Treatment mechanism of the WHO caregiver skills training intervention for autism delivered in community settings
Caregiver skill gain is the active ingredient of WHO CST—focus coaching on interaction skills to unlock child progress.
01Research in Context
What this study did
Settanni et al. (2023) ran a randomized trial of the WHO Caregiver Skills Training (CST).
They enrolled the preschoolers with autism and their caregivers in Italy.
Groups met in local clinics, parks, and community rooms—not in hospitals.
What they found
Caregivers who got CST showed large gains in interaction skills.
These skill gains, not the lessons alone, led to small but real child progress.
Kids spent more time in joint play and showed fewer autism-related behaviors.
How this fits with other research
Dai et al. (2025) extended this idea. They added hospital DTT before home parent coaching and saw larger child gains plus lower parent stress.
Kleinert et al. (2007) was the first to prove parents can learn DTT with BST coaching. CST uses the same teaching steps but in group form.
Hahlweg et al. (2008) tested a booklet plus phone calls and found only small effects. CST’s live group practice appears to give the bigger skill boost.
Why it matters
If you run parent groups, focus your coaching on caregiver interaction skills—those skills are the active ingredient. Use live modeling, role-play, and feedback, not just handouts. When caregivers master clear prompts, shared attention, and positive comments, child joint engagement and autism behaviors improve even in community settings.
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02At a glance
03Original abstract
This study examined the mechanism of effect of the WHO Caregiver Skills Training (CST) through secondary analysis of a pilot RCT conducted in community settings. Participants were 86 caregivers (77% mothers) of children with ASD (78% male, mean age: 44.8 months) randomized to CST (n = 43) or treatment as usual (n = 43). The primary outcomes, measured at baseline (t1), immediately post‐intervention (t2), and 3 months post‐intervention (t3), were derived from the coding of caregiver‐child free play interactions with the Brief Observation of Social‐Communication Change (BOSCC) and the Joint Engagement Rating Inventory scale (JERI). At t3 positive treatment main effects had been observed for caregiver skills supportive of the interaction and for flow of the interaction (JERI), albeit only non‐significant changes in the expected direction for child outcomes: autism phenotypic behaviors (BOSCC), joint engagement and availability to interact (JERI). This study tested the theory of change of CST, hypothesizing that the intervention would lead to an improvement on all child and dyad outcomes through an increase in the caregiver skills supportive of the interaction. Serial mediation analyses revealed that the effect of the intervention was significantly influenced by change in caregiver skills. Participation in the intervention led to notable increases in caregiver skills at t2 and t3, which subsequently contributed to improvements at t3 in flow of the interaction, autism phenotypic behavior, joint engagement, and availability to interact. We confirmed our a priori hypothesis showing that change in caregiver skills significantly mediated the effect of treatment on the dyad primary outcome, as well as on the other child outcomes that had shown non‐significant changes in the expected direction. Implications for intervention design and policy making in the context of public health services are discussed.
Autism Research, 2023 · doi:10.1002/aur.3058