Authors: Ramandeep Kaur, Darryl J Dsouza
Categories: Psychology, Pragmatic communication, Social communication interventions, Caregiver-mediated autism programs, Early childhood pragmatic training, Autism Spectrum Disorder (ASD), Social Interaction Skills in Autism
Source: MethodsX
Authors: Ramandeep Kaur, Darryl J Dsouza
Early intervention programs such as INSPIRE-Core have highlighted the importance of fostering foundational pragmatic skills—including greetings, simple turn-taking, and sharing—among toddlers with autism. While these foundations are crucial, children require advanced support as they enter preschool and school-age years, where social demands involve initiating conversations, turn-taking, making requests, refusing, greeting appropriately, and clarifying misunderstandings. To address this gap, the present study introduces INSPIRE-Steps, a structured and trackable intervention model for children with autism aged 3–9 years.
The program was developed in three phases. In Phase I, a hierarchical toolkit of culturally relevant, story-based modules was created to target higher-order pragmatic competencies such as negotiation, refusal, and communication repair. In Phase II, validation was carried out by a multidisciplinary panel of speech-language pathologists, educators, psychologists, and parents to ensure clarity, developmental appropriateness, and usability. In Phase III, the program was standardized on a stratified sample through caregiver- and teacher-mediated sessions across home and clinical environments.•Continuity: Builds upon INSPIRE-Core by extending to higher-level pragmatic skills.•Toolkit Development: Story-based, stepwise modules for school-age children.•Validation and Standardization: Multidisciplinary review and implementation across home and clinical settings.
Specifications table Subject areaPsychologyMore specific subject areaSpeech Language PathologyName of your methodINSPIRE-Steps: A continuation of INSPIRE-CoreName and reference of original methodPrizant, B. M. W., Amy M.; Rubin, Emily; Laurent, Amy C.; Rydell, Patrick J (2006). The SCERTS Model: A Comprehensive Educational Approach for Children with Autism Spectrum Disorders (Vol. 1). Baltimore, Md., USA: Paul H. BrookesResource availabilityThe authors can make the data available upon a reasonable request.The treatment program will be published as a complete treatment manual along with three stages INSPIRE-Core, Steps and Engage
Between the ages of 3 and 9, children experience a rapid expansion in their ability to use language for social purposes. At this stage, communication extends beyond simple exchanges to more complex skills such as maintaining conversations, negotiating turns, making polite requests, interpreting non-verbal cues, and repairing misunderstandings. These abilities form the backbone of successful peer relationships, classroom participation, and emotional well-being.
For children with autism spectrum disorder (ASD), however, these higher-level pragmatic demands are often particularly challenging. While some may develop vocabulary and grammar, difficulties remain in applying language appropriately across contexts. Limitations in perspective-taking and social cognition [3] often restrict their capacity to anticipate or interpret others’ intentions, which in turn affects conversational flow and repair strategies [1].
Early supports like INSPIRE-Core have addressed foundational skills in toddlers, including eye contact, joint attention, and basic communicative intent. Yet, structured, culturally grounded interventions for older children remain scarce. Existing frameworks, such as SCERTS, often reflect Western social conventions, limiting their generalizability in countries like India.
To address this gap, INSPIRE-Steps was conceptualized as a stepwise, trackable model for children aged 3–9. Building on the foundations of Core, the program emphasizes advanced pragmatic domains such as conversation initiation, respectful refusal, clarification of meaning, and peer-group interactions, delivered through culturally familiar stories and guided play routines within natural environments.
Motivation for Methodology
The success of INSPIRE-Core in strengthening early pragmatic foundations among toddlers provided the motivation to design a program that could extend these gains into the next stage of development. While Core effectively targeted behaviors such as eye contact, joint attention, and basic communicative intent, it also revealed a pressing need for systematic support once children entered preschool and primary school, where social demands are broader and more complex. Many children with autism spectrum disorder (ASD) continue to struggle with higher-level competencies such as initiating conversations, negotiating peer play, clarifying misunderstandings, and managing refusals, despite having acquired basic expressive or receptive language.
INSPIRE-Steps was developed to meet this need through a structured, modular design. Building upon Core’s principle of breaking down pragmatics into teachable units, Steps organizes seven domains—Play, Turns, Greet, Request, Refuse, Give, and Clear—into story-based lessons and practice routines. This approach ensures continuity while expanding the scope from foundational to advanced social-communication skills.
As with Core, cultural relevance was central. Global frameworks like SCERTS® [5], though valuable, often embed Western assumptions about interaction styles. In contrast, INSPIRE-Steps was co-validated with Indian speech-language pathologists, educators, and caregivers to ensure the materials align with local practices and are accessible for home use. Caregiver empowerment remained a key focus, with simple instructions, progress-tracking tools, and visual supports enabling parents to deliver meaningful, sustainable interventions in everyday environments.
Methodological Foundations
Building on the principles established in INSPIRE-Core, the INSPIRE-Steps program was designed to address the more advanced social-communication needs of school-age children with autism spectrum disorder (ASD). Its methodological foundations are grounded in well-established theoretical and clinical frameworks that emphasize narrative, peer interaction, naturalistic learning, and cognitive flexibility.•Narrative-Based and Metapragmatic Teaching [2]: Story-centered activities in INSPIRE-Steps provide children with structured opportunities to practice conversational moves, clarify intentions, and reflect on communication breakdowns.•Peer-Mediated Approaches [4]: Recognizing the increasing role of peer groups in later childhood, modules such as INSPIRE-Turns and INSPIRE-Play integrate peer negotiation and cooperative exchange.•Naturalistic Developmental Behavioral Interventions [6]: Core’s emphasis on play-based learning is retained, but in Steps it is scaled to real-world tasks like group games, classroom routines, and structured play, ensuring generalization across contexts.•Social-Cognitive Frameworks [7]: Modules such as INSPIRE-Greet, INSPIRE-Request, and INSPIRE-Refuse draw on social thinking principles, encouraging children to consider others’ perspectives, anticipate reactions, and adapt their communication accordingly.
Together, these models create a stepwise, culturally adaptable framework that combines structured teaching with naturalistic practice. By moving beyond foundational behaviors, INSPIRE-Steps equips children with autism to manage the pragmatic challenges of peer interaction, academic participation, and community engagement.
This study examined the effectiveness of INSPIRE-Steps, a parent-mediated program designed for children with autism spectrum disorder (ASD) aged 3–9 years. The intervention aimed to extend early pragmatic foundations into advanced social-communication skills relevant for school-age contexts.1. Toolkit Development: A set of storybooks and 70 graded activities was created to target seven pragmatic domains—Play, Turns, Greet, Request, Refuse, Give, and Clear. Activities were structured for home delivery by parents, with periodic guidance from speech-language pathologists.2. Expert Validation: The toolkit was reviewed by clinicians, educators, and caregivers to confirm clarity, developmental suitability, cultural appropriateness, and ease of use.3. Pilot Standardization: The program was implemented with a small sample of children with ASD in home settings. Pre- and post-intervention assessments were used to evaluate feasibility, reliability, and changes in targeted pragmatic skills.
The study adopted a mixed-methods approach, combining expert qualitative feedback with quantitative outcome measures. Parent training and periodic monitoring were provided by licensed speech-language pathologists at Speranza, Mangalore, a multidisciplinary therapy center that also facilitated earlier INSPIRE program development. The inclusion of school-age children and advanced pragmatic domains distinguished this phase from the original INSPIRE-Core study.
Phase I marked the transition from Core to Steps. While INSPIRE-Core had established essential early skills for toddlers, the new program was envisioned to support children as they entered school years, where communication demands become more complex. The outcome was the INSPIRE-Steps toolkit—a parent-led, culturally adaptable resource offering structured activities and stories to strengthen higher-level pragmatic abilities in children with ASD.
Unlike INSPIRE-Core, which emphasized foundational acts like eye contact and pointing, INSPIRE-Steps was designed to address more complex, real-world pragmatic competencies. The intervention focuses on seven skill Play, Turns, Greet, Request, Refuse, Give, and Clear. For each domain, the toolkit •A dedicated illustrated storybook that models the skill in familiar, culturally appropriate contexts.•Ten structured activities (totalling 70) designed to promote progressive learning, with tasks scaffolded from simple to complex within each domain.
To support implementation fidelity and generalization, this phase introduced features not present in INSPIRE-Core, •Embedded routine Each activity includes examples of how it can be naturally embedded in daily routines (e.g., INSPIRE-Request while asking for a snack, INSPIRE-Turns during play).•Optional micro-games: Short, engaging games such as “Guess the Greeting” or “Odd One Out” are included as reinforcements for each module.•Parent cue cards and weekly planning Each module comes with quick-reference cue cards summarizing the week’s focus and a planning/reflection template for caregivers to log implementation and observations.
The toolkit was developed in consultation with a multidisciplinary team of speech-language pathologists, child psychologists, special educators, occupational therapists, teachers and developmental paediatricians, all with at least five years of experience with paediatric population. Input from professionals with backgrounds in instructional design and information sciences supported improvements in layout, flow of materials, and caregiver usability—especially with regard to the structuring of cue cards and logging templates. A professional illustrator created visuals that reflect Indian social norms and are age-appropriate, engaging, and easy to interpret for both children and parents.
INSPIRE-Steps was thus deliberately designed to not only promote child outcomes but also empower caregivers as co-facilitators, equipping them with structured materials, clarity, and confidence to embed pragmatic communication training meaningfully into home life. The modular structure and use of standardized templates also create future possibilities for digitization and integration into caregiver-facing tools or platforms.
Each of the seven modules in the INSPIRE-Steps program targets a critical domain of pragmatic communication that becomes especially relevant during the preschool to early school years. The modules were selected to reflect skills that support classroom learning, peer relationships, and cooperative behavior. These modules 1. INSPIRE-Play
This module introduces structured play-based interactions designed to foster spontaneous language use, social engagement, and symbolic representation. Activities encourage joint play routines, pretend play, and cooperative games that build the foundation for shared attention and turn-taking—skills essential for peer interactions and narrative development.2. INSPIRE-Turns
Focuses on the development of non-verbal and verbal turn-taking, an essential feature of conversation flow. Activities include gesture-based exchanges, verbal pausing, and responsive games that teach children to wait, respond, and anticipate communication cues.3. INSPIRE-Greet
Teaches children how to initiate and respond to greetings across various social contexts. Using role-play and story-based modeling, children learn to adapt their greetings to the setting (e.g., home, school, public places), facilitating social entry and inclusion.4. INSPIRE-Request
This module develops the ability to make clear, polite, and contextually appropriate requests. Children practice using varied sentence forms, expressive tone, and gestures to seek help, ask for objects, or express needs—key for classroom participation and emotional regulation.5. INSPIRE-Refuse
Supports children in learning how to express disagreement, rejection, or disinterest in a respectful and socially appropriate way. The activities include scripted scenarios and guided storytelling that model assertive communication while preserving social harmony.6. INSPIRE-Give
Reinforces the concept of sharing, turn distribution, and prosocial behavior. Children engage in tasks that encourage reciprocal exchanges, gifting language, and cooperative group participation—skills closely linked to empathy and friendship-building.7. INSPIRE-Clear
This final module focuses on improving speech clarity and intelligibility. It includes activities that highlight the importance of being understood and teaches children how to rephrase, repeat, or slow down speech in response to listener feedback.
Each module is designed with layered learning in mind—beginning with story-based comprehension, followed by practical activities and home-based integration tips. This progression ensures that children not only learn what to do in social situations, but also why and how, strengthening both competence and confidence in real-world communication.
The second phase followed same procedure as INSPIRE-Core, focussing on obtaining professional insights to enhance the clarity, contextual fit, and applicability of the proposed toolkit through a systematic expert review.
A panel of 12 individuals with established expertise in child-centred care participated in this phase. All had over 5 years of professional experience with young children. The panel composition was as •Speech-language pathologists (n = 4)•Clinical child psychologists (n = 2)•Developmental paediatricians (n = 2)•Paediatric occupational therapist (n = 1)•Educator trained in both Montessori and special education (n = 1)•Parents of children diagnosed with autism (n = 2)
Experts were provided with all toolkit elements—including visual materials, stories, and structured activities—for independent review. Their feedback was gathered using a standardized assessment tool that focused on five 1. Ease of understanding and simplicity of language2. Cultural familiarity and relevance of narratives and tasks3. Suitability and recognizability of illustrations (including size and clarity)4. Potential to prompt desired behaviors and facilitate transfer across settings5. Practical feasibility for routine use by caregivers or interventionists
Responses were recorded using a 5-point Likert scale (ranging from Very Poor to Excellent). Based on the aggregated •Elements scoring in the higher range (Good to Excellent) were retained with no changes.•Materials evaluated as Fair or Poor were modified following narrative feedback.•Components rated as Very Poor were discarded.
After revisions, the updated materials underwent one final round of internal review. Table 1 outlines the distribution of scores and the nature of adjustments made. This validation phase contributed significantly to improving the toolkit’s relevance, ease of implementation, and developmental appropriateness for children with autism.Table 1Expert ratings of INSPIRE-steps toolkit across parameters.Table 1S. No.Evaluation ParameterVery PoorPoorFairGoodExcellent1Clarity and simplicity of language113432Cultural relevance and familiarity024333Picture size and visual legibility013534Color contrast and visual appeal002645Real-life applicability of story and activity content112536Ease of training caregivers to use the toolkit013447Accessibility in home settings002738Adaptability across routines and environments012459Effectiveness in eliciting target communication acts0034510Potential for generalization beyond training contexts00165
Items that received ratings of Very Poor or Poor were flagged for immediate review. Specifically, concerns raised under clarity of language, real-life applicability, and visual sizing suggested that certain stories used complex vocabulary or had ambiguous cultural references, while some illustrations were either too small or visually cluttered for young children with autism.
Following the initial scoring, all expert reviewers were individually contacted for brief follow-up interviews to clarify and expand upon their ratings. These discussions provided valuable context, such as the need to simplify certain story sequences, modify culturally irrelevant illustrations, and replace abstract concepts with more concrete scenarios. Based on these insights, the content team revised the toolkit materials accordingly. For •Three stories were fully rewritten to better align with day-to-day routines familiar to Indian families.•Four illustrations were redrawn with simplified imagery and increased sizing for better visibility.•Instructional language in two modules was made more directive and broken into smaller actionable steps.
The revised materials were then redistributed to the original validators for confirmation. All adjusted components were endorsed following the individual review meetings, indicating that the concerns raised had been successfully addressed.
Following the iterative process of expert validation, targeted revisions, and confirmatory reviews, the final version of the INSPIRE-Steps toolkit was deemed ready for implementation. The structured feedback loop—comprising quantitative ratings, qualitative insights, and one-on-one interviews—ensured that all content met the standards of developmental relevance, cultural appropriateness, and practical usability.
Children for this phase were referred from preschools, special schools, and private therapy centers in and around Mangalore, where concerns had been noted regarding their pragmatic and social communication development. The referred children were between 3 and 9 years of age, aligning with the target age range for the INSPIRE-Steps program.
A total of 63 children were screened using the Childhood Autism Rating Scale, Second Edition (CARS-2)—a standardized observational tool used to identify autism-related characteristics and categorize severity. Assessments were conducted by licensed speech-language pathologists trained in CARS-2 administration.
Out of the 63 children •57 were identified as having mild-to-moderate autism, with CARS-2 scores between 30 and 36.5.•6 children were excluded due to scoring in the severe range or presenting co-occurring difficulties that required intensive or specialized interventions beyond the scope of the current program.
Among the 57 children who met the diagnostic inclusion criteria, language age was then used as a functional inclusion parameter to ensure that participants could meaningfully engage with the structured communication tasks. Specifically, children were required to •A minimum expressive language age of 1.6 years, irrespective of their chronological age, and•A maximum expressive language age of at least 5 years, to align with the upper language complexity addressed in the toolkit.
This criterion ensured developmental appropriateness by requiring that a child aged 3 years demonstrate a minimum expressive language age of 1.6 years, while a child aged 9 years possess at least a 5-year expressive language level, thereby confirming their readiness for the targeted pragmatic tasks within the INSPIRE-Steps program.
Based on this, the Assessment of Language development Test (ALD; [8]) was conducted on 57 selected children, five children were excluded due to limited expressive language development.
The final sample thus included 52 children. Out of these, as per the sample size estimation 50 children were selected and 2 children were excluded due to limited availability of the parents.
Among these 50 children, it was ensured that all of them continued their existing therapy services—such as speech, occupational, or behavioral therapy—without any alterations at their original schools or therapy centers. Care was taken to avoid interruptions or changes to ongoing interventions during the INSPIRE-Steps program, in order to minimize confounding influences and ensure the validity of outcome observations.
A schematic representation of the recruitment and screening process is provided in Fig. 1.Fig. 1The recruitment process for subjects of INSPIRE-Steps program.Fig 1
The required sample size was calculated using the formula for estimating a sample mean difference in paired
Similar to the Inspire-Core, this yielded a minimum required sample of 44 participants. To account for a 10–15 % dropout rate, a final sample of 50 toddlers was targeted and successfully enrolled.
The final sample for this study thus consisted of 50 children with mild-to-moderate ASD.
•Chronological age between 3 and 9 years•Clinical diagnosis of mild-to-moderate autism spectrum disorder, confirmed through developmental history, clinical evaluation, and CARS-2 scores (30–36.5 range)•Expressive and receptive language age within 1.6 to 5 years, as assessed by ALD, informal language sampling and therapist observation•Availability of a stable caregiver (parent or grandparent) who could participate in the training and implement the intervention consistently at home•Sufficient attention span and joint engagement, enabling participation in adult-guided, play-based, and structured communication tasks
•Severe intellectual disability, identified through developmental assessments (COM-DEALL) indicating significant delays across multiple domains•Unmanaged behavioral concerns, such as frequent aggression, temper tantrums, or self-injurious behavior, which could disrupt structured home-based intervention•Major uncorrected sensory or motor impairments, such as significant vision, hearing, or neuromotor conditions interfering with communication or task engagement
The final sample consisted of 50 children aged between 3 and 9 years (M = 4.6 years, SD = 1.4). There were 32 boys and 18 girls, and most participants demonstrated early expressive language abilities—such as gesture use, vocalizations, echolalia, or basic word combinations—falling within the eligible language age range.
The primary intervention implementers were mothers (72 %), fathers (18 %), and grandparents (10 %), all of whom received training and guidance for home-based application of the INSPIRE-Steps modules.
Prior to participation, all caregivers provided written informed consent after receiving a comprehensive explanation of the study’s goals, procedures, and ethical safeguards. The study protocol was reviewed and approved by the Institutional Review Board of Father Muller Research Center, in compliance with national ethical research standards.
To support structured and transparent participant management, a customized digital tracking system was developed in consultation with professionals from the field of information sciences. This system was designed to monitor each child's progress throughout the selection pipeline—from the point of first referral or consultation, through screening with CARS-2, to caregiver communication and final enrollment. Key data points such as age, diagnostic details, language levels, caregiver availability, and follow-up calls were systematically logged and updated. This ensured that the recruitment process remained organized, traceable, and free from documentation gaps, while also allowing efficient coordination among team members across centers. The system contributed to enhanced reliability and replicability in participant selection for the INSPIRE-Steps program. This is illustrated step by step in Fig. 2.Fig. 2The participant management and tracking system for INSPIRE-Steps program.Fig 2
Intervention Procedure
The INSPIRE-Steps intervention was delivered through a structured, four-phase (1) Pre-Intervention Profiling,(2) Caregiver Training and Intervention Delivery,(3) Post-Intervention Outcome Evaluation, and(4) Maintenance and Follow-Up Support.
This framework ensured systematic baseline documentation, targeted caregiver-mediated practice, and the monitoring of both short-term progress and longer-term sustainability of social communication skills.
The initial phase focused on evaluating each child’s pragmatic language profile across the seven INSPIRE-Steps Play, Turns, Greet, Request, Refuse, Give, and Clear. A custom observational rating checklist was administered jointly by clinicians and caregivers to establish a comprehensive pre-intervention baseline. The checklist consisted of 14 items (2 per domain) and was designed to capture both performance accuracy and contextual generalization.
Each item was rated on a five-point ordinal 1 = Not Observed2 = Rarely Demonstrated / Only with Full Support3 = Inconsistently Demonstrated with Verbal Prompts4 = Demonstrated Independently in Familiar Settings5 = Demonstrated Independently Across Settings and Partners
Sample items •“My child initiates cooperative play and shares play materials with peers.”•“My child adjusts their volume or speech rate when the listener appears confused.”
This structured scale enabled assessment of not only the presence of skills, but also their spontaneity, generalization, and adaptability across settings.
To complement observational data, a semi-structured caregiver interview was conducted to gather contextual insights on each child’s daily social routines, previous therapy exposure, communication styles, and caregiver goals for participation.
All assessment data were entered into a custom digital tracking system, developed in collaboration with information science professionals. This tool allowed real-time logging of scores, caregiver feedback, and progress notes across sessions. It facilitated cross-phase continuity by ensuring that each child’s intervention journey—from screening through follow-up—was consistently documented, easily retrievable, and visible to the core implementation team for planning and monitoring.
This phase marked the structured implementation of the INSPIRE-Steps program over a period of approximately 14 weeks. During this time, caregivers acted as the primary facilitators of intervention, delivering activities from the toolkit in their child’s familiar environments—typically the home. Intervention sessions were conducted three times per week, each lasting 20–30 min, with flexibility to embed tasks into daily routines or structured play times.
The program followed a modular format, wherein each of the seven targeted pragmatic domains (Play, Turns, Greet, Request, Refuse, Give, and Clear) was introduced sequentially. Caregivers implemented the activities in a scaffolded order—from comprehension through modelling, followed by skill practice and real-life generalization.
Caregiver Training and Program Orientation
Prior to beginning the intervention, caregivers attended a structured preparatory session led by certified speech-language pathologists. This session, lasting approximately 2.5 hours, was designed to build caregiver capacity, align expectations, and ensure fidelity to program delivery.
The training comprised two main •Module Demonstration and Practical Techniques•60 Walkthrough of the INSPIRE-Steps toolkit structure, story-based teaching methods, and domain-wise activity flow•Emphasis was placed on modeling, using clear prompting strategies, and tracking child responses using the provided log system•Shared Storybook Reading and Reinforcement Strategies•45 Demonstration of evidence-informed shared reading practices using the seven illustrated storybooks•15 Open discussion on customizing story use, managing attention, and encouraging language elaboration during reading
Training sessions integrated interactive modeling, guided role-play, error-reduction techniques, and reflective dialogue to enhance caregiver confidence and readiness. Each caregiver received a printed intervention manual, visual aids, weekly cue cards, and a digital or paper-based session logbook.
Ongoing Monitoring and Support
To support fidelity and ensure implementation •Weekly phone consultations and bi-weekly in-person check-ins were scheduled to address questions, review challenges, and guide next steps•Progress across domains was logged in the digital tracking system, which allowed for real-time documentation of completed activities, child responses, and caregiver reflections•SLPs reviewed tracking data periodically to tailor coaching, suggest modifications, and ensure adherence to the program structure
This systematic, supported delivery approach ensured that the intervention remained responsive, personalized, and sustainable within the family’s existing routines, while also maintaining fidelity across the 14-week program duration.
Each home-based intervention session in the INSPIRE-Steps program followed a semi-structured yet flexible format, allowing for consistency across families while supporting individual adaptation based on the child's needs and routine context.
Session Format
Each session typically included the following •Warm-Up (5 min):
A brief revisiting of a previously introduced domain, used to re-engage the child in a familiar context and set a positive tone for the session.•Skill-Focused Activity (15–20 min):
One or two structured activities were implemented from the weekly target domain (e.g., practicing structured turn-taking games for INSPIRE-Turns, or role-playing scenarios for INSPIRE-Refuse). Activities were hands-on, child-led, and embedded in play or interactional routines.•Generalization Segment (5 min):
Caregivers were guided to help the child apply the same skill during day-to-day routines—such as during meals, outdoor play, or sibling interactions—promoting functional use of the targeted behavior.•Reinforcement:
Positive reinforcement strategies (e.g., verbal praise, smiles, claps, stickers, or small preferred rewards) were used to increase motivation and reinforce skill use.
After each session, caregivers completed a structured session log, capturing the child’s level of participation, degree of independence, attention span, and any notable contextual adjustments.
The INSPIRE-Steps intervention was implemented over approximately 4 months, targeting seven advanced pragmatic communication Play, Turns, Greet, Request, Refuse, Give, and Clear. Each domain was allotted a two-week focus period, resulting in a total of 14 intervention weeks (excluding breaks and follow-up periods). This approach allowed for concentrated exposure, progressive repetition, and cumulative skill development in a developmentally appropriate sequence.•Week 1, Session 1 of each module began with the introduction of a storybook tailored to that domain. Caregivers were encouraged to read aloud, point to relevant visual cues, and model responses that illustrated key social-pragmatic behaviors (e.g., how to greet politely, how to take turns, how to adjust speech when not understood).•During the remaining two sessions of Week 1 and the three sessions in Week 2, caregivers selected from a set of 10 domain-specific, structured activities designed to scaffold the child’s use of the skill in real-life, meaningful settings. Activities built from concrete to complex formats, ensuring developmental progression.•At the beginning of each week, the same storybook was briefly reviewed to reinforce familiarity and anchor the week’s practice. This story-activity cycle was maintained consistently to promote thematic continuity, skill generalization, and retention.
Each session concluded with caregivers filling out a session-specific tracking form, •The story or activity used•Child’s responsiveness and level of prompting needed•Duration of engagement and attentional consistency•Challenges faced or modifications made during implementation
These logs were submitted for bi-weekly review by the intervention team, who used the data to monitor progress, adapt support, and maintain fidelity across households. The entries were also uploaded to a digital tracking system developed in collaboration with information science professionals, enabling real-time documentation, feedback integration, and communication across the team.
Additionally, weekly telephonic coaching and fortnightly in-person follow-ups were conducted to answer questions, troubleshoot challenges, and reinforce key strategies, ensuring consistency and caregiver confidence throughout the intervention period (Table 2).Table 2Overview of INSPIRE-Core program.Table 2INSPIRE LevelCore FocusSummary of Activities and PurposeINSPIRE-PlayCommunicative GamesUses structured games (e.g., Emotion Charades, Story Dice) to encourage turn-taking, expressive language, narrative building, and social play. Builds foundational pragmatic and linguistic skills through play-based engagement.INSPIRE-TurnsNon-verbal Turn-TakingEmphasizes recognizing and responding to cues like eye contact, gestures, and pauses. Activities (e.g., Balloon Bop, Emotion Relay) teach children the rhythm of interaction without verbal pressure.INSPIRE-GreetSocial GreetingsIntroduces greetings through interactive and playful tasks (e.g., Greeting Relay, Puppet Shows) to develop social initiation, cultural awareness, and peer bonding.INSPIRE-RequestMaking RequestsFocuses on helping children express wants clearly and appropriately. Activities like Time Travel Adventure and Alien Communication use imaginative contexts to practice requesting.INSPIRE-RefuseExpressing RefusalEncourages polite and assertive ways to disagree or decline. Through choice-making games and puppet scenarios, children learn to express preferences respectfully.INSPIRE-GiveSharing and GivingPromotes generosity, empathy, and reciprocity. Activities include Toy Swap, Compliment Cards, and Random Acts of Kindness Day to model prosocial behavior.INSPIRE-ClearSpeech IntelligibilityEnhances articulation and clarity through structured speech tasks (e.g., Mirror Practice, Tongue Twisters). Builds awareness of sound formation and improves listener comprehension.
Recognizing individual differences in learning pace, responsiveness, and temperament, the INSPIRE-Steps program incorporated flexible strategies for adapting activities and managing challenges that arose during implementation. Caregivers were trained to use a graded prompting hierarchy, beginning with higher levels of support—such as physical assistance or direct verbal modeling—and gradually reducing support as the child gained confidence and independence in using the skill.
For children demonstrating slower progress or limited engagement in a specific domain, targeted troubleshooting techniques were drawn from the intervention manual and reinforced during follow-up coaching. Examples •For difficulty initiating using mirror play or puppets to model greeting exchanges in a playful format•For challenges in taking introducing visual turn-taking cues (e.g., “my turn/your turn” cards) or using musical games to build rhythm and pacing•For limited use of refusal offering choices that require the child to express preference or disagreement in a structured context
In contrast, children who mastered a skill more quickly were provided with increased complexity or novel contexts to support deeper generalization. For instance, a child who had acquired clear turn-taking in one-on-one play was encouraged to apply the same skill in small peer group settings or unfamiliar environments, such as visits to extended family or classroom routines.
This responsive approach ensured that the intervention remained developmentally appropriate, engaging, and tailored to each child’s individual profile. The process of adaptation and strategy use was documented through session logs and reviewed during bi-weekly monitoring to inform ongoing guidance and coaching.
A visual summary of the INSPIRE-Steps intervention framework and domain flow is presented in Fig. 3.Fig. 3Structure of the INSPIRE-steps intervention.Fig 3
Upon completion of the 14-week intervention, a comprehensive post-intervention assessment was conducted to measure gains across the seven targeted pragmatic domains and to gather caregiver perspectives on the program’s impact and usability.1. Re-Administration of Pragmatic Skills Checklist
The INSPIRE-Steps Pragmatic Skills Checklist—used during the baseline assessment—was re-administered to capture post-intervention skill performance. The checklist included 14 items (2 per domain), scored by caregivers based on the child’s observed behavior across familiar routines and social contexts.
Each item was rated on the same five-point ordinal scale, allowing for direct comparison of pre- and post-intervention scores. The difference in scores served as a quantitative indicator of skill acquisition, generalization, and contextual independence. A summary of the checklist structure is provided in Table 3.2. Clinical Review Session with Blinded EvaluatorTable 3A 14-item INSPIRE-Steps pragmatic skills checklist.Table 3S.NoQuestions1Never2With Assistance3SometimesIndependently(Verbal Prompts)4Mostly Independently5Always Independently1My child engages in communicative games that involve turn-taking and verbal exchange.2My child follows the rules of communicative games and uses language appropriately.3My child participates in non-verbal turn-taking activities, such as passing an object back and forth.4My child waits for their turn and recognizes when it's another person's turn in non-verbal games.5My child uses appropriate greetings, such as saying "hi" or "hello," when meeting someone.6My child responds to greetings from others with a smile or a verbal acknowledgment.7My child verbally requests objects, actions, or information from others.8My child uses polite forms of requesting, such as "please" or "may I."9My child expresses refusal or disagreement appropriately, using words or gestures.10My child refuses politely without causing offense or misunderstanding.11My child offers objects to others as part of social interaction or sharing.12My child gives items to others with an understanding of the social context, such as giving a gift or sharing a toy.13My child's speech is clear and understandable to others in most situations.14My child adjusts their speech for clarity if they are not understood the first time.
Children were invited for a 45-minute follow-up session, conducted by a speech-language pathologist blinded to the intervention phase. The review •Engaging the child in unstructured and semi-structured play routines designed to naturally elicit each of the seven pragmatic domains•Observing spontaneous social interactions with the clinician and caregiver to assess real-time application and generalization•Scoring for consistency, appropriateness, and flexibility in pragmatic skill use, documented on a structured observation sheet3. Digital Review of Session Logs and Tracking Data
All caregiver-completed session logs, which had been entered into the INSPIRE digital tracking system, were reviewed for completeness, consistency, and trends across weeks. This digital database—co-developed with input from information science professionals—enabled:•Visual tracking of session frequency, skill progression, and prompting levels•Identification of domain-wise strengths and emerging patterns across children•Use of real-time data for post-intervention analysis and feedback formulation4. Caregiver Feedback and Reflective Interview
Caregivers completed a structured feedback form containing •Quantitative items rated on Likert scales (e.g., toolkit usability, child engagement, clarity of materials)•Open-ended questions exploring insights into what worked well and areas for improvement
Additionally, each caregiver participated in a short semi-structured interview to reflect •Notable changes in the child's social communication•Challenges and successes in integrating activities into family routines•Perceived usefulness of specific materials (e.g., storybooks, cue cards)•Recommendations for refining content, delivery, or support features
Although the formal intervention phase concluded at this point, caregivers were encouraged to continue embedding the skills into everyday interactions—such as using storybooks during bedtime, or applying domain-based strategies during school readiness activities and peer play.
This conversation emphasized the importance of maintenance through naturalistic practice, helping families transition into the post-program phase with confidence and clarity.
The final phase focused on sustaining the pragmatic communication gains achieved through the INSPIRE-Steps program. During this period, no new modules or activities were introduced. Instead, families were encouraged to continue embedding the previously learned skills into their child’s daily routines through informal, naturalistic interactions.
Parents were guided to apply the INSPIRE-Steps strategies spontaneously across diverse contexts—such as using INSPIRE-Greet during school drop-offs, INSPIRE-Request at mealtime, or INSPIRE-Refuse while handling sibling conflict. The emphasis was on real-life application rather than structured practice, allowing children to generalize pragmatic behaviors across settings without the pressure of formal sessions.
To support this transition, families were given a Maintenance Toolkit that •A monthly calendar of suggested family activities that promote real-world use of the target skills (e.g., visiting a friend’s house to practice greetings and turn-taking).•A brief tip sheet per month highlighting subtle ways to reinforce skills in daily life (e.g., “Let your child choose a weekend activity to encourage spontaneous requesting and refusal”).
While no formal sessions were scheduled during this phase, the research team maintained ongoing support through monthly check-in calls (10–15 min) with each caregiver. These calls reinforced parent engagement, helped troubleshoot challenges (e.g., a child reverting to single-word refusals), and served as reminders for the final evaluation. If any notable regression was observed or reported, optional booster sessions were offered either at the center or through a teleconsultation.
At approximately two months after the end of the intervention, a follow-up assessment was conducted. This session was carried out by the same speech-language pathologist (SLP) who had previously administered the post-test, whenever possible, to ensure consistency.
The follow-up assessment •Re-administration of the INSPIRE-Steps checklist to evaluate the maintenance of domain-specific skills.•Structured play interactions designed to elicit spontaneous use of the seven targeted pragmatic domains (Play, Turn, Greet, Request, Refuse, Give, Clear).•Caregiver feedback regarding observed behaviors, new learning environments (e.g., school changes), and any concerns related to communication.
To strengthen the documentation and tracking of retention, data from these sessions were directly integrated into the INSPIRE digital tracking system, which had followed each participant’s engagement from pre-intervention through maintenance. Notes on skill retention, any regressions, and contextual variables (e.g., changes in school setting or caregiver routine) were digitally logged for each child.
Based on the final evaluation, families •A written progress summary report across the three time points (Pre-, Post-, and Maintenance Phases),•Individualized recommendations for next steps (e.g., transition to peer-group social skill programs or continued home practice),•Referrals for allied services where needed.
The formal phase of the INSPIRE-Steps program concluded with a final appreciation note to participating families, acknowledging their role as co-therapists in their child’s communication development.
All quantitative and qualitative data from the INSPIRE-STEPS intervention were analysed to evaluate its effectiveness in enhancing early pragmatic communication skills and to document caregiver-reported outcomes. Analyses were conducted using IBM SPSS (Version 25) and supplemented by manual review of qualitative records and digital logs maintained via the Track System.
Quantitative Data Analysis: The core focus of the quantitative analysis was to compare child performance across the 14-item pragmatic skills checklist administered at three time Pre-Intervention (Baseline), Post-Intervention, and Maintenance Follow-Up (approximately 2 months after completion of active intervention). For each item on the five-point ordinal scale (1 = Never; 5 = Always Independently), the following steps were •Descriptive Statistics: Mean, standard deviation, and range were computed across the 14 checklist items and total composite scores for each of the three time points. These were used to characterize baseline performance and identify trends in post-intervention improvement and maintenance.•Normality Assessment: Data were assessed for distribution using Shapiro-Wilk tests. Given that scores were ordinal and item-specific variation existed, non-parametric tests were prioritized unless normality assumptions were met.•Pre-Post Comparison:○For each individual item and the total score, a Wilcoxon Signed-Rank Test was used to compare pre- and post-intervention scores (two-tailed), identifying statistically significant changes across time.○Where normality was confirmed (e.g., total scores), a paired-sample t-test was also conducted to verify findings and compute Cohen’s d effect sizes (interpreted ∼0.2 = small, ∼0.5 = medium, ∼0.8+ = large).•Post-Maintenance Comparison: To evaluate skill retention, post-intervention vs. maintenance scores were compared using the same tests. A non-significant difference was interpreted as evidence of maintained gains.•Longitudinal Change: Where assumptions of sphericity were met, a repeated-measures ANOVA was conducted across the three time points (Pre, Post, Maintenance) for the total composite score.
Caregiver compliance and intervention fidelity were evaluated using data from the Tracking System, which •Session completion logs,•Weekly telephonic coaching reports,•Biweekly in-person review forms,•Digital reflection entries.
Descriptive metrics such as average session completion rate, mean engagement scores, and tracking log adherence rates were compiled to assess the feasibility and acceptability of INSPIRE-Steps in naturalistic home settings.
•Inter-rater reliability of scoring across the 14 checklist items was established by having two independent raters assess a subset of participants. Cohen’s Kappa values were calculated and found to be above the acceptable threshold (κ > 0.80), indicating strong agreement.•Internal consistency of the checklist was examined using Cronbach’s alpha, which demonstrated high reliability (α > 0.85 at both pre- and post-intervention), validating the internal coherence of the skill domains.
Post-intervention caregiver feedback was gathered •Structured satisfaction surveys (5-point Likert scale),•Semi-structured interviews conducted by a blinded researcher,•Optional caregiver reflection logs submitted monthly.
An inductive content analysis approach was used for qualitative data. Two independent coders reviewed transcripts and logs, identifying recurrent themes, perceived improvements, implementation challenges, and recommendations. Themes were triangulated across sources to enhance credibility.
Illustrative examples •“He started pointing at the right things when reading, even without prompts now.”•“We began understanding what she needed just by how she looked or smiled—she’s connecting better.”•“Sometimes we skipped a session when he was too tired, but the storybooks helped us stay on track.”
Satisfaction survey data revealed high caregiver ratings (mean >4.2/5 across items), especially in ease of use, storybook engagement, and observable changes in child interaction.
To establish the reliability and effectiveness of the INSPIRE-Steps caregiver-led intervention, a comprehensive validation approach was adopted. This included statistical comparisons of pre- and post-intervention data, inter-rater agreement analysis, and qualitative caregiver feedback. The study sample consisted of 50 children aged 3 to 9 years, identified with social-communication challenges associated with autism spectrum disorder (ASD).
Validation efforts were focused on determining whether the intervention produced measurable improvements in children's pragmatic skills and whether the observational checklist used to track progress was a robust tool for evaluation. A blinded speech-language pathologist independently scored a sample of pre- and post-intervention recordings to ensure scoring fidelity and eliminate assessor bias. High agreement rates between independent raters strengthened the validity of the tool as a structured, caregiver-usable assessment method.
Post-intervention, children demonstrated substantial improvements across all 14 pragmatic behaviors targeted in the INSPIRE-Steps toolkit—including turn-taking, eye contact, verbal and non-verbal requests, polite forms, social greetings, speech clarity, and refusal strategies. These gains were not limited to structured intervention sessions but extended into spontaneous home and peer interactions, as reported by caregivers and confirmed during follow-up assessments.
In particular, children who had shown limited initiation of interaction or poor response to social bids before intervention were observed engaging more readily in communicative games, responding to greetings, and modifying their behavior to suit social contexts. Caregivers noted significant positive changes in their child’s ability to participate in everyday interactions, with many expressing satisfaction regarding the clarity, simplicity, and adaptability of the intervention content.
Caregiver feedback, collected through structured rating forms and open-ended interviews, highlighted the perceived usability of the toolkit, the cultural relevance of the stories and visuals, and the sense of empowerment parents felt while delivering therapy in naturalistic routines. Several parents reported increased bonding, smoother transitions during routine tasks, and a clearer understanding of how to scaffold communication within their daily life.
Taken together, these findings affirm the methodological rigor and practical value of INSPIRE-Steps as an effective, caregiver-mediated intervention to enhance social-pragmatic development in young children.
To evaluate the psychometric reliability of the INSPIRE-Steps Pragmatic Skills Checklist, internal consistency analysis was performed using Cronbach’s alpha. This 14-item tool was designed to assess diverse yet interrelated aspects of pragmatic communication in children aged 3 to 9 years, including turn-taking, requests, greetings, refusals, polite behaviors, and speech clarity. Unlike INSPIRE-Core, which focused on toddlers and early-emerging social behaviors, INSPIRE-Steps targeted a broader developmental spectrum with more nuanced skill expectations and contextual applications.
Internal consistency was assessed separately for pre- and post-intervention datasets. The results indicated a high degree of reliability in the checklist's ability to capture coherent and unified constructs of pragmatic functioning in older children. As shown in Table 4, the Cronbach’s alpha was 0.89 at pre-intervention, reflecting strong internal consistency even before structured teaching began. Following intervention, the alpha increased to 0.93, further confirming that the items remained consistently interrelated even after developmental changes and skill acquisition.Table 4Internal consistency of the INSPIRE-steps pragmatic skills checklist.Table 4TimepointCronbach’s AlphaPre-Intervention0.89Post-Intervention0.93
This robust internal consistency at both time points suggests that the INSPIRE-Steps checklist functions as a dependable and psychometrically sound tool for measuring progress in pragmatic language skills. The increase in alpha from pre- to post-intervention also supports the notion that improvements occurred in a cohesive and integrated manner rather than as isolated gains, thus reinforcing the tool’s construct validity.
The high internal consistency observed strengthens the case for using the INSPIRE-Steps checklist in both clinical and research settings to monitor change, tailor intervention, and evaluate generalization of skills across domains.
To ensure scoring accuracy and objectivity in the evaluation of children’s pragmatic communication, inter-rater reliability was examined for the INSPIRE-Steps Pragmatic Skills Checklist. Two independent raters—both certified speech-language pathologists with over five years of clinical experience—scored a randomly selected subset (20 %) of the total sample (n = 10 children) during both pre- and post-intervention phases.
Each rater independently reviewed video-recorded segments of child-caregiver interactions, focusing on spontaneous social-communication behaviors targeted by the INSPIRE-Steps intervention (e.g., turn-taking, polite requesting, verbal refusals). Item-level agreement was calculated using Cohen’s Kappa (κ) for categorical consistency and Percent Agreement as a supplementary measure.
Results indicated high inter-rater reliability across all 14 items of the checklist. This is described in Table 5. Kappa values ranged from 0.84 to 0.94, indicating substantial to near-perfect agreement. The average percent agreement across items exceeded 92 %, reflecting excellent consistency in item interpretation and scoring between raters.Table 5Inter-rater reliability of INSPIRE-steps pragmatic skills checklist.Table 5Checklist ItemCohen’s Kappa (κ)% AgreementEngages in verbal turn-taking0.9194 %Follows communicative game rules0.8892 %Participates in non-verbal turn-taking0.8690 %Waits for turn in social play0.8991 %Uses appropriate verbal greetings0.9295 %Responds to greetings0.993 %Verbally requests objects/actions0.9396 %Uses polite request forms0.8790 %Expresses refusal/disagreement appropriately0.8492 %Refuses politely0.8591 %Offers objects for sharing0.9495 %Gives items contextually (e.g., sharing/gifting)0.992 %Speech clarity0.8993 %Adjusts speech for listener understanding0.9194 %Average0.8992.7 %
This high level of reliability strengthens the credibility of outcome assessments in the current study and affirms the clarity and objectivity of the checklist items.
Following the implementation of the INSPIRE-Steps program, a comprehensive comparison of children's performance across the 14 pragmatic skill items revealed marked improvements in functional social-communication behaviors. These gains were consistently observed across all individual checklist items, as depicted in Table 6, demonstrating that the effects of the intervention were not limited to a few domains but rather distributed across multiple pragmatic skills.Table 6Summary of pragmatic skill scores at pre- and post-intervention for INSPIRE-Steps.Table 6Pragmatic Skill ItemPre-MeanPost-MeanGainMaintenance1. My child engages in communicative games that involve turn-taking and verbal exchange.1.463.081.622.992. My child follows the rules of communicative games and uses language appropriately.1.443.121.682.893. My child participates in non-verbal turn-taking activities, such as passing an object.1.443.141.703.104. My child waits for their turn and recognizes others’ turns in non-verbal games.1.463.201.743.205. My child uses appropriate greetings, such as saying "hi" or "hello."1.443.181.743.06. My child responds to greetings with a smile or verbal acknowledgment.1.423.181.763.07. My child verbally requests objects, actions, or information from others.1.443.221.782.998. My child uses polite forms of requesting, such as "please" or "may I."1.463.181.722.889. My child expresses refusal or disagreement appropriately.1.463.201.743.110. My child refuses politely without causing offense.1.463.201.743.111. My child offers objects to others as part of social interaction.1.463.241.783.3612. My child gives items to others with social awareness (e.g., sharing a toy or giving a gift).1.503.301.803.3313. My child's speech is clear and understandable in most situations.1.463.341.883.114. My child adjusts their speech for clarity when not understood.1.463.281.822.89
Children who initially displayed minimal independence in pragmatic functions—such as initiating greetings, participating in turn-taking games, or expressing refusal appropriately—showed significant movement toward greater autonomous and contextually appropriate use of these skills. The majority of children transitioned from ratings of “Never” or “With Assistance” at pre-intervention to “Sometimes,” “Mostly,” or even “Always Independently” by the post-intervention phase.
The most significant improvements were noted in foundational skills such as offering or giving items within a social context (Item 12), adjusting speech for clarity (Item 14), and verbally requesting using polite forms (Item 8). For instance, the number of children demonstrating fully independent use of these behaviours more than quadrupled in several items, indicating not only acquisition but generalization and confident use of the skills in natural settings.
Statistical analysis using the Wilcoxon Signed-Rank Test confirmed that these differences between pre- and post-intervention scores were highly significant across all items (p < 0.001). Additionally, for total composite scores, paired t-tests validated the findings with large effect sizes (Cohen’s d > 1.2), confirming the magnitude of the observed changes and their clinical importance.
These results, presented in Fig. 4, reflect the item-wise pre–post mean scores and the corresponding gain for each pragmatic skill targeted through INSPIRE-Steps.Fig. 4Mean pragmatic skill scores Pre-post and maintenance Phase for INSPIRE-Steps.Fig 4
•T-Test Results: All 14 items showed extremely high t-statistics with p-values of < 0.001, confirming that the post-intervention scores were significantly higher than pre-intervention scores. This suggests large, statistically robust improvements across all pragmatic skill items.•Wilcoxon Signed-Rank Test: The non-parametric results echoed the t-test outcomes, with all Wilcoxon p-values also < 0.001. This confirms that the findings are not dependent on assumptions of normality.
The statistical tests strongly support the effectiveness of the INSPIRE-Steps intervention in enhancing children’s pragmatic communication skills. The consistency across both parametric and non-parametric tests reinforces the validity of the results, this is depicted in Table 7.Table 7INSPIRE-steps pre–post statistical results.Table 7Checklist ItemPre-MeanPost-MeanMean Differencet-valuep-value (t-test)Z (Wilcoxon)p-value (Wilcoxon)Engages in communicative games1.363.121.7614.21< 0.001−6.11< 0.001Follows rules in communicative games1.343.221.8814.58< 0.001−6.17< 0.001Participates in non-verbal turn-taking1.343.261.9215.31< 0.001−6.2< 0.001Waits and recognizes turns in games1.363.341.9815.86< 0.001−6.22< 0.001Uses appropriate greetings1.343.34216.02< 0.001−6.23< 0.001Responds to greetings1.343.362.0216.18< 0.001−6.25< 0.001Requests objects/actions/information1.343.362.0216.12< 0.001−6.25< 0.001Uses polite forms while requesting1.363.341.9815.73< 0.001−6.22< 0.001Expresses refusal appropriately1.383.42.0216.14< 0.001−6.24< 0.001Refuses politely1.363.382.0216.09< 0.001−6.23< 0.001Offers objects in social contexts1.363.52.1416.93< 0.001−6.28< 0.001Gives items with social understanding1.383.462.0816.65< 0.001−6.26< 0.001Speech is clear and understandable1.343.34216.02< 0.001−6.24< 0.001Adjusts speech for clarity1.363.422.0616.12< 0.001−6.25< 0.001
To evaluate the sustainability of intervention gains, a maintenance assessment was conducted approximately two months following the conclusion of the INSPIRE-Steps intervention. Caregiver ratings on the 14-item Pragmatic Skills Checklist were again collected and compared to post-intervention scores. The goal was to determine whether the improvements observed immediately after the intervention were retained over time, or if there was evidence of regression or further development.
Overall, the maintenance scores closely mirrored the post-intervention ratings, indicating strong retention of pragmatic communication skills. As depicted in Table 6, the majority of items showed no significant change from the post-intervention phase, suggesting that children continued to use the learned social-communication behaviors in daily interactions even after formal sessions had ended. Caregivers reported that they were still incorporating the INSPIRE strategies during routines such as play, meals, and outings, supporting the generalization and continued use of skills.
Notably, three items demonstrated slight gains during the maintenance •“Responds to greetings”,•“Expresses refusal appropriately”, and•“Uses polite forms of requesting” all showed marginal increases in mean scores, suggesting that some children continued to consolidate and refine these abilities with ongoing caregiver reinforcement.
Conversely, two items showed minor •“Engages in communicative games involving turn-taking”, and•“Participates in non-verbal turn-taking” had slightly lower scores during the maintenance phase. While the declines were not statistically significant, qualitative reports indicated that these regressions may have been due to reduced opportunities for structured play (e.g., fewer family gatherings or outdoor activities), rather than loss of skill.
The Wilcoxon Signed-Rank Test was conducted to evaluate changes between post-intervention and maintenance scores. As shown in Table 8, none of the differences reached statistical significance (all p-values > 0.05), confirming that the observed changes were minor and not indicative of true regression or advancement.Table 8Caregiver satisfaction ratings following INSPIRE-core intervention.Table 8Feedback AreaAverage Rating (out of 5)Clarity of Visual and Verbal Instructions4.9Child’s Motivation and Enjoyment4.7Relevance of Real-Life Scenarios Used4.8Integration into Daily Schedules4.6Impact on Child’s Communication Behavior4.9Parental Readiness to Continue Independently4.8
These findings support the durability of the INSPIRE-Steps intervention outcomes, highlighting the effectiveness of caregiver-mediated strategies in promoting long-term improvements. The stability in scores also reflects the feasibility of continued implementation without therapist presence, affirming the program’s potential for sustainable use in real-life home settings.
In addition to statistically significant improvements in children’s pragmatic communication skills, insights gathered from caregivers offered critical validation of the INSPIRE-Steps program’s practicality, usability, and overall value in everyday contexts. All participating caregivers engaged in structured feedback sessions following the program, including a 5-point satisfaction survey and semi-structured interviews.
The survey responses indicated high satisfaction across all evaluated areas, with caregivers appreciating the program’s clear layout, engaging content, and realistic integration into daily routines at home and school. The consistency of positive responses across families from diverse backgrounds supports the adaptability of INSPIRE-Steps for widespread use.
An inductive analysis of caregiver comments highlighted three dominant experiential 1. Strengthened Everyday Communication
Many caregivers reported that their children began using social language more spontaneously and purposefully. Improvements were noted in greetings, polite refusals, asking questions, and participating in group routines such as circle time or playgroups. Several parents observed that their child was more aware of turn-taking rules and had become more comfortable initiating or sustaining conversations.“We noticed him actually trying to join in conversations during family dinners—before, he would just sit quietly or hum to himself.”
– Caregiver of a 6-year-old participant2. High Engagement and Activity Appeal
The child-centered design of the intervention—using stories, visuals, and context-based tasks—was frequently cited as a major strength. Caregivers emphasized that children looked forward to sessions and began applying learned behaviors in familiar settings like school, family gatherings, and birthday parties.“She would remind me about the next story—especially the one with the puppet show! She now asks to take turns when we play games.”
– Parent of a 5-year-old participant3. Increased Parental Confidence and Consistency
Caregivers expressed a heightened sense of clarity and confidence in facilitating communication goals. The visual guides, task routines, and progress tracking tools were highlighted as empowering features. Parents felt supported and equipped to continue skill-building practices independently even after the intervention concluded.“I used to feel helpless during his meltdowns. Now, I model polite refusal or give him sentence starters—and he actually uses them.”
– Mother of a 7-year-old participant
Although a few parents mentioned occasional hurdles, such as school exams or minor behavioral regressions, most described these as temporary and manageable with therapist follow-ups and flexible session planning.
These findings validate the INSPIRE-Steps program not only as an evidence-based intervention but also as a parent-friendly toolkit that can be adapted within natural caregiving routines. The overwhelmingly positive caregiver experiences reflect the program’s resonance with both children and families, reinforcing its role as a meaningful tool in shaping social communication in children aged 3–9 years.
While the findings of the INSPIRE-Steps study provide strong preliminary support for the effectiveness and feasibility of the intervention, several limitations should be 1. Limited Sample Diversity: Although the study included 50 children from varied socioeconomic backgrounds, the sample was region-specific and may not reflect the full cultural and linguistic diversity of India. Broader demographic representation is essential for generalizing results to wider populations.2. Short-Term Outcome Monitoring: While the post-intervention and maintenance phases captured changes over a few months, long-term outcomes (e.g., 12-month follow-up) were not tracked. Future studies should include extended follow-up intervals to assess the durability of gains and continued skill generalization.3. Lack of Blinding in Ratings: Scoring was performed by trained raters familiar with the program. Although inter-rater reliability was high, the absence of blinded assessments may have introduced some level of bias. Independent blinded evaluators would enhance objectivity in future trials.4. Caregiver-Led Model Variability: Despite consistent guidance, the degree of caregiver involvement and fidelity in implementing the program may have varied between households. Differences in parental availability, comprehension, and engagement may influence outcomes, and future versions may benefit from a structured fidelity checklist or video-based monitoring system.5. No Control Group: This study used a single-group pre–post design. While statistical significance was achieved, the absence of a control or comparison group limits the ability to isolate the intervention’s effects from natural developmental progress or other external factors. Future randomized controlled trials (RCTs) are warranted.
Ethical approval for this study was obtained from the Father Muller Institutional Ethics Committee (FMIEC), Mangalore, India [Ref. No: FMIEC/CCM/385/2023]. The study adhered to all ethical guidelines outlined by the committee, including the requirement for informed consent from all participants or their guardians. All identifying information of participants has been anonymized to ensure privacy and confidentiality throughout the research process. The ethics committee retains the right to monitor the study as per its guidelines.
None.
Interactive Social Pragmatic Interventions And Responsive Engagement (INSPIRE): An Intervention Program to facilitate Social Skills among Toddlers with autism, MethodsX, 2025, 103,352, ISSN 2215–0161, https://doi.org/10.1016/j.mex.2025.103352.
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.