Testing Scalable Caregiver Interventions for Autism

Autism spectrum disorder is a common neurodevelopmental disability affecting 1-2% of children worldwide. While early intervention is critical for improving outcomes, access to quality services remains severely limited. Families in low-resource settings, both globally and within the U.S, face systemic barriers including workforce shortages, high caregiver burden, and limited culturally appropriate services. There is a critical need for scalable low-cost interventions to support children with autism and their families in communities where robust systems of care are absent.

To address this gap, researchers developed a group-based caregiver training intervention to support caregiver well-being and communication and behavior in children with autism. Piloted successfully in rural U.S. and western Kenya through the Academic Model Providing Access to Healthcare (AMPATH) Program, the intervention demonstrated feasibility, acceptability, and improvements in caregiver stress, child communication and behavior scores, and autism severity scores. Building on this foundation, researchers propose a Hybrid Type 2 effectiveness-implementation trial to rigorously evaluate both the intervention's effectiveness of improving child and caregiver outcomes and the implementation strategies needed for sustainable scale-up across health systems. The researchers embed a reciprocal innovation approach, leveraging insights from Kenya to inform U.S. communities facing similar challenges. Specifically, lessons learned from scaling peer-led delivery models in Kenya, where scare autism resources exist, will directly inform efforts to expand community-based autism support services in underserved areas of the U.S., where similar implementation challenges persist and services are variable.

The long-term goal is to reduce disparities in autism care and outcomes by developing scalable, community-driven caregiver support models. The researchers will bring together a Community Advisory Panel to ensure clinical and scientific rigor to maximize translation of findings. The overall objective of this study is to evaluate the effectiveness and implementation outcomes, including cost-effectiveness, of professional-led versus peer-led caregiver support for children with autism in Kenya, and to leverage lessons learned to reciprocally pilot-test the peer-led intervention in the U.S. To achieve this objective, the investigators propose the following Aims:

Aim 1: Evaluate the effectiveness of a group-based caregiver training program on caregiver and child outcomes in Kenya. Approach: Investigators will conduct a cluster randomized trial comparing two delivery strategies for a caregiver-focused autism intervention, either (1) structured delivery by trained professionals (e.g. therapists, teachers) using standardized scripts and materials, or (2) peer-led delivery by trained caregivers of children with autism with guided instruction; with a staggered wait-list control. Outcomes will be assessed for caregivers (quality of life (QOL), stress/burden, depressive symptoms) and children (functional communication, behavioral challenges, QOL) at enrollment, pre-/post-intervention, and 3-month follow-up. The investigators hypothesize that the caregiver training program will lead to sustained improvements in caregiver and child outcomes overall, and peer-led delivery of the intervention will be non-inferior to professional-led delivery, supporting its potential for scalability and sustainability.

Aim 2: Determine and compare key implementation outcomes, including cost-effectiveness, between two intervention delivery strategies-in-person, professional- vs. peer-led caregiver groups. Approach: Guided by the Consolidated Framework for Implementation Research (CFIR), investigators will use mixed-methods to analyze implementation outcomes of both intervention delivery strategies, including cost-effectiveness, fidelity, acceptability, feasibility, among others. A community advisor board will guide interpretation. The investigators hypothesize that while acceptability and appropriateness may be similar between the two delivery strategies, the trained peer-led delivery will demonstrate greater feasibility and lower cost, providing key insights to support piloting and scale-up in the U.S.

Aim 3: Optimize and pilot a peer-led autism caregiver intervention in the U.S., measuring key effectiveness and implementation outcomes to support scale-up in U.S. underserved settings. Approach: The investigators will use an implementation science and ecological validity framework adaptation process to revise the peer-led program for delivery in the U.S. Building on lessons from the Kenya, trained peers will deliver the adapted pilot program in Virginia. The investigators will use an explanatory sequential mixed-methods approach to evaluate effectiveness and implementation outcomes. The investigators hypothesize that the peer-led model will be feasible, acceptable, and delivered with high fidelity in U.S. under-served settings, with effectiveness, demonstrating reciprocal innovation from Kenya to the U.S. and provide key foundational insights for future scale-up.

This study's innovation lies in that it will be among the first rigorous evaluations of a scalable, caregiver-mediated autism intervention in low-resourced settings using an implementation science framework. Lessons learned from scaling peer-led delivery models in Kenya, where children receive very few services for autism, can directly inform efforts to expand community-based autism support services in underserved areas of the U.S., where similar implementation challenges persist and services are variable, for significant impact. This bidirectional learning model represents a transformative approach to developing and delivering scalable, equitable autism care throughout the U.S. and globally.

• Quality of Life in Caregivers [Time frame: Baseline and 3 months]
• Quality of Life in Children [Time frame: Baseline and 3 months]
• Parenting Stress Index [Time frame: Baseline and 3 months]
• Depressive Symptoms in Caregivers [Time frame: Baseline and 3 months]
• Child Behavior Checklist (CBCL) [Time frame: Baseline and 3 months]
• Delivery Method Comparison: Peer-led vs Professional-led Intervention [Time frame: 3 months]
• Incremental Cost-Effectiveness Ratio (ICER) [Time frame: 3 months]