Consideration of Caregiver Needs and Preferences in the Design and Piloting of an Online Behavioural Caregiver Training Programme for Underserved Regions of Saudi Arabia

Background It is estimated that tens of thousands of autistic children in Saudi Arabia require assistance with various behavioural, communication, educational, and social difficulties. However, services for autistic children are often inaccessible outside large urban areas. Despite strong evidence for interventions based on applied behaviour analysis (ABA), professionals trained in ABA are especially scarce. Online ABA-based caregiver training could be used to support families where services are lacking. Although there is extensive evidence that such training aligns with families' preferences, benefits caregivers and their children, and is feasible and socially valid, most research is from the West. Thus, given cultural differences, the results might not generalise to Saudi Arabia. This project, therefore, explored the preferences of caregivers of autistic children in Saudi Arabia for online caregiver training (Study 1). Next, it examined the feasibility of a novel online caregiver training programme informed by these preferences, whether the programme improved caregivers' ability to use ABA techniques and autistic children's skills, and whether the programme influenced caregivers' views of autism (Study 2). Lastly, it examined the social validity of this programme (Study 3). Methods To explore caregivers' preferences for online caregiver training, Study 1 used a concurrent mixed-methods design comprising a quantitative survey (n = 382) and semi-structured interviews (n = 17) with caregivers of autistic children aged 1-12 years from all 13 regions of Saudi Arabia. Next, a logic model was used to develop the novel online caregiver training programme, which drew upon Study 1's results and existing programmes. To explore the programme's feasibility, Study 2 used a descriptive design and considered data on recruitment, retention, attendance, and task completion from three caregivers of 3-6-year-old autistic children from Saudi Arabia. With the same participants, Study 2 also explored the programme's efficacy using a multiple-probe across-participants design and observational measures of caregivers' use of ABA techniques and children's skills. Additionally, Study 2 used a qualitative design and five-minute speech samples (FMSSs) to examine caregivers' views of autism before and after the programme. With the same participants again, Study 3 explored the programme's social validity using a qualitative design and social validity interviews (SVIs). Results In Study 1, descriptive statistics from survey data and a rapid qualitative analysis of interview data revealed that the most popular training topics were autism itself, communication skills, and behaviour management. Additionally, participants sought a combination of synchronous and asynchronous components, as well as short sessions spread over an extended period. In Study 2, high recruitment, retention, attendance, and task completion rates supported the feasibility of the programme. Furthermore, visual and inferential analyses of data highlighted improvements in caregivers' ability to use ABA strategies and children's engagement, joint attention, imitation, and play skills. Moreover, an applied thematic analysis (ATA) of FMSS data revealed that caregivers developed more nuanced views of autism and more positive views of caring for an autistic child. In Study 3, an ATA of SVI data generally supported the social validity of the programme's goals, techniques, and outcomes. Conclusion These findings support the feasibility, efficacy, and social validity of the programme. As discussed later, although there are ways the programme could be improved in these areas, this project suggests that online ABA-based caregiver training could be used to support families with autistic children in underserved parts of Saudi Arabia. Future studies should explore ways of scaling the programme to reach a greater number of such families.