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Parent-Implemented Interventions for Children with Autism Spectrum Disorder in South Asia: A Systematic Review

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Title: Parent-Implemented Interventions for Children with Autism Spectrum Disorder in South Asia: A Systematic Review
Language: English
Authors: Tvisha Vyas (ORCID 0009-0004-6755-8559), Gulnoza Yakubova (ORCID 0000-0002-4223-3545)
Source: Education and Training in Autism and Developmental Disabilities. 2025 60(4):399-423.
Availability: Division on Autism and Developmental Disabilities, Council for Exceptional Children. DDD, P.O. Box 3512, Fayetteville, AR 72702. Tel: 479-575-3326; Fax: 479-575-6676; Web site: http://www.daddcec.com/
Peer Reviewed: Y
Page Count: 25
Publication Date: 2025
Document Type: Journal Articles
Information Analyses
Education Level: Adult Education
Descriptors: Parent Participation, Intervention, Children, Autism Spectrum Disorders, Foreign Countries, Coaching (Performance), Training Methods, Parent Education, Evidence Based Practice
Geographic Terms: Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, Sri Lanka
DOI: 10.1177/21541647251399488
ISSN: 2154-1647
Abstract: The aim of this systematic review was to synthesize the literature that focused on parent-implemented interventions (PIIs) for children with autism spectrum disorder (ASD) published between 2014 and April 2025 in South Asia. We reviewed 11 studies that met the inclusion criteria to assess various aspects, including participant and intervention characteristics (e.g., intervention type, parent training/coaching techniques, cultural adaptations, etc.). These studies were further evaluated for methodological rigor. We found PIIs can be effective to support children with ASD in various developmental domains and produce positive parent outcomes. However, most studies involved mothers as the primary parent participants, and both the intensity and methods of parent training techniques, as well as cultural adaptations, varied across studies. Of the 11 studies, eight demonstrated strong or adequate evidence based on the assessment of methodological rigor.
Abstractor: As Provided
Entry Date: 2026
Accession Number: EJ1496446
Database: ERIC
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  Value: <anid>AN0189916317;[b6wv]01dec.25;2025Dec11.04:19;v2.2.500</anid> <title id="AN0189916317-1">Parent-Implemented Interventions for Children with Autism Spectrum Disorder in South Asia: A Systematic Review </title> <p>The aim of this systematic review was to synthesize the literature that focused on parent-implemented interventions (PIIs) for children with autism spectrum disorder (ASD) published between 2014 and April 2025 in South Asia. We reviewed 11 studies that met the inclusion criteria to assess various aspects, including participant and intervention characteristics (e.g., intervention type, parent training/coaching techniques, cultural adaptations, etc.). These studies were further evaluated for methodological rigor. We found PIIs can be effective to support children with ASD in various developmental domains and produce positive parent outcomes. However, most studies involved mothers as the primary parent participants, and both the intensity and methods of parent training techniques, as well as cultural adaptations, varied across studies. Of the 11 studies, eight demonstrated strong or adequate evidence based on the assessment of methodological rigor.</p> <p>Keywords: autism; ASD; parent-implemented; parent-mediated; systematic review</p> <p>The global incidence of autism spectrum disorder (ASD), based on the most recent data, is approximately 1 in 100 children ([<reflink idref="bib47" id="ref1">47</reflink>]). However, this statistic does not capture the heterogeneous nature of ASD since there are a wide variety of symptoms and developmental profiles. Further, disparities in access to timely diagnosis, services, and culturally tailored supports differ across the world, complicating service provision ([<reflink idref="bib24" id="ref2">24</reflink>]). In South Asia, child to provider ratio is reported to be more than 100 times lower than in many high-income nations ([<reflink idref="bib7" id="ref3">7</reflink>]). When formal services are scarce and stigma is high, parents often become their child's main or only therapist, learning whatever strategies they can from short clinical visits, online videos, or peer networks ([<reflink idref="bib21" id="ref4">21</reflink>]). Because of high stigma and prevailing cultural beliefs, parents' help-seeking often follows a non-scientific path: some families attribute autism to spiritual causes, fear disability will damage their social standing and first turn to traditional healers whose explanations feel more familiar than biomedical labels ([<reflink idref="bib28" id="ref5">28</reflink>]). When such cultural beliefs drive parents' choices, children with ASD may not benefit from proper techniques to learn skills ([<reflink idref="bib7" id="ref6">7</reflink>]; [<reflink idref="bib27" id="ref7">27</reflink>]).</p> <p>Parent-implemented interventions (PIIs), sometimes referred to as parent-mediated or parent/caregiver-delivered interventions, offer a culturally adaptable, evidence-based alternative to these challenges. Through PIIs, parents are taught specific techniques—such as modeling language, creating predictable routines, prompting social play, and using natural reinforcement—and are encouraged to apply these strategies during daily activities, while their implementation is monitored ([<reflink idref="bib3" id="ref8">3</reflink>]; [<reflink idref="bib25" id="ref9">25</reflink>]). The approach is both practical and theoretically compelling: parents, as the individuals who spend the most time with the child across various settings, can facilitate better generalization of skills compared to clinic-bound sessions. ([<reflink idref="bib11" id="ref10">11</reflink>]). Two recent meta-analyses involving dozens of randomized controlled trials reported moderate-to-large gains in language, social-communication, and adaptive behavior among children whose parents received PII ([<reflink idref="bib3" id="ref11">3</reflink>]; [<reflink idref="bib24" id="ref12">24</reflink>]). However, over 90% of the studies were conducted in high-income Western nations with predominantly White participants ([<reflink idref="bib15" id="ref13">15</reflink>]; [<reflink idref="bib38" id="ref14">38</reflink>]). Thus, optimizing PIIs for effective implementation in the densely populated, culturally diverse, and resource-constrained settings of South Asia requires attention to critical factors such as cultural acceptability, intervention fidelity, family engagement, and the availability of local resources ([<reflink idref="bib7" id="ref15">7</reflink>]; [<reflink idref="bib27" id="ref16">27</reflink>]).</p> <p>In addition to optimizing these implementation-related factors, parent well-being is an equally important consideration for the effectiveness of PIIs. Specifically, parenting stress, psychological strain that arises from balancing daily demands with the unique needs of supporting a child with ASD, can reduce implementation fidelity and deter child gains ([<reflink idref="bib14" id="ref17">14</reflink>]). Longitudinal studies point to a feedback loop—higher stress today predicts more challenging behavior of a child six months later, which in turn raises parental stress ([<reflink idref="bib39" id="ref18">39</reflink>]). Broader indicators of parental mental health, including anxiety, depression, and self-efficacy, influence whether families enroll in programs, attend coaching sessions, and persist when progress slows ([<reflink idref="bib16" id="ref19">16</reflink>]). Similarly, warm, responsive parent–child interactions, characterized by shared affect, contingent language, and joint attention, serve as a proximal mechanism through which PIIs promote language and social learning ([<reflink idref="bib36" id="ref20">36</reflink>]). Interventions that strengthen parental confidence, reduce stress, and foster high-quality interactions hold the greatest promise for sustainable gains ([<reflink idref="bib10" id="ref21">10</reflink>]; [<reflink idref="bib36" id="ref22">36</reflink>]; [<reflink idref="bib43" id="ref23">43</reflink>]). Yet, few PII studies have addressed parent stress or mental health prior to service/intervention delivery.</p> <p>There are emerging examples of successful PIIs in South Asia. The Parent Autism Social Support (PASS) trial in India and Pakistan paired video-feedback coaching with community health-worker visits; trainers spoke local languages, used everyday household objects as teaching aids, and added modules on stigma management and financial planning. Following the intervention, children in the PASS group showed significantly better communication skills than those receiving treatment as usual ([<reflink idref="bib27" id="ref24">27</reflink>]). A smaller pilot in Goa embedded similar coaching techniques within mothers' self-help groups and reported reductions in maternal distress alongside child social-communication gains ([<reflink idref="bib8" id="ref25">8</reflink>]). Nevertheless, such studies remain the exception rather than the norm, and they vary widely in how they describe the cultural adaptations implemented.</p> <p>In the absence of a synthesis that systematically looks at cultural adaptations across studies, clinicians and policymakers lack clear guidance on which adaptations are most impactful. Accordingly, this systematic review examines the intersection of PIIs, parent well-being, and cultural adaptations implemented in South Asia. We aimed to answer the following research questions: (a) What are the demographic characteristics of child and parent participants in the included studies?, (b) What are the characteristics of interventions used in the included studies conducted in South Asia (e.g., cultural adaptations, skill characteristics, interventions for children, parent training/coaching techniques, and any cultural adaptations made)?, (c) What are the effects of PIIs on child and parent outcomes? And (d) What is the methodological rigor of PII studies included in this review?</p> <hd id="AN0189916317-2">Method</hd> <p>All review procedures followed the methodological guidance outlined by [<reflink idref="bib22" id="ref26">22</reflink>] and followed the PRISMA 2020 flow diagram ([<reflink idref="bib26" id="ref27">26</reflink>]) to map the study selection process.</p> <hd id="AN0189916317-3">Eligibility Criteria</hd> <p>To determine study eligibility for inclusion in this review, the following criteria were set: (a) participants had to be children (with no age restrictions) diagnosed with ASD and their parent(s); (b) consistent with prior syntheses ([<reflink idref="bib1" id="ref28">1</reflink>]; [<reflink idref="bib3" id="ref29">3</reflink>]; [<reflink idref="bib25" id="ref30">25</reflink>]), the study provided systematic instruction and/or coaching for parents, required parents to use those strategies directly with their child outside professional sessions, and measured or otherwise monitored parent implementation (e.g., fidelity observation, practice logs, structured self-report); (c) study included both child and parent outcomes, with parent treatment integrity considered a parent outcome; (d) published in English between 2014 and April 2025 in peer-reviewed journals, given the past decade has seen rapid growth in PIIs and technology-mediated coaching models ([<reflink idref="bib8" id="ref31">8</reflink>]; [<reflink idref="bib9" id="ref32">9</reflink>]); (e) used experimental designs such as single-case research designs (SCRD), randomized controlled trials (RCTs), or quasi-experimental designs, and (f) study was conducted in South Asia. In line with the [<reflink idref="bib46" id="ref33">46</reflink>] regional classification, South Asia includes the following countries: Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka. Studies involving participants "at risk of autism" were excluded to maintain the focus on diagnosed cases. A study was also excluded if a group experimental design study included participants other than children with ASD or involved participants from other countries outside Southern Asia but did not disaggregate findings by participant disability categories and country of residence. Grey literature, such as dissertations, conference presentations, and think-tank reports, was excluded to ensure the quality of the evidence synthesized ([<reflink idref="bib12" id="ref34">12</reflink>]). Reports limited to psychoeducational seminars or support groups without documented parent strategy use were excluded during screening.</p> <hd id="AN0189916317-4">Information Sources</hd> <p>A structured approach was adopted to effectively conduct the literature search for this synthesis. During the primary electronic search, peer-reviewed journal articles were searched and screened from the following databases: EBSCOhost (Academic Search Ultimate, APA PsycINFO, APA PsycArticles, Education Source, and ERIC). An advanced search feature of electronic databases using Boolean (AND/OR) operators was utilized. Search terms in the first line included: caregiver*, parent*, mother*, father*. The second line included PII, "parent train*", "parent-mediate*", "parent-facilitate*", "parent coach*", "parent-direct*", "parent implement*", "caregiver implemented", "caregiver mediated", "caregiver train*", "caregiver coach*", "caregiver facilitated", "family implemented", "family coach*", "family-mediated", "family-directed", "family train*", "parent education", "caregiver education", "family education", "parent-led", "parent-deliver*", "caregiver-led", and "caregiver-deliver*". The third line included autis*, autism, ASD, "autism spectrum disorder", Asperger* and "PDD-NOS".</p> <hd id="AN0189916317-5">Search Procedures and Study Selection Process</hd> <p>The study selection procedure involved the screening of title, abstract, and full text of articles based on the set inclusion and exclusion criteria (Refer to Figure 1). All records retrieved from the electronic database searches were exported into <emph>Mendeley Reference Manager</emph> (Elsevier) for citation management and de-duplication. After duplicates were removed in Mendeley, the remaining unique records were transferred into a screening spreadsheet for eligibility review. Use of a structured flow diagram and transparent reporting of the identification, screening, eligibility, and inclusion phases is consistent with PRISMA 2020 guidance for systematic reviews. (Elsevier, n.d.; [<reflink idref="bib26" id="ref35">26</reflink>]). Screening proceeded in three sequential phases: title/abstract screening, full-text screening, and secondary (reference) searching; guided by the eligibility criteria. The first author independently screened titles and abstracts. Records were advanced to full text when eligibility could not be confidently excluded. Records clearly failing one or more mandatory criteria were excluded at this stage. PDFs of all retained records were retrieved and independently reviewed by the first author and three reviewers using the complete eligibility rubric. Any discrepancies between the reviewers and the first author were resolved through discussion. To identify additional eligible studies not captured in the database queries, we hand-searched the reference lists of systematic reviews and meta-analyses published 2020–2023 that focused on (a) ASD and PIIs or (b) telehealth-delivered parent coaching. Unique citations identified through this secondary search were imported into Mendeley and screened in their entirety using the same procedures and criteria described above. Studies meeting all inclusion criteria advanced to data extraction and quality appraisal.</p> <p>Graph: Figure 1. PRISMA Flowchart of the Study Selection Process. Note: Adapted from [<reflink idref="bib26" id="ref36">26</reflink>]. In the public domain. To view a copy of this License, Visit https://creativecommons.org/licenses/by/4.0/.</p> <hd id="AN0189916317-6">Coding Procedures</hd> <p>Each included article was coded for participant demographics, including child characteristics (number, age, gender, grade, diagnoses, and additional services) and parent characteristics (age, gender, education). Intervention details were extracted, including child target skills, intervention type, and cultural adaptations. Parent training features were coded for techniques (e.g., instruction, modeling, rehearsal, feedback, duration/frequency), training setting (e.g., virtual, group, individual, hybrid, web-based, or self-directed), and coach/trainer qualifications (e.g., experience, education, certifications). Child and parent outcomes were coded into multiple categories, including effect sizes when reported, along with the study design (group or SCRD) and the country where the study was conducted.</p> <hd id="AN0189916317-7">Methodological Evaluation</hd> <p>The mixed body of evidence in this review comprises both SCRD and group comparison studies. We sought an appraisal instrument that (a) contains parallel indicators for both designs, (b) yields a common three-level rating that can be synthesized across designs, and (c) attends to constructs central to PIIs—namely intervention fidelity, generalization/maintenance, and social validity. The evaluative method for determining evidence-based practices in autism developed by [<reflink idref="bib30" id="ref37">30</reflink>] meets these criteria ([<reflink idref="bib44" id="ref38">44</reflink>]). Group and SCRD studies were evaluated separately using the [<reflink idref="bib30" id="ref39">30</reflink>] criteria. For SCRDs, we coded participant characteristics, independent and dependent variable(s), baseline, visual analysis, and experimental control as primary indicators; interobserver agreement (IOA), kappa, blind raters, procedural fidelity, generalization/maintenance and social validity were treated as secondary indicators. Similarly, for the group designs primary indicators included participant characteristics, independent and dependent variable(s), comparison condition, link between research question and data analysis (LRQ), statistical analysis, whereas random assignment, IOA, blind raters, fidelity, attrition, generalization/maintenance, effect size, and social validity functioned as secondary indicators. A primary indicator was rated <emph>high</emph> when reporting was sufficiently detailed to permit replication and when procedures met accepted methodological standards; <emph>acceptable</emph> when minor reporting gaps or design limitations were present but threats to validity were limited; and <emph>unacceptable</emph> when critical information was missing or flaws posed substantial risk to internal or external validity. Secondary indicators were coded dichotomously for presence/absence. Overall research strength ratings were derived by combining these indicator scores ([<reflink idref="bib30" id="ref40">30</reflink>]). A study earned a <emph>strong</emph> rating when all primary indicators were high quality and there was evidence of ≥4 sary indicators (group designs) or ≥3 sary indicators (single-case designs). A study was <emph>adequate</emph> when it had at least four high-quality primary indicators, no unacceptable ratings on any primary indicator, and evidence of ≥2 sary indicators; in practice, up to two primary indicators may be scored acceptable without downgrading the study below adequate if none are unacceptable. A study was <emph>weak</emph> if it had fewer than four high-quality primary indicators, any unacceptable primary indicator, or evidence of fewer than two secondary indicators.</p> <hd id="AN0189916317-8">Inter-Rater Agreement</hd> <p>To ensure reliable screening and coding, the first author trained three doctoral students in special education to independently code based on inclusion/exclusion criteria, data extraction, and methodological quality. Then, all raters coded one sample study independently to calibrate coding reliability and discussed until all coders reached 100% agreement on practice coding. Inter-rater agreement (IRA) was calculated as the ratio of coder agreements to total eligible items. During full-text screening, each coder reviewed 40 articles, yielding 97% agreement. For data extraction (study, participants, intervention, outcomes), each coder independently coded 10 articles, covering 20% of included studies, with 98% IRA. For methodological evaluation, coders reviewed 50% of studies, achieving 96.8% IRA. Discrepancies were resolved through discussions until full consensus was reached.</p> <hd id="AN0189916317-9">Results</hd> <p>Eleven studies were included for review in this research synthesis. A summary of the findings is described below, and detailed information can be found in the attached tables.</p> <hd id="AN0189916317-10">Study Selection</hd> <p>The electronic database searches yielded 3,918 records. After de-duplication in Mendeley, 2,331 unique records remained for screening. Title/abstract screening advanced 151 records to full-text review. The secondary reference search identified an additional 23 records that were retrieved in full. In total, 174 full texts were assessed for eligibility. Eleven studies met all inclusion criteria; two of these 11 were identified through the secondary reference search. Reasons for full-text exclusion are detailed in Figure 1, presented in accordance with PRISMA 2020 flow diagram conventions ([<reflink idref="bib26" id="ref41">26</reflink>]).</p> <hd id="AN0189916317-11">Child and Parent Demographics</hd> <p>Eleven studies provided demographic data on approximately 274 children with ASD (see Table 1). Most studies (<emph>n = 9</emph>) reported 81%–86% of participants were boys. All 11studies provided age data, showing ranges from 2 to 9 years (mean age: 3.3–5.5 years). Secondary diagnoses were rarely reported, only two studies explicitly listed co-occurring conditions such as intellectual disability or attention deficit hyperactivity disorder. Parent participants, primarily mothers (reported in all 11 studies), were approximately 25–55 years of age. The educational background of participants varied widely across studies, encompassing a broad socioeconomic spectrum. Parent participants' education levels and ranged from secondary education (n = 2) to doctoral degrees (n = 2; [<reflink idref="bib8" id="ref42">8</reflink>]; [<reflink idref="bib41" id="ref43">41</reflink>]). Most studies were conducted in India (n = 7), with individual studies from Pakistan and Sri Lanka, and two cross-border collaborations between India and Pakistan.</p> <p>Table 1. Child and Parent Demographics.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="left" /><col align="left" /><col align="left" /><col align="left" /><col align="left" /><col align="left" /><col align="left" /><col align="left" /></colgroup><thead><tr><th align="left">Study</th><th align="left">Number of participants</th><th align="left">Diagnosis (Secondary Diagnosis)</th><th align="left">Ongoing additional supports & services</th><th align="left">Age of child participants</th><th align="left">Gender</th><th align="left">Interventionist & age</th><th align="left">Country</th><th align="left">Educational level</th></tr></thead><tbody><tr><td><xref ref-type="bibr" rid="bibr8">Divan et al. (2019)</xref></td><td>Control group (n = 20); PASS Plus group (n = 15)</td><td>ASD</td><td>Usual care including private allopathic, Ayurvedic/homeopathic doctors</td><td>Mean age: 64 months</td><td>34 M; 6 F</td><td>Parents; Age NR</td><td>India</td><td>High school or lower: 16; Undergraduate or higher: 24</td></tr><tr><td><xref ref-type="bibr" rid="bibr17">Ijaz et al. (2021)</xref></td><td>33</td><td>ASD</td><td>NR</td><td>Mean age: 5.5 ± 1.3 years</td><td>NR</td><td>Mothers; Mean age: 35 ± 5 years</td><td>Pakistan</td><td>Minimum: bachelor's degree; 57.6% postgraduates</td></tr><tr><td><xref ref-type="bibr" rid="bibr19">Krishnan et al. (2016)</xref></td><td>8</td><td>ASD</td><td>All children received only the parent-mediated intervention during study period</td><td>2–4.5 years</td><td>NR</td><td>Mothers; Age NR</td><td>India</td><td>5 mothers completed secondary education; 3 had some college or higher</td></tr><tr><td><xref ref-type="bibr" rid="bibr23">Manohar et al. (2019)</xref></td><td>Control group (n = 26); Intervention group (n = 24)</td><td>ASD (ADHD, epilepsy, ID)</td><td>Speech and language therapy, occupational therapy</td><td>2–6 years</td><td>84.6% M</td><td>NR</td><td>India</td><td>Average years of schooling: 13 years for intervention group; 12.71 years for control group</td></tr><tr><td><xref ref-type="bibr" rid="bibr27">Rahman et al. (2016)</xref></td><td>TAU group (n = 33); PASS group (n = 32)</td><td>ASD</td><td>Speech and language therapy, occupational/physiotherapy; similar across groups and countries</td><td>Aged 2–9 years</td><td>81% M; 19% F</td><td>Parent; Age: NR</td><td>Pakistan & India</td><td>Father's education: 48–69% non-graduate</td></tr><tr><td><xref ref-type="bibr" rid="bibr34">Sengupta et al. (2020)</xref></td><td>57</td><td>ASD</td><td>NR</td><td>Mean age: 43.2 months</td><td>84.2% M</td><td>Mothers; NR</td><td>India</td><td>NR</td></tr><tr><td><xref ref-type="bibr" rid="bibr35">Sengupta et al. (2021)</xref></td><td>15</td><td>ASD</td><td>NR</td><td>Mean age: 43.6 months</td><td>86.6% M</td><td>Mothers; Age: NR</td><td>India</td><td>NR</td></tr><tr><td><xref ref-type="bibr" rid="bibr33">Sengupta et al. (2023)</xref></td><td>12</td><td>ASD</td><td>0 to 5 h/week of other therapies (varied across participants)</td><td>Mean age: 47.5 months</td><td>8 M; 4 F</td><td>Mothers; Mean age: 33.8 years</td><td>India</td><td>Minimum: bachelor's degree; some had master's and PhD</td></tr><tr><td><xref ref-type="bibr" rid="bibr37">Sivaraman et al. (2021)</xref></td><td>Total 6 (2 included)</td><td>ASD</td><td>NR</td><td>6 and 7 years</td><td>Both M</td><td>Mothers; Age NR</td><td>India</td><td>NR</td></tr><tr><td><xref ref-type="bibr" rid="bibr41">Tsami et al. (2023)</xref></td><td>Total 9 (4 included)</td><td>ASD (ID, Down syndrome)</td><td>One participant received behavioral intervention at school; one caregiver received online training on ABA</td><td>6–8 years</td><td>2 M; 2 F</td><td>Mothers, 34–41 years</td><td>3 from Pakistan and 1 Indian</td><td>2 PhDs and 2 master's degree</td></tr><tr><td><xref ref-type="bibr" rid="bibr42">Wanniachchi & Sumanasena (2024)</xref></td><td>30</td><td>ASD</td><td>NR</td><td>24–48 months</td><td>NR</td><td>Mothers, 25–55 years</td><td>Sri Lanka</td><td>16.7% up to O/L, 43.3% up to A/L, 40% degree/diploma</td></tr></tbody></table> </ephtml> </p> <p>1 <emph>Note.</emph> PASS Plus = PASS refers to the Parent-mediated Autism Social communication intervention for children with ASD, and PASS Plus is an enhanced or adapted version of this intervention, typically with additional components like support for co-occurring difficulties or more intensive coaching; Tau-U = Tau non-overlap (A→B) + Adjustment for baseline trend; ID = Intellectual Disability; ADHD = Attention Deficit Hyperactivity Disorder; NR = Not Reported; O/L = Ordinary level, A/L = Advanced level; TAU = Treatment as Usual; M = Male; F = Female; PhD = Doctor of Philosophy; ABA = Applied Behavior Analysis.</p> <hd id="AN0189916317-12">Intervention Characteristics</hd> <p>All 11 studies used PIIs primarily grounded in behavioral or developmental approaches, especially naturalistic developmental behavioral intervention (NDBI; n = 6) and play-based developmental models (n = 2) in earlier publications, whereas earlier studies relied more on behavioral skills training and applied behavior analysis (n = 3; see Table 2), signaling a regional trend toward parent -implemented, naturalistic strategies. All included studies involved direct parent implementation with fidelity and interventions varied in emphasis and intensity. For example, [<reflink idref="bib8" id="ref44">8</reflink>] and [<reflink idref="bib27" id="ref45">27</reflink>] used culturally adapted versions of the Parent-mediated communication-focused treatment (PACT; [<reflink idref="bib13" id="ref46">13</reflink>]), while [<reflink idref="bib35" id="ref47">35</reflink>], [<reflink idref="bib33" id="ref48">33</reflink>]) implemented Project ImPACT frameworks ([<reflink idref="bib18" id="ref49">18</reflink>]) adapted for South Asian settings. One study ([<reflink idref="bib42" id="ref50">42</reflink>]) adapted a developmental coaching framework using the Quality of Caregiver–Child Interaction for Infants and Toddlers (Q-CCIIT) checklist.</p> <p>Table 2. Intervention Characteristics.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="left" /><col align="left" /><col align="left" /><col align="left" /><col align="left" /></colgroup><thead><tr><th align="left">Study</th><th align="left">Child and Parent Target Skills</th><th align="left">Type of Intervention & Cultural Adaptations</th><th align="left">Who coached the parents?</th><th align="left">Parent Training Type, Setting & Methods</th><th align="left">Parent Training Frequency & Duration</th></tr></thead><tbody><tr><td><xref ref-type="bibr" rid="bibr8">Divan et al. (2019)</xref></td><td>Child: Social skills, shared attention; Parent: Synchronous responses; treatment fidelity, mental health, empowerment</td><td>PASS Plus: culturally adapted parent-mediated intervention with added modules for comorbidities</td><td>Lay health workers, trained/supervised by senior clinicians; all local (Indian) staff</td><td>Home-based; video-feedback; individualized written practice plans</td><td>12 sessions over 6 months (fortnightly)</td></tr><tr><td><xref ref-type="bibr" rid="bibr17">Ijaz et al. (2021)</xref></td><td>Child: Verbal and non-verbal communication; Parent: Autism knowledge, implementation fidelity</td><td>BST: culturally contextual but no specific adaptations described</td><td>Facilitators/researchers</td><td>Group-based in-person workshops using demonstration, video modeling, and discussion</td><td>11 sessions (60–90 min) over 16 weeks</td></tr><tr><td><xref ref-type="bibr" rid="bibr19">Krishnan et al. (2016)</xref></td><td>Child: Joint attention, social engagement, communication, and early cognitive skills; Parent: Use of evidence-based techniques</td><td>Play-based PMI, included structured play routines, natural environment teaching, and cultural sensitivity in home setting</td><td>Local therapists with support from a supervising developmental pediatrician</td><td>Clinic-based coaching, home visits, modeling, feedback, and problem-solving strategies</td><td>Initial intensive training followed by weekly sessions over 3 months</td></tr><tr><td><xref ref-type="bibr" rid="bibr23">Manohar et al. (2019)</xref></td><td>Child: Social communication, joint attention, imitation, adaptive skills; Parent: Stress and coping</td><td>Intervention based on NDBI approach; Adapted for cultural relevance</td><td>Researchers with background in child psychiatry and pediatrics</td><td>Outpatient, one-on-one sessions, included education and stress management, tailored to cultural context.</td><td>Five sessions over 12 weeks</td></tr><tr><td><xref ref-type="bibr" rid="bibr27">Rahman et al. (2016)</xref></td><td>Child: Social communication; Parent: Parental synchrony</td><td>PASS - culturally adapted version of PACT, flexible for extended family participation, script-based, simplified language</td><td>Non-specialist health workers trained and supervised by local specialists, who were in turn trained by UK team</td><td>One-on-one clinic (Pakistan) or home (India) sessions, video-feedback</td><td>1-h sessions every 2 weeks for 6 months</td></tr><tr><td><xref ref-type="bibr" rid="bibr34">Sengupta et al. (2020)</xref></td><td>Child: Social communication, engagement, imitation, expressive language; Parent: Treatment fidelity</td><td>NDBI-based UPPA adapted from Project ImPACT; culturally adapted (language, metaphors, play, family roles, session structure)</td><td>Local therapists trained in UPPA delivery</td><td>Hybrid (in-person/virtual); group and individual coaching</td><td>6 weeks; 6 group sessions + 6 coaching sessions</td></tr><tr><td><xref ref-type="bibr" rid="bibr35">Sengupta et al. (2021)</xref></td><td>Child: Social communication, imitation, engagement;Parent: Treatment fidelity</td><td>Culturally adapted version of Project ImPACT; modified for language, family roles, metaphors, duration, and accessibility</td><td>Interventionists experienced in NDBI and autism</td><td>Used video modeling, feedback, live coaching</td><td>12 sessions for over 6 weeks; 1 group and 1 individual session per week (∼60–90 min each)</td></tr><tr><td><xref ref-type="bibr" rid="bibr33">Sengupta et al. (2023)</xref></td><td>Child: Social engagement, expressive language, understanding directions, social imitation, and playParent: Treatment fidelity</td><td>Project ImPACT (UPPA version); adapted for local language, context, tech constraints, and group support</td><td>Therapists trained in Project ImPACT</td><td>Synchronous online sessions (Zoom/WhatsApp video); Group learning plus individualized coaching via video feedback</td><td>6 weekly group sessions + 6 weekly individual sessions; each ∼60–90 min</td></tr><tr><td><xref ref-type="bibr" rid="bibr37">Sivaraman et al. (2021)</xref></td><td>Child: Mask wearing ability, compliance with mask wearing, challenging behaviors associated with mask wearing; Parent: Treatment fidelity</td><td>Behavioral strategies such as graduated exposure, shaping, and contingent reinforcement. Materials and instructions were adapted and translated</td><td>Author, masters' degree behavior analyst with 7 years of experience in behavioral interventions, and 3 years telehealth interventions. Fluent in English and Tamil</td><td>Telehealth sessions conducted with the experimenter; included review of progress, discussion of techniques, direct observation and feedback during practice sessions</td><td>Frequency and duration were adapted to each child's progress and compliance levels; details not mentioned.</td></tr><tr><td><xref ref-type="bibr" rid="bibr41">Tsami et al. (2023)</xref></td><td>Child: Behavior management, independent mands.Parent: Procedural integrity</td><td>Telehealth-based FA + FCT; culturally adapted through interpreter use, rapport building, language matching, and flexible implementation</td><td>BCBA with 6 years of experience</td><td>Individual sessions with a blend of virtual, written and oral instruction, modeling, rehearsal opportunities, and performance feedback</td><td>1-h appointments, typically conducted once per week</td></tr><tr><td><xref ref-type="bibr" rid="bibr42">Wanniachchi & Sumanasena (2024)</xref></td><td>Child: SE, cog., and LAN; Parent: Interaction skills supporting social-emotional, cognitive, and language development</td><td>Play-based parent coaching with culturally contextual strategies adapted for local use</td><td>Principal investigator and team of speech and language therapists</td><td>Clinic-based group coaching with video feedback; individualized strategy reflection using pre-training videos</td><td>One 3-h session; daily 2-h home play recommended for 2 weeks</td></tr></tbody></table> </ephtml> </p> <p>2 <emph>Note.</emph> Project ImPACT = Improving Parents as Communication Teachers; PACT = Parent-mediated communication-focused treatment in children with autism; FA = Functional Analysis; FCT = Functional Communication Training; BST = Behavioral Skills Training; UK = United Kingdom; NDBI = Naturalistic Developmental Behavioral Intervention; UPPA = Ummeed Parent Program for Autism is a parent-mediated intervention implemented at a child development center in India that teaches parents of young children with autism how to promote their child's social communication skills during daily routines and activities; BCBA = Board Certified Behavior Analyst; Q-CCIIT checklist = Quality of Caregiver–Child Interaction for Infants and Toddlers checklist; Parental synchrony = A component of parent-child interaction; PMI = Parent-mediated intervention.</p> <p>Cultural adaptations were explicitly described in seven studies. These adaptations included translating materials into local languages, simplifying technical terminology, incorporating culturally familiar examples and metaphors, adjusting intervention scripts to accommodate extended family involvement, and aligning session schedules with religious or community calendars ([<reflink idref="bib27" id="ref51">27</reflink>]; [<reflink idref="bib34" id="ref52">34</reflink>], [<reflink idref="bib35" id="ref53">35</reflink>]; [<reflink idref="bib42" id="ref54">42</reflink>]). Three studies reported adapting play routines to reflect typical family practices ([<reflink idref="bib19" id="ref55">19</reflink>]; [<reflink idref="bib34" id="ref56">34</reflink>], [<reflink idref="bib33" id="ref57">33</reflink>]).</p> <p>In eight studies, parents were coached primarily by local therapists, specialists, and paraprofessionals supervised by experienced clinicians (e.g., [<reflink idref="bib8" id="ref58">8</reflink>]; [<reflink idref="bib27" id="ref59">27</reflink>]; [<reflink idref="bib34" id="ref60">34</reflink>], [<reflink idref="bib35" id="ref61">35</reflink>], [<reflink idref="bib33" id="ref62">33</reflink>]). The qualifications and experience of personnel varied across interventions. Some involved clinicians with extensive training and certifications (e.g., BCBA credential; [<reflink idref="bib41" id="ref63">41</reflink>]), while others employed lay health workers supervised by clinical specialists ([<reflink idref="bib27" id="ref64">27</reflink>]). Parent training settings and methods varied, including telehealth (n = 3), a combination of group and individual sessions (n = 4), and one-on-one outpatient coaching (n = 3). These approaches offered both peer support and personalized coaching. [<reflink idref="bib33" id="ref65">33</reflink>] delivered the intervention entirely through online group sessions. Three other studies described hybrid approaches that combined in-person and virtual components, offering greater flexibility and accessibility ([<reflink idref="bib27" id="ref66">27</reflink>]; [<reflink idref="bib34" id="ref67">34</reflink>], [<reflink idref="bib35" id="ref68">35</reflink>]). Training frequency and duration varied; intensive training over short periods (e.g., a single 3-h session, [<reflink idref="bib42" id="ref69">42</reflink>]) occurred alongside longer, spread-out interventions spanning several months ([<reflink idref="bib8" id="ref70">8</reflink>]; [<reflink idref="bib27" id="ref71">27</reflink>]). Flexible schedules tailored to individual progress were also implemented ([<reflink idref="bib37" id="ref72">37</reflink>]).</p> <hd id="AN0189916317-13">Participant Outcomes</hd> <p></p> <hd id="AN0189916317-14">Child Outcomes</hd> <p>All 11 studies reported child outcomes, primarily targeting social communication, joint attention, imitation, expressive language, adaptive skills, and compliance behaviors (see Table 3). Effect sizes were reported in six studies. [<reflink idref="bib34" id="ref73">34</reflink>] reported large effect sizes in social engagement (d = 0.91), imitation (d = 0.73), and overall social communication (d = 0.65). [<reflink idref="bib8" id="ref74">8</reflink>] observed moderate improvements in child initiations (ES = 1.02), while shared attention improvements were nonsignificant (ES = 0.50). [<reflink idref="bib27" id="ref75">27</reflink>] similarly reported large positive effects on initiations (ES = 0.99) but negative effects on shared attention (ES = -0.70). Variability across studies was attributed to differences in intervention duration, outcome measures, and child characteristics.</p> <p>Table 3. Study Design, Outcomes and Reichow Rating.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="left" /><col align="left" /><col align="left" /><col align="left" /><col align="left" /><col align="left" /><col align="left" /></colgroup><thead><tr><th align="left">Study</th><th align="left">Design</th><th align="left">Social Validity</th><th align="left">Maintenance</th><th align="left">Generalization</th><th align="left">Child Outcomes</th><th align="left">Parent Outcomes</th><th align="left">Strength of Evidence</th></tr></thead><tbody><tr><td><xref ref-type="bibr" rid="bibr8">Divan et al. (2019)</xref></td><td>Two arm single-blinded RCT</td><td>Positive feedback in qualitative interviews/focus groups; not systematically assessed</td><td>NR</td><td>NR</td><td>BOSCC (ES = 0.22, NS); Parent synchrony (ES = 3.97); Child initiations (ES = 1.02); Shared attention (ES = 0.50, NS); DBC (ES = 0.32, NS)</td><td>PHQ-9 (ES = 0.76); RAFIN Empowerment (ES = 0.34), Acceptance (ES = 0.39), Knowledge (ES = 0.02); CIs often include zero</td><td>Strong</td></tr><tr><td><xref ref-type="bibr" rid="bibr17">Ijaz et al. (2021)</xref></td><td>Quasi-experimental pre-post</td><td>Positive feedback from mothers; satisfaction reported</td><td>NR</td><td>NR</td><td>Vineland Communication subscale: Pre = 33.15, Post = 73.4; t = 15.4, p <.001</td><td>Autism Knowledge Scale: Pre = 34.14, Post = 80.10; t = 46.89, p <.00</td><td>Weak</td></tr><tr><td><xref ref-type="bibr" rid="bibr19">Krishnan et al. (2016)</xref></td><td>Case series with pre-post design</td><td>Parents reported high satisfaction with intervention; perceived usefulness in daily routines</td><td>NR</td><td>NR</td><td>Qualitative improvement in joint attention, social responsiveness, and communication skills (no effect sizes reported)</td><td>Improved implementation fidelity and parental confidence (no effect sizes reported)</td><td>Weak</td></tr><tr><td><xref ref-type="bibr" rid="bibr23">Manohar et al. (2019)</xref></td><td>RCT</td><td>Measured acceptability & feasibility, 90% families reported satisfaction.</td><td>NR</td><td>NR</td><td>Significant improvements in social communication skills; CARS Total Score (ES = 0.169); Imitation Skills, Joint Attention, Social Engagement (ES ≈ 0.169); Verbal Communication, Object Engagement (NS)</td><td>Small changes in parental stress; FISC Stress (ES = 0.072); FISC Coping (ES = 0.165); Subjective Distress (ES = 0.27); Understanding & Competence (ES = 0.064)</td><td>Strong</td></tr><tr><td><xref ref-type="bibr" rid="bibr27">Rahman et al. (2016)</xref></td><td>Single-blind RCT</td><td>NR</td><td>NR</td><td>NR</td><td>Child initiations (ES = 0.99); decreased shared attention (ES = -0.70)</td><td>Improved parental synchrony (ES = 1.61)</td><td>Strong</td></tr><tr><td><xref ref-type="bibr" rid="bibr34">Sengupta et al. (2020)</xref></td><td>Quasi- experimental, pre- post</td><td>High satisfaction with content and delivery; parents confident using strategies; average ratings 4.2–4.8/5</td><td>2 booster sessions reported, but not formally evaluated</td><td>NR</td><td>Social engagement (d = 0.91), imitation (d = 0.73), overall SCC (d = 0.65), expressive language (modest gains)</td><td>Parenting stress (PSI-SF total): d = 1.11; parent satisfaction mean ratings > 4.5/5</td><td>Adequate</td></tr><tr><td><xref ref-type="bibr" rid="bibr35">Sengupta et al. (2021)</xref></td><td>Pre-post quasi-experimental pilot study</td><td>High parent satisfaction (mean score 4.6/5); parents appreciated flexible structure and cultural relevance</td><td>Not formally assessed; anecdotal reports indicate continued use of strategies</td><td>Not systematically measured; parents reported applying strategies in routines (feeding, bathing, play)</td><td>SCC total z = -3.05, p =.002 (r =.56); engagement z = -2.67, p =.008 (r =.49); imitation z = -2.36, p =.02 (r =.43)</td><td>Parent Fidelity: z = -3.05, p =.002 (r =.56); all five skill domains improved significantly</td><td>Adequate</td></tr><tr><td><xref ref-type="bibr" rid="bibr33">Sengupta et al. (2023)</xref></td><td>Quasi-experimental pre-post design with mixed methods</td><td>High satisfaction (mean = 4.6/5); parents found program culturally sensitive, convenient, and confidence-boosting</td><td>NR</td><td>Not directly assessed; parent reports noted application of strategies in various daily routines, though limited by lockdown</td><td>SCC total: z = −3.06, p <.002, ES = 0.62; Social Engagement: ES = 0.61; Expressive Language Form/Function & other domains: ES = 0.57–0.63</td><td>Parent Fidelity Total: z = −2.74, p = 0.006, ES = 0.56; domain-wise ES range: 0.50–0.59</td><td>Adequate</td></tr><tr><td><xref ref-type="bibr" rid="bibr37">Sivaraman et al. (2021)</xref></td><td>Non-concurrent MB across participants</td><td>Parents reported high satisfaction with the training and intervention effective.</td><td>NR</td><td>Using a different type of mask and at different settings.</td><td>Both children managed to wear a mask for at least 10 min by the end of the intervention.</td><td>Parent treatment integrity was high across sessions, 100% for five caregivers and 96.8% for one caregiver.</td><td>Adequate</td></tr><tr><td><xref ref-type="bibr" rid="bibr41">Tsami et al. (2023)</xref></td><td>Non-concurrent MB across participants</td><td>High acceptability ratings on modified TARF</td><td>NR</td><td>High parent procedural integrity across settings (93–96%) and maintained low problem behavior.</td><td>Problem behavior was reduced to near-zero levels for all but one participant. independent mands >90% for most; effect sizes not reported</td><td>High acceptability ratings; procedural integrity did not differ significantly. high levels of procedural integrity in generalization sessions; effect sizes not reported</td><td>Adequate</td></tr><tr><td><xref ref-type="bibr" rid="bibr42">Wanniachchi & Sumanasena (2024)</xref></td><td>Mixed-method; prospective pre–post interventional study</td><td>High satisfaction; positive perceptions of training impact and parent–child engagement</td><td>NR</td><td>NR</td><td>SE total: pre = 8.80, post = 22.83; Cog. total: pre = 4.63, post = 14.13; LAN total: pre = 5.53, post = 12.97; All p < 0.001</td><td>Improved interaction scores across all three domains; older age and higher education correlated with better gains</td><td>Weak</td></tr></tbody></table> </ephtml> </p> <p>3 <emph>Note</emph>. ES = Effect size; NS = Not Statistically Significant; RCT = Randomized Controlled Trial; NR = Not Reported; LAN = Language development; Cog. = Cognitive development; MB = Multiple Baseline; TARF = ; BOSCC = Brief Observation of Social Communication Change; SCC = Social Communication Checklist; SE = Social and emotional development; PSI-SF = Parenting Stress Index- Short Form; DBC = Developmental Behavior Checklist; CIs = Confidence Intervals; PHQ-9 = A validated tool used to measure parental mental well-being; RAFIN = Research on Autism and Families in India; CARS = Childhood Autism Rating Scale; FISC = Family interview for stress and coping.</p> <hd id="AN0189916317-15">Parent Outcomes</hd> <p>All studies assessed parent outcomes across distinct domains, with effect sizes reported in five studies. Parental stress, defined as the subjective strain experienced by parents due to parenting an autistic child ([<reflink idref="bib14" id="ref76">14</reflink>]), was measured in six studies, with significant reductions consistently observed (e.g., d = 1.11, [<reflink idref="bib34" id="ref77">34</reflink>]). Parent mental health, reflecting broader psychological wellbeing, including symptoms of depression and anxiety ([<reflink idref="bib32" id="ref78">32</reflink>]), was evaluated in the study by [<reflink idref="bib8" id="ref79">8</reflink>], which reported notable reductions in depressive symptoms (ES = 0.76). Self-efficacy, parental skills & knowledge significantly improved among participants in three studies, notably by [<reflink idref="bib17" id="ref80">17</reflink>], who reported marked increases in autism related knowledge. Parent treatment integrity– defined as the consistent and accurate implementation of intervention strategies ([<reflink idref="bib45" id="ref81">45</reflink>]), was evaluated in four studies, all of which reported fidelity levels consistently exceeding 80% (e.g., [<reflink idref="bib37" id="ref82">37</reflink>]; [<reflink idref="bib33" id="ref83">33</reflink>]).</p> <hd id="AN0189916317-16">Methodological Rigor</hd> <p>Of the 11 studies, nine were evaluated for group design guidelines and two were evaluated for SCRD guidelines using [<reflink idref="bib30" id="ref84">30</reflink>] coding methods (refer to Table 3). Among the group design studies, three received strong ratings, three received adequate ratings, and three received weak ratings. The remaining two single case design studies received adequate ratings. Studies that did not receive a strong rating exhibited one or more of the following: uncontrolled designs; limited procedural detail to permit replication; weak comparison conditions; and limited evidence on secondary indicators (e.g., maintenance/generalization, social validity, or attrition).</p> <hd id="AN0189916317-17">Discussion</hd> <p>Parent-implemented interventions are widely used to deliver evidence-based autism support in everyday contexts ([<reflink idref="bib3" id="ref85">3</reflink>]; [<reflink idref="bib24" id="ref86">24</reflink>]; [<reflink idref="bib25" id="ref87">25</reflink>]). This review extends that narrative into South Asia by synthesizing 11 studies from India, Pakistan, and Sri Lanka. The synthesized literature suggests that even where specialist density is low, parents can master developmentally informed strategies to enhance child communication and relieve parent stress. These findings highlight the global relevance of culturally adapted PIIs, aligning with and expanding upon international research emphasizing the necessity of integrating parent wellbeing and culturally responsive practices into autism interventions ([<reflink idref="bib2" id="ref88">2</reflink>]; [<reflink idref="bib6" id="ref89">6</reflink>]). Such integration not only improves child outcomes but also enhances parent engagement and sustainability, affirming the broader relevance of culturally adapted PIIs ([<reflink idref="bib2" id="ref90">2</reflink>]). Beyond child-level skill acquisition, the current literature—consistent with the included studies—shows improvements in parent outcomes (e.g., reduced parenting stress/strain and increased parenting competence or self-efficacy) and high levels of procedural fidelity in parent implementation; together, these findings support bidirectional benefits of PIIs for parents and children ([<reflink idref="bib3" id="ref91">3</reflink>]; [<reflink idref="bib24" id="ref92">24</reflink>]).</p> <p>Across the six South-Asian studies reporting effect sizes, child outcomes clustered in the moderate-to-large range (g ≈.40–.70). This pattern mirrors pooled estimates from recent global meta-analyses of PIIs and NDBIs, which report g values between.35 and.75 ([<reflink idref="bib3" id="ref93">3</reflink>]; [<reflink idref="bib31" id="ref94">31</reflink>]). When key implementation supports are present, PIIs can achieve comparable efficacy in lower-resource contexts to those observed in high-income Western settings ([<reflink idref="bib8" id="ref95">8</reflink>]; [<reflink idref="bib27" id="ref96">27</reflink>]). Two modifiable implementation variables appear to amplify gains. First, programs offering roughly one hour of coached practice per week for at least 12 weeks—yielding a cumulative dose of greater than or equal to 10–12 h—showed larger improvements, consistent with dose-response evidence in the broader PII literature ([<reflink idref="bib9" id="ref97">9</reflink>]). Second, studies that set explicit fidelity benchmarks (≥ 80%) and paired them with ongoing, competency-based supervision reported effect sizes up to 30% higher than studies relying on ad-hoc checks ([<reflink idref="bib40" id="ref98">40</reflink>]). For practitioners and policy makers, these results suggest prioritizing adequate coaching dosage and ensuring rigorous fidelity support are key to maximizing benefits for children even in resource-constrained settings.</p> <p>Although only seven of the included studies described cultural adaptations, their strategies align with a growing body of evidence indicating that tailoring interventions to local language, caregiving norms, and family structures enhances both engagement and outcomes ([<reflink idref="bib20" id="ref99">20</reflink>]). Studies from South Asia document high attendance, reduced parental stress, and strong social-validity ratings when programs integrate community languages, extended-kin involvement, and culturally salient examples ([<reflink idref="bib27" id="ref100">27</reflink>]; [<reflink idref="bib35" id="ref101">35</reflink>]; [<reflink idref="bib41" id="ref102">41</reflink>]). In our sample, language adaptation, familiar routines/objects, permission for extended family involvement, and flexible delivery (homebased, group formats, and telehealth) were the modal adaptations reported; however, the specificity of reporting varied across studies. These findings reinforce cultural tailoring is not merely cosmetic but a critical mechanism for broadening reach and sustaining behavior change—particularly in collectivist South-Asian contexts, where caregiving is shared among extended family members ([<reflink idref="bib29" id="ref103">29</reflink>]). Even well-designed PIIs may underperform if they overlook local languages, parenting norms, or community values (e.g., [<reflink idref="bib27" id="ref104">27</reflink>]; [<reflink idref="bib35" id="ref105">35</reflink>]). Yet none of the seven studies used formal frameworks, such as the Framework for Reporting Adaptations and Modifications- Enhanced (FRAME) or the Ecological Validity Framework (EVF), to document their changes ([<reflink idref="bib2" id="ref106">2</reflink>]). The systematic use of such tools would help delineate which components require localization and which remain transportable, thereby contributing to a cumulative science of cultural adaptation.</p> <p>Six studies captured parental stress, all of which reported significant reductions – findings that align with international meta-analyses ([<reflink idref="bib40" id="ref107">40</reflink>]). Yet only one trial measured broader mental health symptoms, and none embedded structured stress management modules. This gap is noteworthy, given the evidence that mindfulness or peer support additives can increase parent engagement and reduce attrition ([<reflink idref="bib6" id="ref108">6</reflink>]). For South Asia, where mental-health services are scarce and parents often juggle caregiving responsibilities with economic hardship, integrating brief mindfulness modules or structured peer-support circles into PIIs is not just beneficial but essential. These low-cost additions can help buffer chronic stress, curb attrition, and ultimately protect intervention fidelity – positioning families to sustain gains well beyond the end of formal coaching. Critically, the magnitude of parent benefits appeared to vary by model and delivery. For instance, the UPPA/Project ImPACT group plus individual format reported a large reduction in parenting stress ([<reflink idref="bib34" id="ref109">34</reflink>]), whereas a brief outpatient NDBI trial showed only small stress changes ([<reflink idref="bib23" id="ref110">23</reflink>]). On sustainment, formal maintenance/follow-up was rarely assessed (e.g., [<reflink idref="bib34" id="ref111">34</reflink>], [<reflink idref="bib35" id="ref112">35</reflink>]). These gaps underscore the need for trials that prespecify family outcomes (stress, confidence, relationship quality), compare delivery formats, and include postintervention follow-ups to test maintenance and mechanisms.</p> <hd id="AN0189916317-18">Limitations and Recommendations for Future Research</hd> <p>Although this review was analyzed carefully, the limitations exist. Heterogeneity in intervention components and outcome measures precluded calculation of effect sizes and meta-analysis; instead, a qualitative synthesis was prioritized. Future studies may consider conducting meta-analysis of PIIs focused on a single outcome variable in South Asian contexts. Resource constraints limited inter-rater-coding of titles/abstracts, introducing the possibility of selection or extraction error. Although some studies may have been missed; the review aimed for a comprehensive coverage within its defined scope. Limiting inclusion to English-language, peer-reviewed studies from South Asia introduced language and publication bias. Studies in regional languages (e.g., Hindi, Urdu, Bengali, Sinhala) or local grey literature may have been excluded, possibly skewing findings. Future reviews should use regional databases, include grey literature, apply bias-adjusted synthesis methods, and conduct subgroup analyses by language or culture. Additionally, our choice to appraise study quality with [<reflink idref="bib30" id="ref113">30</reflink>] might be a limitation. Future replications could re-rate a subset using the Council for Exceptional Children standards ([<reflink idref="bib5" id="ref114">5</reflink>]; [<reflink idref="bib4" id="ref115">4</reflink>]) to assess concordance.</p> <p>Participant samples were largely homogeneous—mostly young boys and mothers—limiting generalizability to other groups such as fathers, grandparents, siblings, or females with ASD. Future intervention studies should broaden sample diversity to examine the impact of PIIs across various family roles and demographic groups, apply statistical bias-adjustment methods, and conduct subgroup analyses by language and cultural background. While some studies detailed accounts of cultural adaptations, others lacked specificity, hindering clarity on their effects. Future researchers should include thorough documentation of adaptations and explicitly consider cultural context and participant well-being to enhance the relevance and effectiveness of interventions. Finally, assessing long-term outcomes related to parental stress and parent-child interactions, as well as exploring technology-integrated delivery models, may offer insights into scalable and flexible intervention strategies.</p> <hd id="AN0189916317-19">Implications for Practice</hd> <p>PIIs are most effective when they combine culturally appropriate content with explicit parent -wellbeing- supports. To implement such programs effectively, practitioners require structured pre-service and in-service training in culturally responsive coaching strategies, along with ongoing mentorship and fidelity monitoring. Policymakers in low and middle-income contexts should therefore fund culturally sensitive programs that pair skill coaching with stress management components to meet families' broader needs. Contextual tailoring must extend beyond literal translation: adapting metaphors, session schedules, and family roles—and documenting these changes through rapid formative methods such as focus groups, parent journey mapping, and iterative prototyping—improves acceptability and transparency ([<reflink idref="bib20" id="ref116">20</reflink>]). Program logic models should embed parent wellbeing components – such as brief mindfulness practices, peer support, and -stress appraisal reframing – which have consistently been shown to enhance parent and child outcomes. In parallel, routine stress screening and low intensity supports delivered via mobile messaging platforms can help fill existing -service gaps ([<reflink idref="bib6" id="ref117">6</reflink>]). Reach can be further expanded through hybrid and task sharing models. Trials using teleconsultation, asynchronous video feedback, and community health workers have achieved parent fidelity outcomes comparable to those of specialist-led formats ([<reflink idref="bib3" id="ref118">3</reflink>]), aligning with WHO task-sharing recommendations. Investing in structured paraprofessional training and quality assured- remote supervision will safeguard fidelity. Embedding these scalable, culturally anchored PIIs within national disability and early childhood frameworks is essential to translating trial gains into sustained benefits for children and parents across South Asia.</p> <ref id="AN0189916317-20"> <title> References </title> <blist> <bibl id="bib1" idref="ref28" type="bt">1</bibl> <bibtext> Bearss K., Burrell T. L., Stewart L., Scahill L. (2015). Parent training in autism spectrum disorder: What's in a name? 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Autism Research, 15(5), 778–790. https://doi.org/10.1002/aur.2696</bibtext> </blist> </ref> <ref id="AN0189916317-21"> <title> Footnotes </title> <blist> <bibtext> Tvisha Vyas https://orcid.org/0009-0004-6755-8559 Gulnoza Yakubova https://orcid.org/0000-0002-4223-3545</bibtext> </blist> <blist> <bibtext> This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.</bibtext> </blist> <blist> <bibtext> The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.</bibtext> </blist> </ref> <aug> <p>By Tvisha Vyas and Gulnoza Yakubova</p> <p>Reported by Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib47" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib24" firstref="ref2"></nolink> <nolink nlid="nl3" bibid="bib21" firstref="ref4"></nolink> <nolink nlid="nl4" bibid="bib28" firstref="ref5"></nolink> <nolink nlid="nl5" bibid="bib27" firstref="ref7"></nolink> <nolink nlid="nl6" bibid="bib25" firstref="ref9"></nolink> <nolink nlid="nl7" bibid="bib11" firstref="ref10"></nolink> <nolink nlid="nl8" bibid="bib15" firstref="ref13"></nolink> <nolink nlid="nl9" bibid="bib38" firstref="ref14"></nolink> <nolink nlid="nl10" bibid="bib14" firstref="ref17"></nolink> <nolink nlid="nl11" bibid="bib39" firstref="ref18"></nolink> <nolink nlid="nl12" bibid="bib16" firstref="ref19"></nolink> <nolink nlid="nl13" bibid="bib36" firstref="ref20"></nolink> <nolink nlid="nl14" bibid="bib10" firstref="ref21"></nolink> <nolink nlid="nl15" bibid="bib43" firstref="ref23"></nolink> <nolink nlid="nl16" bibid="bib22" firstref="ref26"></nolink> <nolink nlid="nl17" bibid="bib26" firstref="ref27"></nolink> <nolink nlid="nl18" bibid="bib46" firstref="ref33"></nolink> <nolink nlid="nl19" bibid="bib12" firstref="ref34"></nolink> <nolink nlid="nl20" bibid="bib30" firstref="ref37"></nolink> <nolink nlid="nl21" bibid="bib44" firstref="ref38"></nolink> <nolink nlid="nl22" bibid="bib41" firstref="ref43"></nolink> <nolink nlid="nl23" bibid="bib13" firstref="ref46"></nolink> <nolink nlid="nl24" bibid="bib35" firstref="ref47"></nolink> <nolink nlid="nl25" bibid="bib33" firstref="ref48"></nolink> <nolink nlid="nl26" bibid="bib18" firstref="ref49"></nolink> <nolink nlid="nl27" bibid="bib42" firstref="ref50"></nolink> <nolink nlid="nl28" bibid="bib34" firstref="ref52"></nolink> <nolink nlid="nl29" bibid="bib19" firstref="ref55"></nolink> <nolink nlid="nl30" bibid="bib37" firstref="ref72"></nolink> <nolink nlid="nl31" bibid="bib32" firstref="ref78"></nolink> <nolink nlid="nl32" bibid="bib17" firstref="ref80"></nolink> <nolink nlid="nl33" bibid="bib45" firstref="ref81"></nolink> <nolink nlid="nl34" bibid="bib31" firstref="ref94"></nolink> <nolink nlid="nl35" bibid="bib40" firstref="ref98"></nolink> <nolink nlid="nl36" bibid="bib20" firstref="ref99"></nolink> <nolink nlid="nl37" bibid="bib29" firstref="ref103"></nolink> <nolink nlid="nl38" bibid="bib23" firstref="ref110"></nolink>
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  Label: Title
  Group: Ti
  Data: Parent-Implemented Interventions for Children with Autism Spectrum Disorder in South Asia: A Systematic Review
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  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Tvisha+Vyas%22">Tvisha Vyas</searchLink> (ORCID <externalLink term="https://orcid.org/0009-0004-6755-8559">0009-0004-6755-8559</externalLink>)<br /><searchLink fieldCode="AR" term="%22Gulnoza+Yakubova%22">Gulnoza Yakubova</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-4223-3545">0000-0002-4223-3545</externalLink>)
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  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Education+and+Training+in+Autism+and+Developmental+Disabilities%22"><i>Education and Training in Autism and Developmental Disabilities</i></searchLink>. 2025 60(4):399-423.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Division on Autism and Developmental Disabilities, Council for Exceptional Children. DDD, P.O. Box 3512, Fayetteville, AR 72702. Tel: 479-575-3326; Fax: 479-575-6676; Web site: http://www.daddcec.com/
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 25
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2025
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Information Analyses
– 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="%22Parent+Participation%22">Parent Participation</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Autism+Spectrum+Disorders%22">Autism Spectrum Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Coaching+%28Performance%29%22">Coaching (Performance)</searchLink><br /><searchLink fieldCode="DE" term="%22Training+Methods%22">Training Methods</searchLink><br /><searchLink fieldCode="DE" term="%22Parent+Education%22">Parent Education</searchLink><br /><searchLink fieldCode="DE" term="%22Evidence+Based+Practice%22">Evidence Based Practice</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Afghanistan%22">Afghanistan</searchLink><br /><searchLink fieldCode="DE" term="%22Bangladesh%22">Bangladesh</searchLink><br /><searchLink fieldCode="DE" term="%22Bhutan%22">Bhutan</searchLink><br /><searchLink fieldCode="DE" term="%22India%22">India</searchLink><br /><searchLink fieldCode="DE" term="%22Maldives%22">Maldives</searchLink><br /><searchLink fieldCode="DE" term="%22Nepal%22">Nepal</searchLink><br /><searchLink fieldCode="DE" term="%22Pakistan%22">Pakistan</searchLink><br /><searchLink fieldCode="DE" term="%22Sri+Lanka%22">Sri Lanka</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1177/21541647251399488
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 2154-1647
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: The aim of this systematic review was to synthesize the literature that focused on parent-implemented interventions (PIIs) for children with autism spectrum disorder (ASD) published between 2014 and April 2025 in South Asia. We reviewed 11 studies that met the inclusion criteria to assess various aspects, including participant and intervention characteristics (e.g., intervention type, parent training/coaching techniques, cultural adaptations, etc.). These studies were further evaluated for methodological rigor. We found PIIs can be effective to support children with ASD in various developmental domains and produce positive parent outcomes. However, most studies involved mothers as the primary parent participants, and both the intensity and methods of parent training techniques, as well as cultural adaptations, varied across studies. Of the 11 studies, eight demonstrated strong or adequate evidence based on the assessment of methodological rigor.
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  Group: Date
  Data: 2026
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  Data: EJ1496446
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RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1177/21541647251399488
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 25
        StartPage: 399
    Subjects:
      – SubjectFull: Parent Participation
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Children
        Type: general
      – SubjectFull: Autism Spectrum Disorders
        Type: general
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Coaching (Performance)
        Type: general
      – SubjectFull: Training Methods
        Type: general
      – SubjectFull: Parent Education
        Type: general
      – SubjectFull: Evidence Based Practice
        Type: general
      – SubjectFull: Afghanistan
        Type: general
      – SubjectFull: Bangladesh
        Type: general
      – SubjectFull: Bhutan
        Type: general
      – SubjectFull: India
        Type: general
      – SubjectFull: Maldives
        Type: general
      – SubjectFull: Nepal
        Type: general
      – SubjectFull: Pakistan
        Type: general
      – SubjectFull: Sri Lanka
        Type: general
    Titles:
      – TitleFull: Parent-Implemented Interventions for Children with Autism Spectrum Disorder in South Asia: A Systematic Review
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Tvisha Vyas
      – PersonEntity:
          Name:
            NameFull: Gulnoza Yakubova
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 12
              Type: published
              Y: 2025
          Identifiers:
            – Type: issn-print
              Value: 2154-1647
          Numbering:
            – Type: volume
              Value: 60
            – Type: issue
              Value: 4
          Titles:
            – TitleFull: Education and Training in Autism and Developmental Disabilities
              Type: main
ResultId 1