi.org/10.1002/aur.3058</bibtext> </blist> <blist> <bibtext> Shaia W. E., Nichols H. M., Dababnah S., Campion K., Garbarino N. (2020). Brief report: Participation of Black and African-American families in autism research. Journal of Autism and Developmental Disorders, 50(5), 1841–1846. https://doi.org/10.1007/s10803-019-03926-0</bibtext> </blist> <blist> <bibtext> Shalev R. A., Lavine C., Di Martino A. (2020). A systematic review of the role of parent characteristics in parent-mediated interventions for children with Autism Spectrum Disorder. Journal of Developmental and Physical Disabilities, 32(1), 1–21. https://doi.org/10.1007/s10882-018-9641-x</bibtext> </blist> <blist> <bibtext> Smith K. A., Gehricke J.-G., Iadarola S., Wolfe A., Kuhlthau K. A. (2020). Disparities in service use among children with autism: A systematic review. Pediatrics, 145(Suppl. 1), S35–S46. https://doi.org/10.1542/peds.2019-1895G</bibtext> </blist> <blist> <bibtext> Spier E., de Milliano M., Ranjit V., Bock C., Downes J., Hailu B. H. (2023). Study on parenting for early childhood development in Ethiopia. American Institutes for Research.</bibtext> </blist> <blist> <bibtext> Steinbrenner J. R., McIntyre N., Rentschler L. F., Pearson J. N., Luelmo P., Jaramillo M. E., Boyd B. A., Wong C., Nowell S. W., Odom S. L., Hume K. A. (2022). Patterns in reporting and participant inclusion related to race and ethnicity in autism intervention literature: Data from a large-scale systematic review of evidence-based practices. Autism: The International Journal of Research and Practice, 26(8), 2026–2040. https://doi.org/10.1177/13623613211072593</bibtext> </blist> <blist> <bibtext> Tarver J., Palmer M., Webb S., Scott S., Slonims V., Simonoff E., Charman T. (2019). Child and parent outcomes following parent interventions for child emotional and behavioral problems in autism spectrum disorders: A systematic review and meta-analysis. Autism: The International Journal of Research and Practice, 23(7), 1630–1644. https://doi.org/10.1177/1362361319830042</bibtext> </blist> <blist> <bibtext> Tekola B., Girma F., Kinfe M., Abdurahman R., Tesfaye M., Yenus Z.WHO CST Team, Salomone E., Pacione L., Fekadu A., Servili C., Hanlon C., Hoekstra R. A. (2020). Adapting and pre-testing the World Health Organization's Caregiver Skills Training programme for autism and other developmental disorders in a very low-resource setting: Findings from Ethiopia. Autism, 24(1), 51–63. https://doi.org/10.1177/1362361319848532</bibtext> </blist> <blist> <bibtext> Washington-Nortey M., Angwenyi V., Demissie M., Mwangome E., Eshetu T., Negussie H., Goldsmith K., Healey A., Feyasa M., Medhin G., Belay A., Azmeraw T., Getachew M., Birhane R., Nasambu C., Kifle T. H., Kairu A., Mkubwa B., Girma F...Hoekstra R. A. (2024). Supporting African communities to increase resilience and mental health of kids with developmental disabilities and their caregivers using the World Health Organization's Caregiver Skills Training Programme (SPARK trial): Study protocol for a cluster randomised clinical controlled trial. Trials, 25(1), 713. https://doi.org/10.1186/s13063-024-08488-w</bibtext> </blist> <blist> <bibtext> Wong P. W.-C., Lam Y.-Y., Lau J. S.-P., Fok H.-K. (2022). Adapting and pretesting the World Health Organization's Caregiver Skills Training Program for children with autism and developmental disorders or delays in Hong Kong. Scientific Reports, 12(1), 16932. https://doi.org/10.1038/s41598-022-21343-9</bibtext> </blist> <blist> <bibtext> World Health Organization. (2022a). Caregiver skills training for families of children with developmental delays or disabilities: Adaptation and implementation guide. https://<ulink href="http://www.who.int/teams/mental-health-and-substance-use/treatment-care/who-caregivers-skills-training-for-families-of-children-with-developmental-delays-and-disorders">www.who.int/teams/mental-health-and-substance-use/treatment-care/who-caregivers-skills-training-for-families-of-children-with-developmental-delays-and-disorders</ulink></bibtext> </blist> <blist> <bibtext> World Health Organization. (2022b). Caregiver skills training for families of children with developmental delays or disabilities: Introduction. https://<ulink href="http://www.who.int/teams/mental-health-and-substance-use/treatment-care/who-caregivers-skills-training-for-families-of-children-with-developmental-delays-and-disorders">www.who.int/teams/mental-health-and-substance-use/treatment-care/who-caregivers-skills-training-for-families-of-children-with-developmental-delays-and-disorders</ulink></bibtext> </blist> <blist> <bibtext> Zaidman-Zait A., Mirenda P., Duku E., Szatmari P., Georgiades S., Volden J., Zwaigenbaum L., Vaillancourt T., Bryson S., Smith I., Fombonne E., Roberts W., Waddell C., Thompson A., & Pathways in ASD Study Team. (2014). Examination of bidirectional relationships between parent stress and two types of problem behavior in children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 44(8), 1908–1917. https://doi.org/10.1007/s10803-014-2064-3</bibtext> </blist> <blist> <bibtext> Zeleke W. A., Chitiyo M., Hughes T. L. (2018). Autism service providers report: Behavioral and educational interventions used in Ethiopia. International Journal of School & Educational Psychology, 6(3), 176–187. https://doi.org/10.1080/21683603.2016.1278568</bibtext> </blist> <blist> <bibtext> Zeleke W. A., Dababnah S., Dixon P., Adere A., Reinhold Y., Hagos S., Fejisso H., Tulu A. (2024). Adaptation of the Caregiver Skills Training program for Ethiopian and Eritrean immigrant families of autistic children in the US. International Journal of Developmental Disabilities, 1–8. https://doi.org/10.1080/20473869.2024.2414135</bibtext> </blist> <blist> <bibtext> Zeleke W. A., Hughes T. L., Drozda N. (2019). Disparities in diagnosis and service access for minority children with ASD in the United States. Journal of Autism and Developmental Disorders, 49(10), 4320–4331. https://doi.org/10.1007/s10803-019-04131-9</bibtext> </blist> <blist> <bibtext> Zeleke W. A., Hughes T. L., Tiberi A. E., Drozda N. (2017). Healthcare and educational services used by children with autism spectrum disorders in poverty. Perspectives on Early Childhood Psychology and Education, 31–60.</bibtext> </blist> <blist> <bibtext> Zerihun T., Kinfe M., Koly K. N., Abdurahman R., Girma F.WHO Team, Hanlon C., de Vries P. J., Hoekstra R. A. (2024). Non-specialist delivery of the WHO Caregiver Skills Training Programme for children with developmental disabilities: Stakeholder perspectives about acceptability and feasibility in rural Ethiopia. Autism: The International Journal of Research and Practice, 28(1), 95–106. https://doi.org/10.1177/13623613231162155</bibtext> </blist> </ref> <ref id="AN0189325690-22"> <title> Footnotes </title> <blist> <bibtext> Sarah Dababnah</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0000-0001-8298-1639 Waganesh A. Zeleke</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0000-0002-4604-336X Yoonzie Chung</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0000-0001-5528-6577 Erica Salomone</bibtext> </blist> <blist> <bibtext>Graph https://orcid.org/0000-0002-8083-5942</bibtext> </blist> <blist> <bibtext> Sarah Dababnah: Conceptualization; Data curation; Investigation; Methodology; Project administration; Resources; Supervision; Visualization; Writing—original draft; Writing—review & editing.Waganesh A. Zeleke: Conceptualization; Data curation; Investigation; Methodology; Project administration; Resources; Supervision; Visualization; Writing—original draft; Writing—review & editing.Yoonzie Chung: Formal analysis; Investigation; Visualization; Writing—original draft; Writing—review & editing.Rachel Antwi Adjei: Investigation; Writing—original draft.Pamela Dixon: Conceptualization; Writing—original draft.Erica Salomone: Conceptualization; Methodology; Writing—original draft; Writing—review & editing.WHO CST Team: Conceptualization; Methodology; Writing—original draft.</bibtext> </blist> <blist> <bibtext> The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We received financial support for this study from The Charles Henry Leach II Fund at Dusquesne University.</bibtext> </blist> <blist> <bibtext> The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.</bibtext> </blist> <blist> <bibtext> The measures, aggregated data, and other study and intervention materials from this study are available from the corresponding author on reasonable request. We note that most of these materials are available publicly via https://<ulink href="http://www.who.int/teams/mental-health-and-substance-use/treatment-care/who-caregivers-skills-training-for-families-of-children-with-developmental-delays-and-disorders">www.who.int/teams/mental-health-and-substance-use/treatment-care/who-caregivers-skills-training-for-families-of-children-with-developmental-delays-and-disorders</ulink>.</bibtext> </blist> </ref> <aug> <p>By Sarah Dababnah; Waganesh A. Zeleke; Yoonzie Chung; Rachel Antwi Adjei; Pamela Dixon and Erica Salomone</p> <p>Reported by Author; Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib30" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib13" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib36" firstref="ref4"></nolink> <nolink nlid="nl4" bibid="bib37" firstref="ref5"></nolink> <nolink nlid="nl5" bibid="bib39" firstref="ref6"></nolink> <nolink nlid="nl6" bibid="bib40" firstref="ref7"></nolink> <nolink nlid="nl7" bibid="bib41" firstref="ref8"></nolink> <nolink nlid="nl8" bibid="bib53" firstref="ref9"></nolink> <nolink nlid="nl9" bibid="bib10" firstref="ref11"></nolink> <nolink nlid="nl10" bibid="bib59" firstref="ref14"></nolink> <nolink nlid="nl11" bibid="bib19" firstref="ref16"></nolink> <nolink nlid="nl12" bibid="bib49" firstref="ref17"></nolink> <nolink nlid="nl13" bibid="bib31" firstref="ref20"></nolink> <nolink nlid="nl14" bibid="bib28" firstref="ref22"></nolink> <nolink nlid="nl15" bibid="bib35" firstref="ref23"></nolink> <nolink nlid="nl16" bibid="bib50" firstref="ref24"></nolink> <nolink nlid="nl17" bibid="bib38" firstref="ref25"></nolink> <nolink nlid="nl18" bibid="bib16" firstref="ref26"></nolink> <nolink nlid="nl19" bibid="bib20" firstref="ref27"></nolink> <nolink nlid="nl20" bibid="bib48" firstref="ref28"></nolink> <nolink nlid="nl21" bibid="bib52" firstref="ref29"></nolink> <nolink nlid="nl22" bibid="bib18" firstref="ref30"></nolink> <nolink nlid="nl23" bibid="bib22" firstref="ref31"></nolink> <nolink nlid="nl24" bibid="bib63" firstref="ref32"></nolink> <nolink nlid="nl25" bibid="bib32" firstref="ref34"></nolink> <nolink nlid="nl26" bibid="bib62" firstref="ref36"></nolink> <nolink nlid="nl27" bibid="bib60" firstref="ref44"></nolink> <nolink nlid="nl28" bibid="bib64" firstref="ref45"></nolink> <nolink nlid="nl29" bibid="bib54" firstref="ref46"></nolink> <nolink nlid="nl30" bibid="bib43" firstref="ref47"></nolink> <nolink nlid="nl31" bibid="bib58" firstref="ref48"></nolink> <nolink nlid="nl32" bibid="bib57" firstref="ref50"></nolink> <nolink nlid="nl33" bibid="bib55" firstref="ref54"></nolink> <nolink nlid="nl34" bibid="bib61" firstref="ref55"></nolink> <nolink nlid="nl35" bibid="bib33" firstref="ref58"></nolink> <nolink nlid="nl36" bibid="bib42" firstref="ref59"></nolink> <nolink nlid="nl37" bibid="bib56" firstref="ref60"></nolink> <nolink nlid="nl38" bibid="bib46" firstref="ref61"></nolink> <nolink nlid="nl39" bibid="bib17" firstref="ref68"></nolink> <nolink nlid="nl40" bibid="bib26" firstref="ref69"></nolink> <nolink nlid="nl41" bibid="bib11" firstref="ref87"></nolink> <nolink nlid="nl42" bibid="bib29" firstref="ref88"></nolink> <nolink nlid="nl43" bibid="bib24" firstref="ref90"></nolink> <nolink nlid="nl44" bibid="bib14" firstref="ref91"></nolink> <nolink nlid="nl45" bibid="bib23" firstref="ref109"></nolink> <nolink nlid="nl46" bibid="bib44" firstref="ref112"></nolink> <nolink nlid="nl47" bibid="bib45" firstref="ref113"></nolink> <nolink nlid="nl48" bibid="bib47" firstref="ref116"></nolink> <nolink nlid="nl49" bibid="bib25" firstref="ref117"></nolink> <nolink nlid="nl50" bibid="bib15" firstref="ref126"></nolink> <nolink nlid="nl51" bibid="bib27" firstref="ref128"></nolink> <nolink nlid="nl52" bibid="bib34" firstref="ref129"></nolink> <nolink nlid="nl53" bibid="bib12" firstref="ref130"></nolink> <nolink nlid="nl54" bibid="bib21" firstref="ref131"></nolink> <nolink nlid="nl55" bibid="bib51" firstref="ref137"></nolink>
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Items – Name: Title
  Label: Title
  Group: Ti
  Data: Outcomes of the World Health Organization's Caregiver Skills Training Program for Eritrean and Ethiopian Parents of Autistic Children in the United States
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Sarah+Dababnah%22">Sarah Dababnah</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-8298-1639">0000-0001-8298-1639</externalLink>)<br /><searchLink fieldCode="AR" term="%22Waganesh+A%2E+Zeleke%22">Waganesh A. Zeleke</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-4604-336X">0000-0002-4604-336X</externalLink>)<br /><searchLink fieldCode="AR" term="%22Yoonzie+Chung%22">Yoonzie Chung</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-5528-6577">0000-0001-5528-6577</externalLink>)<br /><searchLink fieldCode="AR" term="%22Rachel+Antwi+Adjei%22">Rachel Antwi Adjei</searchLink><br /><searchLink fieldCode="AR" term="%22Pamela+Dixon%22">Pamela Dixon</searchLink><br /><searchLink fieldCode="AR" term="%22Erica+Salomone%22">Erica Salomone</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-8083-5942">0000-0002-8083-5942</externalLink>)<br /><searchLink fieldCode="AR" term="%22WHO+CST+Team%22">WHO CST Team</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Autism%3A+The+International+Journal+of+Research+and+Practice%22"><i>Autism: The International Journal of Research and Practice</i></searchLink>. 2025 29(12):2941-2954.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 14
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2025
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Audience
  Label: Education Level
  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22Adult+Education%22">Adult Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Autism+Spectrum+Disorders%22">Autism Spectrum Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Skill+Development%22">Skill Development</searchLink><br /><searchLink fieldCode="DE" term="%22Parent+Education%22">Parent Education</searchLink><br /><searchLink fieldCode="DE" term="%22Immigrants%22">Immigrants</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Mothers%22">Mothers</searchLink><br /><searchLink fieldCode="DE" term="%22Anxiety%22">Anxiety</searchLink><br /><searchLink fieldCode="DE" term="%22Stress+Variables%22">Stress Variables</searchLink><br /><searchLink fieldCode="DE" term="%22Coping%22">Coping</searchLink><br /><searchLink fieldCode="DE" term="%22Stress+Management%22">Stress Management</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Neurodevelopmental+Disorders%22">Neurodevelopmental Disorders</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Eritrea%22">Eritrea</searchLink><br /><searchLink fieldCode="DE" term="%22Ethiopia%22">Ethiopia</searchLink><br /><searchLink fieldCode="DE" term="%22Maryland%22">Maryland</searchLink><br /><searchLink fieldCode="DE" term="%22District+of+Columbia%22">District of Columbia</searchLink><br /><searchLink fieldCode="DE" term="%22Virginia%22">Virginia</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1177/13623613251351345
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1362-3613<br />1461-7005
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Autism intervention research has not adequately addressed the needs of Black autistic children and their families, particularly those who are also immigrants to the United States. The World Health Organization designed Caregiver Skills Training (CST), a parent-mediated intervention intended to improve child social communication and behavior, to fill in the global gap of services for caregivers of young children with autism and other neurodevelopmental conditions. While CST has been implemented in Ethiopia, it has not been evaluated for Ethiopian and Eritrean immigrant families in the United States. This single-arm pilot study of CST investigated pre- and post-intervention changes in parent and child outcomes within a sample of 25 mothers of autistic children (ages 2-9 years) in Maryland, Washington, DC, and Virginia. Eritrean and Ethiopian facilitators delivered CST remotely to five parent groups. We used Wilcoxon signed-rank tests and found statistically significant improvements in parents' knowledge, skills, self-efficacy, depression, and empowerment, as well as child communication, sociability, and sensory/ cognitive awareness. There were no statistically significant changes in parents' anxiety, stress, and coping, nor some subscales of the empowerment and child outcome measures. We conclude CST is a promising intervention for Ethiopian and Eritrean immigrant families in the United States. Randomized controlled trials are needed to confirm study findings.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1489391
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1489391
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      – Type: doi
        Value: 10.1177/13623613251351345
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      – Text: English
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      Pagination:
        PageCount: 14
        StartPage: 2941
    Subjects:
      – SubjectFull: Autism Spectrum Disorders
        Type: general
      – SubjectFull: Skill Development
        Type: general
      – SubjectFull: Parent Education
        Type: general
      – SubjectFull: Immigrants
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      – SubjectFull: Foreign Countries
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      – SubjectFull: Mothers
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      – SubjectFull: Program Effectiveness
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      – SubjectFull: Neurodevelopmental Disorders
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      – SubjectFull: Eritrea
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      – SubjectFull: Ethiopia
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      – SubjectFull: Maryland
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      – SubjectFull: District of Columbia
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      – SubjectFull: Virginia
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      – TitleFull: Outcomes of the World Health Organization's Caregiver Skills Training Program for Eritrean and Ethiopian Parents of Autistic Children in the United States
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            NameFull: Sarah Dababnah
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            NameFull: Waganesh A. Zeleke
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            NameFull: Pamela Dixon
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            NameFull: Erica Salomone
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            NameFull: WHO CST Team
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              Y: 2025
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