Feasibility and Acceptability of Group-Based Interventions (Offered in English and Spanish) for Caregivers of Children With LAD

Abstract

Background

Caregivers of children with learning and attentional disabilities (LAD) are at risk for chronic stress and its sequalae, yet there are few interventions to support these caregivers.

Objective

Assess the feasibility and acceptability of a mind-body resiliency group intervention for caregivers of children with LAD.

Methods

Four adapted groups of the Stress Management and Resiliency Training (SMART-LAD) and, its comparator, the Health Education Program (HEP-LAD) were offered to English and Spanish speaking caregivers of children with LAD. Caregivers were recruited from a family services organization who completed baseline and post-treatment surveys.

Results

From 12/24-2/25, 28 participants were enrolled in four groups. 94.6% screened were eligible (35/37); 80% (28/35) enrolled. 83% completed the follow-up survey. Two-thirds attended 6 or more sessions. 91.7% of participants in both groups expressed comfort/trust.

Conclusion

Both interventions are feasible and acceptable. The SMART-LAD program may have fostered deeper engagement and content satisfaction.

clinicaltrials.gov registry

Resiliency Programming for Caregivers of Children with Learning and Attentional Difficulties (SPARK), https://clinicaltrials.gov/study/NCT06492278, NCT06492278 IRB 2024P001219.

Keywords

resiliency caregiver learning and attentional disability neurodivergence caregiver support

Introduction

Caregivers of children with learning and attention disabilities (LAD) are at risk of experiencing chronic stress and resulting negative health impacts. Learning disabilities include difficulties in understanding or using spoken or written language, or difficulties with reading, writing, listening, speaking, reasoning, or math.¹ Attentional disorders include difficulty with ongoing attention and/or hyperactivity that interferes with functioning.² Both disorders fall under the umbrella term “neurodivergence”. Having a child with LAD can present stressors for caregivers (parents, family members, guardians and legal guardians) of children with LAD. Caregivers experience more stress than those of neurotypical children.³ Higher stress can detract from caregiver emotional and physical health,^4-6 yet the literature on stress reduction interventions is scant.⁷

Previous work by this research team sought to improve resiliency among parents with LAD using the Stress Management and Resiliency Training-Relaxation Response Resiliency Program (SMART-3RP).⁸ The SMART-3RP is guided by the diathesis-stress model, which posits that resilience is the outcome of an individual’s experiences and environment in combination with one’s inherent coping ability and genetic predisposition towards anxiety.⁹ The SMART-3RP is an 8-session group program, which is delivered either in-person or virtually (See Appendix 1). This model views adjustment to ongoing, daily stress, such as that experienced by caregivers of children with LAD, as a dynamic process which is achieved by practicing a set of 3 core skills: (1) Relaxation Response (RR) elicitation, (2) Stress Awareness and Management, and (3) Adaptive Strategies. SMART-3RP builds resilience through cultivation of the relaxation response (RR) elicitation strategies (e.g. breath awareness, mindfulness), stress management (cognitive behavioral strategies), and growth enhancement (positive psychology, post-traumatic growth) processes in response to ongoing chronic stressors.

Building on a previously successful pilot trial,¹⁰ the current study (named “Supporting Parents Raising Kids” (Project SPARK)) was developed in collaboration with the Federation for Children with Special Needs (the Federation) to further adapt both the SMART-3RP intervention and its comparator, the Health Education Program (HEP),¹¹ into English and Spanish versions for caregivers of children with LAD. Details of this collaboration development and treatment adaptation process have been described elsewhere.¹² This paper presents the pilot phase of the study, focusing on feasibility and acceptability, as well as exploratory use of trial outcome measures, to assess the appropriateness of study procedures and outcome measures for a full trial.

Methods

Participants

Participants were English- and Spanish-speaking parents/guardians (caregivers) (age 18+ years) of a child (<18 years) with a LAD. Exclusion criteria included caregivers with significant psychiatric conditions (no one met this exclusion criteria). Only one caregiver per family could participate. Caregivers whose children had a primary diagnosis/disability other than a LAD or who had participated in the previous qualitative phase^12,13 were excluded.

Outreach and Recruitment

The Federation led the caregiver recruitment through their social media outlets, listservs, and participants in other programs. After training in research ethics and the study's recruitment plans, Federation staff called caregivers and, with interested caregivers, conducted a prescreen survey over the phone using a secure REDCap. If a caregiver was eligible and available during an intervention time slot, the study staff consented the participant using REDCap electronic Consent (eConsent). Consented participants were sent the baseline survey and were then randomized to a group within their preferred language: English or Spanish.

Intervention Groups

Adapted versions called SMART-LAD and HEP-LAD were delivered in both English and Spanish in 8 one-hour weekly sessions by licensed clinical psychologists or physicians. The co-adaptation process with the Federation has been previously published.¹² Study design modifications included (1) creation of a culturally and linguistically appropriate Spanish language version of LAD and HEP, (2) shortening SMART sessions from 1.5-hour to 1-hour sessions, (3) refinement of in-session exercises to focus on managing current common stressors of caregivers with LAD, (4) simplification of language for both English- and Spanish-language manuals, (5) diversification of illustrations of multiple family types, races, and ethnicities, and (6) a resource list of Federation-sponsored programs to address caregiver concerns.

The content of each group’s session is outlined in Appendix 1. The SMART-LAD program emphasized relaxation response elicitation strategies, stress coping, and positive psychology strategies, while the HEP-LAD program focused on healthy lifestyle behaviors. All groups were conducted virtually via Zoom between December 2024 and February 2025.

Strategies to Enhance Group Adherence

Reminder emails were sent the day prior to each group session and included the respective program manual, Zoom link, and schedule. Additional reminder emails were sent five minutes before the group started and five minutes into the session for those who had not yet joined. Text reminders and follow-up calls were implemented.

Supervision

Group facilitators met weekly for supervision meetings with the study team, to discuss group progress and questions/challenges (e.g., group engagement, cohesion, specific care needs).

Data Collection and Analyses

Baseline and follow-up surveys were completed through REDCap. Following completion of the follow-up survey, participants received $20 gift cards via mail for each completed survey (up to a total of $40). Baseline surveys assessed caregiver characteristics. Feasibility measures were number of group sessions attended (of a total of 8 possible), percent screened who were eligible, percent of eligible participants enrolled, and follow-up survey completion rates. Our target enrollment goal was 4 groups of 6 participants, or 24 in total. Treatment satisfaction was rated by individual 5-point Likert scales assessing satisfaction with content, number of sessions, and video delivery. Group comfort was assessed with a single item from the Group Cohesiveness Scale (GCS-7)¹⁴ rating trust in the group on a 5-point Likert scale. A score of 4 or above on the 5-point Likert scale was used to establish treatment satisfaction and acceptability. To assess feasibility of study methods for a larger planned trial, the follow-up survey additionally asked if the participants would be comfortable providing a hair cortisol sample. The primary outcome measure that will be used for a full trial, the Current Experiences Scale (CES),¹⁵ assessed resiliency. All potential outcome measures¹² (previously described), proposed for a full study, were administered to explore change (Appendix 2). All analyses were conducted using SPSS. Descriptive and frequency statistics characterized the sample and paired t-tests explored pre-post program mean differences in potential outcome measures within each treatment group. See Appendix 3 for participant flow through the study.

Results

We reached our target enrollment for 28 caregivers for 4 groups (n = 16 English-speaking participants and n = 12 Spanish-speaking participants). Participants were all women, with an average age of 43 years. Forty-six percent were White, 45% Hispanic, 48% married, and 36% employed full time (see Table 1).

Table 1.

Caregiver Characteristics at Study Enrollment (Total n = 28; SMART Group n = 15, HEP n = 13)

Variables	n (%) or M ± SD
Variables	Total	SMART	HEP
Age	42.54 ± 7.74	43.80 ± 9.24	41.08 ± 5.56
Language
English	16 (57.1)	8 (53.3)	8 (61.5)
Spanish	12 (42.9)	7 (46.7)	5 (38.5)
Race
American Indian, Alaskan Native, or Pacific Islander	1 (3.6)	1 (6.7)	0 (0.0)
Asian	2 (7.1)	2 (13.3)	0 (0.0)
Black or African American	3 (10.7)	1 (6.7)	2 (15.4)
Native Hawaiian or other Pacific	0 (0.0)	0 (0.0)	0 (0.0)
White	13 (46.4)	7 (46.7)	6 (46.2)
Other	8 (28.6)	4 (26.7)	4 (30.8)
Prefer not to answer	2 (7.1)	1 (6.7)	1 (7.7)
Hispanic/Latino	15 (53.6)	7 (46.7)	8 (61.5)
Employment
Employed	16 (59.3)	13 (86.7)	3 (35.0)
Not employed	11 (40.7)	2 (13.3)	9 (75.0)
Marital status
Married	14 (50.0)	7 (46.7)	7 (53.8)
Single/Never married	9 (32.1)	5 (33.3)	4 (30.8)
Divorced/Separated	5 (17.9)	2 (13.3)	3 (23.1)
Religiosity
Not or slightly	10 (35.7)	4 (26.7)	6 (46.2)
Moderately to very	18 (64.3)	11 (73.3)	7 (53.8)
Spirituality
Not or slightly	21 (75.0)	11 (73.3)	10 (76.9)
Moderately to very	7 (25.0)	4 (26.7)	3 (23.1)
Ability to pay for basic needs
Not hard at all	7 (28.0)	3 (21.4)	4 (36.4)
Somewhat or very hard	18 (72.0)	11 (78.6)	7 (63.6)
Living
Stable	24 (92.3)	15 (100)	9 (81.8)
Unstable	2 (7.7)	0 (0)	2 (18.2)
Lack of reliable transportation
No	22 (84.6)	13 (86.7)	9 (81.8)
Yes	4 (15.4)	2 (13.3)	2 (18.2)
Child diagnosis
ADHD only	19 (67.9)	10 (66.7)	9 (69.2)
Learning-related	2 (7.1)	2 (13.3)	0 (0.0)
Both	7 (25.0)	3 (20.0)	4 (30.8)
>1 Child with LAD	5 (17.9)	2 (13.3)	3 (23.1)
Education level
HS or some college	10 (35.7)	4 (26.7)	6 (46.2)
College graduate	18 (64.3)	11 (73.3)	7 (53.8)

Feasibility

Of the 37 individuals screened, 94.6% were eligible (35/37). Of eligible individuals, 80% (28/35) enrolled (Fig 1). Of the 28 participants enrolled, 25 (89.2%) attended at least one group session. Of participants who attended sessions, 64% attended 6 or more sessions (16/25); among SMART-LAD participants, 78% (11/14) attended 6 or more sessions. Reasons for not attending group sessions included: traveling, illness, child’s event/sport practice (see Table 2).

Table 2.

Feasibility and Acceptability

Measure	SMART-LAD n (%)	HEP-LAD n (%)
Attended 6^a groups	11/14 (78.6%)	5/11 (45.5%)
Attended 4^a groups	12/14 (85.7%)	9/11 (81.8%)
^aSatisfaction with content (4/5)	9/13 (69.2%)	5/11 (45.5%)
^aSatisfaction with Number of Sessions (4/5)	10/13 (76.9%)	9/11 (81.8%)
^aSatisfaction with teleconferencing (4/5)	9/13 (69.2%)	8/10 (80.0%)
^bAgreement with group trust (4/5)	11/13 (84.6%)	11/11 (100%)

^aSatisfaction scales 1-5: 1 = very dissatisfied, 2 = moderately dissatisfied, 3 = neither satisfied nor dissatisfied, 4 = moderately satisfied, 5 = very satisfied.

^bGroup cohesiveness scale: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree.

The follow-up survey response rate was 89.3% (25/28). Resiliency increased in the SMART-LAD group but remained relatively stable in the HEP-LAD group. Other secondary outcome measures (e.g., stress and emotional coping) also indicated sensitivity to change over the course of program participation. Most (79.2%; 19/24) of participants said they would be comfortable giving a hair cortisol sample.

Acceptability

Satisfaction with the intervention was overall positive across all groups, with more satisfaction among SMART-LAD than HEP-LAD, among those who responded. 69.2% (9/13) were satisfied with the SMART-LAD content, while 45.5% (5/11) were satisfied with the HEP-LAD content. 69.2% (9/13) of participants in the SMART-LAD groups were satisfied with teleconferencing, and 80% (8/10) were satisfied with teleconferencing in the HEP-LAD groups. 76.9% (10/13) of SMART-LAD participants and 81.8% (9/11) of HEP-LAD participants felt satisfied with the number of sessions. 84.6% (11/13) of SMART-LAD participants and 100% (11/11) of HEP-LAD participants expressed comfort/trust in groups (see Table 2).

Discussion

Project SPARK assessed the feasibility and acceptability of two virtual, mind-body group-based interventions delivered in English and Spanish to caregivers of children with LAD. Despite the many demands faced by this population, including parenting, employment, competing time demands, and navigating complex care/educational systems, enrollment was very high, with most eligible participants choosing to participate. This success was likely due to a strong partnership with the Federation, with well-developed community outreach and retention strategies, as well as the creation of supportive and safe group environments.

Overall, 64% of participants attended six or more sessions, with SMART-LAD group attendance exceeding the pre-defined target of 75% attending 6/8 sessions. This suggests strong engagement with the SMART-LAD content, particularly among participants who may have found the focus on stress coping and positive psychology strategies (i.e., components that set the SMART-LAD apart from the HEP-LAD) especially useful. In contrast, attendance was lower in the Spanish HEP-LAD group, likely due to early technological issues that disrupted participation and building a consistent routine. When participants missed sessions, the most commonly cited reasons were logistical (e.g., travel, illness, schedule conflicts with their child’s event or sport practice). To address attendance barriers, we implemented day-of text reminders and follow-up calls, which proved helpful in both encouraging participation and identifying logistical challenges. In a future full-scale trial, offering more flexible session times and providing early technical support may further enhance accessibility and engagement.

The majority of participants self-reporteed feeling comfortable and trust in all of the groups. While overall satisfaction was good in both groups, SMART-LAD participants reported greater satisfaction with program content. These findings suggest that while health behavior content was of interest, many caregivers may have been particularly drawn to the psychological skills emphasized in SMART-LAD. Based on our formative results, it was likely that caregivers desired more direct support for their children, not for themselves,¹³ which can be addressed in a larger study.

Survey completion rates were high, and both primary and secondary outcome measures were successfully completed. The small sample size and pilot design constrain interpretation of preliminary outcome trends. However, the primary outcome, resiliency, as well as other secondary outcome measures, showed promising sensitivity to change, supporting their use in a future fully powered trial. Next steps include a fully powered randomized clinical trial, in partnership with the Federation for Children with Special Needs. The primary outcome would be resiliency. Design enhancements would include more flexibility with session timing, involvement of federation staff or other parents in the intervention itself, more technical support prior to the intervention initiation and, in terms of content, the addition of tailored systematic referrals and resources for children themselves.

In conclusion, findings suggest that both interventions in the SPARK Program are feasible and acceptable. The SMART-LAD program may have fostered deeper engagement (i.e., attendance) and content satisfaction. The strong group cohesiveness across both interventions and languages highlights the value of peer support in virtual group settings.

Footnotes

Acknowledgement

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ORCID iDs

Elyse R. Park

Isabelle Miranda

Lucy Finkelstein-Fox

Ethical Considerations

This study was approved by the Mass General Brigham Institutional Review Board (protocol number 2024P001219) on July 7, 2024.

Consent to Participate

All participants provided informed consent via REDCap electronic consent (eConsent) prior to participating.

Funding

The authors disclose receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Center for Complementary and Integrative Health (NCCIH) [grant 1R56AT011869-01A1, Adaptation of virtual group interventions to promote resilience among English and Spanish speaking caregivers of children with Learning and Attentional Disabilities (LAD)].

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

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Appendix

Appendix 1.

An overview of the session content provided in the SMART-LAD and HEP-LAD intervention groups

Session	SMART-LAD	HEP-LAD
1	Introducing resiliency and the relaxation response	HEP program overview, mental-physical health comorbidity
2	Stress management and resiliency training	Sleep hygiene
3	The relaxation response	Healthy exercise
4	Stress awareness	Nutrition I
5	Mending mind and body	Nutrition II
6	Creating an Adaptive Perspective	Health effects of Alcohol use & substance Abuse
7	Healing states of mind	Managing health care: Working as a team with healthcare Providers
8	Humor & staying resilient	Review & long-term goal Setting

Appendix 2.

Within-Group Scores at Enrollment (Time 0) and End of Treatment (Time 1) of SMART-LAD Group and HEP-LAD Group

Variables	M±SD
Variables	SMART t0	SMART t1	HEP t0	HEP t1
Resiliency (CES)^a	83.07 ± 17.14	87.85 ± 17.61	81.18 ± 14.55	81.00 ± 13.58
Stress reactivity/stress coping (MOCS-A)^b	30.38 ± 10.91	32.00 ± 11.56	25.27 ± 11.11	28.45 ± 10.90
Depression/Anxiety (PHQ-4)^c	4.00 ± 2.97	3.62 ± 3.10	4.55 ± 3.70	4.70 ± 3.95
Mindfulness (CAMS-R)^d	23.62 ± 2.96	25.15 ± 4.62	22.45 ± 5.26	23.12 ± 3.87
Fatigue (Fatigue Analogue Scale)^e	7.23 ± 2.80	6.31 ± 2.36	7.91 ± 1.97	7.82 ± 1.66
Positive affect (PANAS-Pos)^f	32.92 ± 9.15	34.38 ± 9.16	31.90 ± 11.00	32.15 ± 10.12
Emotional Support (PROMIS emotional Support 4a)^g	3.92 ± 1.08	3.75 ± 1.06	3.40 ± 0.97	3.80 ± 1.14

^aScores range from 0-115, higher score indicating greater resilience.

^bScores range from 0-52, higher score indicating greater ability to cope with stress.

^cScores range from 0-12, higher score indicating greater depression/anxiety.

^dScores range from 10-40, higher score indicating greater mindful qualities.

^eScores range from 1-10, higher score indicating greater fatigue.

^fScores range from 10-50, higher score indicating greater positive affect.

^gScores range from 1-5, higher score indicating greater emotional support.

Appendix 3.

Open Pilot Consort. Diagram Illustrating Participant Flow Through the Study, Including Numbers Screened, Enrolled, Randomized, and Allocated to Intervention Arm. Reasons for Not Enrolled are Noted

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