Caregiver Skills Training

1. Introduction

Version followed: WHO Caregiver skills training for families of children with developmental delays or disabilities (CST), final published package of April 2022 (Introduction; Facilitators' guide, group sessions 1–9; Participants' guide, group sessions 1–9; Home visit guide for facilitators; Adaptation and implementation guide), plus a note on the 3-session Caregiver well-being add-on (WHO, May 2026). Earlier field-test versions (e.g. the Hong Kong trial, Lau et al. 2022) number and group the sessions differently; ignore their numbering when following the 2022 manual. [source: WHO CST webpage; WHO CST Introduction 2022]

What it is: a manualised, transdiagnostic, caregiver-mediated programme for caregivers of children aged 2–9 years (range locally adjustable) with developmental delays or disabilities, especially in social communication (autism, intellectual disability, speech/language disorders). No diagnosis is needed: families enrol once a delay is identified, which WHO frames as reducing stigma. It is built for delivery by trained, supervised non-specialists (community health workers, nurses, teachers, early-childhood workers, experienced parents) within stepped care, so it is a programme and a task-shared service model, not a psychotherapy. A psychotherapist will usually meet it as a master trainer, supervisor, co-facilitator, or as a source of strategies for parent work. [source: WHO CST Introduction 2022]

How change is thought to happen: caregivers learn a small set of strategies (in groups, through stories, demonstrations, role-play and coaching) and then use them daily inside the child's own play and home routines (dressing, meals, chores). Many short, motivating, shared interactions per day give the child repeated chances to engage, communicate and learn skills, while praise, predictable routines and regulation support reduce challenging behaviour. Caregiver problem-solving and self-care sustain the practice. The theoretical bases named by WHO are applied behaviour analysis, developmental science, naturalistic developmental-behavioural interventions (specifically JASPER and Pivotal Response Treatment), positive parenting, problem-solving and self-care methods. [source: WHO CST Introduction 2022]

2. Framework

Format [source: WHO CST Introduction 2022]

• 9 core group sessions of 2.5–3 hours each (including a break), weekly or fortnightly, in a health facility, school or community venue. Groups of 6–12 participants; two caregivers per household are usually invited. Two facilitators co-deliver every group session.
• 3 individual home visits of 1.5–2 hours: Visit 1 before Session 1; Visit 2 between Sessions 5 and 6 (preferably straight after Session 5); Visit 3 after Session 9. One facilitator may do home visits. If a home visit is not feasible, use a community setting. [source: WHO CST Introduction 2022; Home visit guide 2022]
• Phone check-ins and text reminders between sessions. [source: WHO CST Participants' guide 2022]
• Daily home practice (at least 5 minutes per chosen activity) is treated as essential. [source: Participants' guide 2022]
• Variants: a videoconference adaptation of the core course; optional extension sessions (caregiver well-being, 3 group sessions, deliverable before, after or standalone; materials for children with little or no spoken language announced as forthcoming); a free self-paced OpenWHO eLearning course for caregivers (15 modules, about 8 hours, one module every 4–5 days). [source: WHO CST Introduction 2022; WHO well-being guide page; OpenWHO course page]

Phases and sessions (2022 numbering) [source: Participants' guide 2022; Facilitators' guide 2022; Introduction 2022]

Standard session structure (Sessions 2–9): calm-breathing wellness activity → review of last session's key messages and tips → home-practice discussion → caregiver story with guided questions → teaching of key messages and tips with group activities → break → facilitator demonstration (role-play) with guided questions → planning home practice with paired role-play, coaching and feedback → review and close. Session 1 replaces the opening with welcome, course introduction, group guidelines and goals (about 135 min total). [source: Introduction 2022; Facilitators' guide 2022]

Criteria for moving on. The manual runs on a fixed sequence; progression between sessions is by schedule, not mastery. Individual progression happens inside each family's plan: a child skill counts as mastered only when seen consistently (not briefly, inconsistently or only with one adult); a teaching step is changed when too hard or too easy; help is faded once the child succeeds; new goals are set at Home visits 2 and 3. [source: Home visit guide 2022; Participants' guide 2022] Using these as formal gates for repeating a session is [synthesis].

Who may deliver it under the CST name. WHO describes a training cascade rather than a licence: master trainers/supervisors (post-secondary training in child development or mental health, experience with developmental disabilities) train facilitators through a 3-day course (Sessions 1–5, facilitation, home-visit skills) → supervised co-delivery of Sessions 1–5 and Home visits 1–2 with 20–30 min debriefs → 3-day course (Sessions 6–9) → supervised co-delivery of Sessions 6–9 and Home visit 3 → 2-day advanced course (troubleshooting, coaching) → co-delivery of a full course → ongoing supervision (minimum after every home visit; peer supervision allowed once a team is experienced). The Introduction sets no formal certification or fidelity cut-off. [source: Introduction 2022] Research implementations have used competency gates, e.g. at least 75% on an 11-item adult–child interaction fidelity rating and above 2.5/4 on the ENACT facilitation scale after a 7-day course [source: Lau et al. 2022]; these are study-specific, not WHO requirements [uncertain]. Local adaptation (translation, back-translation, stakeholder meetings, local stories and names) follows the separate Adaptation and implementation guide [uncertain].

3. Guiding principles

[source: WHO CST Introduction 2022 unless marked]

• Family-centred: each family sets its own concrete goals. Practice: write goals in the caregiver's words and check them against what they told you they want.
• Caregiver-mediated: the caregiver, not the facilitator, delivers the strategies daily. Practice: every session ends with a specific home-practice plan rehearsed in role-play.
• Learning happens in everyday routines and play: no special materials or extra time are needed. Practice: choose activities that already happen most days (meals, dressing, chores). [source: Participants' guide 2022]
• All children can learn; delays are not the caregiver's fault. Practice: name non-causes (e.g. vaccines, witchcraft, family sin, insufficient effort) briefly and move on; do not debate myths at length. [source: Facilitators' guide 2022]
• Children learn best when calm and engaged. Practice: check regulation (behaviour thermometer) before teaching. [source: Facilitators' guide 2022]
• Fun, positive, praise-rich interaction. Practice: praise attempts, not only success. [source: Participants' guide 2022]
• Least help needed: Practice: start at the lowest prompt level and fade as soon as the child succeeds. [source: Participants' guide 2022]
• Adult-learning approach: personal goals, guided questions, discussion, drawing on participants' experience. Practice: ask before telling; let the group generate examples.
• Safe, supportive learning environment: responses to wrong answers are supportive, not corrective. Practice: reframe ("that's one idea; what else might work?") rather than correct publicly.
• Confidentiality and respect in the group: agreed group guidelines (privacy, listening, respect, mutual support, phones silent). [source: Facilitators' guide 2022]
• Realistic expectations: the course does not cure the condition. Practice: reframe unrealistic goals into small observable targets. [source: Facilitators' guide 2022]
• Non-specialist delivery with supervision: Practice: consult the supervisor about every safety, health or complex concern; never work unsupervised as a new facilitator.
• Integrated, stepped care: CST sits inside a referral network. Practice: screen for family needs and refer out rather than stretch the course to cover them.
• Stay within scope: e.g. toilet training is excluded and referred to the master trainer. [source: Facilitators' guide 2022]
• Adapt to context: sections flagged for adaptation are tailored to local culture, roles and gender of caregivers. [source: Facilitators' guide 2022]

4. Intervention inventory

The inventory has three parts: (A) facilitator procedures in home visits, (B) facilitator procedures in group sessions, (C) the caregiver strategies taught, session by session. Every strategy name below comes from the 2022 participants' or facilitators' guide unless marked. All example wording is illustrative. Steps are paraphrased. The source text covers Sessions 1–6 in full and Home visit 1 in detail. Sessions 7–9 and Home visits 2–3 draw only on summaries and the home-visit intervention chart, so their step detail is partly [synthesis] and marked.

A. Home-visit procedures

A1. Home visit 1: introduction and interview

• Purpose / when: before Session 1, to build rapport (including with family members who will not attend groups), learn about the child and home, and screen family needs. [source: Home visit guide 2022; Introduction 2022]
• Steps: (1) About 15 min: meet caregiver, child and family. Explain the course, its aims and confidentiality, and ask what the caregiver hopes to get from it. (2) Part 1A interview, about 15 min: the child's skills and difficulties, contact with services, enjoyed activities, how the child requests and shares, play, daily-living skills, challenging behaviour, and other health conditions. (3) Part 1B family needs, about 5 min: note signs of caregiver or family mental-health problems, possible maltreatment (physical, sexual, emotional, neglect, harsh caregiving), and material deprivation. (4) Part 1C (optional): a locally validated developmental checklist. [source: Home visit guide 2022]
• Example language (illustrative): "Before we play, tell me about a normal day with Sam. When is he happiest? When is it hardest?"
• Watch for: safety or maltreatment signs. Note them, consult the supervisor after the visit, and report suspected abuse or neglect to the supervisor even if you think you can handle it. [source: Home visit guide 2022]

A2. Caregiver–child interaction observation

• Purpose / when: Home visit 1 (repeated later as a progress check), to see the caregiver's natural style and which strategies they already use.
• Steps: (1) Ask the caregiver to play with the child for about 10 min (record about 12 min if possible), with a standard toy kit or home toys. (2) Observe quietly. Do not give strategy instructions unless the caregiver is struggling. (3) Note style and existing strategies. (4) Afterwards, give specific positive feedback. [source: Home visit guide 2022]
• Example language (illustrative): "Play the way you usually do. I'm only watching how Sam likes to play." Afterwards: "When you sat on the floor facing him, he looked at you much more."
• Watch for: caregivers performing for you or feeling judged. Keep feedback strengths-first. Video is optional clinically and required in research. [source: Home visit guide 2022]

A3. Facilitator–child interaction (structured probe)

• Purpose / when: Home visit 1 (optional repeat at Visit 3), to estimate the child's current communication and play levels under standard conditions.
• Steps: (1) Play about 10 min with the toy kit. (2) Create at least four opportunities each for requesting and for sharing. (3) Present play tasks at rising levels (people games, simple play, put-together play, early pretend play, advanced pretend play). (4) Start every prompt at Level 1 and go up a level only when needed. [source: Home visit guide 2022]
• Example language (illustrative): holding a bubble wand out of reach, wait; if nothing comes, model a point and say "Bubbles!"
• Watch for: a tired or unresponsive child. Shorten the probe and rely more on the interview. Do not count a skill as present on thin evidence.

A4. Goal setting (child targets, caregiver targets, target routines)

• Purpose / when: end of Home visit 1, re-evaluated at Visits 2 and 3.
• Steps: (1) Part 3: combine interview and both observations into current skills. Be conservative: a skill seen briefly, inconsistently or only with the caregiver is not counted as mastered. (2) Part 4, child targets: communication (requesting gesture, sharing gesture, spoken words), play targets, two daily-living skills, up to two behaviour-regulation targets, and family activities. (3) Part 5, caregiver targets: review the nine strategy domains, note strengths and needs, and pick three domains, starting with the most foundational. (4) Part 6, target routines: three play routines and three home routines that are motivating and happen most days. (5) Review goals against the caregiver's expectations, give the Session 1 date and invite them. [source: Home visit guide 2022]
• Example language (illustrative): "So for the next weeks: getting Sam to reach or point to ask for juice at breakfast, and pulling his trousers up himself after bathing. Does that match what matters to you?"
• Watch for: goals the caregiver did not choose, or goals that are too far ahead of the child's level (e.g. sentences for a child not yet gesturing).

A5. In-vivo coaching (Home visits 2 and 3)

• Purpose / when: the core method of Visits 2 and 3 (optional brief demonstration in Visit 1), to transfer strategies into the family's real routines. Visit 2: review key messages, home practice and goals, coach, discuss barriers, invite to the next session. Visit 3: review progress, coach toward independence, and write a plan for ongoing practice. [source: Home visit guide 2022; Introduction 2022]
• Steps: detailed coaching steps for Visit 2 are [uncertain]. The guide describes coaching as active help during the caregiver's interaction, lasting from a few minutes up to 12–15 minutes, with role-play instead if the child is tired. A usable sequence consistent with the guide [synthesis]: (1) pick one target routine and one strategy; (2) briefly model it with the child; (3) the caregiver tries while you give short in-the-moment prompts; (4) praise specific correct uses; (5) give one adjustment; (6) the caregiver repeats; (7) agree on the home-practice plan.
• Example language (illustrative): "Now wait… keep waiting… there, he looked at the cup. Say 'cup' and hand it to him. Great timing."
• Watch for: the facilitator taking over. The caregiver's hands should be doing it most of the time.

A6. Barrier problem-solving and referral at home visits

• Purpose / when: Visits 1 and 2 (and at any contact), to protect attendance and pick up needs outside CST.
• Steps: (1) Ask what might stop them attending or practising (transport, childcare, work, family opposition). (2) Generate and agree on one or two solutions. (3) For warning signs (child or caregiver health, mental-health problems, maltreatment, material deprivation, gender-based violence, harsh punishment, self-harm or violence in the family): ask privately; if anyone's safety is at risk, contact the supervisor immediately; follow local law on reporting; tell the participant what you will do to keep people safe. [source: Introduction 2022; Home visit guide 2022]
• Example language (illustrative): "Lots of families find getting to the group hard. What could get in the way for you?"
• Watch for: families who drop out may need a different service; discuss this with the supervisor. [source: Introduction 2022]

B. Group-session procedures

B1. Calm breathing (wellness opener)

• Purpose / when: start of Sessions 2–9, and when a caregiver is visibly distressed, to model regulation and settle the group. [source: Facilitators' guide 2022; Introduction 2022]
• Steps: (1) Invite (never require) participation; opting out is allowed. (2) Guide slow breathing for about 5 min. (3) Help anyone breathing fast or looking stressed to slow down. [source: Facilitators' guide 2022] The exact breathing script is not given [uncertain].
• Example language (illustrative): "Sit comfortably. Breathe in gently through your nose… and out slowly, a bit longer than the in-breath."
• Watch for: caregivers for whom focusing on the body raises distress. Let them keep their eyes open or just listen.

B2. Review of key messages and home practice

• Purpose / when: every session after Session 1 (about 20 min), to reinforce learning and detect difficulty early.
• Steps: (1) Recap last session's key messages and tips. (2) Ask each caregiver what they practised, with which routine, and what happened. (3) Praise attempts. (4) Problem-solve difficulties as a group. (5) Save individual detail for home visits if time is short. [source: Facilitators' guide 2022]
• Example language (illustrative): "Who tried offering two choices this week? What did your child do?"
• Watch for: the same people answering every time. Use open questions and go round; never force an answer.

B3. Caregiver stories with guided questions

• Purpose / when: every session; illustrated stories of fictional families (Mary and Jacob, Laila, Shalini and Viran, Fernando and Anna) carry key messages and emotional themes such as stigma and isolation. [source: Facilitators' guide 2022; Participants' guide 2022]
• Steps: (1) Read or tell the story section. (2) Ask the guided questions (strengths, challenges, feelings, what the caregiver did). (3) Link the answers to the key message. (4) Remind the group that personal stories shared in the discussion stay private.
• Example language (illustrative): "What did Mary notice about Jacob here? Has anything like that happened in your family?"
• Watch for: stories needing local adaptation (names, foods, roles, gender of the caregiver). [source: Facilitators' guide 2022]

B4. Facilitator demonstration (role-play)

• Purpose / when: after the break each session (about 15 min), to show the tips in a realistic routine (e.g. "Dressing with Yana"; "Afterschool with Amyah" for more advanced communication). [source: Facilitators' guide 2022]
• Steps: (1) One facilitator plays the caregiver and the other the child. (2) Run a brief scene using the session's tips. (3) Ask guided questions: what did the "caregiver" do and how did the "child" respond? (4) Adapt the gender and caregiver role to the group.
• Example language (illustrative): "Watch what I do before I give Yana the sock… What did you notice?"
• Watch for: demonstrations that are too polished. Showing a child refusing and the adult adjusting is more instructive [synthesis].

B5. Home-practice planning with paired role-play and coaching

• Purpose / when: about 30 min at the end of every session; the main bridge to daily use. [source: Facilitators' guide 2022]
• Steps: (1) Each caregiver picks the routines (typically two daily activities, or one home and one play routine) and writes a plan. (2) Pairs role-play: one is the caregiver and one the child, then swap. (3) Facilitators circulate, coach and give feedback. (4) Confirm the dose: at least 5 min per activity, daily (from Session 6, one small step practised at least three times a week). [source: Participants' guide 2022]
• Example language (illustrative): "Show me how you'll set up breakfast tomorrow. I'll be your child."
• Watch for: vague plans ("play more"). Push for a named routine, time and strategy.

B6. Group guidelines and personal goals

• Purpose / when: Session 1 (about 20 min) and revisited throughout.
• Steps: (1) Propose guidelines (privacy, listening, respect, mutual support, phones silent) and get agreement. (2) Each caregiver records personal goals and reviews them across sessions. (3) If caregivers are reluctant to share goals, read the anonymous list of goals gathered at home visits or point out shared goals. [source: Facilitators' guide 2022]
• Example language (illustrative): "Several of you told us at the home visit you want your child to tell you what they need. That's where we'll start."
• Watch for: unrealistic goals ("I want him to be normal"). Reframe toward observable steps.

C. Caregiver strategies (what caregivers are taught)

C1. Behaviour thermometer: staying regulated (Session 1)

• Purpose / when: Session 1 key message that children learn best when "calm and cool"; used throughout to decide whether to teach or to calm first. [source: Facilitators' guide 2022; Participants' guide 2022]
• Steps: (1) Introduce a three-colour scale: green (calm, ready to learn), yellow (getting upset or over-excited), red (dysregulated). (2) Caregivers describe what each zone looks like in their own child. (3) Rule: teach in green; in yellow, simplify or calm; in red, keep everyone safe and calm first.
• Example language (illustrative): "Where is Ana on the thermometer right now? If she's yellow, this isn't the moment for a new step."
• Watch for: caregivers also noticing their own "temperature". Linking this to the caregiver's own calm is consistent with Session 9 [synthesis].

C2. Set up the space (Session 1, Tip 1)

• Purpose / when: before any shared activity, to reduce distraction and make the caregiver the most interesting thing in view.
• Steps: (1) Remove extra objects. (2) Turn off screens and radio. (3) Clear the space in front of the child. (4) Ask others to move away or watch from behind. (5) Make the area safe. [source: Participants' guide 2022]
• Example language (illustrative): "Let's put the phone away and the other toys in the basket, so it's just you, him and the cups."
• Watch for: the child staying near and looking at the materials and you. Engagement rises once distractions go.

C3. Offer 2–3 motivating choices and follow the child's choice (Session 1, Tip 2)

• Purpose / when: at the start of play or routines, to boost motivation and give the child control within limits.
• Steps: (1) Hold up 2–3 safe, acceptable options: objects, or the order of routine tasks (wash face or brush teeth first). (2) Wait for any choice signal (reach, look, word). (3) Go with it. (4) If the child does not choose, the caregiver chooses. [source: Participants' guide 2022]
• Example language (illustrative): "Washcloth or shirt first?" (holding both up).
• Watch for: repeated rejection of all options, which suggests the options are too easy or too hard. [source: Participants' guide 2022]

C4. Move in front and get to the child's level (Session 1, Tip 3)

• Purpose / when: during any interaction, to make eye contact and shared attention easy.
• Steps: (1) Sit or kneel directly in front of the child. (2) Put the activity between you. (3) If the child is on your lap, turn them to face you. [source: Participants' guide 2022]
• Example language (illustrative): "Try getting down on the mat so your face is at his height."
• Watch for: more looks to the caregiver's face during the activity.

C5. Look and listen: notice motivation and levels of engagement (Session 2, Tip 1)

• Purpose / when: ongoing, to tell whether the child is not engaged, object-engaged (only the toy) or in shared engagement (attending to both the caregiver and the activity), and to find what motivates them. [source: Facilitators' guide 2022; Participants' guide 2022]
• Steps: (1) Pause and observe what the child looks at, reaches for and returns to. (2) Offer 2–3 safe options and follow the choice. (3) Classify the engagement level. Every child spends time in all three. (4) Aim to move gently from object engagement toward shared engagement (e.g. Laila's mother joining her daughter's animal play, then praising).
• Example language (illustrative): "Right now he's busy with the car on his own: object-engaged. Can you get your own car and join in front of him?"
• Watch for: looks that alternate between the toy and the caregiver, which signal shared engagement.

C6. Find how the child plays and show new ways to play (Session 2, Tip 2; "Learning to play")

• Purpose / when: to match play to the child's current level and then stretch it by one step.
• Steps: (1) Identify the child's current play: people games (peekaboo, chase), simple play with objects, put-together play, early pretend play, advanced pretend play, or books and pictures. (2) Play at that level first. (3) Model one slightly more complex action, either a new action with familiar materials or familiar materials used in a new way (e.g. tapping a block with a stick). [source: Participants' guide 2022]
• Example language (illustrative): "He's stacking. Let's add one thing: put the doll on top and say 'up!'"
• Watch for: the child imitating or adding the new action without losing interest. If they drift off, the step was too big.

C7. Notice good behaviour and praise (Session 2, Tip 3)

• Purpose / when: constantly, to make interaction rewarding and strengthen appropriate behaviour.
• Steps: (1) Look for effort and appropriate behaviour. (2) Praise attempts, not only success. (3) Use whatever the child enjoys: smiles, clapping, words, tickles, a favourite game. (4) For hard tasks, a small reward such as a favourite toy or food may help. (5) Get all adults in the household praising. [source: Participants' guide 2022]
• Example language (illustrative): "You put your arm in! Well done!" (with a clap).
• Watch for: praise given only for perfect performance, or too late. It should follow the behaviour immediately.

C8. Build play and home routines (Session 3 key message)

• Purpose / when: to create repeated, predictable shared sequences in which engagement, communication and skills can grow.
• Steps: (1) Pick routines that happen most days. Home examples: clearing after meals, unpacking groceries, hanging laundry, watering plants, feeding animals, making the bed, sweeping, mealtimes, bath, dressing, handwashing. Play examples: cars, blocks, playdough, balls, books, puzzles, dolls, shakers. (2) Set up the space and choices. (3) Take turns using C9–C11. (4) Practise one home and one play routine for at least 5 min daily. [source: Participants' guide 2022]
• Example language (illustrative): "Watering the plants could be your routine: he pours, you pour, he pours."
• Watch for: routines lengthening and the child anticipating the next step.

C9. Join in and imitate the child's turn (Session 3, Tip 1)

• Purpose / when: to enter the child's activity without taking over.
• Steps: (1) Use your own matching object; do not take the child's. (2) Imitate the child's appropriate actions as your turn. (3) Do not imitate throwing or solitary repetitive actions such as lining things up without interaction. (4) Add a word as you imitate (e.g. Shalini says "wash" while copying Viran). [source: Participants' guide 2022]
• Example language (illustrative): "You're stirring—I'm stirring too. Stir, stir!"
• Watch for: the child noticing and looking at the caregiver's copy, which is a step toward turn-taking.

C10. Show and say a new step (Session 3, Tip 2)

• Purpose / when: when you cannot imitate, the child does not know what to do next, is stuck in repetition, or disengages.
• Steps: (1) Show a new action and say a word for it at the same time. (2) Wait for the child to try. (3) Praise. Each added step lengthens the routine and the shared engagement. [source: Participants' guide 2022]
• Example language (illustrative): (putting a block on the truck) "In!"
• Watch for: the child adopting the new step in later rounds.

C11. Restart the routine (Session 3, Tip 3)

• Purpose / when: once all steps are done, to give repetition, which is how children learn.
• Steps: (1) Return quickly to the first step. (2) Keep the tone fun. (3) Repeat while the child stays green and engaged. [source: Participants' guide 2022]
• Example language (illustrative): "All gone! Again? Build it up…"
• Watch for: fatigue or boredom. End on success.

C12. Respond to all communication with words and gestures (Session 4, Tip 1)

• Purpose / when: to show the child that any signal (words, sounds, gestures, gaze, facial expression, even challenging behaviour) gets a response, and to work out its message (request, request to stop, wish to share, feeling such as tiredness or fear). [source: Participants' guide 2022]
• Steps: (1) Look and listen for any communicative act. (2) Ask yourself what message it carries. (3) Respond at once with a gesture (point, show or give) paired with a word.
• Example language (illustrative): child reaches toward the window → caregiver points: "Bird!"
• Watch for: more frequent or clearer signals from the child.

C13. Match words and gestures to the child's language level (Session 4, Tip 2)

• Purpose / when: whenever speaking to the child, so input is learnable.
• Steps: (1) If the child mainly uses sounds, sometimes shape a sound into a word. (2) If the child uses single words, occasionally use two-word phrases. (3) Always pair language with a gesture. [source: Participants' guide 2022]
• Example language (illustrative): child says "ba" → "Ball!"; child says "ball" → "Big ball."
• Watch for: long sentences creeping back in; coach caregivers to shorten them.

C14. Wait to give room to communicate (Session 4, Tip 3)

• Purpose / when: after setting up an opportunity or after the caregiver's turn.
• Steps: (1) Stay quiet for a few seconds. (2) Watch for sounds, words, gestures or gaze. (3) Avoid quizzing questions ("What colour is this?") and do not tell the child what to say. [source: Participants' guide 2022]
• Example language (illustrative): caregiver holds the cup, looks expectantly and silently counts to five.
• Watch for: caregivers who find silence hard. Practise counting in role-play [synthesis].

C15. Talk about what the child is looking at and doing (Session 4, Tip 4)

• Purpose / when: during play and routines, to map words onto the child's current focus.
• Steps: (1) Name what the child sees or does. (2) Point to or show the object as you name it. [source: Participants' guide 2022]
• Example language (illustrative): "Splash! Water. Wet hands."
• Watch for: commentary that turns into questions or instructions; keep it descriptive.

C16. Show and say to share and to request (Session 5, Tip 1)

• Purpose / when: to model the two main functions of communication: requesting (an item, a break, stopping something, continuing something, comfort, attention, help) and sharing (showing something exciting, unexpected or favourite). [source: Participants' guide 2022]
• Steps: (1) Point to or hold up something and say its name. (2) To share, give the object and name it. [source: Participants' guide 2022]
• Example language (illustrative): holding up a leaf: "Leaf! Look!"
• Watch for: the child starting to show or point things out to the caregiver.

C17. Repeat and expand (Session 5, Tip 2)

• Purpose / when: whenever the child uses a word or word-like sound.
• Steps: (1) Repeat the child's word. (2) Add one new word only; too many words overwhelm. (3) Add a point or gesture. [source: Participants' guide 2022]
• Example language (illustrative): in Fernando's story, Anna says "dog" and her father points and adds one word: "big dog." [source: Participants' guide 2022]
• Watch for: the child beginning to use the expanded form.

C18. Create requesting opportunities (Session 5, Tip 3)

• Purpose / when: in motivating routines, to make asking necessary and worthwhile.
• Steps: (1) Keep favourite objects visible but out of reach. (2) Offer a choice between two items held out of reach. (3) "Give, Give, Give, Wait": hand over small amounts one at a time, then pause to see if the child asks for more. (4) Respond immediately to any request. (5) Never withhold food or water. [source: Participants' guide 2022]
• Example language (illustrative): gives three crackers one by one, then holds the fourth and waits; child reaches → "More!" and gives it.
• Watch for: frustration escalating to yellow or red. Lower the demand (accept a reach) and respond quickly.

C19. Create sharing opportunities (Session 5, Tip 4)

• Purpose / when: in familiar routines, to invite the child to share attention spontaneously.
• Steps: (1) Add something surprising or fun to a familiar routine. (2) Wait for the child's response. (3) If none, demonstrate a word or gesture, then wait again. [source: Participants' guide 2022]
• Example language (illustrative): a toy duck appears in the bath bucket; the caregiver gasps, points and says "Duck!"
• Watch for: the child looking from the surprise to the caregiver's face, which shows shared attention.

C20. Break skills into small steps (Session 6, Tip 1)

• Purpose / when: for daily-living skills (dressing, undressing, handwashing) and also play routines.
• Steps: (1) List the steps of the skill (putting on a shirt is shown as five steps). (2) Choose the teaching step: the first step if the child can do none; the last step if it is simplest or most fun; or the first step the child cannot yet do alone. (3) Do the other steps with or for the child. (4) Practise the target step at least three times a week within a routine. [source: Participants' guide 2022]
• Example language (illustrative): "Let's let her do just the last bit, pulling the shirt down, and we'll do the rest for now."
• Watch for: the child completing the target step without help on several occasions, then move on.

C21. Use the lowest level of help needed (Session 6, Tip 2)

• Purpose / when: whenever teaching a step, to support success without creating dependence.
• Steps: (1) Level 1: show and say, then wait, and repeat the instruction if needed. (2) Level 2: a little physical help to start or finish the action. (3) Level 3: a lot of physical help through the whole action. (4) Start low and move up only if needed. (5) Once the child succeeds, step down to less help. If they do not, keep higher help longer. (6) Praise every attempt. [source: Participants' guide 2022]
• Example language (illustrative): "Arm in" (Level 1) → wait → nudge the elbow (Level 2) → hand-over-hand (Level 3) → "You did it!"
• Watch for: physical help that the child resists or that is rough. Help must be gentle. Stop and calm if the child moves into red.

C22. Clear, consistent instructions (Session 6, Tip 3)

• Purpose / when: with every teaching step.
• Steps: (1) Use words the child understands. (2) Use the same phrasing each time. (3) Praise every attempt. [source: Participants' guide 2022]
• Example language (illustrative): always "Hands in water" for handwashing, not "Let's get you cleaned up now, sweetie" one day and "Wash" the next.
• Watch for: different family members using different words; agree on the wording together.

C23. Reassess the step (Session 6, Tip 4)

• Purpose / when: after several practices.
• Steps: (1) Ask whether the step is too hard (pick a different step) or too easy (move to the next step). (2) Once mastered, set a new goal. [source: Participants' guide 2022]
• Example language (illustrative): "He's done the zip pull every day this week. Time to add the next step?"
• Watch for: caregivers sticking with a step out of habit, or jumping ahead too fast.

Sessions 7–9: source note. The strategy names in C24–C33 come from the behaviour-regulation and challenging-behaviour strategy chart in the Home visit guide (2022) and from the OpenWHO module summaries. The session-by-session wording, stories and exact key messages of Sessions 7–9 are not drawn on here. So for these, the strategy names are sourced but the step sequences are my operationalisation [synthesis] in line with the behavioural principles CST names. Check them against the facilitators' guide before delivering under the CST name [uncertain].

C24. Understand the message behind challenging behaviour: before and after (Sessions 7–8)

• Purpose / when: before choosing any response to a recurring challenging behaviour. CST treats challenging behaviour as possible communication and asks caregivers to look at what happens before and after it. [source: Participants' guide 2022, Session 4; Home visit guide 2022; OpenWHO course page]
• Steps [synthesis]: (1) Pick one behaviour and describe it in observable terms. (2) For several episodes, note what happened just before (demand, transition, wait, noise, being alone) and just after (got the item, the task ended, attention, sensation). (3) Name the likely reason: to get something (access), to get attention, to escape or avoid something, or for the sensation. (4) Choose the matching strategy from C25–C32.
• Example language (illustrative): "Let's be detectives. The last three times he hit, what was happening just before? And what happened straight after?"
• Watch for: self-injury, aggression causing injury, or sudden change in behaviour: refer for health and specialist review via the supervisor, as pain or illness can drive behaviour [synthesis]. In the Hong Kong trial, caregivers asked for more help with self-harm and complex behaviour. [source: Lau et al. 2022]

C25. Watch for early signals (Session 7)

• Purpose / when: prevention, to act while the child is still yellow, not red. [source: Home visit guide 2022 strategy chart]
• Steps [synthesis]: (1) List the child's early warning signs (e.g. louder vocalising, pacing, covering ears). (2) When seen, reduce demands, offer a calming or preferred activity, or move away from the trigger. (3) Praise calm behaviour as it returns.
• Example language (illustrative): "His hands over his ears is your yellow sign. That's when you lower the noise or step outside with him."
• Watch for: fewer red episodes over the weeks.

C26. Arrange the environment (Session 7)

• Purpose / when: prevention, removing predictable triggers. [source: Home visit guide 2022 strategy chart]
• Steps [synthesis]: (1) Use what the before-and-after notes show to identify triggers. (2) Change the setting: put tempting forbidden items away, reduce noise and crowding, keep activities at the right level, and build in breaks. (3) Combine with set up the space (C2).
• Example language (illustrative): "If the phone being on the table always ends in a fight, the phone lives in the drawer during meals."
• Watch for: setting changes that restrict the child unnecessarily; aim to prevent triggers, not to confine.

C27. Warnings before transitions and picture schedules (Sessions 7–8)

• Purpose / when: when changes of activity trigger distress; pictures show what happens next and prepare the child. [source: Home visit guide 2022 strategy chart; OpenWHO course page, Module 12]
• Steps [synthesis]: (1) Give a warning before the change (words plus gesture, or a picture). (2) Use a simple sequence of pictures or objects for "now → next". (3) Point to the next picture and name it at the transition. (4) Praise the move.
• Example language (illustrative): "Two more turns, then bath." (shows the bath picture) … "Bath time now."
• Watch for: the child glancing at the schedule unprompted, and calmer transitions.

C28. Stay calm during meltdowns (Sessions 7–8)

• Purpose / when: when the child is red. [source: Home visit guide 2022 strategy chart; Facilitators' guide 2022 behaviour thermometer]
• Steps [synthesis]: (1) Keep the child and others safe; remove dangerous objects. (2) Use few words and a quiet voice. (3) Do not teach or reason during red. (4) The caregiver regulates themselves (slow breathing, see B1). (5) When the child is green again, reconnect warmly and resume an easy activity.
• Example language (illustrative): "You're safe. I'm here." Then silence and waiting.
• Watch for: caregivers responding with shouting or hitting. Screen for harsh punishment and follow the safeguarding route (A6).

C29. Teach communication to replace access-seeking behaviour (Session 8)

• Purpose / when: when behaviour serves to get an item or activity. [source: Home visit guide 2022 strategy chart]
• Steps [synthesis]: (1) Choose a simple replacement signal at the child's level (reach, point, a sign, a word, a picture). (2) Create requesting opportunities (C18). (3) Prompt the new signal at the lowest level of help (C21) before the behaviour starts. (4) Respond to it immediately and reliably. (5) Make sure the challenging behaviour no longer gets the item more easily than the new signal does.
• Example language (illustrative): before he screams for the biscuit tin, model a point and "biscuit"; when he points, "Biscuit!" and give one.
• Watch for: the new signal appearing spontaneously and the old behaviour falling.

C30. Ignore safe attention-seeking behaviour (Session 8)

• Purpose / when: only when the before-and-after notes suggest the behaviour gets attention and the behaviour is safe. [source: Home visit guide 2022 strategy chart]
• Steps [synthesis]: (1) Confirm it is safe to ignore. (2) Withhold eye contact and comment while it lasts. (3) Give rich attention as soon as appropriate behaviour appears. (4) Increase attention for good behaviour through the day (C7). (5) Warn caregivers the behaviour may briefly get worse before it improves.
• Example language (illustrative): "When she whines, look busy. The second she uses a calm voice, turn and give her a big smile."
• Watch for: never planned-ignore dangerous behaviour, self-injury or a child in distress or pain.

C31. Set clear expectations for escape-motivated behaviour (Session 8)

• Purpose / when: when behaviour gets the child out of tasks. [source: Home visit guide 2022 strategy chart]
• Steps [synthesis]: (1) Check that the task step is at the right level (C23). (2) State a short, clear expectation with a visual ("first shoes, then outside"). (3) Give the lowest help needed to finish a small part (C21). (4) Allow a break once a small part is done, and teach a way to ask for a break or for help (C29). (5) Praise completion.
• Example language (illustrative): "First one sock, then the swing."
• Watch for: tasks that are simply too hard. Lower the step rather than escalating demands.

C32. Teach safe alternatives to sensation-seeking behaviour (Session 8)

• Purpose / when: when behaviour seems to occur for the sensation itself (e.g. mouthing, banging, spinning). [source: Home visit guide 2022 strategy chart]
• Steps [synthesis]: (1) Identify the sensation sought. (2) Offer a safe activity that provides similar input. (3) Redirect calmly to it and praise its use. (4) Schedule it into the day.
• Example language (illustrative): "Banging the table? Let's bang the drum instead."
• Watch for: behaviour that risks injury, which needs supervisor review and health referral [synthesis].

C33. Problem-solving, self-care and ongoing practice planning (Session 9; Home visit 3)

• Purpose / when: at the course end, to sustain practice and caregiver well-being. Session 9 covers caregiver well-being, problem-solving and goal-setting for ongoing practice. The eLearning course adds reviewing progress, setting new communication goals and expanding routines by adding and linking steps. Home visit 3 reviews progress and writes a plan for ongoing practice. [source: Introduction 2022; OpenWHO course page; Home visit guide 2022]
• Steps [synthesis]: (1) Each caregiver names one current problem (practical, child or personal). (2) Define it concretely. (3) Brainstorm options as a group without judging them. (4) Choose one and plan when and how. (5) Review at the next contact. (6) Plan self-care: calm breathing, a small pleasant activity, asking family or group members for help. (7) Update child goals and link routines into longer sequences. (8) Agree on a written ongoing practice plan.
• Example language (illustrative): "What's one thing that's making practice hard right now? Let's get every idea on the board before we judge any."
• Watch for: caregiver depression, exhaustion or hopelessness. Screen and refer (A6). The separate 3-session Caregiver well-being course (2026) can be added before, after or alone; its contents are [uncertain].

5. Handling problems

Items marked [source] come from the CST materials; everything marked [synthesis] is my own guidance.

Group-level problems

• Caregivers reluctant to speak or share goals: read the anonymous goals list gathered at home visits, point out shared goals, mention common beliefs about causes to open discussion, use open questions and never force answers. [source: Facilitators' guide 2022]
• One participant dominates; others are silent: make sure everyone speaks without letting anyone speak too long; keep discussion focused and reassure the group there will be time for their own child. [source: Facilitators' guide 2022] Use go-rounds and pair work, and offer the dominant caregiver individual time at the break [synthesis].
• Long debates about causes or cures (vaccines, spirit possession, special diets): acknowledge, state briefly that these do not cause delays and that the course does not cure, and return to the key message; do not let myths take over a session. [source: Facilitators' guide 2022]
• Stigma, self-blame, isolation: acknowledge these experiences, restate that the caregiver did not cause the delay, and encourage peer support in the group. [source: Facilitators' guide 2022]
• Breaches of confidentiality: restate the agreed guideline; speak privately with the person [synthesis].
• Out-of-scope requests (toilet training, medication, diagnosis): toilet training is excluded and referred to the master trainer [source: Facilitators' guide 2022]; route medical and diagnostic questions to the referral network via the supervisor [synthesis].

Caregiver distress, overwhelm and mental health

• Acute distress in session: lead calm breathing, allow opting out, and give individual guidance to anyone breathing fast or looking stressed. [source: Facilitators' guide 2022] Offer a quiet word at the break and a follow-up call [synthesis].
• Signs of depression, exhaustion, family violence or self-harm: ask privately; if anyone's safety is at risk, contact the supervisor immediately, follow local reporting law, and tell the caregiver what steps you are taking. [source: Introduction 2022] For risk of suicide, follow your service's standard risk assessment and safety-planning procedures; CST facilitators should not manage this alone [synthesis].
• Overload from too many strategies: CST deliberately limits each family to three caregiver strategy domains, chosen from the most foundational. [source: Home visit guide 2022] If a caregiver is overwhelmed, drop back to one routine and one tip [synthesis].
• Caregiver well-being needs beyond Session 9: add the 3-session Caregiver well-being course (WHO 2026) or refer for psychological help [source: WHO well-being guide page; synthesis].

Non-adherence to home practice

• Daily practice is treated as essential and planned via role-play every session. [source: Introduction 2022; Facilitators' guide 2022]
• [synthesis] Diagnose before pushing: (1) Was the plan specific (routine, time, strategy)? (2) Was the routine one that actually happens most days? (3) Did the child find it motivating? (4) Practical barriers (work, siblings, space)? (5) Family members undermining it? Then shrink the plan to 5 minutes in an existing routine, use phone or text check-ins between sessions, invite the second household caregiver, and praise any attempt.
• Attendance barriers: problem-solve at home visits [source: Introduction 2022]. Childcare during sessions improved attendance in one implementation [source: Lau et al. 2022]. Drop-out may mean a different service is needed; discuss with the supervisor [source: Introduction 2022].

Child-level stuck points

• Child rejects all choices: options may be too easy or too hard; change them. [source: Participants' guide 2022]
• Child stays object-engaged or repetitive: join and imitate appropriate actions with your own materials, then show and say a new step; do not imitate throwing or isolated lining up. [source: Participants' guide 2022]
• No progress on a teaching step: reassess; choose an easier step or a different step; keep help higher for longer and praise attempts. [source: Participants' guide 2022]
• Child tired or unresponsive in a home visit: shorten the activity and use role-play with the caregiver instead. [source: Home visit guide 2022]
• Overactive child in sessions or visits: seat the child where they cannot wander off and aim for short, positive interactions. [source: Facilitators' guide 2022]
• Child with little or no spoken language: accept gestures, gaze and pictures as targets (CST's targets already include requesting and sharing gestures) [source: Home visit guide 2022]. WHO announced separate materials for this group as forthcoming; their status was not confirmed [uncertain].
• Self-injury, dangerous aggression, sudden behaviour change, seizures or pain: beyond lay delivery; consult the supervisor and refer for medical and specialist behavioural assessment [synthesis]. Caregivers in one trial wanted more guidance on self-harm and complex behaviour than the materials gave [source: Lau et al. 2022].
• Requesting opportunities turning into frustration: lower the demand (accept a reach), respond quickly, and never withhold food or water. [source: Participants' guide 2022; synthesis]

Ruptures and relationship difficulties

• [synthesis] A caregiver who feels judged after an observation or coaching: lead with specific strengths, ask permission before coaching ("Can I suggest one small thing?"), and acknowledge that the facilitator sees the child for an hour while the caregiver lives with them all day. Repair openly: name the misstep, ask what would help, adjust.
• [synthesis] Disagreement with the approach (e.g. a belief that only professionals or medicine can help): validate the wish for more help, link CST to the referral network, and invite a two-week trial of one strategy with observable targets.

Harsh discipline and safeguarding

• Where others in the family punish the child harshly, help caregivers explain the child's needs to relatives, and seek supervisor support. [source: Facilitators' guide 2022] Report suspected abuse or neglect to the supervisor even if you plan to handle it yourself. [source: Home visit guide 2022] Teach C28 (staying calm) and C7 (praise) as alternatives to physical punishment [synthesis].

Modality-specific delivery issues

• Facilitator drift or low skill: use supervision after every home visit, debriefs after sessions, and role-play practice in supervision. [source: Introduction 2022] Video review supports supervision; it is optional clinically and required in research. [source: Home visit guide 2022]
• Facilitator stress and workload: discuss in supervision as a standing item. [source: Introduction 2022]
• Online delivery: the core course has a videoconference adaptation. [source: Introduction 2022] In the Hong Kong trial, a self-paced eLearning format had no live practice or coaching, and live skills-practice sessions were added to hybrid delivery. [source: Lau et al. 2022] Keep paired role-play and live coaching wherever possible [synthesis].
• Cultural fit: localise stories, names, examples, terms and caregiver roles using the Adaptation and implementation guide [source: Facilitators' guide 2022; Lau et al. 2022; uncertain].
• Psychotherapists using CST outside the programme: individual use of the strategies in parent work is a derived application [synthesis]; delivering a course under the WHO CST name implies following the training cascade and supervision structure in section 2.

Sources

Sources:

• WHO Caregivers Skills Training for Families of Children with Developmental Delays and Disorders (programme page)
• Caregiver skills training for families of children with developmental delays or disabilities: Introduction (WHO 2022), via Medbox
• Caregiver skills training: Facilitators' guide, group sessions 1–9 (WHO 2022), via Medbox. The extracted text covered Session 1 and part of Session 2 in detail; the titles of all sessions were visible.
• Caregiver skills training: Participants' guide, group sessions 1–9 (WHO 2022), via Medbox. The extracted text covered Sessions 1–6.
• Caregiver skills training: Home visit guide for facilitators (WHO 2022), via Medbox. The extracted text covered Home visit 1 and the strategy chart.
• Caregiver skills training: Caregiver well-being, facilitators' and participants' guides (WHO 2026), publication page
• OpenWHO: eLearning Caregiver Skills Training course page
• Lau JS-P, Lai SM-K, Ip FT-S, Wong PW-C, WHO CST Team, Servili C, Salomone E, Pacione L, Shire S, Brown FL (2022). Acceptability and feasibility of the WHO CST delivered via eLearning, videoconferencing and in-person hybrid modalities in Hong Kong. Frontiers in Psychiatry
• Pakistan cluster RCT of a parents' skills training adaptation, Table 1 (Int J Ment Health Syst, 2021). This is an earlier adapted version with different session content, used only for orientation and not followed.

Further reading (not drawn on): the WHO IRIS PDF of the facilitators' guide; the CST Adaptation and implementation guide; the full text of Sessions 7–9 and Home visits 2–3; the Autism Speaks CST professional page; Salomone E et al. (2019), Development of the WHO Caregiver Skills Training Program for Developmental Disorders or Delays, Frontiers in Psychiatry [uncertain].

Books/manuals cited: World Health Organization (2022). Caregiver skills training for families of children with developmental delays or disabilities (5-part package). Geneva: WHO. World Health Organization (2026). Caregiver skills training …: caregiver well-being: facilitators' and participants' guides. Geneva: WHO.