Remote Delivery of Culturally Adapted Prevent-Teach-Reinforce      

for Families (PRT-F) Program with Chinese American Families of Young    

Children with Intellectual and Developmental Disability   

by 

Jinlan Zhu 

A dissertation accepted and approved in partial fulfillment of the 

requirements for the degree of  

Doctor of Philosophy 

in Special Education 

Dissertation Committee:  

Wendy Machalicek, Chair & Advisor 

Stephanie Shire, Core Member  

Kimberly Marshall, Core Member  

Megan Kunze, Core Member  

Zhuo Jing-Schmidt, Institutional Representative 

University of Oregon 

Summer 2024 



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

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© 2024 Jinlan Zhu 



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

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DISSERTATION ABSTRACT 

Jinlan Zhu 

Doctor of Philosophy in Special Education 

Title: Remote Delivery of Culturally Adapted Prevent-Teach-Reinforce for Families (PRT-F) 
Program with Chinese American Families of Young Children with Intellectual and 
Developmental Disability 

The prevalence of challenging behavior, such as aggression, self-injurious behavior, 

tantrums, and noncompliance with everyday expectations among young children with intellectual 

and developmental disability (IDD), is higher than the prevalence of challenging behavior for 

children without disabilities. Without appropriate intervention, challenging behavior tends to 

persist in individuals with IDD, contributing to subsequent problems in school, home, and 

community life, as well as negatively impacting future independence. Parent education and 

training programs focused on supporting parents of children with IDD to learn and use evidence-

based behavioral interventions with their child contribute to improved parent strategy use and 

increased confidence in supporting their child’s behavior and ultimately support decreased child 

challenging behavior and increased appropriate adaptive behavior. Prevent, Teach, and Reinforce 

for Families (PTR-F) is a manualized and evidence-based positive behavior support program, 

including parent education and training to assist families in resolving their children’s mild to 

moderate severity challenging behavior in home and community settings. Few studies have 

empirically examined the effectiveness of PTR-F or other positive behavior support parenting 

programs for culturally diverse families of children with disabilities. The current study examined 

the efficacy and social validity of a culturally adapted and telepractice version of the PTR-F for 

Chinese American families of young children with IDD in the United States. The PTR-F 

intervention program was culturally adapted for enhanced cultural responsivity to Chinese 



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American families using Bernal’s Ecological Validity Model as a guiding framework and 

delivered remotely for improved feasibility in recruitment for the planned single-case research 

design study and enhanced scalability in future research. Six mothers and their children with 

autism spectrum disorder (ASD) participated. Two independent randomized concurrent multiple 

baseline designs across six parent-child dyads were used to examine the effects of the culturally 

adapted PTR-F intervention program when delivered by mothers on the decreased rate of target 

child challenging behavior. Two randomization strategies, case randomization and intervention 

start-point randomization, were used in this study. Each dyad was randomly to different baseline 

lengths ,and range-bound start point randomization was used to a priori determine the length of 

the baseline phase for each participant while retaining the logic of the staggered introduction of 

the intervention over time across parent-child dyads. Visual analysis combined with the non-

parametric Tau-U and parametric magnitude of treatment effect size standardized mean 

difference analysis, revealed mixed results with a medium effect found for child challenging 

behavior in the first concurrent multiple baseline design group and small effects found in the 

second group. Parent perceptions of the acceptability, feasibility and effectiveness of the 

culturally adapted PTR-F intervention program’s goals, procedures, and outcomes were collected 

using standardized social validity questionnaires with the addition of open-ended responses and 

reported using descriptive statistics and parent responses to open-ended questions. Chinese 

American families of children with developmental disabilities including ASD are absent in the 

intervention literature. This novel examination of the effects of a culturally adapted family 

centered intervention on child challenging behavior suggests the promise of a culturally adapted 

PTR-F for Chinese American families to address their child’s challenging behavior. Implications 

for future research and practice are discussed. 



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TABLE OF CONTENTS 

DISSERTATION ABSTRACT ...................................................................................................... 3 

LIST OF FIGURES ...................................................................................................................... 10 

LIST OF TABLES ........................................................................................................................ 11 

CHAPTER I INTRODUCTION ................................................................................................... 12 

Prevalence and impact of challenging behavior for children with IDD ................................... 12 

Evidence based practices to address challenging behavior ....................................................... 14 

Behavioral parent training to prevent and address challenging behavior ................................. 17 

Remote parent training to support parent mediated behavioral interventions for challenging 

behavior ..................................................................................................................................... 18 

Chinese American families and the need for culturally adapted parent mediated interventions 

to prevent and address challenging behavior ............................................................................ 20 

Conceptual logic model for the proposed study ....................................................................... 21 

CHAPTER II LITERATURE REVIEW ...................................................................................... 24 

The history of Chinese American immigrants in the United States .......................................... 24 

Chinese American families’ perceptions for individuals with intellectual and developmental 

disability .................................................................................................................................... 26 

Evidence-based parent-training for Chinese American families with intellectual and 

developmental disability ........................................................................................................... 27 

Cultural adaptation research of parent training for Chinese American immigrant group ........ 30 



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Prevent-Teach-Reinforce for families (PTR-F) ........................................................................ 33 

Research purpose ...................................................................................................................... 38 

Research questions .................................................................................................................... 39 

CHAPTER III METHOD ............................................................................................................. 40 

Participants and Setting ............................................................................................................. 40 

Participants ............................................................................................................................ 40 

Setting ................................................................................................................................... 53 

Interventionist and setting ......................................................................................................... 54 

Materials ................................................................................................................................... 54 

Equipment ............................................................................................................................. 54 

Software ................................................................................................................................ 55 

Other materials ...................................................................................................................... 56 

Experimental design .................................................................................................................. 56 

Culturally adapted prevent-teach-reinforce for families (PTR-F) program .............................. 57 

Language ............................................................................................................................... 58 

Person .................................................................................................................................... 58 

Metaphors ............................................................................................................................. 60 

Content and concepts ............................................................................................................ 61 

Goals ..................................................................................................................................... 67 

Methods................................................................................................................................. 68 

Context .................................................................................................................................. 68 



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Procedures ................................................................................................................................. 71 

Phase I: Pre-assessment and baseline ................................................................................... 72 

Phase II: BSP Development .................................................................................................. 96 

Phase III: Parent education and training ............................................................................... 99 

Phase IV: BSP implementation and performance feedback ............................................... 103 

Phase V: Post-assessment and data collection .................................................................... 104 

Data analysis ........................................................................................................................... 110 

CHAPTER IV RESULTS ........................................................................................................... 112 

Visual analysis ........................................................................................................................ 112 

Parents’ fidelity to implementation of BSP ........................................................................ 112 

Children’s challenging behavior ......................................................................................... 114 

Tau-U results for each participant data set ............................................................................. 119 

First MBD group ................................................................................................................. 119 

Second MBD group ............................................................................................................ 120 

Standardized mean difference analysis ................................................................................... 121 

Non-experimental results ........................................................................................................ 121 

Child-PFA ........................................................................................................................... 121 

CDQ .................................................................................................................................... 123 

Social validity ..................................................................................................................... 125 

Families' satisfaction with the virtual training program. .................................................... 127 

CHAPTER V DISCUSSION ...................................................................................................... 128 



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Summary and interpretation of results .................................................................................... 128 

Experimental research questions ......................................................................................... 128 

Non-experimental research questions ................................................................................. 131 

Limitations .............................................................................................................................. 134 

Implication for science ............................................................................................................ 137 

Implications for practice ......................................................................................................... 139 

Concluding remarks ................................................................................................................ 141 

Appendix A Routine Based Inventory (McZhiweis, 2003) ........................................................ 143 

Appendix B Child Behavior Checklist for Age 1.5-5 ................................................................. 148 

Appendix C Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA) ........................... 153 

Appendix D Child-PFA Questionnaire ....................................................................................... 157 

Appendix E Confidence degree questions for families ............................................................... 162 

Appendix F A-B-C data collection form .................................................................................... 163 

Appendix G PTR-F Procedural Documents: Jie and his Family ................................................ 165 

Appendix H PTR-F Procedural Documents: Yifan and his Family ........................................... 179 

Appendix I PTR-F Procedural Documents: Zhiwei and his Family ........................................... 195 

Appendix J PTR-F Procedural Documents: Linlin and her Family ............................................ 208 

Appendix K PTR-F Procedural Documents: Xiaoxie and his Family ........................................ 222 

Appendix L PTR-F Procedural Documents: Meisheng and his Family ..................................... 236 



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Appendix M Example Data Collection Sheet for Child Participant ........................................... 249 

Appendix N Training Fidelity Checklist ..................................................................................... 250 

Appendix O Coaching Fidelity Checklist ................................................................................... 251 

Appendix P Social Validity Questionnaire ................................................................................. 252 

Appendix Q Families' satisfaction with the virtual-training program ........................................ 254 

Reference .................................................................................................................................... 255 

 

 

 

 

 

 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 



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LIST OF FIGURES 

Figure 1 Conceptual model of this study ...................................................................................... 22 

Figure 2 Flow Chart of Procedures and Duration. ........................................................................ 71 

Figure 3 Group 1 BSP Implementation Fidelity Scores for each participated parent ................ 113 

Figure 4 Group 2 BSP Implementation Fidelity Scores for each participated parent ................ 114 

Figure 5 The relation between parents’ fidelity to the implementation of BSP strategies and 

children’s challenging behavior in the first MBD group ............................................................ 117 

Figure 6 The relation between parents’ fidelity to the implementation of BSP strategies and 

children’s challenging behavior in the second MBD group ....................................................... 118 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 



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LIST OF TABLES 

Table 1 Overview of the contextual variables influencing intervention development for Chinese 

American families in the United States. ....................................................................................... 23 

Table 2 Child Demographic Information ...................................................................................... 46 

Table 3 Parent Demographic Information .................................................................................... 47 

Table 4 Child Behavior Checklist for Ages 1.5-5 results for each participant ............................. 49 

Table 5 The detailed results of participated parents’ SL-ASIA .................................................... 52 

Table 6 Interview questions were used to explore parents’ experience of their children’s 

diagnosis process and their family’s perceptions about their child’s disabilities and challenging 

behavior ......................................................................................................................................... 61 

Table 7 Cultural adaptation summary for PTR-F for Chinese immigrant family ......................... 70 

Table 8 Participated children’s reinforcer information summary ................................................. 75 

Table 9 Targeted Family Routine Information ............................................................................. 81 

Table 10 Evidence-based strategies from the PTR-F manual for BSP ......................................... 97 

Table 11 Strategies on the Behavioral Support Plan .................................................................... 98 

Table 12 IOA data of challenging behavior for each participant in each phase ......................... 109 

Table 13 Tau-U results for each participant in the first MBD group .......................................... 119 

Table 14 Tau-U results for each participant in second MBD group ........................................... 120 

Table 15 Pre-test child participation results in family activities ................................................. 122 

Table 16 Parental confidence degree questions result summary ................................................ 124 

Table 17 Social Validity Ratings Across Families ..................................................................... 125 

Table 18 Families' satisfaction with the virtual training program .............................................. 127 



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CHAPTER I  

INTRODUCTION 

This chapter provides a comprehensive problem statement that identifies the core issues 

to be addressed within the research and introduces the purpose of the current study and the 

research questions. The problem statement starts with the introduction of the prevalence and 

impact of challenging behavior for young children with intellectual and developmental 

disabilities (IDD). Next, the procedures and outcomes of common evidence-based practices 

(EBPs) used by professionals to address challenging behavior for children with IDD will be 

summarized. Third, a brief overview of the research on parent training to support caregiver 

implementation of EBPs to prevent and address challenging behavior for children with IDD will 

be provided. Finally, the unique needs of Chinese American families and the need for culturally 

responsive caregiver mediated interventions to prevent and address challenging behavior will be 

discussed. This chapter will conclude with a summary of a conceptual logic model. 

Prevalence and impact of challenging behavior for children with IDD 

The term “challenging behavior” initially promoted in North America by TASH 

(formally known as The Association for People with Severe Handicaps), has come to replace a 

number of related terms including abnormal, aberrant, disordered, disturbed, dysfunctional, 

maladaptive, and problem behavior (Emerson & Einfeld, 2011). In addition to an intellectual 

quotient below 70 and support needs in two or more domains of adaptive behavior, individuals 

with IDD are at increased risk for co-occurring challenging behavior (Lowe et al., 2007; Poppes 

et al., 2010). The prevalence of challenging behavior such as self-injurious behavior (e.g., head 

banging, hand biting), aggression (e.g., kicking, hitting, biting), elopement or wandering, pica, 

and other disruptive behavior occurs at a higher rate among children with IDD than their peers 



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without disabilities (Ali et al., 2014; Dekker et al., 2002; Emerson et al., 2014; Kurtz et al., 2020; 

O’Regan et al., 2022). Estimates vary, but approximately 50% of individuals with IDD 

experience some form of challenging behavior, with a smaller proportion (5 – 10%) exhibiting 

severe challenging behavior (Kurtz et al., 2020) with serious consequences for the individual and 

their families and other caregivers.  

Challenging behavior is more common among children with IDD with a co-occurring 

diagnosis of autism spectrum disorder (ASD, Dekker et al., 2002; Emerson et al., 2001; Farmer 

& Aman, 2011; Kurtz et al., 2020; Lundqvist, 2013). Simo-Pinatella et al. (2019) performed a 

systematic review and selected 20 studies to document the prevalence of challenging behavior 

among school-aged children with disabilities. Higher challenging behavior prevalence scores 

were reported for participants with ASD (94% of 84 children, Jang et al. 2011) and with ASD 

and ID (93.7% of 174 children, McTiernan et al. 2011). Without appropriate intervention, 

challenging behavior tend to persist in individuals with IDD, leading to subsequent problems in 

the quality of family life, school adjustment and success, and educational and vocational success 

as well as poorer outcomes related to independent living in adolescence and adulthood (Dunlap 

et al., 2006; Gavaldá & Qinyi, 2012; Green et al., 2005; Lory et al., 2020).  

The family acts as the key support for the child with IDD, in many cases well into 

adulthood (Boehm et al., 2015; McCausland & O’Donovan, 2023). As such, challenging 

behavior among children with IDD has an impact on their own development but also on their 

family’s quality of life. Having a child with IDD who engages in challenging behavior is 

conceptualized as a risk factor in terms of worsened family well-being, as additional stressors are 

placed on family relationships (i.e., among spouse, parent–child, and sibling interactions), as 

well as increased caregiving burden via expanded family member’s roles and responsibilities 



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(Gardiner & Iarocci, 2012; Gau et al., 2012; Petalas et al., 2012). Over the last several decades, a 

significant amount of research has been conducted to demonstrate that parents raising a child 

with IDD experience higher levels of parenting stress, financial burden, poorer mental health, 

parent well-being and quality of family life compared to other parents (Hsiao, 2018; Neece et al., 

2012; Siu & Hui, 2021; Woodman et al., 2015). Children’s challenging behavior have often been 

selected as a critical contributor for each of these negative impacts (Hsiao, 2018; Neece et al., 

2012; Siu & Hui, 2021; Woodman et al., 2015). Challenging behavior is often experienced by 

the family members as unpredictable, emotionally intense, and these types of behavior present 

physical, instructional, and/or social concerns for parents. Similarly, parental stress can 

negatively impact on the parent– child relationship and in turn can impact on the child’s behavior 

(Neece et al., 2012). For example, Staunton et al. (2023) conducted a quantitative study utilizing 

questionnaires to assess parental stress among 32 parents in families of children with disabilities 

in Ireland. They found a strong correlation between the level of parental stress and challenging 

behavior for children with IDD. Often, when families present to behavioral health or educational 

services to address concerns about their child’s challenging behavior, these behaviors have been 

occurring over a long period of time, occur at high frequency and/or intensity, and are difficult to 

modify due to the learning history and social contingencies maintaining the challenging behavior 

(Dunlap & Carr, 2007; Ogundele, 2018). Therefore, early intervention is crucial to address the 

reduction of challenging behavior in children with IDD in family home and community settings 

to improve the quality of family life.  

Evidence based practices to address challenging behavior  

Applied behavior analysis (ABA) and multi-tiered systems of support frameworks such 

as positive behavior supports (PBS) are commonly used and conceptually congruent and 



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systematic assessment and intervention models addressing and reducing challenging behavior. 

ABA is a broad, scientific discipline in which basic principles of human learning and behavior 

are used to design more effective environments to produce socially meaningful changes in a 

person’s behavior. It involves the application of behavioral principles to systematically analyze 

the motivating operations, antecedents and consequences contributing to the development of and 

maintenance of both appropriate and challenging behavior and the design of interventions that 

capitalize on the knowledge of these basic principles to effectively change behavior. Almost 50 

years of ABA research has demonstrated that non-aversive, reinforcement-based procedures can 

be used to prevent and decrease the occurrence of challenging behavior if one can successfully 

determine the function of the behavior (i.e., why it occurs) and create interventions that address 

the function(s) (e.g., Carr, 1977; Carr & Durand, 1985; Horner et al., 1990; Schieltz & Berg, 

2021; Sugai & Simonsen, 2020). Interventions utilize procedures such as motivating operation 

manipulations, stimulus control, stimulus control transfer and inhibitory control procedures, 

positive and negative reinforcement procedures, prompting hierarchies, shaping, and fading to 

promote behavior change (Cooper et al., 2020; Machalicek et al., 2021). Makrygianni et al. 

(2018) conducted a meta-analytic study of 29 studies spanning from 1987 to 2015, encompassing 

seven different countries to evaluate the effectiveness of ABA interventions for children with 

ASD. The results showed that ABA programs were very effective in improving child intellectual 

abilities; were moderately to very effective in improving the communication skills and 

expressive and receptive language skills of children; were moderately effective in improving IQ 

scores obtained by non-verbal tests, adaptive behavior, socialization, and receptive language 

skills, as well as improving daily living skills although the effectiveness is relatively lower than 

other domains. 



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MTSS such as school wide PBS include arrays of evidence-based strategies organized 

along a continuum, with low-cost, low-intensity strategies used at the foundational or universal 

level, and more expensive and more time intensive strategies deployed as needed at higher levels 

of the continuum (Tiers 2 and 3; Sugai & Horner, 2020). MTSS frameworks addressing 

challenging behavior include three levels: 1) universal strategies designed to promote desirable 

behavior for all members of a designated population (such as students on a school campus), 2) 

secondary strategies intended for a smaller proportion of the population that might be at higher 

risk, and 3) tertiary strategies, which are the most intensive and individualized practices, 

intended only for students whose challenging behavior have been non-responsive to Tiers 1 and 

2 and/or who exhibit mild to moderate levels of challenging behavior. Research indicates MTSS 

can prevent challenging behavior and academic deficits from worsening and ensure that students, 

including those in grades preschool through 12th with the most intensive needs receive the most 

appropriate supports (Nitz et al., 2023; Shepley & Grisham-Brown, 2019; Van Camp et al., 

2020). Shepley and Grisham-Brown (2019) reviewed 16 studies to examine the effects of MTSS 

in preschool settings, they found tiered support systems targeting social–emotional development 

was most successful. Nitz et al. (2023) also conducted a literature review to provide an overview 

of MTSS quality, outcomes, and characteristics in elementary education research. They included 

40 international studies published between 2004 and 2020, revealing that MTSS is effective in 

elementary schools internationally, notably in facilitating behavior change. 

ABA primarily targets behavior changing and modification, whereas multi-tiered 

frameworks emphasize a proactive and preventive approach at the population level by providing 

support at different levels of intensity based on students' needs, which takes a more 

comprehensive approach. Over the past five decades, researchers have integrated ABA principles 



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and strategies into multi-tiered frameworks to develop different approaches to address different 

setting, such as Positive Behavior Interventions and Supports (PBIS; Dunlap & Carr, 2007; 

Sugai et al., 2000), schoolwide positive behavior support (SWPBS; Sailor et al., 2009; Sugai & 

Horner, 2006; see www.pbis.org),  family-centered PBIS (Lucyshyn et al., 2018), and program-

wide positive behavior support (PWPBS; Dunlap et al., 2014). Additionally, according to the 

Individuals with Disabilities Education Act (IDEA), when a child with an identified disability 

has persistent challenging behavior that interfere with their learning or that of their peers or 

results in a change of educational placement that totals more than 10 days, a multidisciplinary 

team must conduct a functional behavior assessment (FBA) and implement an individualized 

behavior intervention plan (IDEA, 2004).  

Behavioral parent training to prevent and address challenging behavior  

For young children with IDD who engage in challenging behavior, family members and 

other caregivers (e.g., childcare providers) play an important role in prevention and treatment 

(Binnendyk & Lucyshyn, 2009; Dunlap & Fox, 2007; Dunlap et al. 2001; McIntyre & Brown, 

2013; Salomone et al., 2019; Tournier et al., 2021; Vargas Londono et al., 2023) as the child 

spends the majority of their time with these caregivers in family home and early childhood care 

settings. Children and adults with IDD who have extensive support needs require the assistance 

of interdisciplinary professionals and often parents and other caregivers to support their full 

development across adaptive behavior domains. Scholarship has emphasized the crucial role of 

parental involvement in enhancing the effectiveness of behavioral interventions for children with 

IDD. For example, parent involvement in ABA based training facilitates long-term management 

of challenging behavior and maintenance of improvements in functional communication and 

other adaptive behavior (e.g., Fettig & Barton, 2014; Fettig et al., 2015; Fisher et al., 2020; 



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Gerow et al., 2023; Musetti et al., 2021; Pennefather et al., 2018; Yakubova & Chen, 2023). In 

addition, parental involvement in behavioral support services can have positive impacts on 

parents’ mental health and well-being (e.g., Crnic et al., 2017; Hoyle et al., 2021; Hsiao, 2018; 

Tournier et al., 2021).  

However, Durand (2021) emphasized that the most significant predictor of later behavior 

problems in children was not the severity of the child's initial issues or cognitive deficits, but 

rather the level of parental optimism or pessimism regarding their capability to shape their child's 

behavior. In other words, parents with lower confidence in their ability to influence their child’s 

behavior were more likely to have children with more severe behavioral problems later in life. 

Thus, developing a comprehensive parent training program tailored to the unique needs of 

families with children with IDD is paramount. Such a program should aim not only to equip 

parents with effective strategies for managing challenging behavior but also aim to bolster their 

confidence and belief in their ability to enact meaningful change in their child's behavior. 

Remote parent training to support parent mediated behavioral interventions for 

challenging behavior  

Although EBPs prevent and address challenging behavior for children with IDD, many 

families and children with IDD cannot access it due to geographic location, economic reasons, 

travel or childcare barriers, and some other barriers including specialist shortage, especially 

minority children and families who are doubly impacted by specialist shortages of bilingual and 

bicultural parent coaches (Antezana et al., 2017; Havercamp & Bonardi, 2022; Xu et al., 2022). 

Telepractice is a promising and efficacious service delivery mechanism for remotely coaching 

caregivers through assessment and intervention for children with IDD who engage in challenging 

behavior in their homes which has been demonstrated across research teams and participants 



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(e.g., Dimian et al. 2018; Lindgren et al. 2020; Simacek et al., 2017; Sump et al. 2018; Wacker et 

al. 2013).  

Telepractice services have played a crucial role in supporting children with IDD during 

the COVID-19 pandemic to reduce the risks of transmitting the virus from therapist to patient or 

vice versa (Biggs et al., 2022; Bundy et al., 2023; Fisher et al., 2020; Gerow et al., 2023; Larsen 

et al., 2023; Ogourtsova et al., 2023). However, since before the COVID-19 pandemic, research 

has demonstrated that specialists can effectively use telecommunication technology (SMS text 

messages, laptops, tablets, smartphones) to deliver time intensive performance feedback to 

parents and teachers implementing behavioral assessments and interventions addressing 

challenging behavior and social communication with children with autism and other IDD (e.g., 

Carnett et al., 2021; Knowles et al., 2017; Kunze et al., 2021; Machalicek et al., 2016; McDuffie 

et al. 2013; Machalicek et al., 2009a; Machalicek et al., 2009b; Machalicek et al., 2010; 

McDuffie et al., 2016a; McDuffie et al., 2016b). For example, Kunze et al. (2021) conducted a 

single-case experimental design study to examine the effectiveness of a 12-week parent-

mediated early intervention program delivered through telehealth for six mother–child dyads. 

The study focused on six toddlers, aged between 21 and 35 months, who were at risk for ASD. 

Four evidence-based ABA strategies were included in the parent-mediated early intervention 

package, namely modeling, prompting, reinforcement of appropriate behavior, and response 

interruption and redirection. The results showed that the parent-mediated play-based package 

increased the frequency of targeted parent strategy utilization. Additionally, there was an 

increase in child flexible behavior, accompanied by a decrease in child inflexible behavior, 

specifically in terms of higher-order restrictive and repetitive behavior and interests, observed 

during parent-child play. Telehealth technologies provide cost savings, efficient and timely 



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service delivery and improved access to care, allowing for widespread dissemination of EBPs 

(Snoswell et al., 2020; Sumarsono et al., 2023), which is an essential consideration when 

developing interventions for underserved populations such as Chinese American families of 

children with IDD.  

Chinese American families and the need for culturally adapted parent mediated 

interventions to prevent and address challenging behavior 

Improving access to EBP to prevent and address challenging behavior for non-dominant 

culture families is essential because the United States is a growing multilingual and multicultural 

country. At roughly 20 million people, Asian Americans are the third significant minority and 

the fastest growing racial group in the US, making up about 6% of the total population (US 

Census Bureau, 2021). Chinese Americans comprise the largest subgroup of a heterogeneous 

community of Asian Americans and Pacific Islanders (AAPI) (Pew Research Center, 2021). 

Chinese American families of their children with IDD face a number of unique barriers to 

utilization of evidence-based services to address their child’s developmental, educational, 

behavioral, and medical needs. These factors mainly include historical and current racism, 

xenophobia and related federal policies affecting Chinese Americans and other Asian Americans 

in the U.S. (“Chinese Exclusion Act”, 2022; Farivar, 2021; Gover et al., 2020), language (AI 

Shamsi et al., 2020; Castro-Hostetler et al., 2021; Chen et al., 2022), low health literacy (Chen et 

al., 2021; Kreps et al., 2020), unique cultural influences impacting family perceptions about 

children with IDD(Chen et al., 2021), structural barriers (Ruiz et al., 2022), and acculturation 

(Chen, 2005; Lee, 1996; Yu et al., 2016). Owing to the barriers, minority children and families 

prefer to seek service providers who share their cultural background to overcome these obstacles 

and receive more culturally sensitive and empathetic care. According to the 2023 data of total 



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Behavior Analyst Certification Board (BACB) certifications for race or ethnicity in the United 

States, White certificants comprise the largest group at 52.76%, followed by Hispanic/Latinx at 

21.39%, Black at 10.93%, and Asian at 7.07%. However, there is no specific data on the number 

of Chinese or Chinese American background behavior analysts or other behavioral health service 

providers who can provide behavioral parent training to Chinese American groups in the United 

States. There is an urgent need to develop a culturally tailored and scalable caregiver-mediated 

intervention to Chinese American families to support their acquisition and effective use of 

research-based strategies to prevent and address their children’s challenging behavior at home 

and in the community. 

Conceptual logic model for the proposed study 

Figure 1 below illustrates an overview of the conceptual model for the proposed study. In 

the model, it is hypothesized that contextual variables such as parent background, children’s 

characteristics, professional’s background, family dynamic and barriers experienced in 

successful access to service and resource to address their child’s challenging behavior and other 

support needs will impact the culturally adapted behavioral parent training telehealth 

intervention will affect the outcome variables of interest including an increase in level of parent 

use of strategies, a concomitant decrease in level of child target challenging behavior and 

increase in level of child target adaptive behavior with subsequent decreased parenting stress, 

and increased parental confidence and child participation in the desired family routines. The 

following table shows more specific detail of the model. 

 
 
 
 
 



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Figure 1 Conceptual model of this study 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 

 
 

Table 1 provides more detail regarding the known contextual variables influencing 

intervention development for Chinese American families in the United States including a) parent 

background, b) child characteristics, c) service providers’ background, d) family dynamic, and e) 

barriers to access of appropriate service and resources.  These culturally unique influences 

impact Chinese American parents’ help seeking behavior, timely access to research-based 

interventions meeting their family’s needs, and utilization of capacity building interventions to 

support their child’s development.  Chinese American parents of children with IDD also 

understand and make meaning of their child’s disability and challenging behavior through their 

culturally bound worldview, experiences of acculturation, and other personal characteristics. The 

sociopolitical context in the United States and available services and supports in the present 

Contextual variables

• Parent background
• Child characteristics
• Service providers’ 

background 
• Family dynamic
• Unique barriers of access 

to service and resources 
for Chinese American 
families

Independent variables

• Culturally adapted PTR-F 
behavioral parent training 
program delivered to 
individual families

• Telepractice delivery of 
culturally adapted PTR-F 
program

Outcome variables

• Parent fidelity of 
implementation of BSP 
strategies

• Decreased child target 
challenging behavior and 
increased target adaptive 
behavior

• Child participation in family 
routines

• Parental confidence
• Social validity

Theoretical orientations and interventions contributing to the culturally adapted intervention 
1. ABA (Cooper et al. 2020): functional analysis of the relations between 

environment and behavior, 
2. PBS (Dunlap, 2006): multi-tiered systems of support emphasize a proactive 

and preventive approach by providing support at different levels of intensity, 
include contributions from ABA, self-determination, lifestyle change 

3. Social learning theory (Bandura, 1986, 2001): parent’s experiences shape their 
self-efficacy and confidence, 

4. Ecological Systems Theory (Bronfenbrenner, 1979): human development is 
influenced by multiple interacting systems including the family unit, 

5. Cultural responsiveness/ awareness (Lynch & Hanson, 2004). 



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

 23 

moment also directly impact parent’s navigation of educational, health, and other services for 

their child and family. 

Table 1 Overview of the contextual variables influencing intervention development for Chinese 
American families in the United States. 

Contextual variable 

Parent background Education level 

Employment status 

Prior knowledge/training experience on challenging behavior and ABA/PBIS 

Past experience with professionals 

Perceptions about disabilities and challenging behavior, parent-mediated interventions and their 
role/responsibility in intervention 
Acculturation level 

Children’s characteristics The severity of disabilities 

The severity, topography, and frequency of challenging behavior 

The duration at home (Homeschool? Go to school/clinic half day and half day at home? Or go to school 
the whole day?) 

Service providers’ background  Ethnic/cultural background 

Professional background in ABA (Prior coursework or training in ABA) 

Prior professional experience of family-based interventions/parent training 

Prior training/working experience of working with diversity family  

Family dynamic Family structure  

Family relationship (grandparents, father and siblings) 

Family engagement 

Chinese American family unique 
barriers of accessing to service and 
resources 

Racism, xenophobia, and politics in the U.S. 

Structural barriers  

Heritage language 

Low Health Literacy 

Cultural influences: (a) Long and deep influence of Confucianism, Taoism and Buddhism, (b) Parenting 
style/belief, (c) Familism/Collectivism, (d) Short history of developmental disability in China, (e) 
Acculturation. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 



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 24 

CHAPTER II  

LITERATURE REVIEW 

This chapter presents a comprehensive examination of various facets related to Chinese 

American immigrants in the United States, particularly focusing on their familial perceptions 

towards individuals with IDD and the efficacy of evidence-based parent-training interventions 

tailored for this demographic. Understanding the historical trajectory of Chinese immigration to 

the United States provides essential context for comprehending the socio-cultural dynamics 

influencing familial attitudes and behavior towards IDD within this community. Additionally, 

this review delves into the current landscape of research on cultural adaptation research of parent 

training for Chinese American immigrant group and Prevent-Teach-Reinforce for Families 

(PTR-F). Through synthesizing these diverse strands of literature, this chapter explores cultural 

adaptations of the PTR-F model for Chinese American families with IDD. This chapter will 

conclude with a summary of a statement of purpose and research questions of the proposed 

empirical investigation. 

The history of Chinese American immigrants in the United States 

 Asian Americans are currently the fastest-growing major racial or ethnic group in the 

United States and the Chinese American (including both foreign-born and United States-born) 

community is the largest ethnic group among Asian Americans (U.S. Bureau of Census, 2022). 

The earliest groups of Chinese American immigrants migrated to the United States during the 

California gold rush in the 1850s, often as construction workers to help build railroads and to 

construct other parts of the physical infrastructure of the rapidly developing West coast (Chen et 

al., 2022; Office of the Historian, 2021; Voss, 2018). These early Chinese immigrants were 

primarily men who worked long hours of back-breaking work as laborers, often in very poor 



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

 25 

work and living conditions, and for minimal pay, while leaving most of their families back in 

China (Office of the Historian, 2021). Although Chinese immigrant laborers worked under harsh 

conditions, they faced intense discrimination and violence from white Americans, who saw them 

as a threat to their jobs and way of life. The Chinese Exclusion Act of 1882, which was the first 

federal law to restrict immigration based on nationality, specifically targeted Chinese immigrants 

and effectively banned them from coming to the United States for more than 60 years (Chinese 

Exclusion Act, 2022). During this time, Chinese Americans who were already living in the 

United States faced ongoing discrimination, including declining wages, segregation, violence, 

and economic exclusion. They often lived in Chinatowns, isolated from the broader American 

society. 

Many of these early Chinese American laborers were able to bring some members of 

their families to the United States once they had earned adequate funds to repatriate with them 

(Chen, 2019). The newer Chinese American arrivals often found work as house servants with 

responsibilities including cooking, cleaning, and taking care of children, adding a more 

domesticated employment path to the established construction laborer vocation for arriving 

Chinese Americans. Importantly, these Chinese American immigrants were often quite 

industrious, thrifty, and entrepreneurial people who eventually began to start their own 

businesses, stores, and restaurants in America (Zhou & Liu, 2017). Over the past five decades, 

there have been increasing numbers of well-educated professionals among Chinese immigrants 

to the United States, reflecting a high priority for educational attainment among members of this 

cultural group (Hooper & Batalova, 2015). 

Chinese immigration to the United States has continued to increase in recent decades, 

with new immigrants coming for various reasons, including education and employment 



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

 26 

opportunities. Chinese Americans comprise the largest subgroup of a heterogeneous community 

of Asian Americans and Pacific Islanders (AAPI) (Budiman et al., 2019). According to the Pew 

Research Center analysis of US Census Bureau population estimates, there were 5.4 million 

Chinese living in the United States and Chinese Americans were the fastest growing immigrant 

population living in the United States in 2019 (Budiman, 2021). Despite large numbers of 

Chinese in the United States for many generations, the history of research on Chinese American 

with IDD in comparison to other ethnic groups has been relatively short. It was not until the 

1980s and 1990s that the attention of some researchers included Asian/Pacific Islander persons 

with disabilities (Cheng, 1990).  

Chinese American families’ perceptions for individuals with intellectual and developmental 

disability 

Some studies have investigated the attitudes of Asian Americans broadly towards 

individuals with IDD (e.g., Choi & Ostendorf, 2015; Cooc & Yang, 2017; Huer et al., 2001; Kim 

et al, 2021; Kim et al, 2023; Lee & Koo, 2022; Mcguire et al., 2022; Nguyen & Hughes, 2013; 

Truong et al., 2023; Yan et al., 2017). However, a paucity of studies exist that focus more 

specifically on the perceptions towards persons with IDD reported by Chinese Americans 

specifically (Chiang & Hadadian, 2007; Parette et al., 2004; Wang & West, 2016). This finding 

is problematic as all Asians do not have the same cultural practices, and the characteristics and 

attitudes of one cultural group cannot necessarily be generalized to others (Huang, 1993; Parette 

et al., 2004). The differences in families' values and beliefs and the uniqueness of each Asian 

ethnic group provide a compelling reason to attempt to better understand Chinese American 

families’ perceptions for individuals with IDD.  

According to Chiang and Hadadian (2007), it is a common perception that many Asian 



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

 27 

American families hold negative attitudes toward their children with disabilities. However, 

Parette et al. (2004) indicated that first generation Chinese American families tended to reveal 

positive attitudes regarding their children's disabilities. Despite encountering significant 

challenges in raising their children, these Chinese American families maintained the faith that 

their children would continue to improve because of the rich educational and community 

resources available for children and parents in the United States, and the legal protections 

provided by the federally funded special education system in the United States. These two 

factors gave the families security and hope regarding their children’s disabilities. Also, it was 

interesting that in all the years that they had resided in the United States, these family members 

never saw disability as a source of shame although the concept of "face" (maintaining dignity 

and honor) is important in Chinese culture (Ho, 1976). Parette et al. (2004) suggested that this 

phenomenon can be attributed to two key factors. First, in each of these families, at least one 

parent had received higher education from American institutions. This educational background 

not only enhanced their understanding of individuals with disabilities but also deepened their 

knowledge of the available societal resources and legislation in the United States. Second, these 

parents had resided in the United States for over a decade and had worked in professional fields. 

Their extensive experience in American life exposed them to individuals with disabilities in 

various social contexts, potentially contributing to their positive perspectives regarding their own 

children and became part of their acculturation process. 

Evidence-based parent-training for Chinese American families with intellectual and 

developmental disability 

Both Parette et al. (2014) and Chiang and Hadadian (2007) highlighted that Chinese 

Americans valued the early intervention and other educational programs received by their 



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

 28 

children with disabilities, regardless of whether these programs were provided through federally 

funded public educational agencies, health insurance or private pay outpatient clinics or in home 

services. Being the largest ethnic subgroup within the Asian American community, the number 

of Chinese American families affected by IDD may be the most commonly represented ethnic 

group among the various ethnic groups comprising the broader group Asian Americans. 

However, few intervention studies to date have specifically focused on Chinese American 

children with IDD (Chiang, 2014; Chiang & Hadadian, 2007; Xu et al., 2023).  

In December of 2023, the principal investigator ran a non-exhaustive search of peer-

reviewed journal articles published between 1997 and 2023 using the electronic databases 

Educational Resources Information Center (ERIC), PsycINFO, Medline, Education Research 

Complete and Social Sciences Premium Collection databases with the combined keywords 

“intellectual and developmental disability” OR “autism” AND  “Chinese American” OR 

“Chinese immigrants” only identified  two studies about family centered support service (i.e., 

Chiang, 2014; Qi et al., 2019). Chiang (2014) conducted a pilot study using a pre-test posttest 

group design to examine the effectiveness of a parent education program on decreasing parenting 

stress and increasing parental confidence and quality of life in Chinese American parents of 

children with ASD in New York. A total of nine families of Chinese American children with 

ASD participated in a 10-week parent education program (including 10 weekly 120-min group 

sessions). The findings of this study revealed that after receiving the program, parents of Chinese 

American children with ASDs showed significant reduction in parenting stress, improvement in 

parental confidence, and improvement in quality of life in physical health and environment 

domains. The parent education program covered topics tailored to parental interests, including 

understanding ASDs, special education, communication and social skills, behavior management, 



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

 29 

academics, and community resources. The program comprised lectures, group discussions, 

parent sharing, and information exchange. The program was led by the author, Chiang, a Chinese 

American with a doctoral degree in special education. Mandarin, Cantonese, and English 

languages were used in the program and these languages were indicated by the parents as the 

languages that they preferred this program to use.  

Similar to Chiang's (2014) study, Qi et al. (2019) undertook a pilot survey study to 

explore how modern online support groups can reduce the stress associated with parenting 

children with ASD. This survey study is not a typical training or treatment effectiveness study. 

Rather, this is an opinion survey study about the impact of an online social chat support group. 

Fifty-three Chinese American parents from the online chat group (e.g., WhatsApp, WeChat) 

responded to a 20-question online survey. The overall results of the pilot survey study 

demonstrated that the online support group was statistically positive in reducing the parental 

stress of Chinese American participants who had children with ASD. This mode of support can 

empower parents with valuable information to share and learn from each other. The pilot survey 

also showed that participants deeply appreciated the benefits of joining such a modern online 

support group and felt very comfortable with this mode of support. In conclusion, both these two 

studies only focused on reducing parents’ stress, neither study aimed to address and reduce 

challenging behavior of children with IDD.  

Even though most Chinese American parents accepted their children with disabilities, 

they have expressed difficulties in caring for them (Chiang & Hadadian, 2007; Parette et al., 

2004), which is common across parents of children with IDD who have extensive support needs. 

They also had difficulties in managing their children’s challenging behavior (Chiang & 

Hadadian, 2007). Surprisingly, there has been no research to date conducted with the aim of 



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

 30 

supporting Chinese American families or parents through parent education and coaching them 

with their child with IDD to prevent and address challenging behavior (Vargas Londono et al., 

2023). 

Cultural adaptation research of parent training for Chinese American immigrant group 

Chinese American families of their children with IDD face a number of unique barriers to 

utilization of evidence-based services to address their child’s developmental, educational, 

behavioral, and medical needs. These factors mainly include historical and current racism, 

xenophobia and related federal policies affecting Chinese Americans and other Asian Americans 

in the United States, language, low health literacy, unique cultural influences impacting family 

perceptions about children with IDD, structural barriers, and degree of acculturation. There are 

differences in degree of acculturation among Chinese immigrants from different parts of the 

world, between foreign-born and American-born Chinese Americans and among different 

generations. These various groups differ along many lines including education and degree of 

exposure to spoken English. Some speak no English, and others are bilingual or multilingual. 

The Pew Research Center (2021) reported that nearly two-third of the Chinese population (61%) 

only speak English at home. 93 percent United States-born Chinese reported speaking English at 

home, and more than half (56%) foreign-born Chinese reported speaking a language other than 

English at home.  

In the previous paragraph, I provided just a sampling of barriers that Chinese American 

families faced in accessing and utilizing services in the United States. Zhu and Machalicek’s 

(2023) unpublished concept paper provides a comprehensive review of these barriers including 

the long and deep influence of Confucianism, Taoism and Buddhism, Chinese American 

families’ parenting style, multigenerational households in Chinese American family and the short 



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

 31 

history of developmental disability in China. These barriers can impact the quality and 

effectiveness of services provided to Chinese American families and may contribute to 

disparities in health outcomes and quality of life. In addition, most evidence-based interventions 

were developed and tested in academic settings for mainstream, highly selected populations, 

especially, for middle-class white Americans (Kumpfer et al., 2002; West et al., 2016; Wong et 

al., 2015). Fewer evidence-based interventions were designed for or have been applied in non-

white and minoritized populations, thus they are not reaching those populations experiencing 

disparate access to intervention (Chinman et al., 2017; Purnell et al., 2016; Shelton, 2021). To 

address these inequities, one approach is to culturally adapt original evidence-based 

interventions. Cultural adaptation is defined as “the systematic modification of an evidence-

based treatment or intervention protocol to consider language, culture, and context in such a way 

that it is compatible with the client’s cultural patterns, meanings, and values” (Bernal et al., 

2009, p.362).  

Despite the challenges and disparities faced by Chinese American immigrant families, 

there is a lack of culturally and linguistically appropriate services and interventions. 

Furthermore, my exploration of prominent academic databases specializing in education (ERIC), 

psychologists and psychiatrists (PsycINFO), medical and biology (Medline/Pubmed), as well as 

the social science and humanities disciplines (Web of Science) with a focus on research 

pertaining to cultural adaptation intervention in Chinese American immigrants population align 

with the findings of Magana et al. (2021) that, when compared to the realm of mental health 

research, the field of IDD is significantly lagging behind in conducting studies on culturally 

adapted interventions, despite persistent racial, ethnic and socioeconomic disparities in IDD 

treatments and supports (Magaña & Vanegas, 2021; Smith et al., 2020).  



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

 32 

To the best of my knowledge, there is only one cultural adaptation article on parent 

training to address the unmet needs of Chinese immigrant families (Xu et al., 2023). Xu et al. 

(2023) provided the cultural adaptation process of an empirically supported parent education 

intervention, "Parents Taking Action" (PTA). In this study, six Chinese immigrant parents of 

children with autism and six providers who serve this population worked together to adapt the 

content and context of the intervention specifically aimed at low-income Chinese immigrant 

families with young children diagnosed with autism. The authors translated the materials first 

and organized two focus groups to discuss with Chinese immigrant parents of children with 

autism about the adaptation content and context parts, and coding the discussion results with 

Stirman et al.'s (2013) coding system. And during the adaptation process, two cultural 

adaptations were used, deep versus surface structure adaptation (Knight et al., 2009) and the 

Ecological Validity Framework (Bernal et al., 1995). The results showed that both contextual 

and content modifications were needed for the intervention, Chinese immigrant parents preferred 

a group format for the intervention and highlighted the importance of delivering services in 

community settings, as well as the role of both Community Health Workers and professionals in 

addressing the unique needs of the Chinese American immigrant population. However, this study 

(Xu et al., 2023) just provided the cultural adaptation process, they did not conduct a specific 

practice to evaluate the feasibility, acceptability, and effectiveness for the families. Clearly, 

culturally adapted parent-mediated interventions are lacking in the Chinese American immigrant 

population, additional research is needed, and more profound cultural adaptations targeting the 

extensive support needs of children with IDD who often have co-occurring challenging behavior 

may be warranted. 



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

 33 

Prevent-Teach-Reinforce for families (PTR-F) 

 Children with IDD are more likely to be diagnosed with a severe behavior disorder than 

are their typically developing counterparts (Emerson & Einfeld, 2011). Relatedly, this dual 

diagnosis of cognitive and behavioral impairments places additional stress, anxiety and 

depression on their caregivers (Baker et al., 2003; Hayes & Watson, 2013; McIntyre et al., 

2006). Additionally, Rohacek et al. (2023) highlighted a well-documented bidirectional 

relationship between caregiver stress and challenging behavior in children with IDD, with 

reductions in caregiver stress associated with behavioral improvements in the child (and 

increased caregiver stress associated with worsening of behavior and then worsening of caregiver 

stress). Similarly, challenging behavior is often learned and maintained by socially mediated 

consequences delivered by the caregivers (Rohacek et al., 2023). Thus, modifying a child's 

challenging behavior often necessitates caregivers adjusting their own behavior (Karst & Van 

Hecke, 2012; Rohacek et al., 2023).  

Given the important link between parenting and child adjustment, a variety of parent 

education and management training interventions have been adopted from the disruptive 

behavior disorder treatment literature and applied to the prevention and treatment of challenging 

behavior in children with IDD. Parenting training has a long history of use with children with 

IDD who also engage in challenging behavior. Parent training is based on social learning theory, 

principles of operant theory and behavior modification, and tenets of developmental 

psychopathology. Prime manualized examples in the parent management training interventions 

are the Incredible Years program (IYPT; Webster-Stratton, 2015), Stepping Stones Triple P 

(Sanders et al. 2003), Signposts for Building Better Behavior program (Hudson et al., 2003), 

Research Units in Pediatric Psychopharmacology Parent Training (RUPP PT) program (Johnson 



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

 34 

et al., 2007), Research Units in Behavioral Intervention (RUBI, RUBI Autism Network, 

2015), the parent management training Oregon model (Forgatch & Patterson, 2010), and parent–

child interaction therapy (PCIT; Eyberg, 1988) and positive parenting program (Triple-P; 

Sanders et al. 2008). 

PTR-F (Dunlap et al., 2017) is a detailed model, a manualized, evidence-based strategy 

for helping families to resolve their children’s serious challenging behavior in home and 

community settings. This model is an extension of the Prevent-Teach-Reinforce (PTR, Dunlap et 

al., 2010) model for use in elementary and middle schools and the Prevent-Teach-Reinforce for 

Young Children (PTR-YC, Dunlap et al., 2013) model that is designed for preschool and 

childcare settings. The PTR model grew out of ABA and research from PBS 

programs. However, the PTR-F model is different from its predecessors in two fundamental 

ways: 1) PTR-F was developed to be effective in typical family circumstances that do not 

include professional educators or behavior specialists, and 2) PTR-F has goals that include 

reducing the child’s challenging behavior and enhancing the overall quality of life for the entire 

family (Dunlap et al., 2017). In this way, it is expected that implementation of the model will 

help transform patterns of parent–child conflict into more positive and mutually enjoyable 

relationships. The user-friendly PTR-F framework includes a five-step process: (a) initiating the 

PTR-F process, (b) PTR-F assessment, (c) PTR-F intervention, (d) coaching, and (e) monitoring 

plan implementation and child progress. The PTR-F manual provides step-by-step instructions, 

checklists, templates, and evaluation tools that help interventionists or behavioral consultants 

guide caregivers to implement BIPs.  

PTR-F was developed and published by Dunlap et al. in 2016. Before the manual was 

published, Sears et al. (2013), Bailey and Blair (2015), and Argumedes et al. (2021) adapted the 



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

 35 

school-based PTR model to examine the feasibility and potential efficacy of using the PTR 

model with families who have children with ASD. Two peer-reviewed articles evaluate the use 

of this recently manualized PTR-F model. The first peer-reviewed article was published by the 

book’s authors. Joseph et al. (2021) evaluated the process and outcomes of the PTR-F in the 

areas of the family’s level of fidelity in implementing the intervention strategies, improvement in 

confidence and satisfaction implementing a BSP, children’s reduction of challenging behavior 

and increase in desirable adaptive behavior, and social validity of the PTR-F process and 

outcomes. The participants were three children, all three years of age, who were diagnosed with 

ASD and had challenging behavior. All three children lived at home with their parents and 

siblings. One child was also commonly cared for by a nanny. The targeted routines during the 

study were morning time, leaving the house, and bedtime. This study used a withdrawal design 

(ABAB) where the parent-implemented BSP intervention was removed briefly and then 

presented again. During the second intervention phase, a researcher provided coaching and 

feedback to help the parents re-implement the intervention. The results showed that all families 

implemented the intervention appropriately, with fidelity scores of 80% or more. During 

intervention, the frequency of child challenging behavior decreased, and alternate replacement 

behavior increased. Each family reported high rates of satisfaction and increased confidence 

during the second intervention phase in implementing the intervention with fidelity and 

monitoring child progress using the behavior rating scales. 

Hodges et al. (2022) adapted the PTR-F in vivo format by replicating and expanding on 

Joseph et al.’s study. The authors replicated the PTR-F process used in the Joseph et al. (2021) 

study and expanded by (a) using a remote format (Zoom), (b) using electronic forms to 

participants, (c) didactic presentation of information during behavior intervention planning (i.e., 



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

 36 

Step 4), (d) adapting coaching strategies due to remote format and provision of equipment (e.g., 

iPads, cases, Bluetooth earpieces, tripods), and (f) guiding self-reflections post-session for 

caregivers to inform procedures and quality improvements. The study included three children, 

one male and two females, between two and four years of age, with challenging behavior. Their 

target routines were getting ready for school in the morning, following bath time, and dinner 

time. This study used a single-case concurrent multiple baseline design across three families. The 

results suggested that parents could accurately implement the PTR-F interventions with high 

levels of implementation fidelity, which resulted in reducing the challenging behavior and 

increasing the appropriate behavior of the three participating children, therefore extending the 

literature. The results indicated that the PTR-F process and outcomes had high social validity. 

Researchers have found that culturally adapted parent training interventions to decrease 

the challenging behavior of children with IDD have been successful in enhancing the 

effectiveness and acceptability of the interventions by minority families. Vargas Londono et al. 

(2023) conducted a systematic review to evaluate the effectiveness of culturally adapted 

caregiver training programs to decrease child and adolescent’s challenging behavior; the results 

showed that culturally adapted interventions have consistently demonstrated substantial 

moderated effects on caregiver behavior, leading to a reduction in negative caregiver behavior 

and an increase in positive parenting practices, while also yielding significant moderation effects 

on decreasing challenging behavior in children and adolescents. However, the majority of the 13 

studies from 1970 and 2020 examined in this systematic review were conducted in the United 

States with Latino/a/e/z families in Spanish. Notably, no research pertaining to Chinese 

immigrant families was identified within the scope of this recent systematic review and meta-

analysis. In addition, studies in the systematic review and meta-analysis utilized different parent 



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

 37 

education programs and methods (e.g., The Basic Incredible Years Parenting Intervention Parent 

Management Training Oregon model, Child Parent Relationship Therapy, Psychoeducation 

program, Parent Management Training intervention), which challenges the interpretation of 

findings for the sake of selecting intervention programs based on participant characteristics and 

presenting issues.   

Santiago (2018) applied the PTR-F program to Hispanic families in a thesis study, which 

has not been published in a refereed journal. In addition, no cultural adaptation process and 

specific strategies were documented within the thesis. The study involved three Hispanic 

families of young children with ASD between the ages of three and six years of age who 

participated in the 5-step PTR-F process and who implemented the PTR-F intervention plan 

during naturally occurring family routines. Target routines were completing the entire morning 

routine, getting in the shower right after waking up and going to the toilet during the morning 

routine, and a tooth brushing routine. A concurrent multiple-baseline across participants design 

was employed to examine the preliminary evidence of the efficacy of using the PTR-F for three 

parents and their children with ASD. The results indicated that Hispanic parents successfully 

implemented intervention strategies with the help of an interventionist using the PTR-F manual. 

All children’s alternative desirable behavior increased, and challenging behavior produced a 

significant amount when the PTR-F intervention was implemented by the parents. The parents 

reported high social validity when implementing the PTR-F intervention.  

In a recent update, Choi (2023) included three additional steps into the PTR-F process to 

explore the responsiveness for culturally and linguistically diverse families: (1) introducing the 

practitioner’s cultural background, (2) explicit conversation about the family’s culture and value, 

and (3) assessment of the BSP’s contextual fit. However, when considering the barriers faced by 



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

 38 

culturally diverse families, relying solely on these three steps might be insufficient for a 

comprehensive adaptation of an intervention. Furthermore, Choi (2023) focused largely on the 

adaptations to the process of the PTR-F, with limited attention given to content such as language, 

metaphor, content, concepts, and method. This emphasis may stem from the fact that only one 

participant shares the same culture as Choi, being from Korea, while the remaining three 

participants are from Thailand and Kazakhstan. As mentioned earlier, not all Asians adhere to 

the same cultural practices, and despite Choi's cultural awareness and practice of cultural 

humility, there still existed a cultural gap between Choi and the other three families. To address 

these limitations, the study aims to expand Choi’s (2023) study, culturally adapt PTR-F using the 

Ecological Validity Model (Bernal et al., 1995) and test the feasibility and effectiveness of the 

culturally tailored PTR-F parent intervention when delivered remotely via telepractice to Chinese 

American parents of young children with IDD in the United States. 

Research purpose 

The purpose of the proposed single-case experimental study is threefold: First, to expand 

the literature on the efficacy of the parent-implemented PTR-F program by empirically 

demonstrating in a single-case research design study the effectiveness of a culturally tailored 

PTR-F intervention program when delivered remotely via telepractice on the a) increased fidelity 

of implementation of parent behavior support plan strategy use and (b) the reduction of target 

challenging behavior and improvement of target adaptive behavior among young children with 

IDD within the context of participating Chinese American families. Second, to investigate the 

social validity of the culturally tailored PTR-F intervention program when delivered remotely via 

telepractice to Chinese American families. This involved asking parents to fill out an adapted 

version of the social validity measures utilized in the randomized controlled trial of PTR-YC 



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

 39 

(Dunlap et al., 2017). Finally, to investigate the impact of the culturally tailored PTR-F 

intervention on family quality of life through two pre- and post-assessments at the beginning and 

end of the program, which includes parental confidence and the involvement of children with 

IDD in family routines and activities. 

Research questions 

RQ1. Is there a functional relation between the implementation of the culturally adapted PTR-F 

parent education and coaching intervention package and decreased level of children’s 

target mild-moderate challenging behavior during desired family routines? 

RQ2. About the training: Do parents perceive the goals, procedures, and outcomes of the 

culturally adapted PTR-F parent training program as acceptable, feasible and effective? 

Do their perceptions differ for specific BSP intervention strategies? How do they 

perceive the components of cultural adaptation for Chinese American families of children 

with IDD? 

RQ3. About the service delivery modality: Do parents perceive the goals, procedures, and 

outcomes of the remote telepractice technologies used to deliver the culturally tailored 

PTR-F program as acceptable, feasible and effective?  

RQ4. How does the culturally adapted PTR-F behavioral parent training program affect children 

with IDD participation in family routines and activities? 

RQ5. How does the culturally adapted PTR-F behavioral parent training program affect parental 

confidence? 

 



REMOTE PTR-F WITH CHINESE AMERICAN FAMILIES OF CHILDREN WITH IDD 

 40 

CHAPTER III  

METHOD 

The purpose of this chapter is to present the methodology. Information regarding the 

participants, setting, and materials will be provided. The screening process will be presented. 

Indirect and direct measurement tools and procedures will be described. Next, the baseline and 

coaching phases will be discussed. Finally, data analysis methods will be reviewed.  

Participants and Setting 

Participants 

This study included six parent-child dyads to ensure an adequate sample size for 

meaningful analysis within a single-case study to demonstrate a functional relation between the 

intervention and the dependent variables. The study aimed to recruit a wide array of families of 

Chinese American children with IDD, inclusive of ASD. However, the vast majority of those 

families contacting the interventionist reported ASD as a primary diagnosis, so no child with 

intellectual disability or general developmental delay was included. The children were between 3 

to 5 years old and had a documented medical diagnosis of ASD. Parent-child dyad information is 

provided in the section below, and all participants are referred to by pseudonyms in the draft. 

 Recruitment Procedures 

Participants were recruited via two Chinese social media applications, Xiaohongshu and 

WeChat. The interventionist searched within the social media application Xiaohongshu for 

relevant target users using keywords related to autism or ASD, intellectual disability, 

developmental delay or disability, and Chinese Americans in the United States to identify 

Chinese parents with children with autism living in the United States. WeChat was also used for 

recruitment. The interventionist shared the recruitment flyer with four Chinese friends residing in 



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 41 

the United States who had informal connections to the online network of Chinese American 

families of children with disabilities. They were asked to forward the recruitment flyer to all their 

potential friends in their WeChat groups and moments. Two of these friends were enrolled in a 

graduate program in special education, and two were working in k-12 special education settings 

or early childhood education settings. During the two-day recruitment period, 56 parents 

expressed interest in participating in the study. Specifically, 42 of them completed the survey on 

Qualtrics by scanning the QR code on the flyer, four parents contacted the interventionist 

directly via phone or text message, one parent reached out via email, and nine parents reached 

out via WeChat. Additionally, the interventionist contacted five Chinese immigrant mothers with 

autism living in the United States via Xiaohongshu. Three of them responded, but none met the 

inclusion criterion, as their children were over five years old. However, one of the mothers 

mentioned that she was part of several WeChat groups consisting of parents of children with 

autism and other developmental disabilities. She offered to share the recruitment flyer in these 

groups and with her WeChat Moments. 

 Screening Procedures 

After three days of recruitment, the interventionist conducted the phone screenings with 

the first 21 out of the 56 interested parents. The selection was based on the principle of first 

come, first served. Before conducting the phone screening, the interventionist asked parents to 

provide verbal consent for the screening data collection. The interventionist read the verbal 

consent script aloud over a phone call and obtained the participant’s verbal consent to participate 

in the screening process. Six screening questions were asked: (a) parents’ basic characteristic 

questions, including “When and where were you born?” as well as “When did you move to the 

United States?”; (b) children’s basic characteristic questions, including the birthplace (i.e., state 



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 42 

and country), year of birth, and primary medical diagnosis or educational eligibility; (c) 

children’s challenging behavioral questions, which were assessed using the Routine Based 

Inventory (RBI; McZhiweis, 2003, See Appendix A) to conduct a routines-based interview 

addressing children’s behavior in family routines; (d) family structure information, including 

“How many family members are living with the child?” and “Who is the primary caregiver for 

the child?”, “Whether your partner or other family members in the family know you will join the 

training program?”, and “What’s their attitude about you attending the program?”; (e) equipment 

availability, such as “Do you have daily access to high-speed Internet in a private location (i.e., 

your home)?”, and “Have you used Zoom for a meeting before?” to know whether the parent 

needs technology training support; and (f) parents learning history, including “Have you received 

any professional guidance or support in addressing your child’s challenging behavior?”. Fourteen 

parents provided answers to all the screening questions that met the inclusion and exclusion 

criteria and were invited to the next stage of the recruitment process. Seven parents were 

excluded during the phone screening for various reasons, such as the age of their children, lack 

of necessary equipment, or previous professional guidance or support history. 

The 14 potential parent participants were asked to attend a 30-minute Zoom meeting after 

the phone call. This screening telepractice meeting included: (a) an introduction of the 

interventionist, which covered the educational background, work experience, and research 

interests, and a brief overview of the research study; (b) completion of the caregiver form of 

Child Behavior Checklist for ages 1 ½-5 (CBCL, Achenbach, 1991, 2001); (c) completion of the 

Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA, Suinn et al., 1992) to get more 

information about their acculturation level; and (d) obtaining verbal consent from participants to 

join this study. Due to limitations in obtaining physical signatures for telepractice research, this 



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 43 

research received approval from the University of Oregon Institutional Review Board to waive 

the signature requirement.  

After the Zoom meeting, nine out of 14 parents met the inclusion criteria for the research 

study. The remaining parents were excluded for reasons such as prior commitments (e.g., travel 

out of the country, surgery) or inability to meet regularly for study sessions. Six parents and their 

children with ASD were invited to participate, while the other three were placed on a waitlist in 

case of attrition. 

Participant Demographics. All six participants were biological mothers with their 

autistic children between 3 and 5 years old. Tables 2 and 3 summarize the participants’ 

demographic information. 

Dyad one: Jie and Xiaoling. Jie was a 4-year-9-month-old boy born in the United States. 

He was diagnosed with moderate ASD by the school district assessment team at the age of 3, 

following his teacher's observation that he had limited interaction with other children at school. 

Jie was receiving occupational therapy, physical therapy, and speech therapy services from his 

special education school for children aged 3 to 5 years old. Xiaoling, his mother, reported that Jie 

was on the ABA service waitlist and had not received any ABA service before. He takes 

vitamins and probiotics, and sometimes he takes Melatonin for sleep. Jie lives with his father, 

mother, grandparents (mother’s parents), older sister, younger sister, and aunt (mother’s sister) - 

a total of eight people in his family. Xiaoling was a 39-year-old female who was born in China 

and immigrated to the United States in 2005. Both of Jie's parents are Chinese. Xiaoling’s 

education level is high school, and she is currently unemployed. She reported that she is the 

primary caregiver for Jie at home.  



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Dyad two: Yifan and Minhua. Yifan was a 4-year-4-month-old boy born in the United 

States. He was diagnosed with ASD when he was 2 years old by his pediatrician. He was 

receiving occupational therapy, speech therapy services, and RBT support at school. His mother, 

Minhua, reported that she had a monthly meeting with his RBT supervisor, who was a BCBA, 

but there was no specific support for Yifan’s challenging behavior at home. He does not take any 

medicine currently. He lives with his mother and grandmother (his mother’s mother) in the 

United States, while his father and older brother live in Shanghai, China. Minhua was a 37-year-

old female who was born in China. Both of Yifan’s parents are Chinese. Minhua moved to the 

United States in 2013 for her master’s program and now holds a green card in the United States. 

Her education level is a master’s degree, and she is employed full-time. She is the primary 

caregiver for Yifan at home, while his grandmother is mainly responsible for housework. 

Dyad three: Zhiwei and Xiaowei. Zhiwei was a 3-year-6-month-old boy who was born in 

the United States. He was diagnosed with mild ASD when he was 3 years old by the early 

intervention program. He was receiving early intervention service and had 20 hours of ABA 

service during the early intervention program. His parents also received some support from the 

early intervention program, but his mother reported that it did not help her. He does not take any 

medicine currently. He lives with his father, mother, grandmother (his father’s mother), and his 

young sister, making a total of 5 people in his family. Zhiwei’s mother, Xiaowei, was a 35-year-

old female who was born in China. Both of Zhiwei’s parents are Chinese. Xiaowei moved to the 

United States in 2015 for her master’s program, and now she holds a green card. She has a 

master’s degree and is currently unemployed. She is the primary caregiver for Zhiwei at home, 

and his grandmother supports the family by taking care of Zhiwei’s younger sister.  



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Dyad four: Linlin and Yanting. Linlin was a 4-year-5-month-old girl who was born in 

the United States. She was diagnosed with ASD when she was 2.5 years old by the early 

intervention program. She was receiving special education in a segregated classroom in a public 

school along with occupational therapy, physical therapy, and speech therapy services at school. 

Her mother, Yanting, reported that Linlin received ABA service for more than six months but 

less than a year when she was 3 years old. Her mother is still looking for an ABA service for her. 

Yanting did not think she received any professional guidance or support in addressing Linlin’s 

challenging behavior at the home setting, though she had monthly meetings with the service 

provider during Linlin’s early intervention program. Linlin does not take any medicine currently. 

She lives with her father, mother, and younger brother, making a total of 4 people in her family. 

Yan was a 38-year-old female who was born in China. Both of Linlin’s parents are Chinese. 

Yanting moved to the United States in 2008 for her master’s program and now holds a green 

card. She has a doctoral degree and is employed full-time. She reported that she and her husband 

share the responsibility of caring for their children. 

Dyad five: Xiaoxie and Luanhong. Xiaoxie was a 4-year-7-month-old boy who was born 

in the United States. He was diagnosed with moderate ASD when he was 2.5 years old by an 

early intervention program. He was receiving occupational therapy and speech therapy services 

under his IEP at a special education school for children aged 3 to 5 years old. His mother 

reported that Xiaoxie received about three months of behavioral intervention during an early 

intervention program at school. He does not take any medicine currently. He lives with his 

father, mother, and older brother, making a total of 4 people in his family. Although his father 

also participated in most of the meetings for this study, due to unstable work schedules, 

Xiaoxie’s mother, Luanhong, was the targeted parent in this family. Luanhong was a 49-year-old 



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female who was born in China. Both of Xiaoxie’s parents are Chinese. Luanhong immigrated to 

the United States in 2016. She has an associate degree and is currently unemployed. She is the 

primary caregiver for Xiaoxie at home. 

Dyad six: Meisheng and Yuanyuan. Meisheng was a 4-year-4-month-old boy who was 

born in the United States. He was diagnosed with ASD when he was 3 years old by an early 

intervention program. He was receiving occupational therapy and speech therapy services under 

his IEP at a special education school for children aged 3 to 5 years old. His mother reported that 

Meisheng received about two months of behavioral intervention during an early intervention 

program at home. Meisheng’s mother reported that she was not satisfied with the service; she 

actively stopped the service because she found it unprofessional and unhelpful for him. She is 

currently looking for a professional ABA service for Meisheng. The parents also received ABA 

home-visiting services for two months from an RBT and parent training weekly via Zoom 

meetings, but Yuanyuan said that although they discussed a lot, they did not get any specific 

support to address Meisheng’s challenging behavior. Meisheng does not take any medicine 

currently. He lives with his father and mother, making a total of 3 people in his family. 

Meisheng’s mother, Yuanyuan, was a 32-year-old female who was born in China. Both of 

Meisheng’s parents are Chinese. Yuanyuan immigrated to the United States in 2016. She has a 

high school degree and is currently unemployed. She is the primary caregiver for Meisheng at 

home when his father is not there, but they share the responsibility for his care when his father is 

home. 

Table 2 Child Demographic Information 

Child Jie Yifan Zhiwei Linlin Xiaoxie Meisheng 

Age 
4 years 9 months 
old 

4 years 4 months 
old 

3 years 6 months 
old 

4 years 5 months 
old 

4 years 7 months 
old 

4 years 4 months 
old 

Gender Male Male Male Female Male Male 



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 47 

Birthplace U.S. U.S. U.S. U.S. U.S. U.S. 

Race Asian Asian Asian Asian Asian Asian 
Home 
language 

English & 
Mandarin 

English & 
Mandarin 

English & 
Mandarin 

English & 
Mandarin 

English & 
Mandarin 

English & 
Mandarin 

Diagnosis ASD  ASD ASD ASD ASD ASD 
Diagnosed 
age 

3 years old 2 years old 2 years old 2.5 years old 2.5 years old 3 years old 

Family 
members 
living with 
child 

Dad, Mom, 
grandparents 
(Mom’s parents), 
elder sister, Jie, 
young sister, 
Aunt (Mom’s 
sister) 

Grandma (Mom’s 
mom), Mom, 
Yifan (Dad and 
older brother in 
China) 

Dad, Mom, 
Grandma (Dad’s 
mom), Zhiwei, 
young sister 

Dad, Mom, 
Linlin, young 
brother 

Dad, Mom, older 
brother, Xiaoxie 

Dad, Mom and 
Meisheng 

Table 3 Parent Demographic Information 

Parent Xiaoling Minhua Xiaowei Yanting Luanhong Yuanyuan 

Relation with 
the child 

mother mother mother mother mother mother 

Age 39 37 35 38 49 32 

Gender Female Female Female Female Female Female 
Race Asian Asian Asian Asian Asian Asian 

Country of 
Origin 

China China China China China China 

Years in US 19 11 9 16 8 8 

Native 
Language 

Mandarin Mandarin Mandarin Mandarin Mandarin Mandarin 

Education High school Master Master Doctorate Associate degree High school 

Marital 
status 

Married Married Married Married Married Married 

Employment Unemployed Risk professional Public health 
inspector (now 
unemployed) 

Data scientist Unemployed Unemployed 

Preferred 
language 

Mandarin English or 
Mandarin 

Mandarin English or 
Mandarin 

Mandarin Mandarin 

 
Screening Measures 

Child Behavior Checklist. Child Behavior Checklist (CBCL, Achenbach, 1991, 2001), 

now called the Achenbach System of Empirically Based Assessment, the versions for preschool 

(CBCL/1.5–5, for ages 1.5–5) children (Achenbach and Rescorla, 2000, 2001) used in this 

research. The CBCL for ages 1 ½-5 is a 99-item checklist (e.g., ‘cries a lot,’ ‘hurts animals or 

people without meaning to,’ ‘physically attacks people’) with a three-point Likert scale 

(0=absent, 1=occurs sometimes, 2=occurs often) that was rated by parents to indicate the 



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 48 

intensity of their child’s internalizing, externalizing, and total challenging behavior (Achenbach, 

1991, 2001). The parents completed the items in about 10 minutes and the optional competence 

items in another 5 to 10 minutes. Scores of 60 or higher on the Externalizing Score or Total 

Problems Score may suggest a clinically significant problem. These were the cut-off scores for 

inclusion in the study. Children were eligible to participate in the study provided they displayed 

challenging behavior as indicated on the CBCL above the cut-off scores and were between 3-5 

years of age. The CBCL has adequate discriminant and convergent validity and is sensitive to 

changes in challenging behavior (Mansolf et al., 2022). The CBCL has been translated into 

Chinese versions (Su et al., 2015), which was also used for three parents. A copy of CBCL for 

ages 1.5–5 is located in Appendix B. 

All six participating mothers completed the CBCL for ages 1 ½-5 for their targeted child 

with the interventionist during the Zoom screening meeting, table 4 summarizes their scores. All 

results showed that their child had a clinically significant problem behavior except Yifan. Jie’s 

internalizing T-score was 70, externalizing T-score was 61, and Total Problem T-score was 70, 

which means a clinically significant problem behavior. Jie’s raw score on the CBCL Attention 

Problems subscale was a 9, which was close to the borderline clinical range. Yifan’s 

internalizing T-score was 56, externalizing T-score was 56, and Total Problem T-score was 58. 

However, Yifan’s CBCL results showed that he did not have a clinically significant problem 

behavior. However, Minhua reported that Yifan did have some challenging behavior at home, 

and Yifan’s raw score on the CBCL Attention Problems subscale was a 10, which was in the 

borderline clinical range. After interviewing Minhua and observing Yifan, the interventionist 

found that Yifan did show some external challenging behavior at home and accepted Yifan and 

his mother to stay in the program. Zhiwei’s internalizing T-score was 91, externalizing T-score 



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 49 

was 68, and Total Problem T-score was 90, which means a clinically significant problem 

behavior. Zhiwei’s raw score on the CBCL Attention Problems subscale was 13, which was in 

the clinically significant range, and the Aggressive Behavior subscale was 25, which was in the 

borderline clinical range. 

Linlin’s internalizing T-score was 64, externalizing T-score was 67, and Total Problem 

T-score was 67, which means a clinically significant problem behavior. More specifically, 

Linlin’s raw score on the CBCL Attention Problems subscale was a 13, which was in the 

clinically significant range, on the Aggressive Behavior subscale, she scored a 16, which was 

very close to the borderline clinical range. Xiaoxie’s internalizing T-score was 75, externalizing 

T-score was 68, and Total Problem T-score was 79, which means a clinically significant problem 

behavior. More specifically, Xiaoxie’s raw score on the CBCL Attention Problems subscale was 

an 11, which was in the borderline clinical range, on the Aggressive Behavior subscale, he 

scored a 27, which was in the borderline clinical range. Meisheng’s internalizing T-score was 93, 

externalizing T-score was 78, and Total Problem T-score was 93, which means a clinically 

significant problem behavior. Meisheng’s raw score on the CBCL Attention Problems subscale 

was 14, which was in the clinically significant range, on the Aggressive Behavior subscale, she 

scored 36, which was in the clinically significant range. 

Table 4 Child Behavior Checklist for Ages 1.5-5 results for each participant 

Participant Internalizing Externalizing Other p