Empowerment, satisfaction, and family quality of life in early intervention: A qualitative study of professional practices received

Abstract

BACKGROUND

Early intervention (EI) has evolved toward the family-centered approach, operationalized through family-centered practices. Evidence suggests that the quality of implementation of these practices is associated with family outcomes such as empowerment, satisfaction, family quality of life (FQoL), and potentially caregiver burden/stress. However, in transitioning contexts, gaps persist between the model and perceived practice.

AIM

To explore from the perspective of Spanish families receiving EI services, how the professional practices they perceive relate to their experiences of empowerment/self-confidence, satisfaction, caregiver burden/stress, and FQoL, and to what extent these practices are perceived as aligned with the principles of the family-centered approach.

METHODS

An exploratory-descriptive qualitative observational study with an interpretative phenomenological orientation. Thirty families from Spain’s 17 Autonomous Communities participated. In-depth individual semi-structured interviews were conducted (in person or via videoconference), audio-recorded, and transcribed verbatim. The matrix analysis was carried out using Atlas. ti (v.9) following an inductive-deductive strategy (open, axial, and selective coding). Rigor was enhanced through expert panel review and interrater agreement (Kappa = 0.83).

RESULTS

An exploratory-descriptive qualitative observational study with an interpretative phenomenological orientation. Thirty families from Spain’s 17 Autonomous Communities participated. In-depth individual semi-structured interviews were conducted (in person or via videoconference), audio-recorded, and transcribed verbatim. Thematic analysis was carried out using Atlas. ti (v.9) following an inductive-deductive strategy (open, axial, and selective coding). Rigor was enhanced through expert panel review and interrater agreement (Kappa = 0.83).

CONCLUSION

From the family perspective, the impact of EI depends on the extent to which family-centered practices are implemented with quality, promoting genuine participation and transfer to daily routines. Trust, self-efficacy, and empowerment emerge as proximal outcomes linked to well-being and FQoL, while caregiver burden/stress may limit these processes. Incorporating family outcomes (FQoL, burden/stress) into service evaluation may help guide improvements in the implementation of EI in Spain.

Key Words: Early intervention; Family-centered approach; Professional practices; Parental empowerment; Family satisfaction; Family quality of life; Caregiver burden; Parental stress

Core Tip: Spanish families report that the benefits of early intervention depend less on service availability and more on how family-centered practices are implemented. Genuine participation, informed choice, and support to transfer strategies into everyday routines are associated with greater parental confidence and empowerment, with positive effects on well-being and family quality of life. Caregiver burden/stress emerges as a moderating condition that may limit participation and generalization.

INTRODUCTION

Early intervention (EI) has become a priority field of action in early childhood, not only because of its potential to optimize children’s development and participation, but also due to its capacity to support primary caregivers and strengthen the family context. From a systemic perspective, the effectiveness of EI is largely explained by family mechanisms (interaction patterns and resources) that mediate child outcomes[1]. The study starts from the hypothesis of the existence of an “implementation gap.” Although family-centered practices (FCP) currently constitute the recommended standard for operationalizing the family-centered approach (FCA) in EI, their translation into everyday practice in Spain is uneven. Services that remain closer to clinical approaches coexist with others more aligned with participatory principles and routine-based approaches. This variability may be differentially associated with family outcomes, shaping how families experience empowerment, satisfaction, caregiver burden/stress, and family quality of life (FQoL). Consequently, the interest of the present study focuses on exploring how these practices are experienced and under what conditions they are perceived as facilitating or limiting family well-being.

This perspective aligns with international frameworks that emphasize caregiving and early childhood development approaches grounded in caregiver capacity, safety, and early learning at home and in the community, positioning families as central agents in promoting positive developmental trajectories[2,3]. Consistent with this view, EI has evolved from predominantly clinical, child-centered models focused on therapeutic sessions toward ecological and family-centered models oriented to routines and natural environments, which assume that sustainable change occurs through real-life daily activities and natural contexts[4,5]. Within this framework, FCPs are understood as processes based on the family-professional partnership that integrate relational components (respect, empathy, cultural sensitivity, listening, and trust) and participatory components (shared decision-making, functional goals, capacity building, and resource mobilization). These practices constitute the operationalization of the FCA in professional practice and have become the recommended standard in EI and childhood disability services[6,7].

In this study, FCP were operationalized by distinguishing between relational and participatory components: (1) Relational, focused on the quality of the helping relationship (respect, listening, empathy, cultural sensitivity, and emotional support); and (2) Participatory, aimed at strengthening family capacity through shared decision-making, joint establishment of functional goals, and explicit support for transferring strategies to routines and natural environments.

This delineation aligns with established frameworks, particularly Recommended Practices[6] and McWilliam’s routine-based intervention model, which emphasizes the functionality and generalization of strategies in everyday activities[4]. Evidence indicates that when FCPs are implemented with quality, they are associated with positive family outcomes - grounded in trust, self-efficacy/empowerment, well-being, and greater satisfaction - and may enhance children’s learning and participation opportunities in daily life through increased family involvement and improved interactions within routines[7-9]. Accordingly, understanding how these family outcomes are promoted requires closer examination of the model’s short-term outcomes, particularly parental empowerment, confidence, and competence.

Empowerment, confidence, and parental competence as key outcomes of family-centered EI

Empowerment in EI can be understood as the increase in caregivers’ perceived autonomy and control to face daily challenges, make informed decisions, and manage and mobilize formal and informal supports for the benefit of the child and the family unit[7-9]. In this sense, empowerment constitutes an outcome sensitive to the quality of interaction with services when families are recognized as experts in their daily lives and shared responsibility is encouraged, as this tends to enhance confidence, perceived control, and self-efficacy. In capacity-building-oriented models, empowerment is promoted through practices that combine a strong helping relationship (listening, respect, and alliance) with real opportunities for participation (shared goals, informed choice, and routine-based learning)[8,9].

The literature indicates that, while relational components are necessary to sustain the professional-family alliance, participatory components (e.g., shared decision-making, setting functional goals, and real opportunities for choice) explain changes in parental self-efficacy and empowerment to a greater extent, as they place the family in an active role with more control over the process[6-9]. Consistent with this evidence, caregiver training and learning strategies have taken a central role in EI, supporting the development of parental competencies and the transfer of learned skills to daily routines and natural environments. From this perspective, interventions aim to promote situated and sustainable learning, so that strategies are integrated into everyday life and generalized beyond the session context[10,11].

In Spain, the transition toward the FCA, operationalized through FCPs, is described as an ongoing process with uneven implementation, where more clinically oriented, child-centered practices coexist with others more aligned with family-centered principles[5,12]. This gap between actual and ideal practice is relevant because empowerment depends not only on service availability but also on the type of professional-family interaction and the extent to which supports are aimed at strengthening family autonomy in natural environments. Along these lines, professional self-perception of competence and confidence in applying recommended practices has been associated with higher levels of parental involvement, suggesting that model change also requires training, shifts in beliefs, and organizational conditions[12]. Moreover, Spanish studies have linked parental confidence and competence with FQoL and other indicators relevant for evaluating the quality of EI supports[13]. Thus, service quality is reflected not only in proximal outcomes such as competence and confidence but also in how families value their overall experience with the care received and its impact on family well-being.

Family satisfaction: An indicator of perceived service quality

Satisfaction with EI services is considered a relevant indicator of perceived quality and of the adequacy of support provided to family priorities. Within the FCA, satisfaction is related to the alignment between expectations and experiences, accessibility and availability of information, professional treatment, and the usefulness of strategies in daily routines[7]. Research such as that by Verger et al[14], which compared two EI models in the same context, showed differences in satisfaction and FQoL depending on service organization and the role assigned to the family, particularly when the intervention was oriented toward routines and natural environments. In these cases, family satisfaction is linked to clear communication, interprofessional coordination, and real opportunities for participation in decision-making, prioritizing family needs and promoting more active family involvement.

Similarly, recent qualitative studies in Spain have described a continuum of perceived practices, ranging from more rehabilitative approaches to FCAs, highlighting that participation, listening, and functional planning are associated with experiences of greater alignment and support[15,16]. Thus, in EI, satisfaction is not limited to the evaluation of professional treatment but also includes the perceived usefulness of services, alignment with routines, and actual support in everyday life. However, to evaluate the impact of EI more broadly, it is necessary to include integrative indicators of family well-being, such as FQoL, which encompass and go beyond momentary satisfaction with the service.

FQoL in EI

FQoL has become a priority outcome for interventions and supports aimed at families of children with disabilities or developmental risk, expanding the focus beyond child-centered indicators to include dimensions such as emotional well-being, family interaction, supports, resources, and organization of daily life[17]. This conceptualization responds to the need to evaluate service impact in broad and meaningful terms, rather than solely through clinical or child development indicators.

Research focused on the 0-6 years stage has shown growing interest in FQoL, describing it as a subjective assessment of family well-being across domains such as family relationships, access to supports and information, child functioning, and participation in the community. These reviews also highlight conceptual and methodological heterogeneity (domains, models, and instruments), prompting efforts to clarify definitions and psychometrically validate measures to advance comparable and useful tools for service evaluation[18].

In Spain, significant contributions have been made to the development and validation of FQoL instruments, enabling more robust approaches to evaluating family outcomes[19,20]. Studies with large samples of Spanish families receiving EI have examined FQoL and its associated factors, showing how child, family, and service-related variables relate to perceived quality of life[21]. In addition, progress has been made in EI-specific instruments, such as the Families in Early Intervention Quality of Life scale, a Rasch-validated instrument designed to assess FQoL in the context of EI. Its validation through Rasch analysis provides evidence of reliability and psychometric adequacy for use with families receiving EI services[22]. Moreover, the relationship between FQoL and “intermediate” variables such as parental confidence/competence and caregiver burden has been documented, supporting an explanatory model in which intervention first impacts short-term outcomes (confidence, autonomy, training, and competence) and subsequently affects FQoL[13,23,24].

From a service evaluation perspective, positioning FQoL as an outcome implies that quality EI should not only aim for child progress but also create conditions for families to experience well-being, coping capacity, empowerment, and sustainability in daily routines. In line with this, a recent systematic review on FCPs in families of children with intellectual disabilities identified psychological and social benefits, including improvements in family well-being, quality of life, and empowerment, albeit with variability across studies and contexts[25].

Overall, this evidence supports the relevance of incorporating FQoL as a key indicator in service evaluation and examining how professional practices experienced by families relate to their overall family well-being, which guides the present study. Consistent with this framework, it is particularly important to consider factors that may compromise family well-being, such as caregiver burden, and protective factors that EI can enhance to mitigate this impact, including confidence and empowerment.

Caregiver burden in EI: Associated factors and protective mechanisms

Caregiver burden and stress are common experiences for families of children with disabilities, arising from caregiving demands, coordination of support, uncertainty, and constraints on time and resources. In EI, these factors are critical because they influence family participation and, indirectly, the child’s learning opportunities in natural environments[1,3]. Within the framework of FCPs, participation is understood as a central element of the intervention process, since effectiveness largely depends on the caregiver’s capacity to integrate strategies into daily routines and contexts[7-9].

Within this context, caregiver burden can reduce the availability of participating actively in the intervention and hinder the transfer of learned strategies to daily life, especially when families perceive that professional support does not translate into functional resources to manage the complexity of everyday life[23,24,26]. In Spain, recent studies have shown that caregiver burden is associated with FQoL and that family confidence can modulate the impact of child- or context-related factors on burden, acting as a potentially intervention-sensitive mechanism[23,24]. Family narratives also emphasize the importance of a strong professional alliance grounded in listening, understanding, and emotional support, which may help mitigate stress and sustain involvement in the intervention[16].

Recent evidence suggests that caregiver burden arises from a combination of individual and contextual conditions. In Spanish EI, a study using fuzzy-set Qualitative Comparative Analysis indicated that caregiver burden is best explained by configurations of psychosocial and contextual conditions (rather than a single predictor), highlighting the need for integrative approaches in support planning[26]. Complementarily, a systematic review with meta-analysis has shown that family-centered interventions can significantly reduce caregiver burden and stress while improving quality of life, emphasizing the role of family empowerment models in decreasing parental burden and stress[27].

Taken together, this evidence supports a key hypothesis for the current research: If EI strengthens confidence and empowerment through FCPs, alongside emotional support and networks aligned with family priorities, it could buffer perceived burden and promote FQoL. Within this scenario, exploring the experiences and narratives of Spanish families allows identification of how FCPs (within the FCA framework) are implemented in practice and what effects families perceive on empowerment, satisfaction, stress, and FQoL, thereby framing the rationale for the present study.

Rationale and objective of the study

Although the FCA and its FCPs are considered a standard of good practice, their implementation can vary in intensity and quality, so families experience different levels of participation, coordination, and functional alignment of the intervention with their routines and priorities. This variability is particularly relevant in contexts where the system is transitioning from more clinical models toward approaches based on routines and natural environments[5,12,15,16]. In Spain, recent evidence suggests progress in adopting the FCA, but gaps persist between the theoretical model and everyday practice, which may affect key family outcomes such as empowerment, satisfaction with services, caregiver burden and stress, and more broadly, FQoL[5,12-14,23,24].

In this context, it is necessary to understand how families interpret and make sense of the professional practices they receive, which elements they identify as facilitators or barriers (e.g., shared decision-making, orientation to functional goals, support for generalization in routines, coordination and continuity), and the extent to which they perceive coherence between the service and the principles of the FCA. This understanding is particularly important because empowerment and satisfaction can act as short-term outcomes and mechanisms of change, with potential downstream effects on perceived burden and FQoL. Therefore, the present qualitative study examines, through the narratives of Spanish families receiving EI, their perspectives on empowerment, satisfaction, and FQoL, as well as caregiver burden associated with the caregiving process, analyzing the role attributed to the professional practices received and the perceived alignment of services with the principles of the FCA.

MATERIALS AND METHODS

Study design and context

A qualitative observational study of an exploratory-descriptive nature with an interpretative phenomenological orientation was conducted to understand the experiences, perceptions, and meanings attributed by Spanish families to the professional practices they received in EI. The analysis was framed within the FCA and its operationalization through FCPs, as well as family outcomes (empowerment, satisfaction, caregiver burden, and FQoL). The study was based on the experiences of families using EI services in Spain, primarily within Child Development and Early Intervention Centers (CDIATs).

Participants, sampling, and recruitment

Thirty families (mothers, fathers, or both parents) of children with disabilities or developmental risk receiving EI participated, representing all 17 autonomous communities of Spain. Participation was voluntary. To contextualize the transferability of the findings, basic sociodemographic variables of the interviewed caregiver were collected (sex, age, and employment status), as well as characteristics of the child (sex, age, and school grade) and the service context (length of involvement in Early Intervention/CDIAT). In addition, the child’s primary condition/diagnosis profile was recorded descriptively using broad categories (e.g., autism spectrum disorder; rare disease/genetic syndrome; developmental and/or language delay; language disorder; physical disability; no diagnosis/under evaluation). These data are presented in aggregate form in Table 1.

Table 1 Descriptive characteristics of the sample and the early intervention service context (n = 30).

Domain	Variable	Value (%)1
Interviewed caregiver	Sex (female)	25 (83.3)
Interviewed caregiver	Sex (male)	5 (16.7)
Interviewed caregiver	Age (years)	Median 37 (22-55 years)
Interviewed caregiver	Employment status: Full-time work	13 (43.3)
Interviewed caregiver	Employment status: Part-time work	7 (23.3)
Interviewed caregiver	Employment status: Unemployed	6 (20.0)
Interviewed caregiver	Employment status: Job seeking	4 (13.3)
Child	Sex (girl)	12 (40.0)
Child	Sex (boy)	18 (60.0)
Child	Age (years)	Median 3 (1-8 years)
Child	School enrollment: Yes	26 (86.7)
Child	School enrollment: No	4 (13.3)
Child	School grade: Preschool (3 years)	7 (23.3)
Child	School grade: Preschool (4 years)	8 (26.7)
Child	School grade: Preschool (5 years)	1 (3.3)
Child	School grade: 1st grade (Primary school)	2 (6.7)
Child	School grade: Other	8 (26.7)
Child	School grade: Not enrolled/not applicable	4 (13.3)
EI service context	Time since EI service entry (n = 29): < 3 months	3 (10.3)
EI service context	Time since EI service entry (n = 29): 3-6 months	2 (6.9)
EI service context	Time since EI service entry (n = 29): 6-12 months	5 (17.2)
EI service context	Time since EI service entry (n = 29): 12-18 months	7 (24.1)
EI service context	Time since EI service entry (n = 29): ≥ 2 years	12 (41.4)
EI service context	Primary condition/diagnosis (n = 29): Autism spectrum disorder (ASD)	6 (20.7)
EI service context	Primary condition/diagnosis (n = 29): Rare disease/genetic syndrome	10 (34.5)
EI service context	Primary condition/diagnosis (n = 29): Developmental delay (including delay + language)	6 (20.7)
EI service context	Primary condition/diagnosis (n = 29): Language disorder	1 (3.4)
EI service context	Primary condition/diagnosis (n = 29): Physical disability	1 (3.4)
EI service context	Primary condition/diagnosis (n = 29): No diagnosis/under assessment	5 (17.2)

¹Percentages for “time since early intervention service entry” and “primary condition/diagnosis” were calculated using n = 29 (one case had missing data for these variables). Percentages may not total exactly 100% due to rounding.

EI: Early intervention.

Inclusion criteria: (1) Being the primary caregiver of a child receiving EI for disability or developmental risk; (2) Residing in Spain; (3) Having received intervention at an EI Center; and (4) Providing informed consent for participation and audio recording.

Exclusion criteria: (1) Not having received EI services; (2) Not providing informed consent and/or not authorizing recording; and (3) Inability to participate in the interview through the planned modalities.

A purposive sampling strategy was used to capture heterogeneity of experiences (territorial diversity and varied EI trajectories), with recruitment concluding upon reaching theoretical saturation. Recruitment was conducted via social media, family groups, and during the 1^st International Meeting on Updates and Research in Early Intervention (Campus Capacitas - Catholic University of Valencia, Spain).

Data collection

Individual in-depth semi-structured interviews were conducted, either in person or via videoconference (Skype/FaceTime), with an average duration of 1.5 hours. All interviews were audio-recorded with authorization and transcribed verbatim. A semi-structured interview guide with open-ended questions was used to explore: (1) Experiences with the EI received; (2) The perceived role of the family (participation and decision-making); (3) Functional alignment of the intervention with routines and family priorities; (4) Perceived supports (information, guidance, coordination); and (5) Effects attributed to professional practices on empowerment, satisfaction, caregiver burden, and FQoL.

The interview guide was also designed to explore specific components of FCP, distinguishing between relational and participatory practices. Relational practices included questions regarding the treatment received, listening, respect, understanding, cultural sensitivity, and emotional support, as well as the appropriateness of communication to family needs. Participatory practices included questions on shared decision-making, the construction of functional goals, active caregiver participation during intervention, and explicit support for transferring strategies to routines and natural environments (e.g., how to apply what was worked at home, anticipating and solving problems in new situations), including training and empowerment strategies. This operationalization aligns with established frameworks, such as recommended practices (FCP) and McWilliam’s routine-based approach[4,6,10,11].

Statistical analysis

The analysis was conducted using thematic analysis with the support of Atlas. ti (v.9). An inductive-deductive strategy was followed, organized into three phases: (1) Open coding - identifying units of meaning; (2) Axial coding - grouping codes into categories and axes; and (3) Selective coding - integrating categories to interpret patterns, convergences, and divergences in the narratives.

For this manuscript, coding and interpretation focused on categories related to empowerment and parental confidence/competence, service satisfaction, caregiver burden/stress, and FQoL, as well as elements of the intervention process that families associate with these outcomes. In the deductive phase, the coding system incorporated guiding categories for relational FCP (e.g., listening/respect, cultural sensitivity, emotional support, clarity of communication, and alliance) and participatory FCP (e.g., shared decision-making, co-construction of functional goals, caregiver practice/training, routine-based planning, and support for generalization/transfer), examining how families linked these components to their family outcomes[8-11].

As a complementary step, a descriptive exploration was conducted using matrix queries in Atlas. ti (e.g., co-occurrence tables and code-document tables) to examine the distribution of codes/categories according to contextual variables recorded at the case level (Table 1), including child age, primary condition/diagnosis category, and duration of involvement in EI/CDIAT. Specifically, the co-occurrence between these case groups and codes related to the family centered practices (relational and participatory components) and family outcomes (empowerment/confidence-competence, satisfaction, caregiver burden/stress, and FQoL) was reviewed. This exploration was not intended for comparative or inferential purposes but to support contextualization of the interpretation and generate hypotheses. Descriptively, no consistent patterns attributable to child age or diagnostic category were observed; therefore, no subgroup comparisons were performed.

Methodological rigor

To strengthen the quality of the analysis, the category system was reviewed by a panel of three EI experts (a speech and language therapist, a psychopedagogue, and an occupational therapist - professionals in the field with ≥ 10 years of clinical and research experience in early childhood intervention). They classified the units of analysis according to relevance and coherence. Interrater agreement was estimated using the Kappa coefficient, which yielded a value of 0.83, indicating high reliability in coding. The criterion of theoretical saturation was also applied as the basis for concluding participant recruitment. Given the interpretative nature of the study, analytical decisions (definition and refinement of categories, grouping criteria, and relationships among codes) were documented, and credibility was strengthened through external review of the coding system and inter-rater agreement assessment, with the aim of minimizing interpretive bias.

Reflexivity and research team positioning: The study was designed and analyzed from an interpretative perspective, explicitly acknowledging that the researchers’ position could influence both data collection and the interpretation of participants’ accounts. In particular, the team’s academic familiarity with the FCA and the literature on FCP could predispose normative readings of empowerment or transfer to routines.

To mitigate this risk, a semi-structured interview guide with open-ended questions and a flexible order was employed, prioritizing the families’ identification of relevant issues and maintaining a conversation focused on their experiences, while avoiding leading or evaluative questions. During analysis, a log of analytical decisions (definition and refinement of codes/categories, grouping criteria, and relationships among categories) was maintained through notes/memos to ensure traceability of interpretations and facilitate critical review. Credibility was further strengthened through external review of the category system by a panel of experts and inter-rater agreement estimation, integrating their feedback to refine categories and minimize interpretative bias.

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board. Approval was obtained from the Ethics Committee of the Catholic University of Valencia (protocol code: No. CEI/UCV/2018-2019/111), approved on 20 January 2020. All participants were provided with information about the study and gave informed consent for both participation and audio recording of the interviews. Confidentiality and anonymity were ensured by assigning codes for discourse analysis and securely handling all data. The manuscript was prepared in accordance with the Observational Study category of the STROBE statement and, additionally, followed the Consolidated Criteria for Reporting Qualitative Research checklist for qualitative interview-based studies. When applicable, relevant STROBE items were also considered for the reporting of observational study aspects.

RESULTS

From the thematic analysis of the individual interviews, four main themes were identified related to the study’s objective: (1) Initial impact and need for guidance; (2) Parental empowerment and capacity-building promoted by collaborative practices; (3) Limits to empowerment when transfer to daily life is lacking; and (4) Perceived impact on FQoL. Although the analysis focused on identifying cross-cutting themes, the descriptive review by child- and service-related variables (Table 1) suggested nuances in the emphasis of certain content. Among families newly enrolled in EI, the need for guidance and support in response to initial uncertainty was more frequently reported. In contrast, narratives reflecting longer trajectories tended to include more detailed descriptions of the strategies that had been adopted and how they were being implemented in daily life, particularly when families perceived the presence of participatory practices (family centered practices) (e.g., shared decision-making, caregiver-guided practice, and planning within daily routines). In families with shorter involvement in EI, accounts more frequently emphasized initial impact, uncertainty, and the need for guidance, whereas in longer trajectories, references to learning strategies/tools and their application in routines appeared more recurrently. In contrast, no consistent patterns were observed that could be attributed to the child’s primary condition/diagnosis or age, beyond individual variation; therefore, these nuances should be interpreted cautiously and are considered hypotheses for future targeted analyses[21,23,24].

Specifically, families particularly valued participatory practices, such as being consulted and making decisions jointly (“What do you think…?”), actively participating during sessions by practicing strategies with professional support (“you get to do it yourself”), and receiving guidance to apply what was learned in routines and manage new situations. These practices were described as facilitating situated learning and fostering a sense of competence in managing daily life.

Initial impact and need for guidance

Families described the beginning of the process as a period marked by uncertainty, disorientation, and emotional burden, associated with difficulty anticipating their child’s development and the need for useful information and guidance. The codes appearing in the text corpora, at the end of each quotation, indicate the interviewee (M = mother; F = father) and the autonomous community. These narratives are primarily linked to relational components of the family centered practices, such as emotional support, attentive listening, and clear communication, which families perceive as the foundation for coping with initial uncertainty and sustaining engagement in the process.

Some narratives also reflected feelings of strangeness or social isolation: “At first, you feel a bit lost (…) Not knowing what would happen tomorrow” (F - Castile and León). “You feel a bit like a weirdo, it’s hard to accept your reality” (M1 - La Rioja). In contrast, several families reported a shift toward greater acceptance and normalization when they perceived ongoing support and understandable guidance: “Thanks to Early Intervention, we have understood the situation and have normalized everything” (M and F - Basque Country).

Parental empowerment and capacity-building are promoted by collaborative practices

Empowerment was linked to experiences in which families perceived a professional relationship based on collaboration, respect, and informed choice, avoiding prescriptive instructions and fostering shared decision-making. The quotes reveal both relational components (respect, attentive listening, and collaborative interaction) and, prominently, participatory components (informed choice, shared decision-making, caregiver-guided practice, and support for applying strategies in daily routines), described as key to enhancing confidence and competence: “It’s not like… you must do this (…) it’s always, ‘What do you think about this?” (M4 - Valencian Community).

Narratives emphasized that acquiring strategies and “tools” increased confidence and security in handling daily situations: “Having enough tools gives you a certain sense of security in everything” (M - Canary Islands). “It has been a school in being parents (…) now we dare to do everything” (M and F - Basque Country). Active participation during sessions was also described as a form of situated learning, where caregivers were seen as recipients of support: “The therapy time with the child is also therapy time for you” (F and M - Madrid). “They let you do it (…) we keep learning more every day” (F and M - Madrid).

Limits to empowerment when the transfer to daily life is lacking

Additionally, some families expressed that they had not received sufficient support to sustain the intervention in daily life, especially when they perceived an approach centered on the child without transfer to the caregiver. In some accounts, this lack of transfer was attributed to dynamics perceived as insufficiently participatory, for example, sessions mainly focused on direct work with their children, with limited joint planning of functional goals and strategies applicable to home routines, or with general guidance without explicit support to anticipate and solve difficulties in new situations experienced. These narratives reflected insecurity, self-directed problem-solving, and difficulty managing new situations. Thus, the expressed insecurity is interpreted as a consequence of insufficient implementation of participatory components (joint planning, functional guidance, and explicit support for generalization), rather than of the interpersonal relationship itself: “The only skills (…) I’ve figured out by myself (…) at home, many times I don’t know how to act” (M1 - Valencian Community). “Sometimes new situations overwhelm you, and you don’t know how to handle them” (F and M - Madrid). Uncertainty was also noted regarding the end of the service, especially when families felt insufficiently prepared to maintain progress or manage emerging demands: “Once early intervention ended (…) we were left there (…) a bit unprepared” (F - Castile-La Mancha).

Perceived impact on FQoL

Families link changes in parental empowerment and confidence with improvements in broader dimensions of well-being, including reduced stress, greater emotional strength, better daily adjustment, and a sense of support. In several narratives, the most significant impact was on caregiver well-being and family climate. In this theme, family well-being is particularly associated with relational components (alliance, understanding, and emotional support) and with recognition of the parental role, which families describe as essential conditions for sustaining participation without “becoming therapists”: “There is nothing more important (…) than the strength it gives you” (M - Murcia). “We feel stronger (…) our stress levels have decreased” (F - Castile and León).

The alliance with professionals (listening, understanding, and emotional support) was described as a component that promoted continued involvement and a greater sense of well-being: “The listening (…) having someone as a support (…) our reality has changed” (M4 - Valencian Community). “You can talk about things you can’t talk about with others (…) I feel much better” (M1 - La Rioja).

Finally, some families emphasized the need to preserve the parental role, without becoming “therapists”, as part of family well-being: “We don’t want to be therapists, we have to be parents (…) I’ve done a lot of therapy, but I haven’t played with him” (F - Canary Islands). Overall, the four themes reveal a consistent pattern: Families link the professional practices they perceive with changes in empowerment and confidence, which in turn affect caregiving burden and family well-being. To facilitate understanding and provide an integrated view of the findings, Table 2 presents a summary of the themes and subthemes identified, along with illustrative quotes representative of the narratives.

Table 2 Summary of themes, subthemes, and illustrative quotes.

Theme	Subtheme	Illustrative quote1
1. Initial impact	Uncertainty and disorientation	“Not knowing what would happen tomorrow” (H - Castile and León)
1. Initial impact	Normalization with support	“We have understood the situation and have normalized everything” (M and F - Basque Country)
2. Empowerment	Informed choice/collaboration	“It’s always, what do you think about this?” (M4 - Valencian Community)
2. Empowerment	Security through “tools”	“Having the tools (…) gives you a certain sense of security” (M - Canary Islands)
2. Empowerment	Situated learning during sessions	“The therapy time with the child is also therapy time for you” (F and M - Madrid)
3. Limits	Lack of transfer to home	“Many times, at home, I don’t know how to act” (M1 - Valencian Community)
3. Limits	New situations/feeling overwhelmed	“New situations overwhelm you” (F and M - Madrid)
4. FQoL	Stress reduction/emotional strength	“Our stress levels have decreased” (F -Castile and León)
4. FQoL	Professional alliance and emotional support	“Having someone as a support (…) our reality has changed” (M4 - Valencian Community)
4. FQoL	Preserving the parental role	“We have to be parents (…) I haven’t played with him” (F - Canary Islands)

¹The citation codes identify the interviewee and the autonomous community: M = mother, F = father; when both parents participated, it is indicated as “M and F” along with the autonomous community.

EI: Early intervention; FQoL: Family quality of life.

Figure 1, shown below, complements this synthesis by schematically representing the relationships perceived by families between the family centered practices components (relational and participatory facilitators), the proximal outcomes (confidence, self-efficacy, and empowerment), and their impact on FQoL. The model also incorporates the moderating role of conditions and barriers (e.g., caregiver overload/stress and difficulties in transferring strategies to routines) on these relationships.

Figure 1 Conceptual model of perceived relationship among family-centered practices and family outcomes. Solid arrows represent perceived associations between facilitators, proximal outcomes, and the global outcome; dashed lines indicate the potential moderating effect of barriers/conditions (e.g., caregiver burden/stress) on these relationships. FCP: Family-centered practices.

DISCUSSION

Main findings

This qualitative study explored how Spanish families interpret the impact of the professional practices they receive in EI on key family outcomes. The narratives revealed a consistent pattern: The initial stage of the process was experienced with uncertainty and a need for meaningful guidance; when practices were perceived as collaborative, experiences of greater parental empowerment and capacity building emerged; when transfer to everyday life was lacking, empowerment was described as limited and accompanied by feelings of insecurity; and, finally, these processes were linked to perceived effects on family well-being and FQoL. Overall, the findings suggest that, from the family perspective, the effects of EI are explained less by the mere provision of services and more by how the FCA is implemented through FCP, particularly with regard to participation, shared decision-making, and support for integrating strategies into daily routines[6-9].

Interpretation in relation to previous literature

Narratives regarding initial uncertainty and the need for support align with frameworks emphasizing the centrality of the caregiver and family environment in child development and well-being, positioning early childhood intervention as a process aimed at strengthening parental capacities and caregiving contexts[2,3]. From a systemic perspective, these findings are consistent with the idea that family mechanisms mediate the effects of intervention on the child and, therefore, require explicit consideration in service planning and evaluation[1].

Regarding empowerment, families described more favorable experiences when they perceived respect, active listening, and collaboration, but especially when participatory components were promoted (informed choice, functional goals, and shared responsibility). This pattern aligns with reviews indicating that, although relational components are necessary, participatory components best explain changes in parental self-efficacy and empowerment[6-9]. Similarly, narratives highlighting the acquisition of strategies and learning during sessions are consistent with caregiver training approaches that aim to promote situated learning and generalization to routines and natural environments[10,11]. Overall, these findings support an interpretation based on family capacity-building.

These results can be interpreted within the framework of well-established models in EI. On the one hand, they are consistent with the family-centered care model proposed by Dunst et al[8], which distinguishes between relational practices (e.g., alliance, listening, and respect) and participatory practices (e.g., genuine opportunities for choice, shared decision-making, and capacity-building), the latter supporting changes in self-efficacy and empowerment[8,9]. On the other hand, McWilliam’s routine-based model emphasizes that sustainable change occurs when strategies are embedded within everyday activities and natural environments, thereby promoting transfer and generalization[4,10]. From this perspective, the lack of transfer to the home context emerges as a critical factor for understanding the limits of family empowerment.

The third theme, concerning the limits of empowerment when strategies are not transferred to the home, provides a particularly useful perspective for FCA implementation: Intervention may be insufficient if confined to the clinical context or direct work with the child, without translating into parental competencies to handle new situations. This tension is consistent with the available evidence in Spain regarding an uneven transition, characterized by the coexistence of more clinically oriented practices alongside those more closely aligned with the FCA operationalized through implemented FCP[5,12]. Specifically, studies such as García-Ventura et al[12] have shown discrepancies between “current” and “desired” professional practices, particularly in participatory components (e.g., genuine family involvement, shared decision-making, definition of functional goals, and supports oriented to routines), which helps contextualize why some families perceive that learning is not sustained in daily life. In this context, the results reinforce that the experience of empowerment depends not only on “receiving services” but on the quality of the professional–family interaction and the extent to which real participation oriented toward routines and natural environments is promoted[6-9,12].

Regarding FQoL, the narratives indicate that the perceived impact of EI extends beyond child outcomes and is expressed in terms of emotional well-being, daily adjustment, and family climate, consistent with the conceptualization and growing use of FQoL as an integrative outcome in early childhood and disability research[17,18]. In Spain, these findings are supported by psychometric advances and studies describing factors associated with FQoL in families receiving EI, as well as the development of specific measures such as the Families in Early Intervention Quality of Life Scale[19-22]. Moreover, the observed relationship between proximal outcomes (confidence/competence) and FQoL aligns with Spanish studies linking FCP with parental confidence/competence and overall FQoL[13].

Finally, incorporating caregiver burden/stress as a moderating condition adds conceptual coherence to the interpretation of the findings: Families suggest that burden can limit participation and strategy transfer, while professional support - when functionally and emotionally available - can buffer stress. This perspective is consistent with recent evidence from Spain linking caregiver burden and FQoL and highlighting family confidence as a relevant mechanism[23,24]. Additionally, recent work indicates that caregiver burden is best explained by configurations of psychosocial and contextual conditions, highlighting the need for integrative approaches in planning supports[26]. Complementarily, synthesized evidence shows that family-centered interventions can reduce caregiver burden and stress while improving well-being outcomes, reinforcing the relevance of family empowerment models[27].

Implications for EI practice and services

These findings have clear implications for improving service quality. First, the initial phase of intervention requires meaningful guidance, comprehensible information, and emotional support. When these elements are lacking, uncertainty intensifies and may hinder family engagement. Second, parental empowerment and skill development appear to depend particularly on genuine participation (beyond courteous treatment): Co-construction of functional goals, informed choice, and explicit support to transfer strategies to daily routines[6-11]. Operationally, this explicit support can be manifested, for example, through the implementation of role-play with the caregiver during the session, the joint planning of an activity based on a family-prioritized routine (e.g., mealtime, bath, or park), including the definition of cues, steps, and possible adjustments, or problem-solving around an upcoming challenge (anticipating barriers, rehearsing alternatives, and agreeing on how to monitor progress at home).

Moreover, this support can be reinforced through concrete follow-up and adjustment strategies: For example, video feedback (short recordings of an agreed-upon routine reviewed jointly to fine-tune supports), simple caregiver logs (diary/checklist of the routine to identify barriers and facilitators), and a “transfer plan” at the end of the session (what will be tried, when, with success indicators, and how it will be reviewed in the next session), thereby promoting generalization and continuity between sessions[10,11].

Third, the findings emphasize the importance of ensuring transfer to the home and natural environments, avoiding interventions that are limited exclusively to the session. Achieving this requires professional development oriented towards the FCA/FCP and the organizational support necessary to sustain it, especially in a national context where implementation remains uneven[5,12]. Finally, integrating FQoL and caregiver burden as evaluation indicators allows for assessment of service impact from a truly family-centered perspective, consistent with advances in measurement in Spain and with the international agenda for caregiver-focused supports[2,3,17-21].

Strengths and limitations

Among the strengths of this study is the inclusion of families from all 17 Spanish Autonomous Communities, providing territorial heterogeneity and a diversity of experiences. The qualitative methodology allowed access to nuanced insights regarding processes (alliance, participation, and transfer) and family outcomes (empowerment, well-being, and FQoL) that are often underrepresented in exclusively quantitative designs. As for limitations, the sampling was intentional, and recruitment was partially conducted via social media and a specific event, which may introduce self-selection bias. The data are based on self-reported narratives and do not permit causal inferences.

Additionally, given that the data were collected through interviews, there is a risk of social desirability bias, insofar as some evaluations may have been influenced by perceived expectations, the relationship with the service, or the desire to present the experience in a socially acceptable manner. Likewise, the study did not incorporate triangulation with data from professionals or direct observation of sessions/practices; therefore, the interpretation relies exclusively on the family perspective and does not allow for verification of the fidelity of family centered practices implementation within the service context.

Furthermore, the paternal perspective is underrepresented, as the majority of participants interviewed were mothers (83.3%, Table 1). This asymmetry may bias the interpretation toward the experience of the primary caregiver and limit transferability to other family members, given that experiences of empowerment, caregiver burden, and FQoL may differ among mothers, fathers, and other caregivers. Additionally, although various family profiles were included, analyses were not differentiated by service type, intervention intensity, or child characteristics; therefore, the results should be interpreted as transferable to similar contexts rather than statistically generalizable.

Although descriptive variables of the child and service context were included (Table 1) and a descriptive qualitative exploration was conducted, the study was not designed to make comparisons between subgroups (e.g., by type of condition/diagnosis, age, or length of involvement in EI). In this regard, the observed nuances should be interpreted as hypotheses: In families newly enrolled in EI, references to initial uncertainty and the need for guidance were more frequent, whereas in longer trajectories, more detailed descriptions of strategies and their implementation in daily life tended to emerge, particularly when families perceived participatory practices (e.g., shared decision-making, caregiver-guided practice, and routine planning). Consequently, the findings should be interpreted as a global thematic pattern, and the observed nuances are considered hypotheses for future analyses with larger samples or mixed methods designs. Finally, by focusing on individual interviews, broader intra-family dynamics may be underrepresented.

Future research directions

Future research could combine mixed methods designs that integrate measurement of FQoL and caregiver burden with qualitative analyses, allowing for the examination of change mechanisms (confidence/empowerment) and moderating conditions (burden and organizational barriers). It would be particularly relevant to investigate differences according to service modality (center-based vs natural environments), intensity, and coaching strategies, as well as to evaluate interventions aimed at implementing FCP with professional training and supervision, measuring effects on family participation, transfer to daily routines, and FQoL[10-13,20-24].

It would also be relevant to incorporate the perspective of professionals (early childhood intervention teams and other resources) to gain a more precise understanding of the barriers and facilitators affecting the implementation of high-quality FCP in everyday practice. This approach would allow the identification of factors such as time constraints and workload, type of initial and ongoing training, availability of supervision and support, and organizational culture (service expectations, institutional priorities, leadership style) that influence the adoption of participatory and routine-based practices.

Similarly, exploring interprofessional and interinstitutional coordination (healthcare-education-social services), referral pathways and continuity of care, and conditions for providing support in natural environments (e.g., flexible schedules, logistical resources, professional-to-family ratios) would provide key information on what hinders or facilitates the transfer of interventions to daily life. Integrating these professional perspectives with those of families would support the design of more realistic and sustainable implementation strategies (e.g., coaching-focused training programs, organizational adjustments to protect time for joint planning, fidelity assessment tools, and supervision models) aimed at reducing the gap between recommended FCA practices and those delivered. Moreover, this approach would allow the comparison of family and professional perceptions, identifying shared critical points and specific areas for improvement to strengthen service quality[5,10-12].

CONCLUSION

Spanish families describe that the impact of EI on their well-being does not depend solely on receiving the service, but on the extent to which professional practices align with the FCA, particularly through genuine participation, functional guidance, and support for transferring strategies to daily life. When these conditions are met, greater experiences of parental empowerment and confidence emerge, with perceived positive effects on well-being and FQoL[17-22]. Conversely, when these conditions are lacking, limits to empowerment and insecurity in daily life are reported. Incorporating family-level indicators such as FQoL and caregiver burden/stress can strengthen quality assessment and guide improvements in the implementation of FCP in EI in Spain[6-9,13,23,24,27].