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A preliminary evaluation of a telehealth approach to acceptance and commitment training (ACT) for enhancing behavioral parent training (BPT) for Chinese parents

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A preliminary evaluation of a telehealth approach to acceptance and commitment training (ACT) for enhancing behavioral parent training (BPT) for Chinese parents

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Content Copyright 2021 Zhen Lin
A Preliminary Evaluation of a Telehealth Approach to Acceptance and Commitment
Training (ACT) for Enhancing Behavioral Parent Training (BPT) for Chinese Parents
by
Zhen Lin
A Thesis Presented to the
FACULTY OF THE USC DORNSIFE COLLEGE OF LETTERS, ARTS AND SCIENCES
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
MASTER OF SCIENCE
(APPLIED BEHAVIOR ANALYSIS)
December 2021
ii
TABLE OF CONTENTS
List of Tables …………………………….………………….………………….……….………iii
List of Figures ……………….………………………….………………….……………….……iv
Abstract ……………….………………….…………………………………………………...…. v
Introduction .………………………………………………………………………………...…….1
Autism Spectrum Disorder Data of China………………………………….…………….…….…1
Behavioral Parent Training ...………………………………………………………………….….1
Benefits of Behavioral Parent Training ...……………….………………….…….……....1
Benefits of Parent Involvement…………………………………………………………...2
Telehealth Behavioral Parent Training……………………………………………………3
Acceptance and Commitment Training……………………………………………….……….….3
Introduction of ACT………………………………………………………………………3
Benefits of ACT for parents……………………………………………………………….4
BPT combined with ACT………………………………………………...…….…….…...5
Method ……………………………………………………………………………………………6
Participants and Settings ………………………………………………………………….6
Materials ………………………………………………………………………………….7
Response Measurement and Interobserver Agreement …………………………………...8
Direct Observation ………………………………………………….…………….8
Psychological Assessments ……………………………………………………...10
Procedure …………………………………………………………….………………….12
Results ………….………………………………………………….…………………………….14
Jiayi ………….……………………………………….……….…………………………15
Yuner …………………………………………………………………………………….16
Xiansan ………………………………………………………………………………….17
Social Validity ………………………………….……………………………………….18
Discussion ……………………………….………………………………………………………19
References …………………………….………………………………...……………………….24

iii
LIST OF TABLES
Table Page
1 Social Validity Questionnaire …………………………………………….…………..……….29
2 Behavioral Parent Training (BPT) protocol ………………………………………….….…….30
3 ACT Training Protocol …………………………………………………………….………….31
4 Psychological functioning and parenting stress measures of participants………….………….32

iv
LIST OF FIGURES
Figure Page
1 Direct Observation of Parents.....................................................................................................33
2 Direct Observation of Children ..................................................................................................34
3 Parental Social Validity Questionnaire.......................................................................................35

v

ABSTRACT
Previous research has shown that behavioral parent training (BPT) is an effective method to
improve parenting skills and promote meaningful parent-child interactions in families of children
with autism. Preliminary research has demonstrated the effects of Acceptance and Commitment
Training (ACT)-based approaches to parent training. However, little or no previous research has
attempted to evaluate whether ACT can enhance the effectiveness of BPT and very little research
has evaluated telemedicine approaches to parent training, especially in languages other than
English. The purpose of the present research was to a) extend BPT training through telehealth, b)
use ACT to enhance the effectiveness of BPT for parents of children with autism spectrum
disorder (ASD), and 3) extend research on BPT and ACT for parents in China. The effects of the
training were evaluated by direct observation of parent-child interaction via telehealth. The
results demonstrated substantial behavior change using telehealth BPT and enhanced behavior
change in a small number of cases when ACT was added. Overall, the results suggest that
combining BPT and ACT, delivered over telehealth and in the Mandarin language, may be
effective and feasible within Chinese culture.

Keywords: Autism Spectrum Disorder, behavioral parent training, Acceptance and Commitment
Training, Telehealth, Chinese, Parenting Stress
1
A Preliminary Evaluation of a Telehealth Approach to Acceptance and Commitment Training for
Enhancing Behavioral Parent Training for Chinese Parents
The rising prevalence of Autism Spectrum Disorder (ASD) has become a global
challenge affecting thousands of families, including many in China. There is a lack of official
reports about the number of children with ASD in China. Zhang and Ji's study (2005) that
screened 7,345 children aged 2-6 years old in Tianjin, China, showed that the ratio of children
with ASD to typically developing children was approximately 1:1000. When one considers that
the population of China is well over 1 billion people, the population of children with autism must
be very large, with some estimates up to 13 million children and adults with autism living in
China (Compton, 2013). Unfortunately, there are fewer than two hundred Board Certified
Behavior Analysts (BCBAs) currently working in China and access to family support services is
severely limited.
Furthermore, many previous studies demonstrate that the stress levels of parents of
children with ASD are significantly higher than levels experienced by parents of typically
developing children (Corti et al., 2018, p.2895; Hsu-Min, 2014, p.88). Therefore, accessible
treatment and effective behavioral parent training are critically needed. Increasing behavioral
parenting skills is particularly important in China, where a comprehensive diagnostic and parent
support system has not yet been developed. Telehealth consulting is accessible and convenient to
many families who have high speed internet connections and therefore may be a viable option
for families living in China.
Behavioral Parent Training (BPT) has been documented by a substantial amount of
previous scientific research as an effective approach for reducing children's challenging
behaviors and helping children increase language and other adaptive skills (Tarbox, Garcia, & St.
2
Clair, 2016). BPT empowers parents by teaching parenting skills that harness behavioral
principles of learning and motivation, so that parents can change their daily interactions with
their children to prevent challenging behavior and strengthen positive interactions with their
children. For example, by learning the concept of positive reinforcement and accompanying
procedures, parents are empowered to tune into what their children want and care about in the
moment and customize their interactions to help their child engage in adaptive behaviors
centered around what they want and what makes them happy. In addition, BPT helps parents
identify and let go of ineffective parenting strategies, such as nagging, coercion, and many others
(Corti et al., 2018). Many previous studies have shown that parents of children with special
needs can be successfully trained and benefited from BPT in multiple perspective, such as
managing challenging behaviors, training daily living skills and evoking language. Tarbox et al.
(2007) used behavioral skill training (BST) to train parents to implement a three-step strategy
when their children engaged in challenging behaviors. The results indicates that parents’
excessive prompting significantly decreased, and compliance of their children increased. Kroger
and Sorensen (2010) trained parents of children with ASD to implement a toilet training method.
The result revealed that with the BST, parents successfully trained their children to use toilet
within 10 days and the effects were maintained. A study from Chaabane et al. (2009) which used
BST trained mothers of children with autism to implement Picture Exchange Communication
System (PECS) indicates that the procedure successfully increased independent child’s verbal
request.
Research has shown multiple benefits for parents when they are actively involved in ASD
interventions, including greater skill generalization and increased training opportunities for
dealing with their children's maladaptive behaviors. For example, a pilot study of Hsu-Min
3
(2014) showed that after receiving treatment, the parents of Chinese American children with
ASD reported significantly reduced parenting stress and improvement in parental confidence. In
addition, research on a telehealth approach to parent training in the Early Start Denver Model
(ESDM) supported parental learning and improved child behaviors for some families (Vismara,
2013). However, participants in the studies were not blind to the purpose of the study, and the
performance of daily parent-child dyad interaction was not directly observed, so the results from
self-report questionnaires may potentially be biased.
Boutain et al. (2020) evaluated a telehealth parent training program in teaching self-care
skills to children with autism. Three parents and their children participated in the study. The
direct observation data indicated that parents did not correctly implement the strategy after
reading a detailed written instruction, however, after implementing the telehealth parent training,
all parents learned the parenting skills successfully. A study by Tsami et al. (2019) evaluated the
effectiveness and acceptability of telehealth parent training for 18 participants. Participants who
could not speak English used a language interpreter during the telehealth sessions. The video
coding data revealed that after the training, parents successfully implemented the trained ABA
strategies and reduced the challenging behaviors of their children. Bearss et al. (2018) conducted
a telehealth parent training study within 14 participants with ASD. Parents attended 11 core
sessions through an online program as well as supplemental sessions through telehealth. The
self-report measure revealed that 7 out of 14 participants greatly improved. Overall, although the
published research is still relatively new, the existing evidence suggests that telehealth may be an
effective format for delivering behavioral parent training, especially at distance.
Acceptance and Commitment Training (ACT) is a contemporary behavior analytic
approach to address the unhelpful private events that influence meaningful overt behavior and
4
increase mindful flexibility (Little et al., 2020). ACT was developed out of Relational Frame
Theory (RFT) to train mindfulness and acceptance processes. Instead of attempting to modify or
control aversive emotions and feelings, ACT works on altering the way that the private events
function and creating contexts for engaging in value-driven overt behaviors (Hayes & Steven,
2019). There are six core therapeutic processes in ACT that help facilitate psychological
flexibility – values, present-moment attention, acceptance, self-as-context, defusion, and
committed action. Values training teaches skills that involve self-reflecting on what an individual
genuinely cares about, especially in times of distress. In terms of behavioral principles, values
have been conceptualized as overarching classes of verbally constructed positive reinforcement,
so values training helps individuals orient their own behavior toward enduring sources of
positive reinforcement in their own lives (Tarbox et al., 2020). Present moment training borrows
much from Eastern spiritual traditions of meditation practice and involves training people to
bring their own attention to the current situation, rather than paying overly rigid attention to the
past or the future, especially when doing so interferes with values-directed overt behavior.
Acceptance training involves training the skill of noticing unwanted thoughts, emotional
responses, and physiological responses, and inhibiting one’s avoidant behaviors.
Defusion training seeks to train more flexible responses to one’s own rigid verbal thinking
patterns, lessening the influence that thoughts have over overt behaviors, thereby creating a
context to choose values-directed behaviors. Self-as-context training helps clients develop more
flexible and contextually sensitive thoughts and beliefs about themselves, especially when rigid
beliefs about self-interfere with values-directed behaviors. All components of ACT are in the
service of helping clients increase their values-directed overt behaviors, so in all sessions,
therapists encourage clients to make committed actions toward their own chosen values.
5
Research has supported the effectiveness of ACT in supporting parents. A smaller
amount of research has been done on ACT for supporting parents of children with autism.
Blackledge and Hayes (2006) conducted the earliest study about parents and children with ASD.
In the study, 20 participants attended a 2 day-ACT workshop and completed repetitive self-report
measures. The result suggest that ACT can mediate the depression and adjust difficulties in
parenting. Gould (2016) conducted a non-concurrent multiple baseline design study across three
parents of children with autism. Participants received 1:1 in person ACT session for at least 6
weeks. Direct observation illustrate that ACT have resulted in substantial decreased parenting
experiential avoidance and increased self-compassion.
As described above, research has supported both BPT and ACT for parents when
implemented individually. One possibility that has not yet been evaluated is that ACT may
enhance the effectiveness of BPT for supporting parents. A very small amount of research has
shown that ACT can enhance the effectiveness of behavioral training procedures in other
populations. For example, A recent study of Little et al. (2020) evaluate the enhancement effects
of ACT after implementing BST for clinical practitioners. The experimenter used BST model to
train the staff participant and then provided 1 hour 1:1 in person ACT. Result suggests a
promising outcome that ACT substantially increases the effectiveness of BST (behavioral skill
training) when training behavioral technicians. Yi and Dixon (2020) conducted a randomized
control trial design study to evaluate a self-paced online parent training program and a brief ACT
protocol which to enhance parental adherence. Thirteen families were included in the study. The
result shows that the families in ACT group is more likely to continue the parent training
program and made more significant progress in parenting.
6
Although little or no research has been done on pairing ACT with a BPT for parents,
existing studies on ACT suggest that it may result in decreased in parental experiential
avoidance, stress level, and positive changes in overt behavior (Gould, 2016; Corti, 2018), so it
seems possible that combining the two approaches could produce additional benefit for parents
of children with autism.
Finally, very little research has been done on treatment or supports for families living
with autism in China. Under the pandemic quarantine, the resources that Chinese caregivers can
receive are very limited. The purpose of this masters thesis research is to extend the BPT and
ACT-based parent training research by evaluating a telehealth model for parents of children with
ASD in China. The present study addresses parent behavior during parent-child interactions, by
conducting direct observations through real-time video recordings via Zoom. Secondary
measures include effects on child behavior during observations, as well as parent reports of
distress and psychological flexibility. The experiment used a multiple baseline experimental
design, which involves different starting points of intervention across three participants.

Method
Participants and Settings
Three parents of children with ASD who received ABA service at a behavior intervention
clinical center in Hangzhou, China, participated in this study. The caregivers were eligible for
the study if they (a) were living in China and fluent in Mandarin Chinese, (b) own or have access
to a laptop or mobile device with a camera and can access the internet consistently, (c) have no
previous experience of attending ACT training, d) have a child or children between three years
old and twelve years old with a diagnosis of ASD, given by a licensed psychologist or physician
7
and are receiving at least 10 hours ABA intervention per week in the agency. There was a
possibility of gender inequality, skewing toward female, in the participants based on typical
cultural practices as well as research findings that mothers reported higher parenting
responsibility than fathers (Foody et al., 2015). Six parents contacted the first author to
participate after receiving the invitation advertisement in the agency. Three of them were
included in the experiment because they met the eligibility listed above and consented to
participate. Jiayi was a 26-year-old female and had a four-year-old boy with high-functioning
autism and ADHD. She was taking care of her child full time, so her husband was the sole
financial provider for the family. Yuner was a thirty-year-old female who had a four year old boy
with very limited verbal ability. For her work, Yuner started a home-based business so that she
could have flexible work time and dedicate more time to caring for her child. Xiansan was a
thirty-nine-year-old mother; she had a four year old boy with autism who demonstrated very
delayed language and adaptive skills. Xiansan has been a stay-at-home mother since her child
was diagnosed. She reported that her child’s condition profoundly impacted her family.
All video conference sessions occurred through Zoom USC, an online video chat
platform. Each session lasted for 1.5 hours. In order to protect the confidentiality and integrity of
the family's health information, sessions were password-protected. The first author conducted
BPT and ACT sessions, and the session times were scheduled based on the availability of the
participants and the first author each week. No more than one session occurred in a single week.
Materials
The research team distributed assignments after each BPT session through
Tengxunwendang (i.e., similar to Google Sheet). The research team created permanent folders to
save the assignments for each participant to refer back to their previous work. Each participant
8
could only access the folder with their name by password protection. During the ACT sessions,
participants completed a three-question form each day by answering completion status to mark
their committed behaviors through Wechat.
Response Measurement and Interobserver Agreement
Direct Observation
During the experiment, each participant scheduled two 30-minutes online observation
sessions with researchers weekly. Researchers watched and recorded sessions using the
recording function of Zoom USC. In order to reduce participants' stress from being observed and
to maintain the naturalness of the interaction, and to reduce child distraction, the researcher
asked the participants to minimize the observation window on their computer screen. During the
observations, participants were instructed to interact with their children as they normally did.
The primary dependent variable of the study consisted of two overt behaviors for each parent.
The specific target behaviors varied between participants, depending on their expressed values
during intake and depending on the participants' needs and the difficulties displayed in their
parent-child interactions that the researchers observed during the baseline phase. A secondary
dependent variable was one overt behavior for each child that was observed and recorded during
the parent-child interaction sessions. The child behavior also varied, depending on the behaviors
displayed by each child.
During intake discussions, Jiayi described herself as a "helicopter mother" that provided
intense protection to her child and she expressed that she wanted to change this. Her target
behaviors were 1) contriving a situation for her child to solve a problem independently (e.g., by
delaying assistance or asking "what can you do at this moment?"), and 2) prompting her child’s
functional communication by using partial verbal prompts to encourage the child to speak a
9
complete sentence. Her child's target behavior was using functional communication
independently.
During intake, Yuner expressed that she wanted to create more verbal training
opportunities and increase her child's positive behavior effectively. Her target behaviors were 1)
implementing establishing operations for evoking her child’s verbal behavior by holding a
preferred item and restrict access until the child attempted to verbally communicate, and 2)
reinforcing her child’s communication by giving immediate positive consequences when the
child responded appropriately. Her child's target behavior was speaking a clearly articulated
Chinese word.
During intake, Xiansan expressed that she wanted to improve interaction skills with her
child and increase her child's language skills. Thus, her target behaviors were 1) implementing
establishing operations to create motivation for her child to ask for help or access to preferred
items, and 2) positively managing consequences for her child’s behavior: provide positive
reinforcement when her child respondeds appropriately and non-coercively helping her child to
try again when he made errors (i.e., instead of nagging or reprimanding). Her child's target
behavior was using functional communication with or without a prompt. The data coders tallied
the frequency of all behavior (1)s in video coding. The correct response of all behavior (2)s was
marked as "+," and the incorrect response was marked as "-." The amount of total opportunities
is calculated by adding up the amount of "+" and "-." The percentage of accuracy is calculated by
the ratio of the amount of "+" to the total opportunities multiplied by 100.
Interobserver agreement. A second, independent observer collected data from video
recordings. Interobserver agreement (IOA) was assessed by having a second independent
observer collect data. IOA was calculated by dividing the smaller frequency tally by the larger
10
and multiplying by 100, yielding an IOA decimal for that session. IOA was calculated for every
participant and most phases of the study. Overall mean IOA was calculated by dividing the sum
of each session’s IOA by the number of sessions.
Overall mean IOA was calculated by dividing the sum of each IOA by the number of
IOA. IOA was calculated for 34% of the total sessions for Jiayi, 35% of the total sessions for
Yuner, and 31% of the total sessions for Xiansan. 100% of Jiayi's baseline sessions had IOA
calculations and 23% of the BPT training sessions and 50% of the BPT-follow up sessions of
hers calculated IOA. 17% of the ACT training sessions of hers calculated IOA and IOA
calculation for the ACT- follow up sessions. The average IOA for Jiayi was 95%. For Yuner,
IOA was calculated for 60% of the baseline sessions and 38% of the BPT training sessions. 50%
of the BPT-follow up sessions and 25% of the ACT training sessions had IOA calculations with
no IOA calculator for the ACT follow up sessions. The average IOA for Yuner was 94%. For
Xiansan, IOA was calculated for 85% of the baseline sessions and 23% of the BPT training
sessions. 18% of the ACT training sessions had IOA calculations with no IOA calculator for both
BPT-follow up and ACT follow up sessions. The average IOA for Xiansan is 85%.
Psychological Assessments
Psychological flexibility and Mindfulness. The Acceptance and Action Questionnaire
(AAQ-II; Bond et al., 2011) is a scale used to assess the overall psychology flexibility. The 7-
item version of the AAQ-II has a single-factor structure with items rated from 1(never) to 7
(always). A higher score of AAQ-II demonstrates a potential of lower psychological flexibility.
An AAQ-II score above a range of 24–28 is suggested as a preliminary cutoff to indicate
clinically relevant distress (Palladino et al., 2013). In this study, a simplified Chinese version of
the AAQ-II from Cao, Ji and Zhu (2013) was utilized.
11
The Mindfulness Attention and Awareness Scale. The MAAS is often used in
measuring mindfulness processes. The MAAS has 15 items with ratings from 1 (always) to 6
(never). Those scoring higher (Chinese adults M=4.4) in mindfulness tend to report higher levels
of pleasant affect, higher self-esteem, optimism, and self-actualization (Black et al., 2011).
Chang, Lin and Huang (2011) translated the MAAS into a Chinese version. Because traditional
Chinese characters can match each of the simplified Chinese characters, the current research
team translated it from Chang, Lin and Huang's version to a simplified Chinese version for
utilization.
Parenting Stress and psychological stress. The Parenting Stress Index-Short Form
(PSI-SF) is a commonly used scale to measure stress in the parent-children relationship. The 36-
item questionnaire has a four-factor structure. A global score (PSI-total) and three subscales,
namely Parental Distress (PSI-PD), Dysfunctional Interaction (PSI-DI) and Difficult Child (DC)
are included. PSI-PD measures the degree of parenting distress; PSI-DI measures the level of
dysfunctional parenting behavior and PSI-DC evaluates the parent's view of having a difficult
child (Abidin 2008). A higher score on the PSI indicates higher parenting stress. Scores above 33
on the PSI-PD and PSI-DC sub-scales and above 27 on the PSI-DI sub-scale are considered
clinically elevated. Total scores above 90 indicate clinically significant levels of stress (Abidin
2008).
Depression, Anxiety and Stress Scale. The DASS (Lovibond and Lovibond, 1995) is a
set of three self-report scales to assess the emotional states of depression, anxiety and stress. The
final score of DASS-21 consists of final scores from each of the three subscales in depression,
anxiety and stress. Each of these three subscales contains 7 items. A Chinese version of the
DASS was utilized in this study and was translated by Zuo and Chang (2008). The Chinese
12
version has been shown to have similar psychometric properties for both normative and clinical
samples with parents with children with ASD (Su et al., 2017). Participants responded using a 4-
point Likert scale ranging from 0 "did not apply to me at all" to 3 "applied to me very much or
most of the time."
Social Validity Questionnaires
In order to assess social validity parents were given a questionnaire after BPT and ACT
phases. Participants were asked to rate seven items each on a scale of 1 (strongly disagree) to 5
(strongly agree). The questions are depicted in Appendix A. The questionnaire does not include a
column for participants to input their name. The first author (i.e., the instructor) was not
responsible for the questionnaire implementation and data analysis intentionally. The other
research team members informed participants that the instructor would be blinded to the result,
and the scores would not affect the participants’ experience in the study. However, the scores
should not be considered completely confidential because only three participants participated in
the study.
Procedures
All sessions occurred on a one-to-one basis over Zoom. This model was chosen over
group training for several reasons. Firstly, one-to-one parent training is a model that is
commonly used within community-based ABA (Applied Behavior Analysis) service delivery
settings, both in the US and in China. Secondly, a one-to-one format allows parents of children
with autism to express their feelings freely without consideration of other parents, a variable that
may be particularly important when parents are experiencing stigma around their child’s
developmental diagnosis. Third, the one-to-one format enables the ACT trainer to individualize
the training content for each participant.
13
The experiment used a multiple baseline design across participants and each participation
experienced five phases: 1) baseline, 2) BPT intervention, 3) two-week follow-up, 4) ACT
intervention, 5) another two-week follow-up. Before the first baseline session, a 30-minute
information meeting was conducted. In the meeting, the researcher built rapport with the
participant and discussed the child’s current level of functioning and the target behaviors they
wanted to improve and learn during the sessions.
Baseline. During the baseline period, parents were told to interact with children as they
usually would (Bradshaw, 2017, p.2447). No feedback was provided to the participants
according to the performance in the videos. The baseline phase continued until stability was
observed in the data, via visual inspection.
Behavioral Parent Training (BPT). Sessions occurred once per week for 90 minutes
and were conducted via Zoom. All of the sessions were conducted in Mandarin Chinese. The
BPT phase consisted of six sessions targeting the acquisition of behavioral parenting skills. The
sessions were conducted in a behavior skill training (BST) format that included introduction (~5
minutes), modeling (~5 minutes), role-play (~20 minutes), and feedback (~15 minutes) (Drifke et
al., 2017). The six sessions covered following six sets of topics in the following sequence: 1)
Antecedent-Behavior-Consequence (ABC) functional analysis and antecedent strategies, 2)
Replacement Behavior Strategies and Reinforcement, 3) Token Systems, Prompting and Fading,
4) Visual schedules and Chaining, 5) Shaping and Functional Communication Training, and 6)
Natural Environment Teaching, Maintenance, and Generalization. Additional details on the
trainings are included in Table 1. After each training session, a related homework assignment
was given to participants. The assignment could be easily completed by the participants with
their cellphone or laptop typing during daily interaction. Participants were encouraged to
14
complete the homework, but it was not a mandatory requirement. A two-week follow-up was
done after the BPT phase. During these two weeks, the researcher met with the participant
weekly but did not provide any additional training.
Acceptance and Commitment Training (ACT). The ACT phase consisted of six ACT
training sessions. Before the training, the participants were told the purpose of the training was to
help them further facilitate functional interactions with their children. The training covered the
six main components of ACT and each session focused on one component. An overview of the
ACT training protocol can be found in Table 2.
Results
Figure 1 displays data on parent implementation of their parenting skills. The left vertical
axis depicts the percentage correct implementation of parent dependent variables that were
measured as percent correct and the right vertical axis depicts the frequency of parent dependent
variables that were measured with frequency data, during each behavioral observation session.
Jiayi’s learning opportunity of problem solution (PS), Yuner’s contrived/capture a motivation for
mand (CM) and Xiansan’s language training opportunity (LT) are calculated in frequency and
are depicted on the right vertical axis. Jiayi’s functional communication training (FCT), Yuner’s
reinforcement (R) and Xiansan’s positive correction procedure (PC) are calculated in accuracy
and are depicted on the left vertical axis. Figure 2 exhibits data on their child’s behaviors. All of
the participants punctually attended all training sessions except for the following special
circumstances. According to Chinese New Year culture, all of the participants went back to their
own hometowns and reunited with their family. Hence, the participants requested various lengths
of vacation leave for Chinese New Year and in order to ensure all participants received similar
training experiences, all participants took two consecutive weeks off of the study for Chinese
15
New Year. The two-week vacation occurred between observation sessions 24 and 25 for Jiayi
and Yuner and bewteeen 28 and 19 for Xiansan. In addition to the national holidays, Yuner had a
one week sick leave between sessions 16 and 17 and Xiansan had a one week leave between
sessions 11 and 12 due to her child's sickness.
Jiayi
Direct Measures
The top panel of Figure 1 displays Jiayi's performance of two parenting skills, with the
accuracy of functional communication training (FCT) depicted on the left vertical axis and the
frequency of contriving learning opportunities for problem solutions (PS) depicted on the right
vertical axis. During baseline, the accuracy of FCT was low with a range from 0% to 50% (M =
22%) and the frequency of PS was either one or zero (M = 0.3). During BPT, the level of FCT
accuracy gradually increased and eventually stabilized at 70%-100% (M = 52%). The frequency
of PS slightly increased (M = 2). Accuracy of FCT increased and the frequency of PS decreased
during the post BPT follow-up observations. During the ACT phase, the accuracy of FCT
remained high (M=86%) and the frequency of PS remained higher than baseline but still at a low
level (M=3.5). During the two-week follow-up sessions after the end of the ACT phase, the
frequency of PS remained in the same range as previously, while the accuracy of FC decreased
moderately.
Figure 2 depicts the frequency of Jiayi’s child’s functional communication behavior
during the behavioral observation sessions. During baseline, the frequency of functional
communication ranged from 0 to 8 (M = 7). During the BPT phase, the behavior initially
decreased and then increased in the second half of the phase (M = 6), with similar levels and an
16
increasing trend during BPT follow-up. The behavior maintained at a moderate level during the
ACT phase (M=8.25) and decreased slightly during the second follow-up phase.
Indirect Measures
The first three columns of Table 3 display data from Jiayi's psychological questionnaires
implemented after baseline, BPT and ACT. Results of Acceptance and Action Questionnaire
(AAQ-II) improved from 22 after baseline, to 15 after BPT and then to 13 after ACT. Total
scores on Parental Stress Index Short Form (PSI-SF) improved from 106 after baseline, to 91
after BPT and then to 88 after ACT. No systematic changes were observed on scores of the
Depression Anxiety Stress Scales (DASS) and Mindful Attention Awareness Scale (MAAS).
Yuner
Direct Measures
The second panel of Figure 1 displays Yuner's performance of two parenting skills with
the accuracy of reinforcement (R) depicted on the left vertical axis and the frequency of
contriving/capturing motivation for mands (CM) depicted on the right vertical axis. During the
baseline, the R was low (M=4%) and her frequency of CM was zero (M=0). After the onset of
the BPT, the level of R accuracy increased substantially and stabilized around 75% (M=53%).
Her frequency of CM gradually increased across the BPT phase (M=2). During the BPT follow-
up phase, the frequency of CM increased. During the ACT phase, R accuracy increased slightly
and stabilized at a high level (M=80%), while the frequency of CM gradually increased (M=6).
The level of R accuracy and the frequency of CM maintained during the post ACT follow up
phase.
Figure 2 depicts the frequency of Yuner’s child clearly articulating words. Yuner’s child
spoke no clearly articulated words during baseline (M=0). The behavior increased substantially
17
and remained highly variable during the BPT phase (M=11) and maintained during follow-up
observations after BPT. During the ACT phase, Yuner’s child initially spoke at a substantially
higher rate, with the overall rate then stabilizing (M=21), and then maintaining during the post-
ACT follow-up phase.
Indirect Measures
In Table 3, the total score results of the Parental Stress Index Short Form (PSI-SF)
showed a decreasing trend, from 101 after baseline, to 90 after BPT and to 87 after ACT. Results
of Parental Stress Index-Difficult Child (PSI-DC) were 35 after baseline, 30 after BPT and 28
after ACT and results of Parental Stress Index-Parental Stress (PSI-PD) were 32 after baseline,
28 after BPT and 26 after ACT. This indicates Yuner has reduced her parenting distress and view
of having a difficult child since the BPT phase. There were no systematic changes observed on
the Acceptance and Action Questionnaire (AAQ-II), Depression Anxiety Stress Scales (DASS)
or Mindful Attention Awareness Scale (MAAS).
Xiansan
Direct Measures
The third panel of Figure 1 displays Xiansan's performance of two parenting skills, with
the accuracy of positive correction procedures (PC) and the frequency of language training
opportunities (LT) depicted on the right vertical axis. During baseline, the accuracy of PC was
low and stable (M=26%) and the frequency of LT was between zero and three (M=1). After the
onset of BPT, the accuracy of PC gradually increased and stabilized at a higher level (M=47%)
and the frequency of LT increased (M=9). During post BPT follow-up sessions PC and LT
maintained. During the ACT phase, the accuracy of PC gradually increased (M=59%) and the
18
frequency of LT increase and remained variable (M=21). In the post ACT follow-up
observations, the dependent variables maintained at similar levels.
The third panel of Figure 2 depicts the frequency of Xiansan’s child's functional communication
behaviors. No functional communication occurred during baseline (M=0). Functional
communication increased substantially during the BPT phase (M=3) and remained at a similar
rate but with higher variability during the ACT phase (M=3).
Indirect Measures
As depicted in Table 3 the results of Xiansan's total score on the Parental Stress Index
Short Form (PSI-SF) changed from 117 after baseline, to 121 after BPT, and then to 112 after
ACT. Results of Parental Stress Index-Dysfunctional Interaction (PSI-DI) were 37 after baseline,
39 after BPT and 33 after ACT. There were no systematic changes observed on the Acceptance
and Action Questionnaire (AAQ-II), Depression Anxiety Stress Scales (DASS) and Mindful
Attention Awareness Scale (MAAS).
Social Validity
Results for the social validity measures are displayed in Figure 3. The questionnaire was
fully anonymous to ensure it represented parents’ genuine opinions and the results of the
questionnaire would not affect the training experience. Overall, the result of the questionnaire
suggests that the participants were satisfied with the BPT and ACT training. The participants
reported that they were satisfied with the learning experiences of BPT and ACT training (M=5,
range: 5-5), wanted to continue the BPT and ACT training after the study (M=4.83, range:4-5),
would like to recommend BPT and ACT training to other people in need (M= 4.83, range: 4-5)
and believed that the study has improved their parenting skills (M=4.83, range: 4-5). The
participants also reported how many hours they used behavioral skills to interact with their child.
19
Jiayi spent more than ten hours a week and Yuner usually had 3-5 hours a week to use behavioral
skills to interact with their child after receiving BPT and ACT training. Xiansan used behavioral
skills to interact with her child around 5-10 hours a week at post BPT phase and reduced the time
to 3-5 hours a week after receiving ACT training.
The questionnaire also investigated general opinions about BPT and ACT training and
how the training improved the participants. After BPT training, parents stated “I had a clearer
goal and better understanding about how to interact with my child after BPT training. I really
appreciated the trainers”, “I am very satisfied with BPT training, thank you very much” and “I do
not have other suggestion so far. The BPT training is easy to understand, and the goal of the
training is clear. My parenting interaction skills have been improved since receiving BPT
training.” After ACT training, parents’ general opinions are “Training are practical and useful to
solve the current problems with my child” and “I am very satisfied with training and appreciated
all of the trainers.” The additional question of "How has the training improved you or helped
you? (daily life/family interaction/self-compassion/parenting/working etc.)", parents reported “I
have better emotion management and understanding of my child's behavior. I learned a better
approach to handle the situations when my child overreacts or becomes angry”, “ Improved my
parenting interaction skills” and “Training improved my parenting interaction skills and also
helped me have a higher self-esteem”.
Discussion
The goal of BPT is to promote positive interactions between parents and children with
autism, to empower parents to support their children’s development and daily functioning. Due
to the limited access to applied behavior analysis treatment and support in China, telehealth
platforms potentially serve an important role in increasing access to interventions for Chinese
20
parents and those on lengthy waitlists (Wainer & Ingersoll, 2015). A small but significant
amount of previous research has supported telehealth ABA parent training approaches, but the
published research on telehealth approaches to ACT-based parent training is severely limited.
The aim of ACT is to promote psychological flexibility for the purpose of facilitating values-
based overt behavior change. The purpose of this study was to investigate whether telehealth-
based BPT can increase positive child-parent dyad interactions for Chinese parents, and whether
additional telehealth ACT sessions would enhance the effectiveness of BPT. Different from most
previous research on ACT-based parent training, our study used a single-case design with direct
observation data. The study took a participatory approach by empowering participants to choose
their and their children's target behaviors. Overall, the results of this study indicate that
telehealth-based BPT alone produced substantial increases in overt behavior for all three Chinese
parents, compared to baseline.
The additive effects of ACT-based parent training, above and beyond BPT, are less
consistent. For Jiayi, FCT was already near 100% correct in the BPT phase, so it may have
constituted a ceiling effect, making any additional effect from ACT difficult to determine.
However, Jiayi’s other target behavior was not at a ceiling and also did not appear to improve
during the ACT condition. Yuner’s behavior of implementing reinforcement improved a small
amount during the ACT condition and her second target behavior improved more substantially
during the ACT condition. Xiansan’s target behavior of positive correction procedures did not
appear to improve substantially during the ACT condition, whereas her behavior of language
training opportunities did. Therefore, across the three participants, ACT appeared to produce
substantial additional benefit for two of six behaviors and small additional benefit for one of six.
The lack of a clear and consistent additive result of ACT after traditional behavioral
21
approaches is somewhat different from the results observed in Little and colleagues (2020), in
which ACT substantially increased the effectiveness of BST (behavioral skills training) when
training behavioral staff, with an additive effect observed for three out of three dependent
variables. Many factors may account for this difference in results. First, the Little’s study was
conducted in-person, whereas the current study was conducted via telehealth. Second, the
participants in the little study were staff at work, rather than parents interacting with their own
children with special needs. Staff in the work environment can be motivated by many intrinsic
(e.g., recognition, achievement) and extrinsic factor (e.g., promotion, compensation) (Lee &
Raschke, 2016).
The results of the PSI-SF suggest that BPT reduced parenting stress for two participants.
Furthermore, PSI-SF scores further reduced after ACT training. No systematic changes were
found in the other self-report questionnaires that measured psychological flexibility (AAQ-II),
mindfulness (MAAS), and depression / anxiety (DASS). In the social validity questionnaire after
ACT phase, participants reported that the ACT session improve their self-compassion ability and
increased their self-esteem. What's more, all participants reported courageous and positive
movements in daily life and verbally shared during the ACT sessions and these anecdotal reports
are not captured in the direct observation data. For example, at the beginning of the ACT phase,
Jiayi expressed a strong wish that she wanted to get a pet cat, but she gave up because she
needed to prioritize her child. After defusion training in the ACT phase, she reported that she
decided to get a cat and that the process was easier than she previously imagined. Yuner reported
that, as a result of her relationship between her and her father, she had difficulty interacting with
her child without judgment. After ACT training, she reported that
the Mindfulness Shower exercise was helpful for her to slow her mind down and sit with her
22
child without reprimanding him. What's more, Xiansan reported that she was a busy housewife,
and could not squeeze a moment in even to wash her face, a self-care activity that was important
to her. During the ACT phase, she proudly shared with the experimenter that she formally
requested a certain amount of beauty fee (i.e., to buy a facial mask) from her husband and started
to do a skincare routine nightly (i.e., made committed action to her stated value of self-care).
Previous studies have demonstrated the effectiveness of BPT and ACT separately (Chiang et al.,
2014; Gould, 2016; Vismara et al., 2013; Yi & Dixon, 2020), but very few studies have
evaluated procedures for implementing BPT in combination with ACT. The current study used
direct observation data to replicate the results of previous research on BPT for improving
parenting skills. The contribution of this study is perhaps most important in its relevance to
extending services to Chinese families. Although preliminary, this study suggests that Chinese
parents may be successfully trained and supported by Mandarin-speaking trainers on different
continents. In the future, more research should be done on group-telehealth formats of BPT and
ACT to improve the efficiency of parenting training overseas.
One variable of the current study that departs from previous research is that BPT was
implemented for fewer sessions (i.e., six sessions). Many previous studies related to BPT (Drifke
et al., 2017; Chiang, 2014; Vismara et al., 2013) included more than 10 BPT sessions. However,
the results of this study suggest that 6 sessions of telehealth BPT can produce substantial effects.
The length of the ACT session is consistent with the previous ACT research (e.g., Gould et al.,
2018).
One potential limitation of the study was the technical challenges that arose. An unstable
internet connection occurred multiple times during the sessions. Furthermore, it was challenging
for children with autism to stay in the designed area for thirty minutes during the direct
23
observation sessions. However, the satisfaction of the learning experience was very high across
training, and the effectiveness of the training was reflected in the consistent changes seen across
overt behaviors. Therefore, the technical challenges may not have substantially affected the
study. Another potential limitation is the sample size. The current study used a single case
design, so the sample size is small. Future research can increase the sample size and compare the
effectiveness of face-to-face and telehealth training by evaluating the interaction performance of
Chinese parents. Of particular interest would be a randomized trial comparing groups of parents
who receive traditional BPT to parents who receive combined BPT and ACT.
In conclusion, a promising finding of this study is that using the telehealth approach can
effective for parents in the Chinese population. An additional ACT intervention can maintain the
efficacy of BPT and may enhance its effectiveness for some behaviors and some participants. In
the current study, the modified training protocols of BPT and ACT in the Chinese version are
suitable and feasible within Chinese culture. Overall, further research on evidence-based
practices across languages and cultures is crucial for enhancing the degree to which behavioral
science is relevant to the diverse world population and telehealth approaches appear to be a
promising method for disseminating behavioral research and practice around the world.

24
References
Abidin, R. R. (2008). Parenting Stress Index.. Firenze: Organizzazioni Speciali Giunti. (Original
work published 1995).
張仁和 (Chang, J., 林以正(Lin, Y., & 黃金蘭(Huang, C. (2011). 中文版「止觀覺察注意量
表」之信效度分析. 測驗學刊, 58, 235–260. https://doi.org/10.7108/PT.201104.0090
Bearss, K., Burrell, T. L., Challa, S. A., Postorino, V., Gillespie, S. E., Crooks, C., & Scahill, L.
(2018). Feasibility of Parent Training via Telehealth for Children with Autism Spectrum
Disorder and Disruptive Behavior: A Demonstration Pilot. Journal of Autism and
Developmental Disorders, 48(4), 1020–1030. https://doi.org/10.1007/s10803-017-3363-2
Blackledge, J. T., & Hayes, S. C. (2006). Using Acceptance and Commitment Training in the
support of parents of children diagnosed with autism. Child & Family Behavior Therapy,
28, 1-18. https://doi.org/1300/J019v28n01_01
Boutain, A. R., Sheldon, J. B., & Sherman, J. A. (2020). Evaluation of a telehealth parent
training program in teaching self‐care skills to children with autism. Journal of Applied
Behavior Analysis, 53(3), 1259–1275. https://doi.org/10.1002/jaba.743
Chaabane, D. B. B., Alber-Morgan, S. R., & DeBar, R. M. (2009). The effects of parent-imple-
mented PECS training on improvisation of mands by children with autism. Journal of
Applied Behavior Analysis, 42(3), 671–677.
Chiang, H. (2014). A Parent Education Program for Parents of Chinese American Children With
Autism Spectrum Disorders (ASDs): A Pilot Study. Focus on Autism and Other
Developmental Disabilities, 29(2), 88–94. https://doi.org/10.1177/1088357613504990
Compton, N. (2018). Teacher Turned Journalist Reports on Autism in China.
https://www.autismspeaks.org/blog/teacher-turned-journalist-reports-autism-china
25
Corti, C., Pergolizzi, F., Vanzin, L., Cargasacchi, G., Villa, L., Pozzi, M., & Molteni, M. (2018).
Acceptance and Commitment Therapy-Oriented Parent-Training for Parents of Children
with Autism. Journal of Child and Family Studies, 27(9), 2887–2900.
https://doi.org/10.1007/s10826-018-1123-3
Drifke, M., Tiger, J., & Wierzba, B. (2017). Using behavioral skills training to teach parents to
implement three-step prompting: A component analysis and generalization assessment.
Learning and Motivation, 57, 1–14. https://doi.org/10.1016/j.lmot.2016.12.001
Defreitas, J., Crosland, K., Blair, K., & Weil, T. (2015). Acceptance and Commitment Training
to Enhance a Behavioral Parent Training with Parents of Children with Autism (ProQuest
Dissertations Publishing). Retrieved from
http://search.proquest.com/docview/1750592084/
Fung, K., Lake, J., Steel, L., Bryce, K., & Lunsky, Y. (2018). ACT Processes in Group
Intervention for Mothers of Children with Autism Spectrum Disorder. Journal of Autism
and Developmental Disorders, 48(8), 2740–2747. https://doi.org/10.1007/s10803-018-
3525-x
Foody, C., James, J., & Leader, G. (2015). Parenting Stress, Salivary Biomarkers, and
Ambulatory Blood Pressure: A Comparison Between Mothers and Fathers of Children
with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders,
45(4), 1084–1095. https://doi.org/10.1007/s10803-014-2263-y
Gould, E., Tarbox, J., Coyne, L., & Guerrero, F. (2016). Evaluating the effects of Acceptance
and Commitment Training on the behavior of parents of children with autism (ProQuest
26
Dissertations Publishing). Retrieved from
http://search.proquest.com/docview/1860875859/
Gould, E. R., Tarbox, J., & Coyne, L. (2018). Evaluating the effects of acceptance and
commitment training on the overt behavior of parents of children with autism. Journal of
Contextual Behavioral Science, 7, 81-88.
Harris, R., Steven C. (2019). ACT Made Simple: An easy-to-read primer on acceptance and
commitment therapy.
Kroeger, K., & Sorensen, R. (2010). A parent training model for toilet training children with
autism. Journal of Intellectual Disability Research, 54(6), 556–567.
Lee, M. T., & Raschke, R. L. (2016). Understanding employee motivation and organizational
performance: Arguments for a set-theoretic approach. Journal of Innovation &
Knowledge, 1(3), 162-169.
Little, A., Tarbox, J., & Alzaabi, K. (2020). Using acceptance and commitment training to
enhance the effectiveness of behavioral skills training. Journal of Contextual Behavioral
Science, 16, 9–16. https://doi.org/10.1016/j.jcbs.2020.02.002
Luo, J., Wang, M.-C., Gao, Y., Zeng, H., Yang, W., Chen, W., Zhao, S., & Qi, S. (2019).
Refining the Parenting Stress Index–Short Form (PSI-SF) in Chinese Parents.
Assessment, 28(2), 551–566. https://doi.org/10.1177/1073191119847757
N., Orcutt, H. K., . . . Zettle, R. D. (2011). Preliminary psychometric properties of the
Acceptance and Action Questionnaire–II: A revised measure of psychological
inflexibility and experiential avoidance. Behavior Therapy, 42(4), 676–688.
https://doi.org/10.1016/j.beth.2011.03.007
27
Palladino, C. L., Ange, B., Richardson, D. S., Casillas, R., Decker, M., Gillies, R. A., House, A.,
Rollock, M., Salazar, W. H., Waller, J. L., Zeidan, R., & Stepleman, L. (2013).
Measuring psychological flexibility in medical students and residents: a psychometric
analysis. Medical education online, 18, 20932. https://doi.org/10.3402/meo.v18i0.20932
Su, X., Cai, R. Y., & Uljarević, M. (2017). Predictors of Mental Health in Chinese Parents of
Children with Autism Spectrum Disorder (ASD). Journal of Autism and Developmental
Disorders, 48(4), 1159–1168. https://doi.org/10.1007/s10803-017-3364-1
Tarbox, J., Garcia, M., & St. Clair, M. (2016). Parent training and support. In J. K. Luiselli
(Ed.), Behavioral Health Promotion and Intervention for People with Intellectual and
Developmental Disabilities. NY: Springer.
Tarbox, C. M., Silverman, E. A., Chastain, A. N., Little, A., Bermudez, T. L., & Tarbox, J.
(2020). Taking ACTion: 18 Simple Strategies for Supporting Children With Autism
During the COVID-19 Pandemic. Behavior analysis in practice, 1–29. Advance online
publication. https://doi.org/10.1007/s40617-020-00448-5
Tarbox, R. S., Wallace, M. D., Penrod, B., & Tarbox, J. (2007). Effects of three-step prompt- ing
on compliance with caregiver requests. Journal of Applied Behavior Analysis, 40 (4),
703–706.
Tsami, L., Lerman, D., & Toper‐Korkmaz, O. (2019). Effectiveness and acceptability of parent
training via telehealth among families around the world. Journal of Applied Behavior
Analysis, 52(4), 1113–1129. https://doi.org/10.1002/jaba.645
Twohig, M. P., Hayes, S. C., & Masuda, A. (2006). A preliminary investigation of acceptance
and commitment therapy as a treatment for chronic skin picking. Behavior Research and
Therapy, 44, 1513-1522.
28
Vismara, L., McCormick, C., Young, G., Nadhan, A., & Monlux, K. (2013). Preliminary
Findings of a Telehealth Approach to Parent Training in Autism. Journal of Autism and
Developmental Disorders, 43(12), 2953–2969.
Wainer, A. L., & Ingersoll, B. R. (2015). Increasing access to an ASD imitation intervention via
a telehealth parent training program. Journal of autism and developmental disorders,
45(12), 3877-3890.
Yi, Z., & Dixon, M. R. (2020). Developing and Enhancing Adherence to a Telehealth ABA
Parent Training Curriculum for Caregivers of Children with Autism. Unpublished.
Zhang, X., & Ji, C. Y. (2005). Autism and mental retardation of young children in China.
Biomedical and Environmental Sciences, 18(5), 334–340.
Zuo K., Chang A. (2008). A Chinese translation of the DASS (simplified characters). Available
online at: http://www2.psy.unsw.edu.au/groups/dass/Chinese/Chinese%20simplified.htm
曹静, 吉阳, & 祝卓宏. (2013). 接纳与行动问卷第二版中文版测评大学生的信效度. 中国心
理卫生杂志, 27(11), 873-877.

29
Table 1: Social Validity Questionnaire
The following questions ask about your satisfaction of your current opinion. Circle the number that closely indicates
the extent to which the item is present your current attitude.
Survey scale:
1 = Strongly Disagree 2 = Disagree 3 = Neutral 4 = Agree 5 = Strongly Agree
I am satisfied with my learning experience of [BPT] [ACT] in the study. 1 2 3 4 5
I want to continue the [BPT] [ACT] after the study. 1 2 3 4 5
I will recommend [BPT] [ACT] to other people in need. 1 2 3 4 5
Generally, the approximate hours that I used behavioral skills to interact
with my child is
Less
than one
1-
2
3-
5
5-
10
Above
10
I believe that this study has improved my parenting skills 1 2 3 4 5
My general suggestion(s) or opinion(s) about the current phase of training
is(are):
Text input
Additional question after two phases of training*
How has the training improved you or helped you? (daily life/family
interaction/self-compassion/parenting/working etc.)
Text input

30
Table 2. Behavioral Parent Training (BPT) protocol.
Session Topic Rationale
1 Antecedence Behavior
Consequence (ABC),
functional assessment, and
antecedent strategies
The session will help parents understand the reasons behind their children’s challenging behaviors
by analyzing antecedents and consequences of the behaviors. Based on this understanding, parents
will learn how to manipulate the antecedents to prevent challenging behaviors.
2 Replacement Behavior and
Reinforcement
The session teaches parents how to strengthen adaptive behaviors to replace challenging
behaviors. Parents were taught to use positive reinforcement (such as, praise and preferred
items/activities), motivate their children, and encourage replacement behaviors.
3 Token System, Prompting
and Fading
The session will help parents to design a token board. The tokens will serve as positive
reinforcement for children. Parents will learn multiple prompting strategies (e.g., full physical
prompting, vocal prompting, gesture prompting etc.) to encourage skill acquisition. They will also
learn how to encourage their child’s independence by fading out prompts and assistance.
4 Visual Schedule and Chaining Parents were taught to design a visual schedule for the children. The visual schedule is a graphic
representation of daily tasks and activities. Parents will also learn how to break a multiple-step
behavior (e.g., washing hands) into small steps (e.g., get soap, rinse) and then teach the steps in a
specific sequence.
5 Shaping and Functional
Communication Training
The session will discuss how to reinforce successive approximations toward a target behavior. For
example, parents want to teach children to say “cookie” and then they teach the children to make
a “k” sound at the beginning. The session will also discuss using meaningful and appropriate
communication to replace challenging behaviors. For example, the child will say “I want to eat a
cookie” when he requests for a cookie, rather than screaming and crying.
6 Natural Environment
Teaching, Maintenance and
Generalization
The session will discuss how to support adaptive behaviors occurs outside of the learning
environment and how to create learning opportunities in the natural environment (e.g., grocery
time or shower time).

31
Table 3. ACT Training Protocol

32

Note. Participants completed psychological questionnaires during baseline, after BPT and after
ACT phases. AAQ =Acceptance and Action Questionnaire; DASS-D = Depression Anxiety
Stress Scales-Depression subscale; DASS-A = Depression Anxiety Stress Scales-Anxiety
subscale; DASS-S = Depression Anxiety Stress Scales-Stress subscale; PSI-DC = Parental Stress
Index-Difficult Child subscale; PSI-PD = Parental Stress Index-Parenting Distress subscale; PSI-
DI = Parental Stress Index-Dysfunctional Interaction subscale; PSI-Total = Parental Stress
Index-total scores; MAAS = Mindful Attention Awareness Scale. * represents clinically
significant scores.

Table 4. Psychological functioning and parenting stress measures of participants.

33

Figure 1. Percent correct of the positive parenting skill implementation, and frequency of
positive parental behaviors across baseline, Behavioral Parent Training (BPT), BPT one week
follow up, Acceptance and Commitment Training (ACT), and ACT one week follow up phases
for each parent.
34

Figure 2. Frequency of positive behaviors for each child.

35
Figure 3. Scores for parental social validity questionnaire.

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Asset Metadata

Creator Lin, Zhen (author)

Core Title A preliminary evaluation of a telehealth approach to acceptance and commitment training (ACT) for enhancing behavioral parent training (BPT) for Chinese parents

School College of Letters, Arts and Sciences

Degree Master of Science

Degree Program Applied Behavior Analysis

Degree Conferral Date 2021-12

Publication Date 10/09/2021

Defense Date 08/13/2021

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag acceptance and commitment training,autism spectrum disorder,behavioral parent training,Chinese,OAI-PMH Harvest,parenting stress,telehealth

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Advisor Tarbox, Jonathan (committee chair), Cameron, Michael (committee member), Saxbe, Darby (committee member)

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