Neurodevelopmental disorders are health conditions which significantly affect the personal, social, and academic functioning of individuals from childhood (American Psychiatric Association, 2014). Among them, Autism Spectrum Disorder (ASD) stands out for its implications on communication and social interaction, in addition to repetitive behavior patterns (Zeidan et al., 2022). The increasing prevalence of these disorders requires effective and accessible interventions, especially in countries with limited resources, since their public health systems have greater difficulty responding to the purpose of diagnosis and intervention (Zeidan et al., 2022; World Health Organization, 2022c). Thus, a need for structured and widely disseminated programs to meet this growing demand is evident, enabling children and their families to have access to the necessary support for more adequate and inclusive development (Salomone et al., 2019).

The World Health Organization (WHO), in partnership with Autism Speaks, developed the Caregiver Skills Training (CST) program to train family members and caregivers of children with neurodevelopmental disorders, especially ASD (Salomone et al., 2019). CST is an evidence-based program designed to be implemented by non-specialists, enabling caregivers to promote child development in everyday activities (World Health Organization, 2022b). Its methodology includes nine group sessions and three home visits focused on communication strategies and adaptive behavior (World Health Organization, 2022b). This model allows knowledge to be disseminated sustainably, reaching a greater number of families, regardless of the availability of specialized professionals. In addition, the CST approach aims to strengthen the role of caregivers as active agents in child development, reducing exclusive dependence on formal clinical services and promoting greater autonomy for families.

Nevertheless, structured and accessible support is essential since an ASD diagnosis can pose emotional and financial challenges for families (Franco, 2016). In this sense, the parental training offered by the CST program not only helps in child development, but also reduces caregivers’ stress and improves their quality of life (Postorino et al., 2017). Furthermore, projects such as CST can reduce the stigma associated with ASD, encouraging greater acceptance and social inclusion (Salomone et al., 2019). Parental training contributes to a more harmonious family environment and the wellbeing of everyone involved by strengthening caregivers’ skills in mediating daily interactions.

The WHO provides guidelines for data collection and analysis through specific guides, such as: “WHO Parent Skills Training Programme for Caregivers of Children with Developmental Disorders - Monitoring and Evaluation Framework”; “CST Draft Adaptation and Implementation Guide”; and “WHO CST Measures for Monitoring and Evaluation.” The process of adapting and validating the program in each country takes place in three stages. The first involves cultural and linguistic adaptation, including translating materials and consultation with local experts and potential target audiences. The second stage, called pre-pilot, consists of the first program test, in which its acceptability and feasibility are assessed. The third stage, the pilot, analyzes the acceptability, feasibility, relevance, and effectiveness of the CST program adapted to the local context and delivered by facilitators.

The CST has been implemented in more than 40 countries, including several low- and middle-income nations, with growing evidence of its acceptability, feasibility, and impact (Dababnah et al., 2025; Montiel-Nava et al., 2022). The program has proven flexible and adaptable to diverse sociocultural contexts and delivery modalities, while maintaining its core principles. In Italy, for instance, Ferrante et al. (2024) compared in-person and virtual versions of CST, showing that both were well-received, although the online format required adjustments related to technological access. Similarly, Wong and Chow (2022) highlighted the need to adapt components such as privacy, home visits, and family engagement pace when pre-testing the program in Hong Kong.

Another relevant aspect concerns delivery by non-specialist facilitators. Zerihun et al. (2024) demonstrated that, in rural Ethiopia, CST was perceived as acceptable and relevant, though continuous supervision was considered essential to maintain quality. Likewise, Salomone et al. (2021) found that CST implementation within the Italian National Health System was feasible and acceptable to families. Together, these findings underscore CST’s potential as a scalable intervention that promotes positive outcomes across contexts and contributes to inclusive public health policies.

The need for accessible and scalable interventions is even more evident in developing countries, where access to specialized diagnostics and treatments is limited (Zeidan et al., 2022). In this context, implementing CST reinforces its potential for replicability and adaptation to different cultural and socioeconomic realities. This global dissemination demonstrates the importance of programs which empower caregivers and promote continuous support for children with neurodevelopmental disorders (Cartwright and Mount, 2022).

Integration of the CST program into the Unified Health System (Sistema Único de Saúde - SUS) in Brazil can expand the reach of interventions for children with neurodevelopmental disorders, promoting a sustainable support network for families (World Health Organization, 2022a). To this end, validating the CST contributes to creating evidence-based intervention guidelines, enabling dissemination of effective practices throughout the country (Ingersoll and Berger, 2015).

The Capacitar Project implemented the CST in Curitiba, Brazil, through a partnership between the City Hall, the Federal University of Paraná (UFPR) and the Ico Project Institute (Rauen, 2020). UFPR conducted research to scientifically validate the acceptability, feasibility and effectiveness of the program. The pre-pilot phase took place on a small scale, in an in-person format, before the pandemic (Rauen, 2020). However, the context of the COVID-19 pandemic required adaptations in the CST delivery to make it accessible in a virtual format. Thus, the remote model was tested in several countries, including Brazil, and proved to be viable, despite limitations imposed by the lack of face-to-face interactions (Salomone et al., 2022). In this context, studies indicate that remote delivery can be an effective solution to ensure that more families have access to essential information, overcoming barriers such as transportation costs and logistical difficulties in participating in in-person sessions (Ferrante et al., 2024).

The impact of the program on autism symptoms in children with ASD (Santos, 2021) was quantitatively assessed in the pilot phase conducted in the pandemic context, as well as on the quality of life, skills, and stigma of participating caregivers (Nogara, 2024). This study deals with the final stage of CST validation research in Brazil, analyzing the participants’ perception of the feasibility, acceptability, and effectiveness of the CST pilot implementation delivered remotely in Brazil. To this end, we seek to describe the perception of facilitators and MTs on the program’s acceptability for the target population, as well as its application feasibility in the local context. In addition, we intend to identify the perception of MTs and facilitators on the quality of CST delivery when taught online, as well as their opinions on virtual supervision and training. Another essential aspect is to understand caregivers’ perceptions of its effectiveness, assessing the program’s impact on the quality of life of caregivers and on child development. Finally, we intend to explore the challenges and benefits reported by caregivers when participating in the program.

This study is part of the final validation stage of the WHO CST Program in Brazil, and consists of a descriptive study with a qualitative approach on the acceptability, feasibility and effectiveness of the program.

The results were obtained from analyzing the textual corpus produced by the Focus Groups conducted with the different participant groups. The qualitative data were analyzed through Descending Hierarchical Classification (DHC), resulting in different thematic categories. The analysis of the MTs’ FG resulted in six main categories, while analysis of the facilitators’ FG resulted in five categories and that of the caregivers in six. The thematic categories are organized in Table 3 below, with the respective percentage indicating the proportion of the text corresponding to each category.

The analysis of data collected from caregivers and professionals on implementing the virtual pilot CST in Brazil allowed us to assess its acceptability, feasibility and effectiveness, in addition to identifying suggestions for future adaptations. The Brazilian experience was compared with international studies, highlighting challenges and opportunities for improvements in the intervention.

Acceptance of CST depends on cultural aspects, social values, and psychological factors (Ahern et al., 2022). Thus, adherence to the program in Brazil (75.7%) was similar to that of the pre-pilot (70%) (Santos, 2021; Rauen, 2020), but lower than in other countries (Seng et al., 2022; Ferrante et al., 2024; Tekola et al., 2020). Participants in this study considered the content acceptable and understandable, despite some difficulties with modeling through videos. In this sense, studies indicate that more realistic videos can facilitate learning (Salomone et al., 2022).

The therapeutic relationship between facilitators and caregivers was a crucial factor in promoting engagement for adherence. Facilitators with less experience demonstrated insecurity, which affected caregivers’ perception of the program. The initial training was considered insufficient, which corroborates experiences from other countries, such as Taiwan, which sought to expand the facilitators’ training, including more supervised practices (Seng et al., 2022). Furthermore, replacing home visits with sending videos made interaction difficult, and greater proximity through synchronous meetings and in-person visits was recommended (Pearson and Thurston, 2006). In addition, it is considered that a lack of home visits may reduce personalization of interventions and continuous monitoring of families.

Parental expectations also influenced program adherence. Facilitators noted that some caregivers had goals which were not aligned with the CST proposal, highlighting the need for greater prior clarification about the program’s benefits and limitations (Arnkoff et al., 2002). Caregivers’ initial resistance to the parental training model was observed, suggesting that acceptance may be influenced by cultural factors and beliefs about child development.

The program also shows encouraging acceptability and perceived impact: Choinski and Minetto (2024) reported that caregivers recognized improvements across multiple domains following CST participation, including enhanced child skill development, caregiver empowerment, better behavior management, more organized routines, improved family relationships, and the creation of support networks.

Implementing remote CST presented challenges, such as difficulties in using technology and unstable internet. In this context, it is productive to conduct specific training for caregivers and facilitators before the intervention, aiming to reduce technological barriers. On the other hand, it was highlighted that the online modality presented the benefit of saving time for facilitators and allowing greater flexibility in the schedule for conducting the sessions (Salomone et al., 2022).

When discussing program adherence, it is important to note differences between formats: earlier Brazilian pilots in person showed higher engagement, supported by direct contact and home visits (Santos, 2021; Nogara, 2024), while the virtual format in this study faced challenges with domestic overload and unstable internet. These contrasts align with international evidence indicating stronger adherence in face-to-face delivery (Salomone et al., 2021; Ferrante et al., 2024).

The duration of the sessions was considered adequate, but greater emphasis was suggested on discussions between caregivers to facilitate sharing experiences. Furthermore, caregivers reported difficulties in reconciling the program with their routines at home, which was a factor also observed in Ethiopia (Zerihun et al., 2024). In this sense, the overload of families, combined with a high level of demand of the program, can affect adherence over time.

Constant supervision of facilitators by MTs was highlighted as essential (Zerihun et al., 2024) to ensure standardization of the intervention and continuous technical support. The need for ongoing support for caregivers was also identified as a relevant aspect. Thus, hybrid models, which combine initial face-to-face meetings with ongoing virtual support, can improve viability of the program and increase its effectiveness.

Quantitative assessments of CST implementation in Brazil have shown improvements in parental learning and the management of child behavior, with caregivers reporting increased self-efficacy and confidence (Santos, 2021; Nogara, 2024). However, previous findings also indicated limited effects on caregiver wellbeing, suggesting that positive impacts on parenting skills may not directly translate into improvements in family quality of life.

Focus group data from the present study provide complementary insights. Caregivers recognized gains in their knowledge, skills, and family routines, as well as the creation of support networks and empowerment to manage child behavior. Yet, they also reported persistent emotional stress and only modest improvements in overall wellbeing. These qualitative reports are consistent with earlier quantitative results from the Brazilian CST pilot, which showed no significant improvements in quality-of-life measures (WHOQOL-Bref® and PedsQL™) for the overall sample, although caregivers without psychiatric diagnoses presented significant gains (Nogara, 2024). Together, these findings underscore that caregiver vulnerabilities—such as mental health challenges and socioeconomic precarity—substantially limited perceived benefits. In particular, 44% of caregivers reported mental health diagnoses and 64% were out of the formal labor market during the study period, factors that likely magnified stress and reduced the program’s impact on quality of life (Benevides et al., 2019; Cidav et al., 2012). Therefore, inclusion of complementary psychological support services for caregivers could increase the positive effects of the program and improve the impact on family wellbeing.

International studies reinforce this interpretation. Evidence from Italy and Hong Kong highlighted that CST promotes caregiver empowerment and child skill development, but sustaining improvements in wellbeing requires contextual adaptations and additional family support (Salomone et al., 2021; Wong and Chow, 2022). In Ethiopia, ongoing supervision was critical to maintaining intervention quality when delivered by non-specialists (Zerihun et al., 2024). These converging results suggest that CST is effective in enhancing parenting practices across diverse settings, yet broader systemic and psychosocial supports remain essential to strengthen its impact on caregiver wellbeing.

The results of the study, together with the analysis of research conducted globally on CST, enabled formulating suggestions for improvements aimed at both in-person and remote work. The proposals, which can contribute to increasing efficiency, viability and acceptance by the target audience, are presented in Table 7.

These results highlight CST’s feasibility, acceptability, and efficacy within Brazil’s public health infrastructure and underscore its promise as a scalable, culturally adapted intervention. Initiatives like the Capacitar Project could further facilitate CST’s integration into the Unified Health System (SUS), expanding access and reinforcing policies that sustain long-term caregiver training and inclusive community support.

The Brazilian CST pilot highlighted several strengths and challenges that resonate with international findings. Caregivers valued the program’s learning content and teaching strategies, which contributed to clarifying their children’s difficulties and to changes in family routines. Similar to Brookman-Frazee et al. (2018), who reported significant reductions in child problem behaviors following parental training, our results suggest that CST has the potential to positively impact both caregiver competence and child development. However, participants also recommended improvements in teaching materials, echoing observations from Postorino et al. (2017), who emphasized the importance of well-structured resources to optimize parental engagement.

Engagement varied according to caregiver profiles, with socio-emotional vulnerabilities, particularly those exacerbated by the pandemic, influencing participation. This aligns with findings from Salomone et al. (2021) and Zerihun et al. (2024), who also noted that contextual and psychosocial factors affect feasibility and adherence across different settings. Regarding delivery format, the Brazilian experience showed that while virtual implementation increased accessibility and reduced costs, it limited opportunities for role-play, modeling, and peer networking. Ferrante et al. (2024) similarly reported trade-offs between virtual and in-person delivery in Italy, and Wong and Chow (2022) stressed the importance of adapting components such as privacy, home visits, and family engagement pace to ensure effectiveness.

Another key finding concerns facilitator preparation. In Brazil, training was perceived as insufficient, while continuous supervision was viewed as essential to program quality. This is consistent with international literature underscoring the need for strong institutional support and monitoring to maintain fidelity and effectiveness (Salomone et al., 2021; Choinski and Minetto, 2024).

To optimize future CST implementations, actionable recommendations can be organized in five dimensions.

Content. Participants emphasized the need to revise and adapt CST materials, including videos, slides, and handouts, to improve clarity and cultural relevance.

Participants. Suggestions included extending time for discussions among caregivers, inviting two caregivers per family when possible, and simplifying questionnaires to reduce burden and increase engagement.

Method. Recommendations stressed extending facilitator training with more opportunities for supervised practice, ensuring ongoing support, offering childcare during sessions, and incorporating in-person visits when feasible.

Context. Caregivers highlighted the need for stable internet access, prior training for families on digital tools, and adjustments to accommodate challenges of the virtual delivery format.

Instrumental. Finally, participants recommended implementing mental health screening of caregivers to identify risks and provide appropriate referrals to psychological support when necessary.

Taken together, these suggestions illustrate that program fidelity must be balanced with contextual adaptations to strengthen feasibility, inclusiveness, and sustainability in low-resource settings.

In summary, the Brazilian pilot demonstrates that CST is not only feasible and acceptable within the public health system but also shows encouraging signs of efficacy in supporting caregivers and children with neurodevelopmental disorders. At the same time, the findings underscore the importance of targeted adaptations—particularly in training materials, facilitator preparation, and delivery formats—to optimize outcomes. Ensuring scalability and sustainability will require continued investment in robust training and ongoing supervision for non-specialist facilitators, alongside integration into intersectoral policies spanning health, education, and social assistance. Furthermore, longitudinal studies and direct comparisons of in-person versus remote delivery will be critical to refining the program’s effectiveness and consolidating CST as a scalable, evidence-based strategy to promote inclusion and family wellbeing in Brazil.